A nurse is caring for a client who attempted suicide. Which of the following actions should the nurse take?

Serve meals with plastic utensils.

Assign another client to accompany the client to therapy sessions.

Assign the client to a private room.

Check on the client every 4 hr.

Answer and Explanation

The Correct Answer is A

- Rationale for A: Serving meals with plastic utensils is a safety measure to prevent self-harm. Metal utensils can be used as weapons, so plastic is a safer alternative. This action reflects the priority of maintaining a safe environment for the client.
- Rationale for B: Assigning another client to accompany the client to therapy sessions is not advisable. It may violate privacy and confidentiality, and it is not the responsibility of other clients to monitor safety.
- Rationale for C: Assigning the client to a private room could be beneficial for monitoring purposes, but it does not directly prevent self-harm. It is also important to consider that constant observation is necessary regardless of room assignment.
- Rationale for D: Checking on the client every 4 hours is not sufficient for a client who is at high risk for suicide. More frequent monitoring is needed to ensure the client's safety and to intervene promptly if necessary.

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Correct Answer is B

Explanation

A. While a cooler foot than in the previous assessment may indicate decreased perfusion, the absence of a palpable pedal pulse is a more significant finding as it suggests compromised arterial blood flow to the foot.
B. The absence of a palpable pedal pulse indicates diminished arterial blood flow to the foot, which is a critical finding following a femoropopliteal bypass graft. It suggests potential complications such as graft occlusion or inadequate blood flow distal to the graft site.
C. Capillary refill time of 5 seconds in the toes may indicate delayed capillary refill, which could be a concern but is not as immediately critical as the absence of a palpable pedal pulse.

D. While pain is an important assessment finding, a pain level of 8 on a scale from 0 to 10 is subjective and does not provide specific information about the client's vascular status. Pain assessment should be considered along with other objective findings.

A. "You will receive an injection of contrast dye during the test." B. "Consume a clear liquid breakfast on the day of the procedure." C. "Someone should drive you home after the procedure." D. "You will have to drink a contrast medium before the test."

Correct Answer is D

Explanation

A. Incorrect. Upper gastrointestinal series typically involve oral ingestion of a contrast medium, not an injection.
B. Incorrect. Clients are usually instructed to fast before an upper gastrointestinal series, not consume breakfast.
C. Incorrect. While it's generally advisable to have someone accompany the client for procedures involving sedation or anesthesia, fluoroscopy itself does not usually require sedation, and the client can typically drive home afterward.
D. Correct. Prior to an upper gastrointestinal series, clients are usually required to drink a contrast medium to outline the digestive tract for fluoroscopy imaging.

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A nurse is caring for a client who attempted suicide. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is about to undergo an upper gastrointestinal series with fluoroscopy. Which of the following information should the nurse provide?

Correct Answer is D

Explanation

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