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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Asking the client to help with the dressing change may not be appropriate, especially if the client is frail or recovering from surgery. Older adults may have limited mobility or strength, and they may require assistance rather than being asked to participate actively.
B. Waiting for the client to approach the nurse for assistance may not be conducive to providing optimal care. Nurses should proactively assess the client's needs and offer assistance as appropriate, especially in the postoperative period when mobility may be limited.
C. Using paper tape for securing the new dressing is a good choice because older adults may have delicate skin that is prone to tearing or irritation. Paper tape is gentle on the skin and less likely to cause damage or discomfort compared to other types of adhesive dressings.
D. Applying the dressing loosely over the incision may compromise its effectiveness in providing wound protection and promoting healing. Dressings should be applied securely but not too tightly to avoid restricting circulation or causing discomfort.
Correct Answer is B
Explanation
A. Telling the client to ignore others minimizes their feelings and does not address the underlying issue of bullying or social discomfort.
B. Validating the client's feelings acknowledges their emotions and demonstrates empathy, which can help build trust and rapport with the client.
C. While it's important to address the client's needs, dismissing their concerns about social interactions may contribute to feelings of isolation and neglect.
D. Offering reassurance without addressing the client's current distress may invalidate their feelings and overlook the need for support and intervention in the present moment.
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