A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
Ask the client to sign a no-suicide contract.
Implement continuous one-to-one observation.
Establish a rapport to foster trust.
Encourage the client to participate in group therapy.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Manage conflict within the group.Conflict management is an important skill for a group facilitator, but it is generally more applicable during the working phase of the group when members begin to express differing opinions and emotions.
B. Encourage the use of problem-solving skills.While encouraging problem-solving is beneficial for group members, this intervention is more appropriate for later phases of the group process, once rapport is established and members are actively discussing their issues.
C. Maintain the group's focus on identified issues.Keeping the group focused on specific issues is important for effective group work. However, in the orientation phase, the primary goal is to introduce the group, establish guidelines, and build relationships.
D. Establish a rapport with group members.In the orientation phase of a support group, the nurse's primary objective is to establish trust and build rapport. Creating a supportive and welcoming environment is essential for adolescents, as it sets the stage for open communication.
Correct Answer is ["A","B","C","D"]
Explanation
A.Bradycardia, or a slow heart rate, is a common physiological finding in individuals with anorexia nervosa due to the body's adaptive response to conserve energy. The heart rate may drop below the normal range of 60-100 bpm.
B.Russell's sign refers to calluses or abrasions on the knuckles or back of the hand caused by self-induced vomiting. It's a physical indicator of recurrent vomiting in individuals with bulimia nervosa or severe anorexia nervosa.
C.Lanugo refers to fine, soft hair that grows on the face, back, and arms of individuals with anorexia nervosa. This is the body's attempt to increase warmth due to insufficient body fat, and it's a result of the malnutrition associated with the disorder.
D.Hypotension, or low blood pressure, is often seen in individuals with anorexia nervosa due to decreased cardiac output and volume. This can lead to dizziness, fatigue, and other cardiovascular symptoms.
E.Diarrhea is not a common finding in anorexia nervosa. Clients with anorexia nervosa are more likely to experience constipation due to malnutrition, dehydration, and the body’s reduced metabolic rate.
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