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?

Implement continuous one-to-one observation.

Ask the client to sign a no-suicide contract.

Encourage the client to participate in group therapy.

Establish a rapport to foster trust.

Answer and Explanation

The Correct Answer is D

The most important action for the nurse to take first is to establish a rapport and foster trust with the client. This is represented by option d.

Here's why the other options are not the best first steps:

a. Implement continuous one-to-one observation: While monitoring safety is crucial, it does not address the immediate emotional need of the client, who has just endured a traumatic experience. Building trust first can facilitate open communication and help the client feel safe enough to express their feelings and needs.
b. Ask the client to sign a no-suicide contract: No-suicide contracts have limited effectiveness and can even be harmful by putting undue pressure on the client. Building trust and a collaborative plan are more effective ways to manage safety.
c. Encourage the client to participate in group therapy: Group therapy can be beneficial, but it's not appropriate as the immediate first step. Individualized attention and establishing a secure relationship are crucial at this early stage.

Therefore, establishing rapport and fostering trust is the most important action for the nurse to take first. This will create a safe space for the client to openly express their thoughts and feelings, allowing the nurse to assess their needs and develop a proper care plan.

Remember, this is just the first step. Subsequent actions will involve a comprehensive assessment, safety measures, and collaborating with the client and other healthcare professionals to develop a personalized treatment plan.

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Correct Answer is B

Explanation

A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? The correct answer is choice B. Notify the client about designated times for meals.

Choice A rationale:

Weighing the client weekly for the first month is not an appropriate intervention in the initial care plan for a client with anorexia nervosa. While monitoring weight is essential, weekly weigh-ins may contribute to anxiety and distress in clients with eating disorders. The frequency of weigh-ins and the timing should be individualized based on the client's specific needs.

Choice B rationale:

Notifying the client about designated times for meals is a crucial intervention in the care plan for someone with anorexia nervosa. Establishing a structured meal schedule is important in promoting regular eating habits and preventing excessive exercise or other behaviors related to the disorder. Providing consistency in meal times can help the client regain control over their eating patterns.

Choice C rationale:

Negotiating with the client on how much weight she should gain each week is not a recommended approach in the initial stages of treatment for anorexia nervosa. Clients with this disorder often have distorted body image and unrealistic weight goals. It's important to set safe and appropriate weight gain goals based on the client's individual needs and in collaboration with a healthcare team, rather than negotiating arbitrary targets with the client.

Choice D rationale:

Decreasing the client's daily intake of fiber is not a suitable intervention in the care plan for anorexia nervosa. While dietary modifications may be necessary, reducing fiber intake can lead to constipation and other digestive issues. Any dietary changes should be made under the guidance of a registered dietitian or healthcare provider and should aim to restore a healthy and balanced diet.

A. Enroll in an online self-help course. B. Practice guided imagery each morning. C. Write in a journal daily. D. Join a low-impact exercise class.

Correct Answer is D

Explanation

The most appropriate recommendation for the client experiencing social isolation due to depression is:

d. Join a low-impact exercise class.

Here's why:

a. Enroll in an online self-help course:While this can be beneficial for learning coping skills,it doesn't directly address the social isolation aspect.
b. Practice guided imagery each morning:This could be helpful for emotional regulation but doesn't necessarily promote socialization.
c. Write in a journal daily:Though journaling can be therapeutic,it's a solitary activity and may not address social withdrawal.
d. Join a low-impact exercise class:Participating in a group activity like a low-impact exercise class provides several benefits:
- Physical activity:Improves mood and energy levels,reducing depression symptoms.
- Social interaction:Creates opportunities to connect with others with similar interests,combating isolation.
- Structure and routine:Provides a sense of purpose and accomplishment,which can be difficult with depression.
- Reduced stress:Exercise releases endorphins,which have mood-boosting effects.

Furthermore, a low-impact class caters to the client's potential lack of motivation and energy.

Therefore, encouraging participation in a low-impact exercise class is the most suitable recommendation for this client's social isolation in the context of depression.

Remember, it's crucial to consider the client's individual preferences and tailor recommendations accordingly.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "I feel unmotivated and don't feel like leaving my home.”. Which of the following recommendations should the nurse make to address the client's social isolation?

Correct Answer is D

Explanation

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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?