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

The correct answer is choice B. Blood pressure.

Choice A rationale:

Bowel sounds. While assessing bowel sounds can be a part of a comprehensive physical assessment, it is not directly related to the interaction between phenelzine and pepperoni pizza. Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression. It does not have a known interaction with the digestive system that would necessitate monitoring bowel sounds after eating pepperoni pizza.

Choice B rationale:

Blood pressure. This is the correct choice. Phenelzine can interact with tyramine, a substance found in certain foods like pepperoni. This interaction can lead to a hypertensive crisis, a sudden and severe increase in blood pressure. Therefore, after the client reports eating pepperoni pizza, the nurse should assess the client’s blood pressure to monitor for this potential reaction.

Choice C rationale:

Oxygen saturation. While oxygen saturation is an important vital sign, it is not directly affected by the interaction between phenelzine and pepperoni pizza. Therefore, it would not be the most relevant assessment in this situation.

Choice D rationale:

Pupil response. Pupil response can be an indicator of neurological status, but it is not directly related to the interaction between phenelzine and pepperoni pizza. Therefore, it would not be the most relevant assessment in this situation.

A. Explain implied consent to the client's family. B. Contact the facility social worker to obtain the consent. C. Request that the client's guardian sign the consent. D. Ask the charge nurse to obtain informed consent.

Correct Answer is C

Explanation

Choice A rationale:

Explaining implied consent to the client's family is not the appropriate action in this situation. Implied consent typically refers to situations where consent is assumed due to the client's actions or circumstances, but it is not applicable when a client has been declared legally incompetent. The nurse should seek consent from a legally authorized representative, such as a guardian, in this case.

Choice B rationale:

Contacting the facility social worker is a good step to take when dealing with complex legal and ethical situations. However, the nurse's primary responsibility is to ensure that the client's legally authorized representative provides informed consent. This means that the client's guardian should be the one to sign the consent form, rather than the social worker.

Choice D rationale:

Asking the charge nurse to obtain informed consent is not the appropriate action because obtaining consent is typically the responsibility of the healthcare provider or a legally authorized representative. The charge nurse may not have the legal authority to provide informed consent on behalf of the client.

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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 assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent.Which of the following actions should the nurse take?

Correct Answer is C

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?