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 A

Explanation

Answer is: **Stop the newly licensed nurse from administering the medication.**

Explanation:the first step in dealing with a client who is manic and refuses treatment is to stop the nurse from administering the medication. This is because giving an injection to a patient in an agitated and manic state could be dangerous for both the patient and the nurse¹². The nurse manager should follow the principle of least restrictive intervention when handling such a situation².

The other options are incorrect because:

- Assessing the need for physical restraints is not a priority action, as it may escalate the situation and cause more harm than good¹².
- Demonstrating how to verbally de-escalate the situation is also not a priority action, as it may not be effective if the client is too agitated or irrational to listen¹².
- Discussing the purpose of the medication with the client may be helpful, but it should be done after assessing the need for physical restraints and trying other methods of communication¹².

A. Withhold the next dose of the medication. B. Ask the client about a recent change in laundry detergent. C. Apply hydrocortisone cream on the client's rash. D. Explain that the medication causes a temporary rash.

Correct Answer is A

Explanation

The correct answer is: A. Withhold the next dose of the medication.

Choice A rationale: Lamotrigine can cause serious skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis. Any rash should be taken seriously, and the medication should be withheld immediately to prevent potential severe reactions1.

Choice B rationale: While a change in laundry detergent could cause a rash, it is less likely to be the cause if the rash appeared after starting lamotrigine.

Choice C rationale: Applying hydrocortisone cream may help with mild skin irritations, but it does not address the potential severity of a drug-induced rash.

Choice D rationale: Explaining that the medication causes a temporary rash is not appropriate without first assessing the severity of the rash and withholding the medication.

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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 manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Correct Answer is A

Explanation

A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take?

Correct Answer is A

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?