A nurse is concerned for a client's safety and is following suicide precautions on the unit.
Which of the following are suicide precaution interventions?
Allowing the client to take a nap with the door closed.
Allowing the client to distract themselves by working on crafts in their room.
Giving the client some headphones to listen to relaxing music.
Rounding and visualizing the client every 15 min.
The Correct Answer is D
Choice A rationale
Allowing a client at risk for suicide to nap with the door closed poses a significant safety concern. This practice eliminates direct visual observation, which is paramount in suicide prevention. The closed door creates an opportunity for the client to engage in self-harm behaviors unobserved, increasing the risk of a successful suicide attempt by removing immediate intervention capabilities.
Choice B rationale
While distraction can be therapeutic, allowing a client on suicide precautions to engage in crafts in their room unobserved introduces potential risks. Craft materials, if not carefully monitored and selected, could be used as instruments for self-harm. Maintaining constant, direct observation, even during seemingly benign activities, is crucial to prevent access to means for suicide.
Choice C rationale
Providing headphones for relaxing music, while potentially calming, can compromise auditory monitoring of a client on suicide precautions. The headphones can obscure sounds that might indicate distress, agitation, or self-harm attempts. Direct sensory observation, including listening for abnormal sounds, is a critical component of ensuring continuous safety and prompt intervention.
Choice D rationale
Rounding and visualizing the client every 15 minutes is a fundamental suicide precaution intervention. This frequent, direct observation allows for continuous assessment of the client's behavior, mood, and immediate environment. It minimizes opportunities for self-harm by providing consistent monitoring and enables timely intervention if any concerning signs or actions are detected, ensuring client safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Biopsy of the tumor is the definitive diagnostic procedure for Wilms tumor. This involves the surgical removal of a tissue sample from the suspected mass, which is then examined microscopically by a pathologist. Histopathological analysis confirms the presence of malignant cells characteristic of nephroblastoma, differentiating it from other renal masses and guiding subsequent treatment protocols. Normal renal tissue structure is preserved in healthy kidneys.
Choice B rationale
Bone marrow aspiration is primarily used to diagnose hematological malignancies or assess for metastatic disease in certain cancers. While Wilms tumor can metastasize, particularly to the lungs, bone marrow involvement is uncommon and not the primary diagnostic method for confirming the initial diagnosis of the tumor itself. Normal bone marrow contains hematopoietic stem cells and a balanced cellularity.
Choice C rationale
A CT scan of the abdomen and chest provides detailed anatomical information about the tumor's size, location, and extent of involvement within the kidney and surrounding structures, as well as checking for metastasis to the lungs. While crucial for staging and surgical planning, a CT scan is an imaging modality and does not provide a definitive tissue diagnosis. Normal abdominal organs appear with distinct densities.
Choice D rationale
Abdominal ultrasonography is often the initial imaging modality used to evaluate a suspected abdominal mass in children due to its non-invasive nature and lack of radiation exposure. It can identify the presence of a renal mass and distinguish between solid and cystic lesions, but like CT, it cannot definitively diagnose Wilms tumor without tissue sampling. Normal kidneys appear as solid, homogeneous organs.
Correct Answer is C
Explanation
Choice A rationale
Gonorrhea is a sexually transmitted infection caused by the bacterium *Neisseria gonorrhoeae*. This gram-negative diplococcus primarily infects mucous membranes of the reproductive tract, mouth, and rectum, leading to symptoms like discharge and dysuria. It is not caused by a protozoan.
Choice B rationale
Chlamydia is a sexually transmitted infection caused by the obligate intracellular bacterium *Chlamydia trachomatis*. This bacterium infects columnar epithelial cells, particularly in the genitourinary tract, often leading to asymptomatic infections or symptoms like urethritis and cervicitis. It is not a protozoal infection.
Choice C rationale
Trichomoniasis is a sexually transmitted infection caused by the anaerobic flagellated protozoan parasite *Trichomonas vaginalis*. This microorganism infects the urogenital tract, leading to vaginitis in females and urethritis in males, characterized by symptoms like itching, burning, and discharge.
Choice D rationale
Syphilis is a sexually transmitted infection caused by the spirochete bacterium *Treponema pallidum*. This bacterium can disseminate throughout the body, causing a multi-stage disease with diverse clinical manifestations affecting skin, mucous membranes, and internal organs. It is not caused by a protozoan.
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