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 D
Explanation
Choice A rationale
While clients with Cushing's syndrome may experience fatigue due to elevated cortisol levels affecting sleep patterns and muscle catabolism, clustering activities only in the morning may not adequately address the fluctuating energy levels or provide sufficient rest periods throughout the day. A more balanced approach involving rest periods and activity modification throughout the day is generally more beneficial.
Choice B rationale
Clients with Cushing's syndrome often experience fluid retention and edema due to the mineralocorticoid effects of excess cortisol. Therefore, increasing fluid intake would exacerbate fluid overload rather than alleviate symptoms. Fluid restriction and diuretic therapy may be necessary to manage fluid balance and prevent complications like hypertension and heart failure.
Choice C rationale
Cushing's syndrome is characterized by endogenous overproduction of cortisol, meaning the body already produces too much. Requesting a medical prescription for cortisol would further elevate cortisol levels, worsening the client's symptoms and potentially leading to adrenal crisis if exogenous cortisol is administered in addition to already elevated endogenous levels. Management focuses on reducing cortisol.
Choice D rationale
Assessing daily weights is crucial for clients with Cushing's syndrome due to the propensity for fluid retention and weight gain caused by increased mineralocorticoid activity of cortisol. Daily weights provide an objective measure of fluid balance and can indicate exacerbation or improvement of edema, helping guide interventions and monitor treatment effectiveness. Normal weight fluctuation should be within 1-2 kg in 24 hours.
Correct Answer is ["0.5"]
Explanation
Step 1 is to convert milligrams (mg) to micrograms (mcg). 0.05 mg × 1000 mcg/mg = 50 mcg.
Step 2 is to determine the number of tablets to administer. 25 mcg ÷ (50 mcg/tablet) = 0.5 tablets. The nurse would administer 0.5 tablets.
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