A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan?
Check on the client every 30 min while they are in their room.
Request that a family member bring personal hygiene items from home.
Provide the client with plastic eating utensils.
Keep the client’s door closed at night.
The Correct Answer is C
Choice A reason: Checking on the client every 30 minutes is not frequent enough for a client who has recently attempted suicide. Standard suicide precautions require continuous observation or checks every 15 minutes to ensure safety. Every 30 minutes leaves too much time for potential self-harm.
Choice B reason: Requesting family members to bring personal hygiene items from home is unsafe because these items may include sharp objects such as razors, scissors, or glass containers. Allowing unscreened items into the client’s environment increases the risk of self-harm.
Choice C reason: Providing plastic eating utensils is the correct intervention because it minimizes the risk of self-injury. Metal utensils can be broken or sharpened into dangerous objects, while plastic utensils are safer and reduce opportunities for harm. This intervention aligns with suicide precautions.
Choice D reason: Keeping the client’s door closed at night is unsafe because it prevents staff from easily observing the client. Doors should remain open or observation should be unobstructed to allow continuous monitoring and rapid intervention if needed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Fresh salmon is safe to consume while taking tranylcypromine. It does not contain high levels of tyramine, which is the substance that interacts dangerously with monoamine oxidase inhibitors (MAOIs) like tranylcypromine.
Choice B reason: Aged cheese is the correct answer because it contains high levels of tyramine. When combined with MAOIs, tyramine can precipitate a hypertensive crisis, which is life-threatening. This is why aged cheese and other tyramine-rich foods must be strictly avoided.
Choice C reason: Smoked meats also contain tyramine, but aged cheese is the most classic and well-documented food to avoid. Smoked meats are risky, but the priority teaching point is aged cheese.
Choice D reason: Red wine contains tyramine and can also interact with MAOIs, but again, aged cheese is the most direct and classic food to highlight in teaching.
Correct Answer is D
Explanation
Choice A reason: Verbalizing difficulty coping reflects ongoing distress rather than adherence. While expressing feelings is important, it does not demonstrate improvement or engagement with treatment goals.
Choice B reason: Frequently seeking reassurance indicates dependence and persistent insecurity. This behavior suggests limited progress in self-efficacy and coping skills, which are essential for adherence.
Choice C reason: Hygiene deficiencies are a hallmark of depressive symptoms and indicate poor functioning. This finding suggests the client is not adhering to treatment or is still severely impaired.
Choice D reason: Increased social engagement is a strong positive indicator of adherence. Clients with major depressive disorder often isolate themselves. Re-engaging socially demonstrates improved mood, motivation, and participation in therapeutic activities, all of which reflect adherence to the treatment plan.
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