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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Clients admitted involuntarily still retain the right to refuse medications unless a court order or emergency situation overrides this right. This statement is incorrect.
Choice B reason: Involuntary admission does not automatically mean a client is incompetent. Competency must be legally determined by a court, not assumed based on admission status.
Choice C reason: Restraints cannot be prescribed on an as-needed basis. They require a specific, time-limited order and must be used only when absolutely necessary to protect the client or others.
Choice D reason: Providers have a duty to warn identifiable individuals if a client makes a credible threat of serious harm. This is a legal and ethical responsibility to protect others from danger, making this the correct statement.
Correct Answer is B
Explanation
Choice A reason: Lanugo is a fine, downy hair that develops on the body as a compensatory mechanism in clients with anorexia nervosa due to severe malnutrition and low body fat. It is not typically associated with bulimia nervosa, since bulimia involves recurrent binge eating followed by compensatory behaviors such as vomiting or laxative use, but does not usually result in the same degree of starvation seen in anorexia.
Choice B reason: Dental caries are expected in bulimia nervosa because repeated self-induced vomiting exposes teeth to gastric acid. This acid erodes enamel, leading to tooth decay, sensitivity, and caries. This is a hallmark physical finding in bulimia and directly reflects the purging behavior characteristic of the disorder.
Choice C reason: Cold extremities are more commonly associated with anorexia nervosa due to severe malnutrition, hypothermia, and poor circulation from low body fat. Clients with bulimia nervosa may have normal weight or even be overweight, so cold extremities are not a typical finding.
Choice D reason: Amenorrhea is more characteristic of anorexia nervosa due to extreme caloric restriction and low body fat, which disrupts hormonal regulation of the menstrual cycle. While menstrual irregularities can occur in bulimia nervosa, amenorrhea is not a defining or expected finding.
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