A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?
Ensure the client swallows each dose of medication.
Limit the personal toiletries in the client's room to cologne.
Observe the client's behavior every 2 hr.
Keep the client's door shut when they are in the room.
The Correct Answer is A
Rationale:
A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.
B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.
C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.
D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Playing music will increase my husband's alertness.": Music therapy is not primarily used to increase alertness in hospice clients. Soothing music may promote relaxation and even drowsiness, especially in clients receiving sedating medications for or end-of-life comfort.
B. "I will discontinue music therapy when my husband is no longer responsive": Music therapy can still provide comfort even when a client is unresponsive. Familiar or calming music may have soothing effects and contribute to emotional peace, making it appropriate throughout all stages of hospice care.
C. "My husband won't need medication for breakthrough pain while using music therapy.": Music therapy is a complementary technique, not a replacement for pharmacologic pain management. Clients may still require medications for breakthrough pain.
D. "Music will distract my husband's awareness of the pain.": Music therapy helps reduce the perception of pain by providing sensory distraction and promoting relaxation. This cognitive diversion is one of the key benefits of using music as part of holistic pain management in hospice care.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Rationale:
• Monitor fetal heart rate: Continuous monitoring is essential after epidural placement to detect changes in fetal status. Minimal variability and early decelerations could indicate emerging fetal distress. Early detection guides timely intervention.
• Assist with administration of ampicillin IV: The client is GBS positive and in active labor with ruptured membranes. IV antibiotics reduce the risk of neonatal infection. Prompt administration is key for prophylaxis.
• Request a prescription for ephedrine: Epidural anesthesia may cause maternal hypotension, which decreases placental perfusion. Ephedrine helps maintain blood pressure. This supports uteroplacental circulation and fetal oxygenation.
• Place the client in left lateral position: This improves uterine perfusion and helps relieve vena cava compression. It is especially important after epidural anesthesia. It also supports better fetal oxygenation during decelerations.
• Decrease the IV flow rate: IV fluids help counteract hypotension that may result from epidural use. Reducing the rate would worsen perfusion and blood pressure. This could compromise fetal oxygen delivery.
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