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 A
Explanation
Rationale:
A. Place a towel in the sink when cleaning the dentures: Lining the sink with a towel or filling it partially with water provides a cushion to prevent the dentures from breaking if accidentally dropped during cleaning. This is a key safety step in proper denture care.
B. Remove the lower dentures before the upper dentures: Upper dentures should be removed first because they are usually looser and easier to dislodge. Removing the lower dentures first increases the risk of damaging the upper set or causing discomfort to the client.
C. Store the dentures in a dry denture cup on the bedside table after cleaning: Dentures should always be stored in water or a denture-cleaning solution when not in use to prevent warping. Leaving them dry can cause them to crack, lose their shape and may increase contamination risk.
D. Use a circular motion to cleanse the biting surface of the dentures: Denture cleaning requires gentle scrubbing using vertical or back-and-forth strokes rather than circular motions, to effectively remove debris and avoid damaging the prosthetic structure.
Correct Answer is A
Explanation
Rationale:
A. Home telephone number: A home telephone number is an acceptable second client identifier under The Joint Commission's guidelines, as it is specific to the individual and can help prevent medication errors when used alongside another unique identifier.
B. Medical diagnosis: A medical diagnosis is not a unique identifier and may be shared by multiple clients in the same facility. It does not provide adequate confirmation of a client's individual identity.
C. Date of admission: Admission dates are not unique and may be the same for several clients. This information is insufficient as a reliable identifier for ensuring safe medication administration.
D. Facility room number: Room numbers can change during hospitalization and are not considered safe identifiers. Clients may be transferred, making room number an unreliable and non-permanent method of identification.
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