A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

Limit the personal toiletries in the client's room to cologne.

Observe the client's behavior every 2 hr.

Ensure the client swallows each dose of medication.

Keep the client's door shut when they are in the room.

Answer and Explanation

The Correct Answer is C

Care planning for a client who has recently attempted suicide requires strict safety precautions to prevent self-harm and ensure continuous monitoring of behaviors that may indicate renewed suicidal intent. In the acute phase of stabilization, interventions focus on environmental safety, close observation, and prevention of access to potential means of self-injury. Clients are considered high risk for repeat attempts, especially during early hospitalization when impulsivity and hopelessness may persist. Nursing priorities emphasize constant safety surveillance and controlled medication administration.

Rationale:
A. Limiting personal toiletries to cologne is inappropriate because cologne is alcohol-based and not a safety-focused restriction. In suicide precautions, the goal is to remove or strictly control all potentially harmful items, not selectively allow non-essential personal products. Safety measures should focus on eliminating objects that could be used for self-harm rather than permitting cosmetic items.

B. Observing the client every 2 hours is insufficient for a post–suicide attempt client who requires much closer supervision. Standard care typically involves continuous observation or frequent checks such as 1:1 supervision depending on risk level. Infrequent monitoring increases the risk of unnoticed self-harm behavior.

C. Ensuring the client swallows each dose of medication is essential because clients at risk for suicide may hoard or conceal medications for potential overdose. Direct observation of medication ingestion reduces the risk of accumulation and misuse. This is a key component of safety management in clients with recent suicidal behavior and aligns with precautions for Suicidal behavior disorder.

D. Keeping the client’s door shut when they are in the room reduces visibility and limits rapid observation by staff. Suicide precautions require increased visibility, often with open doors or direct line-of-sight monitoring. A closed door may delay recognition of self-harm behaviors and compromise patient safety.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Monitoring response to iron therapy in a toddler with iron deficiency anemia involves evaluating hematologic improvement and expected physiologic effects of iron supplementation. Oral iron preparations such as Ferrous sulfate are used to restore iron stores and support hemoglobin synthesis. As iron levels normalize, expected therapeutic effects include improved oxygen-carrying capacity and characteristic benign gastrointestinal changes. Nurses must distinguish therapeutic effects from signs of worsening anemia or adverse reactions.

Rationale:
A. Weight loss indicates worsening nutritional status and is not an expected outcome of effective iron therapy. In iron deficiency anemia, effective treatment should support improved energy levels, appetite, and overall growth in toddlers. Continued or worsening weight loss suggests inadequate treatment response or ongoing underlying nutritional deficiency.

B. Decreased hemoglobin reflects worsening anemia rather than improvement. Effective iron therapy should result in rising hemoglobin levels as iron is incorporated into hemoglobin molecules. A decline indicates treatment failure, poor absorption, nonadherence, or ongoing blood loss.

C. Pica, the ingestion of non-food substances, is commonly associated with iron deficiency anemia and should decrease with effective treatment. Persistence of pica suggests ongoing iron deficiency and inadequate therapeutic response. Therefore, its presence does not indicate medication effectiveness.

D. Tarry, green stools are a common and expected side effect of oral iron therapy and indicate that iron is being ingested and excreted appropriately. These stool changes occur due to unabsorbed iron and oxidation processes in the gastrointestinal tract. In the context of treatment with Ferrous sulfate, this finding supports that the medication is being taken and processed, and is consistent with therapeutic use rather than harm.

A. Tachycardia B. Elevated temperature C. Cramping D. Seizures

Correct Answer is D

Explanation

Acute alcohol withdrawal occurs when a client with chronic alcohol use abruptly reduces or stops alcohol intake, leading to central nervous system hyperactivity. Manifestations can range from mild tremors and anxiety to severe complications such as delirium tremens and seizures. Nursing priorities focus on identifying life-threatening complications early, maintaining airway and safety, and preventing neurologic deterioration. Seizures are especially concerning because they can rapidly progress to respiratory compromise, aspiration, or injury.

Rationale:
A. Tachycardia is a common finding during alcohol withdrawal due to autonomic nervous system stimulation. Although it indicates physiologic stress and may require monitoring, it is not the highest priority finding. It does not pose the same immediate risk to life as neurologic complications such as seizures.

B. Elevated temperature can occur during severe withdrawal and may suggest autonomic instability or developing delirium tremens. While fever requires assessment and intervention, it is not as immediately life-threatening as seizure activity. Priority is given to findings that threaten airway, breathing, or circulation first.

C. Cramping may occur as part of generalized discomfort or electrolyte imbalance during withdrawal, but it is not considered a critical complication. Muscle cramps do not pose an immediate risk of injury or cardiopulmonary compromise compared with severe neurologic manifestations.

D. Seizures are the priority because they are a potentially life-threatening complication of Alcohol withdrawal syndrome. Withdrawal seizures can lead to aspiration, trauma, hypoxia, and progression to status epilepticus. Immediate intervention and close monitoring are necessary to protect airway and prevent serious complications.

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A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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