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.
Keep the client's door shut when they are in the room.
Observe the client's behavior every 2 hr.
The Correct Answer is A
The correct answer is A.
Ensure the client swallows each dose of medication. A client who recently attempted suicide is at high risk of another suicide attempt and needs closemonitoring and supervision. The nurse should ensure that the client swallows each dose of medication to prevent hoarding or overdosing on pills. The nurse should also remove any potential means of self-harm from the client's room, such as sharp objects, belts, cords, or cologne that contains alcohol. The nurse should keep the client's door open or use a window to observe them at all times, not just every 2 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.
Choice B reason
Shoulders is incorrect: The shoulders are not typically indicative of jaundice.
Choice C reason:
Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.
Choice D reason:
Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.
Correct Answer is C
Explanation
The correct answer is C. Paranoid schizophrenia is a type of schizophrenia that involves delusions of persecution or conspiracy. The nurse should use therapeutic communication techniquesto empathize with the client's feelings and encourage them to express their thoughts without challenging or reinforcing their delusions. Therefore, stating that this must be very frightening for them and inviting them to talk more about it is an appropriate response that can help reduce anxiety and build trust. The other statements are not helpful or may be harmful. Asking why or what questions may imply doubt or disbelief in the client'sreality and provoke defensiveness or hostility. Contradicting or correcting the client's delusions may also increase their suspicion and resistance to treatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today