A nurse is preparing the environment for a newly admitted client with a documented history of self-injurious behaviors (SIBs) in a secure inpatient mental health unit. Which of the following environmental modifications is most essential in reducing the client’s risk of harm?
Providing the client with padded clothing and shoes to minimize injury during agitation.
Removing all bedside tables from the client’s room to eliminate surfaces for self-injury.
Allowing the client controlled access to personal electronic devices for distraction.
Ensuring that all sharp objects and breakable items are securely removed from the client’s environment.
The Correct Answer is D
Choice A reason: Padded clothing and shoes may reduce injury during agitation but do not address the broader risk of self-harm using sharp or breakable objects. This is not the most essential intervention.
Choice B reason: Removing bedside tables eliminates one potential surface for injury but does not comprehensively address the risk posed by sharp or breakable items. It is too limited in scope.
Choice C reason: Allowing controlled access to electronic devices may provide distraction but does not directly reduce risk of harm. Safety must be prioritized before therapeutic engagement.
Choice D reason: Removing sharp and breakable items is the most essential environmental modification. These objects pose the greatest risk for self-injury, and their removal directly reduces the client’s ability to harm themselves. This is the most comprehensive and immediate safety measure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Expressing anticipation of seeing grandchildren indicates future orientation and hope, which are protective factors against suicide.
Choice B reason: Giving away possessions is a classic warning sign of suicidal intent. It suggests the client is preparing for death and making arrangements, which is a continuation of suicidal ideation.
Choice C reason: Walking and engaging in healthy coping strategies indicates improvement and reduced suicidal risk.
Choice D reason: Commitment to abstaining from alcohol reflects positive behavioral change and does not indicate suicidal ideation.
Correct Answer is B
Explanation
Choice A reason: Bradycardia is not a common side effect of risperidone. Antipsychotics more often cause tachycardia or orthostatic hypotension.
Choice B reason: Weight gain is a well-documented side effect of risperidone due to metabolic changes, increased appetite, and alterations in glucose and lipid metabolism. Monitoring weight and metabolic parameters is essential.
Choice C reason: Dependent edema is not a typical side effect of risperidone. While fluid retention can occur with some medications, it is not a primary concern with this drug.
Choice D reason: Nightmares are not a common adverse effect of risperidone. Sleep disturbances may occur, but weight gain is the most expected finding.
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