A nurse on a mental health unit is admitting a client following a suicide attempt. Which of the following actions is the nurse's priority?
Establish a therapeutic relationship with the client.
Instruct the client on stress management techniques.
Have the client sign a no-suicide contract.
Maintain constant observation of the client.
The Correct Answer is D
Choice A rationale:
Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.
Choice B rationale:
Instructing the client on stress management techniques is important, but safety comes first.
Choice C rationale:
Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.
Choice D rationale:
Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Developing influenza after receiving the vaccine the previous year is not a contraindication for receiving the vaccine this year. In fact, the vaccine is recommended annually.
Choice B rationale:
Hypertension is not a contraindication for receiving the influenza vaccine.
Choice C rationale:
Clients with a history of Guillain-Barré syndrome should generally avoid receiving the influenza vaccine due to a potential increased risk of recurrence of the syndrome.
Choice D rationale:
Allergies to dairy products are not a contraindication for receiving the influenza vaccine.
Correct Answer is A
Explanation
Choice A rationale:
Low dietary intake of fiber is a significant risk factor for diverticular disease. A diet low in fiber can lead to constipation and increased pressure in the colon, contributing to the formation of diverticula.
Choice B rationale:
Prolonged use of steroids is not a primary risk factor for diverticular disease.
Choice C rationale:
Insufficient intake of protein is not a significant risk factor for diverticular disease.
Choice D rationale:
Family history of gallbladder disease is not directly associated with an increased risk of diverticular disease.
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