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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

A positive Rheumatoid factor is associated with rheumatoid arthritis and is not an adverse effect of methotrexate.

Choice B rationale:

A low WBC count (leukopenia) is an adverse effect of methotrexate and can increase the risk of infection.

Choice C rationale:

A hemoglobin level of 14.8 g/dL is within a normal range and is not an adverse effect of methotrexate.

Choice D rationale:

An erythrocyte sedimentation rate (ESR) of 24 mm/hr is within a normal range and is not an adverse effect of methotrexate.

A. Monitor the client's blood pressure daily. B. Allow the client to exercise once per week. C. Encourage the client to participate in group activities. D. Provide the client with high-calorie finger foods.

Correct Answer is D

Explanation

Choice A rationale:

This is not a priority intervention for a client who is in the manic phase of bipolar disorder. The nurse should monitor the client's vital signs as indicated, but blood pressure is not likely to be affected by mania unless the client has a preexisting condition or is taking medications that affect blood pressure.

Choice B rationale:

This is not an appropriate intervention for a client who is in the manic phase of bipolar disorder. The nurse should not restrict the client's physical activity, as this can increase their frustration and agitation. The nurse should provide a safe environment for the client to expend their energy and channel it into productive activities.

Choice C rationale:

This is not a suitable intervention for a client who is in the manic phase of bipolar disorder. The nurse should avoid stimulating the client's already elevated mood and arousal, as this can worsen their symptoms and increase their risk of injury or aggression. The nurse should limit the client's exposure to noise, crowds, and bright lights, and provide them with opportunities for rest and quiet time.

Choice D rationale:

A client who is in the manic phase of bipolar disorder has increased energy, activity, and metabolism, which can lead to weight loss and nutritional deficiencies. The nurse should provide the client with high-calorie finger foods that are easy to eat and do not require utensils or sitting down. This way, the nurse can help the client meet their nutritional needs while respecting their need for movement and autonomy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring the laboratory values of a client who has rheumatoid arthritis and is taking methotrexate. Which of the following values should the nurse identify as an adverse effect of the medication?

Correct Answer is B

Explanation

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

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