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 D
Explanation
Choice A rationale:
Sildenafil is typically taken as needed, not twice per day.
Choice B rationale:
Constipation is not a common adverse effect of sildenafil.
Choice C rationale:
Changing positions slowly after taking the medication is not related to sildenafil's mechanism of action.
Choice D rationale:
Sildenafil is a medication used to treat erectile dysfunction. Temporary visual changes, often described as a blue-green tinge or increased light sensitivity, are potential side effects of sildenafil due to its effect on the retinal enzyme.
Correct Answer is C
Explanation
Choice A rationale:
Aphasia, or difficulty with language, is more commonly associated with left hemispheric stroke.
Choice B rationale:
Depression can be a common psychological reaction following stroke, but it is not a specific finding associated with right hemispheric stroke.
Choice C rationale:
Right hemispheric stroke can lead to loss of depth perception and spatial awareness due to its impact on the visual-spatial processing areas of the brain.
Choice D rationale:
Slow, cautious behavior is a common finding after stroke regardless of the affected hemisphere.
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