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 A
No explanation
Correct Answer is C
Explanation
Choice A rationale:
Placing the client on a low-protein diet is not appropriate based solely on the provided information.
Choice B rationale:
Restricting dietary sodium might be considered for specific conditions but is not directly related to the client's confusion.
Choice C rationale:
A high magnesium level can contribute to confusion in older adults. Requesting a reduction in the magnesium hydroxide dosage can help address this issue.
Choice D rationale:
Discontinuing diphenhydramine might be considered if it is contributing to the client's confusion, but there is no specific information provided to support this action.
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