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:

Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.

Choice B rationale:

Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.

Choice C rationale:

Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.

Choice D rationale:

Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.

A. Introduce the toddler to new situations slowly. B. Administer valproic acid to the toddler. C. Allow the toddler to choose the daily routine. D. Increase stimulation in the toddler's environment.

Correct Answer is A

Explanation

Choice A rationale:

Children with autism spectrum disorder often have difficulty with transitions and new situations. Introducing new situations slowly can help reduce anxiety and support a smoother adjustment.

Choice B rationale:

Administering valproic acid is not a nursing intervention for autism spectrum disorder.

Choice C rationale:

Allowing the toddler to choose the daily routine might not be effective as they may struggle with decision-making and may prefer structured routines.

Choice D rationale:

Increasing stimulation in the toddler's environment might overwhelm a child with autism, who often prefers a calm and predictable environment.

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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 caring for a client who is suspected to have developed sensitivity to latex. Which of the following interventions should the nurse plan to implement?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a toddler who has autism spectrum disorder. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

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