A patient is admitted with the diagnosis of a gunshot wound to the head due to a suicide attempt. While in the patient care unit, the plan of care should include which intervention?
Overlooking the patient's need to talk about the incident
Discontinuing any psychotropic medications
Validating the patient's worth and self-esteem
Limiting interaction with the patient due to antisocial behaviors exhibited by the suicide attempt
The Correct Answer is C
A. Overlooking the patient's need to talk is incorrect because ignoring their emotional distress may increase feelings of isolation and hopelessness.
B. Discontinuing psychotropic medications is incorrect as these medications may be essential in stabilizing mood and preventing further self-harm.
C. Validating the patient's worth and self-esteem is correct as it helps promote a sense of value, belonging, and hope, which are crucial in suicide prevention and recovery.
D. Limiting interaction with the patient is incorrect because social isolation can worsen depression and increase the risk of further self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The Code of Ethics for Nurses offers broad ethical guidelines, but it does not provide specific clinical practice guidelines.
B. The Code does touch on social justice issues, but it is not primarily focused on critiquing societal oppression or domination.
C. While the Code supports good care, it is more about establishing ethical standards rather than providing direct care guidelines.
D. The Code expresses nursing's commitment to society, outlining the profession's ethical standards and obligations toward patients and society as a whole.
Correct Answer is D
Explanation
A. Auscultating the right upper quadrant of the abdomen while injecting air into the tube is an outdated and unreliable method for confirming tube placement. This technique can lead to false positives and is not recommended.
B. Obtaining radiography of the abdomen is a highly accurate method for confirming nasogastric tube placement but is not always the first-line method due to the need for imaging and exposure to radiation. However, it may be used if other methods are uncertain.
C. Auscultating the left upper quadrant of the abdomen while injecting air into the tube is another outdated and unreliable method, similar to auscultating the right upper quadrant.
D. Checking the pH of fluid aspirated from the tube is the most accurate and recommended method. Gastric fluid typically has a pH of 1.5 to 3.5, whereas respiratory or intestinal fluids have higher pH levels. Checking the pH is a simple and reliable way to confirm the placement of the nasogastric tube.
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