The nurse is teaching a community group about nerve agents.
The nurse evaluates that the teaching has been effective when the participants state:

Choice A rationale

Allowing a client at risk for suicide to nap with the door closed poses a significant safety concern. This practice eliminates direct visual observation, which is paramount in suicide prevention. The closed door creates an opportunity for the client to engage in self-harm behaviors unobserved, increasing the risk of a successful suicide attempt by removing immediate intervention capabilities.

Choice B rationale

While distraction can be therapeutic, allowing a client on suicide precautions to engage in crafts in their room unobserved introduces potential risks. Craft materials, if not carefully monitored and selected, could be used as instruments for self-harm. Maintaining constant, direct observation, even during seemingly benign activities, is crucial to prevent access to means for suicide.

Choice C rationale

Providing headphones for relaxing music, while potentially calming, can compromise auditory monitoring of a client on suicide precautions. The headphones can obscure sounds that might indicate distress, agitation, or self-harm attempts. Direct sensory observation, including listening for abnormal sounds, is a critical component of ensuring continuous safety and prompt intervention.

Choice D rationale

Rounding and visualizing the client every 15 minutes is a fundamental suicide precaution intervention. This frequent, direct observation allows for continuous assessment of the client's behavior, mood, and immediate environment. It minimizes opportunities for self-harm by providing consistent monitoring and enables timely intervention if any concerning signs or actions are detected, ensuring client safety.

Choice A rationale

Climbing stairs does not typically lead to an increase in intracranial pressure (ICP) or disrupt the surgical site following transsphenoidal hypophysectomy. Post-operative care focuses on preventing activities that strain the surgical area or elevate ICP, which could compromise healing or lead to cerebrospinal fluid (CSF) leakage. Therefore, this activity is generally not restricted.

Choice B rationale

Heavy lifting significantly increases intra-abdominal and intrathoracic pressure, which directly translates to increased intracranial pressure. This elevation in ICP can disrupt the fragile surgical site in the sphenoid sinus, leading to complications such as cerebrospinal fluid (CSF) leakage or hemorrhage, thereby impeding proper healing and recovery.

Choice C rationale

Sexual intercourse can lead to increased exertion and potential Valsalva maneuvers, which temporarily elevate intracranial pressure. While not as consistently impactful as heavy lifting, the potential for increased pressure and strain on the healing surgical site warrants restriction to minimize the risk of complications such as cerebrospinal fluid leakage.

Choice D rationale

Breathing exercises, such as deep breathing and incentive spirometry, are crucial post-operatively to prevent pulmonary complications like atelectasis and pneumonia. These exercises do not increase intracranial pressure or strain the surgical site; instead, they promote lung expansion and optimize oxygenation, aiding in overall recovery.