The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
While completing a thorough room search to remove potential self-harming objects is important, it should follow the immediate need for monitoring and intervention.

Choice B rationale:
Providing time alone in the client's room may not be appropriate when the client is exhibiting signs of distress and increased risk.

Choice C rationale:
Closely monitoring the client and having staff intervene as needed (Choice C) is the most important intervention in this situation. Clients with a history of self-mutilation who display signs of increased tension and agitation may be at higher risk for engaging in self-harming behaviors. Close observation and intervention can help prevent self-harm and ensure the client's safety.

Choice D rationale:
Giving firm, consistent expectations is important in the overall care plan but may not be effective in acute situations where immediate monitoring and intervention are required.

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Correct Answer is B

Explanation

Choice A rationale:
Applying prescribed lotions to the radiation site is generally a recommended part of skin care during radiation therapy, as it helps keep the skin moisturized and reduces irritation.

Choice B rationale:
Washing the radiation site with antibacterial soap and water is not recommended. Clients undergoing radiation therapy are typically advised to use gentle, mild soaps and to avoid scrubbing or using harsh cleansers on the treated area. Antibacterial soap may be too harsh and could lead to skin irritation.

Choice C rationale:
Wearing clothing to cover the radiation site is a good practice to protect the area from sun exposure and potential irritation.

Choice D rationale:
Drying the area with patting motions after taking a shower is the correct way to dry the radiation site, as it minimizes friction and reduces the risk of skin damage.

A. Vomiting, seizures, and loss of consciousness. B. Agitation, sweating, and abdominal cramps. C. Depression, fatigue, and dizziness. D. Hypotension, shallow respirations, and dilated pupils.

Correct Answer is B

Explanation

Choice A rationale:
Vomiting, seizures, and loss of consciousness are more severe symptoms that are not typically associated with narcotic withdrawal but could indicate other medical issues.

Choice B rationale:
Agitation, sweating, and abdominal cramps are indicative of narcotic withdrawal. These symptoms are commonly associated with opioid withdrawal, especially when there are needle marks on the client's arms, which may suggest a history of opioid use. Opioid withdrawal symptoms can include restlessness, sweating, and gastrointestinal discomfort, such as abdominal cramps. Therefore, these findings should be documented and reported for further assessment and appropriate intervention related to narcotic withdrawal.

Choice C rationale:
Depression, fatigue, and dizziness are not specific to narcotic withdrawal and could be related to various conditions.

Choice D rationale:
Hypotension, shallow respirations, and dilated pupils may suggest opioid overdose rather than withdrawal.

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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