When implementing nursing interventions for a client who has attempted suicide, which of the following is most important?

Not allowing the client to interact with other clients

Checking on the client every 4 hours

Setting clear boundaries and making sure the client abides by them

Providing a safe environment by removing items that could cause harm

Answer and Explanation

The Correct Answer is D

A.   While isolation may be necessary in certain situations to ensure safety, it is not the most critical
intervention. It’s essential to balance safety with providing the client with support and not making them feel isolated or abandoned. The primary focus should be on creating a safe environment and addressing the immediate risk of self-harm.
B.   Checking on the client every 4 hours may not be frequent enough for a client who is at risk of self- harm or suicide. More frequent monitoring is typically required, especially if the client is deemed at high risk. Immediate and continuous observation is often necessary to prevent further attempts.
C.   While setting boundaries is important for therapeutic interactions, it is secondary to addressing immediate safety concerns. The primary focus should be on preventing self-harm and ensuring a safe environment rather than just enforcing rules.
D.   Providing a safe environment by removing items that could cause harm is the most crucial intervention for a client who has attempted suicide. This step directly addresses the risk of self-harm and helps prevent further suicide attempts. Creating a safe environment is a fundamental aspect of suicide prevention and immediate care.

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Correct Answer is A

Explanation

A. This maneuver is intended to engage other muscle groups and increase overall muscle tone. It can help facilitate the patellar reflex by increasing muscle tension and sensitivity. This technique can enhance the reflex response by engaging the client in a physical action that might make the reflex more pronounced.
B. Squeezing the thigh might create discomfort or involuntary muscle contraction, which could interfere with the reflex response. It is not a recommended technique for eliciting the patellar reflex and may not have a significant effect on reflex assessment.
C. Stretching the arms over the head does not directly influence the patellar reflex. Reflexes are typically assessed in a relaxed state, and this action might not be relevant for improving the patellar reflex response.
D. Clenching the jaw might increase overall muscle tone temporarily, but it does not directly impact the patellar reflex. This technique is less likely to influence the patellar reflex compared to techniques that engage lower body muscle groups.

A. CNV B. CNX C. CNIX D. CN VII

Correct Answer is C

Explanation

A. The trigeminal nerve (CN V) is primarily responsible for sensory information from the face and motor control of the muscles of mastication (chewing). It does not carry taste sensations. Instead, it is involved in sensation (e.g., touch, pain, temperature) of the face and mouth, but not taste.
B. The vagus nerve (CN X) has various functions, including parasympathetic control of the heart, lungs, and digestive tract, and sensory and motor functions in the throat and voice box. It does contribute to taste sensation in the region of the pharynx and the epiglottis, but it is not primarily responsible for the taste sensation on the posterior third of the tongue.
C. The glossopharyngeal nerve (CN IX) is responsible for taste sensation on the posterior one-third of the tongue. It also contributes to the sensory innervation of the pharynx and helps in the regulation of saliva production. This nerve is specifically involved in the taste perception in the back third of the tongue.
D. The facial nerve (CN VII) provides taste sensation to the anterior two-thirds of the tongue. It also controls the muscles of facial expression and contributes to the production of saliva and tears. The facial nerve does not provide taste sensation to the posterior third of the tongue.

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When implementing nursing interventions for a client who has attempted suicide, which of the following is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?

Correct Answer is A

Explanation

Taste in the 1/3 posterior of your tongue is given by:

Correct Answer is C

Explanation

When preparing to test a client for meningeal irritation, what would the nurse do first?

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