Nokea
A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?
- A. Place metal utensils on the client’s meal tray
- B. Assign the client to a private room
- C. Inspect the client's personal belongings
- D. Tuck bedcovers over the client’s hands and arms
Correct Answer: C
Rationale: The correct answer is C: Inspect the client's personal belongings. This action is crucial to ensure the safety of the client by identifying any potentially harmful items that could be used for another suicide attempt. Placing metal utensils (A) on the tray could pose a risk. Assigning to a private room (B) may isolate the client further. Tucking bedcovers (D) could restrict movement. Other choices are not relevant.
You may also like to solve these questions
A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make?
- A. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way."
- B. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable."
- C. "I’m sure your daughter’s diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment."
- D. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?"
Correct Answer: A
Rationale: Encouraging the parents to discuss their feelings helps with emotional processing and coping.
A nurse is providing discharge teaching for a client who has multiple medication prescriptions and must take the medications at specific intervals when at home. Which of the following instructions should the nurse include in the teaching?
- A. "You really shouldn't change the schedule we established here in the facility."
- B. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
- C. "I'll have to talk to your provider about switching to an alternative schedule."
- D. "It doesn't really matter what time you take your medications as long as you don't skip any doses."
Correct Answer: B
Rationale: The correct answer is B. By working together to devise a time schedule convenient for the client, the nurse ensures medication adherence. This approach promotes patient autonomy and empowerment, increasing the likelihood of compliance. Choice A is incorrect as it disregards the client's needs. Choice C involves unnecessary steps and may delay important changes. Choice D is incorrect as adherence to specific timing is crucial for some medications. Choices E, F, and G are omitted due to irrelevance.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
- A. Rapid speech
- B. Tics
- C. Distorted perceptual field
- D. Urinary frequency
Correct Answer: A, D
Rationale: Moderate anxiety is associated with physical restlessness, rapid speech, and increased urinary frequency.
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)
- A. Urinary retention and constipation
- B. Tongue thrusting and lip smacking
- C. Fine hand tremors and pill rolling
- D. Facial grimacing and eye blinking
- E. Involuntary pelvic rocking and hip thrusting movements
Correct Answer: B, D, E
Rationale: Tardive dyskinesia involves involuntary repetitive movements such as lip smacking, facial grimacing, and pelvic rocking.
A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statements should the nurse make?
- A. "I understand your grief. I lost a baby also."
- B. "You may hold your baby as long as you want."
- C. "I have called for the chaplain to come and stay with you."
- D. "This is for the best. Your baby was very ill."
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Offering the client the option to hold the stillborn baby allows for the initiation of the grieving process and provides closure. It shows empathy and respect for the client's loss, allowing them to spend time with their baby and say goodbye. This statement acknowledges the client's emotions and offers them control over their grieving process.
Summary of Incorrect Choices:
A: Sharing personal experiences may unintentionally minimize the client's grief and shift the focus away from them.
C: While spiritual support may be beneficial, it may not align with the client's beliefs or preferences.
D: Telling the client that the stillbirth is for the best may come off as insensitive and dismissive of their feelings, causing further distress.