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The nurse is preparing to implement suicide precautions for an acutely suicidal client. Which nursing interventions are included with regard to these precautions?
- A. Maintain arm's length distance with the client at all times.
- B. Ensure that meal trays contain no glass or metal silverware.
- C. Carefully watch the client swallow each dose of medication.
- D. Conduct one-on-one nursing observation and interaction 24 hours a day.
- E. Document client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol.
- F. Allow the client to totally cover self with the bedcovers during sleep at night as long as the nurse is present.
Correct Answer: A,B,C,D,E
Rationale: Suicide precautions involve constant observation of the client by the nursing staff. This intense attention from the nurse provides for safety and also allows for constant reassessment of risk. Suicide precautions include maintaining arm's length distance with the client at all times; ensuring that meal trays contain no glass or metal silverware; carefully watching the client swallow each dose of medication; conducting one-on-one nursing observation and interaction 24 hours a day and explaining to the client the procedures involved with suicide precautions; and documenting client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol. During observation when the client is sleeping, the client's hands should always be in view and not under the bedcovers.
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When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?
- A. Check the bath water temperature.
- B. Shut the bathroom door.
- C. Ensure that the client has voided.
- D. Provide extra towels.
Correct Answer: A
Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option B), confirming that the client has voided (option C), and providing extra towels (option D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing. Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?
- A. The occurrence of any episodes of sleep apnea
- B. The child's blood pressure, pulse, and respirations
- C. Length of rapid eye movement (REM) sleep that the child is experiencing
- D. Description of the family's home environment
Correct Answer: D
Rationale: When a school-age child has difficulty going to sleep and waking up in the morning, it is important to assess the family's home environment. This includes factors such as bedtime rituals, noise levels, lighting, use of electronic devices, and overall sleep hygiene practices. Understanding the home environment can help identify issues that may be contributing to the child's sleep problems and guide the development of a plan to promote better sleep habits. Options A, B, and C are less relevant in this scenario. Sleep apnea typically causes daytime fatigue rather than resistance to bedtime. Assessing vital signs like blood pressure, pulse, and respirations is unlikely to provide insights into the child's sleep patterns. Monitoring REM sleep duration is not practical in a clinical setting and may not directly address the reported sleep issues in this case.
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?
- A. Left brachial vein
- B. Right cephalic vein
- C. Dorsal side of the right wrist
- D. Right upper extremity
Correct Answer: B
Rationale: The correct answer is the right cephalic vein. The cephalic vein is a large and superficial vein commonly used for IV access. Documenting the specific anatomic name of the vein used for IV access, such as the cephalic vein, is essential for accurate medical records. Option A, the left brachial vein, is incorrect as the brachial vein is too deep to be accessed for IV infusion. Option C, the dorsal side of the right wrist, is not a recommended IV access site due to fragile veins and potential pain for the patient. Option D, right upper extremity, is too broad and lacks the specificity necessary for precise documentation of the IV access site.
The home care nurse visits a client who is receiving total parenteral nutrition, and the client states, 'I really miss eating dinner with my family.' Which statement from the nurse is the most therapeutic?
- A. What you are feeling is very common.'
- B. Tell me more about your family dinners.'
- C. In a few weeks, you may be allowed to eat.'
- D. You can sit down to dinner even if you do not eat.'
Correct Answer: B
Rationale: The nurse assists the client with expressing feelings and dealing with the aspects of illness and treatment by clarifying and helping the client to focus on and explore concerns. In option 1, the nurse characterizes and classifies the feelings on the basis of an assumption. Option 3 provides false hope and option 4 blocks communication by giving advice.
Which of the following mental health situations is considered a psychiatric emergency?
- A. Seasonal Affective Disorder (SAD)
- B. Depression with melancholic features
- C. Major depressive episode with psychotic features
- D. Bipolar depression
Correct Answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SAD) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.