Nokea
Which nursing consideration is most important when administering medications to a suicidal client?
- A. Do not leave any syringe unattended.
- B. Watch the client place all pills in the mouth.
- C. View the inside of the mouth to make sure that all medications are swallowed.
- D. Remove all medications and medication administration equipment from client area.
Correct Answer: C
Rationale: It is most important for the nurse to view the inside of the mouth when administering medications. This is done by inspecting the client's mouth and under the tongue because clients may 'cheek' medications to stockpile and use the medications. Not leaving syringes unattended, watching the client place the pills in their mouth, and removing all medications and equipment are all appropriate nursing actions, but the most important is not allowing the opportunity for the client to overdose on medications.
You may also like to solve these questions
The nurse is caring for an older adult client diagnosed with bipolar disorder. Which manifestation of the disease can the nurse anticipate?
- A. The disease remits as the client ages.
- B. The disease increases as the client ages.
- C. The depression increases as the client ages.
- D. The manic phase increases as the client ages.
Correct Answer: C
Rationale: Older adult clients with bipolar disorder typically experience depressive episodes that increase in frequency and last longer. The increase for functional decline occurs, which may necessitate further care.
The nurse is caring for a client who has selected transcranial magnetic stimulation to treat depression. For which side effect would the nurse provide preprocedural instructions?
- A. Headache
- B. Blurred vision
- C. Hearing loss
- D. Vertigo
Correct Answer: A
Rationale: The most frequent side effect following transcranial magnetic stimulation to treat depression is headache. Preprocedural instruction would include the most common symptom (headache) and interventions (pain management). Blurred vision, hearing loss, and vertigo are not common side effects.
The nurse is admitting a client to a mental health clinic following a recent suicide attempt and hospitalization. In assessing the client's status, which question is most helpful?
- A. How are you currently feeling?
- B. What made you decide to commit suicide?
- C. Do you have a suicide plan or thoughts of harming yourself?
- D. What method did you choose for your suicide attempt?
Correct Answer: C
Rationale: In assessing the client's status, it is best to evaluate suicide risk factors. A client who is at the highest risk for suicide is the client who verbalizes a desire to end life and has a plan. The other questions are relevant but not the best question for gaining essential information.
Which of the following nursing instructions is most helpful to a client experiencing mild seasonal affective disorder symptoms?
- A. Use sunglasses when exposed to sunlight.
- B. Install skylights.
- C. Sleep in a darkened room.
- D. Stay indoors during the winter time.
Correct Answer: B
Rationale: Mild seasonal affective disorder symptoms can be improved by exposing the client to more sunlight. Sunlight stimulates the pineal gland, which releases serotonin. By installing skylights, natural sunlight can enter a room. Using sunglasses, sleeping in a darkened room, and staying indoors limit sunlight exposure.
The nurse is caring for a client diagnosed with seasonal affective disorder (SAD). When caring for the client, at which time of the year does the nurse limit nursing interventions due to an uplifting of mood?
- A. September/October
- B. February/March
- C. April/May
- D. December/January
Correct Answer: C
Rationale: Clients experience an uplifting of mood during the springtime in the months of April/May. During this time, daylight becomes longer. As the mood improves, fewer nursing interventions including phototherapy are needed. As days shorten in fall, the client's mood may begin to worsen until it reaches its lowest point in the dark winter months.