A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan?
(ANS - Provide the client with plastic eating utensils.
-The client can us
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A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan?
(ANS - Provide the client with plastic eating utensils.
-The client can use glass dishes and metal silverware to cause self harm, therefore, the nurse should arrange for the client to have only plastic products on their meal tray.
A nurse is performing an admission assessment for a client who appears withdrawn and fearful. Which of the following actions should the nurse take first?
(ANS - Inform the client that this admission is confidential.
-According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse client relationship. This action establishes trust between the client and the nurse, which in turn decreases the client's anxiety level.
A nurse is caring for an adolescent client who has anorexia nervosa. The client states, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make?
(ANS - You're afraid you have caused physical injury to yourself?
-Repeating the main idea of what the client has said, which will allow for clarification of any misunderstanding on the part of the client or the nurse.
A nurse is caring for a client following a fire that destroyed her home and killed one of her children. The client is crying and does not make eye contact with the nurse. Which of the following questions should the nurse ask first?
(ANS - Have you thought of harming yourself?
-The greatest risk to this client is self harm due to the loss of her child and home, therefore, the first question the nurse should ask a client who is having a personal crisis is to determine if the client has suicidal ideation. If so, the nurse should take action to protect the client from self harm.
A nurse is checking laboratory values for a hospitalized young adult client who has bipolar disorder and is taking lithium. Which of the following values is the priority for the nurse to report to the provider?
(ANS - Serum creatinine 2.1 mg/dL
-Reference range of 0.5-1.2 mg/dL.
The greatest risk to this client is decreased kidney function, which can cause an increase in the client's lithium level; therefore, this value is the priority for the nurse to report to the provider. The clients lithium dosage might need to be modified based on this lab value. The cause of increased serum creatinine include dehydration as well as renal disorders. Lithium is contraindicated for clients who have severe renal disease, cardiac disease, or severe dehydration.
A nurse is providing information to a client who is seeking voluntary admission to a mental health facility. Which of the following information should the nurse include?
(ANS - You will still need to give informed consent for treatment after admission.
-A client who seeks voluntary admission to a mental health facility has the same rights as clients receiving any other kind of health care. The client will still need to give informed consent for treatment and therapies, such as electroconvulsive therapy.
A nurse is developing a plan of care for an adolescent client who has conduct disorder. Which of the following interventions should the nurse include in the plan?
(ANS - Initiate a behavioral contract with the client.
-A client who has conduct disorder can demonstrate patterns of behavior that are aggressive, disrespectful of others rights, and can lead to injury of others. A behavioral contract helps to develop trust between the client and the nurse and emphasizes the client's responsibility to commit to work on changes in behavior.
A hospice nurse is talking with the family of a client who recently died from cancer following a series of chemotherapy treatment. One of the adult children is angry with the provider and blames the provider for their father's death. Which of the following defense mechanisms is the family member using?
(ANS - Displacement
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