A nurse is planning care for an adolescent who is
being admitted to an acute care unit following a suicide
attempt. Which of the following interventions should
the nurse identify as the priority?
1. Arrange one-to-one observation of the client
2. Encourage interaction with the client's peers
3. Administer medication for depressive disorder
4. Encourage the client to attend a support group -
....ANSWER...1. Arrange one-to-one observation of the
client
Rationale: The greatest risk to the client is self-injury.
Therefore, the priority nursing intervention is one-toone observation to promote client safety.
A nurse is caring for a client who gave birth to a
stillborn baby. Which of the following statements
should the nurse make?
1. "You probably want to hold your baby."
2. "I'll stay with you just in case you want to talk."
3. "I know how you must be feeling."
4. "It hurts now, but things will be better soon." -
....ANSWER...2. "I'll stay with you just in case you want
to talk."
Rationale: This response indicates the nurse's interest
in the client and a desire to understand the client's
feelings.
A nurse is providing teaching to a client who is to begin
undergoing light therapy at home to treat seasonal
affective disorder. Which of the following should the
nurse include in the teaching?
1. Have a family member present during treatment
2. Increase fluid intake
3. Change position slowly
4. Wear sunglasses when outdoors - ....ANSWER...4.
Wear sunglasses when outdoors.
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