A client with suicidal impulses is placed on the most stringent level of suicide precautions
The
measures the nurse caring for the client should incorporate into the plan of care include (more than
one answer may be correct)
A. maintaining arm-length, one-on-one nursing observation around the clock.
B. allowing no glass or metal on meal trays.
C. keeping client within visual range while he or she is awake. Check every 15 to 30 minutes while
the client is sleeping.
D. checking client whereabouts every 15 minutes and make frequent verbal contacts.
E. checking whereabouts every hour. Make verbal contact at least three times each shift.
F. removing all potentially harmful objects from the client's possession.
A, B, F
Rationale: One-on-one observation is necessary for anyone who has limited control over suicidal
impulses. Plastic dishes on trays and the removal of potentially harmful objects from the client's
possession are measures included in any level suicide precautions. The other options are seen in less
stringent levels of suicide precautions.
You might also like to view...
What characteristics would cause the manager to classify an employee as marginal? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. The employee works only when client census calls for additional staff. 2. The employee's work does not improve with coaching. 3. The employee just made an error for which discipline has already been done twice. 4. The employee has worked at the facility for less than 1 month. 5. The employee does not mix well with the other staff, but stays on the margins of the group.
Which statement is an example of the use of reflection?
a. "Tell me more about it." b. "It sounds as if you're angry that the pain has returned." c. "Did this pain occur after you ate lunch?" d. "Is this pain similar to, or different from, the pain you experienced before surgery?"
Your client can achieve complete range of motion of both elbows only as you support her joints and without applying manual resistance. How would you record her muscle strength?
a. 4/5, good c. 2/5, poor b. 3/5, fair d. 1/5, trace
What is the action of timolol maleate (Timoptic), a beta-adrenergic blocking agent?
a. Draws aqueous humor from the eye into the circulatory network b. Increases the production of aqueous humor c. Increases the outflow of aqueous humor d. Decreases the production of aqueous humor