which of the following interventions should be prioritized in the care of the suicidal client

NCLEX-RN

NCLEX RN Exam Review Answers

1. Which of the following interventions should be prioritized in the care of the suicidal client?

A. Remove all potentially harmful items from the client's room
B. Allow the client to express feelings of hopelessness
C. Note the client's capabilities to increase self esteem
D. Set a "no suicide"? contract with the client

Correct answer: A

Rationale: accessibility of the means of suicide increases the lethality. Allowing a patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients but not specifically for suicide.

2. How do technological advances relate to HIPAA?

A. Technology can expose us to HIPAA violations.
B. Computers facilitate information sharing.
C. Computer screens should be visible only to authorized personnel.
D. Technology enhances HIPAA confidentiality.

Correct answer: A

Rationale: Technology can expose us to HIPAA violations. For instance, leaving a computer screen unattended and visible to unauthorized individuals can result in breaches of patient confidentiality, leading to HIPAA violations. While computers can indeed aid in sharing information, this is not directly related to HIPAA compliance. Ensuring that computer screens are only visible to authorized personnel is a good practice, but it does not address the broader risks and challenges posed by technological advancements in maintaining HIPAA compliance. Therefore, the correct answer is that technology can expose us to HIPAA violations.

3. Which of the following is an example of libel?

A. A client overhears a nurse telling her assistant that he is 'too high maintenance.'
B. A client reads disparaging remarks that a nurse has written about him in his chart.
C. A nurse fails to notify a physician when a client's hemoglobin level is 8.1 gm/dL.
D. A nurse administers narcotic pain medication to a client in pain but does not have an order.

Correct answer: B

Rationale: Libel involves making defamatory statements against another person in written form. These statements can harm the person's reputation or feelings. In this scenario, the correct answer is when a client reads disparaging remarks that a nurse has written about him in his chart. This constitutes libel because the negative remarks are written down and can potentially damage the client's reputation. Choices A, C, and D do not involve libel. Choice A describes a verbal statement, not written, so it does not constitute libel. Choice C involves a failure to notify a physician, which is a different issue unrelated to libel. Choice D pertains to administering medication without an order, which is a matter of improper practice rather than libel.

4. A client on lithium has diarrhea and vomiting. What should the nurse do first?

A. Recognize this as a drug interaction
B. Give the client Cogentin
C. Reassure the client that these are common side effects of lithium therapy
D. Hold the next dose and obtain an order for a stat serum lithium level

Correct answer: D

Rationale: Diarrhea and vomiting are manifestations of lithium toxicity. The priority action for the nurse is to hold the next dose of lithium and obtain an order for a stat serum lithium level to confirm toxicity. This ensures patient safety and prevents further harm. Recognizing it as a drug interaction is not the first step in this scenario. Cogentin is used to manage extrapyramidal symptoms (EPS) associated with antipsychotics, not lithium toxicity. Reassuring the client about these symptoms as common side effects of lithium therapy is inappropriate as they indicate a more serious issue than typical side effects like hand tremors, nausea, polyuria, and polydipsia.

5. At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?

A. A diabetic client with a blood glucose level of 195 mg/dL
B. A family member of an elderly client who has questions
C. A client with COPD with an oxygen saturation of 84%
D. A client who requires assistance to use the bathroom

Correct answer: C

Rationale: When prioritizing the needs of clients, the nurse must begin with the unstable client or manage conditions that affect airway, breathing, or circulation first. The client with COPD has a condition that affects breathing and is exhibiting decreased oxygen saturation levels; therefore, this client should be the first priority. Option A, the diabetic client with a blood glucose level of 195 mg/dL, does not present an immediate threat to airway, breathing, or circulation. Option B, addressing questions from a family member, is important but can be addressed after addressing critical patient needs. Option D, assisting a client to use the bathroom, is a routine task that can be prioritized after addressing urgent medical needs.