HESI COMPREHENSIVE B REVIEW FOR THE NCLEX-RN® EXAMINATION, 7TH EDITION 2024

A client is admitted to a mental health unit because of mild depression. When asked, the client denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which nursing action is most important for this client? Correct Answer A Orient the client to activities on the unit. B Document suicide precautions on the shift report. C Assign the client to a semiprivate room. D Obtain a verbal no-suicide contract with the client. Rationale: It is most important to prevent the risk of self-harm from social isolation, so the client should be assigned to a semiprivate room. Option A does not have the priority of option C. Options B and D can be implemented if the client admits suicidal ideation. However, based on the fact that this client is mildly depressed and that he attempted suicide 5 years ago using a method that is usually nonlethal (aspirin overdose), it is most important to prevent social isolation. The nurse is providing care to a client who is unresponsive and has curled into the fetal position at the bottom of the bed. The nurse plans on moving the client to a side-lying position, supported by pillows. What will the nurse include in the plan to reposition the client? (Select all that apply.) Correct Answers A Obtain the assistance of at least two others to assist with the transfer. B When lifting the client, stand with feet wide apart. C Coordinate responsibilities with the transfer team. D Count to three and then initiate the transfer. E Ask the client if it is okay to transfer to a side-lying position. Rationale: Providing ergonomic care is essential to the safety of the healthcare staff. All selections but E are incl