Author Question: A client who has attempted suicide by overdosing with a very large number of antidepressant pills ... (Read 108 times)

jeatrice · **on:** Jul 22, 2018

A client who has attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. Which of the following is the priority nursing ac-tion at this time?

1. Stay with the client at all times.
2. Request that a friend of the client remain with the client at all times.
3. Have the client put on a hospital gown, and remove the client's clothing from the room.
4. Suggest placing the client in a seclusion room where all potentially dangerous articles have been removed.

Question 2

The nurse is preparing to care for a newborn infant following creation of a colostomy for the treatment of imperforate anus. In the immediate postoperative period, the nurse plans to inspect the stoma, knowing that it is expected to be:

1. Bleeding
2. Gray in color
3. Dark blue in color
4. Red and edematous

taylorsonier · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1

Rationale: The plan of care for a client with a serious suicide attempt must reflect action that will promote the client's safety. Constant observation status (one on one by the nurse) and never being less than an arm's length away are the best intervention. Have the client put on a hospital gown, and remove the client's clothing from the room and suggest placing the client in a se-clusion room where all potentially dangerous articles have been removed do not provide con-stant surveillance of the client. Request that a friend of the client remain with the client at all times places an unfair burden on the friend of the client, which is inappropriate.

Answer to Question 2

4

Rationale: A fresh colostomy stoma will be red and edematous, but this will decrease with time. The colostomy site will then be pink, without evidence of abnormal drainage, swelling, or skin breakdown. The colostomy should not be bleeding. A gray or dark blue stoma indicates insuffi-cient circulation and should be reported to the physician immediately.