A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?

"Do you have thoughts of suicide?"

"Tell me why you hurt yourself."

"Who can we call to support you?"

"What coping methods help you when you feel bad?"

Answer and Explanation

The Correct Answer is A

Initial assessment of a client with self-inflicted injuries requires immediate evaluation of safety and risk for further harm. Clients who engage in self-harm behaviors are at increased risk for suicidal ideation and suicide attempts, particularly during acute psychiatric distress. In a psychiatric admission setting, priority nursing actions focus on determining intent, lethality risk, and immediate safety needs before exploring contributing factors or coping strategies. Ensuring protection from self-harm is the first clinical priority.

Rationale:
A. Asking directly about suicidal thoughts is the priority because it determines immediate risk to life and guides urgent safety interventions. In a client with self-inflicted cuts, it is essential to assess whether the behavior was non-suicidal self-injury or part of a suicide attempt. In Suicidal behavior disorder, direct questioning is considered safe, appropriate, and does not increase risk of suicide.

B. Asking the client to explain why they hurt themselves is secondary because it focuses on exploration rather than immediate safety. While understanding triggers is important for long-term care planning, it does not address the urgent need to determine suicidal intent. Priority must remain on assessing risk of further self-harm before therapeutic exploration.

C. Identifying support persons is a later intervention that becomes relevant once safety has been established. While social support is protective, it does not determine immediate suicide risk or guide emergency precautions. The nurse must first ensure the client is not actively suicidal before involving external supports.

D. Discussing coping methods is appropriate for therapeutic planning but is not the priority during initial assessment of self-inflicted injury. Effective coping strategies are introduced after determining safety and stabilizing acute risk. At this stage, risk assessment takes precedence over skill-building interventions.

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Correct Answer is C

Explanation

Postoperative pain assessment after an Appendectomy relies primarily on the client’s self-report, as pain is a subjective experience best measured by the individual experiencing it. Effective pain management is essential to promote early mobilization, prevent complications such as atelectasis or thromboembolism, and support wound healing. While physiological and behavioral cues may suggest discomfort, the client’s reported pain level remains the most reliable indicator for administering PRN analgesics.

Rationale:
A. An increased heart rate of 110/min may indicate pain, anxiety, hypovolemia, or other postoperative complications. However, it is a nonspecific physiological response and should not be used alone as the primary indicator for administering analgesia. Pain management decisions should prioritize the client’s direct report over indirect vital sign changes.

B. Grimacing when changing positions is a behavioral sign of discomfort but is not as reliable as self-reported pain. Facial expressions may vary between individuals and can be influenced by factors other than pain, such as anxiety or fatigue. Therefore, it supports but does not independently confirm the need for analgesia.

C. A pain score of 7/10 is a clear, subjective report indicating moderate to severe pain requiring intervention. In postoperative care, self-reported pain intensity is the most valid indicator for administering PRN analgesics. This aligns with individualized pain management principles following surgical procedures like an appendectomy.

D. A decreased attention span may occur due to pain, medications, fatigue, or anxiety. However, it is an indirect and nonspecific indicator of discomfort. It does not provide a reliable or quantifiable measure of pain severity compared to a direct patient report.

A. Decreased skin turgor B. Diminished capillary refill C. Pain relieved by analgesia D. Sensation of tingling E. Pale-colored toes

Correct Answer is ["B","D","E"]

Explanation

Compartment syndrome occurs when increased pressure within a closed muscle compartment compromises circulation, nerve function, and tissue perfusion. It is a medical emergency that can lead to permanent nerve and muscle damage if not treated promptly. Early recognition is essential, especially after casting or trauma to an extremity. Nursing assessment focuses on the classic neurovascular changes known as “6 Ps,” including pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.

Rationale:
A. Decreased skin turgor is not associated with compartment syndrome and instead reflects dehydration or fluid volume deficit. It does not indicate localized neurovascular compromise in an extremity following casting. Therefore, it is unrelated to this condition.

B. Diminished capillary refill is a key sign of impaired perfusion due to increased compartment pressure. Reduced blood flow to the distal extremity indicates compromised vascular supply, which is a hallmark of Compartment syndrome. Delayed capillary refill requires immediate intervention to prevent irreversible tissue damage.

C. Pain relieved by analgesia is incorrect because pain in compartment syndrome is typically severe, unrelenting, and not relieved by standard analgesics. If pain is controlled with medication, it is less likely to indicate this condition. Instead, pain is often disproportionate to the injury and worsens with passive movement.

D. Sensation of tingling (paresthesia) is an early neurologic sign of nerve compression due to rising intracompartmental pressure. It indicates impaired sensory nerve function and is an important early warning of worsening ischemia. Prompt recognition is critical to prevent permanent nerve damage.

E. Pale-colored toes indicate reduced arterial blood flow to the distal extremity. Pallor reflects inadequate oxygenation and perfusion, which are characteristic findings in compartment syndrome. This requires urgent evaluation and possible surgical intervention such as fasciotomy.

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A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 8 hr postoperative following an appendectomy. Which of the following manifestations is the best indication that the client needs a PRN analgesic?

Correct Answer is C

Explanation

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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