A nurse in a well-child clinic receives a phone call from the parent of an adolescent client. The parent states. "I think my son might try to kill himself." Which of the following statements by the parent is the priority for the nurse to investigate further?

“I can hear him crying in the middle of the night.”

"He spends most of his time locked in his room.”

“He refuses to go to the movies with his friends.”

“I noticed several cutting marks on both of his arms.”

Answer and Explanation

The Correct Answer is D

A. “I can hear him crying in the middle of the night.”: While this statement indicates distress, it does not necessarily indicate an immediate risk of suicide. Crying can be a symptom of various emotional or psychological issues, but it does not provide direct evidence of suicidal intent.

B. "He spends most of his time locked in his room.”: Social withdrawal or isolating oneself from others can be a warning sign of depression or other mental health issues, including suicidal ideation. However, it alone may not indicate imminent risk of suicide.

C. “He refuses to go to the movies with his friends.”: Social withdrawal or a decline in interest in previously enjoyed activities can also be indicators of depression or other mental health concerns. However, like spending time alone, it does not provide direct evidence of suicidal intent.

D. “I noticed several cutting marks on both of his arms.”: This statement is the most concerning and indicates a potential self-harm behavior. Self-harm, such as cutting, can be a significant risk factor for suicide, especially if the behavior escalates or if the individual expresses suicidal thoughts or intentions.

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Correct Answer is D

Explanation

A. Refer the client to a support group for survivors of suicide: While support groups can be valuable resources for individuals who have lost loved ones to suicide, it may not be the most immediate or appropriate action to take first. The client may not be ready to engage in group support until her immediate needs are addressed.

B. Offer to contact the client’s family or support system: This option demonstrates empathy and practical support by offering assistance in reaching out to the client's family or support system. It can help ensure that the client has immediate emotional support and assistance with practical matters.

C. Inform the client that feelings of guilt are often felt by survivors of suicide: While providing information about common experiences of survivors of suicide can be helpful, it may not be the most immediate action to take first. The client's emotional needs and immediate concerns should be addressed before discussing broader aspects of grief and guilt.

D. Determine the client's understanding of the suicide events: This option involves assessing the client's understanding of the circumstances surrounding the suicide. Understanding the client's immediate thoughts, feelings, and perceptions of the event is essential for providing appropriate support and intervention.

A. Weight gain and dry mouth B. Oliguria and muscle weakness C. Hallucinations and blurred vision D. Coarse hand tremors and confusion

Correct Answer is A

Explanation

A. Weight gain and dry mouth: Weight gain and dry mouth are common adverse effects of lithium at therapeutic levels. They are not immediately dangerous but can affect compliance with the medication regimen.

B. Oliguria (reduced urine output) and muscle weakness are more concerning symptoms. They can indicate potential toxicity, especially oliguria, which suggests possible renal impairment, a serious concern with lithium therapy.

C. Hallucinations and blurred vision are more severe and typically associated with lithium toxicity rather than therapeutic levels. They indicate a need for immediate medical attention.

D. Coarse hand tremors and confusion: Coarse hand tremors and confusion are signs of lithium toxicity. At therapeutic levels, fine hand tremors can occur, but coarse tremors and confusion suggest higher serum levels.These symptoms are associated with toxicity and require urgent medical evaluation.

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A nurse in a well-child clinic receives a phone call from the parent of an adolescent client. The parent states. "I think my son might try to kill himself." Which of the following statements by the parent is the priority for the nurse to investigate further?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just learned that her partner has died by suicide. Which of the following actions should the nurse take first

Correct Answer is D

Explanation

A nurse is planning to teach a client who is taking lithium. Which of the following should the nurse include in the teaching as adverse effects of therapeutic lithium level?

Correct Answer is A

Explanation

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