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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is ["0.4"]
Explanation
To find out how many milliliters (mL) the nurse should administer, we first need to determine the total dose required per administration. The client is receiving haloperidol 2 mg IM every 6 hours.
First, let's calculate the total dose required per administration:
2 mg (total dose) / 1 dose = 2 mg
Next, we need to determine how many milliliters (mL) of the medication solution contain this dose. The concentration of the haloperidol solution is 5 mg/mL.
We can set up a proportion to find the volume of the solution:
2 mg (dose required) / x mL (volume to administer) = 5 mg/mL (concentration)
Cross-multiplying:
2 mg * 1 mL = 5 mg * x mL
2 mL = 5x
To isolate x (the volume to administer), we divide both sides by 5:
x = 2 mL / 5
x = 0.4 mL
So, the nurse should administer 0.4 mL of haloperidol
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