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 A
Explanation
A. “I check my breasts for lumps every day, but I’m still really scared about getting breast cancer.”: This statement reflects excessive worry about a specific medical condition (breast cancer) despite engaging in frequent checking behaviors. It is consistent with illness anxiety disorder.
B. “I have had several negative pregnancy tests but know they are all wrong.”: This statement suggests a belief that contradicts objective evidence (negative pregnancy tests) and may indicate a somatic symptom disorder or a delusional disorder rather than illness anxiety disorder.
C. “I double-check my pills because I think the pharmacist may be putting poison in them.”: This statement reflects mistrust or paranoia about medications and the intentions of the pharmacist. While it involves health-related concerns, it may be more indicative of paranoid ideation or delusional beliefs.
D. “I feel really nervous when my partner goes to work, and I am home alone during the day.”: This statement describes anxiety related to separation from a partner and being alone, which is not a characteristic feature of illness anxiety disorder. It may be more indicative of generalized anxiety disorder or separation anxiety disorder.
Correct Answer is A
Explanation
A. A nurse did not clarify a client's prescription that was difficult to read resulting in a medication error: This scenario describes a medication error due to the nurse's failure to exercise reasonable care by not clarifying a difficult-to-read prescription. This constitutes negligence, making it an example of an unintentional tort.
B. A nurse posted private information on social media about a client who has substance use disorder: This scenario involves a breach of confidentiality, which is a violation of the client's privacy rights. However, it is considered an intentional tort (specifically, invasion of privacy) rather than an unintentional tort.
C. A nurse placed a client in mechanical restraints without containing a prescription, resulting in injury: This scenario describes a failure to follow proper procedures (restraining a client without a prescription), resulting in harm to the client. This also constitutes negligence, making it an example of an unintentional tort.
D. A nurse threatened a client with physical harm after the client became verbally abusive to staff members: This scenario involves the nurse's intentional act of threatening physical harm to the client, which constitutes an intentional tort (assault).
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