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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Use detailed explanations when providing education to the client: Providing detailed explanations can help the client better understand their condition and treatment, which is essential for managing obsessive-compulsive disorder (OCD). This intervention promotes client education and empowerment, enabling them to participate more effectively in their care and treatment.

B. Maintain a stimulating environment for the client: Individuals with OCD often benefit from a calm and organized environment rather than a stimulating one. A stimulating environment might exacerbate anxiety and OCD symptoms. Therefore, maintaining a calm and structured environment is typically more beneficial for clients with OCD.

C. Provide the client with a structured schedule of daily activities: Providing a structured schedule of daily activities can help regulate the client's routine and provide a sense of predictability, which can be comforting for individuals with OCD. A structured schedule can also help minimize the impact of OCD symptoms on daily functioning by providing a framework for completing tasks and managing time effectively.

D. Limit time for rituals to 20 minutes each day: Limiting time for rituals to a specific duration each day may not be appropriate or effective for all clients with OCD. While gradual exposure and response prevention (ERP) therapy may involve gradually reducing the time spent on rituals, setting a specific time limit may not address the underlying causes of OCD and could potentially increase anxiety and distress for the client.

A. Document the client's behavior once every hour. B. Keep the client in restraints until the prescription expires. C. Conduct a debriefing regarding the client with the unit staff D. Request an evaluation of the client within 12 hr of application of restraints

Correct Answer is C

Explanation

A. Documentation should occur every 15-30 minutes to ensure the client's safety and to assess the need for continuing or removing the restraints.

B. Keep the client in restraints until the prescription expires: Restraints should be used for the shortest duration necessary to ensure the safety of the client and others. Keeping the client restrained until the prescription expires without reevaluation may not align with best practices for restraint use.

C. Conducting a debriefing with the unit staff is crucial to evaluate the situation, discuss the events leading up to the use of restraints, and develop strategies to prevent the need for future restraint use. This helps ensure the safety and well-being of the client and others, as well as improve care practices.

D.Typically, the evaluation should occur within 1-4 hours depending on the facility's policy and the urgency of the situation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing an older adult client's ability to make a successful role transition to widowhood following the death of her partner. Which of the following factors should the nurse include in the assessment? (Select all that apply.)

A nurse is caring for a client who is receiving haloperidol 2 mg IM every 6 hr. Available is haloperidol 5 mg/mL. How many mu should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?

A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?

A nurse is caring for a client who exhibits excessive attention-seeking behaviors, including acting flirtatious and seductive. The nurse should identify these behaviors as manifestations of which of the following personality disorders?

A home health nurse is caring for a client who reports feeling tired and being unable to grocery shop. Which of the following responses by the nurse is an example of therapeutic communication?

A nurse is preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT) Which of the following statements should the nurse include in the teaching?

A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal. Which of the following resources should the nurse recommend to the client?