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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Free Nursing Study Resources

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

A. Grandiosity B. Flight of ideas C. Splitting D. Hyperactivity E. withdrawal

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

Explanation

A. Grandiosity: Individuals experiencing a manic episode may exhibit grandiosity, such as an inflated sense of self-importance, superiority, or power.

B. Flight of ideas: Flight of ideas refers to rapid, continuous speech that jumps from one topic to another, often with loose associations. It is a common manifestation of a manic episode.

C. Splitting: Splitting is a defense mechanism commonly associated with certain personality disorders, such as borderline personality disorder, but it is not typically observed during a manic episode of bipolar disorder.

D. Hyperactivity: Hyperactivity, or increased physical activity, is characteristic of a manic episode. Clients may engage in excessive goal-directed activities or restlessness.

E. Withdrawal: Withdrawal, or social withdrawal, is not a typical behavior during a manic episode. Instead, individuals with mania tend to exhibit increased sociability and extroversion.

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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 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.)

Correct Answer is ["0.4"]

Explanation

A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply.)

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

Explanation

A nurse is providing teaching to a client who has a prescription for disulfiram. Which of the following client statements indicates an understanding of the teaching?

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 discussing discipline techniques with the parent of a preschooler. Which of the following statements by the parent indicates an understanding of time-out as a form of discipline?

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 caring for a client who is taking a tricyclic antidepressant. For which of the following findings should the nurse monitor as an adverse effect of tricyclic antidepressants?

A nurse in an acute mental health facility receives change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?