A nurse is caring for an adolescent who states an intention to self-harm. Which of the following actions should the nurse take first?

Maintain continuous observation of the adolescent.

Apply wrist restraints to the adolescent.

Collect data about the adolescent's mental status.

Obtain consent from the adolescent's guardian for the application of restraints.

Answer and Explanation

The Correct Answer is A

The nurse should maintain continuous observation of the adolescent.

Choice A reason:

The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.

Choice B reason:

Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.

Choice C reason:

Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.

Choice D reason:

Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.

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Correct Answer is B

Explanation

Choice A reason:

The WBC count of 10,000/mm is within the normal range, indicating a normal white blood cell count. There is no cause for concern, and the nurse does not need to report this result to the provider.

Choice B reason:

The Hgb level of 6.8 g/dL is significantly below the normal range, which indicates severe anemia. Menorrhagia, or heavy menstrual bleeding, could be a potential cause of this low hemoglobin level. Anemia can lead to various complications, including fatigue, weakness, and decreased oxygen delivery to tissues. This result requires immediate attention, and the nurse should promptly report it to the healthcare provider for further evaluation and management.

Choice C reason:

The Creatinine level of 0.8 mg/dL is within the normal range. Creatinine is a marker of kidney function, and a normal value suggests that the kidneys are functioning adequately. Since the result is normal, the nurse does not need to report this to the provider.

Choice D reason:

The Potassium level of 3.5 mEq/L is within the normal range, indicating a normal potassium level. There is no immediate concern with this result, and the nurse does not need to report it to the provider.

A. "Drinking warm tea before bed can be helpful.” B. "Doing relaxation exercises before bed can be helpful.” C. "Sleeping on your right side can be helpful.” D. "Soaking in a hot tub for 60 minutes can be helpful.”

Correct Answer is B

Explanation

Choice A reason:

The nurse should not recommend drinking warm tea before bed for a pregnant client. Certain herbal teas might not be safe during pregnancy, and caffeine-containing teas should be limited due to their potential effects on the fetus. Therefore, it is best to avoid suggesting this option to the client.

Choice B reason:

This is the correct choice as relaxation exercises can be beneficial for pregnant clients who are experiencing difficulty sleeping. These exercises can help reduce stress, promote relaxation, and improve sleep quality without any adverse effects on the client or the baby.

Choice C reason:

The nurse should avoid recommending that the client sleep on their right side. While the left side is generally recommended during pregnancy to improve blood flow to the placenta and baby, sleeping on the right side is not harmful either. However, it is better to provide the most suitable option for promoting sleep, which is relaxation exercises as mentioned in Choice B.

Choice D reason:

Soaking in a hot tub for 60 minutes is not advisable during pregnancy. Prolonged exposure to high temperatures, such as in hot tubs or saunas, can raise the body's core temperature, potentially causing harm to the developing fetus. Pregnant individuals should avoid hot tubs to prevent overheating.

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A nurse is caring for an adolescent who states an intention to self-harm. Which of the following actions should the nurse take first?

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