A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client indicates that they are at risk for suicide?
I get nervous when I'm in a large group
My partner and I had our first argument last night
I am not interested in anything anymore.
Im not sleeping much because of all the homework I have."
The Correct Answer is C
A) "I get nervous when I'm in a large group": This statement indicates social anxiety or discomfort, which is common among adolescents. While it may affect the client's well-being, it does not suggest an immediate risk for suicide.
B) "My partner and I had our first argument last night": While relationship issues can cause stress, this statement by itself does not indicate suicidal ideation. Arguments in relationships are a normal part of adolescent development and are not typically associated with a suicide risk unless other risk factors are present.
C) "I am not interested in anything anymore.": This is a concerning statement, as it suggests anhedonia, a hallmark symptom of depression. A lack of interest in activities once enjoyed, especially in adolescents, can be a significant risk factor for suicide and warrants further evaluation and intervention.
D) "I'm not sleeping much because of all the homework I have.": Although sleep disturbances can be a sign of stress, especially related to academic pressure, this is not an immediate indication of suicidal thoughts. Sleep issues can often be managed with lifestyle changes or stress management techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A) Instruct another nurse to record the prescription in the medical record:
The nurse receiving a telephone prescription is responsible for ensuring the prescription is recorded correctly in the medical record. It is not appropriate to delegate this responsibility to another nurse. The nurse should personally document the prescription to ensure accuracy and clarity.
B) Withhold the medication until the provider signs the prescription:
The nurse should not withhold the medication solely based on the provider's signature. Telephone prescriptions are valid once they are received and documented accurately by the nurse. The prescription must be signed by the provider as soon as possible, but withholding medication is not warranted unless there are other concerns with the prescription.
C) Ask the provider to spell out the name of the medication:
When receiving a telephone prescription, the nurse should ask the provider to spell out the name of the medication to avoid errors. Medication names, especially those that sound similar, need to be communicated clearly to ensure correct medication administration. This action helps prevent misinterpretation or confusion, ensuring patient safety.
D) Record the date and time of the telephone prescription:
Recording the date and time of the telephone prescription is essential for accurate documentation and legal purposes. This step ensures that there is a clear record of when the prescription was given and that the provider’s order is traceable in the client’s medical record. It also assists in meeting legal and institutional documentation requirements.
E) Request that the provider confirm the read-back of the prescription:
The nurse should read back the prescription to the provider to confirm accuracy. This action is part of the "read-back" process, a safety measure used to verify that the prescription has been communicated correctly and understood by both the nurse and the provider. This step helps reduce the risk of medication errors.
Correct Answer is D
Explanation
A) "I will make sure that my baby's diaper is applied snugly":
A snug diaper could potentially cause irritation or pressure on the circumcision site, increasing the risk of complications such as discomfort or delayed healing. Diapers should be fitted appropriately but not excessively tight around the area to avoid friction on the circumcised site.
B) "I will wipe away yellow crusts that form around the incision":
Yellow crusts are a normal part of the healing process following a Plastibell circumcision, and they should not be wiped away. These crusts form as part of the natural healing process, and removing them prematurely can disrupt the healing tissue or cause unnecessary bleeding or infection.
C) "I will apply antibiotic ointment to my baby's penis":
Antibiotic ointment is generally not recommended for use after a Plastibell circumcision, as it can interfere with the healing process. The Plastibell procedure typically heals with just proper care and the use of a clean diaper. Applying ointments can cause excess moisture that might lead to infection.
D) "I will apply pressure with gauze if I see bleeding":
This is the correct response. If bleeding occurs after a Plastibell circumcision, the appropriate action is to apply gentle pressure with sterile gauze to control the bleeding. Excessive bleeding or uncontrolled bleeding after the procedure may require medical attention, but applying pressure is the first step in addressing this issue.
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