A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority?
Arrange one-to-one observation of the client
Encourage interaction with the client's peers
Encourage the client to attend a support group
Administer medication for depressive disorder
The Correct Answer is A
Choice A reason: One-to-one observation is the priority after a suicide attempt, as the adolescent’s recent action indicates high risk of recurrence due to serotonin dysregulation and prefrontal cortex deficits. Continuous monitoring prevents self-harm by ensuring immediate intervention, addressing the acute neurobiological risk of impulsivity and suicidal ideation in this critical period.
Choice B reason: Encouraging peer interaction supports long-term mental health but is secondary in an acute post-suicide attempt phase. The adolescent’s serotonin imbalances and heightened impulsivity increase self-harm risk, requiring immediate safety measures over social engagement, which could overwhelm or trigger distress in a neurobiologically vulnerable state.
Choice C reason: Attending a support group aids long-term recovery by fostering social connection and coping skills. However, post-suicide attempt, the adolescent’s acute risk, driven by serotonin dysregulation and prefrontal dysfunction, prioritizes safety. Groups may be premature, as emotional instability could exacerbate distress, making observation the immediate need.
Choice D reason: Administering antidepressants addresses underlying depression but takes weeks to affect serotonin levels. Post-suicide attempt, immediate safety is critical due to ongoing impulsivity and neurobiological instability. Observation prevents harm during this high-risk period, making medication secondary until the acute crisis is stabilized.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Diarrhea and weight gain are less common with SSRIs. While some SSRIs may cause gastrointestinal upset via serotonin receptor stimulation in the gut, weight gain is more associated with atypical antipsychotics. SSRIs primarily affect serotonin reuptake, leading to central and anticholinergic-like effects, not these symptoms predominantly.
Choice B reason: SSRIs, by inhibiting serotonin reuptake, cause dizziness, drowsiness, and dry mouth due to central nervous system effects and mild anticholinergic activity. Dizziness and drowsiness result from serotonin modulation in the brainstem, while dry mouth reflects peripheral serotonin effects on salivary glands, making these the most common side effects.
Choice C reason: Convulsions and respiratory difficulties are rare with SSRIs. Seizures may occur in overdose due to excessive serotonin, but not typically at therapeutic doses. Respiratory issues are not associated, as SSRIs primarily affect serotonin pathways, not respiratory centers, making this choice inaccurate for common side effects.
Choice D reason: Jaundice and agranulocytosis are not common SSRI side effects. These are associated with drugs like chlorpromazine, affecting liver or bone marrow. SSRIs primarily cause serotonin-related central and peripheral effects, not hepatotoxicity or bone marrow suppression, making this choice irrelevant to their pharmacological profile.
Correct Answer is A
Explanation
Choice A reason: Offering dessert to stop yelling uses bargaining, not distraction, and may reinforce agitation in Alzheimer’s, where cortical and amygdala damage impairs emotional regulation. This approach risks escalating distress by focusing on the behavior, which the client cannot control due to neurocognitive deficits, making it ineffective.
Choice B reason: Asking if the client wants to finish the meal focuses on the agitation’s context, potentially worsening distress in Alzheimer’s due to impaired reasoning from cortical degeneration. This confrontational approach does not redirect attention, failing to leverage preserved procedural memory, which distraction techniques use to calm neurobiological agitation.
Choice C reason: Suggesting to watch television is a distraction technique, redirecting attention from agitation triggers in Alzheimer’s. By engaging preserved sensory and procedural memory, it reduces amygdala-driven emotional distress without confronting cognitive deficits, aligning with neurobiological strategies to manage agitation and promote calm in dementia care.
Choice D reason: Stating misunderstanding focuses on the client’s communication deficits, likely increasing frustration in Alzheimer’s due to hippocampal and cortical damage. This does not distract from agitation triggers and may exacerbate distress, as the client cannot process or correct their behavior, making it an ineffective response compared to redirection.
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