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

Answer and Explanation

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

Explanation

ideation, as some clients express relief anticipating death. While concerning, it is less specific than other indicators, as it may not always reflect serotonin-driven despair or intent, requiring further assessment to confirm risk.

Choice B reason: Feeling overwhelmed by simple tasks indicates severe depression, linked to serotonin and prefrontal cortex dysfunction, impairing executive function. This heightens suicidal risk, as cognitive overload and hopelessness increase impulsivity and despair, making it a critical neurobiological marker requiring immediate intervention to prevent self-harm.

Choice C reason: Calling family to make amends signals high suicidal risk, often reflecting intent to resolve relationships before death, driven by serotonin dysregulation and prefrontal cortex deficits. This behavior indicates advanced planning, a neurobiological marker of serious ideation, necessitating urgent safety measures to prevent completion.

Choice D reason: An abrupt mood improvement can indicate suicidal risk, as it may reflect relief from deciding to end life, linked to serotonin and dopamine shifts. This neurobiological change reduces despair temporarily, increasing energy for action, making it a critical warning sign requiring immediate assessment and intervention.

A. Administer phenytoin 30 min prior to the procedure B. Instruct the client to expect a headache following the procedure C. Monitor the client's cardiac rhythm during the procedure D. Place the client in four-point restraints prior to the procedure

Correct Answer is C

Explanation

Choice A reason: Phenytoin, an anticonvulsant, is not routinely given before ECT, as the procedure induces controlled seizures to stimulate brain activity, treating depression via neurochemical changes. Administering phenytoin would inhibit seizure activity, reducing ECT efficacy by blocking neuronal excitability, making this an inappropriate action for the procedure.

Choice B reason: Instructing about post-ECT headaches is valid, as they result from cerebral vasoconstriction or muscle tension during seizures. However, this is a post-procedure expectation, not a priority action during planning. Monitoring cardiac rhythm takes precedence, as ECT’s autonomic stimulation poses immediate cardiovascular risks requiring real-time management.

Choice C reason: Monitoring cardiac rhythm during ECT is critical, as the procedure induces seizures that stimulate the autonomic nervous system, causing transient tachycardia or arrhythmias due to catecholamine surges. These can exacerbate underlying cardiac conditions, risking instability. Continuous monitoring ensures early detection and management of cardiovascular complications, prioritizing patient safety.

Choice D reason: Four-point restraints are not used in ECT, as patients are under general anesthesia, preventing movement. Restraints risk injury and are unnecessary, as muscle relaxants like succinylcholine minimize convulsive movements. This approach contradicts ECT’s controlled, anesthetized protocol, making it inappropriate for ensuring safety during the procedure.

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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?

Nursing Test Bank

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Correct Answer is C

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