A nurse is reviewing documentation for a 10-year-old admitted for suicidal ideation.
Which statement requires immediate follow-up?
Patient denies suicidal thoughts today.
Patient requested to sleep alone with the door closed.
Patient ate lunch with peers and laughed.
Patient states sadness began after pet died.
The Correct Answer is B
Choice A rationale
A patient denying suicidal thoughts today is a positive sign and suggests a temporary reduction in immediate risk. However, it does not negate the overall risk given a recent admission for suicidal ideation. Continuous monitoring and assessment are still required, as suicidal ideation can fluctuate. This statement provides a baseline but needs to be evaluated in the context of ongoing assessment.
Choice B rationale
A patient requesting to sleep alone with the door closed signifies a potential for isolation and an increased opportunity for self-harm, especially in a psychiatric setting where close observation is crucial for individuals with suicidal ideation. This statement demands immediate follow-up to assess the patient's current mental state, ensure safety, and implement appropriate suicide precautions.
Choice C rationale
A patient eating lunch with peers and laughing indicates positive social engagement and an improvement in mood. This is a favorable sign, suggesting a reduction in immediate distress and an increased capacity for social interaction, which is therapeutic. While continued monitoring is necessary, this statement does not require immediate follow-up for safety concerns related to suicidal ideation.
Choice D rationale
A patient stating sadness began after a pet died provides valuable insight into a potential trigger for their suicidal ideation. This information is important for therapeutic intervention and processing grief. While this is a significant piece of information, it is historical data that informs care planning rather than an immediate safety concern requiring urgent intervention compared to a direct request for isolation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
A personal or family history of breast cancer is a significant contraindication for hormonal contraceptive use due to the potential for exogenous hormones to stimulate hormone-sensitive cancers. Estrogen and progesterone can influence the growth of certain breast cancer types, making a thorough assessment of this history critical before prescribing hormonal contraception.
Choice B rationale
Numerous medications can interact with hormonal contraceptives, affecting their efficacy or increasing adverse effects. For instance, certain anticonvulsants, antibiotics, and antiretrovirals can accelerate the metabolism of hormonal contraceptives, reducing their effectiveness and increasing the risk of unintended pregnancy. Therefore, a comprehensive medication history is essential.
Choice C rationale
Smoking, especially in women over 35 years old, significantly increases the risk of serious cardiovascular adverse events such as myocardial infarction, stroke, and thromboembolism when combined with hormonal contraceptive use. Nicotine constricts blood vessels and promotes hypercoagulability, which is exacerbated by exogenous hormones.
Choice D rationale
Hypertension is a contraindication for many hormonal contraceptives, particularly those containing estrogen, as they can exacerbate elevated blood pressure and increase the risk of cardiovascular events. Hormonal contraceptives can affect the renin-angiotensin-aldosterone system, leading to fluid retention and increased vascular tone, thus worsening hypertension.
Choice E rationale
While excessive alcohol consumption can have various health consequences, it is not a direct contraindication to hormonal contraceptive use itself. It may, however, indirectly affect adherence to medication regimens or exacerbate other health issues. The primary concern with alcohol would be if it leads to liver impairment, which could affect hormone metabolism.
Correct Answer is E
Explanation
Choice A rationale
Living in a women's shelter indicates a lack of stable housing, which can be a significant psychosocial stressor. Chronic stress during pregnancy can elevate cortisol levels, potentially impacting fetal development and increasing the risk of preterm birth or low birth weight. Resource scarcity might also limit access to adequate nutrition and consistent prenatal care, both vital for healthy pregnancy outcomes.
Choice B rationale
Unemployment can lead to financial strain, contributing to increased stress and anxiety. This economic insecurity may hinder access to nutritious food, adequate housing, and transportation to prenatal appointments. Chronic psychosocial stress can trigger physiological responses like increased heart rate and blood pressure, potentially impacting maternal and fetal well-being throughout gestation.
Choice C rationale
Being 25 years of age is generally considered within the optimal reproductive age range. Biologically, women in this age group typically have lower risks of chromosomal abnormalities, gestational hypertension, and gestational diabetes compared to adolescents or women of advanced maternal age. This demographic often experiences fewer pregnancy-related complications due to mature physiological systems.
Choice D rationale
White non-Hispanic race does not inherently increase the risk of pregnancy complications. While racial disparities exist in healthcare outcomes, these are primarily attributed to socioeconomic factors, systemic biases, and access to quality care rather than biological predisposition based on race itself. This demographic factor alone is not a direct physiological risk.
Choice E rationale
A history of depression is a significant risk factor for pregnancy complications. Untreated or poorly managed depression can lead to poor self-care, including inadequate nutrition and non-adherence to prenatal care. Furthermore, peripartum depression can recur or worsen, impacting maternal-infant bonding and potentially leading to adverse developmental outcomes for the child due to altered neurochemical environments.
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