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
Support during labor has been shown to significantly decrease the perception of pain. Continuous presence of a supportive individual, such as a doula or partner, provides comfort, encouragement, and various coping mechanisms, which can physiologically reduce stress hormone release and enhance the body's natural pain-modulating systems, leading to a less painful experience.
Choice B rationale
A supportive presence during labor contributes to an improved overall experience for the client. The emotional, physical, and informational support provided can alleviate anxiety, empower the client, and foster a sense of control and confidence, leading to a more positive and satisfying childbirth experience, often with lasting beneficial psychological impacts.
Choice C rationale
Support during labor can contribute to better fetal outcomes by reducing maternal stress and anxiety. Lower maternal stress levels can lead to improved uterine blood flow and oxygenation to the fetus. Additionally, continuous support can lead to fewer interventions, such as operative deliveries, which are associated with potential risks to the fetus.
Choice D rationale
Research indicates that continuous support during labor is associated with improved client outcomes. This includes a reduced likelihood of medical interventions, such as epidural anesthesia, synthetic oxytocin for augmentation, and cesarean sections. Enhanced emotional well-being and reduced maternal stress hormones also contribute to a more positive physiological response during labor.
Choice E rationale
Support during labor is known to decrease, not increase, anxiety. The presence of a supportive individual provides reassurance, reduces fear of the unknown, and offers comfort. This contributes to a calm environment, which can physiologically mitigate the stress response, thereby lowering anxiety levels and promoting a more relaxed labor progression for the client.
Correct Answer is B
Explanation
Choice A rationale
Focusing only on the area around the nipples is insufficient for a comprehensive self-breast exam. Breast tissue extends broadly from the collarbone to the bottom of the rib cage and from the armpit to the breastbone. Limiting the exam to one area could lead to missed abnormalities in other regions.
Choice B rationale
Using the pads of the fingers with varying pressure allows for thorough palpation of all breast tissue. Light pressure assesses superficial tissue, medium pressure evaluates deeper tissue, and firm pressure reaches the tissue closest to the chest wall, ensuring complete coverage and detection of abnormalities.
Choice C rationale
While lying down is one recommended position, conducting the exam only in this position is not sufficient. Performing the exam both lying down and standing (e.g., in the shower) allows for different tissue distributions and helps in detecting abnormalities that might be more palpable in one position over another.
Choice D rationale
Performing the exam every day is too frequent and unnecessary. Breast tissue changes throughout the menstrual cycle, and daily exams might lead to confusion regarding normal physiological variations. Monthly self-breast exams are recommended for consistency and to establish a baseline for individual breast tissue.
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