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 B
Explanation
Choice A rationale
Performing a fasciotomy is a surgical procedure, not an initial nursing intervention. While it may be necessary to relieve compartment syndrome, it is outside the scope of nursing practice and is typically performed by a physician. The nurse's role is to identify the signs and symptoms and escalate to the medical team for this definitive treatment.
Choice B rationale
Loosening the cast dressings or bandages directly addresses the potential cause of compartment syndrome by reducing external compression. This action aims to improve blood flow and nerve function by alleviating pressure on the neurovascular structures within the confined space. This can prevent further tissue ischemia and damage.
Choice C rationale
Elevating the affected limb above heart level can paradoxically worsen compartment syndrome. Elevation decreases arterial perfusion pressure, further compromising blood flow to the already ischemic tissues within the rigid fascial compartment. This can exacerbate tissue hypoxia and cellular damage, increasing the risk of irreversible injury.
Choice D rationale
Applying ice to the affected area causes vasoconstriction, which would further reduce blood flow to the compromised tissues within the compartment. This decrease in perfusion would exacerbate ischemia and hypoxia, potentially worsening tissue damage and accelerating the progression of compartment syndrome. Therefore, ice application is contraindicated.
Correct Answer is A
Explanation
Choice A rationale
According to Erik Erikson's theory of psychosocial development, adolescence (roughly ages 12-18) is characterized by the central crisis of identity versus role confusion. During this stage, adolescents explore various roles, beliefs, and values to form a cohesive sense of self and define their place in society, integrating past experiences with future aspirations.
Choice B rationale
Autonomy versus shame and doubt is the psychosocial crisis associated with early childhood, typically ages 1-3 years. During this stage, children develop a sense of personal control over physical skills and a sense of independence. Successful resolution leads to autonomy, while failure can result in feelings of shame and self-doubt.
Choice C rationale
Trust versus mistrust is the psychosocial crisis of infancy, typically ages 0-1 year. In this stage, infants develop a sense of trust in caregivers and the world based on the consistency and reliability of care received. Successful resolution fosters hope and security, while neglect can lead to mistrust and anxiety.
Choice D rationale
Industry versus inferiority is the psychosocial crisis characteristic of school age, typically ages 6-12 years. Children at this stage are focused on developing competence and mastering academic and social skills. Success in these endeavors leads to a sense of industry, while difficulties can result in feelings of inferiority and low self-esteem.
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