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 C
Explanation
Choice A rationale
At 16 weeks of gestation, the uterine fundus has not yet reached the umbilicus. The umbilicus is typically reached around 20 weeks of gestation. Palpating the fundus at the umbilicus at 16 weeks would suggest a discrepancy in gestational age or a potential complication such as polyhydramnios or multiple gestation, warranting further investigation.
Choice B rationale
The uterine fundus is palpable at 16 weeks of gestation. By this stage, the uterus has grown significantly and ascended out of the pelvis, making it accessible to abdominal palpation. Failure to palpate the fundus at this stage could indicate an inaccurate gestational age, ectopic pregnancy, or other uterine abnormalities, requiring clinical correlation.
Choice C rationale
At 16 weeks of gestation, the uterine fundus is typically palpable approximately halfway between the symphysis pubis and the umbilicus. This anatomical landmark serves as a reliable indicator of gestational age during the second trimester. The fundus ascends by approximately 1 cm per week after 12 weeks of gestation, providing a consistent growth pattern.
Choice D rationale
At 16 weeks of gestation, the uterine fundus is well above the pubic bone. It typically becomes palpable just above the pubic bone around 12 to 14 weeks of gestation as it rises out of the pelvic cavity. Finding the fundus only just above the pubic bone at 16 weeks would suggest a lag in uterine growth or an inaccurate gestational age assessment.
Correct Answer is B
Explanation
GTPAL stands for Gravida, Term, Preterm, Abortions, Living Children. Gravida (G) is the total number of pregnancies, including the current one. This client has had three children plus one miscarriage, and is currently pregnant, making G = 5. Term (T) refers to pregnancies delivered at 37 weeks 0 days gestation or beyond. The client has two full-term children, so T = 2. Preterm (P) refers to pregnancies delivered between 20 weeks 0 days and 36 weeks 6 days gestation. The client had one child born prematurely at 34 weeks, so P = 1. Abortions (A) includes miscarriages and induced abortions before 20 weeks gestation. The client has a history of one miscarriage, so A = 1. Living (L) refers to the number of living children. The client has three children living at home, so L = 3. Therefore, the correct GTPAL is G5 T2 P1 A1 L3.
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