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 D
Explanation
Choice A rationale
Duchenne muscular dystrophy (DMD) is a progressive genetic disorder characterized by muscle degeneration and weakness. Individuals with DMD experience significant muscle weakness, particularly in the lower limbs, leading to an increased risk of falls due to impaired balance and gait instability. Decreased muscle strength directly compromises postural control.
Choice B rationale
Rapid cognitive development is not a typical characteristic of Duchenne muscular dystrophy. While DMD primarily affects skeletal muscles, some individuals may experience cognitive impairments, ranging from mild learning difficulties to more significant intellectual disabilities. The disease is linked to dystrophin deficiency in brain tissue, which can impact neurological function.
Choice C rationale
Increased muscle strength is antithetical to the pathology of Duchenne muscular dystrophy. The hallmark of DMD is progressive muscle weakness caused by the absence or malfunction of dystrophin, a protein vital for maintaining muscle fiber integrity. This leads to chronic muscle damage, inflammation, and eventual replacement of muscle tissue with fat and fibrous tissue.
Choice D rationale
Wheelchair dependence is a common and almost inevitable outcome for individuals with Duchenne muscular dystrophy. Due to the progressive muscle weakness affecting ambulation, most individuals with DMD lose the ability to walk independently between ages 7 and 13, necessitating the use of a wheelchair for mobility as the disease progresses and leg muscles deteriorate.
Correct Answer is D
Explanation
Choice A rationale
Increased energy levels are typically not a symptom of depression in younger children. Instead, depression often manifests as a reduction in energy, leading to fatigue, lethargy, and a general lack of motivation or interest in previously enjoyed activities. This shift in energy levels can significantly impact daily functioning and play.
Choice B rationale
Decreased irritability is not a common symptom of depression in younger children. On the contrary, young children experiencing depression often exhibit heightened irritability, anger outbursts, and defiance as external manifestations of their internal distress and sadness. This can lead to difficulties in social interactions.
Choice C rationale
Improved concentration is not a symptom of depression; rather, impaired concentration and difficulty focusing are hallmark signs. Children with depression often struggle with academic tasks, forgetfulness, and an inability to sustain attention, leading to a decline in school performance and frustration.
Choice D rationale
Changes in appetite and sleep patterns are common neurovegetative symptoms of depression across all age groups, including younger children. This can present as increased or decreased appetite, leading to weight changes, and difficulties with sleep, such as insomnia, hypersomnia, or frequent awakenings, disrupting daily routines.
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