A school counselor refers a teen for evaluation after she gives away personal belongings and writes about death in her journal.
What is the nurse's priority action?
Encourage journaling to express feelings.
Assess for suicide risk and initiate safety measures.
Notify the teen's teacher to monitor behavior.
Provide the teen with information on grief support.
The Correct Answer is B
Choice A rationale
While journaling can be a therapeutic outlet, encouraging it as a priority action in this situation could be detrimental. The teen's writings about death and giving away belongings are strong indicators of potential suicidal ideation, which necessitates immediate assessment and intervention for safety rather than emotional expression without prior safety assurance.
Choice B rationale
Giving away personal belongings and writing about death are significant warning signs of suicidal ideation. The nurse's priority action is to immediately assess for suicide risk, determine the level of intent and plan, and initiate appropriate safety measures to prevent harm. This direct intervention is crucial for ensuring the teen's immediate well-being.
Choice C rationale
Notifying the teen's teacher might be a subsequent step in a comprehensive safety plan, but it is not the immediate priority. The teacher's role is to monitor behavior within the school setting, but they are not equipped to perform a comprehensive suicide risk assessment or implement immediate safety measures like a nurse.
Choice D rationale
Providing information on grief support is not the priority action when there are direct indicators of potential suicide risk. While loss can contribute to suicidal thoughts, the immediate concern is the risk to the teen's life, which requires direct assessment for suicidal intent and the implementation of safety protocols, not generalized grief support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Excessive dental caries and enlarged tonsils are more commonly associated with bulimia nervosa due to the repeated exposure of teeth to gastric acid from purging and chronic inflammation of the tonsils. Anorexia nervosa primarily involves severe caloric restriction, leading to different physiological adaptations.
Choice B rationale
Skeletal appearance with lanugo on arms is a classic physical finding supporting anorexia nervosa. The emaciated or skeletal appearance is due to severe caloric restriction and muscle wasting. Lanugo, fine downy hair, develops as the body attempts to conserve heat due to insufficient adipose tissue.
Choice C rationale
Irregular heart rate, specifically bradycardia, is common in anorexia nervosa due to metabolic slowdown. However, heavy menstruation (menorrhagia) is not typical; instead, amenorrhea (absence of menstruation) is a hallmark sign, resulting from hormonal imbalances due to malnutrition and low body fat.
Choice D rationale
Overweight with a puffy face is not indicative of anorexia nervosa. Anorexia nervosa is characterized by an extreme fear of gaining weight and a disturbed body image, leading to self-starvation and significant underweight. A puffy face can be associated with refeeding syndrome or specific medical conditions, not primary anorexia.
Correct Answer is A
Explanation
Choice A rationale
A fundus that is deviated to the right, boggy, and 2 cm above the umbilicus suggests a distended bladder is displacing the uterus, preventing it from contracting effectively. A full bladder inhibits uterine involution by impeding the muscle fibers from compressing blood vessels, leading to uterine atony and increasing the risk of postpartum hemorrhage. Normal bladder capacity is 300-500 mL.
Choice B rationale
Obtaining a stat hemoglobin level is not the immediate priority. While a boggy uterus can indicate blood loss, the primary issue here is likely bladder distension causing uterine atony. Addressing the cause of the uterine displacement (bladder distension) takes precedence over assessing the degree of blood loss, which would be a secondary consequence. A normal hemoglobin for a woman is typically 12.0 to 15.5 grams per deciliter.
Choice C rationale
Administering methylergometrine is not the first action. Methylergometrine is a uterotonic agent used to promote uterine contractions and prevent postpartum hemorrhage. However, if the uterus is displaced by a full bladder, the medication's effectiveness will be significantly reduced until the bladder is emptied. Treating the underlying cause is crucial before administering uterotonics.
Choice D rationale
Inserting an indwelling urinary catheter is a more invasive intervention than assisting the client to void. While a catheter might be necessary if the client cannot void independently, the initial and least invasive action should always be to encourage spontaneous urination. Catheterization carries risks of urinary tract infection and discomfort, so it's not the first-line intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.