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 A
Explanation
Choice A rationale
At the end of the first trimester, around 12-14 weeks gestation, the uterus is still relatively low in the pelvis. The symphysis pubis serves as a reliable anatomical landmark for locating the fundus of the uterus at this stage. Placing the Doppler just above this bony prominence allows for optimal transmission of sound waves to detect the fetal heart tones.
Choice B rationale
The right upper quadrant contains structures like the liver, gallbladder, and part of the colon. At the end of the first trimester, the uterus is not typically high enough to extend into this region. Therefore, attempting to locate fetal heart tones in this area would be ineffective and unlikely to yield a clear signal, as the fetus is not yet positioned there.
Choice C rationale
Just above the umbilicus is the general location for assessing fetal heart tones later in pregnancy, typically during the second and third trimesters when the uterus has significantly enlarged and risen out of the pelvis. At the end of the first trimester, the uterus is still too small and low for the fetal heart tones to be consistently heard at this location.
Choice D rationale
The left upper quadrant contains the stomach, spleen, and part of the colon. Similar to the right upper quadrant, the uterus is not positioned high enough in the first trimester to extend into this area. Therefore, attempting to locate fetal heart tones in the left upper quadrant would be inappropriate and unlikely to be successful.
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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