An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?

Assess for body image disturbance.

Complete a suicidal risk assessment.

Explore the client’s current life events.

Praise her for seeking professional help.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing body image disturbance is relevant in adolescents but not the priority with self-harm fears and wrist scars, indicating high suicide risk from psychological distress or serotonin dysregulation. A suicidal risk assessment evaluates immediate safety, addressing the neurobiological urgency of potential self-injury over body image concerns.

Choice B reason: Completing a suicidal risk assessment is critical, as self-harm fears and wrist scars suggest active suicidal ideation or past attempts, possibly from depression or trauma. Assessing intent, plan, and means guides urgent interventions like hospitalization, addressing psychological and neurochemical risks to prevent self-injury in this high-risk client.

Choice C reason: Exploring life events provides context for self-harm but is secondary to assessing suicide risk. Stressors may trigger cortisol or serotonin imbalances, contributing to ideation, but evaluating immediate risk of self-harm is urgent to ensure safety, preventing lethal outcomes in an adolescent with evident self-harm history.

Choice D reason: Praising the client for seeking help is supportive but not the priority when self-harm fears and scars indicate high suicide risk. Positive reinforcement does not address immediate evaluation of intent or plan, critical to prevent harm and manage underlying psychological or neurochemical issues promptly.

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Correct Answer is B

Explanation

Choice A reason: A soft diet with milk products may worsen diverticulosis, as dairy can cause bloating or intolerance. High fiber and fluids prevent constipation, reducing diverticular pressure. This is inappropriate, per dietary management and gastrointestinal health guidelines for diverticulosis in nursing education.

Choice B reason: A high fiber diet and increased fluid intake prevent constipation, reducing pressure in diverticula and preventing complications like diverticulitis. This promotes bowel regularity, critical for managing diverticulosis, per evidence-based dietary recommendations and gastrointestinal health protocols in patient education for nursing care.

Choice C reason: Small frequent meals and sitting up after meals aid digestion but do not address diverticulosis-specific needs. High fiber and fluids directly prevent constipation, reducing diverticular strain. This is less effective, per dietary management and patient teaching standards for diverticulosis in nursing.

Choice D reason: A bland diet avoiding spicy foods is unrelated to diverticulosis, which requires fiber to prevent constipation. Spicy foods do not directly affect diverticula. High fiber and fluids are critical, per gastrointestinal health and dietary management guidelines for diverticulosis in nursing education.

A. A client with pancreatitis who has a fasting glucose of 190 mg/dL (10.55 mmol/L) today and had 160 mg/dL (8.88 mmol/L) yesterday. B. A client with a gastrointestinal (GI) bleed who is receiving a blood transfusion and has a hemoglobin of 7.0 g/dL (4.34 mmol/L). C. A client with cancer who has an absolute neutrophil count (ANC) of less than 500/mm3 today and had 2,000/mm3 yesterday. D. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.

Correct Answer is C

Explanation

Choice A reason: Elevated glucose (190 mg/dL) in pancreatitis needs monitoring but is less urgent than severe neutropenia (ANC <500/mm3), which risks life-threatening infections. Glucose can be managed with insulin, per diabetes and pancreatitis care protocols, but neutropenia requires immediate intervention.

Choice B reason: Hemoglobin of 7.0 g/dL in a GI bleed is critical but less immediate, as the client is receiving a transfusion. Neutropenia (ANC <500/mm3) poses an urgent infection risk, requiring isolation. Transfusion addresses anemia, per bleeding and hematology care standards.

Choice C reason: An ANC <500/mm3 indicates severe neutropenia, posing an immediate infection risk in cancer patients, requiring urgent isolation and antibiotics. This rapid drop from 2,000/mm3 demands priority intervention to prevent sepsis, per oncology and infection control protocols in nursing practice.

Choice D reason: Elevated bilirubin in hepatitis is concerning but less urgent than neutropenia (ANC <500/mm3), which risks sepsis. Jaundice requires monitoring and treatment, but severe infection risk takes precedence, per liver disease and critical care prioritization standards in nursing practice.

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An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

Correct Answer is B

Explanation

Which client’s laboratory value requires immediate intervention by a nurse? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

Correct Answer is C

Explanation

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