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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Using a heating pad is contraindicated in Raynaud’s, as reduced sensation from vasospasm risks burns. Raynaud’s involves cold-triggered arteriolar constriction, reducing blood flow. Heat does not address vasospasm’s pathophysiology and may cause tissue damage, making this instruction inappropriate compared to cold protection strategies.

Choice B reason: Wearing gloves when handling cold items prevents vasospasm in Raynaud’s, where cold triggers arteriolar constriction, causing ischemia and pain. Protecting extremities maintains blood flow, preventing episodes. This directly addresses the disease’s pathophysiological trigger, making it the most effective instruction for managing Raynaud’s symptoms.

Choice C reason: Knee-high support stockings improve venous return, relevant for venous insufficiency, not Raynaud’s arterial vasospasm. Stockings do not prevent cold-induced vasoconstriction, the primary trigger. Gloves for cold exposure directly mitigate vasospastic episodes, making this instruction less effective for Raynaud’s disease management.

Choice D reason: Regular walking improves overall circulation but does not prevent Raynaud’s vasospastic episodes, triggered by cold or stress. While exercise supports vascular health, avoiding cold exposure with gloves is more targeted, directly reducing arteriolar constriction and ischemic symptoms, making walking a secondary recommendation.

A. Imbalanced nutrition. B. Deficient fluid volume. C. Risk for infection. D. Urinary incontinence.

Correct Answer is C

Explanation

Choice A reason: Imbalanced nutrition is unrelated to 150 mL residual urine, which indicates incomplete bladder emptying, often from detrusor dysfunction or obstruction. Nutrition affects overall health but does not cause retention. Residual urine increases infection risk due to stasis, making nutrition an irrelevant nursing problem for this urinary issue.

Choice B reason: Deficient fluid volume suggests dehydration, reducing urine output, not causing high residual volumes. Residual urine (150 mL) indicates retention from impaired bladder emptying, not fluid deficit. Hydration prevents stasis, but infection risk from retained urine is more immediate, as bacteria proliferate in stagnant urine.

Choice C reason: Residual urine of 150 mL signifies incomplete bladder emptying, often from obstruction or neurogenic bladder, leading to urinary stasis. This fosters bacterial growth, increasing urinary tract infection (UTI) risk. Including “risk for infection” addresses this pathophysiological concern, guiding interventions like catheterization to reduce infection likelihood.

Choice D reason: Urinary incontinence involves involuntary leakage, not retention, where the bladder fails to empty, as seen with 150 mL residual urine. Retention results from outflow obstruction or weak detrusor, distinct from incontinence’s loss of control, making this nursing problem inappropriate for the client’s condition.

View Question and Answer

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

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

Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?

Correct Answer is B

Explanation

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

Correct Answer is C

Explanation

An older adult client, who is insulin-dependent, arrives at the diabetic clinic with concerns of thick, crusty, and long toenails that are piercing the adjacent toes. Which action should the nurse take?

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

Based on the capillary glucose measurement, a client is to receive 10 units of regular insulin. The client’s medication drawer contains one vial of a 70/30 mixture of regular insulin and isophane insulin. How should the nurse prepare the prescribed dose?

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].

An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?