An adolescent presents with symptoms of depression, including ongoing sadness and withdrawal from friends. Which nursing intervention would best support immediate suicide prevention for this adolescent?
Refer the adolescent for a comprehensive mental health assessment.
Encourage increased social activities to reduce isolation.
Provide information on coping mechanisms and stress management skills.
Offer enrollment in a therapeutic group setting.
The Correct Answer is A
A. Refer the adolescent for a comprehensive mental health assessment is the most appropriate immediate intervention for suicide prevention. Adolescents exhibiting persistent sadness and social withdrawal are at increased risk for suicidal ideation. A mental health assessment allows for risk evaluation, safety planning, and prompt initiation of appropriate interventions, including therapy, monitoring, or hospitalization if needed.
B. Encouraging increased social activities can support long-term mental health but does not provide immediate safety for an adolescent at risk of suicide. Socialization alone cannot replace professional assessment and intervention.
C. Providing information on coping mechanisms and stress management skills is helpful for managing depression over time but is insufficient as a first step in immediate suicide risk prevention. Without assessment, the adolescent may remain at high risk.
D. Offering enrollment in a therapeutic group setting can promote social support and coping skills but does not address urgent safety concerns. Immediate assessment is required before initiating group interventions.
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Related Questions
Correct Answer is C
Explanation
A. Advising parents to limit playtime to reduce overstimulation may help manage sensory overload, but it does not address social withdrawal or promote development of social skills. Limiting interaction can worsen social isolation, so this is not the priority intervention.
B. Focusing purely on managing anxiety without considering social skills is incomplete. While anxiety management is important, children with autism spectrum disorder also benefit from interventions that enhance social engagement. Ignoring social skill development would not address the child’s withdrawal.
C. Encouraging the child to participate in activities with peers to improve social skills is correct. Social interaction is a core area of difficulty in ASD. Structured and supportive peer activities can help the child practice communication, cooperation, and social engagement, while also addressing concurrent withdrawal. This intervention promotes social development in a safe and guided manner, making it the priority.
D. Recommending individualized play activities to avoid peer interaction may reduce anxiety but does not help the child develop social skills. Avoiding peers reinforces social withdrawal and delays social competence, so this is not the most appropriate intervention.
Correct Answer is C
Explanation
A. Hyperkalemia is incorrect. Frequent vomiting causes loss of gastric acid and potassium, leading to hypokalemia, not hyperkalemia. Hypokalemia can result in muscle weakness, arrhythmias, and fatigue.
B. Lower than normal expected reference range of body weight is more characteristic of anorexia nervosa. Clients with bulimia typically maintain a normal weight or may fluctuate slightly above or below normal. Severe underweight is less common.
C. Dental decay is correct. Repeated exposure of the teeth to stomach acid from vomiting erodes enamel, leading to dental erosion, sensitivity, and increased cavities, making dental problems a hallmark physical finding in bulimia nervosa.
D. Amenorrhea is more associated with anorexia nervosa due to extreme weight loss and hormonal disruption. Although menstrual irregularities can occur in bulimia, they are less consistent than in anorexia.
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