During lunch, a patient cuts herself with a plastic eating utensil. The patient refuses redirection and continues to attempt to cut herself. The patient is safely secured in a restraint chair. What is the next priority action for the nurse?

Notify the provider for a restraint order and assessment.

Advise the cafeteria staff of plastic utensils that can be used as weapons.

Ask staff members how the patient was able to acquire the utensil.

Notify the house supervisor for further direction.

Answer and Explanation

The Correct Answer is A

Choice A reason: Notifying the provider ensures legal and medical oversight for restraints, addressing self-harm risk driven by serotonin deficits and amygdala hyperactivity. This prioritizes patient safety and evaluates underlying psychiatric causes, ensuring appropriate intervention to stabilize neural dysregulation.

Choice B reason: Advising cafeteria staff is a preventive measure but not the priority during acute self-harm. Serotonin-driven impulsivity requires immediate medical assessment, and addressing utensil access is secondary to stabilizing the patient’s acute neurochemical crisis.

Choice C reason: Investigating utensil acquisition is important for future prevention but not urgent. The patient’s self-harm, driven by serotonin deficits and amygdala hyperactivity, requires immediate medical intervention to ensure safety and address acute psychiatric needs first.

Choice D reason: Notifying the house supervisor is administrative, not clinical, and delays direct intervention. Self-harm reflects serotonin dysregulation and amygdala-driven impulsivity, requiring immediate provider assessment for restraints and psychiatric evaluation, making this less urgent.

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Correct Answer is B

Explanation

Choice A reason: Absence of symptoms does not indicate the prodromal phase of schizophrenia, which involves subtle cognitive and functional declines driven by early dopamine dysregulation in the prefrontal cortex. This woman shows no signs of prodromal neural changes, making this choice incorrect.

Choice B reason: The prodromal phase of schizophrenia includes decreased concentration and functioning, reflecting early dopamine and glutamate dysregulation in the prefrontal cortex and hippocampus. These subtle neurocognitive changes precede overt psychosis, accurately describing the 20-year-old’s symptoms as prodromal.

Choice C reason: Exacerbation after stopping antipsychotics indicates active schizophrenia, not the prodromal phase. Dopamine receptor hypersensitivity from medication withdrawal causes symptom relapse, not the subtle, pre-psychotic cognitive decline characteristic of the prodromal period, making this incorrect.

Choice D reason: Bizarre and disruptive behavior indicates active schizophrenia, not the prodromal phase. Overt psychosis reflects advanced mesolimbic dopamine hyperactivity, unlike the prodromal period’s subtle cognitive and functional impairments driven by early prefrontal and hippocampal changes.

A. Availability of means and lethality of method. B. Patient’s insight into suicidal motivation. C. Patient’s history of physical or sexual abuse. D. Quality and availability of patient's social support.

Correct Answer is A

Explanation

Choice A reason: Availability and lethality of suicide means are critical, as they determine immediate risk. Serotonin deficits and amygdala-driven impulsivity heighten the likelihood of acting on accessible, lethal methods, making this the priority to prevent fatal outcomes in suicidal patients.

Choice B reason: Insight into suicidal motivation is important but secondary to immediate risk. Serotonin dysregulation drives impulsivity, and without addressing access to lethal means, insight alone cannot prevent action, making it less urgent in acute suicide assessment.

Choice C reason: Abuse history increases suicide risk via trauma-related amygdala hyperactivity but is not the priority. Immediate access to lethal means poses a greater acute risk, as serotonin deficits drive impulsivity, necessitating focus on preventing action first.

Choice D reason: Social support is a protective factor but secondary to immediate risk. Serotonin-driven impulsivity and amygdala hyperactivity make access to lethal means the priority, as support cannot prevent action if means are readily available.

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During lunch, a patient cuts herself with a plastic eating utensil. The patient refuses redirection and continues to attempt to cut herself. The patient is safely secured in a restraint chair. What is the next priority action for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client best exhibits the characteristics that are typical of the prodromal period of schizophrenia?

Correct Answer is B

Explanation

When assessing a patient's plan for suicide, what aspect has priority?

Correct Answer is A

Explanation

A patient diagnosed with major depressive disorder began taking citalopram (Celexa) 4 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to:

A client asks a nurse about the need to alter any activities because of taking lithium. Which response would be most appropriate?

A client is brought to the emergency department after exhibiting vital sign instability, diaphoresis, shivering, incoordination, hyperreflexia, hyperpyrexia, and diarrhea. The client is taking paroxetine (Paxil) for depression. Which condition should the nurse most likely suspect?

A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." To support the patient to reframe this overgeneralization, the nurse's best response is:

A hospitalized client diagnosed with schizophrenia is receiving antipsychotic medications. While assessing the client, a nurse identifies signs and symptoms of a dystonic reaction. Which medication would the nurse expect to administer?

The most appropriate response by the nurse when a despondent patient says "Nothing matters anymore" would be:

A patient states, "I feel detached from myself and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem?

A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and threatening behavior. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?