Patient: Lily, 16-year-old female
Presenting Concerns: Multiple superficial cuts on forearms. Denies suicidal intent. History: Recent family conflict and academic stress.
What is the priority nursing intervention for Lily?
Punish self-harm behaviors
Focus only on academic counseling
Ignore behavior to avoid reinforcement
Ensure wound care and assess for infection
The Correct Answer is D
A. Punish self-harm behaviors: Punitive responses can increase shame, guilt, and secrecy around self-injury. Such approaches may escalate emotional distress and do not address underlying stressors or ensure physical safety. Therapeutic care emphasizes support rather than punishment.
B. Focus only on academic counseling: Academic stress is a contributing factor, but addressing it alone overlooks immediate physical and emotional needs. Self-inflicted wounds require assessment and care to prevent complications.
C. Ignore behavior to avoid reinforcement: Ignoring self-harm behaviors risks missing signs of infection, worsening injury, or escalating distress. Active assessment and engagement are necessary to promote safety and identify ongoing risk. Nonjudgmental attention supports trust and disclosure.
D. Ensure wound care and assess for infection: Immediate attention to physical injuries reduces the risk of infection and complications. This intervention prioritizes safety while allowing the nurse to assess injury patterns and initiate further psychosocial evaluation. It supports both physical care and ongoing therapeutic engagement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tricyclic antidepressant medications: Tricyclic antidepressants are primarily used to treat depression or obsessive-compulsive symptoms. They do not directly reduce the frequency or severity of tics in Tourette’s disorder.
B. Monoamine oxidase inhibitor medications: MAO inhibitors are indicated for certain types of depression and anxiety disorders. They are not effective in controlling motor or vocal tics associated with Tourette’s disorder.
C. Antimanic medications: Antimanic agents, such as lithium, are used to manage bipolar disorder and mood stabilization. They do not target the neurological mechanisms underlying tics in Tourette’s disorder.
D. Antipsychotic medications: Typical and atypical antipsychotics, such as haloperidol or risperidone, are effective in reducing motor and vocal tics. These medications act on dopamine pathways involved in tic generation, helping to manage severity and improve functioning.
Correct Answer is ["B","E"]
Explanation
A. Frequent vomiting: Vomiting is a compensatory behavior more characteristic of bulimia nervosa, not binge eating disorder, which typically lacks purging behaviors.
B. Recurrent binge episodes: Binge eating disorder is defined by repeated episodes of consuming large quantities of food in a short period, often accompanied by a sense of loss of control. These episodes are central to the diagnosis.
C. Eating non-food substances: The consumption of non-food substances, or pica, is a separate eating disorder and is not associated with binge eating disorder.
D. Use of laxatives: Laxative misuse is a compensatory behavior seen in bulimia nervosa. Binge eating disorder does not involve recurrent purging or compensatory behaviors.
E. Feelings of guilt: Individuals with binge eating disorder often experience distress, guilt, or shame following binge episodes. Emotional distress is a common feature associated with loss-of-control eating.
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