The nurse is caring for a 17-year-old patient who was admitted for attempted suicide.
The patient will not speak to anybody.
Which is the best action the nurse can take to help facilitate communication with the patient?
Provide the patient with a journal to write down her thoughts.
Make sure to use phrases which include you when speaking with the patient.
Ask the patient directly how she feels.
Provide toys and games to play with.
The Correct Answer is A
Choice A rationale
For a 17-year-old adolescent who is non-verbal following a suicide attempt, providing a journal is an evidence-based intervention to facilitate expression. Adolescence is characterized by the need for autonomy and privacy. Writing allows the patient to process intense emotions and traumatic thoughts without the immediate pressure of face-to-face verbal interaction. This method respects their current psychological defense mechanisms while still providing a therapeutic outlet for the heavy internal burden they are currently carrying.
Choice B rationale
Using phrases that begin with you can often be perceived as accusatory or confrontational, especially by an adolescent in a mental health crisis. In therapeutic communication, I statements are preferred to express observations without making the patient feel defensive. For a patient who has attempted suicide, you statements might inadvertently increase feelings of guilt or shame. The goal is to reduce pressure on the patient, and direct you-focused language can actually hinder the development of a therapeutic alliance.
Choice C rationale
Directly asking a patient how they feel when they are currently refusing to speak is often ineffective and can be perceived as intrusive. This approach does not account for the patient's current state of psychological withdrawal or elective mutism. Adolescents often shut down when they feel pressured to perform or explain themselves. Therapeutic silence or offering alternative forms of communication, such as writing, is more effective than demanding verbalization during the acute phase of post-suicide attempt recovery.
Choice D rationale
Providing toys and games is developmentally inappropriate for a 17-year-old patient. According to Erikson's stages of development, this patient is in the stage of Identity vs. Role Confusion. Treating a near-adult with pediatric play items can be demeaning and may further alienate them from the nursing staff. While some forms of recreational therapy are useful, they must be age-appropriate. Using toys for an adolescent ignores their cognitive maturity and the gravity of their clinical situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Labor augmentation is the most appropriate next step for a client in the active phase of labor who has experienced an arrest of dilation despite regular contractions. Since the fetal heart rate is reassuring, the goal is to improve the quality, frequency, and duration of uterine contractions to achieve cervical change. This is typically accomplished through the administration of intravenous oxytocin or an amniotomy to stimulate the endogenous release of prostaglandins and enhance mechanical pressure.
Choice B rationale
A cesarean delivery is usually reserved for cases where there is evidence of cephalopelvic disproportion, fetal distress, or when augmentation has failed to produce progress. Since the fetal heart rate is currently reassuring and the client is only 5 cm dilated, a surgical intervention is premature. The medical team will first attempt to correct the labor pattern through less invasive means. Surgery carries higher maternal risks and is not indicated as the first-line response for secondary arrest.
Choice C rationale
Vacuum-assisted delivery is only indicated during the second stage of labor when the client is fully dilated at 10 cm and the fetal head is at an appropriate station. At 5 cm dilation, the cervix is not sufficiently retracted to allow for an operative vaginal birth. Attempting to use a vacuum at this stage would cause significant maternal cervical trauma and fetal scalp injury. It is a tool for the expulsion phase, not for correcting an arrest of dilation.
Choice D rationale
Intrauterine resuscitation measures, such as repositioning the mother, increasing IV fluids, or administering oxygen, are initiated when the fetal heart rate is non-reassuring. In this scenario, the fetal heart rate is specifically described as reassuring, meaning the fetus is currently well-oxygenated. Therefore, the focus remains on managing the dysfunctional labor pattern rather than correcting a hypoxic state that does not exist. The intervention must address the lack of cervical progress.
Correct Answer is B
Explanation
Choice A rationale
Applying the blood pressure cuff directly to a bare arm is the gold standard for achieving an accurate measurement. Placing a cuff over clothing can cause either an overestimation or underestimation of the pressure due to the added thickness or uneven compression of the fabric. Ensuring direct skin contact allows for proper transmission of Korotkoff sounds and ensures that the bladder of the cuff can effectively occlude the brachial artery for a precise reading.
Choice B rationale
Positioning the cuff below the level of the right atrium will result in a falsely elevated blood pressure reading due to the effects of hydrostatic pressure. For every inch the cuff is below heart level, the reading can increase by approximately 2 mmHg. To obtain a clinically valid measurement, the arm must be supported at the level of the fourth intercostal space at the sternum. This ensures that gravity does not artificially inflate the recorded systolic and diastolic values.
Choice C rationale
Allowing the patient to rest for at least five minutes before taking a blood pressure reading is essential to eliminate the influence of recent physical activity or emotional stress. This period of quiescence helps the sympathetic nervous system reach a baseline state, providing a more accurate reflection of the patient's resting hemodynamic status. Failing to wait can result in a transiently elevated reading that does not accurately represent the patient's true cardiovascular health or pregnancy-induced changes.
Choice D rationale
Taking the blood pressure while the woman is seated is a standard and acceptable practice provided her back is supported and her feet are flat on the floor. However, in pregnancy, practitioners must be aware of the potential for uterine compression of the vena cava. While seated is common, some guidelines suggest the left lateral recumbent position to maximize placental perfusion, but a seated position itself does not inherently cause an inaccurate reading if proper technique is used.
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