Which intervention has the highest priority when caring for an adolescent diagnosed with attention-deficit/hyperactivity disorder (ADHD) who has poor judgment, high risk-taking behaviors, and impulsivity?
Develop and sign a "no self-harm" contract with the teenager.
Assign a staff member to one-to-one observation until the treatment team determines the teenager is no longer at risk for harm.
Schedule frequent discussions between the nurse and teenager to explore stressors, coping skills, and behavioral alternatives.
Implement locked seclusion until the teenager is able to identify examples of good judgment and control impulsive reactions.
The Correct Answer is B
Choice A rationale
While a "no self-harm" contract can be a useful tool for enhancing patient accountability and commitment to safety, it is a secondary intervention. Given the immediate, high-risk behaviors associated with poor judgment and impulsivity in ADHD, a contract alone does not provide the necessary physical protection or immediate external control required to prevent potential harm, which necessitates continuous direct observation.
Choice B rationale
Assigning a staff member to one-to-one observation is the highest priority intervention for an individual with poor judgment, high risk-taking behaviors, and impulsivity, as it provides constant, direct visual monitoring. This crucial measure prevents the adolescent from acting on sudden, uncontrolled urges to self-harm or engage in dangerous behaviors, ensuring immediate physical safety until the risk level is professionally reassessed by the multidisciplinary treatment team.
Choice C rationale
Frequent discussions are valuable for building therapeutic rapport and exploring underlying psychological factors, coping mechanisms, and alternative behaviors. However, this is a longer-term, insight-oriented strategy that is secondary to the immediate need for physical safety. It does not, by itself, mitigate the acute risk posed by severe impulsivity and poor judgment.
Choice D rationale
Locked seclusion is a form of physical restraint and is a last-resort intervention used only when a patient presents an imminent, extreme danger to self or others and less restrictive measures have failed. Given the scenario, continuous observation (Choice B) is a more therapeutic, less restrictive, and highly effective safety measure, making seclusion an inappropriate initial priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
This statement reflects a global, self-defeating cognitive distortion known as overgeneralization, applying a single failure to all future attempts ("always fail"). Cognitive Behavioral Therapy (CBT) aims to challenge and modify such rigid, irrational beliefs toward more balanced, realistic thinking, making this statement a lack of progress within the therapeutic framework.
Choice B rationale
This is another example of pervasive cognitive distortion, specifically all-or-nothing thinking or catastrophizing, suggesting a view that all life events are inherently negative ("always go wrong"). Progress in CBT involves moving away from these absolute terms to recognize situational variance and positive outcomes, thus this statement indicates limited therapeutic change.
Choice C rationale
This statement, "Sometimes I do stupid things," demonstrates cognitive restructuring and de-personalization of failure, which are key goals in CBT. By using the word "Sometimes," the client reframes the self-criticism from a global, fixed self-identity ("I'm stupid") to a specific, contextualized behavior ("do stupid things"), showing an awareness that negative actions do not define the whole self.
Choice D rationale
"I'm disappointed in my lack of ability" shifts the language from a global self-label to a feeling about a performance deficit. While less absolute than the original statement, it still focuses on an internal, perceived deficit ("lack of ability") rather than separating the behavior from the self and acknowledging the situational nature of error, which is the hallmark of progress in CBT.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
A family member acting as an interpreter may have a deep-seated desire to protect the patient or maintain a particular family image to the healthcare provider. This protective bias can lead to the intentional omission or softening of details perceived as unpleasant, shameful, or indicative of dysfunction, compromising the fidelity and completeness of the patient's self-report and potentially leading to an inaccurate diagnostic picture.
Choice B rationale
Due to cultural norms, familial hierarchy, or fear of social stigma associated with mental illness, a family member interpreter may unconsciously or deliberately filter and censor the patient's verbalizations. They might alter the words or thoughts expressed, particularly those related to sensitive topics like suicidal ideation or deep distress, to align with perceived social appropriateness or their own protective agenda, fundamentally distorting the therapeutic communication.
Choice C rationale
While a family member may not entirely avoid interpretation, their emotional proximity and lack of professional training fundamentally differ from a certified interpreter's role, which is to render messages accurately without bias. Their personal investment in the situation significantly increases the risk of them inadvertently or intentionally modifying the content, which is the core issue, rather than outright refusing the task.
Choice D rationale
Emotional entanglement and inherent personal biases stemming from a close relationship can profoundly impair a family member's ability to maintain objectivity and accurately convey the patient's affective state. Their pre-existing knowledge of the patient's personality and their own emotional response to the illness can cloud their perception, making it challenging to precisely capture the nuanced meaning and depth of the patient's expressed mood and non-verbal communication.
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