A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?
"What coping methods help you when you feel bad?"
"Do you have thoughts of suicide?"
"Tell me why you hurt yourself."
"Who can we call to support you?"
The Correct Answer is B
Rationale:
A. "What coping methods help you when you feel bad?": While assessing coping mechanisms is important for long-term care planning, it does not immediately address the client's current risk for self-harm or suicide. This question is more appropriate after ensuring the client's safety.
B. "Do you have thoughts of suicide?": Determining if the client has suicidal ideation is the priority in this situation. Clients who self-harm may be at high risk for suicide, and direct questioning helps assess intent, plan, and urgency, which is crucial for ensuring immediate safety.
C. "Tell me why you hurt yourself.": Exploring the reasons behind self-injury can be valuable later during therapy or assessment, but it is not the first priority. The nurse must first evaluate the client’s current mental state and risk for further harm before exploring motives.
D. "Who can we call to support you?": Identifying a support system is important for discharge planning and ongoing therapy, but it does not address the immediate concern of suicide risk. Ensuring the client's current safety takes precedence over external support at the time of admission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Boggy fundus 3 fingerbreadths above the umbilicus: A boggy uterus located above the umbilicus suggests uterine atony, which indicates that the oxytocin may not have been effective. This finding is not expected 30 minutes after administering oxytocin.
B. Client report of burning with urination: Burning during urination is unrelated to oxytocin administration and may point toward a urinary tract infection. It does not reflect the expected physiological response to uterine stimulation for controlling postpartum hemorrhage.
C. Saturation of perineal pad in 15 min: Continued excessive bleeding despite oxytocin administration indicates treatment failure and requires immediate intervention. Oxytocin should reduce uterine bleeding; thus, ongoing hemorrhage is not an expected finding.
D. Client report of uterine cramping: Uterine cramping is an expected response to oxytocin, which works by stimulating uterine smooth muscle contractions. These cramps help compress blood vessels at the placental site, reducing postpartum bleeding and promoting involution.
Correct Answer is D
Explanation
Rationale:
A. Reviewing the results of the client's complete blood count (CBC) with their parents, without the client's consent: CBC results are general health data and not considered sensitive. In most jurisdictions, parents of minors typically have access to such information unless restricted by specific laws or agreements.
B. Reviewing the results of the client's urinalysis with their parents, without the client's consent: Urinalysis is typically used for general health screening or to assess conditions like infections or kidney issues. Unless it's linked to drug testing or STI diagnosis, sharing these results with parents is not considered a breach.
C. Reviewing the results of the client's celiac screening with their parents, without the client's consent: Celiac screening relates to a chronic gastrointestinal condition and is not categorized as confidential reproductive or mental health information. Sharing it with parents does not typically violate confidentiality.
D. Reviewing the results of the client's chlamydia screening with their parents, without the client's consent: Reproductive and sexual health services, including STI screening, are protected under minor consent laws in many regions. Disclosing this information without the adolescent's permission breaches their legal right to confidentiality.
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