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. Hypertension: Hypertension is not typically associated with an allergic reaction to vancomycin. Hypotension may occur in severe reactions like "red man syndrome," but elevated blood pressure is generally unrelated to allergic responses.
B. Headache: Headache is a possible side effect of many medications, including vancomycin, but it does not specifically indicate an allergic reaction. It is a nonspecific symptom and usually does not warrant discontinuation unless severe.
C. Tinnitus: Tinnitus is a sign of ototoxicity, a known adverse effect of vancomycin, especially with high doses or prolonged use. However, it is not indicative of an allergic reaction but rather toxicity affecting the auditory system.
D. Urticaria: Urticaria, or hives, is a classic manifestation of an allergic reaction involving histamine release causing itchy, raised, red skin lesions. Its presence during vancomycin administration signals hypersensitivity and requires immediate attention.
Correct Answer is B
Explanation
Rationale:
A. Nifedipine: Nifedipine is a calcium channel blocker that helps reduce myocardial oxygen demand by decreasing afterload and dilating coronary arteries. However, it is not the priority in acute chest pain management because it has a slower onset compared to nitroglycerin.
B. Nitroglycerin: Nitroglycerin is the priority medication for acute angina. It works rapidly by dilating coronary arteries and reducing myocardial oxygen demand, which helps relieve chest pressure and prevent progression to myocardial infarction.
C. Atenolol: Atenolol, a beta-blocker, decreases heart rate and contractility to reduce myocardial oxygen consumption. While useful for long-term angina management, it is not the first-line agent for immediate chest pain relief in acute settings.
D. Clopidogrel: Clopidogrel is an antiplatelet agent that prevents clot formation, often used in long-term management or following stent placement. It does not provide immediate relief from angina and is therefore not the priority medication in this scenario.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.