A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Initiating suicide precautions

Administering the Hamilton Depression Scale

Making a contract with the client for eating behavior

Reviewing the client's toxicology laboratory report

Answer and Explanation

The Correct Answer is A

In this scenario, the nurse's priority should be initiating suicide precautions. Safety is of utmost importance when caring for a client following a suicide attempt. By implementing suicide precautions, the nurse can take steps to ensure the client's physical and emotional well-being, such as removing potential means of self-harm and closely monitoring the client's behavior. This action aims to prevent further harm and promote a safe environment for the client.

Incorrect:

B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.

C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.

D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.

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Correct Answer is ["A","B","C","E"]

Explanation

When caring for an adolescent female with an eating disorder, the nurse should expect the following manifestations:

A- Amenorrhea: Amenorrhea refers to the absence of menstruation, which is commonly seen in individuals with eating disorders, particularly in cases of severe weight loss or malnutrition.

B- Altered body image: Individuals with eating disorders often have a distorted perception of their body shape and size. They may see themselves as overweight or have a negative body image, even when they are significantly underweight.

C- Hyperactivity: Some individuals with eating disorders may exhibit excessive physical activity or restlessness. This hyperactivity can be a result of increased energy expenditure, driven by a fear of weight gain or a compulsive need to burn calories.

E- Bradycardia: Bradycardia, or a slow heart rate, is a common finding in individuals with severe malnutrition or very low body weight. It can be a result of the body's adaptive response to conserve energy in a state of limited food intake.

Incorrect:

D- Verbalized desire to gain weight is not typically expected in individuals with eating disorders. They may express a desire to lose weight or have a fear of gaining weight instead.

A. "ECT is an effective treatment for personality disorders." B. "It is a myth that clients experience seizures during ECT." C. "Informed consent should be obtained prior to ECT." D. "should monitor the client closely for hypotension following ECT."

Correct Answer is C

Explanation

Obtaining informed consent is a crucial step before administering electroconvulsive therapy (ECT). Informed consent ensures that the client is fully informed about the procedure, its potential risks and benefits, and any alternative treatments available. It allows the client to make an autonomous decision regarding their treatment.

The other responses are not accurate:

A- "ECT is an effective treatment for personality disorders." While ECT may be used in certain cases of severe mental illness, it is not primarily indicated for personality disorders.

B- "It is a myth that clients experience seizures during ECT." Seizures are a common and expected effect of ECT. ECT involves the induction of controlled seizures under anesthesia.

D- "Should monitor the client closely for hypotension following ECT." While monitoring the client for various physiological changes is important, hypotension is not a primary concern following ECT. The nurse would typically monitor for potential adverse effects such as confusion, memory loss, headache, and muscle soreness.

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A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A charge nurse is providing teaching to a staff nurse about assisting the provider with electroconvulsive therapy (ECT). Which of the following responses by the staff nurse indicates understanding of the teaching?

Correct Answer is C

Explanation

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