A nurse is caring for an adolescent who states an intention to self-harm. Which of the following actions should the nurse take first?
Maintain continuous observation of the adolescent.
Apply wrist restraints to the adolescent.
Collect data about the adolescent's mental status.
Obtain consent from the adolescent's guardian for the application of restraints.
The Correct Answer is A
The nurse should maintain continuous observation of the adolescent.
Choice A reason:
The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.
Choice B reason:
Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.
Choice C reason:
Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.
Choice D reason:
Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The nurse should include the statement that "This test measures amniotic fluid volume” in the teaching about the biophysical profile (BPP). The rationale for this is that the BPP is a prenatal screening tool that assesses the well-being of the fetus. One of the components of the BPP is the measurement of amniotic fluid volume, which helps to evaluate fetal kidney function and overall fetal health.
Choice B reason:
The nurse should not include the statement about receiving Rh(D) immune globulin prior to the test because it is not directly related to the biophysical profile (BPP). Rh(D) immune globulin is given to Rh-negative pregnant women to prevent hemolytic disease of the newborn (HDN) if the fetus is Rh-positive. While this may be important information during pregnancy, it is not specific to the BPP.
Choice C reason:
The nurse should not include the statement that "This test is used to assess uterine activity” in the teaching about the BPP. The BPP is a test focused on evaluating fetal well-being and not uterine activity. Uterine activity is typically assessed through other methods, such as monitoring contractions during labor.
Choice D reason:
The correct answer is not Choice D. The nurse should not include the statement that "Your bladder needs to be full to perform this test” in the teaching about the BPP. This statement is incorrect because a full bladder is not necessary for the BPP. Instead, the BPP involves the use of ultrasound to assess fetal movements, breathing, muscle tone, and amniotic fluid volume, and a full bladder is not a requirement for this assessment.
Correct Answer is A
Explanation
Choice A reason:
The nurse should provide the client with a carbonated beverage as a nonpharmacologic intervention to reduce pain from intestinal gas. Carbonated beverages, like soda or sparkling water, can help alleviate gas by promoting burping, which releases trapped gas from the digestive system. The effervescence of the carbonated drink can help relieve the discomfort caused by accumulated gas, offering relief to the client.
Choice B reason:
Encouraging the client to lie on their right side is not an effective nonpharmacologic intervention for reducing pain from intestinal gas. Although positioning can sometimes aid in relieving discomfort, lying on the right side does not specifically target the reduction of gas. Therefore, it is not the most appropriate choice in this scenario.
Choice C reason:
Encouraging the client to ambulate is a beneficial nonpharmacologic intervention for various post-operative conditions. However, when it comes to reducing pain from intestinal gas, it may not be as effective as other options. While movement can aid in gas passage through the digestive system, it might not be the most immediate or direct solution for alleviating the client's discomfort.
Choice D reason:
Providing the client with straws for beverages does not directly address the issue of intestinal gas. It is an unrelated intervention and may not provide any significant relief for the client's discomfort.
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.