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's priority in this situation is the respiratory rate of 10/min. A respiratory rate of 10 breaths per minute is significantly low and could indicate respiratory depression, especially if the patient is receiving morphine, which is known to depress the respiratory system. This could lead to inadequate oxygenation, potential hypoxia, and other life-threatening complications.
Choice B reason:
Bladder distention may be a concern, but it is not the nurse's priority in this situation. Bladder distention can cause discomfort and urinary retention, but it is not an immediate life- threatening condition compared to potential respiratory depression.
Choice C reason:
A blood pressure of 108/64 mm Hg is within the normal range for an adolescent and may not be the nurse's priority at this time. Although it should be monitored, it does not pose an immediate threat to the patient's life.
Choice D reason:
Nausea and vomiting are common side effects of morphine administration, but they are not the nurse's priority in this situation. While they can cause distress and discomfort to the patient, they are not life-threatening conditions.
Correct Answer is B
Explanation
Choice A reason:
Airborne precautions are implemented for diseases that spread through small airborne particles, such as tuberculosis or measles. These diseases can remain suspended in the air for extended periods and be inhaled by others. Pertussis, also known as whooping cough, is primarily spread through respiratory droplets when an infected person coughs or sneezes, making airborne precautions unnecessary.
Choice B reason:
Droplet precautions are appropriate for illnesses that spread through respiratory droplets produced when an infected person talks, coughs, or sneezes. Pertussis falls into this category as it is transmitted mainly through respiratory droplets. By implementing droplet precautions, the nurse will minimize the risk of transmission to others, including healthcare workers and other patients.
Choice C reason:
Standard precautions are the baseline infection prevention practices used for all patients to prevent the spread of infections in healthcare settings. While important, they may not be sufficient to control the transmission of pertussis, as it requires additional measures like droplet precautions due to its specific mode of transmission.
Choice D reason:
Neutropenic precautions are used for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). The purpose is to protect these vulnerable individuals from exposure to infectious agents. However, pertussis precautions are different and do not fall under the neutropenic category.
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