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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason:

Hep B is given at birth, 2 months, and 6 months of age not at 11 years old.

Choice B reason:

Measles, mumps, rubella (MMR) The rationale for not choosing Measles, mumps, rubella (MMR) is the same as for choice A. If the child has already received the required doses of the MMR vaccine, giving extra doses is not necessary and may not provide any additional benefit.

Choice C reason:

This vaccine is recommended for children at age 11-12 years to boost immunity against tetanus, diphtheria, and pertussis. This is a one-time dose, and it's important to ensure that children receive it on schedule.

Choice D reason:

Pneumococcal (PCV) The rationale for not choosing Pneumococcal (PCV) is that this vaccine is typically given in infancy and early childhood as part of the routine immunization schedule.

Since the child is 11 years old and up to date with current recommendations, they are unlikely to require another dose of PCV at this stage.

A. "I will wait 15 seconds between puffs when using my levalbuterol inhaler.” B. "I need to use my fluticasone inhaler when I start to wheeze during exercise.” C. "I need to use my levalbuterol inhaler before I exercise.” D. "I will stop using my fluticasone inhaler if I experience restlessness.”

Correct Answer is C

Explanation

Choice C reason: The correct answer is choice C, "I need to use my levalbuterol inhaler before I exercise.” This statement indicates an understanding of the teaching because using the levalbuterol inhaler before exercise is a preventive measure for asthma symptoms. Levalbuterol is a short-acting beta-agonist that helps to relax the airway muscles and improve breathing. By using it before exercise, the client can prevent exercise-induced bronchoconstriction and reduce the risk of asthma symptoms during physical activity.

Choice A reason:

The statement "I will wait 15 seconds between puffs when using my levalbuterol inhaler” is incorrect. The recommended wait time between puffs of a levalbuterol inhaler is typically 30- 60 seconds to allow the medication to be fully absorbed and work effectively. Waiting only 15 seconds might not provide the desired therapeutic effect.

Choice B reason:

The statement "I need to use my fluticasone inhaler when I start to wheeze during exercise” is incorrect. Fluticasone is a corticosteroid inhaler used for long-term control of asthma symptoms, not for immediate relief during wheezing episodes. The client should use the fluticasone inhaler daily as prescribed to prevent asthma symptoms, including wheezing, from occurring in the first place.

Choice D reason:

The statement "I will stop using my fluticasone inhaler if I experience restlessness” is incorrect. Fluticasone is a long-term controller medication, and abruptly stopping it can lead to uncontrolled asthma symptoms and potentially exacerbate the condition. Restlessness might be a side effect of the medication, but it is not a reason to discontinue its use. If the client experiences any concerning side effects, they should consult their healthcare provider for appropriate management.

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A nurse is caring for an adolescent who states an intention to self-harm. Which of the following actions should the nurse take first?

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