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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Hypothermia. B. Hypertension. C. Diaphoresis. D. Mydriasis.

Correct Answer is A

Explanation

Choice A reason:

Hypothermia. Hypothermia refers to a condition where the body temperature drops significantly below the normal range. However, in cases of acute opioid toxicity, the opposite effect is usually observed. Opioids can cause respiratory depression, leading to a decrease in the body's ability to regulate temperature, resulting in hyperthermia, not hypothermia.

Choice B reason:

Hypertension. Acute opioid toxicity typically causes respiratory depression, which can lead to a decrease in blood pressure rather than hypertension. Opioids are central nervous system depressants that slow down the body's vital functions, including heart rate and blood pressure.

Choice C reason:

Diaphoresis. Diaphoresis is the medical term for excessive sweating. While it may occur in some cases of opioid toxicity due to the body's response to stress or increased sympathetic activity, it is not a specific and consistent finding. It is not as characteristic as other symptoms associated with opioid toxicity.

Choice D reason:

Mydriasis. Mydriasis refers to the dilation of the pupils. This is a hallmark sign of opioid toxicity. Opioids can affect the autonomic nervous system, leading to pupillary constriction (miosis) in most cases. However, when opioid toxicity is severe or acute, the pupils may dilate, resulting in mydriasis.

View Question and Answer

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client 48 hr following cesarean birth. Which of the following nonpharmacologic interventions should the nurse include to reduce pain from intestinal gas?

Correct Answer is A

Explanation

A nurse is assisting in the admission of a client who had recently given birth and is presenting to the emergency department with acute opioid toxicity. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is discussing growth and development milestones with the parents of a 3-year-old preschooler. Which of the following statements by a parent indicates to the nurse that the preschooler is meeting the expected benchmarks of other preschoolers in this age group?

A nurse is reinforcing teaching with a newly licensed nurse about the various indications of pregnancy. Which of the following findings should the nurse include in the teaching as a presumptive sign of pregnancy? (Select all that apply.).

A nurse is contributing to the plan of care for a client who is in the third trimester and reports difficulty sleeping. Which of the following statements should the nurse include?

A nurse is caring for an infant who has pertussis. Which of the following precautions should the nurse implement?

A nurse is collecting data from a client who is 6 weeks postpartum. The client tells the nurse, "I am not a good mother. My baby doesn't like me.” Which of the following actions should the nurse take?

A nurse is assisting with the care of an adolescent who has a partial-thickness burn. When observing the site of the burn, which of the following clinical manifestations should the nurse expect?

A nurse in an antepartum clinic is reinforcing teaching with a pregnant client about breastfeeding. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a parent of a school-age child who has tonic-clonic seizures. Which of the following statements should the nurse make regarding care during a seizure?