A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client indicates that they are at risk for suicide?
I get nervous when I'm in a large group
My partner and I had our first argument last night
I am not interested in anything anymore.
Im not sleeping much because of all the homework I have."
The Correct Answer is C
A) "I get nervous when I'm in a large group": This statement indicates social anxiety or discomfort, which is common among adolescents. While it may affect the client's well-being, it does not suggest an immediate risk for suicide.
B) "My partner and I had our first argument last night": While relationship issues can cause stress, this statement by itself does not indicate suicidal ideation. Arguments in relationships are a normal part of adolescent development and are not typically associated with a suicide risk unless other risk factors are present.
C) "I am not interested in anything anymore.": This is a concerning statement, as it suggests anhedonia, a hallmark symptom of depression. A lack of interest in activities once enjoyed, especially in adolescents, can be a significant risk factor for suicide and warrants further evaluation and intervention.
D) "I'm not sleeping much because of all the homework I have.": Although sleep disturbances can be a sign of stress, especially related to academic pressure, this is not an immediate indication of suicidal thoughts. Sleep issues can often be managed with lifestyle changes or stress management techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Condition: Opioid intoxication – The client's presentation of unresponsiveness, respiratory depression (RR 10/min), and miosis (pinpoint pupils) is consistent with opioid intoxication. Additionally, the presence of a needle in the antecubital space suggests recent intravenous drug use.
Finding: Pupil characteristics – Opioid intoxication commonly causes miosis (pinpoint pupils), which was observed in the client.
Correct Answer is C
Explanation
Correct answers: C
Rationale:
A. Staff members using a class A fire extinguisher for an electrical fire is incorrect and dangerous. Class A extinguishers are for ordinary combustibles like paper and wood. Electrical fires require class C extinguishers to prevent the conduction of electricity.
B. Reviewing the locations of fire extinguishers every 2 to 3 years is insufficient for an effective safety plan. Regular fire safety drills and location reviews should occur at least annually. Frequent reinforcement ensures rapid response during a real fire emergency.
C. An evacuation order when fire extinguishers are ineffective indicates an effective safety plan and sound clinical judgment. The priority in the RACE acronym is to rescue and then evacuate if the fire is not contained. This protects life when suppression fails.
D. Fire alarms having the same sound as other alarms is a failure in safety design. Distinctive auditory signals are required to prevent confusion during an emergency. Unique alarms ensure that staff and patients immediately identify the specific nature of the threat.
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