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 A
Explanation
A) Bran muffin:
Bran is high in fiber, which is beneficial for managing constipation. Fiber helps to promote bowel movements by adding bulk to stool and improving gut motility. A bran muffin is an excellent choice for a client with constipation because it is rich in insoluble fiber, which is particularly effective in relieving constipation.
B) Tomato juice:
While tomato juice can provide some vitamins and nutrients, it is low in fiber, which is essential for managing constipation. For constipation relief, it is better to choose foods high in fiber, such as whole grains, fruits, and vegetables.
C) Puffed rice cereal:
Puffed rice cereal is low in fiber, making it an unsuitable choice for someone with constipation. Although it may provide some calories, it does not offer the beneficial fiber that can help relieve constipation.
D) Cottage cheese:
Cottage cheese is low in fiber and high in protein, but it does not contribute to bowel regularity. For constipation management, it is crucial to choose foods that are high in fiber, like fruits, vegetables, and whole grains, rather than low-fiber foods like cottage cheese.
Correct Answer is A
Explanation
A) Inject 15 units of air into the regular insulin vial:
When drawing insulin from both NPH (a long-acting insulin) and regular insulin (a short-acting insulin), the nurse should first inject air into the NPH insulin vial (which is the intermediate-acting insulin) and then inject air into the regular insulin vial. This technique helps to prevent contamination of the regular insulin vial with NPH insulin. After injecting air into the regular insulin vial, the nurse would then withdraw the regular insulin first and then the NPH insulin to avoid contamination of the regular insulin with the NPH insulin.
B) Withdraw 10 units of NPH insulin:
This action is premature, as the nurse has not yet injected air into the regular insulin vial. The correct sequence involves injecting air into both vials before withdrawing any insulin. Therefore, withdrawing NPH insulin at this stage is not the correct next step.
C) Verify the dosage with another nurse:
While verifying the insulin dosage with another nurse is a good practice for ensuring medication safety, this action is not the immediate next step after injecting air into the NPH insulin vial. The priority is to follow the correct sequence of air injection into the vials before withdrawing the insulin. Verification can occur after the insulin is drawn.
D) Place the cap over the needle:
Placing the cap over the needle is a safety step that is generally performed after withdrawing the insulin and preparing the injection. However, this is not the next step in the process of mixing or drawing insulin, so it is not the correct action to take at this point.
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