A nurse is making a home visit for a 16-year old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

Stating that he wants to be with his peers more than with his parents.

Telling his parents that he doesn't want to talk about the suicide attempt.

Preferring to eat his meals while watching TV.

Planning to give his CD collection to his girlfriend.

Answer and Explanation

The Correct Answer is D

A-Wanting to spend time with peers is not inherently indicative of continued suicidal intent. Adolescents often seek social connections, and while this behavior should be monitored, it is not a specific indicator of ongoing suicidal ideation.

B-While reluctance to discuss the event can be a concern, it doesn't automatically translate to continued suicidal thoughts.

C-Preferring to eat meals while watching TV is a relatively common behavior and does not directly correlate with suicidal intent. While changes in behavior should be noted, this alone is not a strong indicator of continued risk.

D-Giving away prized possessions, especially to loved ones, can sometimes be a sign of hopelessness or finality associated with suicidal ideation. It suggests the adolescent may be putting their affairs in order.

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Correct Answer is C

Explanation

A.While it is important to understand changes in behavior, the sudden shift from depression to a cheerful state could be indicative of a potential risk, such as a plan to self-harm, particularly if the client is showing improved mood quickly.

B.It is not appropriate to reward a change in behavior without understanding the underlying reasons for the change. The sudden improvement in mood could be a sign of a potential risk, such as suicidal ideation or a temporary lift in mood before a possible crisis.

C.This is a crucial intervention. A sudden change in mood can sometimes be associated with an increased risk of self-harm or suicidal ideation, particularly if the client’s mood improves significantly before a more stable improvement in their depressive symptoms. Continuous monitoring helps ensure the client’s safety.

D.This could be premature and potentially unsafe, given the sudden and significant change in the client's condition. It is more important to ensure that the client’s mood change is not indicative of an underlying risk before allowing unsupervised activities.

A. Discourage the client from taking a nap during the day. B. Weigh the client every 3 to 4 days. C. Maintain an environment with low stimuli. D. Offer finger foods to the client every 2 hr. E. Monitor vital signs every 1 to 2 hr throughout the day.

Correct Answer is ["C","D","E"]

Explanation

Correct answers: C, D, E

Choice A rationale:
While a consistent sleep schedule is important in the long term, a short nap during the day might be helpful for someone experiencing mania to prevent complete exhaustion, which can worsen symptoms.

Choice B rationale:
Weighing the client every 3 to 4 days (Choice B) might not be as crucial as the other options provided. While changes in weight can occur during mania, this intervention may not be as directly related to managing the acute symptoms of mania as other interventions.

Choice C rationale:
Maintaining an environment with low stimuli (Choice C) is essential during a manic episode. Clients with mania often experience heightened sensory sensitivity, and reducing environmental stimuli can help decrease agitation and promote a more stable mood.

Choice D rationale:
A client in a manic episode has increased caloric needs due to constant physical activity but may be unable to sit down for regular meals.Providing finger foods allows them to eat while remaining active.

Choice E rationale:

Mania can cause physiological changes like increased heart rate, blood pressure, and body temperature. Frequent monitoring helps detect potential complications and guide treatment decisions.

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A nurse is making a home visit for a 16-year old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.).

Correct Answer is ["C","D","E"]

Explanation

A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?

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