A nurse on a mental health unit is caring for clients who have various d Bryant traction. When determining that the traction is the following client diagnoses as presenting the greatest risk for suicide?

Seasonal affective disorder

Persistent depressive disorder

Major depressive disorder

Premenstrual dysphoric disorder

Answer and Explanation

The Correct Answer is C

A. Seasonal affective disorder (SAD): While individuals with SAD experience depressive symptoms that tend to occur seasonally, typically in the winter months, the severity of symptoms is generally less severe compared to MDD. While suicide risk can still be present in individuals with SAD, it is usually lower compared to those with MDD.

B. Persistent depressive disorder (PDD): Persistent depressive disorder, formerly known as dysthymia, is characterized by chronic depressive symptoms that are less severe than those seen in MDD. While individuals with PDD may experience prolonged feelings of sadness and hopelessness, their symptoms may not reach the severity seen in MDD. Therefore, the risk of suicide may be lower in individuals with PDD compared to those with MDD.

C. Major depressive disorder (MDD): Major depressive disorder is characterized by persistent feelings of sadness, hopelessness, and worthlessness, along with a loss of interest or pleasure in activities. Individuals with MDD are at significant risk of suicide, especially if their depressive symptoms are severe. The presence of traction may exacerbate feelings of hopelessness or helplessness in individuals with MDD, further increasing the risk of suicide.

D. Premenstrual dysphoric disorder (PMDD): PMDD is a severe form of premenstrual syndrome (PMS) characterized by significant mood disturbances and other symptoms that occur in the luteal phase of the menstrual cycle. While PMDD can cause distressing symptoms, including depressive mood, irritability, and anxiety, it is typically limited to the premenstrual period and does not carry the same chronicity or severity as MDD. Therefore, the risk of suicide may be lower in individuals with PMDD compared to those with MDD.

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Correct Answer is C

Explanation

A. Before auscultating the chest and abdomen: Examining the tympanic membrane before auscultating the chest and abdomen is not ideal. It's important to follow a systematic approach in physical examination, typically starting with less invasive assessments before progressing to more invasive or uncomfortable ones. Therefore, examining the tympanic membrane before auscultating the chest and abdomen may disrupt this systematic approach.

B. Before examining the head and neck: Similarly, examining the tympanic membrane before examining the head and neck is not appropriate. The head and neck examination typically includes less invasive assessments such as observing the child's appearance, palpating the fontanelles, and inspecting the scalp, face, and neck. The tympanic membrane examination, which involves using an otoscope, is more invasive and should be performed later in the examination.

C. At the end: This is the correct choice. Examining the tympanic membrane at the end of the physical examination allows the nurse to establish rapport with the child and gain their cooperation before performing a potentially uncomfortable or intrusive examination of the ears. Starting with less invasive and more familiar assessments, such as observing the child's general appearance and behavior, auscultating the chest and abdomen, and examining the head and neck, can help build trust and reduce anxiety before proceeding to more specific assessments, such as otoscopy.

D. At the beginning: Examining the tympanic membrane at the beginning of the physical examination may cause the child distress and anxiety, potentially making the rest of the examination more challenging. It's preferable to perform less invasive assessments first to help the child become more comfortable and cooperative before proceeding to more invasive examinations like otoscopy. Therefore, examining the tympanic membrane at the beginning is not recommended.

A. Administer opioids for pain. B. Apply bilateral wrist restraints C. Implement a soft diet. D. Offer fluids through a straw.

Correct Answer is B

Explanation

A. Administer opioids for pain:

While pain management is crucial after surgery, opioids may not be the first-line choice for pain relief in toddlers due to their potential side effects, including respiratory depression and sedation. Non-opioid pain relief methods such as acetaminophen or ibuprofen may be preferred, depending on the toddler's age and the surgeon's preference.

B. Apply bilateral wrist restraints:

After a cleft palate repair, it's essential to prevent the toddler from putting hands or objects into their mouth, as this could disrupt the surgical site and compromise healing. Bilateral wrist restraints help to immobilize the toddler's arms and prevent them from reaching the mouth area, reducing the risk of injury and promoting healing.

C. Implement a soft diet:

A soft diet may be appropriate for the toddler once they have fully recovered from the surgery and the surgical site has healed adequately. However, 24 hours postoperative is too soon to introduce a soft diet, as the toddler may still be recovering from anesthesia and experiencing discomfort. It's essential to follow the surgeon's orders regarding diet progression.

D. Offer fluids through a straw:

Offering fluids through a straw may pose a risk of aspiration or injury to the surgical site, especially in the immediate postoperative period. It's crucial to follow the surgeon's instructions regarding feeding methods and avoid using straws until the toddler has fully recovered and the surgical site has healed.

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A nurse on a mental health unit is caring for clients who have various d Bryant traction. When determining that the traction is the following client diagnoses as presenting the greatest risk for suicide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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