An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?

Assess for body image disturbance.

Complete a suicidal risk assessment.

Explore the client’s current life events.

Praise her for seeking professional help.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing body image disturbance is relevant in adolescents but not the priority with self-harm fears and wrist scars, indicating high suicide risk from psychological distress or serotonin dysregulation. A suicidal risk assessment evaluates immediate safety, addressing the neurobiological urgency of potential self-injury over body image concerns.

Choice B reason: Completing a suicidal risk assessment is critical, as self-harm fears and wrist scars suggest active suicidal ideation or past attempts, possibly from depression or trauma. Assessing intent, plan, and means guides urgent interventions like hospitalization, addressing psychological and neurochemical risks to prevent self-injury in this high-risk client.

Choice C reason: Exploring life events provides context for self-harm but is secondary to assessing suicide risk. Stressors may trigger cortisol or serotonin imbalances, contributing to ideation, but evaluating immediate risk of self-harm is urgent to ensure safety, preventing lethal outcomes in an adolescent with evident self-harm history.

Choice D reason: Praising the client for seeking help is supportive but not the priority when self-harm fears and scars indicate high suicide risk. Positive reinforcement does not address immediate evaluation of intent or plan, critical to prevent harm and manage underlying psychological or neurochemical issues promptly.

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Correct Answer is C

Explanation

Choice A reason: Dry skin and inelastic turgor reflect dehydration in DI from antidiuretic hormone deficiency, causing water loss. This is less urgent than hypernatremia (185 mEq/L), which dehydrates brain cells, risking seizures or coma, requiring immediate fluid correction to prevent neurological damage in this critical condition.

Choice B reason: Tachycardia (110 beats/minute) compensates for hypovolemia in DI, where water loss reduces preload, triggering sympathetic activation. This is less critical than hypernatremia (185 mEq/L), which causes cerebral dehydration, necessitating urgent hypotonic fluids to prevent neurological complications, making heart rate secondary.

Choice C reason: Serum sodium of 185 mEq/L indicates severe hypernatremia in DI, where water loss concentrates sodium, dehydrating neurons and risking seizures or coma. Immediate IV hypotonic fluids (e.g., 5% dextrose) correct osmolarity, preventing life-threatening cerebral complications, addressing the urgent pathophysiological crisis in DI.

Choice D reason: Polyuria and thirst are hallmark DI symptoms from water loss but expected and less urgent than hypernatremia (185 mEq/L), which threatens neurological function via osmotic brain injury. Correcting sodium is critical to prevent seizures, making these symptoms secondary to urgent electrolyte management.

A. Measure capillary glucose level. B. Monitor for bloody diarrheal stools. C. Obtain vital signs measurements. D. Encourage ambulation in the room.

Correct Answer is C

Explanation

Choice A reason: Measuring glucose monitors corticosteroid-induced hyperglycemia, but a rigid abdomen with rebound tenderness suggests peritonitis, possibly from IBD-related perforation. Vital signs detect systemic effects like sepsis (e.g., tachycardia), more urgent than glucose, as perforation is a life-threatening emergency requiring immediate intervention to prevent shock.

Choice B reason: Monitoring bloody diarrhea is relevant in IBD, but a rigid abdomen with rebound tenderness indicates peritonitis, likely from perforation. Vital signs assess systemic stability (e.g., fever, hypotension), critical for detecting life-threatening complications like sepsis, making this more urgent than tracking expected IBD symptoms.

Choice C reason: A rigid abdomen with rebound tenderness suggests peritonitis from bowel perforation in IBD, causing peritoneal irritation. Vital signs (e.g., heart rate, BP, temperature) detect shock or infection, guiding urgent interventions like surgery or antibiotics. This assessment prioritizes rapid response to a potentially fatal surgical emergency.

Choice D reason: Encouraging ambulation is contraindicated with a rigid abdomen and rebound tenderness, indicating peritonitis. Movement may worsen peritoneal irritation or infection spread. Vital signs assess systemic compromise, critical for managing perforation, ensuring timely intervention to prevent sepsis or shock, making ambulation inappropriate.

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An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?

Nursing Test Bank

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