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: Showing the client how to clean assumes cognitive capacity impaired in schizophrenia, where psychosis or disorganized thinking drives behaviors like fecal smearing. This may reflect delusions, not a lack of cleaning knowledge. Escorting the client out prioritizes hygiene and safety, allowing psychiatric assessment over teaching in an acute situation.

Choice B reason: Assisting with cleaning risks reinforcing the behavior and exposes both to pathogens like E. coli in feces. Schizophrenia may impair compliance or understanding. Escorting the client out ensures safety and hygiene, enabling evaluation of psychotic triggers, making this less appropriate than removing the client from the situation.

Choice C reason: Escorting the client out prevents further pathogen exposure, as feces carry infection risks (e.g., gastroenteritis). In schizophrenia, smearing may stem from psychosis, requiring psychiatric evaluation. This action ensures hygiene and safety, allowing assessment of underlying mental health issues, addressing the behavior’s root cause effectively.

Choice D reason: Explaining that feces belong in the toilet assumes rational understanding, impaired in schizophrenia due to disorganized thought or delusions. This behavior likely reflects psychosis. Escorting the client out prioritizes hygiene and safety, followed by psychiatric intervention, making explanation less effective than immediate removal from the contaminated area.

A. Encourage oral electrolyte solution intake. B. Contact their healthcare provider immediately. C. Provide a quiet time by holding or rocking the toddler. D. Assist the child to a recumbent position.

Correct Answer is B

Explanation

Choice A reason: Electrolyte solutions address dehydration but are inappropriate for pale, cool, lethargic symptoms in Tetralogy of Fallot (TOF), indicating a hypercyanotic spell from right-to-left shunting. Urgent medical intervention restores oxygenation, making this inadequate compared to addressing the critical hypoxic episode requiring provider attention.

Choice B reason: Pale, cool, lethargy in TOF signals a hypercyanotic spell, where pulmonary stenosis increases right-to-left shunting, causing cyanosis and hypoxia. Contacting the provider ensures rapid interventions (e.g., oxygen, beta-blockers), preventing cerebral hypoxia or cardiac arrest, addressing the urgent pathophysiological crisis effectively.

Choice C reason: Quiet time by holding or rocking may calm the toddler but does not treat hypoxic spells in TOF, where pale, cool symptoms indicate shunting and hypoxia. Delaying medical intervention risks severe hypoxia, making this less critical than contacting the provider for urgent management.

Choice D reason: A recumbent position worsens TOF’s hypercyanotic spell, increasing venous return and shunting, exacerbating hypoxia. Knee-chest positioning reduces shunting. Contacting the provider is urgent to address pale, cool, lethargic symptoms, ensuring interventions to restore oxygenation, making this position contraindicated.

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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

Naxlex Comprehensive Predictor Exams

An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?

Correct Answer is C

Explanation

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Correct Answer is B

Explanation

A client with a history of schizophrenia, and drug and alcohol abuse is admitted to the hospital for hepatitis. The nurse should contact the healthcare provider before implementing which prescription?

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