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: Going to the ER for glucose is unnecessary unless hypoglycemia or ketoacidosis is confirmed. Type 1 diabetes with nausea risks hyperglycemia from stress hormones like cortisol. Monitoring glucose and fluids manages the condition at home, preventing escalation unless severe symptoms arise, making this instruction premature.

Choice B reason: Drinking regular cola introduces high sugar, risking hyperglycemia in type 1 diabetes, where insulin deficiency impairs glucose uptake. Stress from illness elevates glucose via glucagon. Monitoring with non-sugar fluids prevents dehydration and ketoacidosis, making this advice dangerous and ineffective for diabetes management.

Choice C reason: Monitoring blood glucose and drinking fluids is critical in type 1 diabetes during illness. Nausea reduces intake, and stress hormones raise glucose, risking ketoacidosis. Frequent checks guide insulin adjustments, and fluids prevent dehydration, maintaining metabolic stability, addressing the physiological needs of insulin deficiency and infection.

Choice D reason: Avoiding insulin risks diabetic ketoacidosis, as type 1 diabetes requires basal insulin despite nausea. Illness increases glucose via stress hormones, even without food. Monitoring allows tailored dosing, preventing hyperglycemia, making this instruction harmful, as it ignores ongoing insulin needs for metabolic control.

A. It’s important to be out of your room and talking to others. B. Watching TV is a passive activity and we want you to be active. C. Sometimes clients feel like the TV is sending them messages. D. You can watch TV as much as you want outside of your room.

Correct Answer is A

Explanation

Choice A reason: Depression involves social withdrawal, driven by low serotonin or dopamine. Encouraging the client to leave the room and engage socially stimulates oxytocin release and cognitive behavioral benefits, counteracting isolation. This therapeutic approach enhances mood and aligns with depression management goals, making it the most effective response.

Choice B reason: Calling TV a passive activity is partially true but less therapeutic, as it doesn’t directly promote social engagement. Depression treatment prioritizes interpersonal interaction to boost neurotransmitters like serotonin. This response misses the opportunity to encourage social therapy, critical for alleviating depressive symptoms in a mental health setting.

Choice C reason: Suggesting TV sends messages is inappropriate without psychotic symptoms, not indicated in this client’s depression. Depression involves low mood, not delusions. This could confuse or stigmatize, failing to promote social engagement, which is essential for improving mood via neurochemical and behavioral pathways in depression management.

Choice D reason: Allowing unlimited TV outside the room does not address depression’s social isolation. Excessive TV may reinforce withdrawal, reducing therapeutic group activities that enhance serotonin. This lacks focus on active engagement, critical for recovery, making it less effective than encouraging social interaction to improve mental health outcomes.

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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

A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide?

Correct Answer is C

Explanation

The nurse orients a client with depression to a new room on the mental health unit. The client states, “It seems strange that I don’t have a television (TV) in my room.” Which statement is best for the nurse to provide?

Correct Answer is A

Explanation

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