An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?

"Why do you want to kill yourself?"

"Do you have access to medications?"

"Have you been taking drugs and alcohol?"

"Did something happen with your parents?"

Answer and Explanation

The Correct Answer is B

A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.

B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.

C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.

D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.

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Correct Answer is C

Explanation

A) Incorrect. This statement does not provide relevant information about the medication or potential risks.

B) Incorrect. This statement is not accurate and may cause unnecessary concern or confusion for the client.

C) Correct. Adolescents and young adults prescribed with antidepressant medications should be informed about the potential increased risk of suicidal thoughts or behaviors, especially in the early stages of treatment. This information is important for the client's safety and allows for appropriate monitoring.

D) Incorrect. Doubling the dose if a dose is missed is not a safe or appropriate practice. The client should be instructed on what to do if they miss a dose according to their healthcare provider's instructions.

A. An idea of reference B. A delusion of infidelity C. An auditory hallucination D. Echolalia

Correct Answer is A

Explanation

A) Correct. An idea of reference is a false belief that ordinary events, objects, or behaviors of others have a particular and unusual meaning directly pertaining to oneself. In this case, the client believes that the doctors' conversation in the hall is about them.

B) Incorrect. A delusion of infidelity involves a false belief that one's partner is being unfaithful.
C) Incorrect. Auditory hallucinations involve hearing things that are not present.
D) Incorrect. Echolalia is the repetition of another person's words.

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An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A physician has prescribed an antidepressant medication for a 15yearold client. Which statement would be appropriate for inclusion in medication teaching?

Correct Answer is C

Explanation

A newly admitted client diagnosed with paranoid schizophrenia is super vigilant and constantly scans the environment. The client states, "I saw doctors talking in the hall. They were plotting to kill me." Which of the following does the nurse correctly identify as this behavior?

Correct Answer is A

Explanation

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