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. Encouraging descriptions of perceived failures may further exacerbate the client's poor self- esteem and is not a therapeutic intervention.
B. While setting limits is important in managing behavior, it may not directly address the underlying issue of poor self-esteem.
C. Providing activities that can be accomplished can help boost the client's confidence and self- esteem.
D. Teaching aggressive communication skills is not appropriate and may contribute to further negative self-perception.

A. Institute reverse isolation B. Withhold the next dose of medication C. Begin high protein, high cholesterol diet D. Notify health care provider stat

Correct Answer is D

Explanation

A) Incorrect. Reverse isolation is not indicated in this situation. The client's symptoms are likely due to a side effect of the medication, not an infectious process.

B) Incorrect. While it may be necessary to withhold the next dose of medication, the client's symptoms require more immediate attention.

C) Incorrect. The client's symptoms are indicative of a serious adverse reaction, and dietary changes would not address the issue.

D) Correct. The client's symptoms, including severe muscle stiffness, difficulty swallowing, drooling, diaphoresis, and elevated vital signs, are indicative of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like risperidone.
The nurse should notify the healthcare provider immediately for further guidance and intervention.

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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

The nurse is caring for a client with poor self-esteem. What intervention would be important for the nurse to include in the plan of care?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms?

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