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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.
B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.
C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.
D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.
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.
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