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. Isolating the client in his room may escalate the situation or make the client feel isolated and misunderstood.

B) Incorrect. Asking the client to stop talking may be perceived as confrontational and could potentially agitate the client further.

C) Correct. Speaking slowly and in a quiet voice can help the client focus and may reduce the flight of ideas. This calm approach can be grounding for the client.

D) Incorrect. Encouraging the client to talk more may exacerbate the flight of ideas and the manic state.

A. Diaphoresis, piloerection, tremors, irritability, insomnia, nausea, and vomiting. B. Diaphoresis, hypertension, hand tremors, hallucination/illusions, and potential seizures. C. Cravings, depression, fatigue, hypersomnolence, and impaired judgment. D. Heightened sense of self, hallucinations, flashbacks, incoordination, and panic attacks.

Correct Answer is A

Explanation

A) Correct. These symptoms are indicative of opioid withdrawal. Opioid withdrawal symptoms include sweating (diaphoresis), goosebumps (piloerection), tremors, irritability, insomnia, and gastrointestinal symptoms like nausea and vomiting.

B) Incorrect. These symptoms are more indicative of withdrawal from substances like alcohol or benzodiazepines, rather than opioids.

C) Incorrect. These symptoms are not specific to opioid withdrawal and may be seen in various conditions.

D) Incorrect. This cluster of symptoms is not characteristic of opioid withdrawal.

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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 client diagnosed with bipolar I disorder is in a manic state, rushing about the unit, and talking regularly with a flight of ideas. What is the most therapeutic intervention?

Correct Answer is C

Explanation

The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor using a Clinical Opioid Withdrawal Scale (COWS). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?

Correct Answer is A

Explanation

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