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 A

Explanation

A. "As depression lifts, physical energy becomes available to carry out suicide." This statement highlights a critical consideration in the care of severely depressed clients. When a client's depression starts to improve due to antidepressant therapy, there may be a period where they have increased energy but have not yet gained full relief from their depressive thoughts. This can potentially increase the risk of carrying out suicidal thoughts or plans.

B. "Suicide may be precipitated by a variety of internal and external events." While this statement is true, it does not specifically address the importance of monitoring a client during antidepressant therapy.

C. "Suicidal clients have difficulty using social supports." This statement acknowledges a potential challenge for clients who are experiencing suicidal thoughts, but it does not directly relate to the need for close monitoring during antidepressant therapy.

D. "Suicide is an impulsive act that has no warning." This statement is not entirely accurate. While some suicides can be impulsive, many individuals give warning signs or exhibit changes in behavior before attempting suicide.

A. Clients who have received long-term neuroleptic treatment. B. Clients who have discontinued their neuroleptic treatment. C. Clients who have experienced neuroleptic malignant syndrome (NMS). D. Clients who have received monoamine oxidase inhibitors (MAOIS).

Correct Answer is A

Explanation

A) Correct. Tardive dyskinesia is a side effect of long-term neuroleptic (antipsychotic) treatment. It is characterized by involuntary, repetitive movements, particularly of the face and tongue. This condition is more commonly seen in clients who have been on neuroleptics for extended periods.

B) Incorrect. Discontinuing neuroleptic treatment may lead to withdrawal symptoms or symptom recurrence, but it does not directly increase the risk of developing tardive dyskinesia.

C) Incorrect. Neuroleptic malignant syndrome (NMS) is a different side effect associated with neuroleptic medications, characterized by hyperthermia, autonomic dysregulation, altered mental status, and generalized muscle rigidity.

D) Incorrect. Monoamine oxidase inhibitors (MAOIs) are a different class of medications and are not associated with the development of tardive dyskinesia.

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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

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed client during antidepressant therapy?

Correct Answer is A

Explanation

What client population is at risk of developing tardive dyskinesia?

Correct Answer is A

Explanation

Which nursing documentation entry accurately describes a client's use of confabulation?

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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The client is experiencing a manic episode. Which of the following activities will be included in the plan of care?

The nurse observes a client drooling during mealtime. The client complains that his tongue feels swollen, and his jaw feels tight. What is the first action by the nurse?