A nurse is performing a psychosocial assessment on an adolescent client.
Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply)

Recent or impending move

Sudden decline in school performance

Death of a parent at a young age

Low parental expectations.

Answer and Explanation

Correct Answer : A,B,C

The correct answer/s is Choices A, B, and C.

Choice A Rationale:

Recent or impending moves can be a significant stressor for adolescents, disrupting their social networks, routines, and sense of belonging. This disruption can exacerbate existing mental health problems or trigger new ones, increasing the risk of suicidal ideation or behavior. Studies have shown that adolescents who relocate are more likely to experience depression, anxiety, and substance abuse, all of which are risk factors for suicide. Additionally, the feeling of loss and displacement associated with moving can lead to feelings of isolation and hopelessness, further increasing the risk.

Choice B Rationale:

A sudden decline in school performance can be a sign of underlying emotional distress in adolescents. This decline may be due to depression, anxiety, or other mental health problems that can impede concentration, motivation, and overall academic functioning. Suicidal ideation or behavior can also lead to a decline in school performance as the adolescent withdraws from their usual activities and struggles to cope with their emotions. Therefore, a sudden drop in grades or academic engagement should raise a red flag for the nurse and warrant further investigation into the adolescent's emotional well-being.

Choice C Rationale:

The death of a parent at a young age is a major life event that can have a profound impact on an adolescent's emotional and psychological development. This loss can lead to feelings of grief, sadness, anger, and isolation, all of which are risk factors for suicide. Additionally, adolescents who lose a parent may be more likely to experience depression, anxiety, and substance abuse, further increasing their vulnerability to suicidal thoughts and behaviors. The nurse should be particularly concerned if the death of the parent was recent or if the adolescent has not adequately processed their grief.

Choice D Rationale:

While low parental expectations can be a negative influence on an adolescent's self-esteem and motivation, it is not directly linked to an increased risk of suicide. In fact, some studies have suggested that high parental expectations can be equally detrimental to adolescent mental health. Therefore, while low parental expectations may not be a standalone risk factor for suicide, it is important to consider this factor in the context of the adolescent's overall psychosocial assessment.

Summary:

A recent or impending move, a sudden decline in school performance, and the death of a parent at a young age are all significant stressors that can increase the risk of suicidal ideation or behavior in adolescents. The nurse should be alert to these warning signs and conduct a thorough psychosocial assessment to identify any underlying mental health issues or risk factors. Early intervention and support can significantly reduce the risk of suicide and help adolescents cope with these challenging life events.

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Correct Answer is A

Explanation

Choice A rationale:

The client’s reported behavior of using laxatives and inducing vomiting after eating can lead to a condition known as hypomagnesemia. Hypomagnesemia is a condition characterized by low levels of magnesium in the blood. This condition can be caused by poor intake, excessive loss, or movement of magnesium from the blood into less accessible locations. The use of laxatives can lead to excessive loss of magnesium through increased bowel movements. Similarly, self-induced vomiting can also result in a loss of magnesium. Therefore, the client’s behavior puts them at risk for developing hypomagnesemia.

Choice B rationale:

Renal failure, also known as kidney failure, occurs when the kidneys lose their ability to filter waste products from the blood. While the use of laxatives and self-induced vomiting can lead to dehydration, which can strain the kidneys, these behaviors are not directly associated with renal failure. Therefore, while it’s possible for the client to develop kidney problems, it’s less likely compared to hypomagnesemia.

Choice C rationale:

Heart failure occurs when the heart muscle doesn’t pump blood as well as it should. This condition can cause symptoms like shortness of breath, swelling, fatigue, and other symptoms. While severe electrolyte imbalances, such as those that might result from the use of laxatives and self-induced vomiting, can affect heart function, they would typically result in arrhythmias (irregular heartbeats) rather than heart failure. Therefore, it’s less likely for the client to develop heart failure based on the behaviors described.

Choice D rationale:

Hyperthyroidism is a condition where the thyroid gland produces and releases too much thyroid hormone. This condition can cause symptoms like rapid heartbeat, weight loss, and anxiety. The client’s behaviors of using laxatives and inducing vomiting after eating do not directly influence the production of thyroid hormones. Therefore, it’s less likely for the client to develop hyperthyroidism based on the behaviors described.

A. The client tells the nurse that he is too tired to attend the group meeting. B. The client states, "I see purple bugs crawling on the wall." C. The client tells the nurse he is a government agent. D. The client states, "My heart is pounding out of my chest.".

Correct Answer is D

Explanation

Choice A rationale: Feeling too tired to attend a group meeting does not necessarily indicate anxiety. It could be due to various reasons such as lack of sleep, side effects of medication, or lack of motivation, which are not indications for administering lorazepam.

Choice B rationale: Seeing “purple bugs crawling on the wall” is a hallucination, which is a symptom of schizophrenia, not anxiety. Lorazepam is not typically used as the first-line treatment for hallucinations.

Choice C rationale: Believing that he is a government agent is a delusion, which is a symptom of schizophrenia. Lorazepam is not typically used as the first-line treatment for delusions.

Choice D rationale: “My heart is pounding out of my chest” is a common symptom of anxiety. It indicates that the client might be experiencing physiological symptoms of anxiety such as increased heart rate and palpitations. In this case, administering lorazepam, which is an anxiolytic medication, would be appropriate.

In conclusion, the nurse should consider administering lorazepam when the client states, “My heart is pounding out of my chest.”

Lorazepam is a medication belonging to the benzodiazepine class, commonly used to treat anxiety and insomnia. It works by slowing down the activity in the brain and nervous system, producing a calming effect.

Generalized Anxiety Disorder (GAD) is a chronic mental health condition characterized by excessive worry and anxiety that persists for at least 6 months, interfering with daily life.

Important Considerations:

Lorazepam is a controlled substance due to its potential for abuse and dependence.

It should only be administered under the supervision of a qualified healthcare professional, who can assess the individual's needs and potential risks.

Self-treating with lorazepam is dangerous and can lead to serious consequences.

If you have concerns about anxiety or are considering using lorazepam, please consult a licensed physician or mental health professional for proper diagnosis and treatment guidance.

Remember,

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A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A mental health nurse is caring for a client who has schizophrenia and generalized anxiety disorder (GAD). The client has a prescription for lorazepam 2 mg PO every 6 hr PRN anxiety.For which of the following client statements should the nurse consider administering lorazepam?

Correct Answer is D

Explanation

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A nurse is performing a psychosocial assessment on an adolescent client.
Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply)