The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

A 16-year-old client diagnosed with major depression who refuses to participate in group.

A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.

An 18-year-old client with antisocial behavior who is being yelled at by other clients.

A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.

Answer and Explanation

The Correct Answer is B

Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.

Choice B reason: This client requires immediate intervention because pacing can be a sign of agitation, restlessness, or escalating mania. Clients with bipolar disorder in a manic phase may exhibit increased energy, impulsivity, irritability, and even aggression. If not addressed promptly, this behavior could escalate to disruptive outbursts, impulsive actions, or even violence toward themselves or others. The nurse should intervene by using calm communication, redirection, and possibly medication if prescribed to help de-escalate the situation and ensure safety.

Choice C reason: This scenario involves peer conflict, which is important to address, but it does not necessarily indicate an immediate risk of harm. Clients with antisocial behavior often engage in conflict due to manipulative or confrontational tendencies, but being yelled at does not mean they are in immediate danger. The nurse should monitor the situation and intervene to prevent escalation, but other safety concerns take priority.

Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.

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Free Nursing Study Resources

Correct Answer is ["4"]

Explanation

Step 1 is to convert the child’s weight from pounds to kilograms.

44 pounds ÷ 2.2 = 20 kilograms.

Result at each step = 20 kilograms.

Step 2 is to calculate the total dosage of furosemide in milligrams.

2 mg × 20 kg = 40 mg.

Result at each step = 40 mg.

Step 3 is to determine the volume of medication to administer in milliliters.

40 mg ÷ 10 mg/mL = 4 mL.

Result at each step = 4 mL.

The nurse should administer 4 mL.

A. Obtain a capillary glucose level. B. Feed 30 mL of 10% dextrose in water. C. Wrap tightly in a blanket. D. Encourage the mother to breastfeed.

Correct Answer is A

Explanation

Choice A: Obtain a capillary glucose level. This is the first action that the nurse should do, as it can diagnose hypoglycemia, which is a low blood sugar level that can cause jitteriness and tachypnea in newborns. Hypoglycemia can be caused by maternal diabetes, prematurity, infection, or delayed feeding. The nurse should check the glucose level using a heel stick and a glucometer.

Choice B: Feed 30 mL of 10% dextrose in water. This is not the first action that the nurse should do, as it may not be appropriate for all newborns with jitteriness and tachypnea. Feeding 10% dextrose in water can raise the blood sugar level, but it may also cause rebound hypoglycemia or fluid overload. The nurse should feed only after confirming hypoglycemia and obtaining a healthcare provider's order.

Choice C: Wrap tightly in a blanket. This is not the first action that the nurse should do, as it may not address the underlying cause of jitteriness and tachypnea in newborns. Wrapping tightly in a blanket can prevent heat loss and conserve energy, but it may also impair breathing or circulation. The nurse should wrap only after ruling out other causes of jitteriness and tachypnea.

Choice D: Encourage the mother to breastfeed. This is not the first action that the nurse should do, as it may not be feasible or effective for all newborns with jitteriness and tachypnea. Breastfeeding can provide nutrition and bonding for newborns, but it may also be difficult or contraindicated for some newborns with respiratory distress or infection. The nurse should encourage breastfeeding only after assessing and stabilizing the newborn's condition.

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The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenously every 12 hours. The medication is available at 10 mg/mL. How many mL should the nurse administer? (Enter numeric value only)

Correct Answer is ["4"]

Explanation

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

Correct Answer is A

Explanation

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