An adolescent female is readmitted for inpatient care after a suicide attempt. What is the most important nursing intervention to accomplish upon admission?

Correct Answer: D

Rationale: The most important nursing intervention upon admission for an adolescent female readmitted for inpatient care after a suicide attempt is to check the patient's belongings for dangerous items (Option D). This is crucial for ensuring the safety of the patient and others in the unit. Suicide risk assessment and prevention are top priorities in psychiatric nursing care, especially in cases of recent suicide attempts. By thoroughly checking for and removing any potentially harmful items, the nurse can significantly reduce the immediate risk of self-harm. Allowing the patient to return to her previous room (Option A) may not address the safety concerns, as dangerous items could still be present. Orienting the patient to the unit (Option B) and building trust through therapeutic communication (Option C) are important aspects of care but may not take precedence over ensuring immediate safety in this critical situation. In an educational context, understanding the hierarchy of needs in psychiatric nursing is essential. Safety always comes first, especially when dealing with patients at risk of harm to themselves. This question highlights the importance of quick and effective risk assessment and intervention in psychiatric nursing practice.

Correct Answer: A

Rationale: In the context of the psychiatric nurse certification exam, understanding the factors that contribute to preventing adults from developing addictions is crucial for providing effective care and interventions. The correct answer, A) Positive self-image, is a protective factor because individuals who have a positive self-image are more likely to have a strong sense of self-worth and self-efficacy, which can serve as a buffer against the development of addictive behaviors. Option B) Single status is not a protective factor as relationship status alone does not determine one's susceptibility to addiction. Option C) Passive personality is not a protective factor either, as individuals with passive personalities may still be at risk for developing addictions due to various other factors. Option D) Being a parent is not necessarily a protective factor against addiction, as parenthood does not immunize individuals from the risk of developing addictive behaviors. In an educational context, it is important for nurses to understand the complex interplay of factors that contribute to addiction vulnerability. By recognizing and addressing protective factors like positive self-image, nurses can better support individuals in maintaining healthy behaviors and overcoming addictive tendencies. This knowledge equips nurses with the skills to provide comprehensive care and interventions for individuals struggling with addiction.

Correct Answer: C

Rationale: In this scenario, the correct conclusion for the nurse to make about the client's blood alcohol content (BAC) of 0.15 mg/dL is option C: "The client ingested enough alcohol to cause them to experience acute cognitive impairment." This is the correct answer because a BAC of 0.15 mg/dL indicates a high level of alcohol in the bloodstream that can lead to significant impairment of cognitive and motor functions. Option A, stating that the client needs inpatient treatment for their drinking problem, is not the most appropriate conclusion to draw solely based on the BAC level. It is important to assess the client comprehensively before recommending a specific treatment plan. Option B, suggesting that the client has a substance use disorder, is also not directly supported by the BAC level alone. While a high BAC may be indicative of alcohol misuse, a diagnosis of a substance use disorder requires a more comprehensive evaluation. Option D, indicating that the client has been a heavy drinker over the past few months, is not the best conclusion to draw solely based on the BAC level. While a high BAC may suggest recent alcohol consumption, it does not provide definitive information about the client's drinking patterns over an extended period. Educationally, this question highlights the importance of understanding the implications of different BAC levels on a client's cognitive and physical functioning. Nurses need to be able to interpret BAC levels accurately to provide appropriate care and interventions for clients who present with alcohol-related issues.

Correct Answer: A

Rationale: In this scenario, option A is the correct answer as it presents behaviors that are indicative of potential substance use disorder in a nurse. The behaviors of volunteering for overtime to have access to medications without supervision, avoiding witnesses when handling narcotics, and needing to be alone in the medication room are all red flags that suggest potential drug diversion for personal use. Option B, manipulation, is a vague term and does not specifically point towards substance use disorder. Option C, displaying emotional distress and personal sharing, may indicate stress or personal issues rather than substance abuse. Option D, increased cheerfulness and energy, as well as helping others, are positive behaviors and do not strongly suggest substance use disorder. Educationally, it is vital for nurse managers to be able to recognize signs of substance use disorder in their staff to ensure patient safety and support for the affected nurse. Understanding these behaviors can lead to early intervention and appropriate support mechanisms to address the issue effectively. Recognizing these signs is crucial in maintaining a safe and healthy work environment in healthcare settings.

Correct Answer: A

Rationale: In this scenario, option A is the correct choice as it indicates a protective factor in the form of a positive childhood experience. The statement reflects a supportive relationship with the English teacher, which can serve as a protective factor against the negative impact of anxiety. This positive interaction can foster a sense of security and trust for the adolescent. Option B is incorrect because frequent relocations due to parents being in the military can contribute to instability and disrupt the sense of security, potentially exacerbating anxiety in the adolescent. Option C is incorrect as being born to a teenage mother may have certain challenges and stigmas attached to it, which could lead to feelings of insecurity or inadequacy for the adolescent. Option D is also incorrect as the constant worry about the health of a sibling and the parents' absence due to caregiving responsibilities can increase stress and anxiety for the adolescent. Educationally, this question highlights the importance of identifying protective factors in a patient's history that can mitigate the impact of mental health challenges. It underscores the significance of positive relationships and experiences in promoting mental well-being, especially in vulnerable populations like adolescents with anxiety disorders.