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 correct answer is D: Checking the patient's belongings for dangerous items. This is important to ensure the safety of the patient and others. By removing any potential harmful items, the risk of another suicide attempt or harm to others can be minimized. This intervention takes priority over the other options as safety is the immediate concern. A: Allowing the patient to return to her previous room may not address the safety issue and could potentially put the patient at risk. B: Orienting the patient to the unit is important but ensuring safety should come first. C: Building trust through therapeutic communication is crucial in the long term, but immediate safety should be the priority.

Correct Answer: B

Rationale: The correct answer is B: Secondary. The sister is considered a secondary information source because she is not the patient themselves. Secondary sources provide information based on knowledge of the primary source (the patient). Primary sources are the patients themselves. Private (C) refers to confidentiality, not the source of information. Informed (D) does not specify the relationship to the patient.

Correct Answer: B

Rationale: The correct answer is B because it reflects active listening and empathy. By acknowledging the patient's conflicting verbal and nonverbal cues, the response shows understanding and encourages further exploration of the patient's feelings. Choice A minimizes the patient's emotions, choice C may come off as confrontational, and choice D makes assumptions without seeking clarification. Overall, choice B promotes a therapeutic relationship by addressing the discrepancy between the patient's words and body language.

Correct Answer: A

Rationale: The correct answer is A: Environmental. Keeping the door open during the assessment is an environmental communication factor because it influences the physical setting where communication takes place. This action ensures transparency and promotes a sense of safety and trust between the nurse and the client. It allows for privacy while still maintaining visibility and accessibility, facilitating effective communication. Summary: - A: Environmental (Correct): Keeping the door open influences the physical setting, promoting transparency and trust. - B: Relationship: This choice refers to the connection between the nurse and the client, not the physical environment. - C: Personal: This refers to individual characteristics or preferences, not the physical environment. - D: Message: This refers to the content of the communication, not the physical setting.

Correct Answer: B

Rationale: The correct answer is B because genetic vulnerability plays a significant role in mental illness. Hugo and Franco, being fraternal twins, may have different genetic predispositions. This means that Hugo may have inherited genetic factors that make him more susceptible to mental illness compared to Franco. Therefore, even though they were raised in the same dysfunctional household, Hugo's genetic vulnerability could be the reason for his mental illness. Choices A, C, and D are incorrect because they do not address the key factor of genetic vulnerability. Choice A suggests a different reason related to abuse by their father, choice C implies Franco's ignorance of the situation, and choice D refers to Hugo's coping mechanism rather than genetic predisposition.