The nurse is caring for a 14-year-old adolescent who was admitted to the hospital after a suicide attempt. The adolescent's mood appears stable, and the healthcare provider has recommended discharge. What is the nurse's priority action?

Correct Answer: A

Rationale: The priority action for the nurse is to ensure that a safety plan is in place before discharge. A safety plan is essential to assist the adolescent in managing future crises and decreasing the likelihood of another suicide attempt. It provides guidance on coping strategies and resources to help the adolescent stay safe in times of distress.

Correct Answer: B

Rationale: In the context of a child with suspected appendicitis, the assessment finding that should be reported to the healthcare provider immediately is sudden relief of pain (Option B). This is a critical sign as it may indicate a ruptured appendix, which is a medical emergency requiring immediate intervention. Sudden relief of pain can occur when the appendix perforates, leading to a temporary decrease in pain sensation due to the leakage of infectious material into the abdominal cavity. Nausea and vomiting (Option A) are common symptoms of appendicitis but are not as concerning as sudden relief of pain. Low-grade fever (Option C) is also a common symptom in appendicitis and may not be as urgent as sudden pain relief. Rebound tenderness (Option D) is a classic sign of appendicitis, but sudden pain relief takes precedence due to the potential complications associated with a ruptured appendix. Educationally, it is important for pediatric nurses to understand the significance of sudden pain relief in a child with suspected appendicitis to ensure prompt recognition and intervention in cases of appendiceal rupture. This knowledge can help prevent delays in treatment and improve patient outcomes.

Correct Answer: C

Rationale: Contact sports should be avoided in mononucleosis due to the risk of spleen rupture, which is a serious complication of the disease. The spleen can enlarge in mononucleosis, making it more susceptible to injury from contact sports, potentially leading to a life-threatening situation if rupture occurs.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to administer a prescribed bronchodilator (Option A). This is based on the assessment findings of a prolonged expiratory phase, wheezing, and a low PEFR of 35% of personal best, indicating respiratory distress in the child with asthma. Administering a bronchodilator aims to relieve bronchoconstriction, improve airway patency, and alleviate the symptoms of wheezing and difficulty breathing, which are crucial in managing an acute asthma exacerbation. This intervention can help improve the child's breathing and prevent further respiratory compromise. Encouraging the child to cough and deep breathe (Option B) may not be effective in addressing the underlying bronchoconstriction and may delay necessary pharmacological treatment. Reporting findings to the healthcare provider (Option C) is important but may cause a delay in providing immediate care to the child in distress. Determining triggers (Option D) is valuable for long-term asthma management but is not the priority in this acute exacerbation scenario. In a pediatric nursing context, timely and appropriate intervention is essential in managing acute asthma exacerbations to prevent respiratory compromise and potential life-threatening complications. Nurses must be prepared to recognize and respond promptly to signs of respiratory distress in pediatric patients with asthma to optimize outcomes and ensure their safety and well-being.

Correct Answer: B

Rationale: During a grand mal seizure, the priority action for the nurse is to ensure the safety of the client. Observing the client carefully allows the nurse to monitor the seizure activity, the client's breathing, and any signs of distress without interfering with the seizure process. Restraining the client or placing objects in the mouth can lead to injury and should be avoided. Calling a CODE is not appropriate for a seizure as it is a normal response to the client's condition.