A 30-year-old female is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of prior suicide attempts. She describes difficulty sleeping at night and has lost 4.5 kg (10 lb) in the past month. Which of the following is the nurse's best response in this situation?

"How do other people treat you?"

"People often feel hopeless, but the feeling resolves within a few weeks"

"Do you own any lethal weapon?"

"Are you feeling so hopeless that you feel like hurting yourself now?"

Answer and Explanation

The Correct Answer is D

A. "How do other people treat you?":
Not focused on the patient’s safety or suicidal ideation-may divert from the urgent concern.

B. "People often feel hopeless, but the feeling resolves within a few weeks":
Minimizes the patient’s distress and offers false reassurance.

C. "Do you own any lethal weapon?":
Important later in risk assessment, but first establish if the patient has suicidal thoughts.

D. "Are you feeling so hopeless that you feel like hurting yourself now?":
Direct, therapeutic, and necessary. It assesses current suicide risk in a nonjudgmental and supportive way.

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Correct Answer is C

Explanation

A. The aortic valve is best heard at the third intercostal space at the right of the midclavicular line:
Incorrect intercostal space. Aortic valve is heard at the second intercostal space, right sternal border.

B. The mitral valve is heard at the second intercostal space in the midclavicular line:
Incorrect. Mitral valve is heard at the fifth intercostal space, midclavicular line (apex).

C. The tricuspid valve is heard at the fourth intercostal space at the left of the sternal border:
This is the accurate location for auscultating the tricuspid valve.

D. The pulmonic valve is heard at the fourth intercostal space at the left of the sternal border:
Incorrect. The pulmonic valve is heard at the second left intercostal space, not the fourth.

A. The mother enjoys preparing nutritious, well-balanced meals for her family. B. The mother is a lone parent and works as a waitress at a small diner. C. The mother has a very supportive husband, who has a stable, high-paying job. D. The mother is very committed to a healthy lifestyle.

Correct Answer is B

Explanation

A. The mother enjoys preparing nutritious, well-balanced meals for her family:
Indicates positive health practices and is not a concern.

B. The mother is a lone parent and works as a waitress at a small diner:
Single parenting and low-income employment may pose risk factors for health challenges due to financial strain, limited access to resources, and potential stress.

C. The mother has a very supportive husband, who has a stable, high-paying job:
Suggests a stable family environment with fewer risk indicators for poor health.

D. The mother is very committed to a healthy lifestyle:
Indicates protective behavior, not a cause for concern.

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Naxlex Comprehensive Predictor Exams

When auscultating the heart, which of the following statements is true?

Correct Answer is C

Explanation

A young mother and her three young children are attending clinic today. During assessment, what information might cause the nurse to have concerns about the family's health?

Correct Answer is B

Explanation

When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. The nurse's next action should be to:

Which of the following is accurate regarding the first heart sound or S1?

What is the expected breath sounds noted over the main bronchi of an adult?

The nurse is assessing a 64-year-old patient whose vital signs are normal, with a capillary refill time of 5 seconds. What should the nurse do next?

To ensure privacy while assessing a patient in a shared hospital room, the nurse needs to use curtains to achieve:

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is:

When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are: