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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Free Nursing Study Resources

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.

A. listening as the patient inhales and then go to the next site during exhalation B. listening to at least one full respiration in each location C. listening to sounds through clothing or the hospital gown if the patient is shy D. having the patient breathe in and out rapidly while listening to the breath sounds

Correct Answer is B

Explanation

A. Listening as the patient inhales and then go to the next site during exhalation:
Incomplete assessment-both inhalation and exhalation are needed to detect abnormalities.

B. Listening to at least one full respiration in each location:
This ensures that both phases of the respiratory cycle are assessed for abnormalities.

C. Listening to sounds through clothing or the hospital gown if the patient is shy:
Inappropriate. Breath sounds must be auscultated directly on skin for accurate assessment.

D. Having the patient breathe in and out rapidly while listening to the breath sounds:
Rapid breathing may distort or exaggerate sounds, making accurate assessment difficult.

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Naxlex Comprehensive Predictor Exams

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

While auscultating for breath sounds, the nurse will use the stethoscope correctly by:

Correct Answer is B

Explanation

A patient has been admitted to the hospital with vertebral fractures related to osteoporosis and is in extreme pain. Which type of pain is the patient experiencing?

During a visit to the clinic, a patient states, "The doctor just told me he thought I ought to stop smoking. He doesn't understand how hard I've tried. I just don't know the best way to do it. What should I do?" The nurse's most appropriate response in this case would be:

When auscultating the lungs to assess breath sounds, what anatomical landmark will indicate the bases of the lung fields?

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:

During a health encounter with a patient, which statement by the patient demonstrates readiness for a health education intervention?

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:

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: