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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Critical Thinking:
Critical thinking is the foundation of sound clinical judgment and decision-making.

B. Diagnostic reasoning:
Part of critical thinking, but it's more focused on identifying a diagnosis rather than the broader assessment and decision process.

C. Clinical Knowledge:
Clinical knowledge is necessary, but alone, it doesn’t drive decision-making without critical thinking.

D. The Nursing Process:
The nursing process is a framework, but critical thinking underpins how the process is applied.

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Expert nurses assess and make decisions through the use of:

Correct Answer is A

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

What are some conditions for which the nurse would normally screen a 75-year-old patient?

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

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?

While auscultating heart sounds, the nurse hears a murmur. Which of these modes should be used to assess this murmur?

When performing a female breast examination, the nurse notes the left breast to be larger than the right. What should the nurse tell the patient?

During a cardiovascular assessment, the nurse knows that a thrill is:

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: