A client has a diagnosis of risk for suicide r/t a past attempt. Which of the following outcome should the nurse prioritize?

The client will verbalize 3 positive attributes about themselves by day 3

The client will perform personal hygiene with no prompting

The client will attend group by day 2

The client will remain free from injury for duration of their hospitalization

Answer and Explanation

The Correct Answer is D

A. The client will verbalize 3 positive attributes about themselves by day 3. This is a good long-term goal but does not directly prevent self-harm.

B. The client will perform personal hygiene with no prompting. Improved self-care is beneficial but is not the primary priority in suicide prevention.

C. The client will attend group by day 2. Participation in therapy is helpful, but ensuring physical safety takes precedence.

D. The client will remain free from injury for the duration of their hospitalization. The most critical goal for a client at risk for suicide is preventing self-harm, making this the priority outcome.

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Correct Answer is D

Explanation

A. The client has a pleasant affect: "Affect" refers to outward emotional expression, whereas "mood" is the client's internal emotional state.

B. The client appears happy with an elevated mood: The nurse should document objective data rather than interpreting the client’s emotions.

C. The client self-isolated today: While self-isolation may indicate mood disturbances, it does not directly document the client’s reported mood.

D. The client rates their mood 4 out of 10: This entry reflects the client’s subjective report using a measurable scale, making it the most accurate documentation.

A. Weight gain/loss B. Dry mouth C. Insomnia D. Rash

Correct Answer is D

Explanation

A. Weight gain/loss. Weight changes (gain or loss) are common with antidepressants, particularly SSRIs and TCAs.

B. Dry mouth. Dry mouth is a well-known side effect of many antidepressants, especially tricyclic antidepressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

C. Insomnia. Many antidepressants, particularly SSRIs and SNRIs, can cause insomnia or increased energy levels.

D. Rash. A rash is not a common side effect of antidepressants. While allergic reactions can occur, they are not considered routine side effects.

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A client has a diagnosis of risk for suicide r/t a past attempt. Which of the following outcome should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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