A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

"I just feel like my life is filled with emptiness."

"I have three firearms locked in a safe at home."

"My daughter is the only reason I keep trying."

"My panic attacks happen once every month."

Answer and Explanation

The Correct Answer is B

Choice A rationale:
This statement expresses the client's emotional state but does not provide information about immediate access to lethal means.

Choice B rationale:
This comment is the most crucial to document because it indicates the client's access to potentially lethal means, which is a significant risk factor for committing suicide.

Choice C rationale:
This statement provides information about a source of support in the client's life but does not indicate immediate access to lethal methods.

Choice D rationale:
This statement provides information about the frequency of panic attacks but does not indicate immediate access to lethal means.

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Correct Answer is C

Explanation

Choice A rationale:
Using an incentive spirometer is not directly related to the post-TUNA discharge instructions for a client with BPH. Incentive spirometry is typically used to improve lung function and prevent respiratory complications.

Choice B rationale:
Monitoring the urinary stream for a decrease in output may be important, but it is a general instruction that may not be specific to the TUNA procedure. The primary focus after TUNA is often on monitoring for complications related to the procedure.

Choice C rationale:
Reporting when hematuria (blood in the urine) becomes pink-tinged is important. While some degree of hematuria is expected after TUNA, a change in color to pink or any other concerning changes should be reported to the healthcare provider as it could indicate complications.

Choice D rationale:
There is typically no need to restrict physical activities after a TUNA procedure. In fact, healthcare providers often encourage patients to resume normal activities gradually unless otherwise instructed due to specific complications.

A. Ask the client why she checks the locks. B. Determine the type and size of the locks. C. Discuss checking the time frequently. D. Plan a list of activities to be carried out daily.

Correct Answer is D

Explanation

A. "Ask the client why she checks the locks."
Asking "why" questions may put the client on the defensive and does not effectively address the compulsive behavior. Clients with obsessive-compulsive disorder (OCD) often do not have a logical explanation for their compulsions.

B. "Determine the type and size of the locks."
This action does not address the client’s compulsive behavior and is not relevant to the nursing intervention. The focus should be on reducing the compulsive behavior rather than assessing the locks themselves.

C. "Discuss checking the time frequently."
This response does not directly address the client’s compulsive checking behavior. Instead, structured interventions that promote time management and coping strategies should be implemented.

D. "Plan a list of activities to be carried out daily."
Providing a structured daily schedule can help redirect the client’s focus away from compulsive behaviors and toward productive activities. A schedule can reduce anxiety and limit the time available for compulsions, promoting better functioning.

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A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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