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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["E","F","H"]
Explanation
Choice A rationale:
This order is useful to evaluate the client's electrolyte levels, renal function, and acid-base balance, as she has ERSD and missed her dialysis session. She may have hyperkalemia, metabolic acidosis, or uremia, which can affect her cardiac and neurological status.
Choice B rationale:
This order is helpful to assess the client's cardiac structure and function, as she has a history of CAD and HTN and may have developed heart failure or valvular disease.
Choice C rationale:
This order is beneficial to rule out any intra-abdominal causes of the client's nausea and poor appetite, such as infection, obstruction, or bleeding.
Choice D rationale:
This order is necessary to identify any possible source of infection or sepsis, as the client has been ill for 3 days and has a history of diabetes, which can impair her immune system.
Choice E rationale:
This order is important to assess the client's cardiac and pulmonary status, as she has a history of CAD and is presenting with chest discomfort and lightheadedness, which could indicate a cardiac event or pulmonary edema.
Choice F rationale:
This order is essential to monitor the client's heart rate and rhythm, as she has a history of CAD and HTN and is at risk for arrhythmias, ischemia, and infarction.
Choice G rationale:
This order is important to evaluate the client's hematological status, as she has ERSD and may have anemia, leukocytosis, or thrombocytopenia.
Choice H rationale:
This order is crucial to obtain a baseline of the client's cardiac electrical activity and to detect any signs of acute coronary syndrome, such as ST-segment elevation or depression, T wave inversion, or Q waves.
Correct Answer is D
Explanation
Choice A rationale:
An adult with schizophrenia who often refuses to take prescribed antipsychotic medications may require a different approach, such as medication education or supportive therapy.
Choice B rationale:
A hyperactive 4-year-old who has recently been tested for autism may benefit from play therapy or other age-appropriate interventions rather than role-playing.
Choice C rationale:
An older adult resident of a long-term care facility who sometimes takes other residents' belongings may require interventions focused on behavior management and addressing the underlying causes of this behavior.
Choice D rationale:
Role-playing can be an effective therapeutic intervention for individuals who need to practice social skills, communication, and problem-solving in a safe and controlled environment. In this case, the adolescent who is depressed over not being accepted by peers may benefit from role-playing to develop and practice social skills, assertiveness, and coping strategies for peer interactions.
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