A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan?
Moderate level
High level
No risk
Low level
The Correct Answer is B
A. Moderate level would suggest a plan that has some risk but may be less imminent or less likely to result in death.
B. A plan involving a loaded gun aimed at a vital organ like the heart, coupled with alcohol consumption and intent, indicates a high level of lethality.
C. This scenario presents a significant risk given the method and the caller's intent, so "No risk" would not be appropriate.
D. Low level would suggest a plan that is less likely to cause severe harm or death, which is not the case here.
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Related Questions
Correct Answer is D
Explanation
A. While social support is essential, sudden changes in behavior warrant assessment and understanding before taking the client outside the facility.
B. Monitoring might be necessary but does not directly address the reason behind the sudden change in behavior.
C. This approach may reinforce the behavior without addressing the underlying cause.
D. This intervention is crucial for assessment and understanding the sudden shift in the client's mood, which could provide insight into the effectiveness of the treatment or other factors contributing to the change.
Correct Answer is C
Explanation
A. Sleep disturbances are common in PTSD but might not address the immediate distress related to the sexual assault.
B. While discussing triggers is relevant, it might not directly address the current acute symptoms of reliving the traumatic event.
C. Asking about current experiences of flashbacks directly relates to one of the hallmark symptoms of PTSD, especially given the recent severe anxiety related to the assault.
D. Avoidance behavior is a symptom of PTSD, but asking about flashbacks addresses more immediate distress.
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