A nurse in a community clinic is speaking to a parent who expresses concern for her adolescent son.
Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?
“He spends much of his time with his school friends.”
“He has slept 9 hours each night for the past 2 years.”
“He is very religious and attends services twice a week.”
“His basketball coach committed suicide last month.”
The Correct Answer is D
A rationale:
Spending time with friends can be a protective factor against suicide, as it provides social support and connection.
While isolation can be a risk factor, spending time with friends does not inherently indicate suicide risk.
It's important to assess the quality of relationships and the presence of other risk factors.
Choice B rationale:
Regular sleep patterns often indicate healthy mental health.
Significant changes in sleep patterns (either too much or too little) can be warning signs, but consistent sleep of 9 hours is not typically a concern.
It's essential to evaluate sleep quality and any recent changes.
Choice C rationale:
Religious involvement can provide a sense of purpose, belonging, and support, which can be protective against suicide.
While it's not a guarantee of protection, it's generally a positive factor.
It's crucial to assess the individual's level of engagement and any potential conflicts within their religious beliefs.
Choice D rationale:
Exposure to suicide, especially in a close connection like a coach, can significantly increase a person's risk for suicide.
It can lead to normalization of suicide as a coping mechanism, imitation of behavior, or triggering of underlying mental health issues.
This is a strong risk factor that warrants immediate attention and assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.
Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.
Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.
Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Establishing rapport with the client is essential when caring for someone experiencing acute anxiety. It creates a foundation of trust and understanding, which can help the client feel more comfortable and willing to engage in therapeutic interventions. Here's a detailed explanation of why rapport is crucial in this context:
Reduces Anxiety: A strong rapport can help to reduce the client's anxiety by fostering a sense of safety and security. When a client feels understood and supported, it can help to calm their nervous system and decrease the intensity of their anxiety symptoms.
Increases Communication: Effective communication is essential for identifying the cause of anxiety and developing appropriate interventions. When a nurse has a good rapport with a client, the client is more likely to be open and honest about their thoughts, feelings, and experiences. This can lead to a more accurate assessment and a more effective treatment plan.
Improves Cooperation: Clients who have a good rapport with their nurse are more likely to cooperate with treatment recommendations. This is because they trust the nurse's expertise and feel confident that the nurse has their best interests in mind.
Enhances Coping: A strong therapeutic relationship can help to improve the client's coping skills. The nurse can provide support, encouragement, and guidance as the client learns to manage their anxiety.
Techniques for establishing rapport:
Active listening: Pay close attention to the client's verbal and nonverbal communication, demonstrating that you are genuinely interested in what they have to say.
Empathy: Show understanding and compassion for the client's experiences and feelings.
Respect: Treat the client with dignity and respect, acknowledging their autonomy and choices.
Genuineness: Be authentic and honest in your interactions with the client.
Trustworthiness: Demonstrate that you are reliable and dependable, and that you will maintain confidentiality.
Cultural sensitivity: Be aware of and respect the client's cultural background and beliefs.
Choice B rationale:
Avoiding eye contact can convey disinterest, disrespect, or dishonesty, which can further heighten anxiety. Maintaining appropriate eye contact demonstrates attentiveness, empathy, and understanding, which can help to build trust and rapport.
Choice C rationale:
Speaking in a high-pitched voice can be perceived as agitated or tense, which can exacerbate the client's anxiety. It's essential to speak in a calm, soothing, and reassuring tone to promote relaxation and a sense of safety.
Choice D rationale:
Validating the client's feelings and identifying the cause of anxiety are crucial steps in effective anxiety management.
Validation helps the client feel understood and accepted, while identifying the cause can guide the development of appropriate interventions to address the underlying triggers.
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