A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)

Currently married

Alcohol use disorder

Sibling history of suicide

Access to guns in the home

Terminal liver cancer

Answer and Explanation

Correct Answer : B,C,D,E

A.   Being married is generally considered a protective factor against suicide. Married individuals often have social support and a sense of belonging, which can reduce suicide risk. Therefore, this would not be identified as a risk factor for suicide.
B.   Alcohol use disorder is a significant risk factor for suicide. Alcohol can impair judgment, increase impulsivity, and exacerbate underlying mental health issues. It is associated with higher rates of suicidal ideation and attempts.
C.   Family history of suicide, including among siblings, is a known risk factor. Exposure to suicide within the family can contribute to feelings of hopelessness, increase perceived acceptability of suicide, and impact mental health negatively.
D.   Access to firearms is a well-established risk factor for completed suicide. Firearms are highly lethal, and their presence increases the likelihood of a fatal suicide attempt compared to other means.
E.   Terminal illness, including conditions like terminal liver cancer, can contribute to feelings of hopelessness and despair, potentially increasing suicide risk. The distress related to the prognosis and physical symptoms can exacerbate mental health issues.

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Correct Answer is A

Explanation

A. Diarrhea is a common symptom of opioid withdrawal. Opioids slow down gastrointestinal motility, so when their use is discontinued, it can lead to increased peristalsis and diarrhea. This occurs due to the rebound effect of the gastrointestinal tract.
B. Opioids typically cause pupil constriction (pinpoint pupils) when they are active in the body. During withdrawal, the opposite occurs, and pupils dilate (mydriasis). However, the question asks about withdrawal symptoms, not effects of opioid use, so this would not be expected in opioid withdrawal.
C. Bradycardia, or a slow heart rate, is not typically associated with opioid withdrawal. Instead, opioid withdrawal can cause tachycardia (rapid heart rate) due to the sympathetic nervous system activation that occurs during withdrawal.
D. Hypokinesis refers to decreased movement or activity, which is not a typical symptom of opioid withdrawal. Instead, opioid withdrawal often presents with symptoms such as restlessness, agitation, and muscle aches, which are indicative of hyperactivity rather than hypokinesis.

A. Place the client in a room close to the nurses' station. B. Request a consult with recreational therapy. C. Lower the window shade in the client's room. D. Obtain a PRN prescription for a vest restraint.

Correct Answer is A

Explanation

A. This is a proactive measure to enhance supervision and quick response to any signs of agitation, wandering, or attempts to get out of bed without assistance. Being closer to the nurses' station allows for more frequent monitoring and timely intervention to prevent falls.
B. Recreational therapy can play a significant role in enhancing the client's physical and cognitive abilities through tailored activities. Activities such as balance exercises, supervised walks, or engaging in structured programs can help improve mobility and reduce the risk of falls.
C. Lowering the window shade can reduce distractions and provide a calmer environment for the client. Excessive light or glare can sometimes contribute to confusion or disorientation in individuals with dementia. A more subdued environment can potentially decrease agitation and wandering behaviors, indirectly lowering the risk of falls.

D. The use of physical restraints, such as vest restraints, is generally discouraged in clients with dementia due to the potential for physical and psychological harm. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying causes of falls. The focus should be on environmental modifications, supervision, and non-pharmacological interventions.

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A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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