A nurse in an emergency department is assessing a client who verbalized to a family member that they do not want to live anymore after the death of their child. Which of the following assessments should the nurse plan to perform first?
Ask the client if they have a trusted person they can talk with.
Ask the client if they have a plan for ending their life.
Ask the client if they have attempted to harm themselves in the past.
Ask the client if they are currently having suicidal thoughts.
The Correct Answer is D
Choice A reason: Assessing social support is important but not the priority when suicide risk is suspected.
Choice B reason: Assessing for a plan is critical but should follow confirmation of current suicidal ideation.
Choice C reason: Past attempts are relevant for risk stratification but secondary to current ideation.
Choice D reason: Determining current suicidal thoughts is the first and most urgent step in suicide risk assessment to guide immediate safety interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Difficulty recognizing objects (agnosia) is expected in dementia progression and does not require immediate reporting unless it leads to safety concerns.
Choice B reason: Loss of interest (anhedonia) is a hallmark of depression but not an acute change requiring urgent intervention unless accompanied by suicidal ideation.
Choice C reason: Rapid weight gain may indicate metabolic syndrome or fluid retention, but without other symptoms, it is not immediately life-threatening.
Choice D reason: Decreased urine output in a client on lithium may signal nephrotoxicity or lithium toxicity. This is a potentially life-threatening complication requiring prompt evaluation.
Correct Answer is D
Explanation
Choice A reason: Equal time allocation is part of equitable care but does not reflect advocacy, which involves active representation of client interests.
Choice B reason: Providing emotional support is compassionate but not advocacy unless it involves acting on the client’s behalf.
Choice C reason: Educating clients is essential but is a standard nursing role. Advocacy involves going beyond education to ensure client preferences are honored.
Choice D reason: Speaking on behalf of the client to ensure their treatment preferences are respected exemplifies advocacy. It protects autonomy and supports informed decision-making.
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