A nurse is caring for a client who has a history of suicide attempts. Which of the following findings places the client at risk for another suicide attempt? (Select all that apply.)

Hallucinations

Depression

Delusions

Catatonia

Tinnitus

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason:

Hallucinations, particularly if they are distressing or command hallucinations, can increase the risk of suicide attempts.

Choice B reason:

Depression is a major risk factor for suicide. Clients with a history of depression are at higher risk for attempting suicide again.

Choice C reason:

Delusions, especially those that are paranoid or persecutory, can contribute to suicidal thoughts and behaviors.

Choice D reason:

Catatonia, a state of psychomotor disturbance, can be associated with severe depression and increase the risk of suicide.

Choice E reason:

Tinnitus, while distressing, is not typically a direct risk factor for suicide attempts. It may contribute to overall distress but is not a primary indicator of suicide risk.

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Correct Answer is D

Explanation

Choice A reason:

Agreeing with the parent and assuming the situation will not happen again is not appropriate. It dismisses the potential risk to the child and does not address the seriousness of the situation.

Choice B reason:

Telling the parent to file charges against their partner is a strong directive that may not be appropriate without further understanding of the situation. It is important to gather more information before making such recommendations.

Choice C reason:

Stating that the situation is clearly child endangerment and immediately calling the police may escalate the situation without fully understanding the context. It is important to assess the situation thoroughly before taking such actions.

Choice D reason:

Expressing a desire to know more about what happened and offering to talk is an appropriate response. It allows the nurse to gather more information, assess the situation, and provide support to the parent and child.

A. Document the client’s behavior once every hour. B. Keep the client in restraints until the prescription expires. C. Conduct a debriefing regarding the client with the unit staff. D. Request an evaluation of the client within 12 hours of application of restraints.

Correct Answer is D

Explanation

Choice A reason: Documenting the client’s behavior once every hour is important for monitoring the client’s condition and ensuring their safety. However, it is not the most immediate action to take after applying restraints.

Choice B reason: Keeping the client in restraints until the prescription expires is not appropriate. Restraints should be used for the shortest duration necessary and should be removed as soon as the client is no longer a threat to themselves or others.

Choice C reason: Conducting a debriefing with the unit staff is important for reviewing the incident and planning future care. However, it is not the immediate action required after applying restraints.

Choice D reason: Requesting an evaluation of the client within 12 hours of applying restraints is crucial. This ensures that the client’s condition is reassessed, and the need for continued restraints is evaluated. It also helps in planning further interventions to manage the client’s aggressive behavior.

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A nurse is caring for a client who has a history of suicide attempts. Which of the following findings places the client at risk for another suicide attempt? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an urgent-care clinic is caring for a school-age child who has several visible bruises. The child’s parent states, “My partner got fired today and came home angry. I don’t think this will happen again.” Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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