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 C

Explanation

Choice A reason:

While detailed explanations can be helpful, they are not the primary intervention for managing OCD. The focus should be on structured activities and behavioral interventions.

Choice B reason:

Maintaining a stimulating environment is not appropriate for clients with OCD as it may increase anxiety and compulsive behaviors. A calm and structured environment is more beneficial.

Choice C reason:

Providing a structured schedule of daily activities helps clients with OCD manage their time and reduce the frequency of compulsive behaviors. It promotes routine and predictability, which can alleviate anxiety.

Choice D reason:

Limiting time for rituals to 30 minutes each day is not a practical intervention. Instead, the focus should be on gradually reducing the time spent on rituals through behavioral therapy techniques.

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 is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

Correct Answer is D

Explanation

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