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:

An illusion is a misinterpretation of a real external stimulus. The client’s statement does not indicate a misinterpretation of reality but rather a direct expression of intent to harm themselves.

Choice B reason:

A hallucination is a perception of something that is not present, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.

Choice C reason:

Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement may draw attention, it is more indicative of a serious risk of self-harm rather than merely seeking attention.

Choice D reason:

Self-mutilation refers to deliberate self-injury without suicidal intent. The client’s statement about using a pen to cut the pain out of their chest indicates a risk of self-harm, which requires immediate intervention to ensure their safety.

A. Use detailed explanations when providing education to the client. B. Maintain a stimulating environment for the client. C. Provide the client with a structured schedule of daily activities. D. Limit time for rituals to 30 minutes each day.

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.

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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 caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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