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?

Illusion

Hallucination

Attention-seeking behavior

Self-mutilation

Answer and Explanation

The Correct Answer is D

Choice A reason:
An illusion is a misinterpretation of a real external stimulus. For example, seeing a shadow and thinking it is a person. The client’s statement does not indicate a misinterpretation of reality but rather a desire to inflict harm on themselves.
Choice B reason:
A hallucination is a false sensory perception without any real external stimulus, 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 could be seen as a cry for help, it is more accurately identified as a risk for self-mutilation due to the explicit mention of wanting to cut themselves.
Choice D reason:
Self-mutilation refers to deliberate self-inflicted harm, often as a way to cope with emotional pain. The client’s statement, “Give me your pen to cut the pain out of my chest,” clearly indicates a risk for self-mutilation, as they are expressing a desire to harm themselves to alleviate emotional distress.

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Correct Answer is D

Explanation

Choice A reason:
Developmental theories focus on the progression of human growth and development through various stages of life. While these theories are important in understanding patient behavior and needs, they do not directly relate to the implementation of a privilege system in an inpatient unit. Privilege systems are more aligned with behavioral theories, which emphasize the modification of behavior through reinforcement and consequences.
Choice B reason:
Humanistic theories emphasize the individual’s capacity for self-actualization and personal growth. These theories focus on the holistic development of the person and the importance of empathy and unconditional positive regard in therapeutic relationships. Although humanistic approaches are valuable in mental health care, they do not specifically address the structured reinforcement strategies used in privilege systems.
Choice C reason:
Cognitive theories focus on the role of thought processes in influencing emotions and behaviors. These theories are crucial in understanding and treating mental health conditions, particularly through cognitive-behavioral therapy (CBT). However, the privilege system, which relies on tangible rewards and consequences to shape behavior, is more closely related to behavioral theories rather than cognitive ones.
Choice D reason:
Behavioral theories are directly related to the use of a privilege system. These theories emphasize the use of reinforcement and punishment to modify behavior. In an inpatient setting, a privilege system is used to encourage desirable behaviors by providing rewards (privileges) and discouraging undesirable behaviors through the removal of privileges. This approach is grounded in the principles of operant conditioning, a key concept in behavioral theories.

A. Recent marriage B. Age greater than 55 C. Bachelor’s degree D. Male gender E. Diagnosis of schizophrenia

Correct Answer is ["B","D","E"]

Explanation

Choice A reason:
Recent marriage is generally considered a protective factor against suicide rather than a risk factor. Marriage can provide emotional support and stability, which can reduce the risk of suicidal behavior. However, the quality of the relationship and other individual factors should also be considered.
Choice B reason:
Age greater than 55 is a recognized risk factor for suicide, particularly among men. Older adults may face multiple stressors such as chronic illness, loss of loved ones, and social isolation, which can increase the risk of suicide. It is important to monitor and support older adults who may be at risk.
Choice C reason:
Having a bachelor’s degree is not typically associated with an increased risk of suicide. In fact, higher educational attainment is often linked to better mental health outcomes and access to resources. However, individual circumstances and stressors should always be considered.
Choice D reason:
Male gender is a significant risk factor for suicide. Men are more likely to die by suicide compared to women, although women may attempt suicide more frequently. This gender disparity is attributed to various factors, including the methods used and societal expectations around expressing emotions.
Choice E reason:
A diagnosis of schizophrenia is a known risk factor for suicide. Individuals with schizophrenia may experience severe symptoms, including delusions and hallucinations, which can contribute to suicidal thoughts and behaviors. It is crucial to provide comprehensive care and support to individuals with this diagnosis to mitigate the risk of suicide.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A psychiatric-mental health nurse is working on an inpatient unit that uses a privilege system. The nurse understands that this intervention integrates which group of theories?

Correct Answer is D

Explanation

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

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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?