A nurse on a mental health unit is assisting with the care of a client.
Complete the following sentence by using the lists of options.
The client is at risk of
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
This question focuses on identifying suicide risk factors in a client experiencing severe depressive symptoms after major life stressors. The client has experienced the loss of a long-term relationship and employment, both of which are significant psychosocial triggers for depression and suicidal thinking. Progressive withdrawal, hopelessness, flat affect, and verbal expressions about not wanting to live are major warning signs requiring immediate intervention. Early recognition of suicidal ideation is critical because emotional distress can rapidly progress to self-harm or suicide attempts without timely support and safety measures.
Rationale for correct choices:
• Suicidal ideation: The client demonstrates multiple classic indicators of suicidal ideation, including hopelessness, social withdrawal, worthlessness, and the statement, “I wish I weren’t here.” Verbalizing a desire not to live is a significant warning sign that must always be taken seriously. The initiation of one-on-one observation further supports concern for self-harm risk and indicates the need for close monitoring and suicide precautions. Clients experiencing major losses are particularly vulnerable to suicidal thoughts during depressive episodes.
• Statements of hopelessness and wishing not to be alive: Hopelessness is one of the strongest psychological predictors of suicide risk because it reflects a belief that circumstances will not improve. The client’s statements reveal despair, emotional exhaustion, and passive death wishes, all of which are concerning for suicidal ideation. Combined with tearfulness, isolation, and feelings of worthlessness, these statements suggest significant emotional instability. Such findings require immediate assessment of suicidal intent, plan, and access to means.
Rationale for incorrect choices:
• Acute stress disorder: Acute stress disorder occurs after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. Symptoms typically include dissociation, intrusive memories, hypervigilance, and avoidance behaviors shortly after the trauma. Although this client is under emotional stress, the presentation is more consistent with depressive symptoms and suicide risk rather than trauma-related stress pathology. No evidence of dissociative or trauma-reexperiencing symptoms is present.
• Borderline personality disorder: This is characterized by chronic interpersonal instability, impulsivity, fear of abandonment, unstable self-image, and recurrent self-destructive behaviors beginning in early adulthood. The scenario does not describe a long-standing maladaptive personality pattern or impulsive relationship instability. Instead, the symptoms appear linked to recent situational losses and depressive reactions.
• Recent increase in appetite and energy level: An increase in appetite and energy level is not documented in this scenario and would not directly support suicide risk in the way hopeless verbalizations do. In some depressed clients, sudden increased energy after severe depression can raise concern for suicide because the individual may gain energy to act on suicidal thoughts. However, this client instead demonstrates lethargy, withdrawal, tearfulness, and hopelessness.
• Participation in group activities with peers: Participation in group activities generally suggests social engagement and willingness to interact with others, which are protective rather than high-risk behaviors. The client in this scenario is withdrawn from family and friends and remains isolated in bed. Social isolation commonly worsens depression and increases suicide risk by reducing emotional support systems. Therefore, active peer participation would not support the identified concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Wound evisceration is a rare but catastrophic surgical emergency characterized by the total separation of all layers of a surgical wound (dehiscence) with the protrusion of internal visceral organs through the incision. It occurs most frequently 3 to 11 days postoperatively and is associated with risk factors that increase intra-abdominal pressure, such as coughing, straining, or vomiting. Evisceration poses an immediate threat to the blood supply of the protruded organs, creating a high risk for tissue ischemia, necrosis, and overwhelming systemic peritonitis. Nursing interventions must focus on minimizing tension on the abdominal wall and protecting the exposed viscera until emergency surgical repair can be performed.
Rationale:
A. Positioning the client in a semi-Fowler's position is an incorrect choice. While a slight elevation of the head can sometimes be used in general respiratory care, a standard semi-Fowler's position can cause the torso to stretch or bend in a way that increases intra-abdominal pressure and allows gravity to force more of the internal organs out through the abdominal wall incision.
B. Covering the wound with a transparent dressing is an incorrect and contraindicated choice. Transparent film dressings do not provide adequate protection or moisture for exposed visceral organs. Eviscerated organs must be kept continuously moist; a transparent film dressing would trap air and cause the exposed bowel to dry out rapidly, leading to tissue friction, ischemia, and necrosis.
C. Instructing the client to lie supine with his knees flexed is the correct action the nurse should take. Placing the client in a low-Fowler's or supine position with the knees bent reduces tension on the abdominal muscles, decreases intra-abdominal pressure, and prevents further protrusion of the internal organs. Alongside this positioning, the immediate nursing priority is to cover the exposed organs with sterile dressings soaked in warm, sterile normal saline to maintain tissue perfusion and moisture, while simultaneously preparing the client for an emergency return to the operating room.
D. Covering the wound with a dry sterile dressing is an incorrect and highly dangerous act. Placing a dry dressing directly onto exposed internal organs causes the visceral tissue to adhere to the gauze fibers. When the dressing is eventually removed or shifted, it will cause severe tissue tearing, capillary damage, and significantly increase the risk of infection and necrosis. All dressings applied to an evisceration must be thoroughly saturated with sterile saline.
Correct Answer is C
Explanation
Prioritization of pediatric postoperative and medical-surgical clients requires rapid identification of findings that indicate compromised neurovascular status or risk of permanent tissue damage. After procedures such as cast application, children are at risk for impaired circulation and nerve compression due to swelling or tight casting. Early recognition of neurovascular compromise is critical to prevent complications such as compartment syndrome and irreversible limb damage. Nurses must prioritize assessment of findings that suggest impaired perfusion or nerve function.
Rationale:
A. A toddler with periorbital cellulitis and a mild temperature of 37.6°C (99.7°F) is stable and does not require immediate attention. This condition is treated with antibiotics and close monitoring, but a low-grade temperature is not an urgent finding. Airway and vision compromise would be more concerning but are not indicated here.
B. An infant who had a pyloromyotomy 12 hours ago and spit up after feeding is expected to have mild postoperative gastrointestinal adjustment. Small episodes of emesis or regurgitation can occur as feeding is gradually reintroduced. While monitoring is important, this finding is not immediately life-threatening compared to neurovascular compromise.
C. Numbness in a limb 4 hours after cast placement indicates possible neurovascular compromise, which is an emergency. This may suggest nerve compression or impaired circulation due to swelling or a tight cast, potentially leading to Compartment syndrome. Immediate assessment is required to prevent permanent tissue and nerve damage.
D. An adolescent with influenza reporting a headache rated 6/10 is uncomfortable but stable. Influenza symptoms are typically managed with supportive care, and a moderate headache does not indicate acute deterioration. This finding does not take priority over potential limb ischemia in another client.
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