Susan, the nurse is caring for a client who states "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority?

Lethality of the method and availability of means

Client's educational and economic background

Client's insight into the reasons for the decision.

Quality of the client's social support

Answer and Explanation

The Correct Answer is A

A. Lethality of the method and availability of means. Assessing the method and means helps determine the immediacy and seriousness of the threat. Knowing the lethality of the method and whether the means are readily available informs the level of intervention needed to keep the client safe.

B. Client's educational and economic background: While socioeconomic factors can influence mental health, they are not immediate priorities in a suicidal crisis.

C. Client's insight into the reasons for the decision: Insight is important for understanding motivations but is secondary to immediate safety concerns.

D. Quality of the client's social support: Social support is crucial but is secondary to assessing imminent risk of harm.

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Correct Answer is C

Explanation

A. Systemic lupus erythematosus (SLE): SLE is an autoimmune disease but is not directly linked to the pathophysiology of HIT.

B. Placental abruption: Placental abruption is a complication of pregnancy and is not a risk factor for HIT.

C. Heparin therapy for deep-vein thrombosis (DVT): Correct Answer. Heparin therapy itself, especially in the treatment of deep-vein thrombosis, is a significant risk factor for developing HIT due to the exposure to heparin.

D. Warfarin therapy for atrial fibrillation: Warfarin is not associated with the development of HIT.

A. "Exposure to sunlight will help to strengthen your eyes." B. "These are unusual symptoms. I will ask the provider for an ophthalmology referral." C. "Eye drops and dim lighting can improve your symptoms." D. "Surgery will be necessary to correct the damage to your eyes."

Correct Answer is C

Explanation

A. "Exposure to sunlight will help to strengthen your eyes.": Sunlight exposure is not recommended as it can exacerbate symptoms.

B. "These are unusual symptoms. I will ask the provider for an ophthalmology referral.": These symptoms are characteristic of Graves' ophthalmopathy and do not require an immediate referral unless severe.

C. "Eye drops and dim lighting can improve your symptoms." These interventions can help alleviate discomfort associated with dryness and light sensitivity in hyperthyroidism-related eye changes (Graves' ophthalmopathy). Dim lighting reduces glare, which can be uncomfortable for clients with sensitivity to light. Eye drops can provide lubrication for dry eyes.

D. "Surgery will be necessary to correct the damage to your eyes.": Surgery is considered for severe cases or when other treatments fail, not typically as an initial intervention.

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Susan, the nurse is caring for a client who states "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority?

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