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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A 45-year-old female who has a family history of autoimmune disorders. Autoimmune disorders can increase the risk of some thyroid conditions, but not necessarily hyperthyroidism.
B. A 73-year-old male who has an iodine deficiency: Iodine deficiency can lead to goiter and hypothyroidism but is not a common cause of hyperthyroidism.
C. A 25-year-old female who has metabolic syndrome: Metabolic syndrome is not directly linked to thyroid dysfunction.
D. A 35-year-old male who has Graves' disease: Graves’ disease is an autoimmune disorder that leads to overproduction of thyroid hormones, resulting in hyperthyroidism..
Correct Answer is D
Explanation
A. Decreased thyrotropin receptor antibodies: Graves' disease is characterized by the presence of thyrotropin receptor antibodies, so they are typically increased, not decreased.
B. Decreased free thyroxine index: Graves' disease typically results in increased levels of thyroid hormones, not decreased.
C. Decreased triiodothyronine: T3 levels may be elevated in Graves' disease due to increased thyroid hormone production.
D. Decreased thyroid-stimulating hormone (TSH): Graves' disease causes excessive thyroid hormone production, leading to suppressed TSH levels. TSH is typically low in hyperthyroidism because the thyroid gland is overactive and not being stimulated by the pituitary gland.
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