The family brings a client to the emergency room because the client is depressed, and they are concerned he might be suicidal. What is the best approach for the nurse to take in his assessment?

Ask the client directly if he has thoughts of suicide.

Ask the family if the client wrote a suicide note.

Ask the family if the client verbalized any thoughts of suicide to them.

Ask the client in a roundabout way about suicide.

Answer and Explanation

The Correct Answer is A

Choice A reason: Directly asking the client about suicidal thoughts is the most effective and evidence-based approach. It demonstrates concern, reduces stigma, and allows for accurate risk assessment. Research shows that asking about suicide does not increase risk—it opens the door for intervention and support.

Choice B reason: Asking the family about a suicide note may provide collateral information but does not replace direct assessment. It is a secondary measure and may not yield accurate or timely data.

Choice C reason: While family input is valuable, relying solely on their observations may miss critical internal experiences of the client. The nurse must assess the client directly to understand intent, plan, and risk level.

Choice D reason: Indirect or vague questioning can lead to misunderstanding or avoidance. Clients may not recognize the intent of the question or may feel dismissed. Clear, direct communication is essential in suicide risk assessment.

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Correct Answer is B

Explanation

Choice A reason: Prioritizing the client’s rights and welfare is a cornerstone of ethical and legal nursing practice. It ensures that care is patient-centered, respectful, and protective of autonomy. This approach helps prevent negligence and supports informed consent, thereby reducing liability risk.

Choice B reason: Working alone when caring for clients increases the risk of errors, miscommunication, and lack of accountability. It limits opportunities for collaboration, supervision, and support. In high-risk or complex situations, working alone may violate institutional policies and compromise patient safety, making it a liability concern.

Choice C reason: Practicing within the scope of state laws and the nurse practice act ensures that nurses operate within their legal boundaries. It protects both the nurse and the client by defining permissible actions, responsibilities, and limitations. Violating these standards can result in disciplinary action or legal consequences.

Choice D reason: Using established practice standards provides a framework for safe, evidence-based care. These standards are developed by professional organizations and regulatory bodies to guide clinical decision-making. Adhering to them helps ensure consistency and protects against claims of negligence.

A. Idea of reference B. Hallucination C. Delusion D. Loose association

Correct Answer is C

Explanation

Choice A reason: Ideas of reference involve misinterpreting neutral events as having personal significance. Believing that others are plotting against them goes beyond this and reflects a fixed false belief.

Choice B reason: Hallucinations are false sensory perceptions, such as hearing voices or seeing things that are not present. The client’s belief is cognitive, not sensory, so hallucination is not applicable.

Choice C reason: Delusions are fixed false beliefs that are not based in reality and are resistant to evidence. Paranoid delusions involve beliefs of persecution, such as thinking others are out to get them. This is the most accurate classification.

Choice D reason: Loose associations refer to disorganized speech where ideas are poorly connected. The client’s statement is coherent and focused on a specific belief, not disorganized thought flow.

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The family brings a client to the emergency room because the client is depressed, and they are concerned he might be suicidal. What is the best approach for the nurse to take in his assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Steps to avoid liability would include all of the following, except:

Correct Answer is B

Explanation

The client who believes everyone is out to get them is experiencing a(n):

Correct Answer is C

Explanation

All of the following contribute to a healthy sense of belonging, except:

A client’s ability to understand can be impacted by:

A client made threats to harm his parents if they come too close to him. The parents called 911, and the client is now held involuntarily for a psychiatric evaluation. During this time of involuntary admission, the client retains all client rights, except:

A nurse observes a client talking to himself at the end of the hall. The client states, “No, I don't want to go." What does the nurse suspect regarding this information?

To assess a client’s ability to concentrate, the nurse would instruct the client to do which of the following?

A client was noted to have tangential thinking. An example of this would be:

A client reported to the nurse that, on his way to the clinic, a policeman in a patrol car turned on his lights and pulled him over. When asked what he did next, the client stated, "I pulled over, of course." Which of the following was the nurse trying to assess?

A client is showing no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the client's affect?