The nurse is interviewing a client with major depression. Which of the following statements by the client would most indicate to the nurse that the client is at risk for suicide?
"I feel like everyone depends on me too much."
"Life has lost its meaning for me."
wish I could just take a vacation and get away from it all."
"I feel like a failure and wish one thing would just go right."
The Correct Answer is B
A. "I feel like everyone depends on me too much." This statement indicates a sense of responsibility and connection to others, which may not directly indicate suicidal ideation.
B. "Life has lost its meaning for me." This statement is a strong indicator of hopelessness, which is a key risk factor for suicide. The client feels that life is meaningless, which could indicate a desire to end their life.
C. "I wish I could just take a vacation and get away from it all." While this statement may indicate stress or a desire to escape, it does not directly suggest suicidal intent.
D. "I feel like a failure and wish one thing would just go right." This statement indicates frustration and low self-worth, but it doesn't necessarily indicate an immediate risk of suicide as clearly as statement B.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. the client feels vulnerable to stigma: While stigma can prevent clients from reporting suicidal thoughts, this is not the primary reason for initiating a suicide risk assessment.
B. young adults tend to use manipulation: Assuming that young adults manipulate their symptoms is not a valid reason for initiating a suicide risk assessment. This response is inappropriate and can harm the therapeutic relationship.
C. this is a standard assessment: A suicide risk assessment is a standard part of care for clients with depression and thoughts of hopelessness, even if suicidal ideation is not explicitly reported. This ensures comprehensive evaluation and appropriate intervention.
D. the client lives with extended family: The living situation may influence the support system, but it is not the primary reason to initiate a suicide risk assessment.
Correct Answer is ["A","C","D"]
Explanation
A. Unequal pupils: Unequal pupils (anisocoria) can indicate a potential neurological issue, such as intracranial pressure or brain injury, especially after trauma. It is a significant finding requiring further evaluation.
B. Pupil reaction quick: Quick pupil reaction is typically normal and indicates proper neurological function, not a concern.
C. Pinpoint pupils: Pinpoint pupils can indicate opioid overdose or certain types of brainstem injury and should be evaluated as a potential neurological concern.
D. Absence of pupillary response: Absence of pupillary response to light can be a serious neurological concern, indicating severe brain injury or significant neurological compromise.
E. Pupil reacts to light: A pupil that reacts to light is a normal finding and indicates proper neurological function.
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