The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? (Select all that apply.)

"Where do you keep your gun?"

"Are you thinking about hurting yourself or someone else?"

"Have you thought about how you would hurt yourself?"

"Can you tell me your feelings about dying?"

"Have you told your psychiatrist you feel like dying?"

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason: While it’s important to assess access to lethal means, this question is too specific and assumes the client owns a gun. A more appropriate question might be, “Do you have access to any means to harm yourself?”

Choice B reason: Inquiring about thoughts of self-harm or harming others is a direct question that assesses suicidal ideation and intent, which is essential for determining immediate risk.

Choice C reason: Understanding if the client has specific plans for self-harm can help gauge the immediacy and seriousness of the suicide risk.

Choice D reason: Discussing feelings about dying can provide insight into the client's emotional state and potential risk for suicide.

Choice E reason: This question is important but it should not replace direct questions about the client’s current thoughts and feelings. It’s possible for a client to deny feelings of suicidality to their psychiatrist while still experiencing them.

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Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Feeling mildly anxious can be a normal reaction after a traumatic event and does not necessarily indicate PTSD.

Choice B reason: Emotional numbing and detachment from others are common symptoms of PTSD, reflecting an avoidance of reminders of the trauma.

Choice C reason: The timeframe of symptoms occurring specifically 2 weeks after the trauma is more indicative of acute stress disorder rather than PTSD.

Choice D reason: Reexperiencing the trauma through dreams or intrusive thoughts is a hallmark symptom of PTSD, often leading to significant distress.

Choice E reason: Hyperarousal, including being on guard and irritable, is a symptom of PTSD that involves an increased state of anxiety and heightened emotional response.

A. Persistently ask the same question until answered. B. Give the client ample time to answer the questions asked. C. Ask simple questions instead of compound questions. D. Provide simple explanations to the client as often as required. E. Take frequent breaks during the interview process.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason: Persistently asking the same question can increase agitation in clients with dementia.

Choice B reason: Allowing ample time for responses can reduce pressure and agitation in clients with dementia.

Choice C reason: Simple questions are easier for clients with dementia to understand and respond to.

Choice D reason: Providing simple explanations can help clients with dementia understand the purpose of the questions.

Choice E reason: Taking frequent breaks can help prevent fatigue and agitation during the assessment process.

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The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is seeking counseling due to difficulty coping with being a victim of a violent attack 16 months ago. Which elements will the nurse assess for when determining the major components of posttraumatic stress disorder (PTSD)? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?

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