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

Explanation

Choice A reason: This statement shows that the client is willing to ground their decisions in reality, which is a key step in managing paranoid personality disorder.

Choice B reason: Trusting others is important, but it does not indicate that the client has learned to validate their ideas before acting.

Choice C reason: Differentiating true suspicions is part of managing the disorder, but it does not demonstrate an understanding of the need to validate ideas with others.

Choice D reason: Understanding the origins of paranoid thinking is insightful, but it does not show that the client has learned to validate their ideas before taking action.

A. "Your doctor is a man, so it should not be a problem." B. "I can review the assignments and arrange for a female nurse to care for you." C. "The nurse assigned to you is very capable and cares for other women in this situation." D. "I can arrange for a female assistive personnel to do your personal hygiene care."

Correct Answer is B

Explanation

Choice A reason: This response is dismissive of the client's concerns and does not address her discomfort with a male nurse.

Choice B reason: This response is respectful of the client's wishes and offers a solution that could make her more comfortable.

Choice C reason: This response does not acknowledge the client's specific discomfort with a male nurse and does not offer an alternative.

Choice D reason: While this offers an alternative, it may not fully address the client's discomfort with having a male nurse responsible for her overall care.

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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

The nurse is teaching a client with paranoid personality disorder to validate ideas with another person before taking action. Which statement made by the client indicates that the teaching is effective?

Correct Answer is B

Explanation

A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client expresses discomfort with a male nurse as her caregiver. Which response should the nurse manager provide?

Correct Answer is B

Explanation

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