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 A

Explanation

Choice A reason: Given Brian's recent substance use and expression of not being able to tolerate depressive feelings, a suicide risk assessment is the highest priority to ensure his immediate safety.

Choice B reason: While a neurological assessment may be relevant, it is not the highest priority when there is a potential risk of suicide.

Choice C reason: Assessing the amount of current cannabis use is important but secondary to evaluating the risk of suicide.

Choice D reason: Marital status may inform social support but is not the highest priority in the context of potential self-harm.

A. The client will assess strengths and weaknesses realistically. B. The client will verbalize plans to join a community support group. C. The client will receive only prescribed medications. D. The client will initiate interactions with at least two other people in the facility. E. The client will share feelings openly within 48 hours.

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

Explanation

Choice A reason: Assessing strengths and weaknesses realistically helps the client to understand their capabilities and limitations post-withdrawal.

Choice B reason: Verbalizing plans to join a community support group indicates the client's commitment to ongoing recovery and support after discharge.

Choice C reason: Receiving only prescribed medications ensures the client does not relapse into drug use and maintains the treatment plan's integrity.

Choice D reason: Initiating interactions with others in the facility can help the client rebuild social skills and integrate into a community, which is beneficial for recovery.

Choice E reason: While sharing feelings is important, setting a specific timeframe such as 48 hours may not be realistic for every client and can vary based on individual readiness.

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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.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is planning the care of a client with bipolar disorder and addiction to heroin who is in a rehabilitation facility. Which outcomes will the nurse assign in the immediate phase after withdrawal symptoms are over? (Select all that apply.)

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

Explanation

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