When considering an individual's risk for suicide, which client will the nurse consider the priority?
The recent Middle Eastern immigrant from a war-torn country
The gay male who has been diagnosed with HIV
The older transgender female who has been repeatedly assaulted
The teenager recovering from a self-inflicted gunshot wound
The Correct Answer is D
A. Being an immigrant from a war-torn country is a risk factor but not an immediate priority based on the information provided.
B. While being diagnosed with HIV poses mental health risks, there's no immediate suicidal attempt or ideation described in the scenario.
C. Repeated assaults are traumatic, but there's no indication of immediate suicidal risk.
D. The teenager recovering from a self-inflicted gunshot wound indicates an immediate and recent attempt at suicide, making them the highest priority for monitoring and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Demonstrating empathy would involve acknowledging the client's feelings or beliefs, but the nurse does not validate the client's delusion or express understanding of the client's emotional state. Instead, the nurse redirects the client to the reality of the situation, which is the group therapy session.
B: The nurse's response is therapeutic because it clearly communicates the expectations of the therapy environment. By stating "it is time for group therapy and we expect everyone to attend," the nurse is providing clear, structured guidance without engaging with the delusion, which can help the client understand the reality of the situation and what is required of them.
C: Setting limits on manipulative behavior would involve addressing and curtailing attempts by the client to control or influence a situation for their own benefit. In this scenario, the client's behavior is delusional rather than manipulative, and the nurse's response does not directly set limits on manipulation but rather on adhering to the therapy schedule.
D: Using reflection would mean the nurse is mirroring the client's thoughts or feelings to help them self-reflect. However, the nurse does not reflect the client's statement but instead focuses on the expectations of the therapy program. The nurse's response does not encourage the client to reflect on their own thoughts or feelings but redirects them to the activity at hand.
Correct Answer is B
Explanation
A. Clients with major depressive disorder often exhibit decreased response to stimuli rather than an exaggerated response.
B. Weight changes, either a significant gain or loss, are common in individuals with major depressive disorder due to changes in appetite.
C. Hyperexcitability is not typically associated with major depressive disorder. Instead, individuals with depression often exhibit decreased energy and enthusiasm.
D. While seeking attention can manifest in some individuals with mental health conditions, it's not a defining characteristic of major depressive disorder.
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