When seeing a young adult client who has been depressed and expressing thoughts of hopelessness but has not overtly reported having thoughts of suicide. Despite the fact that the client has not reported suicidal thoughts, the nurse should initiate a suicide risk assessment with the client for which reason?

the client feels vulnerable to stigma

young adults tend to use manipulation

this is a standard assessment

the client lives with extended family

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is D

Explanation

A. Most restrictive: A most restrictive environment may not be necessary if the client does not require intensive supervision or care.

B. Least restrictive: A least restrictive environment is generally preferred if the client can function with less supervision and support. It supports independence while providing necessary care.

C. Nursing home: A nursing home may be appropriate for clients needing extensive care, but it is often more restrictive than needed for clients who do not require 24-hour nursing care.

D. Transitional care unit: A transitional care unit is designed to support clients transitioning from hospital to home or other settings, which may be suitable if the client needs further rehabilitation or adjustment.

A. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. B. Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. C. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. D. Stay with the client, emphasizing that he is safe and that you will remain with him.

Correct Answer is D

Explanation

A. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. This is not appropriate as it could exacerbate the client’s anxiety rather than alleviate it. The nurse should remain calm and provide reassurance.

B. Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. Leaving the client alone during a panic attack could increase their feelings of fear and isolation, worsening the situation.

C. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. While this information is correct, it does not directly address the client's immediate need for reassurance and safety during the panic attack.

D. Stay with the client, emphasizing that he is safe and that you will remain with him. This is the most appropriate intervention as it provides the client with a sense of safety and security, which is crucial during a panic attack.

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Naxlex Comprehensive Predictor Exams

A client has lived independently prior to being admitted to an inpatient unit. The client will be unable to return home following discharge. Which environment would be most appropriate for the client?

Correct Answer is D

Explanation

The nurse is caring for a client who is being treated in the emergency department for a panic attack. Which of the following nursing interventions would be most appropriate?

Correct Answer is D

Explanation

A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring?

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