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 C

Explanation

A. Alcohol tolerance: Alcohol tolerance refers to the decreased effect of alcohol with repeated use, not withdrawal symptoms.

B. Korsakoff's psychosis: Korsakoff's psychosis is a chronic condition related to thiamine deficiency and characterized by memory impairment and confabulation, not acute withdrawal symptoms.

C. Delirium tremens: Delirium tremens (DTs) is a severe form of alcohol withdrawal that can present with tremors, agitation, elevated blood pressure, tachycardia, and confusion. The client’s symptoms and recent history suggest DTs.

D. Wernicke's encephalopathy: Wernicke's encephalopathy typically presents with ataxia, confusion, and ophthalmoplegia rather than the acute withdrawal symptoms described.

A. Baked chicken B. Bagels C. A factory-sealed box of chocolates D. Fresh fruit basket

Correct Answer is D

Explanation

A. Baked chicken: Baked chicken, if cooked thoroughly, is generally safe for a client with neutropenia (low WBC count) as it does not pose a high risk for infection.

B. Bagels: Bagels, if they are from a safe, uncontaminated source, are generally considered safe for neutropenic clients.

C. A factory-sealed box of chocolates: Factory-sealed chocolates are usually safe as they are unlikely to be contaminated.

D. Fresh fruit basket: Fresh fruits can carry bacteria, especially on the skin or peel, and pose a risk of infection for a client with neutropenia. Therefore, this is the item that should be prohibited.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client?

Correct Answer is D

Explanation

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