Which behavior observed by the nurse causes a suspicion that a depressed client may be suicidal?
Giving away valued possessions
Engaging in high-risk behaviors
Talkative, with pressured speech
Guilt, decreased self-esteem
The Correct Answer is A
A. Giving away valued possessions - This is a classic sign of suicidal ideation, as individuals may feel they no longer need their belongings or want to say goodbye to loved ones in a symbolic way.
B. Engaging in high-risk behaviors - While high-risk behaviors can be a sign of depression, they are not necessarily indicative of suicidal thoughts.
C. Talkative, with pressured speech - This could be indicative of a manic episode or high anxiety, but it is not a common sign of suicidal behavior.
D. Guilt, decreased self-esteem - Although guilt and low self-esteem are symptoms of depression, they do not directly indicate suicidal thoughts or behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mobitz II is a type of second-degree AV block characterized by constant PR intervals and sudden dropped QRS complexes (i.e., the PR interval does not lengthen progressively). This is a more serious block because the dropped beats are unpredictable and could lead to complete block.
B. Sinus bradycardia is a slower-than-normal heart rate (usually less than 60 beats per minute) that originates from the sinus node. First-degree AV block is characterized by a prolonged PR interval, but unlike second-degree block, there are no dropped QRS complexes.
C. Mobitz I (Wenckebach) is a second-degree AV block where the PR interval gradually lengthens with each successive beat until a QRS complex is dropped. After the dropped beat, the cycle repeats. This is a relatively benign block and often resolves without intervention, though it requires monitoring.
D. Third-degree heart block (also known as complete heart block) occurs when there is no communication between the atria and ventricles. The atria and ventricles beat independently of each other. There are no relationship between the P waves and QRS complexes, and the ventricular rate is typically slower than the atrial rate.
Correct Answer is ["B","C","D"]
Explanation
A. Fluid intake may need to be regulated in heart failure patients, consuming 2500mL of fluids per day may be too high for some patients, depending on their condition and whether they are on fluid restriction. Fluid management should be individualized, and the provider should specify the amount based on the patient's condition.
B. A low-sodium diet is essential for heart failure patients to help reduce fluid retention, decrease blood pressure, and lessen the burden on the heart. The American Heart Association recommends a sodium intake of no more than 2,000-2,300 mg per day for heart failure patients.
C. Rapid weight gain is a sign of fluid retention, which can indicate worsening heart failure. A gain of 2-3 pounds in a single day or 5 pounds in a week should prompt the client to contact their healthcare provider for further evaluation.
D. Shortness of breath with minimal activity can be a sign of worsening heart failure or fluid overload. This symptom should be reported immediately to a healthcare provider for further evaluation and possible adjustments to treatment.
E. Furosemide (a diuretic) is often prescribed to reduce fluid retention but it should not be taken without proper guidance or as a response to symptoms without consulting the healthcare provider. Taking diuretics at the wrong time or in excessive amounts can lead to dehydration and electrolyte imbalances, which could worsen the condition.
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