Which individual should the nurse consider at highest risk for suicide?

A retired older male whose significant other has passed away.

A nurse who works in a pediatric emergency department.

An adolescent male whose parents recently divorced.

A single working mother with three pre-school aged children.

Answer and Explanation

The Correct Answer is C

A.   While the loss of a significant other can be a risk factor for suicide, retired older males may have developed coping mechanisms over time that could mitigate the risk.
B.   While working in a pediatric emergency department can be stressful, it does not necessarily indicate a higher risk for suicide compared to other factors such as personal life stressors or mental health issues.
C.   Adolescents experiencing significant life changes such as parental divorce are at increased risk for suicide due to the emotional upheaval and lack of coping skills typical of this age group.

D.   While being a single working mother with three preschool-aged children can be stressful, it does not inherently indicate a higher risk for suicide compared to other factors such as social support, coping mechanisms, and mental health status.

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Correct Answer is B

Explanation

Rationale for A: Ineffective sexual patterns would not be the priority as the client's focus on sexual concerns appears to be delusional rather than a reflection of actual sexual dysfunction.

Rationale for B: The client is experiencing delusions, such as an inflated IQ and beliefs about being married to a movie star. These indicate altered perception of reality, making disturbed sensory perception the priority problem to address.

Rationale for C: Compromised family coping could be a concern but is not the primary issue in this situation. The client’s delusions take precedence as they directly impact his mental health and perception of reality.

Rationale for D: Impaired environmental interpretation refers to difficulty understanding the environment, but this client’s issue is more related to delusional thinking rather than misinterpretation of physical surroundings. Therefore, disturbed sensory perception is the more accurate nursing problem.

A. Responds with illogical answers to questions. B. Admits to frequently thinking about committing suicide. C. Describes times of depression followed by feelings of euphoria. D. Exhibits compulsive, ritualistic behaviors.

Correct Answer is A

Explanation

A. Responding with illogical answers to questions is characteristic of schizophrenia, particularly during periods of psychosis when the client may experience disorganized thinking and impaired reality testing.
B. Admitting to frequently thinking about committing suicide is not specific to schizophrenia and may occur in various mental health conditions, such as depression or bipolar disorder.
C. Describing times of depression followed by feelings of euphoria suggests a mood disorder, such as bipolar disorder, rather than schizophrenia.
D. Exhibiting compulsive, ritualistic behaviors may be seen in obsessive-compulsive disorder (OCD) but is not typically characteristic of schizophrenia. Schizophrenia is primarily characterized by positive symptoms (such as hallucinations and delusions), negative symptoms (such as blunted affect and social withdrawal), and cognitive symptoms (such as disorganized thinking and impaired executive function).

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Which individual should the nurse consider at highest risk for suicide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is B

Explanation

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

Correct Answer is A

Explanation

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?