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

A. "The snakes on the wall are going to eat me." describes a visual hallucination, not a delusion. Hallucinations involve false sensory perceptions, such as seeing things that are not present. While hallucinations are common in schizophrenia, this statement does not indicate a delusion.

B. "The nurse at night is trying to poison me with pills." confirms a delusion, specifically a paranoid delusion. Delusions are fixed, false beliefs that are not based in reality and cannot be changed by logic or reasoning. In this case, the client irrationally believes that the nurse is trying to harm them, which is a classic symptom of schizophrenia.

C. "The voices are telling me to kill the next person I see." describes an auditory hallucination, which involves hearing voices or sounds that are not real. While auditory hallucinations are a common symptom of schizophrenia, this statement does not indicate a delusion.

D. "The fire is burning my skin away right now." describes a tactile hallucination, where the client falsely perceives sensations (e.g., burning). This is another form of hallucination, not a delusion, as it involves sensory misperception rather than a false belief.

A. Ask the client to describe and identify the source of the feelings. B. Provide education about ways to cope with anxiety. C. Assist the client with relaxation techniques in the group. D. Escort the client from the group to reduce stimuli.

Correct Answer is C

Explanation

A. While it's important for the client to explore the source of their anxiety, this may not be the most appropriate intervention during a group therapy session where immediate relief is needed.
B. Providing education about coping mechanisms is valuable, but it may not address the client's immediate needs for anxiety reduction in the group setting.
C. Assisting the client with relaxation techniques in the group is the best intervention as it provides immediate support and can help alleviate the client's anxiety in the moment.

D. Escorting the client from the group to reduce stimuli may be appropriate if the anxiety becomes overwhelming, but it should be considered after attempting relaxation techniques within the group setting.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

Correct Answer is B

Explanation

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

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 caring for a client Exhibits In order to help the client disclose a situation that is upsetting to him, what therapeutic communication tools could the nurse use? Select all that apply.

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