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

A nurse who works in a pediatric emergency department.

An adolescent male whose parents recently divorced.

A retired older male whose significant other has passed away.

A single working mother with three preschool-aged children.

Answer and Explanation

The Correct Answer is B

A.   While working in a pediatric emergency department can be stressful, the information provided does not suggest an increased risk for suicide in this scenario.
B.   Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide.
C. While the loss of a significant other can contribute to increased suicide risk in older adults, the information provided does not indicate an immediate concern.
D.   While being a single working mother with young children is challenging, the information provided does not suggest an increased risk for suicide in this scenario.

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Correct Answer is D

Explanation

A. Telling the client that the voices they are hearing are not real may invalidate their experience and could increase their distress or resistance to the nurse's intervention.
B. While discussing strategies for the next occurrence might be helpful, it does not address the immediate situation or acknowledge the client's current experience.
C. Asking the client to focus on something else may be perceived as dismissive and may not effectively engage them in conversation or provide support.
D. Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices. This comment encourages the client to express themselves and provides an opening for further communication, allowing the nurse to assess the situation more effectively.

A. Support the client to list small behavioral changes needed. B. Explain the specific skills needed to prevent a relapse. C. Provide teaching on the symptoms of substance use dependence. D. Advise the client to reschedule until committing to recovery.

Correct Answer is A

Explanation

A. Supporting the client to list small behavioral changes is a person-centered and achievable approach to promote progress.
B. Explaining specific skills needed to prevent a relapse may be overwhelming at this early stage.
C. Providing teaching on symptoms of substance use dependence may not be the most immediate and practical response to the client's expressed desire for positive change.
D. Advising the client to reschedule until committing to recovery is not supportive and may discourage the client's motivation for positive change.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

Correct Answer is A

Explanation

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?