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 A

Explanation

A. Allowing the client to rest and sleep is a priority, as sleep deprivation can exacerbate symptoms of depression. Addressing immediate physical needs is crucial.
B. Planning for discharge can be addressed later in the treatment process; the immediate focus should be on ensuring the client's basic needs are met.
C. Encouraging verbalization of feelings is important but should not take precedence over addressing the client's sleep deprivation.
D. Ensuring the client attends groups addressing coping skills for dealing with depression is valuable but may be addressed after the client has had sufficient rest. Prioritizing sleep helps address the most immediate concern.

A. Determine the client’s reason for attempting suicide. B. Obtain the client’s serum hydrocodone/acetaminophen level. C. Encourage the client to increase fluid intake. D. Observe the client for further narcotic effects.

Correct Answer is D

Explanation

A. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.

B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.

C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.

D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

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