A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan?

Moderate level

High level

No risk

Low level

Answer and Explanation

The Correct Answer is B

A.   Moderate level would suggest a plan that has some risk but may be less imminent or less likely to result in death.
B.   A plan involving a loaded gun aimed at a vital organ like the heart, coupled with alcohol consumption and intent, indicates a high level of lethality.
C.   This scenario presents a significant risk given the method and the caller's intent, so "No risk" would not be appropriate.
D.   Low level would suggest a plan that is less likely to cause severe harm or death, which is not the case here.

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Correct Answer is C

Explanation

A. Dismissing the client's statement as manipulation without proper assessment can be dangerous.
B. While involving family support is important, this response doesn’t address the immediate safety concerns of the client.
C. Asking about suicidal plans helps assess the level of risk and informs subsequent actions to ensure the client's safety.
D. The situation requires more immediate assessment and action due to the expressed suicidal ideation.

A. "On a regular basis, do you get enough restful sleep?" B. "Can we discuss what triggered your angry outburst a few minutes ago?" C. "Are you experiencing a flashback of the rape right now?" D. "Am I correct to say that you try to avoid certain family members?"

Correct Answer is C

Explanation

A. Sleep disturbances are common in PTSD, but they might not address the current acute symptoms the client is experiencing.
B. This question explores the immediate trigger for an outburst but might not directly address the PTSD symptoms related to the sexual assault.
C. Inquiring about flashbacks directly relates to one of the hallmark symptoms of PTSD, especially given the recent severe anxiety related to the assault.
D. Avoidance behavior is a symptom of PTSD, but the question about experiencing a flashback addresses more immediate distress.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Correct Answer is C

Explanation

When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager?

Correct Answer is C

Explanation

A nurse teaching a patient about a tyramine-restricted diet would approve which meal?

A client has made a successful suicide attempt while hospitalized on a unit that specializes in the treatment of depression. When considering both milieu control and crisis management, which intervention will the nursing staff implement?

A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to do what?

Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? (Select all that apply.)

A nurse caring for a patient prescribed a selective serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to what outcome?

The decision to intervene as a patient advocate is clearly identified by the American Nurses Association's (ANA) code of ethics in which situation?

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

An individual has been diagnosed with a dissociative disorder. Which comorbid psychiatric disorders are most likely to accompany this type of mental illness? (Select all that apply.)