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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While assessing coping skills is essential, in a crisis situation, determining immediate risks to the client's safety takes precedence.
B. Assessing for psychotic thinking is crucial to address immediate safety concerns. Psychosis can present significant risks and requires immediate attention.
C. While support systems are important for long-term recovery, determining immediate safety concerns is a priority.
D. Identifying the cause of the crisis is relevant but may not be the immediate priority when the client's safety is at risk due to potential psychotic thinking.
Correct Answer is D
Explanation
A. Avoiding exposure to bright sunlight is not specifically related to SSRIs; it may be a
consideration with certain medications due to photosensitivity but isn't a primary concern with SSRIs.
B. Restricting sodium intake isn't a directive associated with SSRI antidepressant therapy.
C. Maintaining a tyramine-free diet is a concern with certain antidepressants like MAOIs (Monoamine Oxidase Inhibitors) but not typically with SSRIs.
D. Reporting increased suicidal thoughts is a crucial directive because SSRIs may initially increase the risk of suicidal ideation, especially in the early stages of treatment.
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