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. While staying alone can be concerning, it might not be the strongest indicator of an impending suicide attempt in this scenario.
B. Excessive crying is a potential sign of distress but might not directly point towards an impending suicide attempt.
C. Giving away prized possessions or making significant gifts is often considered a strong indicator of an impending suicide attempt, indicating a sense of "getting affairs in order."
D. Attempting to communicate with family might suggest seeking support rather than indicating an impending suicide attempt.

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 might not address the immediate distress related to the sexual assault.
B. While discussing triggers is relevant, it might not directly address the current acute symptoms of reliving the traumatic event.
C. Asking about current experiences of 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 asking about flashbacks addresses more immediate distress.

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Naxlex Comprehensive Predictor Exams

After failing two tests, a college student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt?

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 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 nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hr hold is over for which of the following conditions?

When assessing a patient's plan for suicide, what aspect has priority?

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

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy?

A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?

Nursing behaviors associated with the implementation phase of the nursing process are concerned with the responsibilities of the psychiatric mental health nurse?