A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says. "My business is bankrupt and was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a covert suicidal message?
"My family will be better off without me."
"Life is not worth living."
"I wish I were dead."
"I have a plan that will fix everything"
The Correct Answer is A
A. "My family will be better off without me" is an indirect or covert suicidal statement (passive ideation) that suggests the patient believes others would be better off if they were gone. Such remarks require immediate assessment of suicide risk (ask directly about thoughts, intent, plan, access to means) and appropriate safety interventions.
B. "Life is not worth living" is an explicit expression of hopelessness and indicates suicidal ideation, but it is more overt than covert. It still warrants urgent assessment, but the question asked specifically for the covert message.
C. "I wish I were dead" is a direct statement of suicidal desire (overt) rather than a covert hint.
D. "I have a plan that will fix everything" is the most concerning because it indicates a specific plan (high lethality risk), but it is overt rather than covert.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While laboratory tests are important for assessing electrolyte imbalances and liver function, they are not the immediate priority in acute alcohol withdrawal.
B. Acute alcohol withdrawal can rapidly lead to seizures and delirium tremens, which are life-threatening. Patient safety and prevention of injury are the priority.
C. Neurological assessment is important, but first ensuring the client’s safety from potential seizures takes precedence.
D. IV access is necessary for fluid or medication administration, but it follows implementing immediate safety measures.
Correct Answer is C
Explanation
A. Patients do not need to double fluid intake, just maintain adequate hydration (2–3 L/day). Drinking twice the usual amount could lead to fluid overload or dilute sodium balance.
B. Lithium should never be doubled. In fact, vomiting and diarrhea increase risk of lithium toxicity, so the provider must be notified instead.
C. Lithium excretion is closely tied to sodium and fluid balance. A stable diet with normal salt and adequate fluid intake helps prevent fluctuations in lithium levels and reduces risk of toxicity.
D. Avoiding aged cheese, processed meats, and red wine is teaching for MAOI therapy (to prevent hypertensive crisis due to tyramine), not for lithium.
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