A nurse in a community clinic is speaking to a parent who expresses concern for her adolescent son.
Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?
“He spends much of his time with his school friends.”
“He has slept 9 hours each night for the past 2 years.”
“He is very religious and attends services twice a week.”
“His basketball coach committed suicide last month.”
The Correct Answer is D
A rationale:
Spending time with friends can be a protective factor against suicide, as it provides social support and connection.
While isolation can be a risk factor, spending time with friends does not inherently indicate suicide risk.
It's important to assess the quality of relationships and the presence of other risk factors.
Choice B rationale:
Regular sleep patterns often indicate healthy mental health.
Significant changes in sleep patterns (either too much or too little) can be warning signs, but consistent sleep of 9 hours is not typically a concern.
It's essential to evaluate sleep quality and any recent changes.
Choice C rationale:
Religious involvement can provide a sense of purpose, belonging, and support, which can be protective against suicide.
While it's not a guarantee of protection, it's generally a positive factor.
It's crucial to assess the individual's level of engagement and any potential conflicts within their religious beliefs.
Choice D rationale:
Exposure to suicide, especially in a close connection like a coach, can significantly increase a person's risk for suicide.
It can lead to normalization of suicide as a coping mechanism, imitation of behavior, or triggering of underlying mental health issues.
This is a strong risk factor that warrants immediate attention and assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.
Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.
Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.
Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.
Correct Answer is D
Explanation
A rationale:
Incorrect. While patients typically do sleep for a period after ECT, the duration is usually shorter, around 30-60 minutes.
Providing inaccurate information about the length of sleep can lead to confusion and anxiety for the patient.
Evidence: Studies have shown that the average recovery time following ECT is around 30-60 minutes, with most patients feeling alert and oriented within that time frame. (Source: NIH.gov) Choice B rationale:
Incorrect. While ECT can be highly effective in treating depression, it is not considered a cure. It's important to manage expectations and emphasize that ECT is a treatment option that can significantly improve symptoms but may not guarantee a complete cure.
Evidence: Research indicates that ECT has a remission rate of approximately 50-70% in patients with severe depression, meaning that many patients experience a significant reduction or disappearance of symptoms. However, relapse rates can range from 30-50%, indicating that ongoing maintenance treatment is often necessary. (Source: American Psychiatric Association)
Choice C rationale:
Incorrect. Muscle relaxants, not seizure-preventing medications, are administered during ECT to protect the patient from injury during the induced seizure. It's crucial to clarify this distinction to avoid misunderstandings about the procedure's mechanism of action.
Evidence: Standard ECT protocols involve the use of a short-acting muscle relaxant, such as succinylcholine, to prevent muscle contractions during the seizure. This helps to minimize the risk of physical injury and ensure patient safety. (Source: Healthline.com)
Choice D rationale:
Correct. Temporary memory loss is a common side effect of ECT, and it's essential to inform patients about this potential issue to prepare them for the experience and address any concerns they may have.
Evidence: Studies have shown that approximately 40-50% of patients experience some degree of memory impairment following ECT, primarily affecting short-term memory of events occurring around the time of treatment. However, this memory loss is usually temporary and resolves within a few weeks or months for most patients. (Source: Studocu.com)
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