A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)

Currently married

Alcohol use disorder

Sibling history of suicide

Access to guns in the home

Terminal liver cancer

Answer and Explanation

Correct Answer : B,C,D,E

A.   Being married is generally considered a protective factor against suicide. Married individuals often have social support and a sense of belonging, which can reduce suicide risk. Therefore, this would not be identified as a risk factor for suicide.
B.   Alcohol use disorder is a significant risk factor for suicide. Alcohol can impair judgment, increase impulsivity, and exacerbate underlying mental health issues. It is associated with higher rates of suicidal ideation and attempts.
C.   Family history of suicide, including among siblings, is a known risk factor. Exposure to suicide within the family can contribute to feelings of hopelessness, increase perceived acceptability of suicide, and impact mental health negatively.
D.   Access to firearms is a well-established risk factor for completed suicide. Firearms are highly lethal, and their presence increases the likelihood of a fatal suicide attempt compared to other means.
E.   Terminal illness, including conditions like terminal liver cancer, can contribute to feelings of hopelessness and despair, potentially increasing suicide risk. The distress related to the prognosis and physical symptoms can exacerbate mental health issues.

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Correct Answer is B

Explanation

A. Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B. When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C. Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D. Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

A. "You must be mistaken. Snakes cannot be in the clinic." B. "Your provider requires this blood specimen." C. "I'm using a syringe to obtain your blood, not a snake." D. "I don't see a snake, but that must be scary for you."

Correct Answer is D

Explanation

A. This response dismisses the client's experience and hallucination as a mistake. It invalidates the client's feelings and does not acknowledge the client's reality. It can increase the client's distress and undermine trust in the nurse's communication.
B. While this statement provides factual information about the need for the blood specimen, it does not address the client's hallucination or their fear related to it. It may come off as indifferent to the client's feelings and concerns.
C. This option dismisses the client’s feelings without addressing them appropriately.
D. This response validates the client's experience and expresses empathy for their feelings of fear. It acknowledges the hallucination without confirming its reality and shows understanding of how

frightening the experience might be for the client. This response is supportive and helps build trust between the nurse and the client.

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A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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