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 D

Explanation

A. The PSDA applies to all adult clients regardless of age. It ensures that adults have the right to make decisions about their medical care, including the right to accept or refuse treatment, regardless of whether they are elderly or not. Age is not a factor in the applicability of the PSDA.
B. While it's common for a living will to be witnessed, it is not a legal requirement under the PSDA.
C. Advance directives are applicable to all clients, including those receiving mental health care.
D. The Patient Self-Determination Act (PSDA) ensures that adult patients are informed about their rights to make decisions regarding their medical care, including the right to accept or refuse treatment and to prepare an advance directive.

A. "Can you see these spiders crawling all over me?" B. "The aliens are going to abduct me tonight." C. "The voices told me to quit eating the food” D. "Are you planning to kill me?"

Correct Answer is C

Explanation

A. This statement describes a visual hallucination (seeing spiders crawling), not a command hallucination. Visual hallucinations involve seeing things that are not actually present.

B. This statement reflects a delusion rather than a hallucination. Delusions are false beliefs that are firmly held despite evidence to the contrary. In this case, the belief in aliens and abduction is not related to hearing voices commanding actions.
C. This statement indicates a command hallucination. The client hears voices instructing them to stop eating. Command hallucinations often involve direct, imperative commands from voices that are perceived as real.
D. This statement reflects paranoia or fear of harm from others, which can be a common symptom in schizophrenia. However, it does not directly indicate a command hallucination.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?

Correct Answer is C

Explanation

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