A nurse in a mental health facility is assessing a client.
For each client assessment finding, click to specify if the finding is a potential risk for suicide or a protective factor against suicide.
Access to lethal means
Feelings of self-worth
Mental health support
Support systems
Physical health
Family history
Alcohol consumption
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}
Risk Factor:
Access to lethal means: The client reported having a large supply of alprazolam and thoughts of taking all of them, indicating an immediate means and plan, increasing suicide risk.
Feelings of self-worth: The client has increased depression and thoughts of self-harm, reflecting low self-worth.
Family history: Mother died by suicide, which is a strong familial risk for suicide due to both genetic and environmental factors.
Alcohol consumption: Even though the client is sober now, a history of alcohol misuse is a known long-term suicide risk factor.
Protective Factor:
Mental health support: Has had ongoing psychotherapy for 10 years, suggesting an established support and coping resource.
Support systems: Voluntarily self-admitted based on therapist’s advice, showing willingness to seek help and some external support.
Physical health: The client is in good physical health, which reduces the burden of comorbid conditions and may support recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"},"H":{"answers":"A"}}
Explanation
Anticipated Actions:
Maintain same staff members: Provides consistency and builds trust—essential in managing clients with emotional instability.
Encourage talking about feelings prior to self-harm: Helps identify emotional triggers and promotes healthy coping strategies.
Initiate suicide precautions: Critical given self-harm, feelings of hopelessness, and verbalizations of loneliness.
Explore feelings of abandonment: Therapeutic to address the underlying emotional distress linked to relationship loss.
Offer opportunities for physical exercise: Can reduce tension and improve mood in a structured, healthy way.
Contraindicated Actions:
Offer sympathy and attention to maladaptive behavior: Reinforces self-harm as a means to gain attention, which can perpetuate the behavior.
Apply wrist restraints: Physical restraints are only appropriate when a client poses an immediate risk to self or others and all less restrictive options have failed. In this scenario, suicide precautions and monitoring are more appropriate first-line interventions.
Non-essential Action:
Instruct the client to avoid foods with tyramine: Relevant only if the client is taking MAOIs (e.g., phenelzine), which isn’t indicated in the scenario.
Correct Answer is D
Explanation
A. Heat intolerance is incorrect. Myxedema, which is a severe form of hypothyroidism, is typically associated with cold intolerance rather than heat intolerance. Clients with hypothyroidism often feel cold even in warm environments.
B. Diarrhea is incorrect. Clients with myxedema are more likely to experience constipation due to the slowed metabolic processes associated with hypothyroidism.
C. Tachycardia is incorrect. Myxedema is associated with bradycardia (slow heart rate), not tachycardia (fast heart rate). Hypothyroidism can slow down the body's overall processes, including heart rate.
D. Facial edema is correct. Facial edema (or puffiness) is a common sign of myxedema, which results from the accumulation of mucopolysaccharides in the tissues due to severe hypothyroidism. This can cause swelling, especially in the face, around the eyes, and the hands.
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