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 ["B","C","D","E","F"]
Explanation
A. ECG can detect complications like bradycardia or QT prolongation, but does not in itself indicate progress unless compared over time. It's more useful as a diagnostic tool than a treatment response marker.
B. Weight gain is one of the most reliable markers of recovery in anorexia nervosa. If the client is gaining weight steadily as part of a refeeding plan, it strongly indicates progress.
C. Sodium level: Electrolyte imbalances (such as hyponatremia) are common due to malnutrition and purging behaviors. A normalized sodium level indicates physiological recovery.
D. Respiratory assessment: Improvement in respiratory rate (from 24 → 20/min) and increased SpO2 (93% → 96%) suggest better respiratory and overall metabolic function.
E. Temperature: An increase in body temperature indicates improvement in metabolic rate and nutritional status, both of which are impaired in severe malnutrition.
F. Creatinine level reflects kidney function and muscle mass. Improvement or normalization of creatinine levels is a positive sign of physiological restoration in anorexia.
Correct Answer is ["C","D","E","F"]
Explanation
A. Restricting airplane travel is not typically a restriction for clients undergoing hemodialysis. With appropriate planning, travel can still be possible, though it may require adjustments such as scheduling dialysis treatments while traveling. Therefore, it may not have a major impact on quality of life for most clients.
B. Limiting social activities to twice a week is not a typical restriction associated with hemodialysis. Although dialysis treatments may limit the time available for activities, it does not specifically limit social interactions to twice a week unless the client’s health deteriorates.
C. Time constraints are a significant concern. Hemodialysis typically requires the client to spend several hours (usually 3-5 hours) per session, 3 times a week, which can disrupt daily routines, work, and personal activities. This can impact the client’s quality of life.
D. Driving restrictions may apply. Many clients on hemodialysis are advised not to drive immediately after dialysis treatments due to potential fatigue, dizziness, or changes in blood pressure. This can impact the client's ability to travel independently and manage daily activities.
E. Restricting fluid intake is a common and critical aspect of hemodialysis. Clients with end-stage kidney disease need to be very careful about how much fluid they consume because their kidneys cannot excrete excess fluid effectively. This restriction can lead to discomfort and can significantly impact quality of life.
F. Restricting foods high in potassium, sodium, and phosphorus is important for clients with end-stage kidney disease undergoing hemodialysis. These dietary restrictions help maintain electrolyte balance and prevent complications like hyperkalemia and hyperphosphatemia, which can be life-threatening. However, adhering to these dietary restrictions can impact social and cultural aspects of the client's life and overall enjoyment of food.
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