A nurse in a mental health facility is assessing a client.
- The client has a medical history of major depressive disorder for 20 years, anxiety disorder, suicide ideation during teenage years, and psychotherapy for the past 10 years with a therapist.
- The client's mother committed suicide when the client was 25 years of age, and the father died of heart disease 10 years ago.
- The client has a history of alcohol misuse, attended in-patient rehabilitation 4 years ago with no alcohol use since that time.
- The nurse notes indicate good physical health with no reported morbidities.
For each client assessment finding, specify if the finding is a potential risk for suicide or a protective factor against suicide.
Mental health support
Family history
Physical health
Support systems
Alcohol consumption
Access to lethal means.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
The correct answer/s is Choice/s.
Choice A rationale: Mental health support is generally considered a protective factor against suicide. Effective mental health care can help individuals manage their mental health conditions, which can reduce the risk of suicide.
Choice B rationale: Family history, particularly a family history of suicide, is a risk factor for suicide. The client’s mother’s suicide could potentially increase the client’s risk.
Choice C rationale: Good physical health is typically seen as a protective factor against suicide. Serious physical health conditions, including chronic pain, can increase suicide risk, but the client is reported to be in good physical health.
Choice D rationale: Support systems, such as feeling connected to family and community, are protective factors against suicide. They can provide emotional support and help individuals feel less isolated.
Choice E rationale: Alcohol consumption, especially misuse or addiction, is a risk factor for suicide. However, the client has attended rehabilitation and has not used alcohol for the past 4 years, which could be seen as a protective factor.
Choice F rationale: Access to lethal means is a risk factor for suicide. Limiting access to lethal means is a societal protective factor.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Obsession over a fictitious defect in physical appearance is characteristic of body dysmorphic disorder, not generalized anxiety disorder (GAD).
Individuals with body dysmorphic disorder become preoccupied with an imagined or slight defect in their appearance, often to the point of significant distress and impairment in functioning.
They may engage in excessive grooming behaviors, repeatedly check their appearance in mirrors, or avoid social situations due to their appearance concerns.
While individuals with GAD may also experience concerns about their physical appearance, these concerns are typically not as severe or pervasive as those seen in body dysmorphic disorder.
Choice B rationale:
Constant worry about the undiagnosed presence of an illness is a hallmark feature of GAD.
Individuals with GAD often experience excessive worry about a variety of things, including health, finances, relationships, and work.
This worry is often accompanied by physical symptoms such as restlessness, fatigue, difficulty concentrating, and muscle tension.
The worry is typically difficult to control and can significantly interfere with daily life.
Choice C rationale:
Sudden unexplained loss of vision without a physical medical explanation is not a common symptom of GAD. It may be indicative of a more serious medical condition, such as a stroke or a neurological disorder.
It is important to rule out any potential medical causes before attributing a symptom like this to GAD.
Choice D rationale:
Prior physical health followed by the need for two surgeries within the last three months may be a stressful life event that could contribute to the development of GAD.
However, it is not a specific symptom of GAD.
Many people experience stressful life events without developing GAD.
The presence of other symptoms, such as excessive worry and physical symptoms, is necessary for a diagnosis of GAD.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale: The client’s magnesium level is 1.7 mg/dL, which is below the normal range of 1.8 to 2.4 mg/dL. Hypomagnesemia can cause neuromuscular irritability, muscle weakness, tremors, and even seizures or cardiac arrhythmias in severe cases.
It’s often associated with other electrolyte imbalances such as hypokalemia and hypocalcemia.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, malabsorption, or excessive losses from the gastrointestinal tract.
Choice B rationale: The client’s chloride level is 98 mmol/L, which falls within the normal range of 96 to 106 mmol/L. Chloride is an important electrolyte that helps maintain acid-base balance, fluid balance, and is a component of gastric juice as hydrochloric acid.
There’s no immediate concern regarding the client’s chloride level.
Choice C rationale: The client’s phosphate level is 2.5 mg/dL, which is below the normal range of 2.8 to 4.5 mg/dL. Hypophosphatemia can lead to muscle weakness, bone pain, mental changes, and potentially life-threatening complications such as respiratory failure and heart failure.
In the context of anorexia nervosa, hypophosphatemia is a common complication during refeeding due to shifts in electrolytes.
Choice D rationale: The client’s potassium level is 3.5 mmol/L, which is at the lower end of the normal range of 3.5 to
5.0 mmol/L. Hypokalemia can cause muscle weakness, cramps, arrhythmias, and in severe cases, it can be life- threatening.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, excessive losses due to vomiting or laxative abuse, or shifts in electrolytes during refeeding.
In conclusion, the nurse should follow up on the client’s magnesium, phosphate, and potassium levels due to their potential implications on the client’s health, especially considering the client’s current health status and the process of refeeding.
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