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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
While the client's statement might seem like other defense mechanisms, here's why Denial is the most fitting choice: Denial:
Involves refusing to acknowledge a painful or threatening reality.
The client attributes their cough, a potential symptom of lung cancer, to a common cold, dismissing the possibility of their condition worsening.
This allows them to avoid the emotional distress associated with facing their illness. Other options and their rationales:
Reaction formation (Choice A): This involves expressing the opposite of what one truly feels or desires. The client doesn't show any outward signs of expressing emotions opposite to their actual feelings about their health.
Suppression (Choice C): This involves consciously pushing unpleasant thoughts or feelings out of awareness. While the client might downplay the cough, they haven't completely pushed the thought of their illness away.
Regression (Choice D): This involves reverting to an earlier stage of development in response to stress. There's no indication of the client displaying behaviors characteristic of an earlier developmental stage.
Addressing other potential mechanisms:
Displacement: Redirecting emotions towards a less threatening target is not evident in the scenario.
Rationalization: Justifying behavior in a way that avoids facing the true reasons is not seen in the client's explanation. Projection: Attributing one's own feelings or desires to others is not present in the client's statement.
Remember:
Denial is a common coping mechanism for dealing with difficult realities like illness.
It's crucial for the nurse to assess the extent of the client's denial and offer support without judgment.
The goal is to help the client acknowledge their illness while providing emotional support and resources for managing their condition.
Correct Answer is A
Explanation
A. A client who has depression - Correct.
Explanation:
Depression is a significant risk factor for suicide. Individuals with depression may experience feelings of hopelessness, helplessness, and despair, which can contribute to suicidal ideation. It is crucial for the mental health nurse to carefully assess and monitor individuals with depression for any signs of suicidal thoughts or behaviors. Prompt intervention and support are essential to address the underlying issues and mitigate the risk of suicide.
Explanation for other choices:
B. A client whose family visits him every week from out of town.
- Family support is generally considered a protective factor against suicide. Regular family visits can provide emotional support and a sense of connection, reducing the risk.
C. A pregnant female client who is at 8 months gestation.
- Pregnancy alone is not a direct risk factor for suicide. However, mental health issues during pregnancy, such as depression, should be assessed and addressed appropriately.
D. A client who has a lot of friends.
- This scenario does not provide enough information for a clear assessment of suicide risk. Social interactions can be both protective and risk factors, depending on the individual's overall situation and support network. Further assessment would be needed to determine the significance of this factor.
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