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 A
Explanation
Choice A rationale:
1. Understanding OCD:
OCD is a chronic mental health condition characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions).
Individuals with OCD feel compelled to perform rituals to relieve anxiety or prevent perceived harm, even if they recognize the behaviors as excessive or irrational.
Rituals can consume significant time and interfere with daily functioning.
2. Rationale for Choice A:
Acknowledges the client's needs: Planning for rituals demonstrates understanding and acceptance of the client's experience, fostering trust and rapport.
Reduces anxiety: Allowing time for rituals can temporarily reduce anxiety, making the client more receptive to other interventions.
Gradual approach: It's a stepping stone towards Exposure and Response Prevention (ERP), the gold-standard treatment for OCD.
Enhances control: Scheduling rituals can help the client feel more in control, reducing the urge to engage in them compulsively.
3. Addressing potential concerns:
Reinforcing rituals: While there's a possibility of temporarily reinforcing rituals, it's a necessary first step to build trust and engagement in therapy.
Interfering with treatment: Scheduling rituals is a part of a comprehensive treatment plan that includes ERP and other therapies to address the underlying causes of OCD.
4. Importance of individualized care:
The specific approach to planning for rituals should be tailored to the client's unique needs, preferences, and severity of symptoms.
Collaboration with the client is essential to ensure their active participation in treatment. I'll now address the rationales for the incorrect choices:
Choice B rationale:
Setting strict limits on behaviors can be counterproductive: Triggers anxiety and distress
Impedes trust and therapeutic alliance Diminishes sense of control
Heightens resistance to treatment
Choice C rationale:
Confronting the client about the senselessness of rituals is ineffective and potentially harmful: Exacerbates anxiety and shame
Alienates the client
Disregards the involuntary nature of OCD Undermines motivation for treatment Choice D rationale:
Isolating the client is unethical and detrimental:
Increases distress and loneliness Impedes therapeutic interactions Reinforces negative self-perceptions
Lacks evidence of efficacy in OCD treatment
Correct Answer is B
Explanation
The correct answer is choice b. Moderate.
Choice A rationale: Severe anxiety is characterized by a significant reduction in the ability to perceive and process information. The individual may experience intense physical symptoms such as dizziness, hyperventilation, and a sense of impending doom. The client’s ability to focus is greatly diminished, and they may have difficulty functioning.
Choice B rationale: Moderate anxiety involves a heightened sense of awareness and a narrowing of the perceptual field. The individual may experience physical symptoms such as increased heart rate, sweating, and muscle tension. They can still focus and problem-solve but may need assistance. The client’s symptoms of chest pain, headache, and shortness of breath, along with their emotional distress, align with moderate anxiety.
Choice C rationale: Mild anxiety is associated with a slight increase in alertness and perception. The individual may feel restless and have minor physical symptoms like slight muscle tension. They can still function effectively and use coping mechanisms to manage their anxiety.
Choice D rationale: Panic level anxiety is the most severe form and involves a complete disruption of the ability to function. The individual may experience extreme physical symptoms such as chest pain, palpitations, and a sense of losing control. They may be unable to communicate effectively or respond to their environment.
Each level of anxiety presents differently, and understanding these differences helps in providing appropriate care and interventions.
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