A nurse is caring for a client following a suicide attempt.
The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?
Administering the Hamilton Depression Scale.
Making a contract with the client for eating behavior.
Reviewing the client's toxicology laboratory report.
Initiating one to one continuous observation.
The Correct Answer is D
Administering the Hamilton Depression Scale is a tool used to assess the severity of depression. While it can provide valuable information about the client's mental state, it is not the priority intervention in this case. The client has already attempted suicide, indicating a high level of risk. It is essential to focus on ensuring the client's immediate safety before conducting further assessments.
Rationale for Choice B:
Making a contract with the client for eating behavior can be a helpful intervention for clients with anorexia nervosa. However, it is not the priority in the immediate aftermath of a suicide attempt. The client's safety must take precedence over addressing their eating disorder.
Rationale for Choice C:
Reviewing the client's toxicology laboratory report can provide information about the substances the client ingested in their suicide attempt. However, this information is not necessary for determining the immediate course of action. The priority is to initiate safety measures to prevent another attempt.
Rationale for Choice D:
Initiating one-to-one continuous observation is the most critical intervention for a client who has recently attempted suicide. This level of observation ensures that the client is constantly monitored and cannot make another attempt without being interrupted. It also allows the nurse to assess the client's mental state and behaviors closely and intervene if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice B rationale:
Male gender is a significant risk factor for suicide. Men are more likely to die by suicide than women, with rates being approximately 3.5 times higher in men than women in the United States.
Several factors contribute to this increased risk:
Men are less likely to seek help for mental health issues. This may be due to societal expectations of masculinity, which often discourage men from expressing emotions or seeking help for emotional distress.
Men are more likely to use more lethal means of suicide. For example, men are more likely to use firearms, which have a higher fatality rate than other methods such as poisoning or cutting.
Men may be more likely to experience social isolation and loneliness. These factors can increase the risk of suicide, as they can lead to feelings of hopelessness and despair.
Men may be more likely to experience substance abuse problems. Substance abuse can increase the risk of suicide, as it can impair judgment and impulse control, and can also lead to feelings of hopelessness and despair.
Choice C rationale:
Recent marriage is not a risk factor for suicide. In fact, some studies have shown that marriage may have a protective effect against suicide.
However, it's important to note that relationship problems, including separation, divorce, or domestic violence, can be significant risk factors for suicide.
Choice D rationale:
Age greater than 55 is a risk factor for suicide. Suicide rates are highest among older adults, particularly among men aged 85 and older.
Several factors contribute to this increased risk:
Older adults are more likely to experience chronic health conditions and pain. These conditions can lead to feelings of hopelessness and despair, and can also make it more difficult to cope with stress.
Older adults are more likely to experience social isolation and loneliness. These factors can increase the risk of suicide, as they can lead to feelings of hopelessness and despair.
Older adults are more likely to experience bereavement and loss. The loss of a spouse, family members, or friends can be a major stressor, and can increase the risk of suicide.
Choice E rationale:
Diagnosis of schizophrenia is a significant risk factor for suicide.
People with schizophrenia are approximately 10 times more likely to die by suicide than the general population. Several factors contribute to this increased risk:
Schizophrenia is a severe mental illness that can cause significant distress and impairment.
People with schizophrenia may experience hallucinations, delusions, and disorganized thinking. These symptoms can be very distressing and can lead to feelings of hopelessness and despair.
People with schizophrenia may also experience social isolation and stigma. These factors can further increase the risk of suicide.
Correct Answer is C
Explanation
The correct answer/s is C
Choice A rationale: Hyperkalemia, or high potassium levels in the blood, is not typically associated with anorexia nervosa. In fact, individuals with anorexia nervosa are more likely to experience hypokalemia, or low potassium levels, due to inadequate dietary intake and excessive loss of potassium through vomiting or use of diuretics1.
Choice B rationale: Metrorrhagia, or irregular menstrual bleeding between periods, can occur in females with anorexia nervosa due to hormonal imbalances caused by extreme weight loss and malnutrition. However, amenorrhea, or the absence of menstruation, is more commonly observed1.
Choice C rationale: Lanugo, which is fine, soft hair that grows on the face and body, is a common finding in individuals with anorexia nervosa. It is the body’s response to severe weight loss and starvation as an attempt to provide insulation and maintain body temperature1.
Choice D rationale: Tachycardia, or a rapid heart rate, is not typically associated with anorexia nervosa. Instead, individuals with anorexia nervosa often experience bradycardia, or a slower than normal heart rate, as the body’s response to starvation1.
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