A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Ask the client if she has a plan to commit suicide.

Assist the client to her room and allow her to rest before resuming activity.

Recognize the attempt at manipulation and escort the client back to her activity.

Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

Answer and Explanation

The Correct Answer is A

Choice A reason:
When a client expresses thoughts of wanting to end their life, it is crucial for the nurse to immediately assess the risk of suicide. Asking the client if they have a plan to commit suicide is a direct approach to gauge the immediacy and seriousness of the risk. This information is vital for determining the next steps in care, which may include close supervision, safety precautions, and urgent psychiatric evaluation.

Choice B reason:
While ensuring the client is comfortable is important, allowing the client to rest without further assessment or intervention may not be safe if the client is at immediate risk of self-harm. The priority is to assess and secure the client's safety.

Choice C reason:
It is inappropriate and potentially dangerous to dismiss the client's statement as manipulation. All expressions of suicidal ideation should be taken seriously, and the nurse should provide a supportive response that addresses the client's emotional state and safety concerns.

Choice D reason:
Notifying the client's family can be part of a broader safety plan, but it should not replace immediate assessment and intervention by the healthcare team. Family members may provide support, but they are not a substitute for professional care and suicide risk assessment.

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Correct Answer is A

Explanation

Choice A reason:
Alcohol use disorder (AUD) is associated with various workplace problems. Individuals with AUD may experience a decline in their work performance due to cognitive, emotional, and behavioral impairments caused by alcohol use. This can manifest as frequent tardiness, absenteeism, and a decrease in productivity. Moreover, alcohol use can lead to workplace injuries and conflicts, which further affect an individual's ability to perform their job effectively. Therefore, asking about the impact of alcohol use on work performance can provide insights into the extent of the disorder's effect on the client's psychosocial behaviors.

Choice B reason:
The age at which an individual begins drinking alcohol is a significant factor in the development of AUD. Studies have shown that early onset of drinking increases the risk of developing alcohol dependence later in life. While this information is valuable for understanding the client's history with alcohol, it does not directly address the current impact of alcohol use on their psychosocial behaviors.

Choice C reason:
Previous treatment for substance use disorder can indicate the severity of the client's condition and their history of seeking help. Treatment history can also reveal patterns of relapse or recovery, which are important in the management of AUD. However, this choice does not specifically inquire about the current psychosocial impact of alcohol use.

Choice D reason:
Mental health disorders often co-occur with AUD, and the presence of such disorders can exacerbate the psychosocial impact of alcohol use. While it is crucial to understand the client's overall mental health, this question does not focus on the specific effects of alcohol use on work performance and other psychosocial behaviors.

A. The client assumes an active role in her care planning process. B. The client identifies positive qualities about herself. C. The client exhibits expected grieving behaviors. D. The client makes a contract to avoid self-harm.

Correct Answer is D

Explanation

Choice A reason:
While it is beneficial for clients to be involved in their care planning, this is not the immediate priority. Active participation in care planning is a goal that can be pursued once the client's safety and stability are ensured.

Choice B reason:
Identifying positive qualities about oneself is an important step in improving self-esteem and promoting recovery in clients with major depressive disorder. However, this is not the most immediate priority when compared to ensuring the client's safety¹.

Choice C reason:
Exhibiting expected grieving behaviors is a natural and necessary process for healing after the loss of a loved one. However, the priority in the acute phase of care, especially when a client is at risk for self-harm, is to ensure safety.

Choice D reason:
The priority nursing goal for a client with major depressive disorder, especially following a significant loss, is to ensure safety. Making a contract to avoid self-harm is a critical intervention that addresses the risk of suicide, which is heightened in individuals with major depressive disorder and recent significant loss. This contract is a verbal or written agreement between the client and the healthcare provider that the client will not harm themselves and will seek help if they have thoughts of self-harm.

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A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client's psychosocial behaviors?

Correct Answer is A

Explanation

A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

Correct Answer is D

Explanation

A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

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