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 C

Explanation

Choice A Reason:
Elevated blood pressure and heart rate are not typically indicative of sedative-hypnotic drug use. These symptoms are more commonly associated with stimulant use or withdrawal from depressants.

Choice B Reason:
Increased energy and hyperactivity are also not indicative of sedative-hypnotic drug use. These are symptoms that might be observed with stimulant drugs or during withdrawal from depressants.

Choice C Reason:
Excessive drowsiness and sedation are hallmark signs of sedative-hypnotic drug use. Sedative-hypnotics, which include drugs like benzodiazepines and barbiturates, work by depressing the central nervous system, leading to a decrease in brain activity and causing drowsiness and sedation.

Choice D Reason:
While improved sleep quality and duration might be an intended effect of sedative-hypnotic drugs, they are not indicative of acute use or intoxication. These drugs are often prescribed to help with sleep; however, their misuse can lead to excessive sedation beyond normal sleep patterns.

A. "I check any room I enter because the enemy is still after me and could be hiding anywhere." B. "My child was born with a birth defect due to an exposure I had overseas." C. "I killed four enemy soldiers with my bare hands and saved my entire battalion." D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."

Correct Answer is D

Explanation

Choice A reason:
This statement reflects hypervigilance and a persistent sense of threat, which are symptoms associated with PTSD. Individuals with PTSD may feel constantly on edge as if danger is always imminent, leading to behaviors such as checking rooms repeatedly.

Choice B reason:
While this statement indicates a traumatic experience, it does not directly suggest symptoms of PTSD. PTSD is characterized by specific symptoms such as intrusive thoughts, flashbacks, and avoidance behaviors related to the traumatic event.

Choice C reason:
This statement may be indicative of a distressing combat experience but does not directly align with the symptoms of PTSD. It does not reflect the re-experiencing, avoidance, or arousal symptoms typically seen in PTSD.

Choice D reason:
This statement is a clear example of re-experiencing symptoms, which is a core feature of PTSD. Nightmares about the traumatic event and intrusive, distressing memories are common in individuals with PTSD. The vivid and distressing nature of such dreams can significantly impact an individual's well-being.

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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 caring for a patient with a history of sedative use disorder. Which cue is indicative that a client has used a sedative-hypnotic drug?

Correct Answer is C

Explanation

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

Correct Answer is D

Explanation

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