A nurse is collecting data from a client who has had major depressive disorder for 5 years. Which of the following statements made by the client should the nurse identify as a covert statement regarding suicide?

"I feel that soon everything will be ok."

"I just cannot take this anymore.

"My family would be better off if i was dead."

"I do not want to be here anymore."

Answer and Explanation

The Correct Answer is A

Rationale:

A. "I feel that soon everything will be ok.": This is a covert statement because it sounds hopeful but may actually reflect a decision to end one’s life. Sudden calmness or vague optimism in someone with a history of major depressive disorder can indicate suicidal planning and should prompt immediate follow-up.

B. "I just cannot take this anymore.": This is an overt expression of emotional distress and hopelessness. While serious, it clearly communicates the client's feelings and is more direct than covert.

C. "My family would be better off if I was dead.": This is an overt suicidal statement suggesting that the client believes their death would benefit others. It requires immediate attention and suicide risk assessment.

D. "I do not want to be here anymore.": This is another overt expression that directly indicates a desire to no longer live or be present. It reflects suicidal ideation and needs urgent intervention but is not considered covert.

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Correct Answer is D

Explanation

Rationale:

A. Ask the client's partner to sign as next of kin: The partner cannot legally provide informed consent on behalf of the client unless they have legal power of attorney. Consent must come from the client unless they are incapacitated.

B. Document the client's refusal in their medical record: While documentation is important, it should only occur after ensuring the client fully understands the procedure. Without effective communication, refusal may not be informed.

C. Check to see if the client has an advance directive: Advance directives guide care if the client is incapacitated but may not apply if the client is alert and able to make decisions about the current procedure.

D. Ask the provider to explain the procedure through an interpreter: Using a professional interpreter ensures clear communication so the client can make an informed decision about the cesarean birth, respecting autonomy and reducing misunderstanding.

A. Reinforce client teaching about walking with crutches B. Plan care for a client who has dysphagia. C. Transfer a client who is receiving radiation therapy to radiology D. Record urine output for a client who has a suprapubic catheter E. Measure vital signs for a client who requires contact precautions.

Correct Answer is ["C","D","E"]

Explanation

Rationale:

A. Reinforce client teaching about walking with crutches: Teaching or reinforcing client education is a nursing responsibility and should not be delegated to assistive personnel. It requires assessment, evaluation, and knowledge of the client's learning needs and physical limitations.

B. Plan care for a client who has dysphagia: Care planning involves critical thinking and individualized assessment, which fall under the registered nurse’s scope of practice. Dysphagia management also requires knowledge of aspiration risk and appropriate interventions.

C. Transfer a client who is receiving radiation therapy to radiology: Transferring stable clients to departments such as radiology is within the scope of assistive personnel, as long as the client does not require specialized monitoring or assessment during the transfer.

D. Record urine output for a client who has a suprapubic catheter: Measuring and documenting urinary output is a routine task that assistive personnel can perform. The catheter type does not affect the ability to carry out this basic observation.

E. Measure vital signs for a client who requires contact precautions: Assistive personnel are trained to take vital signs and follow isolation protocols. Measuring vital signs under contact precautions is appropriate as long as proper PPE and hygiene practices are followed.

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A nurse is collecting data from a client who has had major depressive disorder for 5 years. Which of the following statements made by the client should the nurse identify as a covert statement regarding suicide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is speaking with the partner of a client who speaks a different language than the nurse. The partner tells the nurse that the client does not want to sign an informed consent for an urgent cesarean birth. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

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