A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

"Can you tell me about the stresses in your life?"

"Has anyone in your family ever died by suicide?

“Do you have a plan for harming yourself?"

“Do you have someone to discuss your feelings with?"

Answer and Explanation

The Correct Answer is C

Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.

While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.

The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.

Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.

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Correct Answer is D

Explanation

It is common for school-age children to exhibit magical thinking and believe that their actions or thoughts have the power to cause events, including the illness or death of a loved one. Therefore, it would be expected for the school-age brother of a child with terminal cancer to have thoughts or beliefs that his own behavior is causing his brother's death.

It is important for the nurse to provide age-appropriate education and support to help the brother understand the nature of the illness and address any misconceptions or feelings of guilt.

A. Decrease daily fluid intake. B. Withhold the medication if pulse rate is less than 60/min C. Rise slowly from a sitting position to a standing position D. Increase dietary potassium

Correct Answer is C

Explanation

Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can be a side effect of enalapril and may lead to syncope. Instructing the client to rise slowly from a sitting to a standing position helps minimize the risk of a sudden drop in blood pressure and decreases the chances of syncope occurring.

Decreasing fluid intake is not likely to be the cause of syncope related to enalapril. It is important for clients to maintain adequate hydration, especially if they are experiencing side effects such as orthostatic hypotension.

While a low pulse rate may indicate bradycardia, it is not the primary concern in this situation. Orthostatic hypotension leading to syncope is the main issue, and the client should be instructed to rise slowly to prevent it.

While enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can increase potassium levels in the blood, it is not directly related to syncope. Dietary changes should be made under the guidance of a healthcare provider based on individual needs and blood test results.

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A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

Correct Answer is D

Explanation

A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?

Correct Answer is C

Explanation

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