A nurse is collecting data from a client who reports manifestations of depression. Which of the following findings should the nurse identify as a risk factor for suicide?

The client is married and has children.

The client has a strong religious affiliation.

The client recently received a pay raise at work.

The client has a history of chronic back pain.

Answer and Explanation

The Correct Answer is D

Choice A reason: Being married with children often buffers suicide risk by providing social support and purpose, reducing isolation—a key factor in depression. Scientifically, strong familial ties correlate with lower rates, making this a protective, not risk-enhancing, element in mental health assessments.

Choice B reason: Strong religious affiliation typically lowers suicide risk, as faith offers coping mechanisms and community, countering despair. Scientifically, studies show religiosity inversely relates to suicide, acting as a protective factor, not a contributor, in depression-related risk evaluations.

Choice C reason: A recent pay raise suggests improved financial stability, reducing stress—a suicide risk factor. Positive life events like this bolster resilience in depression, not heighten risk. Scientifically, this aligns with lower suicidal ideation, making it a protective rather than aggravating circumstance.

Choice D reason: Chronic back pain increases suicide risk in depression, as persistent pain erodes quality of life, amplifying hopelessness. Scientifically, chronic conditions correlate with higher rates, as physical suffering compounds psychological distress, making this a significant risk factor per mental health research.

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Correct Answer is D

Explanation

Choice A reason: Offering multiple choices overwhelms a delirious client, whose impaired cognition struggles with decisions. Scientifically, delirium reduces attention and processing, so simplifying options aids comfort, making this counterproductive to managing their acute confusional state effectively.

Choice B reason: Alternating caregivers disrupts continuity, worsening disorientation in delirium. Consistent faces aid recognition, reducing anxiety. Scientifically, familiarity stabilizes perception in acute confusion, making this detrimental to the client’s need for a predictable environment during recovery.

Choice C reason: Avoiding fears ignores emotional distress, potentially increasing agitation in delirium. Addressing concerns gently can calm. Scientifically, unaddressed anxiety exacerbates confusion, so this neglects a holistic approach needed for managing the client’s psychological state effectively.

Choice D reason: Reminding of day and time reorients the client, countering delirium’s disorientation. Frequent cues anchor perception, aiding recovery. Scientifically, this aligns with evidence-based care, as repeated orientation reduces confusion’s impact, supporting cognitive stabilization in acute delirium management.

A. New onset of hearing loss B. Slurred speech C. Constipation D. Hypotension

Correct Answer is A

Explanation

Choice A reason: Hearing loss is a known gentamicin ototoxicity effect, damaging cochlear hair cells irreversibly. Scientifically, this aminoglycoside targets the inner ear, causing tinnitus or deafness, a critical adverse reaction to monitor in pyelonephritis treatment per pharmacology evidence.

Choice B reason: Slurred speech suggests neurological issues (e.g., stroke), not gentamicin effects. Scientifically, this drug affects kidneys and ears, not speech centers, making this unrelated to its toxicity profile, which focuses on auditory and renal damage.

Choice C reason: Constipation isn’t linked to gentamicin; it’s more typical of opioids or immobility. Scientifically, this antibiotic’s side effects center on nephrotoxicity and ototoxicity, not gastrointestinal motility, rendering this an unlikely adverse reaction in this context.

Choice D reason: Hypotension may occur with rapid IV gentamicin, but it’s less common than ototoxicity. Scientifically, hearing loss is a hallmark toxicity, outweighing transient blood pressure drops, which are manageable and less specific to this drug’s adverse profile.

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A nurse is collecting data from a client who reports manifestations of depression. Which of the following findings should the nurse identify as a risk factor for suicide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

Correct Answer is A

Explanation

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