A nurse must be alert when a client is giving away possessions, getting his/her life in order, or making vague goodbyes to people. Which of the following should the nurse be concerned about?
Depressive State
Suicidal intent
A plan to relocate
Elopement with partner
The Correct Answer is B
A. A depressive state may involve feelings of hopelessness, but giving away possessions and saying goodbyes are signs of potential suicidal intent.
B. Suicidal intent is the primary concern in this situation. These behaviors are commonly seen when a client is preparing to end their life.
C. A plan to relocate would not typically involve giving away possessions or saying goodbyes in such a manner.
D. Elopement with a partner is not a typical behavior associated with suicidal intent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A pulse deficit refers to a condition where there is a difference between the radial and apical pulse rates, not a phenomenon heard during blood pressure measurement.
B. Diastolic pressure is the point at which sounds fade away or become muffled, but the silence between sounds refers to a different concept, not the actual diastolic pressure.
C. An auscultatory gap is the term used to describe a silent interval between the systolic and diastolic sounds during blood pressure measurement. This can lead to inaccurately low readings if not identified.
D. A widened pulse pressure refers to a larger-than-normal difference between systolic and diastolic pressure, which is not related to the auscultatory silence.
Correct Answer is B
Explanation
A. Hostility and sarcasm are concerning, but they are not as urgent as the risk of injury associated with hyperactivity.
B. Pacing in the hallway during the day and night is indicative of extreme restlessness and may lead to exhaustion or self-harm. The nurse should address this behavior to prevent harm.
C. Giving money away may be problematic, but it is a less immediate risk compared to physical safety.
D. Flight of ideas is a common symptom of mania, but it is less dangerous than pacing and hyperactivity, which can lead to physical harm.
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