A nurse on a mental health unit is caring for a client.
Complete the following sentence by using the lists of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for correct choices
• Thoughts of self‑harm: The client recently experienced multiple major stressors, loss of a job and the end of a long-term relationship, while displaying flat affect, tearfulness, withdrawal, and refusal to eat. These changes, combined with the statement, “My life is a mess,” indicate worsening depression and internal distress. These findings elevate the risk for self‑harm and require immediate monitoring.
• Hopelessness: The client’s statements reflect feelings of worthlessness and an inability to see a path forward, which are hallmark signs of hopelessness. Their withdrawal, refusal to eat, and persistent tearfulness reinforce that they are overwhelmed and unable to cope with current stressors. Hopelessness is closely linked with suicidal ideation, explaining the elevated self‑harm risk.
Rationale for incorrect choices
• Anorexia nervosa: Although the client is refusing meals, this refusal occurs in the context of emotional distress rather than weight‑loss motivation or body‑image disturbance. The client’s BMI is low but not critically low, and there is no fear of gaining weight or distorted self‑perception. Appetite changes are common in depression and better explained by mood not eating disorders.
• Acute dystonic reaction: Acute dystonia is associated with antipsychotic medications, not sertraline, which the client is currently taking. No signs such as muscle spasms, stiff neck, or oculogyric crisis are present. The client’s symptoms are emotional and cognitive, not neuromuscular.
• Refusal to eat: While refusal to eat is concerning, it alone does not most strongly indicate risk for self‑harm. Poor appetite is common in depression and may reflect low motivation or energy. It lacks the direct emotional connotation that hopelessness carries in predicting self‑harm.
• Family history: A family history of major depressive disorder increases long‑term vulnerability but does not explain the client’s immediate risk situation. The client’s current behaviors and statements provide more immediate clinical evidence than hereditary factors. Family history does not sufficiently reflect the acute emotional state contributing to self‑harm risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client drank 240 mL of water at 0800: This is objective data because it is a measurable and observable fact that can be verified by the nurse. Documentation of intake is based on direct observation rather than the client’s perception.
B. The client's gait is steady while using a walker: This is objective data as it is based on the nurse’s direct observation of the client’s physical performance. It can be measured or assessed without relying on the client’s personal experience.
C. The client cries while answering questions: Crying is an observable behavior, making it objective data. While it may indicate distress, the nurse is reporting what was seen rather than the client’s internal experience.
D. The client points to a 6 on the visual analog pain scale: This is subjective data because it reflects the client’s personal perception of pain, which cannot be independently measured or verified. Pain is inherently subjective, relying on the client’s self-report.
Correct Answer is D
Explanation
A. Updating a family member on a client's condition following surgery: Communicating clinical information and updates to family members requires professional nursing judgment and understanding of the client’s status. This task cannot be delegated to assistive personnel because it involves interpretation of medical information and legal responsibility.
B. Observing a client's abdominal laceration for indications of infection: Assessment of wounds for signs of infection requires professional knowledge and clinical judgment to identify subtle changes and make appropriate care decisions. This task must be performed by a licensed nurse and cannot be delegated to assistive personnel.
C. Instructing a client about the use of an incentive spirometer: Teaching a client involves providing information, evaluating understanding, and demonstrating correct technique. This requires nursing knowledge and judgment, making it inappropriate to delegate to assistive personnel.
D. Documenting the amount of drainage from a client's NG tube: Measuring and recording output from an NG tube is a routine, non-invasive task that does not require clinical judgment. This task can be safely delegated to assistive personnel as long as they follow proper procedures and report abnormal findings to the nurse.
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