Susan, the nurse is caring for a client who states "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority?
Lethality of the method and availability of means
Client's educational and economic background
Client's insight into the reasons for the decision.
Quality of the client's social support
The Correct Answer is A
A. Lethality of the method and availability of means. Assessing the method and means helps determine the immediacy and seriousness of the threat. Knowing the lethality of the method and whether the means are readily available informs the level of intervention needed to keep the client safe.
B. Client's educational and economic background: While socioeconomic factors can influence mental health, they are not immediate priorities in a suicidal crisis.
C. Client's insight into the reasons for the decision: Insight is important for understanding motivations but is secondary to immediate safety concerns.
D. Quality of the client's social support: Social support is crucial but is secondary to assessing imminent risk of harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "You have had a gastrointestinal bleed.": While this can cause fatigue due to anemia, it's not directly related to sickle cell anemia.
B. "You have fewer red blood cells." Sickle cell anemia causes chronic hemolysis, leading to anemia and fatigue. The characteristic sickle-shaped cells are less flexible and prone to hemolysis, resulting in fewer functional red blood cells and reduced oxygen-carrying capacity.
C. "You have an autoimmune disease.": Sickle cell anemia is not an autoimmune disorder.
D. "You have a low ferritin level.": Ferritin levels may be affected, but the primary cause of fatigue in sickle cell anemia is anemia itself, not low ferritin.
Correct Answer is C
Explanation
A. Cold intolerance: Incorrect. Cold intolerance is associated with hypothyroidism, not hyperthyroidism.
B. Fatigue and lethargy: Symptoms typically seen in hypothyroidism.
C. Tremors and nervousness Correct Answer. Hyperthyroidism often presents with symptoms such as tremors (especially in the hands) and nervousness due to increased sympathetic activity. Increased metabolism and sympathetic nervous system activity lead to these symptoms.
D. Weight gain: Typically seen in hypothyroidism due to slowed metabolism.
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