The nurse is interviewing a client with major depression. Which of the following statements by the client would most indicate to the nurse that the client is at risk for suicide?

"I feel like everyone depends on me too much."

"Life has lost its meaning for me."

wish I could just take a vacation and get away from it all."

"I feel like a failure and wish one thing would just go right."

Answer and Explanation

The Correct Answer is B

A. "I feel like everyone depends on me too much." This statement indicates a sense of responsibility and connection to others, which may not directly indicate suicidal ideation.

B. "Life has lost its meaning for me." This statement is a strong indicator of hopelessness, which is a key risk factor for suicide. The client feels that life is meaningless, which could indicate a desire to end their life.

C. "I wish I could just take a vacation and get away from it all." While this statement may indicate stress or a desire to escape, it does not directly suggest suicidal intent.

D. "I feel like a failure and wish one thing would just go right." This statement indicates frustration and low self-worth, but it doesn't necessarily indicate an immediate risk of suicide as clearly as statement B.

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Correct Answer is C

Explanation

A. Alcohol tolerance: Alcohol tolerance refers to the decreased effect of alcohol with repeated use, not withdrawal symptoms.

B. Korsakoff's psychosis: Korsakoff's psychosis is a chronic condition related to thiamine deficiency and characterized by memory impairment and confabulation, not acute withdrawal symptoms.

C. Delirium tremens: Delirium tremens (DTs) is a severe form of alcohol withdrawal that can present with tremors, agitation, elevated blood pressure, tachycardia, and confusion. The client’s symptoms and recent history suggest DTs.

D. Wernicke's encephalopathy: Wernicke's encephalopathy typically presents with ataxia, confusion, and ophthalmoplegia rather than the acute withdrawal symptoms described.

A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

Correct Answer is B

Explanation

A. Generalized pain: Generalized pain is not a typical early sign of deterioration following a hemorrhagic stroke.

B. Alteration in level of consciousness (LOC): An alteration in LOC is often the earliest and most sensitive sign of neurological deterioration in clients who have had a hemorrhagic stroke. This can indicate increased intracranial pressure or further bleeding.

C. Tonic-clonic seizures: While seizures can occur after a stroke, they are not typically the earliest sign of deterioration. Changes in LOC usually precede seizure activity.

D. Shortness of breath: Shortness of breath may indicate respiratory issues but is not directly related to early neurological deterioration following a stroke.

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The nurse is interviewing a client with major depression. Which of the following statements by the client would most indicate to the nurse that the client is at risk for suicide?

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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