The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? (Select all that apply.)
"Where do you keep your gun?"
"Are you thinking about hurting yourself or someone else?"
"Have you thought about how you would hurt yourself?"
"Can you tell me your feelings about dying?"
"Have you told your psychiatrist you feel like dying?"
Correct Answer : A,B,C,D
Choice A reason: While it’s important to assess access to lethal means, this question is too specific and assumes the client owns a gun. A more appropriate question might be, “Do you have access to any means to harm yourself?”
Choice B reason: Inquiring about thoughts of self-harm or harming others is a direct question that assesses suicidal ideation and intent, which is essential for determining immediate risk.
Choice C reason: Understanding if the client has specific plans for self-harm can help gauge the immediacy and seriousness of the suicide risk.
Choice D reason: Discussing feelings about dying can provide insight into the client's emotional state and potential risk for suicide.
Choice E reason: This question is important but it should not replace direct questions about the client’s current thoughts and feelings. It’s possible for a client to deny feelings of suicidality to their psychiatrist while still experiencing them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: This statement is an example of rationalizing the spouse's behavior, which can perpetuate the cycle of substance abuse.
Choice B reason: Providing money for drugs, even under the guise of preventing theft, is enabling because it facilitates the continuation of the substance abuse.
Choice C reason: Suggesting rehab as a condition for coming home is not enabling; it is a step towards addressing the substance use disorder.
Choice D reason: Calling in sick on behalf of the spouse to cover for their potential job loss due to substance abuse is an enabling behavior that prevents the spouse from facing the natural consequences of their actions.
Choice E reason: Securing valuables to prevent theft due to the spouse's substance abuse is also enabling because it adjusts normal routines to accommodate the substance use, rather than confronting or addressing the issue.
Correct Answer is B
Explanation
Choice A reason: While encouragement is important, it does not necessarily indicate that the family understands the complexities of anorexia nervosa.
Choice B reason: Eating together can provide support and structure, which are important aspects of recovery in eating disorders.
Choice C reason: While resolving family conflicts is beneficial, it does not directly relate to understanding the eating disorder itself.
Choice D reason: Spending less time discussing troublesome family members does not reflect an understanding of how to support a family member with an eating disorder.
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