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?"

Answer and Explanation

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.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

A. The client has supportive and encouraging relationships. B. There are multiple siblings in the household. C. The family appears to lack interest in the client. D. The client has overprotective parents.

Correct Answer is C

Explanation

Choice A reason: Supportive and encouraging relationships are typically protective against the development of eating disorders, not a contributing factor?.

Choice B reason: Having multiple siblings in the household does not directly indicate a cause for an eating disorder.

Choice C reason: A family's lack of interest can contribute to feelings of neglect or low self-worth, which are known risk factors for the development of eating disorders?.

Choice D reason: While overprotective parents can contribute to stress, they are not necessarily an indicator of why a client may be experiencing an eating disorder. The relationship between parenting style and eating disorders is complex and not solely causative?.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

During an assessment of family dynamics for a client with an eating disorder, which observed issue could indicate a reason for the client's eating disorder?

Correct Answer is C

Explanation

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