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 ["B","D","F"]
Explanation
Choice A reason: Increasing dietary fiber can help manage constipation, which is a common side effect of antipsychotic medications. The normal range for dietary fiber intake in adults is 25 to 30 grams per day from food, not supplements.
Choice B reason: Antipsychotic medications can increase photosensitivity, making the skin more susceptible to sunburn. Using sunscreen can help protect the skin when outdoors.
Choice C reason: While laxatives can be used to manage constipation, they should be used sparingly and only as needed to avoid dependence and potential electrolyte imbalances.
Choice D reason: Regular physical activity can help counteract weight gain, another potential side effect of antipsychotic medications. It's recommended to engage in at least 150 minutes of moderate-intensity exercise per week.
Choice E reason: Doubling the dose at the next scheduled time for missed doses is not recommended as it can lead to an overdose and exacerbate side effects.
Choice F reason: Drinking plenty of fluids, including fruit juice, can help prevent dehydration. However, it's important to monitor sugar intake from fruit juices due to the risk of weight gain.
Correct Answer is B
Explanation
Choice A reason: This statement reflects assertiveness and self-advocacy rather than suppressed anger. It shows the client's awareness of her value to the team and her willingness to negotiate for fair compensation.
Choice B reason: This statement suggests frustration and possible feelings of being undervalued or obstructed in career advancement, which could be indicative of suppressed anger.
Choice C reason: This statement seems to express gratitude for the accommodation provided for her needs as a new mother, rather than suppressed anger.
Choice D reason: This statement indicates a recognition of her own expertise and the demand for her skills within the team, which is a positive self-assessment and not suggestive of suppressed anger.
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