Which behavior observed by the nurse causes a suspicion that a depressed client may be suicidal?

Giving away valued possessions

Engaging in high-risk behaviors

Talkative, with pressured speech

Guilt, decreased self-esteem

Answer and Explanation

The Correct Answer is A

A.   Giving away valued possessions - This is a classic sign of suicidal ideation, as individuals may feel they no longer need their belongings or want to say goodbye to loved ones in a symbolic way.
B.   Engaging in high-risk behaviors - While high-risk behaviors can be a sign of depression, they are not necessarily indicative of suicidal thoughts.
C.   Talkative, with pressured speech - This could be indicative of a manic episode or high anxiety, but it is not a common sign of suicidal behavior.
D.   Guilt, decreased self-esteem - Although guilt and low self-esteem are symptoms of depression, they do not directly indicate suicidal thoughts or behaviors.

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Correct Answer is C

Explanation

A. While family support is important, encouraging complete assistance with all activities of daily living (ADLs) is not an ideal intervention. The goal is to maintain as much independence as possible, even if that means modifying or pacing activities. Encouraging complete dependency can lead to deconditioning and further loss of function.
B. Clustering activities is not the best intervention for this problem. Clustering involves grouping multiple tasks together at once, which can overwhelm the patient and lead to fatigue. Instead, the nurse should encourage pacing and spreading out activities to avoid overexertion, even if the patient has energy.
C. Providing alternating periods of activity and rest is a fundamental strategy in managing activity intolerance due to chronic heart failure. This approach helps balance the energy demands of daily activities with rest to prevent fatigue and overexertion. By alternating activity and rest, the patient can perform necessary tasks while minimizing strain on the heart.
D. The goal in chronic heart failure is to help the patient maintain independence and function as much as possible. Limiting self-care could lead to increased dependency and reduced quality of life. Activity modifications and appropriate pacing are better strategies.

A. "A wire is in the left ventricle and will pace when needed." B. "There are pacemaker wires in the right atrium and ventricle and will pace as needed." C. "The wires are in both ventricles and fires when your heart rate is 50. D. "The device is set to fire with each heart beat."

Correct Answer is B

Explanation

A. The pacemaker wire for a DDD device is placed in the right atrium and right ventricle, not the left ventricle.
B. This is the correct description of a DDD pacemaker, which has wires in both the right atrium and right ventricle to monitor and pace both chambers when needed.
C. This is incorrect because a DDD pacemaker does not pace both ventricles.
D. This is inaccurate because a DDD pacemaker does not fire with every heartbeat; it only fires when the heart’s natural electrical activity is insufficient.

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Which behavior observed by the nurse causes a suspicion that a depressed client may be suicidal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?

Correct Answer is C

Explanation

The nurse is providing discharge instructions to a client who has had a permanent pacemaker inserted. The information in the chart indicates that the device is a DDD. What will the nurse explain about this pacemaker?

Correct Answer is B

Explanation

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