Which individual should the nurse consider at the highest risk for suicide?

A nurse who works in a pediatric emergency department.

An adolescent male whose parents recently divorced.

A retired older male whose significant other has passed away.

A single working mother with three preschool-aged children.

Answer and Explanation

The Correct Answer is B

A.   While working in a pediatric emergency department can be stressful, the information provided does not suggest an increased risk for suicide in this scenario.
B.   Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide.
C. While the loss of a significant other can contribute to increased suicide risk in older adults, the information provided does not indicate an immediate concern.
D.   While being a single working mother with young children is challenging, the information provided does not suggest an increased risk for suicide in this scenario.

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Correct Answer is C

Explanation

A. Inquiring about recent stresses is relevant but may not specifically address the emotional state associated with depression.
B. Asking about food preferences is important for a comprehensive assessment but may not be the most direct question for assessing depression.
C. Inquiring about whether the client often feels sad is crucial for assessing the emotional aspect of depression.
D. While changes in sleep patterns are significant, the question about feeling sad directly addresses the emotional component of depression, which is important for a comprehensive assessment.

A. Usual level of activity and average sleep pattern. B. Blood pressure when sitting and standing. C. Dentures to determine if they are poorly fitted. D. Body weight over the past three months.

Correct Answer is C

Explanation

A. Assessing the usual level of activity and average sleep pattern is relevant but does not directly address the observed symptoms related to speech and tongue movements.
B. Blood pressure assessment is important for overall health monitoring but is not the most immediate concern related to the observed speech and tongue abnormalities.
C. Assessing the fit of dentures is crucial in this context, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities.
D. Body weight assessment is important for overall health but is not the most immediate concern in this situation. Assessing denture fit addresses the observed speech and tongue abnormalities more directly.

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Which individual should the nurse consider at the highest risk for suicide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

Correct Answer is C

Explanation

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Correct Answer is C

Explanation

A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain?

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?

The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?