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 D

Explanation

A. The healthcare provider's history and physical may provide information about the client's overall health but may not specifically address the observed symptoms.
B. Recent urine drug testing (UDT) results may reveal drug use but may not be directly related to the observed involuntary movements.
C. The baseline nursing admission assessment may provide general information but may not specifically address medication side effects.
D. The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool in this situation.

A. Instruct the client to reduce the volume of his voice. B. Accompany the client to a quiet area of the unit. C. Encourage the client to attend a support group. D. Administer a PRN sedative by injection.

Correct Answer is B

Explanation

A. Instructing the client to reduce the volume of his voice may not be effective during a manic episode and could escalate the situation.
B. Accompanying the client to a quiet area of the unit provides a more supportive and calming environment, allowing the client to deescalate.
C. Encouraging the client to attend a support group is a positive intervention but may not be immediately effective during an agitated state.
D. Administering a PRN sedative by injection may be considered, but less restrictive interventions should be attempted first to promote a therapeutic environment.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

Correct Answer is B

Explanation

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

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A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?