While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?
The client displays agitation.
The client becomes suddenly cheerful.
The client experiences psychomotor retardation.
The client does not attend group therapy.
The Correct Answer is B
A. Agitation can be a sign of distress, but sudden cheerfulness may be indicative of a decision to act on suicidal thoughts, as the individual may feel relieved to have made a decision.
B. Sudden cheerfulness can be a concerning sign, as it may indicate that the client has made a decision to carry out suicidal thoughts.
C. Psychomotor retardation is a symptom of depression and may not necessarily indicate imminent risk of suicide.
D. Not attending group therapy may be a sign of withdrawal or isolation, but it does not directly indicate immediate suicidal risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect. This statement is a straightforward denial rather than rationalization.
B) Incorrect. This response is an example of avoidance or distraction, not rationalization.
C) Correct. Rationalization involves offering logical or reasonable explanations to justify behaviors or actions that might otherwise be unacceptable. In this case, the client is rationalizing her alcohol consumption as a means to relax and cope with the day treatment.
D) Incorrect. This statement reflects a defensive response but is not an example of rationalization.
Correct Answer is B
Explanation
A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.
B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.
C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.
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