Nokea
A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
- A. Use of substances 6 hours before the assessment
- B. Speech patterns
- C. Availability of support resources
- D. Amount of sleep in past 24 hours
Correct Answer: A
Rationale: The correct answer is A: Use of substances 6 hours before the assessment. This is important to assess as substance use can increase the risk of impulsive behavior and exacerbate suicidal thoughts. It is crucial to determine if the individual has recently used substances as it may impact their judgment and decision-making. The other choices are not directly related to immediate risk assessment for suicide. Speech patterns (B) may provide insight into the individual's mental state, but substance use takes precedence in assessing immediate risk. Availability of support resources (C) is important for long-term prevention but does not address immediate risk. The amount of sleep in the past 24 hours (D) may impact mental health but does not directly assess immediate risk of suicide.
You may also like to solve these questions
A twenty-eight-year-old client enters the family therapy meeting clutching a blanket and holds the blanket throughout the session while rocking back and forth in the chair. What defense mechanism is the client demonstrating?
- A. denial
- B. projection
- C. undoing
- D. regression
Correct Answer: D
Rationale: The correct answer is D: regression. The client clutching a blanket and rocking back and forth indicate a return to an earlier stage of development to cope with stress or anxiety. Regression involves reverting to behaviors from a less mature stage. Denial (A) involves refusing to acknowledge reality, projection (B) involves attributing one's feelings onto others, and undoing (C) involves trying to undo or reverse an unacceptable action or thought. These defense mechanisms do not align with the client's behavior of regression.
A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?
- A. Self-esteem–building activities
- B. Anxiety self-control measures
- C. Sleep enhancement activities
- D. Suicide precautions
Correct Answer: D
Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates suicidal ideation and intent. Priority is to ensure immediate safety. Suicide precautions involve continuous monitoring, removing harmful objects, and providing a safe environment. A: Self-esteem activities, B: Anxiety measures, and C: Sleep enhancement are important, but not the priority when a patient is at risk of self-harm.
A nursing student is assigned to care for a patient diagnosed with schizophrenia. When talking about this patient in a clinical postconference, the student would use which terminology when referring to the patient?
- A. Committed patient
- B. Schizophrenic
- C. Schizophrenic patient
- D. Person with schizophrenia
Correct Answer: D
Rationale: The correct answer is D: Person with schizophrenia. This terminology aligns with person-first language, which emphasizes the individuality and humanity of the patient over their diagnosis. It is important to use person-first language to promote respect and reduce stigma. Using terms like "committed patient" (A) can be stigmatizing and inaccurate, as not all patients with schizophrenia are committed involuntarily. "Schizophrenic" (B) and "schizophrenic patient" (C) both label the individual by their diagnosis, which can be dehumanizing and reduce their identity to just their condition. In contrast, "person with schizophrenia" (D) acknowledges the personhood of the individual first and foremost.
A nurse is performing an assessment interview of a 14-year-old boy who is being admitted to an adolescent substance abuse unit. His parents are concerned about their son's repeated problems at school that they associate with his drug use. The boy stalks into the office, abruptly sits down, crosses his arms, and says, 'Okay, ask your stupid questions, but don't expect me to cooperate!' Which response by the nurse would be most appropriate?
- A. Your attitude is offensive; I can see why your parents brought you here.
- B. Why don't we wait until you've calmed down a bit to start the interview?
- C. Why are you so angry?
- D. You seem pretty upset. Tell me about what is upsetting you.
Correct Answer: D
Rationale: The correct response is D because it acknowledges the boy's emotions, shows empathy, and invites him to share his feelings. By acknowledging his upset feelings, the nurse can build rapport and establish trust, which is crucial in therapeutic communication. This response also opens the door for the boy to express himself and potentially reveal the underlying reasons for his behavior.
Choices A and C are confrontational and judgmental, which can escalate the situation and hinder communication. Choice B suggests waiting until the boy calms down, which may be dismissive of his emotions and doesn't address the immediate need for connection and understanding.
A client is prescribed disulfiram as part of his alcohol treatment program to prevent relapse. The client asks the nurse, 'How will this drug help me?' Which response by the nurse would be most appropriate?
- A. It will help to cure your alcoholism.'
- B. It can help to prevent you from drinking.'
- C. It makes the withdrawal symptoms less troublesome.'
- D. It helps to clear the alcohol out of your body.'
Correct Answer: B
Rationale: The correct answer is B: It can help to prevent you from drinking. Disulfiram works by causing unpleasant symptoms (such as nausea, vomiting, and headache) when alcohol is consumed, acting as a deterrent to drinking. This helps the client stay sober and avoid relapse.
Incorrect choices:
A: It will help to cure your alcoholism - Disulfiram does not cure alcoholism but helps manage it.
C: It makes the withdrawal symptoms less troublesome - Disulfiram does not address withdrawal symptoms.
D: It helps to clear the alcohol out of your body - Disulfiram does not clear alcohol from the body but rather prevents its metabolism, leading to adverse effects if alcohol is consumed.