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A nurse in a mental facility is assessing a client for suicide risk factors using the SAD PERSONS scale. Which of the following findings indicates a risk for suicide?
- A. The client is married
- B. The client is female
- C. The client is 50 years of age
- D. The client has diabetes mellitus
Correct Answer: C
Rationale: The correct answer is C: The client is 50 years of age. The SAD PERSONS scale includes age as a risk factor for suicide. As individuals get older, they may face more challenges such as chronic health conditions, loss of loved ones, or financial difficulties, which can increase suicidal ideation. This age group is considered at higher risk for suicide compared to younger individuals. Choices A, B, and D do not directly relate to suicide risk factors according to the scale. Being married (A) can sometimes be a protective factor, being female (B) is not a specific risk factor, and having diabetes mellitus (D) is a medical condition that is not directly associated with suicide risk based on the scale.
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A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?
- A. I don’t know how I could cope if I didn’t have my family’s support
- B. It’ll be a long time before I’m happy again
- C. I don’t feel anything but numbness anymore
- D. I feel like I’m angry at the whole world right now
Correct Answer: C
Rationale: The correct answer is C: "I don’t feel anything but numbness anymore." This statement indicates a significant emotional numbness, which is a common symptom of clinical depression. It suggests a lack of normal emotional responses, which can be concerning.
Choice A does not specifically indicate clinical depression but rather expresses a need for support. Choice B reflects a natural response to grief and does not necessarily indicate depression. Choice D suggests anger, which can also be a normal part of the grieving process.
In summary, Choice C is the correct answer as it directly points to a key symptom of clinical depression, while the other choices reflect common emotional responses to grief that may not necessarily indicate depression.
A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
- A. Rationalization
- B. Denial
- C. Compensation
- D. Displacement
Correct Answer: C
Rationale: The client is demonstrating the defense mechanism of Compensation. Compensation involves covering up weaknesses by emphasizing strengths in other areas. In this scenario, the client is compensating for feeling inadequate or unappreciated by becoming angry and defensive when his actions are questioned. This behavior serves to divert attention away from his perceived shortcomings and protect his self-esteem.
Rationalization (A) involves creating logical explanations to justify behaviors or feelings. Denial (B) is refusing to acknowledge unpleasant realities. Displacement (D) is redirecting emotions from the real target to a substitute target. In this case, these defense mechanisms are not as applicable as Compensation, which directly relates to the client's behavior of overcompensating for his perceived lack of attention.
A nurse is planning care for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following interventions should the nurse include in the plan?
- A. Administer disulfiram
- B. Monitor for seizures
- C. Restrict fluid intake
- D. Provide a high-protein diet
Correct Answer: B
Rationale: The correct answer is B: Monitor for seizures. During alcohol withdrawal, clients are at risk for seizures due to central nervous system hyperexcitability. Monitoring for seizures allows for prompt intervention if they occur. Administering disulfiram (A) is used to deter alcohol consumption, not for withdrawal. Restricting fluid intake (C) can worsen dehydration, while providing a high-protein diet (D) is not a priority during alcohol withdrawal.
A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?
- A. Slurred speech
- B. Hypotension
- C. Bradycardia
- D. Hyperthermia
Correct Answer: D
Rationale: The correct answer is D: Hyperthermia. Heroin withdrawal can lead to hyperthermia due to increased metabolic activity, dehydration, and dysregulation of the body's temperature control mechanisms. Slurred speech (A) is not a typical manifestation of heroin withdrawal. Hypotension (B) and bradycardia (C) are more commonly associated with opioid overdose rather than withdrawal. In withdrawal, the client may actually experience hypertension and tachycardia due to increased sympathetic activity.
A nurse is assessing a client who has opioid withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Hyperthermia
- C. Insomnia
- D. Bradycardia
Correct Answer: C
Rationale: The correct answer is C: Insomnia. Opioid withdrawal often presents with symptoms like insomnia due to increased sympathetic activity. Hypotension (A) is less likely as opioids can cause hypertension. Hyperthermia (B) is not typically associated with opioid withdrawal. Bradycardia (D) is also less common, as opioid withdrawal can lead to tachycardia. Insomnia is a hallmark symptom of opioid withdrawal, making it the most appropriate choice.