Nokea
A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply.)
- A. Substance use disorder
- B. Age greater than 45 years old
- C. Female gender
- D. Currently married
- E. Schizophrenia
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. Substance use disorder is a known risk factor for suicide as it can lead to increased impulsivity and impaired decision-making. Age greater than 45 years old is a risk factor due to factors such as isolation, health issues, and life changes. Schizophrenia is associated with a higher risk of suicide due to the symptoms of the disorder and the impact on one's mental well-being. Choices C and D are incorrect as being female or currently married are not universal risk factors for suicide. The absence of choices F and G also indicates that they are not relevant risk factors for suicide.
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A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
- A. Disclose some personal information to the client to demonstrate approachability.
- B. Wait for the client to initiate interaction.
- C. Approach the client frequently throughout the day for brief interactions.
- D. Adopt a neutral attitude when providing care.
Correct Answer: D
Rationale: The correct answer is D: Adopt a neutral attitude when providing care. This approach is appropriate because it helps to build trust with a suspicious client by not evoking any feelings of threat or manipulation. By maintaining a neutral attitude, the nurse can establish a safe and non-threatening environment for the client to gradually open up and develop a therapeutic relationship.
Other choices are incorrect because:
A: Disclosing personal information may blur professional boundaries and make the client more suspicious.
B: Waiting for the client to initiate interaction may prolong the time it takes to establish a connection.
C: Approaching the client frequently may overwhelm the client and reinforce their suspicions.
E, F, G: These options are not provided in the question, so they cannot be evaluated.
A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?
- A. The sense of self among individual family members
- B. The future goals of the family
- C. The roles of family members
- D. The family's religious practices
Correct Answer: D
Rationale: The correct answer is D: The family's religious practices. When assessing sociocultural context, understanding the family's religious practices is essential as it influences beliefs, values, behaviors, and interactions within the family system. Religious practices can shape decision-making processes and coping strategies. A: The sense of self focuses on individual identity rather than the collective family system. B: Future goals pertain to the family's aspirations and plans, which are important but not directly related to sociocultural context. C: Roles of family members are significant in understanding family dynamics but do not capture the broader sociocultural influences.
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?
- A. "You should be aware that excessive sleeping is an early sign of relapse."
- B. "Relapse is an indication that you are not taking your medications properly."
- C. "You should keep your provider's and therapist's number with you."
- D. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."
Correct Answer: C
Rationale: The correct answer is C because keeping the provider's and therapist's number with the client is crucial for quick access to support during a potential relapse. This step promotes timely intervention and communication with the healthcare team, which can help prevent escalation of symptoms. Option A is incorrect because excessive sleeping may not be a universal early sign of relapse for all individuals with schizophrenia. Option B is incorrect because relapse can occur despite proper medication adherence. Option D is incorrect because self-medicating without healthcare provider guidance can be dangerous and may worsen symptoms.
A nurse in a mental health facility is preparing to interview a client who has schizophrenia. Which of the following actions should the nurse take?
- A. Sit on the other side of a table from the client.
- B. Place the client in a chair higher than the nurse.
- C. Start the interview with a question the client can answer with “yes” or "no."
- D. Sit beside the client rather than facing him.
Correct Answer: C
Rationale: The correct answer is C: Start the interview with a question the client can answer with “yes” or "no." This approach is recommended for clients with schizophrenia to establish rapport and ease anxiety. It allows the client to engage in a simple way, reducing the pressure of providing complex answers. Sitting on the other side of a table (A) may create a barrier, placing the client in a higher chair (B) may be perceived as intimidating, and sitting beside the client (D) may invade personal space. The other choices do not promote effective communication or rapport-building.
A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?
- A. Implement seizure precautions.
- B. Insert an IV access site.
- C. Obtain a blood specimen.
Correct Answer: A
Rationale: The correct answer is A: Implement seizure precautions. The priority in caring for a client experiencing acute alcohol withdrawal is to prevent potential life-threatening complications like seizures. Implementing seizure precautions involves ensuring a safe environment, such as padding the bed and removing any harmful objects. This step takes precedence over inserting an IV access site (B) or obtaining a blood specimen (C) because seizures pose an immediate risk to the client's safety. It is crucial to address the most urgent need first to ensure the client's well-being.