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Which client is at highest risk for carrying out a suicide plan?
- A. A client who plans to take a bottle of sleeping pills.
- B. A client who says, 'My life is over.'
- C. A client who has a private gun collection.
- D. A client who says, 'I'm going to jump off the next bridge I see.'
Correct Answer: C
Rationale: Access to a lethal means like a gun collection significantly increases the likelihood of completing a suicide plan.
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A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale?
- A. As soon as lunch is over, the client will calm down.
- B. Other clients need to be protected from the intrusive behavior.
- C. The client's behavior is not an imminent threat to anyone's physical safety.
- D. The client needs food and fluids in any way possible.
Correct Answer: B
Rationale: Protecting other clients from intrusive behavior upholds their rights and maintains a safe environment.
A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?
- A. Immediately after a family visit
- B. On the anniversary of significant life events in the client's life
- C. During the first few days after admission
- D. Approximately 2 weeks after starting antidepressant medication
Correct Answer: D
Rationale: The risk of self-harm increases about 2 weeks after starting antidepressants, as energy improves before mood stabilizes.
A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which nursing intervention is most likely to help the client successfully participate?
- A. Allowing the client to direct her participation at her own pace.
- B. Giving the client several choices of projects, so she can choose her favorite.
- C. Staying away from the client during the session to encourage free expression.
- D. Structuring the activity to facilitate completion of one specific task.
Correct Answer: D
Rationale: Structuring the activity ensures success for a lethargic client, supporting engagement and achievement.
Which variables represent the highest risk for developing major depressive disorder? Select all that apply.
- A. Male gender
- B. Mood disorder in first-degree relatives
- C. Substance abuse
- D. Divorced
- E. Older adult
Correct Answer: B,D
Rationale: Family history of mood disorders and being single or divorced increase the risk of major depressive disorder.
The client with mania attempts to hit the nurse. Which is the best response by the nurse?
- A. Do not swing at me again. If you cannot control yourself, we will help you.
- B. If you do that one more time, you will be put in seclusion immediately.
- C. Stop that. I didn't do anything to provoke an attack.
- D. Why do you continue that kind of behavior? You know I won't let you do it.
Correct Answer: A
Rationale: This response sets clear behavioral expectations and ensures safety without escalating the situation.