Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client who recently went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit.
Which of the following nursing diagnoses has the highest priority?
A. Ineffective coping related to inadequate stress management.
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this scenario. The client’s threat to commit suicide with a handgun indicates a clear and immediate risk.
B. Hopelessness related to recent divorce.
Hopelessness related to recent divorce is a significant concern and may contribute to the client’s suicidal ideation. However, the immediate threat of suicide takes precedence.
C. Spiritual distress related to conflicting thoughts about suicide and sin.
Spiritual distress related to conflicting thoughts about suicide and sin may be a factor in the client’s mental state, but it is not the immediate concern. The client’s life is in danger, which must be addressed first.
D. Risk for suicide related to highly lethal plan.
Risk for suicide related to a highly lethal plan is the highest priority nursing diagnosis. The client has a clear plan (using a handgun) and means (access to a handgun), indicating a high risk for suicide.
This question is an excerpt from Nurse Dive's nursing test bank - Lpn Ati Mental Health Psychosocial Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this scenario. The client’s threat to commit suicide with a handgun indicates a clear and immediate risk.
Choice B rationale
Hopelessness related to recent divorce is a significant concern and may contribute to the client’s suicidal ideation. However, the immediate threat of suicide takes precedence.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin may be a factor in the client’s mental state, but it is not the immediate concern. The client’s life is in danger, which must be addressed first.
Choice D rationale
Risk for suicide related to a highly lethal plan is the highest priority nursing diagnosis. The client has a clear plan (using a handgun) and means (access to a handgun), indicating a high risk for suicide.
Similar Questions
What are the goals of therapeutic communication?
A. Foster a social relationship.
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. Therapeutic communication in nursing is patient-centered and should involve a holistic approach, including aspects of psychological, physiological, spiritual, and environmental care of the patient.
B. Focus on the attitude of the client.
Focusing on the attitude of the client is not the main goal of therapeutic communication. While understanding the client’s attitude can provide valuable insights into their feelings and perspectives, the primary goal is to build a rapport and focus on the client.
C. Focus on the client and build a rapport.
Focusing on the client and building a rapport is the main goal of therapeutic communication in nursing. It helps nurses build trust with patients while also helping establish collaborative efforts to promote efficient and effective patient care, improving patient outcomes.
D. Focus on the staff member and build rapport.
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The focus should be on the client, their needs, and their experiences.
Full Explanation
Choice A rationale
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. Therapeutic communication in nursing is patient-centered and should involve a holistic approach, including aspects of psychological, physiological, spiritual, and environmental care of the patient.
Choice B rationale
Focusing on the attitude of the client is not the main goal of therapeutic communication. While understanding the client’s attitude can provide valuable insights into their feelings and perspectives, the primary goal is to build a rapport and focus on the client.
Choice C rationale
Focusing on the client and building a rapport is the main goal of therapeutic communication in nursing. It helps nurses build trust with patients while also helping establish collaborative efforts to promote efficient and effective patient care, improving patient outcomes.
Choice D rationale
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The focus should be on the client, their needs, and their experiences.
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
A. Increasing feelings of anger.
Anger is a common and expected response to trauma, including sexual assault. It can stem from various sources, including: Feelings of violation and powerlessness: Survivors may feel intense anger towards the perpetrator for taking control of their bodies and lives. Betrayal: If the assault was committed by someone they knew or trusted, survivors may feel intense anger towards that person for breaking their trust. Frustration and injustice: Survivors may feel angry at the injustice of the situation, the lack of control they had, and the ongoing impact of the trauma. Difficulty processing other emotions: Anger can sometimes mask other emotions that are difficult to deal with, such as fear, sadness, or guilt. Anger can manifest in various ways, including: Irritability and outbursts: Survivors may have a short temper, snap at others easily, or have difficulty controlling their anger. Aggression: In some cases, anger can lead to physical or verbal aggression towards others or self-harming behaviors. Withdrawal and isolation: Some survivors may withdraw from social interactions and relationships to avoid potential triggers for their anger. Substance abuse: Some survivors may turn to alcohol or drugs to numb their feelings or cope with their anger.
B. Sleeping 12 hours or more each day.
Sleeping 12 hours or more each day can be a symptom of PTSD, but it is not a specific indicator of anger. It can also be a sign of depression, anxiety, or hypersomnia, a sleep disorder characterized by excessive daytime sleepiness.
C. Increasing sense of attachment to others.
PTSD can sometimes lead to an increased sense of detachment from others, rather than attachment. Survivors may feel emotionally numb, have difficulty trusting others, or withdraw from relationships.
D. Constant need to talk about the event.
While some survivors of sexual assault may feel a need to talk about the event, it is not a universal symptom of PTSD. Some survivors may avoid talking about the event altogether due to the distress it causes.
Full Explanation
Choice A rationale:
Anger is a common and expected response to trauma, including sexual assault. It can stem from various sources, including:
Feelings of violation and powerlessness: Survivors may feel intense anger towards the perpetrator for taking control of their bodies and lives.
Betrayal: If the assault was committed by someone they knew or trusted, survivors may feel intense anger towards that person for breaking their trust.
Frustration and injustice: Survivors may feel angry at the injustice of the situation, the lack of control they had, and the ongoing impact of the trauma.
Difficulty processing other emotions: Anger can sometimes mask other emotions that are difficult to deal with, such as fear, sadness, or guilt.
Anger can manifest in various ways, including:
Irritability and outbursts: Survivors may have a short temper, snap at others easily, or have difficulty controlling their anger. Aggression: In some cases, anger can lead to physical or verbal aggression towards others or self-harming behaviors.
Withdrawal and isolation: Some survivors may withdraw from social interactions and relationships to avoid potential triggers for their anger.
Substance abuse: Some survivors may turn to alcohol or drugs to numb their feelings or cope with their anger.
Choice B rationale:
Sleeping 12 hours or more each day can be a symptom of PTSD, but it is not a specific indicator of anger. It can also be a sign of depression, anxiety, or hypersomnia, a sleep disorder characterized by excessive daytime sleepiness.
Choice C rationale:
PTSD can sometimes lead to an increased sense of detachment from others, rather than attachment. Survivors may feel emotionally numb, have difficulty trusting others, or withdraw from relationships.
Choice D rationale:
While some survivors of sexual assault may feel a need to talk about the event, it is not a universal symptom of PTSD. Some survivors may avoid talking about the event altogether due to the distress it causes.
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. Currently pregnant.
B. Schizophrenia.
Schizophrenia is a severe mental illness that is characterized by disturbances in thought, perception, emotion, and behavior. It is associated with an increased risk of suicide, with estimates suggesting that up to 10% of individuals with schizophrenia will die by suicide. Several factors contribute to the increased risk of suicide in individuals with schizophrenia, including: Hopelessness and despair: Individuals with schizophrenia often experience profound feelings of hopelessness and despair, which can lead to suicidal thoughts and behaviors. Psychotic symptoms: Psychotic symptoms, such as delusions and hallucinations, can also contribute to suicide risk. For example, an individual with schizophrenia may experience auditory hallucinations that command them to harm themselves. Impaired judgment: Schizophrenia can impair an individual's judgment and decision-making abilities, which can make it more difficult for them to resist suicidal urges. Social isolation: Individuals with schizophrenia often experience social isolation, which can further increase their risk of suicide. Comorbidity with other mental disorders: Schizophrenia is often comorbid with other mental disorders, such as depression and anxiety, which can also increase suicide risk. Substance abuse: Substance abuse is a common problem among individuals with schizophrenia, and it can further increase suicide risk.
C. Alcohol use disorder.
Alcohol use disorder is a chronic, relapsing brain disease characterized by compulsive alcohol use, despite harmful consequences. It is a significant risk factor for suicide, with studies suggesting that individuals with alcohol use disorder are 10-14 times more likely to die by suicide than the general population. Several factors contribute to the increased risk of suicide in individuals with alcohol use disorder, including: Depression: Alcohol use disorder is often comorbid with depression, which is a major risk factor for suicide. Impulsivity: Alcohol can impair judgment and increase impulsivity, which can lead to suicidal behaviors. Social isolation: Alcohol use disorder can lead to social isolation, which can increase suicide risk. Access to lethal means: Individuals with alcohol use disorder may have access to lethal means, such as firearms, which can increase the risk of suicide completion.
D. Substance use disorder.
Substance use disorder is a chronic, relapsing brain disease characterized by compulsive drug use, despite harmful consequences. It is a significant risk factor for suicide, with studies suggesting that individuals with substance use disorder are 6-12 times more likely to die by suicide than the general population. Several factors contribute to the increased risk of suicide in individuals with substance use disorder, including: Depression: Substance use disorder is often comorbid with depression, which is a major risk factor for suicide. Impulsivity: Substance use can impair judgment and increase impulsivity, which can lead to suicidal behaviors. Hopelessness: Individuals with substance use disorder may experience feelings of hopelessness and despair, which can increase suicide risk. Social isolation: Substance use disorder can lead to social isolation, which can increase suicide risk. Access to lethal means: Individuals with substance use disorder may have access to lethal means, such as firearms, which can increase the risk of suicide completion.
E. Currently married.
F. Age greater than 65 years old.
Age greater than 65 years old is a risk factor for suicide. Suicide rates are highest among older adults, particularly white men over the age of 85. Several factors contribute to the increased risk of suicide in older adults, including: Chronic health conditions: Older adults are more likely to experience chronic health conditions, such as pain, disability, and cognitive decline, which can increase suicide risk. Social isolation: Older adults are more likely to experience social isolation due to factors such as retirement, loss of loved ones, and decreased mobility. Loss of independence: Older adults may experience a loss of independence due to physical and cognitive decline, which can contribute to suicide risk. Access to lethal means: Older adults may have access to lethal means, such as firearms or medications, which can increase the risk of suicide completion.
Full Explanation
Choice B rationale:
Schizophrenia is a severe mental illness that is characterized by disturbances in thought, perception, emotion, and behavior. It is associated with an increased risk of suicide, with estimates suggesting that up to 10% of individuals with schizophrenia will die by suicide.
Several factors contribute to the increased risk of suicide in individuals with schizophrenia, including:
Hopelessness and despair: Individuals with schizophrenia often experience profound feelings of hopelessness and despair, which can lead to suicidal thoughts and behaviors.
Psychotic symptoms: Psychotic symptoms, such as delusions and hallucinations, can also contribute to suicide risk. For example, an individual with schizophrenia may experience auditory hallucinations that command them to harm themselves.
Impaired judgment: Schizophrenia can impair an individual's judgment and decision-making abilities, which can make it more difficult for them to resist suicidal urges.
Social isolation: Individuals with schizophrenia often experience social isolation, which can further increase their risk of suicide.
Comorbidity with other mental disorders: Schizophrenia is often comorbid with other mental disorders, such as depression and anxiety, which can also increase suicide risk.
Substance abuse: Substance abuse is a common problem among individuals with schizophrenia, and it can further increase suicide risk.
Choice C rationale:
Alcohol use disorder is a chronic, relapsing brain disease characterized by compulsive alcohol use, despite harmful consequences. It is a significant risk factor for suicide, with studies suggesting that individuals with alcohol use disorder are 10-14 times more likely to die by suicide than the general population.
Several factors contribute to the increased risk of suicide in individuals with alcohol use disorder, including: Depression: Alcohol use disorder is often comorbid with depression, which is a major risk factor for suicide. Impulsivity: Alcohol can impair judgment and increase impulsivity, which can lead to suicidal behaviors.
Social isolation: Alcohol use disorder can lead to social isolation, which can increase suicide risk.
Access to lethal means: Individuals with alcohol use disorder may have access to lethal means, such as firearms, which can increase the risk of suicide completion.
Choice D rationale:
Substance use disorder is a chronic, relapsing brain disease characterized by compulsive drug use, despite harmful consequences. It is a significant risk factor for suicide, with studies suggesting that individuals with substance use disorder are 6-12 times more likely to die by suicide than the general population.
Several factors contribute to the increased risk of suicide in individuals with substance use disorder, including: Depression: Substance use disorder is often comorbid with depression, which is a major risk factor for suicide. Impulsivity: Substance use can impair judgment and increase impulsivity, which can lead to suicidal behaviors.
Hopelessness: Individuals with substance use disorder may experience feelings of hopelessness and despair, which can increase suicide risk.
Social isolation: Substance use disorder can lead to social isolation, which can increase suicide risk.
Access to lethal means: Individuals with substance use disorder may have access to lethal means, such as firearms, which can increase the risk of suicide completion.
Choice F rationale:
Age greater than 65 years old is a risk factor for suicide. Suicide rates are highest among older adults, particularly white men over the age of 85.
Several factors contribute to the increased risk of suicide in older adults, including:
Chronic health conditions: Older adults are more likely to experience chronic health conditions, such as pain, disability, and cognitive decline, which can increase suicide risk.
Social isolation: Older adults are more likely to experience social isolation due to factors such as retirement, loss of loved ones, and decreased mobility.
Loss of independence: Older adults may experience a loss of independence due to physical and cognitive decline, which can contribute to suicide risk.
Access to lethal means: Older adults may have access to lethal means, such as firearms or medications, which can increase the risk of suicide completion.