Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan?
A. Moderate level
Moderate level would suggest a plan that has some risk but may be less imminent or less likely to result in death.
B. High level
A plan involving a loaded gun aimed at a vital organ like the heart, coupled with alcohol consumption and intent, indicates a high level of lethality.
C. No risk
This scenario presents a significant risk given the method and the caller's intent, so "No risk" would not be appropriate.
D. Low level
Low level would suggest a plan that is less likely to cause severe harm or death, which is not the case here.
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Full Explanation
A. Moderate level would suggest a plan that has some risk but may be less imminent or less likely to result in death.
B. A plan involving a loaded gun aimed at a vital organ like the heart, coupled with alcohol consumption and intent, indicates a high level of lethality.
C. This scenario presents a significant risk given the method and the caller's intent, so "No risk" would not be appropriate.
D. Low level would suggest a plan that is less likely to cause severe harm or death, which is not the case here.
Similar Questions
A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. What is the likely conclusion regarding the patient's behavior?
A. Patient is attempting to use relaxation strategies.
Relaxation strategies involve deliberate and often structured activities aimed at reducing tension and stress, which isn't depicted in the described behavior.
B. Patient is demonstrating withdrawal behaviors.
Withdrawal behaviors typically involve avoiding social interaction or retreating, which doesn't align with the observed actions.
C. Patient is exhibiting clues to potential aggression.
The described behavior, including pacing, clenching fists, and staring at a staff member, indicates potential signs of aggression or agitation.
D. Patient is trying to work through angry feelings.
Working through angry feelings might involve communication or expression of emotions, but the described behavior leans more towards agitation and potential aggression.
Full Explanation
A. Relaxation strategies involve deliberate and often structured activities aimed at reducing tension and stress, which isn't depicted in the described behavior.
B. Withdrawal behaviors typically involve avoiding social interaction or retreating, which doesn't align with the observed actions.
C. The described behavior, including pacing, clenching fists, and staring at a staff member, indicates potential signs of aggression or agitation.
D. Working through angry feelings might involve communication or expression of emotions, but the described behavior leans more towards agitation and potential aggression.
A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to do what?
A. Avoid exposure to bright sunlight
Avoiding exposure to bright sunlight is not specifically related to SSRIs; it may be aconsideration with certain medications due to photosensitivity but isn't a primary concern with SSRIs.
B. Restrict sodium intake to 1g daily.
Restricting sodium intake isn't a directive associated with SSRI antidepressant therapy.
C. Maintain a tyramine-free diet.
Maintaining a tyramine-free diet is a concern with certain antidepressants like MAOIs (Monoamine Oxidase Inhibitors) but not typically with SSRIs.
D. Report increased suicidal thoughts
Reporting increased suicidal thoughts is a crucial directive because SSRIs may initially increase the risk of suicidal ideation, especially in the early stages of treatment.
Full Explanation
A. Avoiding exposure to bright sunlight is not specifically related to SSRIs; it may be a
consideration with certain medications due to photosensitivity but isn't a primary concern with SSRIs.
B. Restricting sodium intake isn't a directive associated with SSRI antidepressant therapy.
C. Maintaining a tyramine-free diet is a concern with certain antidepressants like MAOIs (Monoamine Oxidase Inhibitors) but not typically with SSRIs.
D. Reporting increased suicidal thoughts is a crucial directive because SSRIs may initially increase the risk of suicidal ideation, especially in the early stages of treatment.
A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?
A. "Clients should be given medications even if they refuse them."
Providing medications against a patient's will generally requires a legal process or evaluation of capacity rather than a blanket statement of administration.
B. "Clients who are involuntarily admitted have the right to informed consent."
Clients who are involuntarily admitted might not have the right to refuse treatment initially based on the nature of the admission.
C. "Clients who are admitted involuntarily can be hospitalized for as long as the provider deems necessary."
Involuntary admissions often allow for extended hospitalization based on the judgment of the treatment team.
D. "The laws regarding restraints are different for clients who are admitted involuntarily."
Laws regarding restraints are generally consistent regardless of the mode of admission, focusing on safety and necessity rather than the mode of admission.
Full Explanation
A. Providing medications against a patient's will generally requires a legal process or evaluation of capacity rather than a blanket statement of administration.
B. Clients who are involuntarily admitted might not have the right to refuse treatment initially based on the nature of the admission.
C. Involuntary admissions often allow for extended hospitalization based on the judgment of the treatment team.
D. Laws regarding restraints are generally consistent regardless of the mode of admission, focusing on safety and necessity rather than the mode of admission.