Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide.
Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.) .
A. Alcohol use disorder
A rationale: Alcohol use disorder is a risk factor for suicide. Alcohol can increase impulsivity and decrease inhibitions, which can lead to suicidal behaviors.
B. Currently married.
B rationale: Being currently married is generally considered a protective factor against suicide, not a risk factor.
C. Access to guns in the home.
C rationale: Access to lethal means, such as guns in the home, is a significant risk factor for suicide.
D. Sibling history of suicide.
D rationale: A family history of suicide, including a sibling history of suicide, is a risk factor for suicide.
E. Terminal liver cancer.
E rationale: Terminal illnesses, such as liver cancer, can increase feelings of hopelessness and despair, which are risk factors for suicide.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Mental health DEC 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Alcohol use disorder is a risk factor for suicide. Alcohol can increase impulsivity and decrease inhibitions, which can lead to suicidal behaviors.
Choice B rationale:
Being currently married is generally considered a protective factor against suicide, not a risk factor.
Choice C rationale:
Access to lethal means, such as guns in the home, is a significant risk factor for suicide.
Choice D rationale:
A family history of suicide, including a sibling history of suicide, is a risk factor for suicide.
Choice E rationale:
Terminal illnesses, such as liver cancer, can increase feelings of hopelessness and despair, which are risk factors for suicide.
Similar Questions
A nurse is collecting data from a client who has anorexia nervosa.
Which of the following findings should the nurse expect? (Select all that apply.) .
A. Diarrhea
A rationale: Diarrhea is not typically associated with anorexia nervosa. Constipation is more common due to reduced food intake.
B. Hypotension.
B rationale: Hypotension can occur in anorexia nervosa due to decreased circulating blood volume from inadequate fluid and food intake.
C. Cold extremities.
C rationale: Cold extremities can be a sign of anorexia nervosa due to the body’s attempt to conserve heat in response to inadequate caloric intake.
D. Tooth erosion.
D rationale: Tooth erosion can occur in anorexia nervosa due to frequent vomiting, which exposes the teeth to stomach acid.
E. Lanugo.
E rationale: Lanugo, or fine body hair, can develop in anorexia nervosa as the body’s attempt to insulate itself due to loss of body fat.
Full Explanation
Choice A rationale:
Diarrhea is not typically associated with anorexia nervosa. Constipation is more common due to reduced food intake.
Choice B rationale:
Hypotension can occur in anorexia nervosa due to decreased circulating blood volume from inadequate fluid and food intake.
Choice C rationale:
Cold extremities can be a sign of anorexia nervosa due to the body’s attempt to conserve heat in response to inadequate caloric intake.
Choice D rationale:
Tooth erosion can occur in anorexia nervosa due to frequent vomiting, which exposes the teeth to stomach acid.
Choice E rationale:
Lanugo, or fine body hair, can develop in anorexia nervosa as the body’s attempt to insulate itself due to loss of body fat.
A nurse is collecting data from an older adult client who was admitted with heart failure.
The nurse should report which of the following findings to the provider as an indication of delirium? .
A. Consistent state of depression
A rationale: A consistent state of depression is not indicative of delirium, but rather a mood disorder.
B. Fluctuating level of orientation.
B rationale: Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
C. Demonstrates obsessive behaviors.
C rationale: Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
D. Family report of gradual memory loss.
D rationale: Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
Full Explanation
Choice A rationale:
A consistent state of depression is not indicative of delirium, but rather a mood disorder.
Choice B rationale:
Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
Choice C rationale:
Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
Choice D rationale:
Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
A nurse is caring for an adolescent who was recently sexually assaulted.
Which of the following statements by the adolescent's guardian represents the presence of a positive support system? .
A. "I anticipate that my child will feel some self-blame.”.
Recognizing that the adolescent may experience self-blame demonstrates understanding and empathy from the guardian. This statement suggests that the guardian is aware of potential emotional challenges the adolescent might face and can provide appropriate support.
B. "I will have to do all I can to monitor my child's relationships.”. .
While monitoring relationships may come from a place of concern, overly controlling behavior could potentially harm the adolescent's social development and trust in their support system.
C. "I should encourage my child to focus solely on the future.”. .
Encouraging the adolescent to focus solely on the future might dismiss their current emotional state and the importance of processing their feelings. A positive support system should provide space for the adolescent to work through their emotions.
D. "I can encourage my child to think about what they did that allowed this event to happen.”. .
Encouraging the adolescent to think about what they did that allowed the event to happen can promote feelings of guilt and self-blame. This approach is not supportive and could exacerbate the adolescent's trauma.
Full Explanation
The correct answer is choice A: "I anticipate that my child will feel some self-blame."
Choice A rationale: Recognizing that the adolescent may experience self-blame demonstrates understanding and empathy from the guardian. This statement suggests that the guardian is aware of potential emotional challenges the adolescent might face and can provide appropriate support.
Choice B rationale: While monitoring relationships may come from a place of concern, overly controlling behavior could potentially harm the adolescent's social development and trust in their support system.
Choice C rationale: Encouraging the adolescent to focus solely on the future might dismiss their current emotional state and the importance of processing their feelings. A positive support system should provide space for the adolescent to work through their emotions.
Choice D rationale: Encouraging the adolescent to think about what they did that allowed the event to happen can promote feelings of guilt and self-blame. This approach is not supportive and could exacerbate the adolescent's trauma.