Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
When considering an individual's risk for suicide, which client will the nurse consider the priority?
A. The recent Middle Eastern immigrant from a war-torn country
Being an immigrant from a war-torn country is a risk factor but not an immediate priority based on the information provided.
B. The gay male who has been diagnosed with HIV
While being diagnosed with HIV poses mental health risks, there's no immediate suicidal attempt or ideation described in the scenario.
C. The older transgender female who has been repeatedly assaulted
Repeated assaults are traumatic, but there's no indication of immediate suicidal risk.
D. The teenager recovering from a self-inflicted gunshot wound
The teenager recovering from a self-inflicted gunshot wound indicates an immediate and recent attempt at suicide, making them the highest priority for monitoring and intervention.
This question is an excerpt from Nurse Dive's nursing test bank - Ati RN Psychtriac Nursing Proctored Exam. Take the full exam now
Full Explanation
A. Being an immigrant from a war-torn country is a risk factor but not an immediate priority based on the information provided.
B. While being diagnosed with HIV poses mental health risks, there's no immediate suicidal attempt or ideation described in the scenario.
C. Repeated assaults are traumatic, but there's no indication of immediate suicidal risk.
D. The teenager recovering from a self-inflicted gunshot wound indicates an immediate and recent attempt at suicide, making them the highest priority for monitoring and intervention.
Similar Questions
Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
A. Discuss the client's suicide plan.
Discussing the client's suicide plan might inadvertently trigger or worsen suicidal thoughts and is not recommended.
B. Restrict visitors to family members only.
Restricting visitors might hinder the client's social support system, which is essential in managing depression.
C. Reinforce statements regarding a will to live and realistic plans for the future.
Reinforcing statements regarding a will to live and realistic plans for the future promotes hope and positive thinking.
D. Encourage the client to discuss thoughts and feelings about wanting to die.
Encouraging the client to discuss thoughts and feelings about wanting to die allows for expression and processing of emotions.
E. Limit time allowed to play video games.
Limiting time allowed to play video games might be part of a broader plan, but it's not directly addressing depression and might not be as impactful as other interventions.
Full Explanation
A. Discussing the client's suicide plan might inadvertently trigger or worsen suicidal thoughts and is not recommended.
B. Restricting visitors might hinder the client's social support system, which is essential in managing depression.
C. Reinforcing statements regarding a will to live and realistic plans for the future promotes hope and positive thinking.
D. Encouraging the client to discuss thoughts and feelings about wanting to die allows for expression and processing of emotions.
E. Limiting time allowed to play video games might be part of a broader plan, but it's not directly addressing depression and might not be as impactful as other interventions.
A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?
A. Recognize the attempt at manipulation and escort the client back to her activity.
Dismissing the client's statement as manipulation without proper assessment can be dangerous.
B. Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.
While involving family support is important, this response doesn’t address the immediate safety concerns of the client.
C. Ask the client if she has a plan to commit suicide.
Asking about suicidal plans helps assess the level of risk and informs subsequent actions to ensure the client's safety.
D. Assist the client to her room and allow her to rest before resuming activity.
The situation requires more immediate assessment and action due to the expressed suicidal ideation.
Full Explanation
A. Dismissing the client's statement as manipulation without proper assessment can be dangerous.
B. While involving family support is important, this response doesn’t address the immediate safety concerns of the client.
C. Asking about suicidal plans helps assess the level of risk and informs subsequent actions to ensure the client's safety.
D. The situation requires more immediate assessment and action due to the expressed suicidal ideation.
A nurse teaching a patient about a tyramine-restricted diet would approve which meal?
A. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
Contains foods high in tyramine like avocado, ham, and chocolate cake.
B. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls
Includes smoked sausage and yeast rolls which are high in tyramine.
C. Mashed potatoes, ground beef patty, corn, green beans, apple
This meal consists of foods typically low in tyramine content, suitable for a tyramine- restricted diet.
D. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
Macaroni and cheese, hot dogs, and banana bread can contain high levels of tyramine
Full Explanation
A. Contains foods high in tyramine like avocado, ham, and chocolate cake.
B. Includes smoked sausage and yeast rolls which are high in tyramine
C. This meal consists of foods typically low in tyramine content, suitable for a tyramine- restricted diet.
D. Macaroni and cheese, hot dogs, and banana bread can contain high levels of tyramine
