Nclex Review: *******
A client who overdosed on barbiturates is being transferred to the inpatient psychiatric unit from the intensive care unit. Assessing the client for which of the following needs should be a priority for the nurse receiving the client in the intensive care unit? 1. Nutrition. 2. Sleep. 3. Safety. 4. Hygiene.
3. Client safety is the priority to prevent further self-harm. Nutrition, sleep, and hygiene are important concerns, but they are secondary to safety.
The friend of a client with depression and suicidal ideation asks the nurse, "How should I act around her?" Which of the following responses by the nurse is best? 1. "Try to cheer her up." 2. "Be caring and genuine." 3. "Control your expressions." 4. "Avoid asking how she's feeling."
2. The best response would be for the nurse to advise the visitor to be caring and genuine to the client as a friend normally would. Family and friends are commonly afraid or at a loss about how to act or what to say to someone with a mental illness or to someone who may voice thoughts of self-harm. The statement, "Try to cheer her up," is inappropriate because the client may feel overwhelmed and thus become more despondent when she cannot meet or match the cheerful demeanor. The statement, "Control your expressions," is inappropriate because the client is not helped when interactions are not natural and genuine. The statement, "Avoid asking how she's feeling," is inappropriate because it conveys a lack of interest in and concern for the client.
Which of the following activities should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur? 1. Keeping track of feelings in a journal. 2. Reading a magazine. 3. Talking with the nurse. 4. Playing a card game with other clients
3. Talking with a staff member when suicidal thoughts occur is an important part of contracting for safety. The nurse or another staff member can then assess whether the client will act on the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a journal, reading, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse.
The client states to the nurse at the outpatient clinic, "I don't feel ready to go back to work. It's only been a week since I left the hospital." Assessment reveals a flat affect, disheveled appearance, poor posture, and minimal eye contact during interaction. The nurse asks the client whether he is thinking about harming himself. The client tells the nurse he has a loaded revolver at home and will probably use it. Which of the following should the nurse do next? 1. Tell the client to go and remove the gun from his home. 2. Ask the client to call the nurse every hour when he gets home. 3. Ask the client to promise not to harm himself. 4. Initiate plans for hospitalization immediately.
4. Based on the client's statement, the nurse must initiate plans for hospitalization immediately because the client has suicidal ideation with a definite plan, lethal method, and immediate access to the method.
When developing the plan of care for a client with suicidal ideation, developing goals to address which of the following is a priority? 1. Self-esteem. 2. Sleep. 3. Hygiene. 4. Safety.
4. For the client with suicidal ideation, client safety is the priority. The nurse protects the client from self-harm or self-destruction. Although self-esteem, sleep, and hygiene are common areas that require intervention for a client with suicidal ideation, ensuring the client's safety is the most immediate and serious concern.
A 20-year-old client diagnosed with paranoid schizophrenia is recovering from his first psychotic break. Before discharge from the hospital, the client becomes depressed and states, "I don't want this illness. I'm about to begin my junior year in college." Which of the following issues would be most important for the nurses to address at this time? 1. Disturbed thought process. 2. Disturbed sensory perceptions. 3. Communication problems. 4. Potential for medication non-compliance.
4. Though disturbed thoughts and sensory perceptions would be a concern to the nurse, as well as communication issues, the primary issue for this client in terms of his comments would be the potential for medication noncompliance and relapse. Most college students want to be like their peers and perceive themselves as capable and well. These beliefs can lead a young client with schizophrenia to stop taking medication which leads to relapse.
Which of the following amounts of medications is appropriate for a client who is being treated with imipramine (Tofranil) on an outpatient basis for recurring depression and suicidal ideation to have at one time? 1. A 30-day supply. 2. A 21-day supply. 3. A 14-day supply. 4. A 7-day supply.
4. Because the client has a history of recurring depression and suicidal ideation, the nurse would give the client a 7-day supply of imipramine to prevent possible overdose. Giving the client a 14-, 21-, or 30-day supply of medication would provide the client with enough medication to complete a suicide attempt. Tricyclic antidepressants are associated with a higher rate of death than are selective serotonin reuptake inhibitors.
The nurse is teaching two nursing assistants who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which of the following statements is made? 1. "I need to check the client precisely at 15-minute intervals." 2. "Documenting suicide checks is absolutely necessary." 3. "Clients on one-to-one suicide precautions can never be left alone." 4. "All clients using razors must be supervised by staff."
1. Clients on 15-minute suicide checks must be observed by a staff member every 15 minutes. However, the staff member must stagger the timing of the check so that the client cannot predict the precise time. The staff member could check the client at 10 minutes and then at 8 minutes, and so on, to protect the client from self-harm. The nurse would further explain the necessity of this procedure to help the staff understand its importance. Documenting that suicide checks have been done is absolutely necessary. Clients on one-to-one suicide precautions can never be left alone. All clients using razors must be supervised by staff.
A 68-year-old client has improved with medication and treatment and no longer experiences suicidal ideation. She can manage her diabetic care and understands her diet requirements. She will be discharged to live alone in her apartment. Visits by which of the following caregivers are most important for the nurse to arrange before the client's discharge? 1. Psychiatric home care nurse. 2. Medical social worker. 3. Her minister. 4. Occupational therapist.
1. The nurse should arrange for a psychiatric home care nurse to visit the client and follow her care. The psychiatric home care nurse will help the client manage her psychiatric disorder, medications for her mental illness and diabetes, diabetic care, and nutrition. A medical social worker may be involved with the client's care after discharge to help with interactions among agencies, and visits by clergy may be helpful, but a psychiatric home care nurse would be most important to help the client manage the many needs associated with her illness. An occupational therapist could help the client consider home management adjustments that might be needed after discharge but no ongoing disability is noted.
The widow of a client who successfully completed suicide tearfully says, "I feel guilty because I'm so angry at him for killing himself. It must have been what he wanted." After assisting the widow with dealing with her feelings, which of the following is most helpful? 1. Referring her to a group for survivors of suicide. 2. Encouraging her to receive counseling from a chaplain. 3. Providing her with the local suicide hotline number. 4. Suggesting she receive individual therapy by the nurse.
1. The survivor of suicide, in this situation, would be referred to a group for survivors of suicide to help her with her feelings and to work through the grief reaction. This group provides support and understanding of what the individual is experiencing by members who are experiencing similar reactions, including anger and guilt. Depression and unresolved grief can occur when the survivor does not receive appropriate help. Counseling by a chaplain or individual therapy by the nurse may be appropriate in addition to referral to the group. Giving the survivor the suicide hotline number would be appropriate if the survivor herself were thinking about suicide.
Which of the following questions should the nurse ask to best determine the seriousness of a client's suicidal ideation? 1. "How are you planning on harming yourself?" 2. "Have you made out a will?" 3. "Does your family know you're here?" 4. "How long have you been thinking about harming yourself?"
1. To determine the seriousness of the suicidal ideation, the nurse must ask directly about the intent and the plan. The nurse needs to determine whether the client has a concrete plan and will act on his thoughts. Then the nurse assesses the lethality of the method, immediacy, means to complete suicide, and possibility of rescue. Asking the client, "Have you made out a will?" is not as important and does not necessarily imply that he is planning self-harm. Many individuals have made out wills without planning self-harm. Asking the client, "Does your family know you're here?" provides no information about the client's intent and plan. Asking the client, "How long have you been thinking about harming yourself?" does provide information that the client is thinking about self-harm. However, it does not provide information about the client's immediate intent and plan.
When assessing a client for suicidal risk, which of the following methods of suicide should the nurse identify as most lethal? 1. Aspirin overdose. 2. Use of a gun. 3. Head-banging. 4. Wrist-cutting.
2. A crucial factor in determining the lethality of a method is the amount of time that occurs between initiating the method and the delivery of the lethal impact of the method. Lethal methods of suicide include using a gun, jumping from a high place, hanging, drowning, carbon monoxide poisoning, and overdose with certain drugs, such as central nervous system depressants, alcohol, and barbiturates. The more detailed the suicide plan, the more lethal and accessible the method, and the more effort exerted to block rescue, the greater the chance is for the suicide to be completed. Impulsive attempts at suicide even with rescuers in sight may be lethal depending on the method. Less lethal methods may include overdosing on aspirin and wrist cutting. Head-banging is a self-injurious behavior that requires intervention and is not to be taken lightly; however, it is not considered a lethal method of suicide.
The client with recurrent depression and suicidal ideation tells the nurse, "I can't afford this medicine anymore. I know I'll be okay without it." The nurse should: 1. Inform the physician of the client's statement. 2. Ask the social worker to find assistance for the client. 3. Schedule a follow-up appointment in 3 months. 4. Ask the client whether a family member could help.
2. Because the client is in danger of noncompliance with the medication due to financial concerns, the nurse should contact the social worker to assist with locating available resources for the client to ensure continuation of the medication needed for the recurrent illness. The client needs to continue the medications with no interruptions to minimize the chance of decompensation. Although the physician is the person responsible for ordering the client's medication, routinely the physician is not involved in finding financial assistance for the client's medication needs. The client needs the medication at the present time. Three months is too long to wait for a follow-up appointment. The client could be severely depressed and could even attempt suicide. A family member's assistance may not be a sufficient or a permanent means of financial help for the client in terms of medication needs.
The history of a female client who has just been admitted to the unit and is very depressed reveals a weight loss of 10 lb in 2 weeks, sleeping 3 hours a night, and poor hygiene. The client states, "I'm no good to anyone. Everyone would be better off without me." Which of the following questions should the nurse ask first? 1. "What do you mean?" 2. "Are you thinking about hurting yourself?" 3. "Doesn't your family care about you?" 4. "What happened to make you think that?"
2. On hearing the client's statement, the nurse must ask the client directly if she plans to kill herself. It is erroneous to think that talking to the client about suicide will drive her to it. Asking directly about suicidal intent is absolutely necessary. Commonly, doing so provides the client with a sense of relief. In addition, the nurse conveys concern for and a sense of worth to the client, thus enabling appropriate planning for care. Asking "What do you mean?" is an indirect method of inquiry that provides the client with the opportunity to evade the nurse's intent. Asking, "Doesn't your family care about you?" shows poor judgment on the nurse's part and is demeaning to the client. Asking, "What happened to make you think that?" conveys a lack of knowledge of psychopathology.
A client with depression and suicidal ideation voices feelings of self-doubt and powerlessness and is very dependent on the nurse for most aspects of her care. According to Erikson's stages of growth and development, the nurse determines the client to be manifesting problems in which of the following stages? 1. Trust versus mistrust. 2. Autonomy versus shame/ doubt. 3. Initiative versus guilt. 4. Industry versus inferiority.
2. The client with feelings of self-doubt, inability to control her life, and dependency is manifesting problems evident in autonomy versus shame/ doubt. Because of illness, regression has occurred and the client's behaviors affect how the nurse will intervene with the client. With trust versus mistrust, some behaviors reflecting problems include suspiciousness, projection of blame, and withdrawal from others. With initiative versus guilt, some behaviors reflecting problems include excessive guilt, reluctance to show emotions, and passivity. With industry versus inferiority, some behaviors reflecting problems include feelings of being unworthy, poor work history, and inadequate problem-solving skills.
A client who was recently discharged from the psychiatric unit telephones the unit to speak to the nurse. The client states that she took her children to the neighbors' house and has turned on the gas to kill herself. She is home alone and gives the nurse her address. Which of the following actions should the nurse do next? 1. Refer the caller to a 24-hour suicide hotline. 2. Tell the caller that another nurse will telephone the police. 3. Ask the caller whether she telephoned her physician. 4. Instruct the caller to telephone her family for help
2. The immediate priority is to save the caller's life. Therefore, the nurse should tell the caller that another nurse will telephone the police. The immediate goal is to rescue the caller because the suicide attempt has begun. Referring the caller to a 24-hour suicide hotline or instructing the caller to telephone her family for help may be appropriate as part of discharge planning. Asking the caller whether she has telephoned her physician is not appropriate. The nurse is responsible for notifying the physician.
A suicidal client is placed in the seclusion room and given lorazepam (Ativan) because she tried to harm herself by banging her head against the wall. After 10 minutes, the client starts to bang her head against the wall in the seclusion room. Which of the following should the nurse do next? 1. Tell the client to stop doing that and act like a responsible adult. 2. Place the client in leather restraints. 3. Call the physician for additional medication orders. 4. Instruct a staff member to sit in the room with the client.
2. The nurse and staff should place the client in leather restraints to protect her from further self-harm. The client's behavior is out of control and necessitates external controls for her safety. Telling the client to stop and act like a responsible adult is ineffective and not therapeutic. Calling the physician for additional medication orders is not appropriate because the lorazepam (Ativan) given by the nurse may take effect if the client remains still. The nurse is responsible for judging whether additional medication is needed later. Instructing a staff member to sit in the room with the client is unsafe for the client and the staff member.
A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which of the following questions by the nurse is most important to ask? 1. "When do you hear the voices?" 2. "Are you going to hurt yourself?" 3. "How long have you heard the voices?" 4. "Why are the voices starting again?"
2. The nurse needs to ask the client whether he is going to hurt himself to determine the client's ability to cope with the voices and to assess the client's impulse control. The nurse's assessment will then determine the course of action to take regarding the client's safety. Asking when the client hears the voices and how long the client has heard them is important but not as important as determining whether the client will act on what the voices are saying. Asking "Why are the voices starting again?" would be inappropriate because the client may not know why and may not be able to answer the nurse.
The nursing assistant states to the nurse, "My client talks about how awful and useless she is. Sometimes she sounds angry for no reason. I'm tired of listening to her." Which of the following responses by the nurse is most appropriate? 1. "I'll switch your assignment to someone who's less depressed and less tiring." 2. "It's important for you to listen to her because she needs to verbalize how she is feeling." 3. "Don't worry about it. I know you haven't done anything to make her angry." 4. "Clients with depression are hard to deal with, but don't take what they say seriously."
2. The nurse's best response is to teach the nursing assistant about the appropriate intervention and why it is important for the client. Staff members need to be client-focused and to understand why a specific intervention is important and appropriate. Telling the assistant that the assignment will be switched or not to worry about it is not appropriate because it does not teach the nursing assistant about the client's illness and appropriate client care. The statement, "Clients who are depressed are hard to deal with, but don't take what they say seriously," does not help the staff member understand why listening is important and may jeopardize the client's safety.
The client has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving? 1. "I couldn't kill myself because I don't want to go to hell." 2. "I don't think about killing myself as much as I used to." 3. "I'm of no use to anyone anymore." 4. "I know my kids don't need me anymore since they're grown."
2. The statement, "I don't think about killing myself as much as I used to," indicates a lessening of suicidal ideation and improvement in the client's condition. The statement, "I couldn't kill myself because I don't want to go to hell," indicates that the client will not attempt suicide but could still be thinking about death. The statements, "I'm of no use to anyone anymore," and "I know my kids don't need me anymore since they're on their own," indicate that the client feels worthless and may be experiencing suicidal ideation.
The nurse manager in the emergency department (ED) is conducting an in-service for the nursing staff about screening clients for suicide. One of the nurses states, "Questioning adolescents about suicide will only increase their thinking about self-harm and they would not admit it to me anyhow." How should the nurse manager respond? 1. "You could be correct. Let's assess only adults because they'll be more honest." 2. "We will limit the assessment to adolescents with psychiatric diagnoses." 3. "It's a myth that talking about suicide leads to suicide attempts. Adolescents will disclose suicidal thoughts when asked directly." 4. "If you think the adolescent is not telling you
3. Assessing for suicide risk in the ED is important because suicidal clients can be discharged without being assessed for suicide potential. Many visitors to the ED are there for comprehensive health care needs and lack primary care providers. It is a myth that talking about suicide will cause young people to think about suicide, and evidence exists that they will talk about suicide if asked directly. Assessing adults only because they will be more honest is an incorrect assumption. Limiting the assessment of suicide risk only to adolescents with psychiatric diagnoses falsely assumes that other young people are not at risk for suicide. Questioning the parents about their adolescent's suicide risk may be an unreliable method because the parents may not be aware that suicide risk is present.
The husband of a client to be discharged from the hospital after an episode of major depression and a suicide attempt asks, "What can I do if she tries to kill herself again?" Which of the following responses is most appropriate? 1. "Don't worry. She'll be okay as long as she takes her medication." 2. "She told me she wants to live so I don't think she'll try again." 3. "Let's talk about some behavioral clues and resources that can help." 4. "Tell her about your concern and just take care of her."
3. The most appropriate response is to discuss the behavioral clues and resources because it provides the husband with important information that he needs to cope with his wife's condition. Family members are commonly afraid of future suicidal activity and need helpful information and resources to turn to in a crisis. Telling the husband not to worry minimizes the husband's concern and is not necessarily true. Additionally, past suicide attempts need to be considered when evaluating the client's future risk of suicide. The statement, "She told me she wants to live so I don't think she'll try again," ignores the husband's request and concerns. Additionally, there is no way for the nurse to know whether the client will attempt suicide again. The statement, "Tell her about your concern and just take care of her," is not helpful because the husband needs information and resources to turn to should a crisis develop.
A client states, "I'm so tired of living and just want to end it all." Which of the following responses is most therapeutic? 1. "I'll walk with you to your room so that you can get some rest." 2. "Perhaps after your son visits you'll feel better about things." 3. "You're in a lot of pain now but you will feel better. I'm here to help you." 4. "You are very depressed right now and want to die but you need to focus on life.".
3. The most therapeutic response is for the nurse to state, "You're in a lot of pain now but you will feel better and I'm here to help you." The client with active suicidal ideation believes that the solution to his problems is suicide. This statement by the nurse conveys empathy and hope to the client that he will get better and offers the nurse's help in doing so. The statement, "I'll walk with you to your room so that you can get some rest," is inappropriate because it focuses only on the client's use of the word tired, not theunderlying feeling or intent of the statement. The statement about feeling better after the client's son visits is inappropriate because the nurse does not recognize the client's suicidal behavior and does not convey an understanding of the psychopathology of depression. The statement, "You are very depressed right now and want to die but you need to think about life," is inappropriate because it will not change the way the client is thinking or feeling. It also minimizes the client's feelings.
A client with depression is exhibiting a brighter affect, ability to attend to hygiene and grooming tasks, and beginning participation in group activities. The nurse asks the client to identify three of her strengths. After much hesitation and thinking, the client can state she is usually a nice person, a good cook, and a hard worker. Which of the following should the nurse do next? 1. Ask the client to identify an additional three strengths. 2. Volunteer the client to lead the cooking group later in the day. 3. Educate the client about the importance of medication. 4. Reinforce the client for identifying and sharing her strengths.
4. After the client identifies and shares her strengths, the nurse reinforces the client for her ability to evaluate herself in a positive manner. Doing so promotes self-esteem and offers hope for improvement. Asking the client to identify an additional three strengths or volunteering the client to lead the cooking group could be too overwhelming for the client at this time and may increase her anxiety and feelings of worthlessness. Although educating the client about the importance of medication is important, doing so at another time would be more appropriate.
A client is brought to the psychiatric unit from the emergency department (ED) escorted by ED staff and a security officer. The client's shoulder is bandaged and his arm is in a sling because of a self-inflicted gunshot wound to his shoulder. Later, the client's wife follows with a bag of her husband's belongings. Which of the following nursing actions is most appropriate at this time? 1. Tell the wife to take her husband's things home because he is suicidal. 2. Instruct the wife to unpack the bag and put her husband's things in the dresser. 3. Ask the wife whether the bag contains anything dangerous. 4. Inspect the bag and its contents in the presence of the client and his wife.
4. The nurse inspects the bag and its contents in the presence of the client and his wife so that they know what is allowed on the unit and what should be returned home and why. The nurse is responsible for the client's safety and that of the other clients and staff. Telling the wife to take her husband's things home because he is suicidal diminishes the client's self-worth and is inaccurate. Instructing the wife to unpack the bag and put her husband's things away is inappropriate because it is the nurse's responsibility to manage safety issues pertaining to the client and the unit. Asking the wife whether the bag contains anything dangerous would be poor judgment on the part of the nurse because the wife would not be knowledgeable about the safety factors.
A client walks into the clinic and tells the nurse she wants to die because her boyfriend broke up with her. The client states, "I'll show him, he'll be sorry." The nurse notes which of the following as the underlying theme and method to deal with the client? 1. Sadness— ask client to reveal how long she has felt this way. 2. Escape— ask client to indicate from what she wants to escape. 3. Loneliness— ask client to state who she believes to be her friends. 4. Retaliation— ask client about her specific plans to harm herself and/ or her boyfriend.
4. The statement refers to the suicidal client's wish to use her own death to retaliate or get even with her boyfriend. If a client wishes to retaliate, discovering the specific plans would be important to maintaining her safety as well as possibly her boyfriend's. Though sadness, escape, and loneliness can all be themes expressed by a suicidal client, they do not apply to the comment made by this client.
The nurse manager overhears two staff members talking in the snack room. One of the staff members states, "Her superficial cuts are just a means of getting our attention. She never should have been admitted. I hope she's out of here soon." Which of the following responses by the nurse manager is most appropriate? 1. "It's our job to help her no matter how we feel about her or what she did. She'll be discharged soon." 2. "I won't tolerate that kind of discussion from my staff. Now, it is time for you to go back to work." 3. "I know it's hard to understand, but we need to do the best we can even though she'll be back." 4. "No matter what the intent, all suicidal behavior is serious and deserves our serious consideration."
4. The statement, "No matter what the intent, all suicidal behavior is serious and deserves our serious consideration," is most appropriate because it provides accurate information for the staff. Superficial cuts may be termed suicide gestures. Nevertheless, they still are a cry for help and may indicate ambivalence about dying. Clients have accidentally and unintentionally killed themselves because previous attempts were not taken seriously, they acted on impulse, or rescue attempts were foiled. Stating, "It's our job to help her no matter how we feel about her or what she did; she'll be discharged soon," is inappropriate because it does not provide the staff members with accurate information. Stating, "I won't tolerate that kind of discussion from my staff; now it is time for you to go back to work," is authoritarian and punitive. Additionally, it does not help the staff members gain insight. Stating, "I know it's hard to understand, but we need to do the best we can even though she'll be back," voices agreement with the staff's bias and lack of knowledge. As such, this statement is inappropriate.
