A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of prior suicide attempts. She describes difficulty sleeping at night and has lost 4.5 kg (10 lb) in the past month. Which of the following is the nurse's best response in this situation?

Correct Answer: C

Rationale: The correct answer is C: "Are you feeling so hopeless that you feel like hurting yourself now?" This response directly addresses the patient's suicidal ideation and assesses the immediate risk of harm. It shows the nurse's concern for the patient's safety and allows for further evaluation and intervention if necessary. Option A is incorrect because asking about owning a lethal weapon does not directly address the patient's current mental state and immediate risk of harm. Option B is incorrect as it focuses on external factors rather than the patient's internal feelings of hopelessness and suicidal thoughts. Option D is incorrect as it minimizes the seriousness of the patient's symptoms and may lead to overlooking the urgency of the situation.

Correct Answer: C

Rationale: The correct answer is C: Chicken liver. Chicken liver is the best source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods like spinach or oranges. Eggs do contain iron, but in smaller amounts compared to chicken liver. Oranges, on the other hand, are a source of vitamin C which can enhance iron absorption but do not contain significant amounts of iron themselves.

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.

Correct Answer: D

Rationale: The correct answer is D: Worsening heart failure. Shortness of breath, fatigue, and leg swelling are common symptoms of heart failure. Monitoring for signs of worsening heart failure, such as increased dyspnea, weight gain, and decreased exercise tolerance, is crucial. Pulmonary embolism (A) presents with sudden chest pain and shortness of breath, not typically associated with chronic heart failure. Renal failure (B) may present with decreased urine output and electrolyte imbalances. Liver failure (C) may present with jaundice and changes in mental status. However, given the symptoms presented by the patient, monitoring for worsening heart failure is the most appropriate choice.

Correct Answer: A

Rationale: The correct answer is A: Chronic liver disease. Patients with a history of alcohol abuse are at increased risk for chronic liver disease due to the toxic effects of alcohol on the liver. Alcohol can lead to fatty liver, alcoholic hepatitis, cirrhosis, and liver cancer. The liver plays a crucial role in metabolizing alcohol, and excessive alcohol consumption can overwhelm the liver's ability to detoxify the body. Chronic kidney disease (B), pulmonary embolism (C), and stroke (D) are not directly associated with alcohol abuse. Kidney disease is more commonly linked to conditions like diabetes and hypertension, pulmonary embolism is often related to blood clotting disorders, and stroke can be caused by factors such as hypertension and atherosclerosis.