During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, “I'm here for my heart, not my head problems.” Which is the nurse's best response?

Correct Answer: C

Rationale: The correct answer is C because it provides a logical and evidence-based explanation for why psychosocial questions are relevant to the client's heart condition. By highlighting the connection between psychological factors and medical conditions, the nurse can help the client understand the importance of addressing both aspects for optimal health outcomes. Choice A is incorrect as it simply dismisses the client's concerns without providing a meaningful explanation. Choice B is incorrect as it fails to address the client's resistance and may come off as confrontational. Choice D is incorrect as it undermines the significance of psychosocial questions in the assessment process.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Generativity versus stagnation. Erikson's psychosocial theory posits that during middle adulthood (generativity versus stagnation stage), individuals seek to contribute to the world and leave a legacy. The 55-year-old man's distress over being laid off and his perceived failure as a parent align with feelings of stagnation, where he may feel unproductive and disconnected from his family and society. Option A) Ego integrity versus despair pertains to late adulthood and involves reflecting on one's life, which is not the primary issue for the man in this scenario. Option C) Identity versus role confusion is more relevant to adolescence, focusing on self-discovery and identity formation. Option D) Intimacy versus isolation relates to young adulthood and the struggle between forming close relationships and feeling isolated, which is not the main concern for the man in this case. Educationally, understanding Erikson's stages can help mental health professionals assess and support individuals experiencing crises related to specific life stages. By applying this knowledge, practitioners can tailor interventions to address the underlying psychosocial challenges clients face, ultimately enhancing therapeutic outcomes and promoting holistic well-being.

Correct Answer: D

Rationale: In this scenario, option D, jumping from a railroad bridge located in a deserted area late at night, presents the highest suicide risk. This method is considered highly lethal due to the high likelihood of fatal injuries upon impact, making it a more immediate and certain means of suicide compared to the other options. Option A, turning on the oven to let gas escape, may not result in death as quickly or reliably as jumping from a height. Option B, cutting the wrists, can be survivable and may allow time for intervention if discovered promptly. Option C, overdosing on aspirin with codeine, also carries a lower immediate lethality compared to jumping from a height. From an educational perspective, it is crucial to understand the concept of lethality in suicide risk assessment. Educators should emphasize the importance of recognizing high-risk suicide methods that are more likely to result in fatal outcomes. Training in suicide prevention should include identifying and assessing the lethality of suicide plans to ensure effective intervention strategies are implemented to prevent tragic outcomes.

Correct Answer: C

Rationale: The correct answer is C) Suicide potential. The SAD PERSONS scale is a tool used in psychiatric assessment to evaluate suicide risk factors. It assesses various aspects such as sex, age, depression, previous suicide attempts, ethanol abuse, rational thinking loss, social supports lacking, organized plan, and no spouse. These factors contribute to determining an individual's suicide potential, making option C the most relevant data obtained through this tool. Option A) Current stress level is incorrect because while stress can be a contributing factor to psychiatric emergencies, the SAD PERSONS scale specifically focuses on suicide risk factors, not general stress levels. Option B) Mood disturbance is incorrect as the SAD PERSONS scale is more focused on risk factors for suicide rather than mood disturbances, which may be assessed through other tools or assessments. Option D) Level of anxiety is incorrect as the SAD PERSONS scale does not primarily assess anxiety levels. While anxiety may play a role in psychiatric emergencies, it is not the main focus of this particular tool. In an educational context, understanding the purpose and application of assessment tools like the SAD PERSONS scale is crucial for healthcare providers working with individuals in psychiatric emergencies. By correctly applying tools like this, nurses and other professionals can gather essential data to identify and address the specific risk factors associated with suicide potential, ultimately improving patient care and safety.

Correct Answer: B

Rationale: The most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills is option B) "Do you have access to medications?" This question is crucial because it assesses the immediate risk of the adolescent having access to the means to carry out the overdose, which is a critical aspect of suicide prevention. Asking why the adolescent wants to kill themselves (option A) is important for understanding their emotional state, but the immediate concern is ensuring their safety. Inquiring about drug and alcohol use (option C) is relevant for assessing potential contributing factors to the crisis but is not as urgent as determining access to medications. Asking about parental issues (option D) may provide important context but is not as time-sensitive as assessing the immediate risk of overdose. In an educational context, it is essential for healthcare providers to prioritize questions that address the immediate safety and risk factors in a psychiatric emergency. Understanding the rationale behind each question helps nurses and other professionals provide effective crisis interventions and support for individuals experiencing mental health crises.