Practice Question
A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?
Answer Choices:
Correct Answer:
Determine the presence and degree of suicidal risk.
Rationale:
🔴 Safety is priority: According to Maslow’s hierarchy of needs and the ABC (Airway, Breathing, Circulation) + Safety principle, assessing for suicidal ideation is the highest priority in a client with depression, alcohol withdrawal, and recent major loss.
🔴 High-risk combination: Depression, substance withdrawal, and a recent significant stressor (job loss) greatly increase the risk of suicide.
🔴 Guides immediate care: Determining suicidal intent, plan, and means allows the nurse to implement urgent safety measures, such as one-to-one observation or hospitalization if needed.
🔴 Other interventions follow: Referrals, education, and support groups are important but are secondary to ensuring the client’s immediate safety.
Want to practice more questions like this?
This question is from ATI LPN Mental Health level 4 test I which contains 39 questions.
More Questions from This Exam
A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe?
Answer Choices:
The nurse is assessing the drinking history of a client with a history of alcohol abuse. The client is being admitted after being found unresponsive in a public place. Which statement would indicate the use of defense mechanisms?
Answer Choices:
A nurse manager is reviewing a recent client report related to a staff nurse. Which of the following behaviors by a nurse at work might be red flags for a substance use disorder?
Answer Choices:
A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?
Answer Choices:
Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Mental Health
- Answer Choices: 4