Practice Question
A nurse in a primary care provider's office is caring for a client.
Answer Choices:
Rationale:
"Questions reason to live if not working"
🔹 This statement indicates possible suicidal ideation, which is the highest priority based on Maslow’s hierarchy (safety needs) and NCLEX safety & risk-reduction principles.
🔹 Clients expressing feelings of hopelessness or lack of purpose following major life changes, such as retirement, are at increased risk for self-harm or suicide.
🔹 The nurse must perform an immediate suicide risk assessment, asking direct questions about thoughts, plan, and means of self-harm.
🔹 Timely intervention, including mental health referral or crisis intervention, is crucial to prevent potential self-injury or suicide attempts.
"Became teary when asked about plans for activities"
🔹 Emotional lability and tearfulness are clinical signs of depression, which can progress to major depressive disorder (MDD) if untreated.
🔹 This reaction suggests emotional distress and anhedonia, often associated with feelings of worthlessness or hopelessness, increasing suicide risk.
🔹 Emotional changes should never be dismissed as “normal sadness,” particularly in older adults with recent life stressors (retirement).
🔹 Early detection and treatment, such as cognitive-behavioral therapy or pharmacologic therapy (SSRIs), can prevent worsening of depressive symptoms.
"Reports sleeping most of the day"
🔹 Hypersomnia or changes in sleep pattern is a hallmark symptom of depression.
🔹 Excessive sleeping can worsen feelings of fatigue, social isolation, and low self-esteem, creating a cycle that increases suicide risk.
🔹 Assessment should include evaluating energy level, daily functioning, and mood changes, as well as screening for other depressive symptoms.
🔹 Addressing sleep disturbances through behavioral activation strategies or adjusting treatment can help improve overall mood stability.
"Reports loss of appetite"
🔹 Appetite changes, whether loss of appetite (anorexia) or overeating, are part of the diagnostic criteria for major depressive disorder.
🔹 Loss of appetite can contribute to nutritional deficiencies, weight loss, and physical weakness, further reducing the client’s energy and motivation.
🔹 In combination with other symptoms (hopelessness, hypersomnia), it signals a significant change in daily functioning, warranting further psychiatric evaluation.
🔹 The nurse should monitor weight trends and assess for possible dehydration or malnutrition, especially in older adults.
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This question is from RN Mental Health 2023(Summer ~2025) which contains 70 questions.
More Questions from This Exam
A nurse on an inpatient mental health unit is assessing a client.
Answer Choices:
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Answer Choices:
A nurse is assessing a client who has a new diagnosis of alcohol use disorder. Which of the following client statements should the nurse expect if the client is in denial about their diagnosis?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Mental Health
- Answer Choices: 1