NCLEX Psychosocial Integrity

Correct! The combination of a prior suicide attempt and a specific plan with identified means (firearm at home) represents the highest immediate suicide risk. A prior suicide attempt is the single strongest predictor of future attempt. A specific plan with accessible means dramatically increases imminent risk. This client requires immediate intervention including means restriction (removing the firearm from the home).

Clinical pearl: Clinical Pearl: The SAD PERSONS scale risk factors: Sex (male higher risk), Age (adolescent and above 65), Depression, Previous attempt, Ethanol/substance use, Rational thinking loss (psychosis), Social support lacking, Organized plan, No spouse, Sickness (chronic illness). The single highest risk indicator is a PRIOR SUICIDE ATTEMPT combined with a SPECIFIC CURRENT PLAN AND ACCESSIBLE MEANS. Means restriction (removing firearms, medications, ropes from the environment) is one of the most evidence-based suicide prevention interventions.

Option C is correct. This response acknowledges the therapeutic value of the nurse-client relationship without reinforcing unhealthy dependency. The therapeutic relationship is a means to an end — helping the client develop coping skills and the capacity for healthy relationships — not a substitute for those relationships. By redirecting toward therapy and long-term goals, the nurse maintains warmth and validation while preserving appropriate professional boundaries and promoting the client's autonomy.

Clinical pearl: Clinical Pearl: Signs of a boundary crossing in the therapeutic relationship: the nurse shares personal information with the client, the nurse gives the client special privileges not given to others, the nurse contacts the client outside of professional settings, the nurse begins to feel that only they understand the client, or the nurse feels personally hurt when the client improves and needs them less. Countertransference — the nurse's emotional reaction to the client — is normal. Allowing it to influence professional behavior is a boundary violation.

Option C indicates a need for further teaching. Feeling well is the expected outcome of lithium therapy, not a signal that the medication is no longer needed. Lithium manages symptoms of bipolar disorder but does not cure the underlying condition. Discontinuing lithium abruptly when stable can precipitate a rebound manic or depressive episode. The client must understand that symptom control is evidence the medication is working, which reinforces the importance of adherence.

Clinical pearl: Clinical Pearl: Lithium and sodium: lithium and sodium compete for renal reabsorption. When sodium is depleted (from low sodium diet, excessive sweating, diarrhea, vomiting, or diuretics), the kidneys reabsorb more lithium to compensate — causing toxicity. Key teaching: maintain consistent sodium intake (not low-sodium diet), adequate fluid intake, and avoid situations that cause significant sodium loss (intense exercise without hydration, sauna, illness with vomiting or diarrhea).