The nurse is planning care for a patient who is suspected of being at risk for suicide. Which question would be most appropriate for the nurse to ask the patient when determining the presence of protective measures?
1. "Do you have any thoughts of suicide?"
2. "Do you have a history of trauma in your past?"
3. "What symptoms of depression are you experiencing?"
4. "Do you identify with a religious or spiritual group?"
Answer: 4
Explanation: Protective measures are factors that can help the individual to feel hopeful and worthy enough to begin problem solving, even when he or she feels that there are no answers to the presenting problem. Both religion and spirituality are protective measures that help reduce suffering and promote hope. Asking the patient, "Do you identify with a religious or spiritual group?" will help the nurse identify protective measures. Asking the patient if he or she has any thoughts of suicide, has a history of trauma, or has symptoms of depression, are appropriate questions; however, these questions assesses the patient's risk for suicide and do not address protective measures.
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Answer the following statement true (T) or false (F)
The presence of FHR accelerations in the intrapartum and antepartum periods is a sign of adequate fetal oxygenation.
a. true b. false