A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

Leaving the client alone to give them space.

Removing any potential means of self-harm from the client's environment.

Encouraging the client to confront their feelings of hopelessness.

Telling the client that they should be grateful for what they have.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Leaving the client alone to give them space is not a suitable intervention for someone with a history of suicide attempts and depression. Isolation can increase the risk of acting on suicidal thoughts, and the client needs close monitoring and support during this vulnerable time.

Choice B rationale:

Removing any potential means of self-harm from the client's environment is essential. This intervention helps reduce the immediate risk by limiting access to harmful items. It's a crucial step in creating a safer environment for the client and preventing impulsive acts of self-harm.

Choice C rationale:

Encouraging the client to confront their feelings of hopelessness is important, but it should be done in a supportive and therapeutic manner. Simply telling someone to confront their feelings without appropriate guidance can be overwhelming and unproductive.

Choice D rationale:

Telling the client that they should be grateful for what they have minimizes their emotional experience and does not address the complexity of depression and suicidal ideation. This statement lacks empathy and understanding of the client's struggles.

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Correct Answer is B

Explanation

Choice A rationale:

Building rapport and trust with the patient. Building rapport and trust is a crucial aspect of the assessment phase, not the diagnosis phase, of the nursing process. While it's important to establish a strong nurse-patient relationship, the primary goal of the diagnosis phase is to identify and define the patient's health problems and needs.

Choice B rationale:

Identifying the nursing diagnoses related to suicide risk. The diagnosis phase involves analyzing the assessment data to identify and define the patient's health issues and needs. In the case of a patient at risk for suicide, it's essential to accurately identify the specific nursing diagnoses related to the suicide risk. This lays the foundation for developing an appropriate plan of care.

Choice C rationale:

Developing a plan of care for the patient's needs. While developing a plan of care is a critical step in the nursing process, it comes after the diagnosis phase. Once nursing diagnoses are identified, the nurse can then proceed to plan interventions and strategies to address the patient's needs.

Choice D rationale:

Evaluating the effectiveness of interventions. Evaluation is the final phase of the nursing process and occurs after interventions have been implemented. It involves determining whether the interventions have been successful in achieving the desired outcomes. The primary goal of the diagnosis phase is to identify the patient's health problems, not to evaluate interventions.

A. Monitoring the client's access to lethal means. B. Encouraging the client to isolate themselves for self-reflection. C. Providing the client with a detailed plan for coping. D. Collaborating with the client's family and friends. E. Administering sedative medications to keep the client calm.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is A. Monitoring the client’s access to lethal means, C. Providing the client with a detailed plan for coping, and D. Collaborating with the client’s family and friends.

Choice A rationale:

Monitoring the client’s access to lethal means is crucial to prevent any immediate risk of self-harm. This includes removing or securing items that could be used for suicide, such as medications, sharp objects, or firearms.

Choice B rationale:

Encouraging the client to isolate themselves for self-reflection is not advisable. Isolation can increase feelings of loneliness and hopelessness, which may exacerbate suicidal ideation.

Choice C rationale:

Providing the client with a detailed plan for coping helps them manage their thoughts and emotions more effectively. This plan can include strategies for dealing with stress, identifying triggers, and knowing when and how to seek help.

Choice D rationale:

Collaborating with the client’s family and friends is essential for creating a support network. Involving loved ones can provide the client with emotional support and help monitor their well-being.

Choice E rationale:

Administering sedative medications to keep the client calm is not a primary intervention for suicidal ideation. While medication may be part of a broader treatment plan, it should not be the sole strategy for ensuring safety.

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A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is analyzing data collected during the assessment phase for a patient at risk for suicide. What is the primary goal of the diagnosis phase in the nursing process?

Correct Answer is B

Explanation

A nurse is providing care to a client who is displaying warning signs of suicidal ideation. Which interventions should the nurse prioritize to ensure the client's safety? (Select all that apply.).

Correct Answer is ["A","C","D"]

Explanation

A client is diagnosed with "Hopelessness." How would the nurse define this nursing diagnosis for a patient with suicidal ideation?

A nurse is assessing a patient with suicidal ideation. Which step of the nursing process involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system?

(Select All That Apply): A client has expressed thoughts of suicide during a therapy session. Which therapeutic interventions should the nurse incorporate into the client's care plan? (Select three.).

A nurse is conducting an assessment of a client who may be at risk for suicide. Which of the following are common risk factors associated with suicide and suicidal ideation? (Select All That Apply):

(Select all that apply): A nurse is establishing a therapeutic relationship with a patient at risk for suicide. Which of the following skills should the nurse use to build rapport and trust with the patient?

(Select all that apply): A nurse is analyzing data collected during the assessment phase for a patient at risk for suicide. Which of the following nursing diagnoses are commonly associated with suicidal ideation? Select three.

A nurse is evaluating the effectiveness of the plan of care for a patient with suicidal ideation. What action should the nurse take during the evaluation phase?

A nurse is caring for a client who has expressed suicidal thoughts. Select all the interventions that the nurse should include in the implementation phase of the client's care.