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 A

Explanation

Choice A rationale:

The nursing diagnosis "Impaired coping" signifies that the client is experiencing difficulty in dealing with stressors and challenges. While it's true that impaired coping can contribute to various negative outcomes, the most critical concern when dealing with a client diagnosed with impaired coping and suicidal ideation is the risk of self-inflicted harm, which aligns with choice A. Clients with impaired coping and suicidal ideation are at a heightened risk for engaging in self-destructive behaviors, including attempts at self-inflicted, life-threatening injury. This choice is the most relevant and urgent, as it directly addresses the potential harm the client may cause to themselves due to their impaired coping skills.

Choice B rationale:

Although feelings of aloneness can contribute to psychological distress and could potentially be relevant to the client's situation, choice B does not directly address the immediate risk of self-inflicted injury associated with impaired coping and suicidal ideation. The focus in this case should be on the client's safety and preventing self-harm.

Choice C rationale:

This choice accurately describes one aspect of impaired coping but does not specifically address the increased risk of self-inflicted harm or the severity of the situation presented in the question. While impaired coping does involve the inability to use appropriate skills to manage stressors, the urgency of addressing the immediate risk of self-inflicted injury takes precedence in this scenario.

Choice D rationale:

Negative self-evaluation may contribute to impaired coping, but the question specifically relates to the client's risk for self-inflicted, life-threatening injury. While negative self-evaluation could be part of the client's overall presentation, it's not the most direct or urgent concern in this situation.

A. "Sometimes, I just wish all of this would end.". B. "I have been feeling really down lately.". C. "I've been making a list of things I want to do before I die.". D. "I think things might get better if I reach out to my friends.".

Correct Answer is A

Explanation

Choice A rationale:

This statement indicates a clear and direct expression of suicidal ideation. The phrase "wish all of this would end" strongly implies a desire for one's life to end, which is a significant concern in assessing a patient with suicidal thoughts. Immediate intervention is necessary to ensure the patient's safety and address their emotional distress.

Choice B rationale:

This statement, "I have been feeling really down lately," expresses a general sense of sadness and low mood. While it suggests emotional distress, it does not explicitly convey a direct intention for self-harm or suicide. However, it should not be ignored and should be explored further during the assessment.

Choice C rationale:

"I've been making a list of things I want to do before I die" is a statement that may have different implications. While it could relate to the patient's interests and goals, it does not necessarily indicate a current intent for suicide. It is important to clarify the context and content of the list before drawing any conclusions.

Choice D rationale:

"I think things might get better if I reach out to my friends" suggests that the patient is considering seeking support from friends, which is generally a positive coping strategy. This statement does not express an immediate risk of self-harm or suicide. However, it's still essential to evaluate the patient's overall emotional state and social support.

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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 client is diagnosed with "Impaired coping." Which statement accurately describes this nursing diagnosis for a patient with suicidal ideation?

Correct Answer is A

Explanation

A nurse is assessing a patient with suicidal ideation. Which statement made by the patient requires immediate intervention?

Correct Answer is A

Explanation

A nurse is conducting an assessment for a patient with suicidal ideation. Which skill involves acknowledging the patient's feelings and thoughts as real and understandable without agreeing or disagreeing with them?

A nurse is assessing a client for potential suicidal ideation. The client says, "I've been thinking a lot about death lately. I wonder what it's like to not exist anymore." What would be an appropriate response by the nurse?

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.).

(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 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 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?

A client with a history of suicide attempts is admitted to the hospital. Which statement by the client should the nurse address during the assessment phase?

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):