A client has expressed suicidal thoughts to the nurse. Select all the warning signs for suicide that the nurse should be aware of.

Expressing hopelessness or worthlessness.

Engaging in positive coping strategies.

Increasing alcohol or drug use.

Talking about wanting to die.

Withdrawing or isolating oneself.

Answer and Explanation

Correct Answer : A,C,D,E

The correct answers are A. Expressing hopelessness or worthlessness, C. Increasing alcohol or drug use, D. Talking about wanting to die, and E. Withdrawing or isolating oneself.

Choice A rationale:

Expressing feelings of hopelessness or worthlessness is a significant warning sign of suicide. These feelings often indicate severe emotional distress and a lack of perceived future.

Choice B rationale:

Engaging in positive coping strategies is generally a protective factor against suicide, not a warning sign.

Choice C rationale:

Increasing alcohol or drug use can be a sign of self-medicating to cope with emotional pain, which is a common warning sign of suicidal ideation.

Choice D rationale:

Talking about wanting to die is a direct indicator of suicidal thoughts and should always be taken seriously.

Choice E rationale:

Withdrawing or isolating oneself is a common behavior in individuals contemplating suicide, as they may feel disconnected from others or believe they are a burden.

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Correct Answer is C

Explanation

Choice A rationale:

Advising the client to keep their feelings to themselves is not an appropriate intervention in this situation. Suicidal ideation is a serious concern, and keeping feelings hidden could potentially lead to the client not receiving the necessary support and intervention they need to stay safe.

Choice B rationale:

Encouraging the client to isolate themselves until they feel better is not an appropriate intervention either. Isolation can exacerbate feelings of hopelessness and increase the risk of acting on suicidal thoughts. Connecting with the client and providing a supportive environment is crucial.

Choice C rationale:

Asking the client directly if they are thinking about harming themselves is the most appropriate intervention. This approach helps the nurse assess the severity of the situation, open a dialogue about the client's feelings, and determine the level of risk. Direct communication allows for a better understanding of the client's mental state and the need for further intervention.

Choice D rationale:

Providing the client with alcohol or drugs to help them cope is a dangerous and inappropriate intervention. Substance use can further impair judgment and increase the risk of acting on suicidal thoughts. This action also fails to address the underlying issues contributing to the client's distress.

A. Risk for suicide. B. Ineffective family coping. C. Chronic low self-esteem. D. Altered nutrition. E. Risk for infection.

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

Explanation

Choice A:

Risk for suicide.

Choice B:

Ineffective family coping.

Choice C:

Chronic low self-esteem.

Choice A rationale:

This choice aligns with the primary concern of the patient being at risk for suicide, which is the focus of the assessment. Identifying this diagnosis is crucial for implementing appropriate interventions to ensure the patient's safety.

Choice B rationale:

Ineffective family coping could contribute to the patient's stressors and emotional state. It's relevant because the support system plays a significant role in a patient's mental health. However, it might not be as immediate a concern as the risk for suicide itself.

Choice C rationale:

Chronic low self-esteem is relevant to the patient's overall mental health and might contribute to their suicidal ideation. However, it might not directly address the immediate risk and urgency of the situation compared to the diagnosis of "Risk for suicide."

Choice D rationale:

Altered nutrition and risk for infection are not directly related to the primary concern of suicidal ideation and the associated nursing diagnoses. While they may be aspects of the patient's overall health, they are not the most pertinent concerns when addressing the risk of suicide.

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A client has expressed suicidal thoughts to the nurse. Select all the warning signs for suicide that the nurse should be aware of.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of substance use disorder and recent job loss is exhibiting signs of suicidal ideation. Which nursing intervention is most appropriate in this situation?

Correct Answer is C

Explanation

(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.

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

Explanation

A nurse is assessing a patient's suicide risk using standardized tools. Which statement is accurate regarding the Columbia-Suicide Severity Rating Scale (C-SSRS)?

A nurse is teaching a client's family about suicide prevention. What information should the nurse emphasize when discussing resources for help and support?

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

A nurse is providing education to a client and their family about suicide prevention. Which information should the nurse prioritize in the education?

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 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.).

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.

(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?