A client is diagnosed with "Hopelessness." How would the nurse define this nursing diagnosis for a patient with suicidal ideation?
The client is at risk for self-inflicted, life-threatening injury.
The client has a subjective state with limited personal choices.
The client is unable to cope with stressors.
The client experiences compromised family coping.
The Correct Answer is B
The client has a subjective state with limited personal choices.
Choice A rationale:
The client is at risk for self-inflicted, life-threatening injury. This choice does not accurately define the nursing diagnosis of "Hopelessness." While it is true that hopelessness can lead to self-harm or suicide, the nursing diagnosis focuses on the client's emotional state and personal choices rather than the immediate risk of injury.
Choice B rationale:
The client has a subjective state with limited personal choices. This choice accurately defines the nursing diagnosis of "Hopelessness." Hopelessness refers to the client's emotional state of feeling devoid of hope, often resulting in a perceived lack of personal choices and options. This sense of hopelessness can contribute to feelings of despair and potentially suicidal ideation.
Choice C rationale:
The client is unable to cope with stressors. This choice is not the most accurate definition of "Hopelessness." While hopelessness can certainly impact a client's ability to cope with stressors, the primary focus of the diagnosis is on the subjective emotional state and perceived lack of choices, rather than their coping abilities.
Choice D rationale:
The client experiences compromised family coping. This choice is not directly related to the nursing diagnosis of "Hopelessness." Family coping refers to how a family unit manages stressors together, whereas hopelessness pertains to an individual's emotional state and perceived choices.
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Correct Answer is C
Explanation
Choice A rationale:
This statement is not accurate. The Columbia-Suicide Severity Rating Scale (C-SSRS) is not focused on assessing suicide-related thoughts and behaviors in the past year. Instead, it is designed to assess the severity of suicidal ideation and behavior over a specified time frame.
Choice B rationale:
This statement is not accurate. The C-SSRS is not a self-report questionnaire for depression and suicidal ideation in the past two weeks. It is a structured interview that involves a series of questions and prompts administered by a trained clinician to assess the severity of suicidal ideation and behavior.
Choice C rationale:
This statement is accurate. The Columbia-Suicide Severity Rating Scale (C-SSRS) guides the evaluation and triage of patients with suicidal ideation or behavior based on five steps: Determining the presence of active suicidal ideation. Assessing the intensity of ideation. Examining the presence and severity of any preparatory behavior. Evaluating the level of intent to die. Determining the lethality of the suicide plan. The C-SSRS is widely used in clinical and research settings to assess suicide risk and guide appropriate interventions.
Choice D rationale:
This statement is not accurate. The C-SSRS does not measure the severity and intensity of suicidal ideation and behavior in the past month. It focuses on assessing the severity of suicidal ideation and behavior based on the steps mentioned in choice C.
Correct Answer is ["B","D"]
Explanation
The correct answer is B. Reflecting back the patient’s feelings and thoughts and D. Encouraging patient involvement in decision making.
Choice A rationale:
Asking close-ended questions is not effective in building rapport and trust. Close-ended questions can limit the patient’s ability to express their feelings and thoughts, which is crucial in understanding their mental state and providing appropriate support.
Choice B rationale:
Reflecting back the patient’s feelings and thoughts helps in validating their emotions and shows that the nurse is actively listening and empathetic. This technique fosters trust and encourages the patient to open up more about their feelings.
Choice C rationale:
Imposing personal views and opinions can be detrimental to the therapeutic relationship. It can make the patient feel judged or misunderstood, which can hinder open communication and trust.
Choice D rationale:
Encouraging patient involvement in decision making empowers the patient and promotes a sense of control over their situation. This collaborative approach can enhance the therapeutic relationship and support the patient’s autonomy.
Choice E rationale:
Disregarding patient preferences is counterproductive in establishing a therapeutic relationship. It can lead to feelings of disrespect and neglect, which can further isolate the patient and exacerbate their risk.
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