A client is diagnosed with "Impaired coping." Which statement accurately describes this nursing diagnosis for a patient with suicidal ideation?
The client is at risk for self-inflicted, life-threatening injury.
The client experiences aloneness as a negative or threatening state.
The client is unable to use appropriate skills to cope with stressors.
The client has long-standing negative self-evaluation.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale:
In the nursing process, the step of diagnosis involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system. This step is critical in identifying the patient's current condition, problems, and needs. By assessing these aspects, the nurse can accurately diagnose the patient's situation and develop an appropriate care plan. Suicide risk assessment is an essential component of this step, as it helps determine the severity of the patient's ideation and potential for harm.
Choice B rationale:
Planning is the phase of the nursing process where the nurse, in collaboration with the patient, sets goals and develops a strategy to address the identified problems. While planning does involve considering the patient's suicide risk assessment, it primarily focuses on outlining interventions and actions to achieve the desired outcomes. It does not encompass the comprehensive data collection and assessment of the patient's mental and physical health status that are central to the diagnosis phase.
Choice C rationale:
Implementation is the stage in the nursing process where the nurse carries out the planned interventions and treatments. It involves executing the care plan that was developed during the planning phase. While suicide risk factors and protective factors may influence the choice of interventions, implementation itself does not encompass the data collection and assessment aspects required to fully evaluate the patient's condition.
Choice D rationale:
Evaluation is the final step of the nursing process, during which the nurse assesses the effectiveness of the interventions and evaluates the patient's progress toward achieving the established goals. It involves comparing the patient's current status with the expected outcomes and making necessary adjustments to the care plan. While suicide risk assessment may play a role in evaluating the patient's response to interventions, it is not the primary focus of the evaluation phase, which is centered around the assessment of treatment outcomes.
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