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?
Advise the client to keep their feelings to themselves.
Encourage the client to isolate themselves until they feel better.
Ask the client directly if they are thinking about harming themselves.
Provide the client with alcohol or drugs to help them cope.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This statement reflects a significant red flag for potential suicide risk. The client's acknowledgment of losing their job and perceiving their family would be better off without them suggests feelings of worthlessness and burden. These emotions are associated with an increased risk of self-harm or suicide. Immediate attention and intervention are necessary to address the client's distorted thoughts and emotions.
Choice B rationale:
"I enjoy spending time with my pet dog; it helps me relax" is not an alarming statement related to suicide risk. While it highlights a coping mechanism, it doesn't provide direct insight into the client's emotional state or thoughts about self-harm.
Choice C rationale:
"I have a supportive group of friends who are always there for me" indicates a positive aspect of the client's social support network. This statement does not raise immediate concerns about suicide risk. However, a comprehensive assessment should still explore the client's overall emotional well-being.
Choice D rationale:
"I find it challenging to express my emotions to others" suggests a difficulty in emotional expression, which can be relevant to the assessment but does not inherently indicate imminent suicide risk. It's important to further explore the client's reasons for struggling with emotional expression.
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.
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