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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Building rapport and trust with the patient. Building rapport and trust is a crucial aspect of the assessment phase, not the diagnosis phase, of the nursing process. While it's important to establish a strong nurse-patient relationship, the primary goal of the diagnosis phase is to identify and define the patient's health problems and needs.

Choice B rationale:

Identifying the nursing diagnoses related to suicide risk. The diagnosis phase involves analyzing the assessment data to identify and define the patient's health issues and needs. In the case of a patient at risk for suicide, it's essential to accurately identify the specific nursing diagnoses related to the suicide risk. This lays the foundation for developing an appropriate plan of care.

Choice C rationale:

Developing a plan of care for the patient's needs. While developing a plan of care is a critical step in the nursing process, it comes after the diagnosis phase. Once nursing diagnoses are identified, the nurse can then proceed to plan interventions and strategies to address the patient's needs.

Choice D rationale:

Evaluating the effectiveness of interventions. Evaluation is the final phase of the nursing process and occurs after interventions have been implemented. It involves determining whether the interventions have been successful in achieving the desired outcomes. The primary goal of the diagnosis phase is to identify the patient's health problems, not to evaluate interventions.

A. Leaving the client alone to give them space. B. Removing any potential means of self-harm from the client's environment. C. Encouraging the client to confront their feelings of hopelessness. D. Telling the client that they should be grateful for what they have.

Correct Answer is B

Explanation

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is analyzing data collected during the assessment phase for a patient at risk for suicide. What is the primary goal of the diagnosis phase in the nursing process?

Correct Answer is B

Explanation

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

Correct Answer is B

Explanation

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 is being assessed for nursing diagnoses related to suicidal ideation. Which nursing diagnosis prioritization principle should the nurse apply according to Maslow's hierarchy of needs?

(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?

(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.

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

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 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 educating a group of teenagers about warning signs of suicide. Which of the following signs should the nurse emphasize as potential indicators of suicidal ideation? (Select three.).