A client with a history of suicide attempts is admitted to the hospital. Which statement by the client should the nurse address during the assessment phase?

"I lost my job recently, and my family would be better off without me.".

"I enjoy spending time with my pet dog; it helps me relax.".

"I have a supportive group of friends who are always there for me.".

"I find it challenging to express my emotions to others.".

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

Choice A rationale:

Modifying the plan of care based on the patient's current status is a fundamental aspect of the evaluation phase. Patients' conditions can change, and the plan of care should be flexible enough to adapt to their evolving needs. By making necessary adjustments, the nurse ensures that the patient continues to receive appropriate and effective care.

Choice B rationale:

Comparing the patient's current status with baseline data only is insufficient for a comprehensive evaluation. Baseline data is useful for establishing a starting point, but it doesn't account for changes that may have occurred since then. Effective evaluation involves considering both baseline data and the patient's current condition.

Choice C rationale:

Disregarding the patient's feedback about their care is not appropriate during the evaluation phase. Patient feedback provides valuable insights into their experience, concerns, and whether the current plan of care is meeting their needs. Ignoring their feedback can lead to unaddressed issues and a lack of patient-centered care.

Choice D rationale:

Documenting outcomes without assessing the patient's response undermines the purpose of the evaluation phase. Evaluation involves not only documenting outcomes but also assessing how the patient has responded to interventions. This assessment informs whether the outcomes are positive, need adjustment, or require a different approach.

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 with a history of suicide attempts is admitted to the hospital. Which statement by the client should the nurse address during the assessment phase?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

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 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.).

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?

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?

A client who recently lost their spouse to a terminal illness expresses, "I just can't go on without them. Life feels meaningless now." Which statement by the nurse would be appropriate in this situation?

A nurse is developing a plan of care for a patient with suicidal ideation. Which of the following is a priority principle to consider in the planning phase for this patient's care?

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 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.).

(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?