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 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. "You shouldn't feel that way. There are many people who care about you.". B. "I understand how you feel. Grief can be overwhelming.". C. "You need to stay strong for your children.". D. "Try not to think about it too much. Time heals all wounds.".

Correct Answer is B

Explanation

Choice A rationale:

Telling the client that they shouldn't feel a certain way and suggesting that others care about them minimizes their emotions and can be invalidating. It's essential to acknowledge the client's feelings without dismissing them.

Choice B rationale:

Expressing understanding and acknowledging the overwhelming nature of grief is appropriate and empathetic. This response validates the client's emotions and creates a safe space for them to express their feelings.

Choice C rationale:

While the intention behind encouraging the client to stay strong for their children might be positive, it oversimplifies the complexity of grief and emotional responses. Grief is a personal experience, and implying that they should suppress their emotions for the sake of others is not ideal.

Choice D rationale:

Suggesting that the client avoid thinking about their loss or that time will heal their wounds can invalidate their current emotional state. Grief doesn't always follow a linear path, and minimizing the impact of the loss can hinder the client's healing process.

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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 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 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?

Correct Answer is B

Explanation

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?

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?

(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?

A nurse is providing care to a client with suicidal ideation. Select all the interventions that the nurse should include in the implementation phase of the client's care.

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

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)?

(Select All That Apply): A client has expressed thoughts of suicide during a therapy session. Which therapeutic interventions should the nurse incorporate into the client's care plan? (Select three.).

A client is diagnosed with "Hopelessness." How would the nurse define this nursing diagnosis for a patient with suicidal ideation?