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?

Building rapport and trust with the patient.

Identifying the nursing diagnoses related to suicide risk.

Developing a plan of care for the patient's needs.

Evaluating the effectiveness of interventions.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is B

Explanation

Choice A rationale:

Encouraging isolation to minimize potential stressors is not a appropriate intervention for a client with suicidal ideation. Isolation can exacerbate feelings of loneliness and hopelessness, which can further contribute to the client's distress.

Choice B rationale:

Assisting the client in creating a safety plan is a crucial intervention for a client with suicidal ideation. A safety plan helps the client identify strategies and resources to use when they experience overwhelming emotions or thoughts of self-harm. This plan provides a sense of control and practical steps to follow during times of crisis, promoting hope that they can manage their emotions and stay safe.

Choice C rationale:

Teaching the client relaxation techniques is a valuable intervention, but it may not directly address the immediate need for a safety plan. Relaxation techniques can be helpful for managing anxiety and stress, but they might not be sufficient to prevent self-harm or suicide attempts.

Choice D rationale:

Focusing solely on the client's past failures is counterproductive and can further erode the client's self-esteem and hope. It's important to focus on the client's strengths, coping skills, and the potential for positive change rather than dwelling on past difficulties.

A. "This scale assesses suicide-related thoughts and behaviors in the past year.". B. "This self-report questionnaire screens for depression and suicidal ideation in the past two weeks.". C. "It guides the evaluation and triage of patients with suicidal ideation or behavior based on five steps.". D. "The C-SSRS measures the severity and intensity of suicidal ideation and behavior in the past month.".

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a client who has suicidal ideation. Which intervention should the nurse implement to promote hope in the client?

Correct Answer is B

Explanation

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)?

Correct Answer is C

Explanation

A nurse is providing education to a client and their family about suicide prevention. Which information should the nurse prioritize in the education?

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 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?

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

A nurse is caring for a client who has expressed suicidal thoughts. Select all the interventions that the nurse should include in the implementation phase of the client's care.

A nurse is conducting an assessment of a client who may be at risk for suicide. Which of the following are common risk factors associated with suicide and suicidal ideation? (Select All That Apply):

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 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.).