A nurse is assessing a client for potential suicidal ideation. The client says, "I've been thinking a lot about death lately. I wonder what it's like to not exist anymore." What would be an appropriate response by the nurse?
"You shouldn't dwell on those thoughts. They're not healthy.".
"I can see that you're feeling down, but these thoughts will pass.".
"Tell me more about what you're experiencing.".
"Just remember that things will get better soon.".
The Correct Answer is C
Choice A rationale:
Dismissing the client's thoughts and labeling them as unhealthy might cause the client to feel judged or reluctant to share further. It's important to approach the situation with openness and empathy.
Choice B rationale:
While it's true that the client's thoughts might pass, this response doesn't address the client's feelings or encourage them to express themselves. It's important to engage in a more in-depth conversation to understand their emotions.
Choice C rationale:
Asking the client to elaborate on their thoughts and experiences opens the door for meaningful conversation and assessment. This response shows genuine interest in the client's well-being and allows the nurse to gather more information to determine the appropriate level of support.
Choice D rationale:
Telling the client that things will get better soon might come across as dismissive of their current struggles. It's important to validate their emotions and explore their feelings further rather than offering premature reassurances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nursing diagnosis "Impaired coping" signifies that the client is experiencing difficulty in dealing with stressors and challenges. While it's true that impaired coping can contribute to various negative outcomes, the most critical concern when dealing with a client diagnosed with impaired coping and suicidal ideation is the risk of self-inflicted harm, which aligns with choice A. Clients with impaired coping and suicidal ideation are at a heightened risk for engaging in self-destructive behaviors, including attempts at self-inflicted, life-threatening injury. This choice is the most relevant and urgent, as it directly addresses the potential harm the client may cause to themselves due to their impaired coping skills.
Choice B rationale:
Although feelings of aloneness can contribute to psychological distress and could potentially be relevant to the client's situation, choice B does not directly address the immediate risk of self-inflicted injury associated with impaired coping and suicidal ideation. The focus in this case should be on the client's safety and preventing self-harm.
Choice C rationale:
This choice accurately describes one aspect of impaired coping but does not specifically address the increased risk of self-inflicted harm or the severity of the situation presented in the question. While impaired coping does involve the inability to use appropriate skills to manage stressors, the urgency of addressing the immediate risk of self-inflicted injury takes precedence in this scenario.
Choice D rationale:
Negative self-evaluation may contribute to impaired coping, but the question specifically relates to the client's risk for self-inflicted, life-threatening injury. While negative self-evaluation could be part of the client's overall presentation, it's not the most direct or urgent concern in this situation.
Correct Answer is A
Explanation
Choice A rationale:
In the nursing process, the step of diagnosis involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system. This step is critical in identifying the patient's current condition, problems, and needs. By assessing these aspects, the nurse can accurately diagnose the patient's situation and develop an appropriate care plan. Suicide risk assessment is an essential component of this step, as it helps determine the severity of the patient's ideation and potential for harm.
Choice B rationale:
Planning is the phase of the nursing process where the nurse, in collaboration with the patient, sets goals and develops a strategy to address the identified problems. While planning does involve considering the patient's suicide risk assessment, it primarily focuses on outlining interventions and actions to achieve the desired outcomes. It does not encompass the comprehensive data collection and assessment of the patient's mental and physical health status that are central to the diagnosis phase.
Choice C rationale:
Implementation is the stage in the nursing process where the nurse carries out the planned interventions and treatments. It involves executing the care plan that was developed during the planning phase. While suicide risk factors and protective factors may influence the choice of interventions, implementation itself does not encompass the data collection and assessment aspects required to fully evaluate the patient's condition.
Choice D rationale:
Evaluation is the final step of the nursing process, during which the nurse assesses the effectiveness of the interventions and evaluates the patient's progress toward achieving the established goals. It involves comparing the patient's current status with the expected outcomes and making necessary adjustments to the care plan. While suicide risk assessment may play a role in evaluating the patient's response to interventions, it is not the primary focus of the evaluation phase, which is centered around the assessment of treatment outcomes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.