A nurse is assessing a patient with suicidal ideation. Which statement made by the patient requires immediate intervention?
"Sometimes, I just wish all of this would end.".
"I have been feeling really down lately.".
"I've been making a list of things I want to do before I die.".
"I think things might get better if I reach out to my friends.".
The Correct Answer is A
Choice A rationale:
This statement indicates a clear and direct expression of suicidal ideation. The phrase "wish all of this would end" strongly implies a desire for one's life to end, which is a significant concern in assessing a patient with suicidal thoughts. Immediate intervention is necessary to ensure the patient's safety and address their emotional distress.
Choice B rationale:
This statement, "I have been feeling really down lately," expresses a general sense of sadness and low mood. While it suggests emotional distress, it does not explicitly convey a direct intention for self-harm or suicide. However, it should not be ignored and should be explored further during the assessment.
Choice C rationale:
"I've been making a list of things I want to do before I die" is a statement that may have different implications. While it could relate to the patient's interests and goals, it does not necessarily indicate a current intent for suicide. It is important to clarify the context and content of the list before drawing any conclusions.
Choice D rationale:
"I think things might get better if I reach out to my friends" suggests that the patient is considering seeking support from friends, which is generally a positive coping strategy. This statement does not express an immediate risk of self-harm or suicide. However, it's still essential to evaluate the patient's overall emotional state and social support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Identifying and challenging positive thoughts is a cognitive-behavioral strategy that can be beneficial for managing mental health, but it is not the top priority in suicide prevention education. While it contributes to overall emotional well-being, recognizing signs of suicide risk is more directly relevant to preventing self-harm.
Choice B rationale:
Recognizing the signs and symptoms of suicide risk is crucial for early intervention and support. Educating clients and their families about these signs, such as increased isolation, giving away possessions, or talking about death, enables them to identify when someone might be in danger and take appropriate action.
Choice C rationale:
Promoting alcohol consumption as a stress-relieving strategy is inappropriate in a suicide prevention context. Alcohol can exacerbate emotional distress and impair judgment, potentially leading to impulsive behaviors, including self-harm. This choice goes against safe and effective strategies for managing distress.
Choice D rationale:
Encouraging isolation during times of distress is counterproductive and potentially harmful. Isolation can exacerbate feelings of loneliness and hopelessness, increasing the risk of suicidal ideation and actions. Connecting with a support network is a more appropriate recommendation during times of distress.
Correct Answer is C
Explanation
Choice A rationale:
Psychological needs are more important than physiological needs. This statement contradicts Maslow's hierarchy of needs. According to Maslow's theory, physiological needs, such as air, water, food, and shelter, are at the base of the hierarchy and must be satisfied before addressing higher-level psychological needs.
Choice B rationale:
Social isolation takes precedence over impaired coping. While social isolation can indeed have a significant impact on a person's well-being, Maslow's hierarchy places physiological needs as the foundation. Without satisfying basic physiological needs, addressing higher-level psychological and social needs becomes less effective.
Choice C rationale:
Physiological needs are more important than psychological needs. This choice aligns with Maslow's hierarchy of needs. The hierarchy starts with physiological needs as the most fundamental, followed by safety, belongingness and love, esteem, and finally, self-actualization. A person's physiological needs (like breathing, food, water, sleep) must be met before psychological needs (such as self-esteem, achievement) can be effectively addressed.
Choice D rationale:
Grieving is considered the highest priority diagnosis. Grieving, while important, isn't necessarily the highest priority diagnosis according to Maslow's hierarchy. It falls under psychological and emotional needs, which are secondary to physiological needs. Urgent physiological needs take precedence over emotional needs in this context.
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