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:
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.
Correct Answer is ["B","D"]
Explanation
Choice B:
Encouraging active patient involvement.
Choice D:
Reflecting the patient's feelings and thoughts.
Choice A rationale:
Closed-ended questions often limit conversation and do not encourage deeper exploration of feelings or thoughts. In a therapeutic relationship with a patient at risk for suicide, the focus should be on open communication and building trust, which is not achieved through the use of closed-ended questions. Therefore, this choice is not suitable for building rapport and trust.
Choice B rationale:
Encouraging active patient involvement is crucial for establishing a therapeutic relationship. It empowers the patient to share their thoughts, concerns, and feelings openly. This choice promotes a sense of collaboration and trust between the nurse and the patient, creating a safe space for discussing sensitive topics like suicidal thoughts.
Choice C rationale:
Imposing personal opinions can create a power imbalance and hinder the therapeutic relationship. Patients should feel that their thoughts and feelings are respected and valued. Imposing personal opinions could alienate the patient and undermine the trust-building process.
Choice D rationale:
Reflecting the patient's feelings and thoughts involves active listening and showing empathy. This technique validates the patient's emotions and experiences, fostering a sense of understanding and trust. Reflecting feelings and thoughts demonstrates that the nurse is genuinely engaged and interested in the patient's perspective.
Choice E rationale:
Disregarding the patient's preferences goes against the principles of patient-centered care and building a therapeutic relationship. The patient's preferences and needs should be acknowledged and respected to establish trust and rapport. Disregarding preferences can lead to feelings of invalidation and hinder the development of a meaningful connection.
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