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 D
Explanation
Collaborate with the patient and the healthcare team.
Choice A rationale:
Prioritize long-term goals over short-term outcomes. This choice is not the most appropriate principle to consider in the planning phase for a patient with suicidal ideation. While setting long-term goals is important, immediate safety and addressing the patient's emotional state take precedence in this situation.
Choice B rationale:
Develop a rigid and unchangeable plan of care. This choice is not suitable for a patient with suicidal ideation. Flexibility in the plan of care is essential to accommodate the patient's changing emotional state and needs. A rigid plan might not effectively address the dynamic nature of suicidal ideation.
Choice C rationale:
Focus only on the patient's physical health. This choice is not comprehensive enough for a patient with suicidal ideation. While physical health is important, addressing the patient's emotional well-being, safety, and mental health concerns should be a priority in the plan of care.
Choice D rationale:
Collaborate with the patient and the healthcare team. This choice is the most appropriate principle to consider. Collaboration involves actively involving the patient in the care planning process and working with the healthcare team to develop a holistic plan that addresses the patient's emotional, psychological, and safety needs. Inclusion of the patient's perspective enhances engagement and increases the likelihood of successful interventions.
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Being extroverted is not a common risk factor associated with suicide and suicidal ideation. Extroverted individuals typically have strong social interactions and connections, which are often considered protective factors against suicide.
Choice B rationale:
Having strong family support is not a common risk factor for suicide. In fact, strong family support is generally considered a protective factor that can mitigate the risk of suicidal thoughts and behaviors. Close familial relationships can provide emotional support and a sense of belonging.
Choice C rationale:
Experiencing chronic physical illness is a common risk factor for suicide. Chronic physical illness can lead to prolonged suffering, decreased quality of life, and feelings of hopelessness, which are all associated with an increased risk of suicidal ideation.
Choice D rationale:
Having a history of positive life events is not a common risk factor for suicide. Positive life events are more likely to act as protective factors against suicide, as they contribute to an individual's overall well-being and resilience.
Choice E rationale:
Suffering from a substance use disorder is a common risk factor for suicide. Substance abuse can impair judgment, increase impulsivity, exacerbate emotional distress, and weaken the individual's ability to cope effectively, all of which contribute to an elevated risk of suicidal thoughts and behaviors.
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