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","C","E"]
Explanation
Choice A rationale:
Engaging in team sports is generally a positive activity and does not typically indicate suicidal ideation. While team sports can have mental health benefits, it is important to focus on the other signs that are more strongly associated with potential suicide risk.
Choice B rationale:
Expressing feelings of hopelessness is a significant warning sign of suicidal ideation. When individuals consistently express a sense of hopelessness, it could indicate that they feel trapped in their current situation and may be contemplating suicide as a way out.
Choice C rationale:
Withdrawing from social activities is a red flag for potential suicidal ideation. Social withdrawal can be indicative of a lack of interest in activities once enjoyed, a desire to isolate oneself, and an increased sense of loneliness and isolation, all of which are concerning signs.
Choice D rationale:
Demonstrating good academic performance is generally not a strong indicator of suicidal ideation. It's important to consider other emotional and behavioral signs that are more closely related to mental distress.
Choice E rationale:
Participating in creative hobbies can be a warning sign of suicidal ideation, especially if there is a sudden loss of interest in activities that the person used to enjoy. Creative hobbies may serve as an outlet for emotions, and a decrease in engagement could signal emotional turmoil.
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.
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