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:
Leaving the client alone to give them space is not a suitable intervention for someone with a history of suicide attempts and depression. Isolation can increase the risk of acting on suicidal thoughts, and the client needs close monitoring and support during this vulnerable time.
Choice B rationale:
Removing any potential means of self-harm from the client's environment is essential. This intervention helps reduce the immediate risk by limiting access to harmful items. It's a crucial step in creating a safer environment for the client and preventing impulsive acts of self-harm.
Choice C rationale:
Encouraging the client to confront their feelings of hopelessness is important, but it should be done in a supportive and therapeutic manner. Simply telling someone to confront their feelings without appropriate guidance can be overwhelming and unproductive.
Choice D rationale:
Telling the client that they should be grateful for what they have minimizes their emotional experience and does not address the complexity of depression and suicidal ideation. This statement lacks empathy and understanding of the client's struggles.
Correct Answer is C
Explanation
Choice A rationale:
The importance of isolation during times of distress is not accurate information. Isolation can exacerbate feelings of loneliness and hopelessness, potentially increasing the risk of suicidal thoughts. Encouraging isolation can prevent individuals from seeking help and support when they need it the most.
Choice B rationale:
The role of faith healing in preventing suicidal thoughts is not a universally applicable solution. While faith and spirituality can provide comfort and support to some individuals, it's important to recognize that suicide prevention requires a comprehensive approach that often involves professional intervention and evidence-based strategies. Relying solely on faith healing may neglect other important aspects of mental health care.
Choice C rationale:
Crisis hotline numbers, such as the National Suicide Prevention Lifeline, are crucial resources for individuals in crisis. These hotlines provide immediate access to trained professionals who can offer support, intervention, and referrals to mental health services. Sharing these hotline numbers empowers the client's family to take proactive steps in seeking help during times of crisis.
Choice D rationale:
The necessity of solving all life problems before seeking help is an unrealistic expectation. Mental health challenges, including suicidal thoughts, do not always correlate with external life problems. Waiting until all problems are solved could delay necessary intervention and support. It's essential to encourage seeking help early, even if all problems cannot be immediately resolved.
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