A nurse is assessing a patient with suicidal ideation. Which step of the nursing process involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system?

Diagnosis.

Planning.

Implementation.

Evaluation.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

In the nursing process, the step of diagnosis involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system. This step is critical in identifying the patient's current condition, problems, and needs. By assessing these aspects, the nurse can accurately diagnose the patient's situation and develop an appropriate care plan. Suicide risk assessment is an essential component of this step, as it helps determine the severity of the patient's ideation and potential for harm.

Choice B rationale:

Planning is the phase of the nursing process where the nurse, in collaboration with the patient, sets goals and develops a strategy to address the identified problems. While planning does involve considering the patient's suicide risk assessment, it primarily focuses on outlining interventions and actions to achieve the desired outcomes. It does not encompass the comprehensive data collection and assessment of the patient's mental and physical health status that are central to the diagnosis phase.

Choice C rationale:

Implementation is the stage in the nursing process where the nurse carries out the planned interventions and treatments. It involves executing the care plan that was developed during the planning phase. While suicide risk factors and protective factors may influence the choice of interventions, implementation itself does not encompass the data collection and assessment aspects required to fully evaluate the patient's condition.

Choice D rationale:

Evaluation is the final step of the nursing process, during which the nurse assesses the effectiveness of the interventions and evaluates the patient's progress toward achieving the established goals. It involves comparing the patient's current status with the expected outcomes and making necessary adjustments to the care plan. While suicide risk assessment may play a role in evaluating the patient's response to interventions, it is not the primary focus of the evaluation phase, which is centered around the assessment of treatment outcomes.

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Correct Answer is D

Explanation

Choice D rationale:

Suicidal ideation can be a symptom of various underlying mental health conditions. It is not a diagnosis in itself but rather a manifestation of an individual's thoughts about self-harm or suicide. Suicidal ideation can range from passive thoughts of death to active and detailed plans for self-harm. It is essential for healthcare professionals to recognize and assess suicidal ideation as it can indicate significant distress and potential risk.

Choice A rationale:

Suicidal ideation is not a diagnosis on its own. It is a symptom that indicates emotional or psychological distress. Diagnoses are typically related to specific mental health disorders (e.g., major depressive disorder, borderline personality disorder) that may or may not involve suicidal ideation.

Choice B rationale:

Suicidal ideation is not solely more common in older adults. It can affect individuals of all age groups, including children, adolescents, and adults. While the prevalence and characteristics of suicidal ideation may vary across age groups, it is not accurate to state that it is more common in older adults.

Choice C rationale:

Suicidal ideation does not always involve a detailed plan for self-harm. Suicidal ideation exists on a continuum, ranging from vague thoughts of death to well-formed plans for suicide. Some individuals may experience fleeting thoughts of wanting to die without having a detailed plan, while others may have specific plans and intent.

A. Advise the client to keep their feelings to themselves. B. Encourage the client to isolate themselves until they feel better. C. Ask the client directly if they are thinking about harming themselves. D. Provide the client with alcohol or drugs to help them cope.

Correct Answer is C

Explanation

Choice A rationale:

Advising the client to keep their feelings to themselves is not an appropriate intervention in this situation. Suicidal ideation is a serious concern, and keeping feelings hidden could potentially lead to the client not receiving the necessary support and intervention they need to stay safe.

Choice B rationale:

Encouraging the client to isolate themselves until they feel better is not an appropriate intervention either. Isolation can exacerbate feelings of hopelessness and increase the risk of acting on suicidal thoughts. Connecting with the client and providing a supportive environment is crucial.

Choice C rationale:

Asking the client directly if they are thinking about harming themselves is the most appropriate intervention. This approach helps the nurse assess the severity of the situation, open a dialogue about the client's feelings, and determine the level of risk. Direct communication allows for a better understanding of the client's mental state and the need for further intervention.

Choice D rationale:

Providing the client with alcohol or drugs to help them cope is a dangerous and inappropriate intervention. Substance use can further impair judgment and increase the risk of acting on suicidal thoughts. This action also fails to address the underlying issues contributing to the client's distress.

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A nurse is assessing a patient with suicidal ideation. Which step of the nursing process involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a group of healthcare professionals about suicide and suicidal ideation. Which of the following statements accurately describes suicidal ideation?

Correct Answer is D

Explanation

A client with a history of substance use disorder and recent job loss is exhibiting signs of suicidal ideation. Which nursing intervention is most appropriate in this situation?

Correct Answer is C

Explanation

A client with a history of suicide attempts is admitted to the hospital. Which statement by the client should the nurse address during the assessment phase?

A client has expressed suicidal thoughts to the nurse. Select all the warning signs for suicide that the nurse should be aware of.

A nurse is teaching a client's family about suicide prevention. What information should the nurse emphasize when discussing resources for help and support?

(Select all that apply): A nurse is analyzing data collected during the assessment phase for a patient at risk for suicide. Which of the following nursing diagnoses are commonly associated with suicidal ideation? Select three.

A nurse is conducting an assessment for a patient with suicidal ideation. Which skill involves acknowledging the patient's feelings and thoughts as real and understandable without agreeing or disagreeing with them?

(Select All That Apply): A client has expressed thoughts of suicide during a therapy session. Which therapeutic interventions should the nurse incorporate into the client's care plan? (Select three.).

A nurse is evaluating the effectiveness of the plan of care for a patient with suicidal ideation. What action should the nurse take during the evaluation phase?

A nurse is assessing a patient's suicide risk using standardized tools. Which statement is accurate regarding the Columbia-Suicide Severity Rating Scale (C-SSRS)?