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 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.

A. Active listening. B. Empowerment. C. Validation. D. Open-ended questions.

Correct Answer is C

Explanation

Choice A rationale:

Active listening. Active listening is an important communication skill that involves attentively hearing and interpreting what the patient is saying. However, it doesn't specifically address the aspect of acknowledging the patient's feelings and thoughts as real and understandable without agreeing or disagreeing.

Choice B rationale:

Empowerment. Empowerment refers to the process of enabling and supporting patients to take control of their own health and make informed decisions. While this is an essential aspect of patient care, it doesn't directly address the skill of acknowledging the patient's feelings and thoughts without expressing agreement or disagreement.

Choice C rationale:

Validation. Validation involves recognizing and accepting the patient's feelings and thoughts as valid, even if you don't share the same perspective. It shows empathy and understanding without passing judgment. In the context of a patient with suicidal ideation, validation is crucial as it helps build trust and rapport, creating an environment where the patient feels heard and supported.

Choice D rationale:

Open-ended questions. Open-ended questions are inquiries that can't be answered with a simple "yes" or "no" and encourage patients to provide more detailed responses. While they are valuable for eliciting information, they don't specifically address the act of acknowledging the patient's feelings and thoughts as real and understandable without taking a stance.

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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 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 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?

Correct Answer is C

Explanation

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

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 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 nurse is working with a client who has suicidal ideation. Which intervention should the nurse implement to promote hope in the client?

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 providing care to a client who is displaying warning signs of suicidal ideation. Which interventions should the nurse prioritize to ensure the client's safety? (Select all that apply.).

A nurse is providing education to a client and their family about suicide prevention. Which information should the nurse prioritize in the education?

A client is being assessed for nursing diagnoses related to suicidal ideation. Which nursing diagnosis prioritization principle should the nurse apply according to Maslow's hierarchy of needs?