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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
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.
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