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 ["A","C","D","E"]

Explanation

The correct answers are A. Expressing hopelessness or worthlessness, C. Increasing alcohol or drug use, D. Talking about wanting to die, and E. Withdrawing or isolating oneself.

Choice A rationale:

Expressing feelings of hopelessness or worthlessness is a significant warning sign of suicide. These feelings often indicate severe emotional distress and a lack of perceived future.

Choice B rationale:

Engaging in positive coping strategies is generally a protective factor against suicide, not a warning sign.

Choice C rationale:

Increasing alcohol or drug use can be a sign of self-medicating to cope with emotional pain, which is a common warning sign of suicidal ideation.

Choice D rationale:

Talking about wanting to die is a direct indicator of suicidal thoughts and should always be taken seriously.

Choice E rationale:

Withdrawing or isolating oneself is a common behavior in individuals contemplating suicide, as they may feel disconnected from others or believe they are a burden.

A. Monitoring the client's access to lethal means. B. Encouraging the client to isolate themselves for self-reflection. C. Providing the client with a detailed plan for coping. D. Collaborating with the client's family and friends. E. Administering sedative medications to keep the client calm.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is A. Monitoring the client’s access to lethal means, C. Providing the client with a detailed plan for coping, and D. Collaborating with the client’s family and friends.

Choice A rationale:

Monitoring the client’s access to lethal means is crucial to prevent any immediate risk of self-harm. This includes removing or securing items that could be used for suicide, such as medications, sharp objects, or firearms.

Choice B rationale:

Encouraging the client to isolate themselves for self-reflection is not advisable. Isolation can increase feelings of loneliness and hopelessness, which may exacerbate suicidal ideation.

Choice C rationale:

Providing the client with a detailed plan for coping helps them manage their thoughts and emotions more effectively. This plan can include strategies for dealing with stress, identifying triggers, and knowing when and how to seek help.

Choice D rationale:

Collaborating with the client’s family and friends is essential for creating a support network. Involving loved ones can provide the client with emotional support and help monitor their well-being.

Choice E rationale:

Administering sedative medications to keep the client calm is not a primary intervention for suicidal ideation. While medication may be part of a broader treatment plan, it should not be the sole strategy for ensuring safety.

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

Correct Answer is ["A","C","D","E"]

Explanation

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.).

Correct Answer is ["A","C","D"]

Explanation

A client is diagnosed with "Impaired coping." Which statement accurately describes this nursing diagnosis for a patient with suicidal ideation?

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