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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
Engaging in team sports is generally a positive activity and does not typically indicate suicidal ideation. While team sports can have mental health benefits, it is important to focus on the other signs that are more strongly associated with potential suicide risk.
Choice B rationale:
Expressing feelings of hopelessness is a significant warning sign of suicidal ideation. When individuals consistently express a sense of hopelessness, it could indicate that they feel trapped in their current situation and may be contemplating suicide as a way out.
Choice C rationale:
Withdrawing from social activities is a red flag for potential suicidal ideation. Social withdrawal can be indicative of a lack of interest in activities once enjoyed, a desire to isolate oneself, and an increased sense of loneliness and isolation, all of which are concerning signs.
Choice D rationale:
Demonstrating good academic performance is generally not a strong indicator of suicidal ideation. It's important to consider other emotional and behavioral signs that are more closely related to mental distress.
Choice E rationale:
Participating in creative hobbies can be a warning sign of suicidal ideation, especially if there is a sudden loss of interest in activities that the person used to enjoy. Creative hobbies may serve as an outlet for emotions, and a decrease in engagement could signal emotional turmoil.
Correct Answer is ["A","B","C"]
Explanation
Choice A:
Risk for suicide.
Choice B:
Ineffective family coping.
Choice C:
Chronic low self-esteem.
Choice A rationale:
This choice aligns with the primary concern of the patient being at risk for suicide, which is the focus of the assessment. Identifying this diagnosis is crucial for implementing appropriate interventions to ensure the patient's safety.
Choice B rationale:
Ineffective family coping could contribute to the patient's stressors and emotional state. It's relevant because the support system plays a significant role in a patient's mental health. However, it might not be as immediate a concern as the risk for suicide itself.
Choice C rationale:
Chronic low self-esteem is relevant to the patient's overall mental health and might contribute to their suicidal ideation. However, it might not directly address the immediate risk and urgency of the situation compared to the diagnosis of "Risk for suicide."
Choice D rationale:
Altered nutrition and risk for infection are not directly related to the primary concern of suicidal ideation and the associated nursing diagnoses. While they may be aspects of the patient's overall health, they are not the most pertinent concerns when addressing the risk of suicide.
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