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","D"]
Explanation
The correct answer is B. Reflecting back the patient’s feelings and thoughts and D. Encouraging patient involvement in decision making.
Choice A rationale:
Asking close-ended questions is not effective in building rapport and trust. Close-ended questions can limit the patient’s ability to express their feelings and thoughts, which is crucial in understanding their mental state and providing appropriate support.
Choice B rationale:
Reflecting back the patient’s feelings and thoughts helps in validating their emotions and shows that the nurse is actively listening and empathetic. This technique fosters trust and encourages the patient to open up more about their feelings.
Choice C rationale:
Imposing personal views and opinions can be detrimental to the therapeutic relationship. It can make the patient feel judged or misunderstood, which can hinder open communication and trust.
Choice D rationale:
Encouraging patient involvement in decision making empowers the patient and promotes a sense of control over their situation. This collaborative approach can enhance the therapeutic relationship and support the patient’s autonomy.
Choice E rationale:
Disregarding patient preferences is counterproductive in establishing a therapeutic relationship. It can lead to feelings of disrespect and neglect, which can further isolate the patient and exacerbate their risk.
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Being extroverted is not a common risk factor associated with suicide and suicidal ideation. Extroverted individuals typically have strong social interactions and connections, which are often considered protective factors against suicide.
Choice B rationale:
Having strong family support is not a common risk factor for suicide. In fact, strong family support is generally considered a protective factor that can mitigate the risk of suicidal thoughts and behaviors. Close familial relationships can provide emotional support and a sense of belonging.
Choice C rationale:
Experiencing chronic physical illness is a common risk factor for suicide. Chronic physical illness can lead to prolonged suffering, decreased quality of life, and feelings of hopelessness, which are all associated with an increased risk of suicidal ideation.
Choice D rationale:
Having a history of positive life events is not a common risk factor for suicide. Positive life events are more likely to act as protective factors against suicide, as they contribute to an individual's overall well-being and resilience.
Choice E rationale:
Suffering from a substance use disorder is a common risk factor for suicide. Substance abuse can impair judgment, increase impulsivity, exacerbate emotional distress, and weaken the individual's ability to cope effectively, all of which contribute to an elevated risk of suicidal thoughts and behaviors.
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