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 B

Explanation

The client has a subjective state with limited personal choices.

Choice A rationale:

The client is at risk for self-inflicted, life-threatening injury. This choice does not accurately define the nursing diagnosis of "Hopelessness." While it is true that hopelessness can lead to self-harm or suicide, the nursing diagnosis focuses on the client's emotional state and personal choices rather than the immediate risk of injury.

Choice B rationale:

The client has a subjective state with limited personal choices. This choice accurately defines the nursing diagnosis of "Hopelessness." Hopelessness refers to the client's emotional state of feeling devoid of hope, often resulting in a perceived lack of personal choices and options. This sense of hopelessness can contribute to feelings of despair and potentially suicidal ideation.

Choice C rationale:

The client is unable to cope with stressors. This choice is not the most accurate definition of "Hopelessness." While hopelessness can certainly impact a client's ability to cope with stressors, the primary focus of the diagnosis is on the subjective emotional state and perceived lack of choices, rather than their coping abilities.

Choice D rationale:

The client experiences compromised family coping. This choice is not directly related to the nursing diagnosis of "Hopelessness." Family coping refers to how a family unit manages stressors together, whereas hopelessness pertains to an individual's emotional state and perceived choices.

A. The client is at risk for self-inflicted, life-threatening injury. B. The client experiences aloneness as a negative or threatening state. C. The client is unable to use appropriate skills to cope with stressors. D. The client has long-standing negative self-evaluation.

Correct Answer is A

Explanation

Choice A rationale:

The nursing diagnosis "Impaired coping" signifies that the client is experiencing difficulty in dealing with stressors and challenges. While it's true that impaired coping can contribute to various negative outcomes, the most critical concern when dealing with a client diagnosed with impaired coping and suicidal ideation is the risk of self-inflicted harm, which aligns with choice A. Clients with impaired coping and suicidal ideation are at a heightened risk for engaging in self-destructive behaviors, including attempts at self-inflicted, life-threatening injury. This choice is the most relevant and urgent, as it directly addresses the potential harm the client may cause to themselves due to their impaired coping skills.

Choice B rationale:

Although feelings of aloneness can contribute to psychological distress and could potentially be relevant to the client's situation, choice B does not directly address the immediate risk of self-inflicted injury associated with impaired coping and suicidal ideation. The focus in this case should be on the client's safety and preventing self-harm.

Choice C rationale:

This choice accurately describes one aspect of impaired coping but does not specifically address the increased risk of self-inflicted harm or the severity of the situation presented in the question. While impaired coping does involve the inability to use appropriate skills to manage stressors, the urgency of addressing the immediate risk of self-inflicted injury takes precedence in this scenario.

Choice D rationale:

Negative self-evaluation may contribute to impaired coping, but the question specifically relates to the client's risk for self-inflicted, life-threatening injury. While negative self-evaluation could be part of the client's overall presentation, it's not the most direct or urgent concern in this situation.

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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 is diagnosed with "Hopelessness." How would the nurse define this nursing diagnosis for a patient with suicidal ideation?

Correct Answer is B

Explanation

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

Correct Answer is A

Explanation

A nurse is assessing a patient with suicidal ideation. Which statement made by the patient requires immediate intervention?

A nurse is caring for a client who has expressed suicidal thoughts. Select all the interventions that the nurse should include in the implementation phase of the client's care.

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

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 nurse is developing a plan of care for a patient with suicidal ideation. Which of the following is a priority principle to consider in the planning phase for this patient's care?

A nurse is providing care to a client with suicidal ideation. Select all the interventions that the nurse should include in the implementation phase of the client's care.

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 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?