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 C

Explanation

Choice A rationale:

Advising the client to keep their feelings to themselves is not an appropriate intervention in this situation. Suicidal ideation is a serious concern, and keeping feelings hidden could potentially lead to the client not receiving the necessary support and intervention they need to stay safe.

Choice B rationale:

Encouraging the client to isolate themselves until they feel better is not an appropriate intervention either. Isolation can exacerbate feelings of hopelessness and increase the risk of acting on suicidal thoughts. Connecting with the client and providing a supportive environment is crucial.

Choice C rationale:

Asking the client directly if they are thinking about harming themselves is the most appropriate intervention. This approach helps the nurse assess the severity of the situation, open a dialogue about the client's feelings, and determine the level of risk. Direct communication allows for a better understanding of the client's mental state and the need for further intervention.

Choice D rationale:

Providing the client with alcohol or drugs to help them cope is a dangerous and inappropriate intervention. Substance use can further impair judgment and increase the risk of acting on suicidal thoughts. This action also fails to address the underlying issues contributing to the client's distress.

A. Administering prescribed antidepressant medication. B. Creating a hope box for the client. C. Teaching relaxation techniques to the client. D. Encouraging social isolation to prevent triggers. E. Providing crisis hotline numbers to the client.

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

Explanation

Choice A:

Administering prescribed antidepressant medication.

Choice B:

Creating a hope box for the client.

Choice C:

Teaching relaxation techniques to the client.

Choice E:

Providing crisis hotline numbers to the client.

Choice A rationale:

Administering prescribed antidepressant medication. This intervention can be included in the implementation phase of care for a client with expressed suicidal thoughts. Antidepressant medication, when prescribed by a healthcare provider, can help alleviate depressive symptoms and improve the client's overall mental state.

Choice B rationale:

Creating a hope box for the client. Creating a hope box, filled with personal mementos, coping strategies, and reminders of positive experiences, can provide the client with a tangible tool for managing moments of despair. This can contribute to the client's emotional well-being and resilience.

Choice C rationale:

Teaching relaxation techniques to the client. Teaching relaxation techniques, such as deep breathing, mindfulness, or progressive muscle relaxation, can equip the client with coping skills to manage anxiety, stress, and overwhelming emotions. These techniques can be valuable in preventing escalation of suicidal thoughts.

Choice D rationale:

Encouraging social isolation to prevent triggers. This choice is not appropriate for a client with expressed suicidal thoughts. Encouraging social isolation can exacerbate feelings of loneliness and hopelessness, potentially increasing the risk of self-harm. Social support and connection are essential protective factors.

Choice E rationale:

Providing crisis hotline numbers to the client. Supplying crisis hotline numbers ensures that the client has access to immediate support during times of distress. This intervention helps the client reach out for help when needed and promotes 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 with a history of substance use disorder and recent job loss is exhibiting signs of suicidal ideation. Which nursing intervention is most appropriate in this situation?

Correct Answer is C

Explanation

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.

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

Explanation

A nurse is conducting an assessment of a client who may be at risk for suicide. Which of the following are common risk factors associated with suicide and suicidal ideation? (Select All That Apply):

A nurse is assessing a patient's suicide risk using standardized tools. Which statement is accurate regarding the Columbia-Suicide Severity Rating Scale (C-SSRS)?

A nurse is conducting an assessment for a patient with suicidal ideation. Which skill involves acknowledging the patient's feelings and thoughts as real and understandable without agreeing or disagreeing with them?

A nurse is assessing a client for potential suicidal ideation. The client says, "I've been thinking a lot about death lately. I wonder what it's like to not exist anymore." What would be an appropriate response by the nurse?

A nurse is educating a group of teenagers about warning signs of suicide. Which of the following signs should the nurse emphasize as potential indicators of suicidal ideation? (Select three.).

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

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

(Select All That Apply): A client has expressed thoughts of suicide during a therapy session. Which therapeutic interventions should the nurse incorporate into the client's care plan? (Select three.).