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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Dismissing the client's thoughts and labeling them as unhealthy might cause the client to feel judged or reluctant to share further. It's important to approach the situation with openness and empathy.
Choice B rationale:
While it's true that the client's thoughts might pass, this response doesn't address the client's feelings or encourage them to express themselves. It's important to engage in a more in-depth conversation to understand their emotions.
Choice C rationale:
Asking the client to elaborate on their thoughts and experiences opens the door for meaningful conversation and assessment. This response shows genuine interest in the client's well-being and allows the nurse to gather more information to determine the appropriate level of support.
Choice D rationale:
Telling the client that things will get better soon might come across as dismissive of their current struggles. It's important to validate their emotions and explore their feelings further rather than offering premature reassurances.
Correct Answer is D
Explanation
Choice D rationale:
Suicidal ideation can be a symptom of various underlying mental health conditions. It is not a diagnosis in itself but rather a manifestation of an individual's thoughts about self-harm or suicide. Suicidal ideation can range from passive thoughts of death to active and detailed plans for self-harm. It is essential for healthcare professionals to recognize and assess suicidal ideation as it can indicate significant distress and potential risk.
Choice A rationale:
Suicidal ideation is not a diagnosis on its own. It is a symptom that indicates emotional or psychological distress. Diagnoses are typically related to specific mental health disorders (e.g., major depressive disorder, borderline personality disorder) that may or may not involve suicidal ideation.
Choice B rationale:
Suicidal ideation is not solely more common in older adults. It can affect individuals of all age groups, including children, adolescents, and adults. While the prevalence and characteristics of suicidal ideation may vary across age groups, it is not accurate to state that it is more common in older adults.
Choice C rationale:
Suicidal ideation does not always involve a detailed plan for self-harm. Suicidal ideation exists on a continuum, ranging from vague thoughts of death to well-formed plans for suicide. Some individuals may experience fleeting thoughts of wanting to die without having a detailed plan, while others may have specific plans and intent.
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