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.
Administering prescribed antidepressant medication.
Creating a hope box for the client.
Teaching relaxation techniques to the client.
Encouraging social isolation to prevent triggers.
Providing crisis hotline numbers to the client.
Correct Answer : A,B,C,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This statement indicates a clear and direct expression of suicidal ideation. The phrase "wish all of this would end" strongly implies a desire for one's life to end, which is a significant concern in assessing a patient with suicidal thoughts. Immediate intervention is necessary to ensure the patient's safety and address their emotional distress.
Choice B rationale:
This statement, "I have been feeling really down lately," expresses a general sense of sadness and low mood. While it suggests emotional distress, it does not explicitly convey a direct intention for self-harm or suicide. However, it should not be ignored and should be explored further during the assessment.
Choice C rationale:
"I've been making a list of things I want to do before I die" is a statement that may have different implications. While it could relate to the patient's interests and goals, it does not necessarily indicate a current intent for suicide. It is important to clarify the context and content of the list before drawing any conclusions.
Choice D rationale:
"I think things might get better if I reach out to my friends" suggests that the patient is considering seeking support from friends, which is generally a positive coping strategy. This statement does not express an immediate risk of self-harm or suicide. However, it's still essential to evaluate the patient's overall emotional state and social support.
Correct Answer is ["B","D"]
Explanation
Choice B:
Encouraging active patient involvement.
Choice D:
Reflecting the patient's feelings and thoughts.
Choice A rationale:
Closed-ended questions often limit conversation and do not encourage deeper exploration of feelings or thoughts. In a therapeutic relationship with a patient at risk for suicide, the focus should be on open communication and building trust, which is not achieved through the use of closed-ended questions. Therefore, this choice is not suitable for building rapport and trust.
Choice B rationale:
Encouraging active patient involvement is crucial for establishing a therapeutic relationship. It empowers the patient to share their thoughts, concerns, and feelings openly. This choice promotes a sense of collaboration and trust between the nurse and the patient, creating a safe space for discussing sensitive topics like suicidal thoughts.
Choice C rationale:
Imposing personal opinions can create a power imbalance and hinder the therapeutic relationship. Patients should feel that their thoughts and feelings are respected and valued. Imposing personal opinions could alienate the patient and undermine the trust-building process.
Choice D rationale:
Reflecting the patient's feelings and thoughts involves active listening and showing empathy. This technique validates the patient's emotions and experiences, fostering a sense of understanding and trust. Reflecting feelings and thoughts demonstrates that the nurse is genuinely engaged and interested in the patient's perspective.
Choice E rationale:
Disregarding the patient's preferences goes against the principles of patient-centered care and building a therapeutic relationship. The patient's preferences and needs should be acknowledged and respected to establish trust and rapport. Disregarding preferences can lead to feelings of invalidation and hinder the development of a meaningful connection.
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