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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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

This statement is not accurate. The Columbia-Suicide Severity Rating Scale (C-SSRS) is not focused on assessing suicide-related thoughts and behaviors in the past year. Instead, it is designed to assess the severity of suicidal ideation and behavior over a specified time frame.

Choice B rationale:

This statement is not accurate. The C-SSRS is not a self-report questionnaire for depression and suicidal ideation in the past two weeks. It is a structured interview that involves a series of questions and prompts administered by a trained clinician to assess the severity of suicidal ideation and behavior.

Choice C rationale:

This statement is accurate. The Columbia-Suicide Severity Rating Scale (C-SSRS) guides the evaluation and triage of patients with suicidal ideation or behavior based on five steps: Determining the presence of active suicidal ideation. Assessing the intensity of ideation. Examining the presence and severity of any preparatory behavior. Evaluating the level of intent to die. Determining the lethality of the suicide plan. The C-SSRS is widely used in clinical and research settings to assess suicide risk and guide appropriate interventions.

Choice D rationale:

This statement is not accurate. The C-SSRS does not measure the severity and intensity of suicidal ideation and behavior in the past month. It focuses on assessing the severity of suicidal ideation and behavior based on the steps mentioned in choice C.

A. Advise the client to keep their feelings to themselves. B. Encourage the client to isolate themselves until they feel better. C. Ask the client directly if they are thinking about harming themselves. D. Provide the client with alcohol or drugs to help them cope.

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.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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)?

Correct Answer is C

Explanation

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 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 working with a client who has suicidal ideation. Which intervention should the nurse implement to promote hope in the client?

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?

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.).

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 client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

A client who recently lost their spouse to a terminal illness expresses, "I just can't go on without them. Life feels meaningless now." Which statement by the nurse would be appropriate in this situation?