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?

The correct answers are A. Expressing hopelessness or worthlessness, C. Increasing alcohol or drug use, D. Talking about wanting to die, and E. Withdrawing or isolating oneself.

Choice A rationale:

Expressing feelings of hopelessness or worthlessness is a significant warning sign of suicide. These feelings often indicate severe emotional distress and a lack of perceived future.

Choice B rationale:

Engaging in positive coping strategies is generally a protective factor against suicide, not a warning sign.

Choice C rationale:

Increasing alcohol or drug use can be a sign of self-medicating to cope with emotional pain, which is a common warning sign of suicidal ideation.

Choice D rationale:

Talking about wanting to die is a direct indicator of suicidal thoughts and should always be taken seriously.

Choice E rationale:

Withdrawing or isolating oneself is a common behavior in individuals contemplating suicide, as they may feel disconnected from others or believe they are a burden.

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.