A nurse is evaluating the effectiveness of the plan of care for a patient with suicidal ideation. What action should the nurse take during the evaluation phase?

Modify the plan of care based on the patient's current status.

Compare the patient's current status with baseline data only.

Disregard the patient's feedback about their care.

Document outcomes without assessing the patient's response.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Modifying the plan of care based on the patient's current status is a fundamental aspect of the evaluation phase. Patients' conditions can change, and the plan of care should be flexible enough to adapt to their evolving needs. By making necessary adjustments, the nurse ensures that the patient continues to receive appropriate and effective care.

Choice B rationale:

Comparing the patient's current status with baseline data only is insufficient for a comprehensive evaluation. Baseline data is useful for establishing a starting point, but it doesn't account for changes that may have occurred since then. Effective evaluation involves considering both baseline data and the patient's current condition.

Choice C rationale:

Disregarding the patient's feedback about their care is not appropriate during the evaluation phase. Patient feedback provides valuable insights into their experience, concerns, and whether the current plan of care is meeting their needs. Ignoring their feedback can lead to unaddressed issues and a lack of patient-centered care.

Choice D rationale:

Documenting outcomes without assessing the patient's response undermines the purpose of the evaluation phase. Evaluation involves not only documenting outcomes but also assessing how the patient has responded to interventions. This assessment informs whether the outcomes are positive, need adjustment, or require a different approach.

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

Explanation

Choice A:

Risk for suicide.

Choice B:

Ineffective family coping.

Choice C:

Chronic low self-esteem.

Choice A rationale:

This choice aligns with the primary concern of the patient being at risk for suicide, which is the focus of the assessment. Identifying this diagnosis is crucial for implementing appropriate interventions to ensure the patient's safety.

Choice B rationale:

Ineffective family coping could contribute to the patient's stressors and emotional state. It's relevant because the support system plays a significant role in a patient's mental health. However, it might not be as immediate a concern as the risk for suicide itself.

Choice C rationale:

Chronic low self-esteem is relevant to the patient's overall mental health and might contribute to their suicidal ideation. However, it might not directly address the immediate risk and urgency of the situation compared to the diagnosis of "Risk for suicide."

Choice D rationale:

Altered nutrition and risk for infection are not directly related to the primary concern of suicidal ideation and the associated nursing diagnoses. While they may be aspects of the patient's overall health, they are not the most pertinent concerns when addressing the risk of suicide.

A. Encourage isolation to minimize potential stressors. B. Assist the client in creating a safety plan. C. Teach the client relaxation techniques. D. Focus solely on the client's past failures.

Correct Answer is B

Explanation

Choice A rationale:

Encouraging isolation to minimize potential stressors is not a appropriate intervention for a client with suicidal ideation. Isolation can exacerbate feelings of loneliness and hopelessness, which can further contribute to the client's distress.

Choice B rationale:

Assisting the client in creating a safety plan is a crucial intervention for a client with suicidal ideation. A safety plan helps the client identify strategies and resources to use when they experience overwhelming emotions or thoughts of self-harm. This plan provides a sense of control and practical steps to follow during times of crisis, promoting hope that they can manage their emotions and stay safe.

Choice C rationale:

Teaching the client relaxation techniques is a valuable intervention, but it may not directly address the immediate need for a safety plan. Relaxation techniques can be helpful for managing anxiety and stress, but they might not be sufficient to prevent self-harm or suicide attempts.

Choice D rationale:

Focusing solely on the client's past failures is counterproductive and can further erode the client's self-esteem and hope. It's important to focus on the client's strengths, coping skills, and the potential for positive change rather than dwelling on past difficulties.

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A nurse is evaluating the effectiveness of the plan of care for a patient with suicidal ideation. What action should the nurse take during the evaluation phase?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

(Select all that apply): A nurse is analyzing data collected during the assessment phase for a patient at risk for suicide. Which of the following nursing diagnoses are commonly associated with suicidal ideation? Select three.

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

Explanation

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

Correct Answer is B

Explanation

A nurse is providing care to a client who is displaying warning signs of suicidal ideation. Which interventions should the nurse prioritize to ensure the client's safety? (Select all that apply.).

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.

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 analyzing data collected during the assessment phase for a patient at risk for suicide. What is the primary goal of the diagnosis phase in the nursing process?

A nurse is teaching a client's family about suicide prevention. What information should the nurse emphasize when discussing resources for help and support?

A nurse is providing care to a client with suicidal ideation. Select all the interventions that the nurse should include in the implementation phase of the client's care.

A nurse is establishing a therapeutic relationship with a patient at risk for suicide. Which of the following skills should the nurse use to build rapport and trust with the patient? (Select all that apply):

A nurse is caring for a client who recently attempted suicide and is now stabilized. What is a priority nursing goal for this client?