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 ["B","D"]

Explanation

The correct answer is B. Reflecting back the patient’s feelings and thoughts and D. Encouraging patient involvement in decision making.

Choice A rationale:

Asking close-ended questions is not effective in building rapport and trust. Close-ended questions can limit the patient’s ability to express their feelings and thoughts, which is crucial in understanding their mental state and providing appropriate support.

Choice B rationale:

Reflecting back the patient’s feelings and thoughts helps in validating their emotions and shows that the nurse is actively listening and empathetic. This technique fosters trust and encourages the patient to open up more about their feelings.

Choice C rationale:

Imposing personal views and opinions can be detrimental to the therapeutic relationship. It can make the patient feel judged or misunderstood, which can hinder open communication and trust.

Choice D rationale:

Encouraging patient involvement in decision making empowers the patient and promotes a sense of control over their situation. This collaborative approach can enhance the therapeutic relationship and support the patient’s autonomy.

Choice E rationale:

Disregarding patient preferences is counterproductive in establishing a therapeutic relationship. It can lead to feelings of disrespect and neglect, which can further isolate the patient and exacerbate their risk.

A. Psychological needs are more important than physiological needs. B. Social isolation takes precedence over impaired coping. C. Physiological needs are more important than psychological needs. D. Grieving is considered the highest priority diagnosis.

Correct Answer is C

Explanation

Choice A rationale:

Psychological needs are more important than physiological needs. This statement contradicts Maslow's hierarchy of needs. According to Maslow's theory, physiological needs, such as air, water, food, and shelter, are at the base of the hierarchy and must be satisfied before addressing higher-level psychological needs.

Choice B rationale:

Social isolation takes precedence over impaired coping. While social isolation can indeed have a significant impact on a person's well-being, Maslow's hierarchy places physiological needs as the foundation. Without satisfying basic physiological needs, addressing higher-level psychological and social needs becomes less effective.

Choice C rationale:

Physiological needs are more important than psychological needs. This choice aligns with Maslow's hierarchy of needs. The hierarchy starts with physiological needs as the most fundamental, followed by safety, belongingness and love, esteem, and finally, self-actualization. A person's physiological needs (like breathing, food, water, sleep) must be met before psychological needs (such as self-esteem, achievement) can be effectively addressed.

Choice D rationale:

Grieving is considered the highest priority diagnosis. Grieving, while important, isn't necessarily the highest priority diagnosis according to Maslow's hierarchy. It falls under psychological and emotional needs, which are secondary to physiological needs. Urgent physiological needs take precedence over emotional needs in this context.

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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 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?

Correct Answer is ["B","D"]

Explanation

A client is being assessed for nursing diagnoses related to suicidal ideation. Which nursing diagnosis prioritization principle should the nurse apply according to Maslow's hierarchy of needs?

Correct Answer is C

Explanation

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?

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 assessing a client for potential suicidal ideation. The client says, "I've been thinking a lot about death lately. I wonder what it's like to not exist anymore." What would be an appropriate response by the nurse?

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 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 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?

(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 providing education to a client and their family about suicide prevention. Which information should the nurse prioritize in the education?