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.
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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Naxlex Comprehensive Predictor Exams
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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.
Correct Answer is D
Explanation
Choice D rationale:
Suicidal ideation can be a symptom of various underlying mental health conditions. It is not a diagnosis in itself but rather a manifestation of an individual's thoughts about self-harm or suicide. Suicidal ideation can range from passive thoughts of death to active and detailed plans for self-harm. It is essential for healthcare professionals to recognize and assess suicidal ideation as it can indicate significant distress and potential risk.
Choice A rationale:
Suicidal ideation is not a diagnosis on its own. It is a symptom that indicates emotional or psychological distress. Diagnoses are typically related to specific mental health disorders (e.g., major depressive disorder, borderline personality disorder) that may or may not involve suicidal ideation.
Choice B rationale:
Suicidal ideation is not solely more common in older adults. It can affect individuals of all age groups, including children, adolescents, and adults. While the prevalence and characteristics of suicidal ideation may vary across age groups, it is not accurate to state that it is more common in older adults.
Choice C rationale:
Suicidal ideation does not always involve a detailed plan for self-harm. Suicidal ideation exists on a continuum, ranging from vague thoughts of death to well-formed plans for suicide. Some individuals may experience fleeting thoughts of wanting to die without having a detailed plan, while others may have specific plans and intent.
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