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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.

Administering prescribed antidepressant medication.

Assisting the client in creating a hope box.

Teaching relaxation techniques to the client.

Encouraging social isolation.

Answer and Explanation

Correct Answer : A,B,C,E

A. Administering prescribed antidepressant medication,
B. Assisting the client in creating a hope box,

C. Teaching relaxation techniques to the client, and E. Providing education about the importance of follow-up care.

Choice A rationale:

Administering prescribed antidepressant medication is an important intervention for a client with suicidal ideation who may be experiencing underlying depression. Antidepressants can help alleviate depressive symptoms, which can contribute to an improved mental state and decreased risk of self-harm.

Choice B rationale:

Assisting the client in creating a hope box is a valuable intervention. A hope box is a collection of items that hold personal significance and provide comfort to the client during times of distress. This intervention encourages the client to focus on positive aspects of their life, fostering hope and resilience.

Choice C rationale:

Teaching relaxation techniques to the client equips them with coping strategies to manage stress and anxiety. These techniques can help the client regulate their emotions and reduce feelings of distress, which are essential for preventing suicidal ideation.

Choice D rationale:

Encouraging social isolation is not appropriate for a client with suicidal ideation. Isolation can exacerbate feelings of loneliness and hopelessness, increasing the risk of self-harm. Instead, promoting social connections and a supportive network can contribute to the client's well-being.

Choice E rationale:

Providing education about the importance of follow-up care is crucial for a client's ongoing well-being. Follow-up care ensures that the client continues to receive necessary support and interventions, reducing the risk of relapse and maintaining their progress toward recovery.

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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.

A. Risk for suicide. B. Ineffective family coping. C. Chronic low self-esteem. D. Altered nutrition. E. Risk for infection.

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.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

(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 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?

(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? Select three.

A client is diagnosed with "Impaired coping." Which statement accurately describes this nursing diagnosis for a patient with suicidal ideation?

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

A nurse is assessing a patient with suicidal ideation. Which step of the nursing process involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system?