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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 A

Explanation

Choice A rationale:

This statement reflects a significant red flag for potential suicide risk. The client's acknowledgment of losing their job and perceiving their family would be better off without them suggests feelings of worthlessness and burden. These emotions are associated with an increased risk of self-harm or suicide. Immediate attention and intervention are necessary to address the client's distorted thoughts and emotions.

Choice B rationale:

"I enjoy spending time with my pet dog; it helps me relax" is not an alarming statement related to suicide risk. While it highlights a coping mechanism, it doesn't provide direct insight into the client's emotional state or thoughts about self-harm.

Choice C rationale:

"I have a supportive group of friends who are always there for me" indicates a positive aspect of the client's social support network. This statement does not raise immediate concerns about suicide risk. However, a comprehensive assessment should still explore the client's overall emotional well-being.

Choice D rationale:

"I find it challenging to express my emotions to others" suggests a difficulty in emotional expression, which can be relevant to the assessment but does not inherently indicate imminent suicide risk. It's important to further explore the client's reasons for struggling with emotional expression.

A. Building rapport and trust with the patient. B. Identifying the nursing diagnoses related to suicide risk. C. Developing a plan of care for the patient's needs. D. Evaluating the effectiveness of interventions.

Correct Answer is B

Explanation

Choice A rationale:

Building rapport and trust with the patient. Building rapport and trust is a crucial aspect of the assessment phase, not the diagnosis phase, of the nursing process. While it's important to establish a strong nurse-patient relationship, the primary goal of the diagnosis phase is to identify and define the patient's health problems and needs.

Choice B rationale:

Identifying the nursing diagnoses related to suicide risk. The diagnosis phase involves analyzing the assessment data to identify and define the patient's health issues and needs. In the case of a patient at risk for suicide, it's essential to accurately identify the specific nursing diagnoses related to the suicide risk. This lays the foundation for developing an appropriate plan of care.

Choice C rationale:

Developing a plan of care for the patient's needs. While developing a plan of care is a critical step in the nursing process, it comes after the diagnosis phase. Once nursing diagnoses are identified, the nurse can then proceed to plan interventions and strategies to address the patient's needs.

Choice D rationale:

Evaluating the effectiveness of interventions. Evaluation is the final phase of the nursing process and occurs after interventions have been implemented. It involves determining whether the interventions have been successful in achieving the desired outcomes. The primary goal of the diagnosis phase is to identify the patient's health problems, not to evaluate interventions.

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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 suicide attempts is admitted to the hospital. Which statement by the client should the nurse address during the assessment phase?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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?

A client who recently lost their spouse to a terminal illness expresses, "I just can't go on without them. Life feels meaningless now." Which statement by the nurse would be appropriate in this situation?

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

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.).

(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?

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?

(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.

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.).