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.
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 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.
Correct Answer is B
Explanation
Choice A rationale:
Telling the client that they shouldn't feel a certain way and suggesting that others care about them minimizes their emotions and can be invalidating. It's essential to acknowledge the client's feelings without dismissing them.
Choice B rationale:
Expressing understanding and acknowledging the overwhelming nature of grief is appropriate and empathetic. This response validates the client's emotions and creates a safe space for them to express their feelings.
Choice C rationale:
While the intention behind encouraging the client to stay strong for their children might be positive, it oversimplifies the complexity of grief and emotional responses. Grief is a personal experience, and implying that they should suppress their emotions for the sake of others is not ideal.
Choice D rationale:
Suggesting that the client avoid thinking about their loss or that time will heal their wounds can invalidate their current emotional state. Grief doesn't always follow a linear path, and minimizing the impact of the loss can hinder the client's healing process.
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