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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 B

Explanation

The client has a subjective state with limited personal choices.

Choice A rationale:

The client is at risk for self-inflicted, life-threatening injury. This choice does not accurately define the nursing diagnosis of "Hopelessness." While it is true that hopelessness can lead to self-harm or suicide, the nursing diagnosis focuses on the client's emotional state and personal choices rather than the immediate risk of injury.

Choice B rationale:

The client has a subjective state with limited personal choices. This choice accurately defines the nursing diagnosis of "Hopelessness." Hopelessness refers to the client's emotional state of feeling devoid of hope, often resulting in a perceived lack of personal choices and options. This sense of hopelessness can contribute to feelings of despair and potentially suicidal ideation.

Choice C rationale:

The client is unable to cope with stressors. This choice is not the most accurate definition of "Hopelessness." While hopelessness can certainly impact a client's ability to cope with stressors, the primary focus of the diagnosis is on the subjective emotional state and perceived lack of choices, rather than their coping abilities.

Choice D rationale:

The client experiences compromised family coping. This choice is not directly related to the nursing diagnosis of "Hopelessness." Family coping refers to how a family unit manages stressors together, whereas hopelessness pertains to an individual's emotional state and perceived choices.

A. Advise the client to keep their feelings to themselves. B. Encourage the client to isolate themselves until they feel better. C. Ask the client directly if they are thinking about harming themselves. D. Provide the client with alcohol or drugs to help them cope.

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.

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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 is diagnosed with "Hopelessness." How would the nurse define this nursing diagnosis for a patient with suicidal ideation?

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?

Correct Answer is C

Explanation

(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 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 teaching a client's family about suicide prevention. What information should the nurse emphasize when discussing resources for help and support?

A nurse is working with a client who has suicidal ideation. Which intervention should the nurse implement to promote hope in the client?

A nurse is developing a plan of care for a patient with suicidal ideation. Which of the following is a priority principle to consider in the planning phase for this patient's care?

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 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?

(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.