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

Encourage isolation to minimize potential stressors.

Assist the client in creating a safety plan.

Teach the client relaxation techniques.

Focus solely on the client's past failures.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Encouraging isolation to minimize potential stressors is not a appropriate intervention for a client with suicidal ideation. Isolation can exacerbate feelings of loneliness and hopelessness, which can further contribute to the client's distress.

Choice B rationale:

Assisting the client in creating a safety plan is a crucial intervention for a client with suicidal ideation. A safety plan helps the client identify strategies and resources to use when they experience overwhelming emotions or thoughts of self-harm. This plan provides a sense of control and practical steps to follow during times of crisis, promoting hope that they can manage their emotions and stay safe.

Choice C rationale:

Teaching the client relaxation techniques is a valuable intervention, but it may not directly address the immediate need for a safety plan. Relaxation techniques can be helpful for managing anxiety and stress, but they might not be sufficient to prevent self-harm or suicide attempts.

Choice D rationale:

Focusing solely on the client's past failures is counterproductive and can further erode the client's self-esteem and hope. It's important to focus on the client's strengths, coping skills, and the potential for positive change rather than dwelling on past difficulties.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

Choice A:

Administering prescribed antidepressant medication.

Choice B:

Creating a hope box for the client.

Choice C:

Teaching relaxation techniques to the client.

Choice E:

Providing crisis hotline numbers to the client.

Choice A rationale:

Administering prescribed antidepressant medication. This intervention can be included in the implementation phase of care for a client with expressed suicidal thoughts. Antidepressant medication, when prescribed by a healthcare provider, can help alleviate depressive symptoms and improve the client's overall mental state.

Choice B rationale:

Creating a hope box for the client. Creating a hope box, filled with personal mementos, coping strategies, and reminders of positive experiences, can provide the client with a tangible tool for managing moments of despair. This can contribute to the client's emotional well-being and resilience.

Choice C rationale:

Teaching relaxation techniques to the client. Teaching relaxation techniques, such as deep breathing, mindfulness, or progressive muscle relaxation, can equip the client with coping skills to manage anxiety, stress, and overwhelming emotions. These techniques can be valuable in preventing escalation of suicidal thoughts.

Choice D rationale:

Encouraging social isolation to prevent triggers. This choice is not appropriate for a client with expressed suicidal thoughts. Encouraging social isolation can exacerbate feelings of loneliness and hopelessness, potentially increasing the risk of self-harm. Social support and connection are essential protective factors.

Choice E rationale:

Providing crisis hotline numbers to the client. Supplying crisis hotline numbers ensures that the client has access to immediate support during times of distress. This intervention helps the client reach out for help when needed and promotes safety.

A. "This scale assesses suicide-related thoughts and behaviors in the past year.". B. "This self-report questionnaire screens for depression and suicidal ideation in the past two weeks.". C. "It guides the evaluation and triage of patients with suicidal ideation or behavior based on five steps.". D. "The C-SSRS measures the severity and intensity of suicidal ideation and behavior in the past month.".

Correct Answer is C

Explanation

Choice A rationale:

This statement is not accurate. The Columbia-Suicide Severity Rating Scale (C-SSRS) is not focused on assessing suicide-related thoughts and behaviors in the past year. Instead, it is designed to assess the severity of suicidal ideation and behavior over a specified time frame.

Choice B rationale:

This statement is not accurate. The C-SSRS is not a self-report questionnaire for depression and suicidal ideation in the past two weeks. It is a structured interview that involves a series of questions and prompts administered by a trained clinician to assess the severity of suicidal ideation and behavior.

Choice C rationale:

This statement is accurate. The Columbia-Suicide Severity Rating Scale (C-SSRS) guides the evaluation and triage of patients with suicidal ideation or behavior based on five steps: Determining the presence of active suicidal ideation. Assessing the intensity of ideation. Examining the presence and severity of any preparatory behavior. Evaluating the level of intent to die. Determining the lethality of the suicide plan. The C-SSRS is widely used in clinical and research settings to assess suicide risk and guide appropriate interventions.

Choice D rationale:

This statement is not accurate. The C-SSRS does not measure the severity and intensity of suicidal ideation and behavior in the past month. It focuses on assessing the severity of suicidal ideation and behavior based on the steps mentioned in choice C.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has expressed suicidal thoughts. Select all the interventions that the nurse should include in the implementation phase of the client's care.

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is assessing a patient's suicide risk using standardized tools. Which statement is accurate regarding the Columbia-Suicide Severity Rating Scale (C-SSRS)?

Correct Answer is C

Explanation

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 evaluating the effectiveness of the plan of care for a patient with suicidal ideation. What action should the nurse take during the evaluation phase?

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 all that apply):

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

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?

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.).

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?