A nurse is performing a psychosocial assessment on an adolescent client.
Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply)

Choice A rationale:

It's okay to feel scared. Let's talk about what you are afraid of.

Acknowledges the client's feelings: This response directly acknowledges the client's fear and regret, which is a crucial first step in providing emotional support. It validates the client's experience and creates a safe space for open communication.

Invites the client to share: By inviting the client to talk about their fears, the nurse encourages open expression of emotions. This can help the client to process their feelings and gain a sense of control over their situation.

Promotes understanding: By actively listening to the client's concerns, the nurse can gain a better understanding of their individual needs and fears. This understanding can then guide the nurse in providing tailored support and interventions.

Facilitates coping: Talking about fears can help the client to identify and explore coping strategies. The nurse can assist in this process by offering suggestions, providing resources, and teaching relaxation techniques.

Strengthens the nurse-client relationship: By demonstrating empathy, active listening, and support, the nurse can foster a trusting relationship with the client. This relationship can provide a source of comfort and reassurance during a challenging time.

Choice B rationale:

Don't worry. The important thing is you have now quit smoking.

Dismisses the client's feelings: This response minimizes the client's fear and regret, which can be invalidating and hinder emotional expression.

Focuses on the past: While it's important to acknowledge the positive step of quitting smoking, this response shifts the focus away from the client's current emotional state and concerns about the upcoming surgery.

Offers false reassurance: Telling the client not to worry can be unrealistic and unhelpful, as it doesn't address the underlying fears.

Choice C rationale:

Your doctor is a great surgeon. You will be fine.

Provides premature reassurance: While it's appropriate to express confidence in the medical team, this response may not fully address the client's emotional needs. It can also inadvertently downplay the seriousness of the surgery and potential risks.

Shifts focus away from the client: This response focuses on the surgeon's skills rather than the client's feelings and concerns.

Choice D rationale:

I understand your fears. I was a smoker also.

May be perceived as self-focused: While sharing a personal experience can sometimes build rapport, it's important to ensure the focus remains on the client's needs and experiences. This response could inadvertently shift the attention to the nurse's own story.

Does not directly address the client's fears: While expressing understanding can be helpful, it's important to follow up with s and encouragement to explore the client's specific concerns.

Choice A, "Do you think your anxiety is worse than everyone else's?", is invalidating and minimizes the client's experience. Comparing their anxiety to others is unhelpful and could further distress the client.

Choice B, "It doesn't appear as though you are feeling anxious.", is dismissive and ignores the client's self-report. This dismissive response could damage the therapeutic relationship and discourage the client from sharing openly.

Choice D, "I think you should see a therapist and a doctor tomorrow.", is directive and potentially premature. While suggesting mental health resources can be helpful, it's crucial to first understand the client's situation and preferences before making recommendations. Additionally, suggesting both a therapist and a doctor without further assessment might overwhelm the client.

Choice C, "Tell me what has been happening lately.", is an open-ended and validating that encourages the client to share their experiences and concerns. This shows the nurse is actively listening and creates a safe space for the client to explore their anxiety. By understanding the context and potential triggers, the nurse can then provide more tailored support and guidance.

Further rationale for Choice C:

Open-ended s are key tools in therapeutic communication. They promote client engagement, facilitate exploration of thoughts and feelings, and gather valuable information needed for assessment and planning.

Validating the client's experience is crucial in building trust and rapport. Recognizing and acknowledging their anxiety shows the nurse cares and is taking their concerns seriously.

This initial allows the client to guide the conversation, focusing on aspects they feel most comfortable sharing. This empowers the client and promotes autonomy.

Following the client's lead in the conversation also helps the nurse gather specific details about the nature and severity of the anxiety, informing subsequent assessment and intervention strategies.

In conclusion, Choice C, "Tell me what has been happening lately.", is the most appropriate response for a mental health nurse to use when assessing a client who reports an increase in anxiety. It demonstrates active listening, validates the client's experience, encourages engagement, and provides a foundation for further assessment and support.