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.).

Monitoring the client's access to lethal means.

Encouraging the client to isolate themselves for self-reflection.

Providing the client with a detailed plan for coping.

Collaborating with the client's family and friends.

Administering sedative medications to keep the client calm.

Answer and Explanation

Correct Answer : A,C,D

The correct answer is A. Monitoring the client’s access to lethal means, C. Providing the client with a detailed plan for coping, and D. Collaborating with the client’s family and friends.

Choice A rationale:

Monitoring the client’s access to lethal means is crucial to prevent any immediate risk of self-harm. This includes removing or securing items that could be used for suicide, such as medications, sharp objects, or firearms.

Choice B rationale:

Encouraging the client to isolate themselves for self-reflection is not advisable. Isolation can increase feelings of loneliness and hopelessness, which may exacerbate suicidal ideation.

Choice C rationale:

Providing the client with a detailed plan for coping helps them manage their thoughts and emotions more effectively. This plan can include strategies for dealing with stress, identifying triggers, and knowing when and how to seek help.

Choice D rationale:

Collaborating with the client’s family and friends is essential for creating a support network. Involving loved ones can provide the client with emotional support and help monitor their well-being.

Choice E rationale:

Administering sedative medications to keep the client calm is not a primary intervention for suicidal ideation. While medication may be part of a broader treatment plan, it should not be the sole strategy for ensuring safety.

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

Explanation

Choice A:

Risk for suicide.

Choice B:

Ineffective family coping.

Choice C:

Chronic low self-esteem.

Choice A rationale:

This choice aligns with the primary concern of the patient being at risk for suicide, which is the focus of the assessment. Identifying this diagnosis is crucial for implementing appropriate interventions to ensure the patient's safety.

Choice B rationale:

Ineffective family coping could contribute to the patient's stressors and emotional state. It's relevant because the support system plays a significant role in a patient's mental health. However, it might not be as immediate a concern as the risk for suicide itself.

Choice C rationale:

Chronic low self-esteem is relevant to the patient's overall mental health and might contribute to their suicidal ideation. However, it might not directly address the immediate risk and urgency of the situation compared to the diagnosis of "Risk for suicide."

Choice D rationale:

Altered nutrition and risk for infection are not directly related to the primary concern of suicidal ideation and the associated nursing diagnoses. While they may be aspects of the patient's overall health, they are not the most pertinent concerns when addressing the risk of suicide.

A. Exploring the client's feelings and thoughts about suicide. B. Developing a safety plan with the client. C. Avoiding any discussion of suicide to prevent negative feelings. D. Instructing the client to suppress their emotions. E. Identifying the client's support systems and resources.

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

Explanation

Choice A rationale:

Exploring the client's feelings and thoughts about suicide is crucial to understanding their perspective, emotions, and reasons behind their thoughts. Openly discussing these feelings can help the client feel understood and validated, fostering a therapeutic relationship and potentially reducing their distress.

Choice B rationale:

Developing a safety plan with the client is essential. A safety plan outlines strategies the client can use when they experience suicidal thoughts or overwhelming emotions. It includes steps to manage their emotions, reach out for support, and avoid harmful behaviors. Having a concrete plan in place empowers the client to take control of their safety.

Choice E rationale:

Identifying the client's support systems and resources is important for their recovery. Building a network of people who can offer emotional support, as well as identifying professional resources such as therapists or support groups, can enhance the client's coping mechanisms and reduce feelings of isolation.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

(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.

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

Explanation

(Select All That Apply): A client has expressed thoughts of suicide during a therapy session. Which therapeutic interventions should the nurse incorporate into the client's care plan? (Select three.).

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

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 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?

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 client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

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?

(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 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 nurse is assessing a patient with suicidal ideation. Which step of the nursing process involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system?