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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nursing diagnosis "Impaired coping" signifies that the client is experiencing difficulty in dealing with stressors and challenges. While it's true that impaired coping can contribute to various negative outcomes, the most critical concern when dealing with a client diagnosed with impaired coping and suicidal ideation is the risk of self-inflicted harm, which aligns with choice A. Clients with impaired coping and suicidal ideation are at a heightened risk for engaging in self-destructive behaviors, including attempts at self-inflicted, life-threatening injury. This choice is the most relevant and urgent, as it directly addresses the potential harm the client may cause to themselves due to their impaired coping skills.
Choice B rationale:
Although feelings of aloneness can contribute to psychological distress and could potentially be relevant to the client's situation, choice B does not directly address the immediate risk of self-inflicted injury associated with impaired coping and suicidal ideation. The focus in this case should be on the client's safety and preventing self-harm.
Choice C rationale:
This choice accurately describes one aspect of impaired coping but does not specifically address the increased risk of self-inflicted harm or the severity of the situation presented in the question. While impaired coping does involve the inability to use appropriate skills to manage stressors, the urgency of addressing the immediate risk of self-inflicted injury takes precedence in this scenario.
Choice D rationale:
Negative self-evaluation may contribute to impaired coping, but the question specifically relates to the client's risk for self-inflicted, life-threatening injury. While negative self-evaluation could be part of the client's overall presentation, it's not the most direct or urgent concern in this situation.
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.
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