The nurse is interviewing a client with major depression. Which of the following statements by the client would most indicate to the nurse that the client is at risk for suicide?
"I feel like everyone depends on me too much."
"Life has lost its meaning for me."
wish I could just take a vacation and get away from it all."
"I feel like a failure and wish one thing would just go right."
The Correct Answer is B
A. "I feel like everyone depends on me too much." This statement indicates a sense of responsibility and connection to others, which may not directly indicate suicidal ideation.
B. "Life has lost its meaning for me." This statement is a strong indicator of hopelessness, which is a key risk factor for suicide. The client feels that life is meaningless, which could indicate a desire to end their life.
C. "I wish I could just take a vacation and get away from it all." While this statement may indicate stress or a desire to escape, it does not directly suggest suicidal intent.
D. "I feel like a failure and wish one thing would just go right." This statement indicates frustration and low self-worth, but it doesn't necessarily indicate an immediate risk of suicide as clearly as statement B.
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Correct Answer is D
Explanation
A. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. This is not appropriate as it could exacerbate the client’s anxiety rather than alleviate it. The nurse should remain calm and provide reassurance.
B. Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. Leaving the client alone during a panic attack could increase their feelings of fear and isolation, worsening the situation.
C. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. While this information is correct, it does not directly address the client's immediate need for reassurance and safety during the panic attack.
D. Stay with the client, emphasizing that he is safe and that you will remain with him. This is the most appropriate intervention as it provides the client with a sense of safety and security, which is crucial during a panic attack.
Correct Answer is A
Explanation
A. "I am not on vacation. I am here with you." This response calmly reassures the client by affirming the mother’s presence, which helps address the son’s confusion without directly challenging his perception.
B. "How can I go on vacation? I do not have any money." This response could increase confusion and does not address the son's needs effectively. It could also lead to unnecessary discussions that might not be helpful.
C. "Stop saying that. You know better. No one told you that." This response is dismissive and confrontational, which may exacerbate the son’s distress and could damage the therapeutic relationship.
D. "Just forget about that and let's talk about something else." This response avoids addressing the son’s concerns, which can make him feel dismissed and not listened to, potentially worsening his symptoms.
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