A client who recently went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit.

Which of the following nursing diagnoses has the highest priority?

Choice A rationale
When a client expresses feelings of hopelessness and exhibits behaviors such as giving away possessions, it is crucial for the nurse to further explore these feelings. Asking the client to elaborate on their feelings allows the nurse to gather more information and assess the severity of the client’s emotional state. It also communicates to the client that the nurse is there to listen and provide support.
Choice B rationale
While it is important to assess for suicidal ideation in clients expressing hopelessness, asking directly, “You’re not thinking of killing yourself, are you?” can come across as confrontational and may cause the client to become defensive or close off.
Choice C rationale
Suggesting therapy is a potential intervention, but it is not the best initial response. The immediate priority is to assess the client’s emotional state and risk for self-harm.
Choice D rationale
Discussing coping strategies may be beneficial once the client’s immediate emotional state and safety have been addressed. However, it is not the best initial response when a client is expressing intense feelings of hopelessness.

Choice A rationale
A treatment plan serves as an instrument for communication and coordination of care among the healthcare team. It ensures that all members of the team are on the same page regarding the client’s care.
Choice B rationale
The treatment plan helps in evaluating the effectiveness of interventions. By comparing the client’s progress to the goals set in the treatment plan, the healthcare team can determine whether the interventions are working or if they need to be adjusted.
Choice C rationale
The treatment plan guides the planning and implementation of care. It outlines the steps that need to be taken to help the client achieve their health goals.
Choice D rationale
Ensuring that the client follows their treatment is not a purpose of the treatment plan. While the treatment plan can guide the client’s treatment, it is ultimately up to the client to adhere to the treatment.
Choice E rationale
The treatment plan serves as a means of monitoring the client’s progress. Regular reviews of the treatment plan can show whether the client is making progress towards their health goals.