A client with a history of substance use disorder and recent job loss is exhibiting signs of suicidal ideation. Which nursing intervention is most appropriate in this situation?
Advise the client to keep their feelings to themselves.
Encourage the client to isolate themselves until they feel better.
Ask the client directly if they are thinking about harming themselves.
Provide the client with alcohol or drugs to help them cope.
The Correct Answer is C
Choice A rationale:
Advising the client to keep their feelings to themselves is not an appropriate intervention in this situation. Suicidal ideation is a serious concern, and keeping feelings hidden could potentially lead to the client not receiving the necessary support and intervention they need to stay safe.
Choice B rationale:
Encouraging the client to isolate themselves until they feel better is not an appropriate intervention either. Isolation can exacerbate feelings of hopelessness and increase the risk of acting on suicidal thoughts. Connecting with the client and providing a supportive environment is crucial.
Choice C rationale:
Asking the client directly if they are thinking about harming themselves is the most appropriate intervention. This approach helps the nurse assess the severity of the situation, open a dialogue about the client's feelings, and determine the level of risk. Direct communication allows for a better understanding of the client's mental state and the need for further intervention.
Choice D rationale:
Providing the client with alcohol or drugs to help them cope is a dangerous and inappropriate intervention. Substance use can further impair judgment and increase the risk of acting on suicidal thoughts. This action also fails to address the underlying issues contributing to the client's distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
In the nursing process, the step of diagnosis involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system. This step is critical in identifying the patient's current condition, problems, and needs. By assessing these aspects, the nurse can accurately diagnose the patient's situation and develop an appropriate care plan. Suicide risk assessment is an essential component of this step, as it helps determine the severity of the patient's ideation and potential for harm.
Choice B rationale:
Planning is the phase of the nursing process where the nurse, in collaboration with the patient, sets goals and develops a strategy to address the identified problems. While planning does involve considering the patient's suicide risk assessment, it primarily focuses on outlining interventions and actions to achieve the desired outcomes. It does not encompass the comprehensive data collection and assessment of the patient's mental and physical health status that are central to the diagnosis phase.
Choice C rationale:
Implementation is the stage in the nursing process where the nurse carries out the planned interventions and treatments. It involves executing the care plan that was developed during the planning phase. While suicide risk factors and protective factors may influence the choice of interventions, implementation itself does not encompass the data collection and assessment aspects required to fully evaluate the patient's condition.
Choice D rationale:
Evaluation is the final step of the nursing process, during which the nurse assesses the effectiveness of the interventions and evaluates the patient's progress toward achieving the established goals. It involves comparing the patient's current status with the expected outcomes and making necessary adjustments to the care plan. While suicide risk assessment may play a role in evaluating the patient's response to interventions, it is not the primary focus of the evaluation phase, which is centered around the assessment of treatment outcomes.
Correct Answer is B
Explanation
Choice A rationale:
Telling the client that they shouldn't feel a certain way and suggesting that others care about them minimizes their emotions and can be invalidating. It's essential to acknowledge the client's feelings without dismissing them.
Choice B rationale:
Expressing understanding and acknowledging the overwhelming nature of grief is appropriate and empathetic. This response validates the client's emotions and creates a safe space for them to express their feelings.
Choice C rationale:
While the intention behind encouraging the client to stay strong for their children might be positive, it oversimplifies the complexity of grief and emotional responses. Grief is a personal experience, and implying that they should suppress their emotions for the sake of others is not ideal.
Choice D rationale:
Suggesting that the client avoid thinking about their loss or that time will heal their wounds can invalidate their current emotional state. Grief doesn't always follow a linear path, and minimizing the impact of the loss can hinder the client's healing process.
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