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?

Choice A rationale:

Encouraging isolation to minimize potential stressors is not a appropriate intervention for a client with suicidal ideation. Isolation can exacerbate feelings of loneliness and hopelessness, which can further contribute to the client's distress.

Choice B rationale:

Assisting the client in creating a safety plan is a crucial intervention for a client with suicidal ideation. A safety plan helps the client identify strategies and resources to use when they experience overwhelming emotions or thoughts of self-harm. This plan provides a sense of control and practical steps to follow during times of crisis, promoting hope that they can manage their emotions and stay safe.

Choice C rationale:

Teaching the client relaxation techniques is a valuable intervention, but it may not directly address the immediate need for a safety plan. Relaxation techniques can be helpful for managing anxiety and stress, but they might not be sufficient to prevent self-harm or suicide attempts.

Choice D rationale:

Focusing solely on the client's past failures is counterproductive and can further erode the client's self-esteem and hope. It's important to focus on the client's strengths, coping skills, and the potential for positive change rather than dwelling on past difficulties.

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.