A nurse is providing care to a client with suicidal ideation. Select all the interventions that the nurse should include in the implementation phase of the client's care.
Administering prescribed antidepressant medication.
Assisting the client in creating a hope box.
Teaching relaxation techniques to the client.
Encouraging social isolation.
Correct Answer : A,B,C,E
A. Administering prescribed antidepressant medication,
B. Assisting the client in creating a hope box,
C. Teaching relaxation techniques to the client, and E. Providing education about the importance of follow-up care.
Choice A rationale:
Administering prescribed antidepressant medication is an important intervention for a client with suicidal ideation who may be experiencing underlying depression. Antidepressants can help alleviate depressive symptoms, which can contribute to an improved mental state and decreased risk of self-harm.
Choice B rationale:
Assisting the client in creating a hope box is a valuable intervention. A hope box is a collection of items that hold personal significance and provide comfort to the client during times of distress. This intervention encourages the client to focus on positive aspects of their life, fostering hope and resilience.
Choice C rationale:
Teaching relaxation techniques to the client equips them with coping strategies to manage stress and anxiety. These techniques can help the client regulate their emotions and reduce feelings of distress, which are essential for preventing suicidal ideation.
Choice D rationale:
Encouraging social isolation is not appropriate for a client with suicidal ideation. Isolation can exacerbate feelings of loneliness and hopelessness, increasing the risk of self-harm. Instead, promoting social connections and a supportive network can contribute to the client's well-being.
Choice E rationale:
Providing education about the importance of follow-up care is crucial for a client's ongoing well-being. Follow-up care ensures that the client continues to receive necessary support and interventions, reducing the risk of relapse and maintaining their progress toward recovery.
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Related Questions
Correct Answer is D
Explanation
Collaborate with the patient and the healthcare team.
Choice A rationale:
Prioritize long-term goals over short-term outcomes. This choice is not the most appropriate principle to consider in the planning phase for a patient with suicidal ideation. While setting long-term goals is important, immediate safety and addressing the patient's emotional state take precedence in this situation.
Choice B rationale:
Develop a rigid and unchangeable plan of care. This choice is not suitable for a patient with suicidal ideation. Flexibility in the plan of care is essential to accommodate the patient's changing emotional state and needs. A rigid plan might not effectively address the dynamic nature of suicidal ideation.
Choice C rationale:
Focus only on the patient's physical health. This choice is not comprehensive enough for a patient with suicidal ideation. While physical health is important, addressing the patient's emotional well-being, safety, and mental health concerns should be a priority in the plan of care.
Choice D rationale:
Collaborate with the patient and the healthcare team. This choice is the most appropriate principle to consider. Collaboration involves actively involving the patient in the care planning process and working with the healthcare team to develop a holistic plan that addresses the patient's emotional, psychological, and safety needs. Inclusion of the patient's perspective enhances engagement and increases the likelihood of successful interventions.
Correct Answer is ["A","B","C"]
Explanation
Choice A:
Risk for suicide.
Choice B:
Ineffective family coping.
Choice C:
Chronic low self-esteem.
Choice A rationale:
This choice aligns with the primary concern of the patient being at risk for suicide, which is the focus of the assessment. Identifying this diagnosis is crucial for implementing appropriate interventions to ensure the patient's safety.
Choice B rationale:
Ineffective family coping could contribute to the patient's stressors and emotional state. It's relevant because the support system plays a significant role in a patient's mental health. However, it might not be as immediate a concern as the risk for suicide itself.
Choice C rationale:
Chronic low self-esteem is relevant to the patient's overall mental health and might contribute to their suicidal ideation. However, it might not directly address the immediate risk and urgency of the situation compared to the diagnosis of "Risk for suicide."
Choice D rationale:
Altered nutrition and risk for infection are not directly related to the primary concern of suicidal ideation and the associated nursing diagnoses. While they may be aspects of the patient's overall health, they are not the most pertinent concerns when addressing the risk of suicide.
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