(Select all that apply): A nurse is analyzing data collected during the assessment phase for a patient at risk for suicide. Which of the following nursing diagnoses are commonly associated with suicidal ideation? Select three.
Risk for suicide.
Ineffective family coping.
Chronic low self-esteem.
Altered nutrition.
Risk for infection.
Correct Answer : A,B,C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nursing diagnosis "Impaired coping" signifies that the client is experiencing difficulty in dealing with stressors and challenges. While it's true that impaired coping can contribute to various negative outcomes, the most critical concern when dealing with a client diagnosed with impaired coping and suicidal ideation is the risk of self-inflicted harm, which aligns with choice A. Clients with impaired coping and suicidal ideation are at a heightened risk for engaging in self-destructive behaviors, including attempts at self-inflicted, life-threatening injury. This choice is the most relevant and urgent, as it directly addresses the potential harm the client may cause to themselves due to their impaired coping skills.
Choice B rationale:
Although feelings of aloneness can contribute to psychological distress and could potentially be relevant to the client's situation, choice B does not directly address the immediate risk of self-inflicted injury associated with impaired coping and suicidal ideation. The focus in this case should be on the client's safety and preventing self-harm.
Choice C rationale:
This choice accurately describes one aspect of impaired coping but does not specifically address the increased risk of self-inflicted harm or the severity of the situation presented in the question. While impaired coping does involve the inability to use appropriate skills to manage stressors, the urgency of addressing the immediate risk of self-inflicted injury takes precedence in this scenario.
Choice D rationale:
Negative self-evaluation may contribute to impaired coping, but the question specifically relates to the client's risk for self-inflicted, life-threatening injury. While negative self-evaluation could be part of the client's overall presentation, it's not the most direct or urgent concern in this situation.
Correct Answer is C
Explanation
Choice A rationale:
Dismissing the client's thoughts and labeling them as unhealthy might cause the client to feel judged or reluctant to share further. It's important to approach the situation with openness and empathy.
Choice B rationale:
While it's true that the client's thoughts might pass, this response doesn't address the client's feelings or encourage them to express themselves. It's important to engage in a more in-depth conversation to understand their emotions.
Choice C rationale:
Asking the client to elaborate on their thoughts and experiences opens the door for meaningful conversation and assessment. This response shows genuine interest in the client's well-being and allows the nurse to gather more information to determine the appropriate level of support.
Choice D rationale:
Telling the client that things will get better soon might come across as dismissive of their current struggles. It's important to validate their emotions and explore their feelings further rather than offering premature reassurances.
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