A nurse is providing care to a client who is displaying warning signs of suicidal ideation. Which interventions should the nurse prioritize to ensure the client's safety? (Select all that apply.).
Monitoring the client's access to lethal means.
Encouraging the client to isolate themselves for self-reflection.
Providing the client with a detailed plan for coping.
Collaborating with the client's family and friends.
Administering sedative medications to keep the client calm.
Correct Answer : A,C,D
The correct answer is A. Monitoring the client’s access to lethal means, C. Providing the client with a detailed plan for coping, and D. Collaborating with the client’s family and friends.
Choice A rationale:
Monitoring the client’s access to lethal means is crucial to prevent any immediate risk of self-harm. This includes removing or securing items that could be used for suicide, such as medications, sharp objects, or firearms.
Choice B rationale:
Encouraging the client to isolate themselves for self-reflection is not advisable. Isolation can increase feelings of loneliness and hopelessness, which may exacerbate suicidal ideation.
Choice C rationale:
Providing the client with a detailed plan for coping helps them manage their thoughts and emotions more effectively. This plan can include strategies for dealing with stress, identifying triggers, and knowing when and how to seek help.
Choice D rationale:
Collaborating with the client’s family and friends is essential for creating a support network. Involving loved ones can provide the client with emotional support and help monitor their well-being.
Choice E rationale:
Administering sedative medications to keep the client calm is not a primary intervention for suicidal ideation. While medication may be part of a broader treatment plan, it should not be the sole strategy for ensuring safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client has a subjective state with limited personal choices.
Choice A rationale:
The client is at risk for self-inflicted, life-threatening injury. This choice does not accurately define the nursing diagnosis of "Hopelessness." While it is true that hopelessness can lead to self-harm or suicide, the nursing diagnosis focuses on the client's emotional state and personal choices rather than the immediate risk of injury.
Choice B rationale:
The client has a subjective state with limited personal choices. This choice accurately defines the nursing diagnosis of "Hopelessness." Hopelessness refers to the client's emotional state of feeling devoid of hope, often resulting in a perceived lack of personal choices and options. This sense of hopelessness can contribute to feelings of despair and potentially suicidal ideation.
Choice C rationale:
The client is unable to cope with stressors. This choice is not the most accurate definition of "Hopelessness." While hopelessness can certainly impact a client's ability to cope with stressors, the primary focus of the diagnosis is on the subjective emotional state and perceived lack of choices, rather than their coping abilities.
Choice D rationale:
The client experiences compromised family coping. This choice is not directly related to the nursing diagnosis of "Hopelessness." Family coping refers to how a family unit manages stressors together, whereas hopelessness pertains to an individual's emotional state and perceived choices.
.
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.
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