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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:

Psychological needs are more important than physiological needs. This statement contradicts Maslow's hierarchy of needs. According to Maslow's theory, physiological needs, such as air, water, food, and shelter, are at the base of the hierarchy and must be satisfied before addressing higher-level psychological needs.

Choice B rationale:

Social isolation takes precedence over impaired coping. While social isolation can indeed have a significant impact on a person's well-being, Maslow's hierarchy places physiological needs as the foundation. Without satisfying basic physiological needs, addressing higher-level psychological and social needs becomes less effective.

Choice C rationale:

Physiological needs are more important than psychological needs. This choice aligns with Maslow's hierarchy of needs. The hierarchy starts with physiological needs as the most fundamental, followed by safety, belongingness and love, esteem, and finally, self-actualization. A person's physiological needs (like breathing, food, water, sleep) must be met before psychological needs (such as self-esteem, achievement) can be effectively addressed.

Choice D rationale:

Grieving is considered the highest priority diagnosis. Grieving, while important, isn't necessarily the highest priority diagnosis according to Maslow's hierarchy. It falls under psychological and emotional needs, which are secondary to physiological needs. Urgent physiological needs take precedence over emotional needs in this context.

A. "You shouldn't feel that way. There are many people who care about you.". B. "I understand how you feel. Grief can be overwhelming.". C. "You need to stay strong for your children.". D. "Try not to think about it too much. Time heals all wounds.".

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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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.).

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Naxlex Comprehensive Predictor Exams

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