(Select all that apply): A nurse is providing care to a patient with MDD. Which of the following are components of nursing assessment for suicide risk in patients with MDD? (Select three).

Choice C rationale:

Responding with, "It sounds like you're feeling really hopeless right now," is an empathetic and therapeutic response. It reflects active listening and shows that the nurse acknowledges the client's feelings without making assumptions or offering false reassurance. This response validates the client's emotions and opens the door for further discussion, potentially leading to better understanding and support.

Choice A rationale:

Responding with, "Don't worry, things will get better soon," is dismissive and invalidating. It minimizes the client's feelings and offers premature reassurance without addressing the client's current emotional state.

Choice B rationale:

Responding with, "I know how you feel. I've been there too," shifts the focus from the client to the nurse. While sharing personal experiences can be helpful in certain contexts, it's important to prioritize the client's emotions and experiences first.

Choice D rationale:

Responding with, "You need to focus on the positive aspects of life," is directive and dismissive of the client's emotions. It implies that the client's feelings are invalid and suggests a solution without fully understanding the client's perspective.

Choice A rationale:

The patient's thought content and organization. Rationale: While monitoring thought content and organization is important in psychiatric assessment, it is not directly related to observing and documenting the patient's mood state. Thought content and organization involve assessing the coherence, relevance, and logic of the patient's thoughts, which can provide insights into their cognitive functioning and potential psychiatric conditions like schizophrenia.

Choice B rationale:

The patient's physical vital signs and laboratory tests. Rationale: This choice is unrelated to the assessment of the patient's mood state. Vital signs and laboratory tests are essential in medical assessments, but when evaluating a patient with bipolar disorder, the focus should be on their psychological and emotional state rather than physical parameters.

Choice C rationale:

The patient's cognitive abilities, memory, and concentration. Rationale: While cognitive abilities, memory, and concentration are important factors to consider in a comprehensive mental status assessment, they are distinct from the patient's mood state. Cognitive assessment provides information about cognitive impairments that might accompany mood disorders, but it does not directly reflect the patient's current emotional state.

Choice D rationale:

The patient's mood state, such as euphoric, irritable, depressed, or mixed. Rationale: This statement is correct. Assessing and documenting the patient's mood state is crucial when evaluating individuals with bipolar disorder. The mood state can provide valuable information about the phase of the disorder (e.g., manic, hypomanic, depressive) and guide treatment decisions. Mood variations are a hallmark of bipolar disorder, and accurately identifying the patient's mood at the time of assessment is essential for effective care.