The nurse in the mental health clinic is performing an assessment on a client with a history of major depressive disorder and is taking prescribed medications. The client reports feeling hopeless, has withdrawn from his usual activities, and states, "I just don’t see the point anymore." When asked about suicidal thoughts, he admits to thinking about death frequently but denies having a plan.
Based on this information, the nurse should initially
The nurse in the mental health clinic is performing an assessment on a client with a history of major depressive disorder and is taking prescribed medications. The client reports feeling hopeless, has withdrawn from his usual activities, and states, "I just don’t see the point anymore." When asked about suicidal thoughts, he admits to thinking about death frequently but denies having a plan.
Based on this information, the nurse should initially
A. Reassure the client and arrange for a follow-up appointment in two weeks.
[1%]
B. Determine if the client has adhered to his prescribed medications.
[10%]
C. Conduct a more detailed suicide risk assessment, including intent and means.
[70%]
D. Notify the physician and recommend involuntary admission.
[19%]
Statistics
Subject/Lesson
Subject
Mental Health
Lesson
Mental Health
Client Need
Test Plan
Psychosocial Integrity
Related Topic
Crisis Intervention
Item Type
Item Type
Analysis
Explanation
Choice C is correct. The client's statements indicate an increased risk of suicide, given their feelings of hopelessness, withdrawal from activities, and frequent thoughts about death. However, since the client denies having a plan, the next priority is to conduct a more thorough suicide risk assessment to determine the level of risk. This includes evaluating intent, means, and access to lethal methods.
Choice A is incorrect. Delaying intervention could increase the client's risk, as they are already experiencing significant distress. The nurse must expand the assessment to determine the client's intent, means, and access to lethal methods.
Choice B is incorrect. While medication adherence is important, it does not directly address the immediate suicide risk. A suicide risk assessment takes priority. The nurse must conduct a thorough assessment to determine the overall level of risk.
Choice D is incorrect. A more detailed assessment is necessary before reporting findings to the physician. Additionally, a comprehensive evaluation is required to determine whether hospitalization is necessary. The nurse must complete a full suicide risk assessment before taking further action.
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2 Key Topics
Suicide Precautions
32.2 Psychological Concepts & Safety
Additional Info
