Difficulty: Medium
Average Score: 69%
Simulated
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct answer
A
Rationale
Correct Answer: A. "Have you thought about harming yourself?"
Rationale: This response is crucial in assessing the client's risk of suicide. It shows the nurse's immediate concern for the client's safety and opens a dialogue to understand the severity of the client's suicidal ideation. By directly addressing the client's statement about wanting to die, the nurse can determine the level of risk and take appropriate actions to ensure the client's safety.
Incorrect Choices:
B: "Tell me more about your partner." - This response does not address the immediate concern of suicidal ideation and misses the opportunity to assess the client's safety.
C: "You should discuss these feelings with your provider." - While important, this response does not address the urgent need to assess the client's risk of harm to self.
D: "Why did you stop taking your medication?" - While medication adherence is important, the client's statement about wanting to die takes precedence in this situation.
Rationale: This response is crucial in assessing the client's risk of suicide. It shows the nurse's immediate concern for the client's safety and opens a dialogue to understand the severity of the client's suicidal ideation. By directly addressing the client's statement about wanting to die, the nurse can determine the level of risk and take appropriate actions to ensure the client's safety.
Incorrect Choices:
B: "Tell me more about your partner." - This response does not address the immediate concern of suicidal ideation and misses the opportunity to assess the client's safety.
C: "You should discuss these feelings with your provider." - While important, this response does not address the urgent need to assess the client's risk of harm to self.
D: "Why did you stop taking your medication?" - While medication adherence is important, the client's statement about wanting to die takes precedence in this situation.