After assessing a client, a nurse noted the following: He was ...

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After assessing a client, a nurse noted the following: He was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate,
 
  and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the client's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnosis would be the most appropriate?
 
  A) Ineffective Role Performance
  B) Risk for Infection
  C) Risk for Suicide
  D) Risk for Self-Mutilation

Question 2

A client was admitted to the hospital after a suicide attempt following his daughter's death in an automobile accident; the client had been driving and survived with only minor injuries.
 
  Even though the accident was unavoidable, he feels responsible. During the assessment interview, the client begins to describe the last conversation he had with his daughter before he lost control of the automobile. As he speaks about his daughter, his voice trembles, and a tear rolls down his face. He makes a visible attempt to straighten up and smiles superficially at the nurse, stating, I'll get over this. I just need to keep a stiff upper lip. I think all I need to do is stay overnight. I'll be as good as new by tomorrow. Which response by the nurse would be most appropriate?
 
  A) Tell me about your daughter. How would you describe the relationship you had with her?
  B) I'm sure you are right; a good night's rest should make a big difference.
  C) As good as new?
  D) You made a serious attempt on your life; you will not be ready go home by tomorrow.

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Answer to Question 1

Ans: C
The client's history of a recent suicide attempt in conjunction with his signs of depression, such as difficulty sleeping, lack of appetite, and inability to concentrate, put him at risk for suicide. The information described in the nurse's observations does not support ineffective role performance, infection, or self-mutilation.

Answer to Question 2

Ans: D
The response about making a serious attempt on his life and not being ready to go home by tomorrow addresses the client's unrealistic assumption and presents him with the reality of his situation. Presenting reality is one assessment interview behavior that enhances the effectiveness of an assessment interview. Asking the client to tell the nurse about his daughter changes the subject and focus of the client's statement. Telling the client that he is right is false reassurance. The response, As good as new?, although a reflective and clarifying statement, shifts the focus of the interaction.