The advanced practice nurse is caring for a patient in an ...

[krzymel]

The advanced practice nurse is caring for a patient in an outpatient clinic who has expressed thoughts of suicide, but who does not have a plan or means in place. The patient tells the nurse,
 
  I sometimes think it would be easier for me to just go to sleep and never wake up. But I don't hurt myself because I love my children too much. Which nursing interventions are most appropriate for this patient? Select all that apply.
  1. Place the patient on constant observation for safety.
  2. Teach the use of the National Suicide Prevention Lifeline.
  3. Admit the patient to the behavioral health hospital immediately.
  4. Encourage the patient to use internal and external support systems.
  5. Be aware that the patient is likely to reject any attempt at intervention, including teaching.

Question 2

The nurse is caring for a patient who has expressed a desire to commit suicide. Which statement by the nurse is most appropriate?
 
  1. Your problems will get better. Hurting yourself is not the answer.
  2. Your family and friends will be very upset at you if you hurt yourself.
  3. I am shocked that you would consider hurting yourself. You have so much to live for.
  4. I am here for you. I know you want to hurt yourself, but there are things we can do to help you.

[Sweetkitty24130]

Answer to Question 1

Answer: 2, 4
Explanation: The patient is likely in Stage II of the Stage of Severity of Suicide Risk. Stage II is manifested by fleeting thoughts of suicide with no intent to carry out suicidal action. Also, the patient's love of his or her children is a protective measure. Appropriate nursing actions for a patient in Stage II include teaching the use of the National Suicide Prevention Lifeline and encouraging the patient to use internal and external support systems. Placing the patient on constant safety observation, admitting the patient to the behavioral health hospital immediately, and recognizing that the patient is likely to reject teaching are all interventions for patients who are in stages III, IV, and V of the Stage of Severity of Suicide Risk.

Answer to Question 2

Answer: 4
Explanation: For a patient who is expressing thoughts of suicide, it is important for the nurse to offer self and instill hope. The statement, I am here for you. I know you want to hurt yourself, but there are things we can do to help you, best demonstrates offering self and instilling hope. The nurse should not provide false reassurance by stating, Your problems will get better. Hurting yourself is not the answer. The nurse is acting in a judgmental way when stating, Your family and friends will be very upset at you if you hurt yourself, or I am shocked that you would consider hurting yourself. You have so much to live for. These statements are not therapeutic and not beneficial to a patient who is experiencing suicidal thoughts.