A client with schizophrenia has made the comment to the nurse, My ...

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A client with schizophrenia has made the comment to the nurse, My family's life would be a whole lot simpler if I was dead and gone. When responding to this client's allusion to suicide, what principle should the nurse enact?
 
  A) Take every threat of suicide seriously.
  B) Counter every threat of suicide with an encouraging response.
  C) Respond to mentions of suicide with sympathy.
  D) View references to suicide as a symptom of disease rather than a threat to health.

Question 2

During a depressed client's admission assessment, she makes the statement to the nurse, I don't see how there's any possible way out of this. I don't feel like things are ever going to get any better for me.
 
  This statement would provide evidence for what nursing diagnosis?
  A) Risk for Complicated Grieving related to depression as evidence by the client's statement that there is no possible way out of this
  B) Hopelessness related to depression as evidence by the client's statement that things will never get any better
  C) Chronic Low Self-Esteem related to depression as evidence by the client's statement that things will never get any better
  D) Stress Overload related to depression as evidence by the client's statement that there is no possible way out of this

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Answer to Question 1

Ans: A
Feedback:
Nurses must take any threat of suicide (ideation or attempt) seriously. An encouraging response is often simplistic, and sympathy is not normally an appropriate response. Even though a statement may be symptomatic of a disease process, it should still be seen as an acute threat.

Answer to Question 2

Ans: B
Feedback:
This client's statement is best characterized as expressing hopelessness. There is no indication that the client's self-esteem is chronically low. Stress overload and grief are plausible diagnoses in individuals with depression but neither is directly suggested by this client's statements.

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