A nurse is caring for a client with major depressive disorder. The client avoids eye contact and states, "I am nothing but a burden to my family. They would be so much better off without me." Which of the following nursing actions are appropriate? (Select all that apply.)
- Ask the client directly, 'Are you having thoughts of killing yourself?'Answer
- BTell the client, 'I am sure your family loves you very much and would miss you.'
- Respond by stating, 'It sounds like you are feeling incredibly sad and overwhelmed right now.'Answer
- DOffer reassurance by saying, 'Everything will look brighter in a few days once your medication starts working.'
- EAssume this is a typical phase of depression and document the statement without further intervention.
Answer
The appropriate actions are to ask the client directly about suicidal thoughts and to use empathetic, reflective communication to acknowledge their feelings.
The correct actions prioritize client safety and utilize therapeutic communication. Asking directly about suicidal thoughts is the required standard of care when a client makes statements indicating they feel like a burden. Acknowledging and reflecting the client's feelings ('It sounds like you are feeling incredibly sad') validates their emotional state and encourages them to elaborate on their distress without feeling judged.
Step-by-Step Solution
Key Concept
Therapeutic Communication and Suicide Risk Assessment