MH Ch 25 SQ

1. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male

A, B, D Whites have suicide rates almost twice those of non-whites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males.

7. A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness c. Risk for suicide b. Social isolation d. Compromised family coping

C This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options.

13. A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of the nurse conducting the assessment interview is to: a. assess lethality of suicide plan. c. establish rapport with the patient. b. encourage expression of anger. d. determine risk factors for suicide.

C This scenario presents a potential crisis. Establishing rapport facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.

17. A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, My business is bankrupt, and I was served with divorce papers. Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. I wish I were dead. b. Life is not worth living. c. I have a plan that will fix everything. d. My family will be better off without me.

C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patients suicide as being a way to fix everything but does not say it outright.

A student nurse on the psychiatric unit expresses being uncomfortable about discussing possible suicidal ideations with clients because "It might put ideas in their head about suicide." What is the nurse's best response to this student's concern? A. "I'm glad you are thinking that way. They may not have thought of suicide before, and we don't want to introduce that." B. "You are right; however, because of professional liability, we have to ask that question." C. "Actually, it's a myth that asking about suicide puts ideas into someone's head." D. "If I were you, I'd ask the health provider to talk to the patient about that subject."

C. "Actually, it's a myth that asking about suicide puts ideas into someone's head."

Which suicide prevention intervention that has the greatest impact on a client's safety? A. Educating visitors about potentially dangerous gifts. B. Restricting the client from potentially dangerous areas of the unit. C. One-on-one observation by the staff. D. Removal of personal items that might prove harmful.

C. One-on-one observation by the staff.

The nursing diagnosis Risk for self-directed violence has been added to the care plan of a suicidal client. Which is the most appropriate short-term goal for this diagnosis? A. Will reclaim any prized possessions that were given away. B. Be able to name three personal strengths. C. Seek help when feeling self-destructive. D. Consistently participate in a self-help group.

C. Seek help when feeling self-destructive.

Which neurotransmitter has been implicated as playing a part in the decision to commit suicide? A. γ-Amino-butyric acid B. Dopamine C. Serotonin D. Acetylcholine

C. Serotonin

What are the most important characteristics for staff members who work with suicidal clients? A. Organization B. Problem-solving skills C. Warm, consistent interaction D. Effective interview and counseling skills

C. Warm, consistent interaction

When working with a client who may have made a covert reference to suicide, the nurse should base the response on what statement? A. Being careful not to mention the idea of suicide. B. Listening carefully to see whether the client mentions suicide more overtly. C. Asking about the possibility of suicidal thoughts in a covert way. D. Asking the client directly if they are thinking of attempting suicide.

D. Asking the client directly if they are thinking of attempting suicide.

The nurse observes the meal tray about to serve a suicidal client. Which item should be removed from the tray? A. Plastic plate B. Cloth napkin C. Styrofoam cup D. Metal utensils

D. Metal utensils

While intoxicated a client unsuccessfully attempted suicide by using a gun. This method of using a gun to attempt suicide should be described in what terms? A. It is high risk, or a hard method. B. It is low risk, or a soft method. C. It was not an actual suicide attempt because the client was intoxicated. D. Considering the results, it is a nonlethal means.

A. It is high risk, or a hard method.

18. A depressed patient says, Nothing matters anymore. What is the most appropriate response by the nurse? a. Are you having thoughts of suicide? b. I am not sure I understand what you are trying to say. c. Try to stay hopeful. Things have a way of working out. d. Tell me more about what interested you before you became depressed.

A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation.

21. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is a. hopelessness. c. elation. b. sadness. d. anger.

A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

9. A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, We should have seen this coming. We did not do enough. The parents reaction reflects: a. guilt. c. shame. b. denial. d. rescue feelings.

A The parents statements indicate guilt. Guilt is evident from the parents self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario.

11. It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.

A The patient now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk.

16. Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

A Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

A client tells the nurse that he believes his situation is intolerable and is observed isolating socially. Which nursing diagnosis should be considered? A. Hopelessness B. Deficient knowledge C. Chronic low self-esteem D. Compromised family coping

A. Hopelessness

24. After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. Genetics are associated with suicide risk. Monitoring and support are important. b. Apathy underlies suicide. Instilling motivation is the key to health maintenance. c. Your child is unlikely to act out suicide when identifying with a suicide victim. d. Fraternal twins are at higher risk for suicide than identical twins.

A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification.

2. Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply. a. Maintain arms-length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the patients eyeglasses to prevent self-injury. e. Interact with the patient every 15 minutes.

A, B, C One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; no silver or glassware orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arms-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arms length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.

2. Which interventions will help make the environment on the unit safer for suicidal patients? Select all that apply. a. All windows are kept locked. b. Every shower has a breakaway shower rod. c. Eating utensils are counted when trays are collected. d. Patient doors are kept open. e. Staying within listening distance of the patient.

A, B, C, D

3. What are the nursing responsibilities to a patient expressing suicidal thoughts? Select all that apply. a. Instituting one-to-one observation. b. Documenting the patient's whereabouts and mood every 15 to 30 minutes. c. Ensuring that the patient has no contact with glass or metal utensils. d. Ensuring that patient has swallowed each individual dose of medication. e. Discussing triggers of depression.

A, B, C, D

4. When considering community suicide prevention programs, what population should the nurse plan to service with regular suicide screenings? Select all that apply. a. 10- to 34-year-olds b. Males c. College-educated adults d. Rural population e. Native American

A, B, E

3. A college student is extremely upset after failing two examinations. The student said, No one understands how this will hurt my chances of getting into medical school. The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? Select all that apply. a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

A, C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, No one can understand, can be seen as recent lack of social support. Terminating access to ones social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack.

A client with a history of repeated suicidal attempts refuses to participate in a no-suicide contract. What intensity of nursing observation should be instituted? A. Constant 24-hour, one-to-one observation at arm's length B. One-to-one observation while client is awake C. Every 15-minute observation around the clock D. Seclusion with 15-minute observation

A. Constant 24-hour, one-to-one observation at arm's length

Unit practice requires inspection of all items being brought onto the unit by visitors. How can this be most effectively done? A. Having a staff member sit at the door and check packages as visitors enter. B. Having a staff member make frequent rounds during visiting hours to inspect gifts. C. Asking all visitors to report to the nurse's station before visiting a client. D. Asking clients to give staff any unsafe item that might have been left by a visitor.

A. Having a staff member sit at the door and check packages as visitors enter.

1. Which patient statement does not demonstrate an understanding of a suicide safety plan? a. "I know that when I start thinking about my dad, I'm going to start thinking about killing myself." b. "Going for a really long, hard run helps clear my mind and stops the suicidal thoughts." c. "My sister is always there for me when I start getting suicidal." d. "I keep the suicide prevention phone number in my wallet."

B

7. Martin is a 23-year-old male with a new diagnosis of schizophrenia, and his family is receiving information from a home health nurse. The topic of education is suicide prevention, and the nurse recognizes effective teaching when the mother says: a. "Persons with schizophrenia rarely commit suicide." b. "Suicide risk is greatest in the first few years after diagnosis." c. "Suicide is not common in schizophrenia due to confusion." d. "Most persons diagnosed with schizophrenia die of suicide."

B

8. Sigmund Freud, Karl Menninger, and Aaron Beck theorized that hopelessness was an integral part of why a person commits suicide. A more recent theory suggest suicide results from: a. Elevated serotonin levels b. The diathesis-stress model c. Outward aggression turned inward d. A lack of perfectionism

B

22. Which statement by a depressed patient will alert the nurse to the patients need for immediate, active intervention? a. I am mixed up, but I know I need help. b. I have no one to turn to for help or support. c. It is worse when you are a person of color. d. I tried to get attention before I cut myself last time.

B Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk.

23. A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing measure will be most important regarding this event? a. Ask the information technology manager to verify the hospital information system is secure. b. Hold a staff meeting to express feelings and plan care for the other patients. c. Ask the patients roommate not to discuss the event with other patients. d. Prepare a report of a sentinel event.

B Interventions should help the staff and patients come to terms with the loss and grow because of the incident. Then, a community meeting should occur to allow other patients to express their feelings and request help. Staff should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. A sentinel event report can be prepared later. The other incorrect options will not control information or would result in unsafe care.

4. Which change in the brains biochemical function is most associated with suicidal behavior? a. Dopamine excess c. Acetylcholine excess b. Serotonin deficiency d. Gamma-aminobutyric acid deficiency

B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality.

1. An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patients history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline (Elavil), a sedating tricyclic medication b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor c. Desipramine (Norpramin), a stimulating tricyclic medication d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

B Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patients history of overdosing, it is important that the medication be as safe as possible in case she takes an overdose of her prescribed medication.

10. Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. a. Why do you want to kill yourself? b. Do you have access to medications? c. Have you been taking drugs and alcohol? d. Did something happen with your parents?

B The nurse must assess the patients access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the patients safety. The information in the other questions may be important to ask but are not the most critical.

10. Kara is a 23-year-old patient admitted with depression and suicidal ideation. Which intervention(s) would be therapeutic for Kara? Select all that apply. a. Focus primarily on developing solutions to the problems leading the patient to feel suicidal. b. Assess the patient thoroughly and reassess the patient at regular intervals as levels of risk fluctuate. c. Avoid talking about the suicidal ideation as this may increase the patient's risk for suicidal behavior. d. Meet regularly with the patient to provide opportunities for the patient to express and explore feelings. e. Administer antidepressant medications cautiously and conservatively because of their potential to increase the suicide risk in Kara's age group. f. Help the patient to identify positive self-attributes and to question negative self-perceptions that are unrealistic.

B, D, E, F

Which statement factually describes the act of suicide? A. More women than men commit suicide. B. The Jewish culture has the lowest suicide rate. C. Suicide is the leading cause of death in the United States. D. A client diagnosed with schizophrenia is at great risk for attempting suicide

D. A client diagnosed with schizophrenia is at great risk for attempting suicide

Which is the greatest protective factor against the risk of suicide? A. One or more previous suicide attempts B. A sense of responsibility to family C. Fear of dying D. A cultural belief that suicide is a shameful resolution for a dilemma

B. A sense of responsibility to family

When a colleague committed suicide, the nurse stated "I do not understand why she would take her own life." This is an expression of which feeling? A. Anger B. Disbelief C. Confusion D. Sympathy

B. Disbelief

What is the focus of the SAFE-T assessment tool? Select all that apply. A. Facilitate hospitalization. B. Identify level of suicidal risk. C. Development of client focused treatment. D. Introduce antidepressant medication therapy E. Stress collaboration with the client

B. Identify level of suicidal risk. C. Development of client focused treatment. E. Stress collaboration with the client

Which of the following statements is true regarding culture and protective factors against suicide? A. Asian Americans have the highest rates of suicide. B. Religion and the importance of family are protective factors for Hispanic Americans. C. Older women have the highest risk for suicide among African Americans. D. American Indians and Pacific Islanders have the lowest rates of suicide.

B. Religion and the importance of family are protective factors for Hispanic Americans.

An assessment tool that is useful to nurses in rating suicide risk is the A. AIMS scale. B. SAFE-T. C. CAGE questionnaire. D. Mini-Mental Status Examination.

B. SAFE-T.

Nurses should assess the lethality of the client's plan for suicide. What factor would be irrelevant to that assessment? Select all that apply. A. How long the client has been suicidal B. Whether the plan has specific details C. Whether the method is one that could cause death D. Whether the client has the means to implement the plan E. Has the client been suicidal in the past

B. Whether the plan has specific details C. Whether the method is one that could cause death D. Whether the client has the means to implement the plan

6. Gladys is seeing a therapist because her husband committed suicide 6 months ago. Gladys tells her therapist, "I know he was in pain, but why didn't he leave me a note?" The therapist's best response would be: a. "He probably acted quickly on his impulse to kill himself." b. "He did not want to think about the pain he would cause you." c. "He was not able to think clearly due to his emotional pain." d. "He thought you may think it was an accident if there was no note."

C

9. Which person is at the highest risk for suicide? a. A 50-year-old married white male with depression who has a plan to overdose if circumstances at work do not improve. b. A 45-year-old married white female who recently lost her parents, suffers from bipolar disorder, and attempted suicide once as a teenager. c. A young single white male who is alcohol dependent, hopeless, impulsive, has just been rejected by his girlfriend, and has ready access to a gun he has hidden. d. An older Hispanic male who is Catholic, is living with a debilitating chronic illness, is recently widowed, and who states, "I wish that God would take me too."

C

5. A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents c. Giving away sweaters b. Excessive crying d. Staying alone in dorm room

C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.

20. When assessing a patients plan for suicide, what aspect has priority? a. Patients financial and educational status b. Patients insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patients social support

C If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question.

15. Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy

C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide.

6. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. c. suicide potential. b. mood disturbance. d. level of anxiety.

C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed.

12. A nurse and patient construct a no-suicide contract. Select the preferable wording. a. I will not try to harm myself during the next 24 hours. b. I will not make a suicide attempt while I am hospitalized. c. For the next 24 hours, I will not in any way attempt to harm or kill myself. d. I will not kill myself until I call my primary nurse or a member of the staff.

C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks I am not going to harm myself, I am going to kill myself or I am not going to attempt suicide, I am going to commit suicide. A patient may call a therapist and leave the telephone to carry out the suicidal plan.

14. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, I am considering committing suicide. a. Im glad you shared this. Please do not worry. We will handle it together. b. I think you should admit yourself to the hospital to keep you safe. c. Bringing up these feelings is a very positive action on your part. d. We need to talk about the good things you have to live for.

C The correct response gives the patient reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as You have a lot to live for. It uses the patients ambivalence and sets the stage for more realistic problem solving.

A client on one-to-one supervision at arm's length indicates a need to go to the bathroom but reports, "I cannot 'go' with you standing there." How should the nurse respond to the client's concern? A. "I understand" and allow the client to close the door. B. Keep the door open, but step to the side out of the client's view. C. Leave the client's room and wait outside in the hall. D. "For your safety I can be no more than an arm's length away."

D. "For your safety I can be no more than an arm's length away."

Which statement, made by a patient admitted with a diagnosis of depression, indicates the need for further assessment? A. "I know a lot of people care about me and want me to get better." B. "I have suicidal thoughts at times, but I don't have any plan and don't think I would ever actually hurt myself." C. "I don't have a good support system, but I am planning on joining a recovery group." D. "I think things will be better soon."

D. "I think things will be better soon."

5. Research supports which intervention implemented on a long-term basis significantly reduces the incidence of suicide and suicide attempts in a patient diagnosed with bipolar disorder? a. A selective serotonin reuptake inhibitor (SSRI) b. Electroconvulsive therapy (ECT) c. One-on-one observation d. Lithium

D

25. Which individual in the emergency department should be considered at highest risk for completing suicide? a. An adolescent Asian American girl with superior athletic and academic skills who has asthma b. A 38-year-old single, African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with twelve grandchildren who has type 2 diabetes d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

D High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

8. A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

19. A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic comment? a. Lets make a list of all your problems and think of solutions for each one. b. Im happy youre taking control of your problems and trying to find solutions. c. When you have bad feelings, try to focus on positive experiences from your life. d. Lets consider which problems are very important and which are less important.

D The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

2. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted area late at night

D This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question.

3. Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient

D This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure.