QUIZ SUICIDE PREPU
The nurse is planning a presentation about suicide to a group of health professionals. Which should be included in the nurse's teaching plan? Men are more likely to commit suicide than women are. Suicide rates for women are highest among women with children. Suicide tends to be most prevalent in the those in the age group of 30 to 40. The most common method of committing suicide is the use of sleeping pills.
Correct response: Men are more likely to commit suicide than women are. Explanation: The nurse should include in the teaching plan that men are four times more likely to commit suicide than women are. Suicide rates are highest in the age group of 15 to 24. Firearms contribute to high rates of suicide among adolescents.
After assessing a client, the nurse identifies that the client is at risk for suicide. Which would be the nurse's priority intervention? Communicate a desire to help the client. Remove means of suicide from the client's access. Determine the course of the client's suicidal thoughts. Provide mood-stabilizing medications per physician order.
Correct response: Remove means of suicide from the client's access. Explanation: Immediate interventions involve removing the means of suicide to reduce the risk of it happening. If the person is hospitalized, methods may include ensuring pills or medications are not available to clients or that they are not taking any measures to accumulate needed drugs. If in a community or home care setting, nurses may enlist the help of family or friends to remove the means and to provide immediate support.
What is a myth regarding suicide? Suicidal people are fully intent on dying. The suicide rate is lowest in December. Most suicidal people are undecided about living or dying. Many people who die by suicide have given definite warnings of their intentions.
Correct response: Suicidal people are fully intent on dying. Explanation: A myth regarding suicide is that suicidal people are fully intent on dying. Most suicidal people are undecided about living or dying. Facts about suicide include that the suicide rate is the lowest in December and that many people who die by suicide have given definite warnings of their intentions.
When teaching prevention to the parents of a 15-year-old client who recently attempted suicide by taking an overdose of alprazolam, the nurse describes which behavioral clue? Angry outbursts at significant others Inquiry about doses of lethal drugs Giving away valued personal items Experiencing the loss of a boyfriend or girlfriend
Correct response: Giving away valued personal items Explanation: The suicidal individual may exhibit behaviors that provide clues to his or her intent, including the following:• Talking about death, suicide, and wanting to be dead• Talking or thinking about punishment, torture, and being persecuted• Hearing voices and suddenly seeming very happy after being very depressed for some time• Being very aggressive or very impulsive, and acting suddenly and unexpectedly• Showing an unusual amount of interest in getting his or her affairs in order• Giving away personal belongings
The nurse is seeing an adolescent female client who has superficial cuts to both wrists and ankles. The client denies the desire to kill herself but reports recent family stress due to her parents recently separating. Which phenomena explains the client's response to stress? Parasuicide Suicide attempt Suicide contagion Impulsivity
Correct response: Parasuicide Explanation: Parasuicide is a voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death (e.g., taking a sublethal drug). Parasuicidal behavior varies by intent. Some people truly wish to die, but others simply wish to feel nothing for a while. Still others want to send a message about their emotional state. Parasuicide occurs frequently in younger age groups but declines after the age of 44 years. A suicide attempt is a nonfatal, self-inflicted destructive act with explicit or implicit intent to die. Social exposure to suicide is associated with an increased personal risk for suicidal behavior, particularly among adolescents. Suicide behavior that occurs after the suicide death of a known other is called suicide contagion or cluster suicide. Impulsivity is a risk factor for both parasuicide and suicide attempts. Impulsivity alone does not explain why the client engages in self-harming behaviors.
The primary nursing goal for a client who is admitted for suicidal ideation or attempt would be what? Assist him or her in the expression of sad and helpless feelings. Assess the cause of his or her depression. Develop rapport based on trust and understanding. Prevent self-destructive behavior.
Correct response: Prevent self-destructive behavior. Explanation: Preventing self-destructive behavior is the primary nursing goal. Other important goals, such as assisting the client in expressing feelings, assessing for causes of depression, and developing rapport, may be important for intervention after the primary goal of maintaining safety is met.
Which of the following is a primary risk factor for suicide? Social isolation Unemployment Poverty Economic deprivation
Correct response: Social isolation Explanation: Social isolation is a primary risk factor for suicide. Other social factors associated with suicide risk include economic deprivation, unemployment, and poverty, especially among young people.
Which question by a depressed, inpatient, psychiatric-mental health client should the nurse interpret as a potential suicide clue? "Are clients allowed to keep drugstore medications at their bedside?" "When is my next scheduled electroconvulsive therapy session?" "When do you think the doctor will let me get my street clothes back?" "Are we allowed to use the client kitchen whenever we want?"
Correct response: "Are clients allowed to keep drugstore medications at their bedside?" Explanation: Asking whether medications can be kept at the bedside is a suspicious question if a client is depressed and may precede an attempted overdose. The other questions are not necessarily suggestive of suicidal ideation.
The nurse is conducting an interview with an adult client who is being treated for major depression. What question should the nurse prioritize in an effort to determine the client's risk for suicide? "Do you ever feel like your situation is hopeless?" "How would you describe your relationship with your parents?" "Do you feel like your antidepressant is helping your mood?" "What are your plans for the next few days?"
Correct response: "Do you ever feel like your situation is hopeless?" Explanation: Hopelessness is a significant risk factor for suicide among persons who are depressed. For an adult client, relationships with parents are significant but not among the major risk factors for suicide. Similarly, the client's perception of medication effectiveness is important but not a key risk factor. It is common for depressed individuals to lack firm plans for their days, and a lack of planning does not necessarily indicate a heightened suicide risk.
Which is an accurate statement regarding women and suicide? They are less likely to complete suicide than men. They are more likely to choose a more lethal method than men. They are more likely to die from attempted suicide than men. They attempt suicide less often than men.
Correct response: They are less likely to complete suicide than men. Explanation: Women are less likely to complete a suicide than men, in part because they are more likely to choose a less lethal method. Women are less likely to die from an attempted suicide than men, but they attempt suicide more often.
The nurse is conducting an interview with an adult client who is being treated for major depression. What question should the nurse prioritize in an effort to determine the client's risk for suicide? "Do you ever feel like your situation is hopeless?" "How would you describe your relationship with your parents?" "Do you feel like your antidepressant is helping your mood?" "What are your plans for the next few days?" TAKE ANOTHER QUIZ
Correct response: "Do you ever feel like your situation is hopeless?" Explanation: Hopelessness is a significant risk factor for suicide among persons who are depressed. For an adult client, relationships with parents are significant but not among the major risk factors for suicide. Similarly, the client's perception of medication effectiveness is important but not a key risk factor. It is common for depressed individuals to lack firm plans for their days, and a lack of planning does not necessarily indicate a heightened suicide risk.
The nurse is seeing a client for counselling in a mental health clinic. The nurse notes the client has new superficial cuts to the inside of the upper forearm. Which is the best way for the nurse to discuss this observation with the client? "I notice some cuts on your arm. Am I correct to think that things have been difficult?" "I notice some cuts on your arm. Have you not been using the coping skills I taught you?" "I notice some cuts on your arm. Do you want me to put a dressing on the wounds?" "I notice some cuts on your arm. Are our counseling sessions not working for you?"
Correct response: "I notice some cuts on your arm. Am I correct to think that things have been difficult?" Explanation: Parasuicide is a voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death (e.g., taking a sublethal drug). Parasuicidal behavior varies by intent. Some people truly wish to die, but others simply wish to feel nothing for a while. Still others want to send a message about their emotional state. Parasuicide behavior is never normal and should always be taken seriously. Parasuicide occurs frequently in younger age groups but declines after the age of 44 years. The nurse should discuss the observation of the parasuicidal behavior with the client by communicating that he or she understands the client may be attempting to communicate that there is some social or emotional stress. The nurse should ask the client if the assumption that stress has led to this way of coping is correct to offer the client a sense of control over the personal experience of parasuicide. Asking the client if his or her coping skills are ineffective can elicit defensiveness in the client due feeling blamed or inadequate. In this case the cuts are superficial, therefore, likely do not need to be dressed.By asking if the client would like the wounds dressed, the nurse has not addressed the fact that the client is seeking support by having the cuts visible. If it is determined that the cuts are deeper and at risk for infection, further assessment and treatment of the cuts is warranted. As stated previously, making assumptions risks eliciting a defensive response from the client. Asking if the counseling sessions are not working for the client may hinder the relationship and take away from the therapeutic relationship.
The nurse is interviewing a client with a diagnosis of depression and the client states, "Honestly, I know my family would be a lot better off if I wasn't around to be a burden on them. That's just between you and me, though, okay?" What is the nurse's best response? "I'm obliged to share what we talk about with the other people on your care team." "Why is it important to you that this be kept between you and I?" "In my experience, nothing good ever comes of keeping secrets." "What can I do to get your permission to share with the other members of the care team?"
Correct response: "I'm obliged to share what we talk about with the other people on your care team." Explanation: The nurse has a binding obligation to communicate information suggesting a suicide risk to other members of the care team. The nurse should certainly assess the motivations for the client's desire for secrecy, but the priority is clearly communicating to the client that this is not possible. The nurse should avoid trite advice ("Nothing good ever comes ..."). The client's permission is not required to share this information, though the nurse should make efforts to preserve rapport and trust.
A psychiatric-mental health nurse is conducting an in-service education program about suicide for a group of nurses working at a community mental health center. The nurse determines that the teaching was successful based on which statement by the group? "Suicide is more of a concern in countries other than the United States." "Suicide does not occur in affluent neighborhoods, indicating poverty is a factor." "Suicide has profound effects on those connected to the individual." "Suicide rates among older adults are low."
Correct response: "Suicide has profound effects on those connected to the individual." Explanation: Suicide is a major public health concern, both in the United States and around the world. Although certain factors may increase risk for suicide, suicide knows no bounds of person, age, class, race, or gender. It is an act that profoundly affects those left in its wake. Suicide among the older adult population has increased.
When conducting a risk assessment for suicide, the nurse most likely identifies which client as having the greatest risk for completing suicide? A 50-year-old male client who lives on a farm outside the city A 30 year-old male client who is married with a new baby A 25-year-old female client who attends school full time A 30-year-old female client who had a baby three months prior
Correct response: A 50-year-old male client who lives on a farm outside the city Explanation: Males have a higher suicide completion rate four times more than females. Rural men have a much higher risk of suicide than urban men, and that gap is widening, perhaps attributable to the higher rates of gun ownership in rural areas. Unmarried, unsociable men between the ages of 42 and 77 years with minimal social networks and no close relatives have a significantly increased risk for committing suicide. The 50-year-old client living on a rural farm is the most likely in this list of clients to complete suicide. The 30-year-old male client with the new baby does not fit the profile of a client most likely to complete suicide. Females are more likely to attempt suicide but not kill themselves as a result of the attempt.
The nurse is preparing a community education session on suicide awareness. Which point should the nurse include in the presentation? A firearm in the home increases the risk that a person will complete suicide. Suicide is attributable solely to social and psychological factors. Being a Hispanic male poses the greatest risk for completing suicide. Suicide rates are lowest among adolescent minorities who identify as bisexual.
Correct response: A firearm in the home increases the risk that a person will complete suicide. Explanation: Access to firearms is associated with the risk of completed suicides, particularly for white males. In 2009, 51.8% of deaths from suicide were firearm related and most suicides occur in the victim's home. Firearm ownership in more prevalent in the United States than in any other country—approximately 35% to 39% of households have firearms. The nurse should be sure to include this in the educational session as this is a critical topic for discussion in suicide prevention in any age group. Suicide is attributable to a multitude of factors including biological and genetic factors. In 2014, suicide rate per 100,000 for white males was 23.3 versus for Hispanic males, the rate was 10.3. Although suicide is prevalent in the Hispanic population, it has been found to be the most common in white males. Depressive symptoms and suicidality rates in early adolescence are higher among bisexual minority youth than among heterosexual youth and these disparities persist into young adulthood. These disparities are largest for females and bisexually identified youth.
The nurse who is conducting a suicide risk assessment with a client determines the lethality of the plan is as high if which condition is present? A male client keeps a loaded firearm in the closet A female client has several bottles of over-the-counter medications An adolescent client refuses to consume any more food An older adult client verbalizes the desire to drown in the river
Correct response: A male client keeps a loaded firearm in the closet Explanation: In each of the answer options, the client has some level of personal risk for self-harm or suicide. However, the client who is at highest risk of lethality is the male client with direct access to a firearm. Lethality is determined by the seriousness of the person's intent and the likelihood that the planned method of death will succeed. A plan to use an accessible firearm to commit suicide has greater lethality than the other options listed. Males are also more likely to be successful with following through with a suicide plan than other groups.
The nurse is told by a client that the client is having suicidal thoughts. Which intervention has lowest priority? Assessing the client for past history of suicidal attempts Determining the client's concerns and if the client has a plan Administering a mental status exam to assess for psychosis Maintaining a safe, secure environment
Correct response: Administering a mental status exam to assess for psychosis Explanation: About 50% to 80% of people who commit suicide have previously attempted suicide; the more violent and lethal the plan, the higher the potential for suicide. Assessment of past attempts and current plan (not psychosis) as well as maintaining client safety would be priorities. Maintaining a safe, secure environment is an important intervention by the nurse to prevent a suicide attempt.
The nurse caring for a client who is high risk for suicide on a psychiatric inpatient unit can help the client re-establish a sense of control by including what in the client's care? Asking the client about diet preferences for meals Ensuring the client's room door remains locked at all times Observing the client at regular intervals Administering medication to decrease acting out behaviors
Correct response: Asking the client about diet preferences for meals Explanation: Nurses can help clients reestablish personal control by including them in decisions about their care and restricting their behavior only as necessary. Including the client in his or her own care by ensuring diet preferences are honored is a means to give the client a sense of control. Ensuring the client's room door remains locked at all times may serve to increase the client's distress, therefore, it does not help the client re-establish a sense of control. Observation is not, in itself, therapeutic. An observation becomes therapeutic when interaction occurs with the patient. Administering medication for acting out behaviors does not offer the client a sense of control. As needed medication should be administered to client's when the level of distress is so high the client may be at risk to him/herself or others.
The policies and procedures at a community psychiatric-mental health center include an emphasis on case finding. How can a nurse at the center best perform case finding? Assessing all clients carefully to identify those at risk for suicide Modifying the center's environment to maximize client safety Organizing the layout of the center to allow observation of clients Encouraging clients not to be ashamed of previous suicide attempts or suicidal thoughts
Correct response: Assessing all clients carefully to identify those at risk for suicide Explanation: Case finding involves the identification of people who are at risk for suicide so that proper treatment can be initiated. Modifying the layout of the center would not be necessary in order to carry out the necessary assessments. Observation would not be a part of community-based care. The nurse should address the shame that often accompanies suicide, but this action is not a key component of case finding.
A client has just been admitted to the inpatient psychiatry unit following a suicide attempt. During the client's first 24 hours of care, what outcome should be identified? Client will express that the client feels safe on the unit Client will implement strategies for managing stress Client will participate actively in cognitive behavioral therapy Client will state that the client feels optimistic about the client's future
Correct response: Client will express that the client feels safe on the unit Explanation: The initial care of a client who has had a suicide attempt focuses on helping the client feel safe and instilling the beginnings of hope. It would be premature to expect the client to learn and apply new stress management strategies after only 24 hours. Cognitive behavioral therapy would not begin during the acute stage of recovery. A sense of overall optimism will likely require long-term therapy to achieve it.
When a nurse assesses prior self-harm behavior, this can provide information about the motivation behind the client's actions and allows the nurse to do what? Communicate concern and empathy to the client Provide an understanding of the reactions of others Create a judgmental attitude Ignore the past attempts and focus on the here and now
Correct response: Communicate concern and empathy to the client Explanation: Assessing the context of each act of prior self-harm behavior begins to paint a picture of motivation behind the behavior. Exploration of prior behavior also gives a message of interest and concern on the part of the health professional.
A recent sentinel event involving a suicide attempt on a psychiatric-mental health unit has prompted a reevaluation of practices on the unit. What action is most likely to reduce the incidence of suicide on the unit. Conducting a survey the unit facilities and practices to ensure items that can be used for hanging are unavailable Reconfiguring medication delivery practices so that clients cannot see other clients taking medications Introducing a "buddy" system for staff to ensure that nurses are not alone with clients unless absolutely necessary Increasing patients' access to cognitive behavioral therapy early in their admission
Correct response: Conducting a survey the unit facilities and practices to ensure items that can be used for hanging are unavailable Explanation: Hanging is used in 75% of inpatient suicides. Consequently, efforts to eliminate the necessary equipment have the potential to reduce the risk. The described change in medication delivery is not relevant to suicide risk. Similarly, a buddy system for nurses will have no appreciable effect on suicide risk. For some patients, cognitive behavioral therapy may be useful, but this is not the case for all patients.
A client has been successfully treated on the psychiatric mental health unit following a suicide attempt. In preparation for discharge, the nurse should prioritize what action? Ensuring a plan is in place for the client's community-based care Ensuring that the client has created a commitment to treatment statement Documenting the client's psychiatric advance directive Communicating with the pharmacy where the client will obtain prescribed medications
Correct response: Ensuring a plan is in place for the client's community-based care Explanation: Following a suicide attempt, it is imperative that a plan be in place for continuity of care in the community. Arrangements such as advance directives and commitment to treatment statements are optional, not mandatory. Communication with the pharmacy is just one component of a discharge plan and is not necessary in every circumstance.
Following the failure of a woman's recent in vitro fertilization (IVF), the nurse recognizes that she may be at risk of depression. Which intervention is considered a primary suicide prevention measure? Establishing a support system for the woman and teaching her some coping measures Beginning treatment with a selective serotonin reuptake inhibitor Placing the woman on suicide precautions and establishing a no-suicide contract Beginning a course of therapy with a nurse-therapist or psychologist
Correct response: Establishing a support system for the woman and teaching her some coping measures Explanation: Primary prevention involves the identification and elimination of factors that cause or contribute to the development of an illness or disorder that could lead to suicide. Medication management, psychotherapy, and suicide precautions are more aggressive measures that would not be classified as primary prevention.
The nurse is assessing a client for warning signs of suicide. Which would be a concern? The client has decreased substance use. The client is reaching out to family and friends. The client has forgiven those who have caused emotional pain. The client has engaged in risky behaviors and tends to be impulsive.
Correct response: The client has engaged in risky behaviors and tends to be impulsive. Explanation: According to the "Is Path Warm" mnemonic, a risk factor for suicide is risk-taking behavior without thinking.
A client has admitted to the nurse that the client is "tempted to end it all." How can the nurse prevent a future malpractice lawsuit if the client makes a suicide attempt? Promptly act on, and document, the client's statement. Verbally communicate the client's statement to the psychiatrist immediately. Facilitate a prompt referral to the psychiatric-mental health advanced practice registered nurse. Inform a colleague about the client's statement as soon as possible.
Correct response: Promptly act on, and document, the client's statement. Explanation: Prompt action and documentation are the best defenses against a future lawsuit. Verbal communication does not constitute proof of the nurse's due diligence. A referral may be needed, but this in itself does not prove the timeline of the nurse's actions.
A 20-year-old college student has been admitted to the emergency department after taking an overdose of Acetaminophen (Tylenol). Which of the following nursing diagnoses should be prioritized in the care of this client after she is medically stabilized? Impaired Social Interaction related to alienation secondary to depressive behavior Hopelessness as evidenced by recent suicide attempt Risk for Violence, Self-Directed, related to recent suicide attempt Ineffective Coping as evidenced by recent suicide attempt
Correct response: Risk for Violence, Self-Directed, related to recent suicide attempt Explanation: The client's risk for subsequent suicide attempts is a priority over other psychosocial diagnoses, even though these are each likely applicable in this client's case.
Family education concerning the safe care of a client with a history of suicide attempts includes what? Select all that apply. Signs and symptoms that indicate a mood change that could indicate the client is suicidal Information regarding the stressors that trigger the client's suicidal ideations Techniques to help the client cope with known triggers List of emergency service telephone numbers Information on how to determine if the threat of suicide is legitimate
Correct response: Signs and symptoms that indicate a mood change that could indicate the client is suicidal Information regarding the stressors that trigger the client's suicidal ideations Techniques to help the client cope with known triggers List of emergency service telephone numbers Explanation: Family education should include information regarding recognizing changes in mood or behavior that could indicate a plan for self-injury (e.g., irritability, anger, agitation, withdrawal, or self-deprecating comments) and notify the client's health care provider. It should also include how to anticipate future stressors that trigger the client, along with information regarding how to assist the client with coping skills. Also important to family education is information regarding a 24-hour emergency hotline phone number—and the need to keep the information readily available.
Trying to kill oneself and surviving the ordeal is identified as what? Suicide attempt Parasuicide Suicidal behavior Suicidal ideation
Correct response: Suicide attempt Explanation: An attempt of suicide can be characterized as living through an experience of suicide despite having expected or intended to die.
The nurse has been contacted by the parent of an adolescent who has posted a note on social media about the desire to kill oneself. Which additional sign is a warning that there is an acute risk of suicide for the client? The client has been stealing prescription medication from home. The client has been experiencing increased anxiety. The client has appeared more angry lately. The client has experience changes in sleep pattern.
Correct response: The client has been stealing prescription medication from home. Explanation: According to the American Association for Suicidology, warning signs for acute risk for suicide include a threat to hurt or kill the self, and/ or looking for ways to kill the self such as with available pills or others means. The alternative answer options listed are also warning signs for suicide, however, they are considered expanded warning signs and are not captured within 'acute risk.' Nonetheless, the expanded factors must be taken into account when the acute factors are present as they serve to heighten the risk that the client will engage in a suicidal act.
The nurse is working with an inpatient who has a history of suicide attempts. What action by the client should the nurse follow up on because it may constitute a suicide planning behavior? The client has requested extra bedding despite the warm weather The client has begun stockpiling food in the room The client is consistently late in coming to the nurses' station to receive scheduled medications The client states that the client is agitated and would like to be in the comfort room
Correct response: The client has requested extra bedding despite the warm weather Explanation: A depressed client's request for extra sheets or blankets, especially during warm weather, should signal the nurse to the possibility of a hanging attempt. The nurse should address the client's food stockpiling and being late for medications, but these are less likely to be suicide planning behaviors. The nurse must always carefully assess clients' requests to be in a comfort room, but this is less likely to be a suicide planning behavior than an unwarranted request for bedding.
The nurse is assessing a client who has presented to the emergency department in emotional distress. What client data represents the greatest risk for suicide? The client overdosed on pills 2 years earlier The client states, "Everything just seems really dark right now." The client has been treated with a variety of antidepressants over the years. The client sits silently after being asked several of the assessment questions
Correct response: The client overdosed on pills 2 years earlier Explanation: The greatest predictor of suicide risk is a previous attempt. All of the other listed variables must be addressed, but none is as significant a risk factor as a previous suicide attempt.
For which client would the nurse be obligated to take immediate and focused action to prevent imminent death? The client with depression who has been using alcohol and owns a gun The client with depression who lives in poverty and has chronic pain The client with depression who is withdrawn and spends most of the time playing video games The client who is grieving is often tearful and does not want to be left alone
Correct response: The client with depression who has been using alcohol and owns a gun Explanation: A true psychiatric emergency exists when an individual presents with one or more symptoms associated with imminent risk for suicidal behavior. Immediate and focused action is needed to prevent the patient's death. The client who is depressed, using alcohol and has access to the most lethal means to commit suicide is the highest risk and requires imminent intervention. The client who is depressed, lives in poverty and has chronic pain meets criteria for someone at risk, however, the risk in this case is not imminent and would not warrant immediate intervention. The client who is depressed, withdrawn and spending most of the time playing video games would certainly warrant assessment and therapeutic intervention, however, based on the information provided the client would not be deemed an imminent risk. The grieving client who is tearful and does not want to be left alone is experiencing a normative response to death and does not meet the criteria for imminent suicide intervention.
A patient is being treated for depression on the psychiatric mental health unit. The nurse can best promote the patient's development of an effective crisis management plan by: helping the patient create a written outline of strategies that can be applied. describing the unit's crisis management protocol and applying it to the patient's circumstances. educating the client about many of the distortions in thinking that characterize depression. presenting the patient with research evidence about coping strategies.
Correct response: helping the patient create a written outline of strategies that can be applied. Explanation: A written crisis management plan, developed by the patient, is a proven strategy for countering some of the thinking that leads to suicide. The plan must be individualized and cannot be imposed from a unit policy. Teaching about the thinking that characterizes depression is appropriate, but does not directly result in a crisis management plan. Similarly, presenting evidence will not necessarily lead to the development of a plan.
Which is the greatest predictor of a future suicide attempt? previous attempt degree of hopelessness suicide planning seriousness of suicidal ideation
Correct response: previous attempt Explanation: The greatest predictor of a future suicide attempt is a previous attempt, in part because that individual already has broken the "taboo" around suicidal behavior. Assessing for risk includes determining the seriousness of the suicidal ideation, degree of hopelessness, and suicide planning.
The nurse is caring for an inpatient who has a diagnosis of depression and who describes pervasive thoughts of suicide this morning. In order to redirect this patient's current mindset, the nurse should: provide the patient with meaningful and appropriate distraction. administer a PRN benzodiazepine as prescribed. administer the patient's scheduled sustained serotonin reuptake inhibitor. ask another patient to engage the patient in conversation.
Correct response: provide the patient with meaningful and appropriate distraction. Explanation: Distraction can be beneficial in the short-term management of suicidal thoughts. Medications are not normally used for redirection of thinking in the short term. It is not appropriate to delegate care to another patient.
What is the primary nursing concern related to a depressed client who has been taking amitriptyline 50 mg three times a day for the past 3 weeks? anxiety ineffective coping risk for self-injury chronic low self-esteem
Correct response: risk for self-injury Explanation: Clients with depression are at increased risk for suicide when they have been on antidepressant medication for 2 weeks, because they are regaining some energy but may not have achieved full therapeutic effect with mood improvement. Poor coping is important but it is not the priority. Evidence of noncompliance is lacking. The medication is not prescribed for anxiety disorders.
When assessing risk of suicide, which are important assessment components? Select all that apply. seriousness of suicidal ideation degree of hopelessness previous attempt lethality of method Unemployment
Correct response: seriousness of suicidal ideation degree of hopelessness previous attempt lethality of method Explanation: Assessing for suicide risk includes determining the seriousness of the suicidal ideation, degree of hopelessness, disorders, previous attempt, suicide planning and implementation, and availability and lethality of the suicide method.
People who complete suicide often have extremely low levels of which neurotransmitter? serotonin acetylcholine norepinephrine GABA
Correct response: serotonin Explanation: People who complete suicide often have extremely low levels of the neurotransmitter serotonin. Impairments in the serotonergic system contribute to suicidal behavior. People who make near-lethal suicide attempts have much lower levels of the neurotransmitter dopamine and omega-3. Low levels of the other neurotransmitters have not been implicated in completed suicides.