ch 22 psych! suicide prevention: assessment and screening
Which question by a depressed, inpatient, psychiatric-mental health client should the nurse interpret as a potential suicide clue? "When is my next scheduled electroconvulsive therapy session?" "Are clients allowed to keep drugstore medications at their bedside?" "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?"
"Are clients allowed to keep drugstore medications at their bedside?" 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.
A psychiatric-mental health nurse performs weekly visits to a youth center. The nurse should recognize the highest risk of suicide among what client of the center? A teenage girl who has been ostracized by her best friend A teenage boy who is often bullied after disclosing that he is gay A boy whose family recently emigrated from Southeast Asia and who has a language barrier A 16 year-old girl who has recently found out that she is pregnant
A teenage boy who is often bullied after disclosing that he is gay Each client is facing significant life changes that constitute risk factors for suicide. However, youth who are lesbian, gay, bisexual and transgender are at a particularly high risk.
The community mental health nurse is providing care for a large number of clients. What client should the nurse monitor most closely for the warning signs of suicide? An adult female who is mourning the death of her husband 5 months ago A young male with schizophrenia who is in danger of becoming homeless A middle-aged female client who is receiving treatment for obsessive-compulsive disorder An older adult client who has recently been diagnosed with early stage Alzheimer disease
A young male with schizophrenia who is in danger of becoming homeless Being a young male, having a mental illness, and facing a situational crisis are all significant risk factors for suicide. This constellation of factors is likely to create a greater risk for suicide than a client with a new diagnosis of dementia, a bereaved client, or a client with obsessive-compulsive disorder.
After being diagnosed with a chronic disease, a client has been feeling depressed. Which diagnosis has the strongest association with an increased suicide risk? Congestive heart failure Coronary heart disease Chronic obstructive pulmonary disease Acquired immunodeficiency syndrome
Acquired immunodeficiency syndrome The World Health Organization notes that chronic physical illness and certain physical illnesses contribute to higher suicide risk in some individuals. Neurologic diseases such as epilepsy and spinal and brain injury have been associated with increased suicide risk. HIV infection and AIDS also pose increased suicide risk, particularly at the time of diagnosis. Pain also has been identified as a significant contributing factor.
The nurse is planning a presentation about suicide to a group of health professionals. Which should be included in the nurse's teaching plan? The most common method of committing suicide is the use of sleeping pills. Suicide rates for women are highest among women with children. Men are more likely to commit suicide than women are. Suicide tends to be most prevalent in the those in the age group of 30 to 40.
Men are more likely to commit suicide than women are. 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? Remove means of suicide from the client's access. Provide mood-stabilizing medications per physician order. Communicate a desire to help the client. Determine the course of the client's suicidal thoughts.
Remove means of suicide from the client's access. 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.
A nurse is assessing several clients. Which factor would the nurse most likely identify as increasing a client's risk for committing suicide? Female gender High self-esteem Social isolation History of anorexia during adolescence
Social isolation Social isolation is a primary risk factor for suicide as well as male gender, low self-esteem, and a history of mental illness during adolescence, most commonly depressive disorders and personality disorders
Which of the following is a primary risk factor for suicide? Economic deprivation Poverty Unemployment Social isolation
Social isolation 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.
A 50-year-old client who has recently been diagnosed with a chronic degenerative illness has announced to the nurse the intention to commit suicide in order to prevent future suffering. Which fact should underlie the nurse's response to this client? The nurse is required to document the client's wishes and begin to facilitate an assisted suicide. The nurse is obliged to protect the client from self-harm. The nurse is ethically obliged to inform law enforcement. The nurse must refer the client to a physician who is authorized to assist the client with a suicide.
The nurse is obliged to protect the client from self-harm. While the nurse is not obliged to inform law enforcement, he or she is ethically obligated to protect the client from self-harm. Participation or referral for assisted suicide has not been recognized as an acceptable component of nursing practice.
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.
They are less likely to complete suicide than men. 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.
A nurse maintains a safe environment for a client who is suicidal by ... ensuring the client has access to all personal belongings to make the client feel at home. observing the client frequently. maintaining confidentiality at all times with the client. creating a stimulating environment.
observing the client frequently. Maintaining a safe environment includes observing the client frequently for suicidal behavior, removing dangerous objects, and providing counseling opportunities for the client.
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: administer the patient's scheduled sustained serotonin reuptake inhibitor. administer a PRN benzodiazepine as prescribed. ask another patient to engage the patient in conversation. provide the patient with meaningful and appropriate distraction.
provide the patient with meaningful and appropriate distraction. 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.
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? "What can I do to get your permission to share with the other members of the care team?" "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."
"I'm obliged to share what we talk about with the other people on your care team." 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.
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? "How would you describe your relationship with your parents?" "What are your plans for the next few days?" "Do you feel like your antidepressant is helping your mood?" "Do you ever feel like your situation is hopeless?"
"Do you ever feel like your situation is hopeless?" 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.
When talking with the spouse of a client who attempted suicide, the psychiatric nurse demonstrates understanding of the priority areas of assessment by asking which questions? Select all that apply. "Looking back on it, did your spouse give you any clue that he or she was suicidal?" "Does your spouse harm himself or herself physically when stressed?" "Who will be responsible for getting your spouse to weekly hospital therapy sessions?" "Has your spouse attempted to kill himself or herself by injuring him- or herself." "Has your spouse ever been psychiatrically unstable before?"
"Does your spouse harm himself or herself physically when stressed?" "Has your spouse attempted to kill himself or herself by injuring him- or herself." Case finding requires careful and concerned questioning and listening that make the client feel valued and cared about. Similar questions can be used when talking with the spouse of a client who attempted suicide, the psychiatric nurse shows an understanding of the priority areas of assessment by the following: "Does your spouse harm himself or herself physically when stressed?"; "Has your spouse attempted to kill himself or herself by injuring him- or herself?" Asking about who will be responsible for getting the client to therapy sessions, if the client has ever been psychiatrically unstable, or if the client gave any clues do not provide information needed to determine suicide risk. People who are contemplating suicide often do not share their ideation. This lack of disclosure often means that family, friends, and health professionals are unable to intervene until the suicidal ideation and planning have progressed.
The nurse provides care for a client who is depressed and expresses hopelessness with the current situation. Which client statement indicates a need to implement safety precautions? "I haven't been able to sleep for the past week because I am anxious." "I just started my new medication and I hope to feel better soon." "I just started a new job so at least I have that." "I decided that I should stop drinking alcohol for a while."
"I haven't been able to sleep for the past week because I am anxious." Identification of clients who are considering suicide is a priority nursing action. The nurse can use the mnemonic IS PATH WARM to assess the client for warning signs for suicide. The A in this mnemonic stands for anxiety and may be manifested by an inability to sleep; therefore, the statement that indicates a need to explore the implementation of safety precautions is, "I haven't been able to sleep for the past week." Starting a new antidepressant and stating, "I hope I feel better soon; I decided that I should stop drinking alcohol for a while; I just started a new job so at least I have that." do not correspond with any of the warning signs for suicide.
The nurse is seeing a client for counseling 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. Do you want me to put a dressing on the wounds?" "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. Are our counseling sessions not working for you?"
"I notice some cuts on your arm. Am I correct to think that things have been difficult?" 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 assessing a female client who discloses she is having thoughts of killing herself. The client tells the nurse she owns a gun. The client tells the nurse she is not ready for anyone to know she feels this way and would prefer that the information not be shared with anyone else. What is the nurse's best response? "You are high risk for harming yourself. I am obligated by law to disclose what you just told me." "This must be so difficult for you to share. I will respect your privacy and let you disclose when you are ready." "You are a individual with rights. You have the right to privacy, however, you should tell family members." "I'm going to keep you safe. In order to do that I need to share how you are feeling with the health care team."
"I'm going to keep you safe. In order to do that I need to share how you are feeling with the health care team." Under no circumstances should a patient be promised secrecy about suicidal thoughts, plans, or acts. Instead, tell patients that disclosure of suicidal intent will be shared with other interdisciplinary team members so the safety of the patient can be ensured. The response options in which the nurse does not disclose the client's desire to harm herself along with the added risk of the firearm heighten the risk that the client will carry out the suicide attempt. The response in which the nurse indicates there is an obligation by law to disclose what the client just stated is not a therapeutic approach. The nurse risks losing the client's trust and establishing a therapeutic relationship for treatment.
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 female client has several bottles of over-the-counter medications An older adult client verbalizes the desire to drown in the river A male client keeps a loaded firearm in the closet An adolescent client refuses to consume any more food
A male client keeps a loaded firearm in the closet 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? Maintaining a safe, secure environment Determining the client's concerns and if the client has a plan Administering a mental status exam to assess for psychosis Assessing the client for past history of suicidal attempts
Administering a mental status exam to assess for psychosis 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 conducts a seminar regarding suicide at the community center. Which fact about suicide should the nurse include in the teaching session? An active suicidal ideation is often short term and specific to the situation. Suicide only affects people who are diagnosed with a mental health condition. Most cases of suicide happen very suddenly with no warning signs. Suicide should not be spoken about of because this encourages it.
An active suicidal ideation is often short term and specific to the situation. There are many myths about suicide that must be clarified with factual information; this is essential to decreasing the stigma associated with suicide. A fact about suicide that the nurse should include in the seminar is that active suicidal ideation is often short term and specific to the situation that individual is currently facing. The other statements regarding suicide are myths.
The nurse is seeing a 43-year-old client whose spouse just died by suicide. Which is a common emotional response that the nurse should anticipate from this client? Unpredictable behavior and a potential for risk-taking behaviors Turning toward alcohol or drugs The development of a panic disorder Anger toward the loved one who committed suicide
Anger toward the loved one who committed suicide Some of the emotional responses suicide survivors may experience include feelings of unreality, shock, disbelief, and emotional numbness; grief, sadness, and despair; confusion over not knowing why the loved one chose suicide; anger toward the mental health practitioner, another family member, or a friend for failing to prevent the suicide; self-anger and guilt for failing to prevent the suicide; feelings of anger toward and betrayal by the loved one who committed suicide; and social stigmatization and isolation.
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 Administering medication to decrease acting out behaviors Observing the client at regular intervals
Asking the client about diet preferences for meals 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? Organizing the layout of the center to allow observation of clients Modifying the center's environment to maximize client safety Encouraging clients not to be ashamed of previous suicide attempts or suicidal thoughts Assessing all clients carefully to identify those at risk for suicide
Assessing all clients carefully to identify those at risk for suicide 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.
How can nurses contribute with knowledge of early intervention to make a difference when responding to an active suicidal client? By allowing client to have time alone By living close by a health clinic By encouraging clients to not think about suicide By knowing how to engage and respond
By knowing how to engage and respond Nurses are in a unique position to contribute to preventive efforts. With knowledge of early risk assessment and interventions—understood within the context of a person's family, social world, and broader community—as well as knowledge of how to engage with and respond to the actively suicidal person, nurses can make a difference.
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 implement strategies for managing stress Client will state that the client feels optimistic about the client's future Client will participate actively in cognitive behavioral therapy Client will express that the client feels safe on the unit
Client will express that the client feels safe on the unit 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.
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 Increasing patients' access to cognitive behavioral therapy early in their admission Introducing a "buddy" system for staff to ensure that nurses are not alone with clients unless absolutely necessary Reconfiguring medication delivery practices so that clients cannot see other clients taking medications
Conducting a survey the unit facilities and practices to ensure items that can be used for hanging are unavailable 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 Communicating with the pharmacy where the client will obtain prescribed medications Documenting the client's psychiatric advance directive Ensuring that the client has created a commitment to treatment statement
Ensuring a plan is in place for the client's community-based care 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? Beginning a course of therapy with a nurse-therapist or psychologist Placing the woman on suicide precautions and establishing a no-suicide contract Establishing a support system for the woman and teaching her some coping measures Beginning treatment with a selective serotonin reuptake inhibitor
Establishing a support system for the woman and teaching her some coping measures 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.
Which statement regarding gender and suicide is correct? Females engage in suicidal behaviors more frequently than males. Females are more likely to die by firearm than males. Females are more likely than males to die from suicide. Females choose more violent means of suicide than males.
Females engage in suicidal behaviors more frequently than males. While females engage in suicidal behaviors approximately three times more frequently than males, males are at least four times more likely to die from suicide. This outcome may be because men generally tend to choose more violent methods. In the United States, two thirds of male suicide victims die by firearm. The most common cause of death by suicide in women is overdose or poisoning.
A psychiatric mental health nurse is administering scheduled medications to several inpatients on the unit with depression and at high risk for suicide. Which medication would the nurse expect to administer to assist in reducing the patient's risk of suicide? Select all that apply. fluoxetine haloperidol valproic acid diazepam citalopram
Fluoxetine Citalopram Medication management focuses on treating the underlying psychiatric disorder. For depression, a nonlethal antidepressant, such as a selective serotonin reuptake inhibitor, usually will be prescribed. SSRI's such as fluoxetine and citalopram increase serotonin levels; low serotonin levels have been linked to suicide. Benzodiazepines (diazepam), mood stabilizers (valproic acid) and typical antipsychotics (haloperidol) do not have this effect on serotonin levels.
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 Giving away valued personal items Inquiry about doses of lethal drugs Experiencing the loss of a boyfriend or girlfriend
Giving away valued personal items 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 caring for an adolescent client who returned to the psychiatric unit from therapeutic pass with superficial cuts to the insides of both forearms. The nurse knows the client is engaging in which self-harm behavior? Copycat suicide Volition Suicide attempt Parasuicide
Parasuicide Parasuicide is a voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death. The client who has superficial cuts to the insides of the forearms is either engaging in maladaptive coping in response to distress or communicating hopelessness without directly engaging in an act that ends life. Parasuicide occurs frequently in younger age groups but declines after the age of 44 years. A suicide attempt differs from parasuicide in that it is a nonfatal, self-inflicted destructive act with explicit or implicit intent to die. Volition refers to the progression from suicide ideation to suicide attempt in which the client gains clarity in the method by which he or she intends to end their own life. A copycat suicide refers to the phenomenon where there is a rise in the number of suicides that are attempted or completed in the same manner as a public figure or celebrity whose suicide has had significant media attention.
A newly admitted client's history includes multiple suicide attempts. How can the nurse on the psychiatric-mental health unit best protect the client's safety? Establishing a no-suicide contract with the client Performing vigilant assessment and close observation Administering the client's prescribed selective serotonin reuptake inhibitor Facilitating a referral for cognitive behavioral therapy
Performing vigilant assessment and close observation Assessment and observation are among the core nursing actions to prevent suicide. Medication is a cornerstone of treatment but does not prevent suicide in and of itself. No-suicide contracts have not been shown to be effective. Therapy is not always indicated for all clients and does not supersede assessment and observation as a safety measure.
A client on the inpatient psychiatric-mental health unit was discovered attempting to asphyxiate himself or herself using a blanket. Which measure should the care team prioritize in the client's immediate care? Managing the client's anxiety Assessing the specific motivation for the client's attempted suicide Placing the client under constant observation Teaching the client improved coping skills
Placing the client under constant observation The need for safety and suicide prevention supersedes the importance of client education, anxiety management, and assessment of the client's motivations. To prevent further suicide attempts, the safest approach is to monitor the client constantly until stabilized.
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. Develop rapport based on trust and understanding. Prevent self-destructive behavior. Assess the cause of his or her depression.
Prevent self-destructive behavior. 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.
A high risk for suicide would be assessed as what? Feelings of self-worth Previous suicidal behavior Support systems available Adequate sleep pattern
Previous suicidal behavior Previous suicidal behaviors increase the risk of suicide.
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? Facilitate a prompt referral to the psychiatric-mental health advanced practice registered nurse. Promptly act on, and document, the client's statement. Inform a colleague about the client's statement as soon as possible. Verbally communicate the client's statement to the psychiatrist immediately.
Promptly act on, and document, the client's statement. 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 client with a diagnosis of schizophrenia has been admitted to the psychiatric mental health unit following a suicide attempt. Shortly after admission, the client has agreed to a commitment to treatment statement (CTS). What effect will the CTS have on the client's inpatient care? The client explicitly agrees to participate in all aspects of treatment The client waives his right to make decisions about his care The client waives his status as legally competent The client specifies which treatments he is willing to participate in
The client explicitly agrees to participate in all aspects of treatment A CTS is a commitment to engage in treatment and access emergency care when necessary. It does not mean that the client waives his legal rights his ethical right to make decisions. A CTS is not a document that specifies which treatments the client desires.
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 experiencing increased anxiety. The client has been stealing prescription medication from home. The client has appeared more angry lately. The client has experience changes in sleep pattern.
The client has been stealing prescription medication from home. 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 assessing a client for warning signs of suicide. Which would be a concern? The client has engaged in risky behaviors and tends to be impulsive. 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. According to the "Is Path Warm" mnemonic, a risk factor for suicide is risk-taking behavior without thinking.
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 sits silently after being asked several of the assessment questions The client has been treated with a variety of antidepressants over the years.
The client overdosed on pills 2 years earlier 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 who is grieving is often tearful and does not want to be left alone 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 with depression who has been using alcohol and owns a gun 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.
The nurse is facilitating a support group for people who have lost a family member or friend to suicide. When discussing strategies for coping with grief, which should the nurse include? Select all that apply. cognitive behavioral therapy completing a daily journal entry before bedtime writing out the events leading up to the loved one's suicide take anti-anxiolytic medications as often as possible encourage time spent in solitude
completing a daily journal entry before bedtime writing out the events leading up to the loved one's suicide cognitive behavioral therapy The intensity and duration of the post-suicide grief process for many survivors has led to the development of family intervention programs. Although the evidence base for these interventions is still small, strategies that support a positive sense of self, enhance problem-solving such as that embedded within cognitive behavioral therapy, promote the formation of a suicide story, encourage social reintegration, reduce stigma, use journaling, or permit the survivor to debrief may be effective in reducing subjective distress and to resolve grief. Clients should be encouraged to spend time with others, not only to encourage social reintegration, but also because recovery from grief may be most effective when delivered in survivor peer help groups. Although clients may benefit from medications for relief of anxiety symptoms early in post-suicide, anti-anxiolytic medication is not an effective long term coping strategy and may delay an adaptive recovery process for survivors.
Which mental health disorder has the most significant risk factor for suicide? anxiety schizophrenia mania depression
depression Depression is a major risk factor of suicide. Anxiety, schizophrenia, and mania are significant risk factors but to a lesser degree than depression.
A nurse is reviewing the medical record of a young client to determine the client's risk for suicide. Which factor would alert the nurse to an increased risk for this client? fears of growing older experiencing unemployment that has lasted a year diagnosed with an acute illness starting a new business with friends
experiencing unemployment that has lasted a year Social factors associated with suicide risk include economic deprivation, unemployment, and poverty, especially among the younger population. Internal distress, low self-esteem, and interpersonal distress have long been associated with suicide. Cognitive risk factors include problem-solving deficits, impulsivity, rumination, and hopelessness. Impulsivity, anger, and reduced inhibition increase the risk of suicide. Fear of growing older is not a common concern for this population. With the likelihood of a positive outcome, acute illness is not generally viewed as being hopeless. Chronic medical illnesses increase the likelihood of chronic depression, which in turn contributes to the increased suicide rate of those older than the age of 65 years. While starting a new business may create a degree of anxiety, it is usually viewed with hopefulness and enthusiasm.
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: 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. helping the patient create a written outline of strategies that can be applied. presenting the patient with research evidence about coping strategies.
helping the patient create a written outline of strategies that can be applied. 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.
