Chapter 11: Suicide Prevention - Combined (Townsend)

19. Which nursing intervention strategy is most appropriate to implement initially with a suicidal client? A. Ask a direct question such as, Do you ever think about killing yourself? B. Ask client, Please rate your mood on a scale from 1 to 10. C. Establish a trusting nurseclient relationship. D. Apply the nursing process to the planning of client care.

A. Ask a direct question such as, Do you ever think about killing yourself?

24. A client has been brought to the emergency department for signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation? A. Assessing the clients pulse oximetry and vital signs B. Developing a plan for safety for the client C. Assessing the client for suicidal ideations D. Establishing a trusting nurse client relationship

A. Assessing the clients pulse oximetry and vital signs

25. After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply. A. I cant believe this is happening. B. If only I had been more understanding. C. How dare he do this to me! D. I'm just going to have to accept that he was gay. E. Well, that was a selfish thing to do.

A. I cant believe this is happening. B. If only I had been more understanding. C. How dare he do this to me!

26. A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? Select all that apply. A. In the Middle Ages, suicide was viewed as a selfish and criminal act. B. During the Roman Empire, suicide was followed by incineration of the body. C. Suicide was an offense in ancient Greece, and a common-site burial was denied. D. During the Renaissance, suicide was discussed and viewed more philosophically. E. Old Norse traditionally set a person who committed suicide adrift in the North Sea.

A. In the Middle Ages, suicide was viewed as a selfish and criminal act. C. Suicide was an offense in ancient Greece, and a common-site burial was denied. D. During the Renaissance, suicide was discussed and viewed more philosophically.

2. A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, Im going to use a knotted shower curtain when no one is around. Which information would determine the nurses plan of care for this client? A. The more specific the plan is, the more likely the client will attempt suicide. B. Clients who talk about suicide never actually commit it. C. Clients who threaten suicide should be observed every 15 minutes. D. After a brief assessment, the nurse should avoid the topic of suicide.

A. The more specific the plan is, the more likely the client will attempt suicide.

4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurses priority at this time? A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client to share mood improvement in group. C. Increase frequency of client observation. D. Request that the psychiatrist reevaluate the current medication protocol.

C. Increase frequency of client observation.

20. A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this clients risk for suicide? A. Encouraging participation in the milieu to promote hope B. Developing a strong personal relationship with the client C. Observing the client at intervals determined by assessed data D. Encouraging and redirecting the client to concentrate on happier times

C. Observing the client at intervals determined by assessed data

11. A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include? A. Elderly people use less lethal means to commit suicide. B. Although the elderly make up less than 13% of the population, they account for 16% of all suicides. C. Suicide is the second leading cause of death among the elderly. D. It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality.

B. Although the elderly make up less than 13% of the population, they account for 16% of all suicides.

10. After years of dialysis, an 84-year-old states, Im exhausted, depressed, and done with these attempts to keep me alive. Which question should the nurse ask the spouse when preparing a discharge plan of care? A. Have there been any changes in appetite or sleep? B. How often is your spouse left alone? C. Has your spouse been following a diet and exercise program consistently? D. How would you characterize your relationship with your spouse?

B. How often is your spouse left alone?

22. Which statement indicates that the nurse is acting as an advocate for a client who was hospitalized after a suicide attempt and is now nearing discharge? A. I must observe you continually for 1 hour in order to keep you safe. B. Lets confer with the treatment team about the resources that you may need after discharge. C. You must have been very upset to do what you did today. D. Are you currently thinking about harming yourself?

B. Lets confer with the treatment team about the resources that you may need after discharge.

5. A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this clients safety upon discharge? A. Provide a 6-month supply of Elavil to ensure long-term compliance. B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments. C. Provide a pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine.

B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments.

9. A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information? A. Your grieving will subside within 1 year; until then I recommend antidepressants. B. Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area. C. The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them. D. Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone

B. Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area.

16. Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? A. The client will not physically harm self. B. The client will express three positive self-attributes by day 4. C. The client will reveal a suicide plan. D. The client will establish a trusting relationship.

B. The client will express three positive self-attributes by day 4.

18. A nurse is caring for four clients diagnosed with major depressive disorder. When considering each clients belief system, the nurse should conclude which client would potentially be at highest risk for suicide? A. Roman Catholic B. Protestant C. Atheist D. Muslim

C. Atheist

21. Which client data indicate that a suicidal client is participating in a plan for safety? A. Compliance with antidepressant therapy B. A mood rating of 9/10 C. Disclosing a plan for suicide to staff D. Expressing feelings of hopelessness to nurse

C. Disclosing a plan for suicide to staff

3. A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurses priority intervention at this time? A. Obtaining an order for locked seclusion until client is no longer suicidal B. Conducting 15-minute checks to ensure safety C. Placing the client on one-to-one observation while monitoring suicidal ideations D. Encouraging client to express feelings related to suicide

C. Placing the client on one-to-one observation while monitoring suicidal ideations

A nurse discovers a clients suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action? A. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note B. Establishing room restrictions, because the clients threat is an attempt to manipulate the staff C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide D. Calling an emergency treatment team meeting, because the clients threat must be addressed

C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide

14. A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse managers best reply? A. Suicide is a DSM-5 diagnosis. B. Suicide is a mental disorder. C. Suicide is a behavior. D. Suicide is an antisocial affliction.

C. Suicide is a behavior.

23. A client is newly admitted to an inpatient psychiatric unit. Which of the following is most critical to assess when determining risk for suicide? A. Family history of depression B. The clients orientation to reality C. The clients history of suicide attempts D. Family support systems

C. The clients history of suicide attempts

7. The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the teams decision? A. No previous admissions for major depressive disorder B. Vital signs stable; no psychosis noted C. Able to comply with medication regimen; able to problem-solve life issues D. Able to participate in a plan for safety; family agrees to constant observation

D. Able to participate in a plan for safety; family agrees to constant observation

7. The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the teams decision? A. No previous admissions for major depressive disorder B. Vital signs stable; no psychosis noted C. Able to comply with medication regimen; able to problem-solve life issues D. Able to participate in a plan for safety; family agrees to constant observation

D. Able to participate in a plan for safety; family agrees to constant observation

15. A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? A. Communicate therapeutically. B. Observe the client. C. Provide a hazard-free environment. D. Assess suicide risk.

D. Assess suicide risk.

8. The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? A. Address only serious suicide threats to avoid the possibility of secondary gain. B. Promote trust by verbalizing a promise to keep suicide attempt information within the family. C. Offer a private environment to provide needed time alone at least once a day. D. Be available to actively listen, support, and accept feelings.

D. Be available to actively listen, support, and accept feelings.

17. A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred? A. Suicidal threats and gestures should be considered manipulative and/or attention-seeking. B. Suicide is the act of a psychotic person. C. All suicidal individuals are mentally ill. D. Fifty to eighty percent of all people who kill themselves have a history of a previous attempt.

D. Fifty to eighty percent of all people who kill themselves have a history of a previous attempt.

6. During a one-to-one session with a client, the client states, Nothing will ever get better, and Nobody can help me. Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time? A. Powerlessness R/T altered mood AEB client statements B. Risk for injury R/T altered mood AEB client statements C. Risk for suicide R/T altered mood AEB client statements D. Hopelessness R/T altered mood AEB client statements

D. Hopelessness R/T altered mood AEB client statements

13. A suicidal client says to a nurse, Theres nothing to live for anymore. Which is the most appropriate nursing reply? A. Why dont you consider doing volunteer work in a homeless shelter? B. Lets discuss the negative aspects of your life. C. Things will look better in the morning. D. It sounds like you are feeling pretty hopeless.

D. It sounds like you are feeling pretty hopeless.

2. During the planning of care for a suicidal client, which correctly written outcome should be a nurses first priority? A. The client will not physically harm self. B. The client will express hope for the future by day 3. C. The client will establish a trusting relationship with the nurse. D. The client will remain safe during the hospital stay.

D. The client will remain safe during the hospital stay.

15. 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 began feeling depressed."

a. "Are you having thoughts of suicide?" The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation.

28. The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate? 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. "Genetics are associated with suicide risk. Monitoring and support are important." Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult.

27. A new nurse says to a peer, "My newest patient is diagnosed with schizophrenia. At least I won't have to worry about suicide risk." Which response by the peer would be most helpful? a. "Let's reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia." b. "Suicide is a risk for any patient diagnosed with schizophrenia who uses alcohol or drugs." c. "Patients diagnosed with schizophrenia are usually too disorganized to attempt suicide." d. "Visual hallucinations often prompt suicide among patients diagnosed with schizophrenia."

a. "Let's reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia." Up to 10% of patients diagnosed with schizophrenia die from suicide, usually related to depressive symptoms occurring in the early years of the illness.

3. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white man b. 17-year-old white female adolescent c. 39-year-old African-American man d. 29-year-old African-American woman e. 22-year-old man with traumatic brain injury

a. 82-year-old white man b. 17-year-old white female adolescent e. 22-year-old man with traumatic brain injury Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, adolescents, and young adults. Other high risk groups include young African-American men, Native-American men, older Asian Americans, and persons with traumatic brain injury.

2. A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient's possession. c. Maintain arm's length, one-on-one nursing observation around the clock. d. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift. e. Check the patient's whereabouts every 15 minutes, and make frequent verbal contacts. f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.

a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient's possession. c. Maintain arm's length, one-on-one nursing observation around the clock. One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions.

13. Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.

a. As depression lifts, physical energy becomes available to carry out suicide. Antidepressant medication has the objective of relieving depression. The 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 nurse in the emergency department encounters a patient, Niko, who is expressing suicide ideation. The nurse recognizes that which of the following considerations are important to good suicide risk assessment? (Select all that apply.) a. Collaborating with the patient b. Asking specific questions about leisure activities c. Establishing trust and open communication with the patient d. Asking the patient specific questions about the strength of his intention to die e. Identifying whether the patient has thought about a plan for trying to kill himself

a. Collaborating with the patient c. Establishing trust and open communication with the patient d. Asking the patient specific questions about the strength of his intention to die e. Identifying whether the patient has thought about a plan for trying to kill himself

Which of the following individuals is at highest risk for a suicide attempt? a. John, who reports he is in deep emotional pain, feels hopeless, and says "No one is there for me." b. Kelly, who has been seeing a doctor for chronic, intractable pain and is taking pain medication. c. Jim, an American Indian who just graduated from high school with honors. d. Mike, a physician who reports feeling 'burnt out" and is considering retirement.

a. John, who reports he is in deep emotional pain, feels hopeless, and says "No one is there for me."

21. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends

a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.

Which of the following interventions are appropriate for a client on suicide precautions? (Select all that apply.) a. Remove all sharp objects, belts, and other potentially dangerous articles from the client's environment. b. Accompany the client to off-unit activities. c. Reassess intensity of suicidal thoughts and urges on a regular basis. d. Put all of the client's possessions in storage and explain to her that she may have them back when she is off suicide precautions.

a. Remove all sharp objects, belts, and other potentially dangerous articles from the client's environment. b. Accompany the client to off-unit activities. c. Reassess intensity of suicidal thoughts and urges on a regular basis.

8. An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. 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 the discontinuation of suicide precautions.

a. Supervise the patient 24 hours a day. The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient is still a suicide risk; therefore, continuous supervision is indicated.

The nurse identifies the primary nursing diagnosis for Theresa as Risk for suicide related to feelings of hopelessness from loss of relationship. Which is the outcome criterion that would be most appropriate for this diagnosis?" a. The client has experienced no physical harm to herself. b. The client sets realistic goals for herself. c. The client expresses some optimism and hope for the future. d. The client has reached a stage of acceptance in the loss of the relationship with her boyfriend.

a. The client has experienced no physical harm to herself.

6. A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.

a. denial. The parents' statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distractors are not clearly described in the scenario.

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

a. hopelessness. 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.

24. A staff nurse tells another nurse, "I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse. a. "That action would seem appropriate." b. "A score over 8 requires immediate hospitalization." c. "I think you should strongly consider hospitalization for this patient." d. "Give the patient a follow-up appointment. Hospitalization may be needed soon."

b. "A score over 8 requires immediate hospitalization." A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization.

7. An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: 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. "Do you have access to medications?" The nurse must assess the patient's access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical.

19. Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I shot myself."

b. "I have no one for help or support." Lack of social support and social isolation increase the suicide risk.

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

b. Attending a self-help group for survivors 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.

Theresa, who has been hospitalized following a suicide attempt is placed on suicide precautions on the psychiatric unit. She admits that she is still feeling suicidal. Which of the following interventions are most appropriate in this instance? (Select all that apply.) a. Restrict access to any item that might be harmful by placing the client in a seclusion room. b. Check on Theresa every 15 minutes at irregular intervals, or assign a staff person to stay with her on a one-to-one basis. c. Obtain an order from the physician to give Theresa a sedative to calm her and reduce suicide ideas. d. Do not allow Theresa to participate in any unit activities while she is on suicide precautions. e. Ask Theresa specific questions about her thoughts, plans, and intentions related to suicide.

b. Check on Theresa every 15 minutes at irregular intervals, or assign a staff person to stay with her on a one-to-one basis. e. Ask Theresa specific questions about her thoughts, plans, and intentions related to suicide.

In determining degree of suicidal risk with a client, the nurse assesses the following behavioral manifestations: severely depressed, withdrawn, statements of worthlessness, difficulty accomplishing activities of daily living, no close support systems. The nurse identifies the client's risk for suicide as which of the following? a. Low risk b. High risk c. Imminent risk d. Unable to be determined

b. High risk

25. A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patient's roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic.

b. Hold a staff meeting to express feelings and plan the care for other patients. Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident.

1. Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

b. Serotonin deficiency

Success of long-term psychotherapy with Theresa (who attempted suicide following a break-up with her boyfriend) could be measured by which of the following behaviors? a. Theresa has a new boyfriend. b. Theresa has an increased sense of self-worth. c. Theresa does not take antidepressants anymore. d. Theresa told her old boyfriend how angry she was with him for breaking up with her.

b. Theresa has an increased sense of self-worth.

Which is a misconception about suicide? a)Eight out of ten individuals who commit suicide give warnings about their intentions. b)Most suicidal individuals are ambivalent about their feelings regarding suicide. c)Most individuals commit suicide by taking an overdose of drugs. d)Initial mood improvement can precipitate suicide.

c)Most individuals commit suicide by taking an overdose of drugs.

The nurse is caring for an actively suicidal client on the psychiatric unit. What is the nurse's priority intervention? a)Discuss strategies for the management of anxiety, anger, and frustration. b)Provide opportunities for increasing the client's self-worth, morale, and control. c)Place client on suicide precautions with one-to-one observation. d)Explore experiences that affirm self-worth and self-efficacy.

c)Place client on suicide precautions with one-to-one observation.

9. A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract. 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 kill or harm myself in any way." d. "I will not kill myself until I call my primary nurse or a member of the staff."

c. "For the next 24 hours, I will not kill or harm myself in any way." 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 assesses a patient who reports a 3-week history of depression and crying spells. 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. "I have a plan that will fix everything." 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 patient's suicide as being a way to "fix everything" but does not say it outright.

Theresa is hospitalized following a suicide attempt after breaking up with her boyfriend. Theresa says to the nurse, "When I get out of here, I'm going to try this again, and next time I'll choose a no-fail method." Which is the best response by the nurse? a. "You are safe here. We will make sure nothing happens to you." b. "You're just lucky your roommate came home when she did." c. "What exactly do you plan to do?" d. "I don't understand. You have so much to live for."

c. "What exactly do you plan to do?"

Theresa, age 27, was admitted to the psychiatric unit from the medical intensive care unit where she was treated for taking a deliberate overdose of her antidepressant medication, trazodone (Desyrel). She says to the nurse, "My boyfriend broke up with me. We had been together for six years. I love him so much. I know I'll never get over him." Which is the best response by the nurse? a. "You'll get over him in time, Theresa." b. "Forget him. There are other fish in the sea." c. "You must be feeling sad about your loss." d. "Why do you think he broke up with you, Theresa?"

c. "You must be feeling sad about your loss."

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

c. Availability of means and lethality of method

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

c. Giving away sweaters

4. A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimen

c. Risk for suicide This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.

4. A nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Oppositional defiant disorder e. Post-traumatic stress disorder

c. Traumatic brain injury e. Post-traumatic stress disorder Traumatic brain injury and post-traumatic stress disorder each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distractors would be expected to parallel the general population.

10. 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 the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determine risk factors for suicide.

c. establish a rapport with the patient. Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.

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

c. suicide potential. 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 appropriate categories to provide information on the other options listed.

A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. At this time, which is the most appropriate nursing intervention for this client? a)Provide the client with a safe and structured environment. b)Isolate the client from all stressful situations that may precipitate a suicide attempt. c)Observe the client continuously to prevent self-harm. d)Assist the client to develop more effective coping mechanisms.

d)Assist the client to develop more effective coping mechanisms.

26. A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response? a. "I wonder what this sudden change is all about. Please tell me more." b. "I am glad you are feeling better. The team will consider your request." c. "You should not try to direct your care. Leave that to the treatment team." d. "Because we are concerned about your safety, we will continue with our plan."

d. "Because we are concerned about your safety, we will continue with our plan." When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide.

11. Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to get help." c. "We need to talk about the good things you have to live for." d. "Bringing this up is a very positive action on your part."

d. "Bringing this up is a very positive action on your part." This response gives the patient reinforcement 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 patient's ambivalence and sets the stage for more realistic problem-solving strategies.

16. A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're 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. "Let's consider which problems are most important and which are less important."

d. "Let's consider which problems are most important and which are less important." The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

22. Which individual in the emergency department should be considered at the 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 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland

d. A 79-year-old single white man with cancer of the prostate gland

23. A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level

d. High level The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.

Theresa is hospitalized following a suicide attempt after breaking up with her boyfriend. Freudian psychoanalytic theory would explain Theresa's suicide attempt in which of the following ways? a. She feels hopeless about her future without her boyfriend. b. Without her boyfriend, she feels like an outsider with her peers. c. She is feeling intense guilt because her boyfriend broke up with her. d. She is angry at her boyfriend for breaking up with her and has turned the anger inward on herself.

d. She is angry at her boyfriend for breaking up with her and has turned the anger inward on herself.

5. A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? 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 gestures or attempts to kill self for 24 hours.

d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours. 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.

18. Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness.

d. experiencing hopelessness. Hopelessness is the characteristic common among people who attempt suicide.