Chapter 21: Suicide Prevention: Screening, Assessment, and Intervention
The majority of suicides among men are attributed to which of the following means?
firearms
A client who is depressed tells the nurse, "If I'm honest, I really see suicide as the only way out." In order to challenge the client's belief, the nurse should:
help the client to identify and explore other options.
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.
A newly-admitted client's history includes multiple suicide attempts. The nurse on the psychiatric-mental health unit can best protect the client's safety by:
performing vigilant assessment and close observation.
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.
A client has been treated following a suicide attempt. When providing anticipatory guidance during the client's discharge education, the nurse should teach the client that:
she is likely to experience stigma around her suicide attempt from some people.
Which of the following is a primary risk factor for suicide?
social isolation
Trying to kill oneself and surviving the ordeal is identified as which of the following?
suicide attempt
Which of the following terms describes a nonfatal, self-inflicted destructive act with an explicit or implicit intent to die?
suicide attempt
Women make how many suicide attempts for every attempt by their male counterparts?
three
Family education concerning the safe care of a client with a history of suicide attempts includes which of the following? Select all that apply.
• Techniques to help the client cope with known triggers • Information regarding the stressors that trigger the client's suicidal ideations • Signs and symptoms that indicate a mood change that could indicate the client is suicidal • List of emergency service telephone numbers
A psychiatric mental health nurse is using the IS PATH WARM mnemonic in order to assess a client for warning signs of suicide. Within this framework, what assessment findings should the nurse document? Select all that apply.
• The client states that she often "turns to the bottle" • The client has recently exhibited impulsive behavior • The client states that she frequently experiences insomnia
Which of the following questions 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?"
The nurse has been asked to assess a client to determine if she has a suicide plan. Which of the following questions would assist the nurse in assessing this area?
"Are you thinking about killing yourself right now?"
A nurse is assessing a client who has a previous history of suicide attempts. The nurse is applying the IS PATH WARM mnemonic. When addressing the "S" within this framework, the nurse should document what finding?
"Client states that he drinks between one and two bottles of wine daily."
A psychiatric nurse's colleague has expressed a reluctance to assess a client's risk for suicide, stating, "The last thing I want to do is to plant the thought in her head and bring on a suicide attempt." What is the nurse's best response?
"Evidence shows that talking about suicide with clients doesn't cause suicide attempts."
The nurse is providing care for a client who deliberately overdosed on acetaminophen several days ago. The nurse should assess the current severity of the client's suicidal ideation by asking what question?
"How often are you having thoughts about suicide this morning?"
During a night shift, a hospitalized client with depression tells a nurse that she is going to kill herself. The client is placed on constant observation. When the client asks to use the toilet, the nurse follows her into the bathroom. The client says, "You don't need to follow me into the bathroom. Give me some space." Which of the following responses by the nurse is most appropriate?
"I must stay with you until we are sure you will not hurt yourself."
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."
A client with a diagnosis of depression tells the nurse that her mood was especially bad this morning but that she pushed through it to attend her support group. How can the nurse best validate the client?
"That shows an admirable level of perseverance on your part. Well done!"
The nurse is assessing a client with depression and a colleague suggests that the client be encouraged to sign a no-suicide contract. What is the nurse's best response to the colleague?
"There's no demonstrated benefit of no-suicide contracts, though they're not believed to be harmful."
The nurse is working in a psychiatric-mental health facility and assessing the clients' risk for suicidal behaviors. Which of the following clients would be at highest risk?
A client with schizophrenia who has a previous suicide attempt
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?
A young male with schizophrenia who is in danger of becoming homeless
After being diagnosed with a chronic disease, a female client has been feeling depressed. Which of the following diagnoses has the strongest association with an increased suicide risk?
Acquired immunodeficiency syndrome
The nurse is told by a client that she is having suicidal thoughts. Which of the following interventions has lowest priority?
Administering a mental status exam to assess for psychosis
The mother of a suicidal adolescent is concerned that "only crazy people commit suicide." When helping her understand her daughter's suicidal behavior, the nurse would explain what?
Analysis of suicide notes reveals that most people who commit suicide are extremely unhappy.
The nurse is seeing a 43-year-old man whose wife just died by suicide. Which of the following is a common emotional response should the nurse anticipate from this client?
Anger toward the loved one who committed suicide
An adult client was admitted to the psychiatric mental health unit following a suicide attempt. The client has responded well to treatment, so discharge is being considered. In anticipation of the client's discharge, the nurse should:
collaborate with the family to make sure the client's home environment is safe.
When it is noted in the medical record that the client is diagnosed as parasuicidal, which of the following is the most effective nursing intervention?
Assess the client for indications of self-induced injuries
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
A client who lost a child as a result of an automobile accident by impaired driver is seen by the nurse in an outpatient mental health clinic. He is exhibiting signs of depression in the context of complicated grief. During the session, the nurse should recognize which of the following as a priority?
Assessing the client for suicidal ideations
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 she feels safe on the unit
When a nurse assesses prior self-harm behavior, this can provide information about the motivation behind the clients' actions and allows the nurse to do which of the following?
Communicate concern and empathy to the client
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
The tendency for suicide to have a "contagious" effect is most likely to occur among what age group?
High school students
When teaching prevention to the parents of a 15-year-old client who recently attempted suicide by taking an overdose of Xanax (alprazolam), the nurse describes which of the following behavioral clues?
Giving away valued personal items
Which of the following mental health disorders is a the most significant risk factor for suicide?
Depression
A patient on the psychiatric mental health unit completed suicide. A nurse who care for him has been experiencing insomnia and anxiety attacks since the event. What is the nurse's best initial action?
Dialogue with a trusted colleague about these feelings
Which client population has the highest risk for suicide?
Elderly men
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
During an interview, the nurse has asked a client with depression about any hopes or plans for the future. In response, the client silently made a gesture of drawing his index finger from one side of his throat to the other. The nurse has informed the client that this must be communicated to the care team. What is the main rationale for the nurse's action?
Ensuring the client's safety
Following the failure of a woman's recent in vitro fertilization (IVF), the nurse recognizes that she may be at risk of depression. Which of the following interventions is considered a primary suicide prevention measure?
Establishing a support system for the woman and teaching her some coping measures
A nurse providing community education for parents regarding adolescent suicide should include in the teaching session that the most frequent cause or motive for suicide in this age group is which of the following?
Feelings of alienation or isolation
Which of the following statements regarding gender and suicide is correct?
Females engage in suicidal behaviors more frequently than males.
A 32-year-old female is admitted to the inpatient unit for depression with suicidal thoughts. During the nursing assessment, why it is important for the nurse to assess and explore if there is any family member who has committed suicide?
Genetic predisposition
A nurse is preparing a client for discharge. As part of the discharge process, the nurse provides education to the client regarding safety from self harm. Which of the following interventions should the nurse employ?
Include family members to provide a better understanding of symptoms the illness
The nurse is planning a presentation about suicide to a group of health professionals. Which of the following should be included in the nurse's teaching plan?
Men are more likely to commit suicide than women are.
The nurse is planning a presentation about suicide to a group of health professionals. Which of the following should be included in the nurse's teaching plan?
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 15 to 24 year group. Firearms contribute to high rates of suicide among adolescents.
Which of the following statements most accurately describes the relationship between psychiatric illness and suicide risk?
The vast majority of people who commit suicide have a diagnosed mental disorder.
The correct definition for suicide is which of the following?
The voluntary and intentional act of killing oneself
A nurse maintains a safe environment for a client who is suicidal by ...
Observing the client frequently
A client on the inpatient psychiatric-mental health unit was discovered attempting to asphyxiate himself using a blanket. Which of the following measures should the care team prioritize in the client's immediate care?
Placing the client under constant observation
The primary nursing goal for a client who is admitted for suicidal ideation or attempt would be what?
Prevent self-destructive behavior.
Which of the following is the greatest predictor of a future suicide attempt?
Previous attempt
A client has admitted to the nurse that she 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
After assessing a client, the nurse identifies that the client is at risk for suicide. Which of the following would be the nurse's highest priority intervention?
Remove means of suicide from the client's access.
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?
Risk for Violence, Self-Directed, related to recent suicide attempt
Which of the following is an accurate statement regarding women and suicide?
They are less likely to complete suicide than men.
Which of the following statements regarding suicide is correct?
Suicide has profound effects on those connected to the individual.
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 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 two years earlier
The nurse is working with an outpatient who has a history of depression and suicide attempts. What assessment finding should the nurse interpret as indicating a high degree of planning for a future attempt?
The client recently purchased a large bottle of over-the-counter analgesics
The psychiatric-mental health nurse is working with a young adult client who has complex mental health and psychosocial needs. The nurse should identify what characteristic as constituting a risk factor for suicide?
The client was abused as a child by her stepfather
A 50-year-old man who has recently been diagnosed with a chronic degenerative illness has announced to the nurse his intention to commit suicide in order to prevent future suffering. Which of the following facts should underlie the nurse's response to this client?
The nurse is obliged to protect the client from self-harm.