Chapter 22: Suicide Prevention: Assessment and Screening

The nurse has been asked to assess a client to determine if the client has a suicide plan. Which question would assist the nurse in assessing this area? a) "Are you thinking about killing yourself right now?" b) "Are you a religious person?" c) "Do you have people in your life who are supportive of you?" d) "How do you generally cope with problems in your life?"

a) "Are you thinking about killing yourself right now?"

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? a) "Do you ever feel like your situation is hopeless?" b) "How would you describe your relationship with your parents?" c) "What are your plans for the next few days?" d) "Do you feel like your antidepressant is helping your mood?"

a) "Do you ever feel like your situation is hopeless?"

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? a) "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." b) "You are a individual with rights. You have the right to privacy, however, you should tell family members." c) "This must be so difficult for you to share. I will respect your privacy and let you disclose when you are ready." d) "You are high risk for harming yourself. I am obligated by law to disclose what you just told me."

a) "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."

When conducting a suicide risk assessment with a client, the nurse should identify the client as a high imminent risk if which statement is made? a) "There are no solutions to my problems." b) "My son is really the only reason I stick around." c) "I think about starving myself to death sometimes" d) "I just need someone to talk to"

a) "There are no solutions to my problems."

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) A teenage boy who is often bullied after disclosing that he is gay b) A boy whose family recently emigrated from Southeast Asia and who has a language barrier c) A 16 year-old girl who has recently found out that she is pregnant d) A teenage girl who has been ostracized by her best friend

a) A teenage boy who is often bullied after disclosing that he is gay

How can nurses contribute with knowledge of early intervention to make a difference when responding to an active suicidal client? a) By knowing how to engage and respond b) By allowing client to have time alone c) By encouraging clients to not think about suicide d) By living close by a health clinic

a) By knowing how to engage and respond

When a nurse assesses prior self-harm behavior, this can provide information about the motivation behind the client's actions and allows the nurse to do what? a) Communicate concern and empathy to the client b) Ignore the past attempts and focus on the here and now c) Provide an understanding of the reactions of others d) Create a judgmental attitude

a) 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. a) Conducting a survey the unit facilities and practices to ensure items that can be used for hanging are unavailable b) Introducing a "buddy" system for staff to ensure that nurses are not alone with clients unless absolutely necessary c) Increasing patients' access to cognitive behavioral therapy early in their admission d) Reconfiguring medication delivery practices so that clients cannot see other clients taking medications

a) Conducting a survey the unit facilities and practices to ensure items that can be used for hanging are unavailable

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? a) Ensuring a plan is in place for the client's community-based care b) Communicating with the pharmacy where the client will obtain prescribed medications c) Ensuring that the client has created a commitment to treatment statement d) Documenting the client's psychiatric advance directive

a) Ensuring a plan is in place for the client's community-based care

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? a) Placing the client under constant observation b) Managing the client's anxiety c) Assessing the specific motivation for the client's attempted suicide d) Teaching the client improved coping skills

a) Placing the client under constant observation

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? a) Risk for Violence, Self-Directed, related to recent suicide attempt b) Ineffective Coping as evidenced by recent suicide attempt c) Hopelessness as evidenced by recent suicide attempt d) Impaired Social Interaction related to alienation secondary to depressive behavior

a) Risk for Violence, Self-Directed, related to recent suicide attempt

Trying to kill oneself and surviving the ordeal is identified as what? a) Suicide attempt b) Suicidal behavior c) Suicidal ideation d) Parasuicide

a) Suicide attempt

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? a) The client explicitly agrees to participate in all aspects of treatment b) The client waives his status as legally competent c) The client specifies which treatments he is willing to participate in d) The client waives his right to make decisions about his care

a) The client explicitly agrees to participate in all aspects of treatment

For which client would the nurse be obligated to take immediate and focused action to prevent imminent death? a) The client with depression who is withdrawn and spends most of the time playing video games b) The client with depression who lives in poverty and has chronic pain c) The client who is grieving is often tearful and does not want to be left alone d) The client with depression who has been using alcohol and owns a gun

a) The client with depression who is withdrawn and spends most of the time playing video games

The nurse is seeing a client for counselling in a mental health clinic. The nurse notes the client has new superficial cuts to the inside of the upper forearm. Which is the best way for the nurse to discuss this observation with the client? a) "I notice some cuts on your arm. Do you want me to put a dressing on the wounds?" b) "I notice some cuts on your arm. Am I correct to think that things have been difficult?" c) "I notice some cuts on your arm. Have you not been using the coping skills I taught you?" d) "I notice some cuts on your arm. Are our counseling sessions not working for you?"

b) "I notice some cuts on your arm. Am I correct to think that things have been difficult?"

A client with a diagnosis of depression tells the nurse that the client's mood was especially bad this morning but that the client pushed through it to attend a support group. How can the nurse best validate the client? a) "Many people who are battling depression find that support groups are beneficial." b) "That shows an admirable level of perseverance on your part. Well done!" c) "Excellent! This shows that you're nearly recovered from your depression." d) "You really showed that you're able to rise above your fear and anxiety."

b) "That shows an admirable level of perseverance on your part. Well done!"

The parent of a suicidal adolescent is concerned that "only crazy people commit suicide." When helping the parent understand a daughter's suicidal behavior, the nurse would explain what? a) Fifty percent of all suicides occur as a result of major psychoses. b) Analysis of suicide notes reveals that most people who commit suicide are extremely unhappy. c) Suicide attempts are very common in teenage girls. d) Suicidal tendencies are inherited.

b) Analysis of suicide notes reveals that most people who commit suicide are extremely unhappy.

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? a) Modifying the center's environment to maximize client safety b) Assessing all clients carefully to identify those at risk for suicide c) Encouraging clients not to be ashamed of previous suicide attempts or suicidal thoughts d) Organizing the layout of the center to allow observation of clients

b) Assessing all clients carefully to identify those at risk for suicide

The tendency for suicide to have a "contagious" effect is most likely to occur among what age group? a) Those between the age of 30 and 50 b) High school students c) Elderly individuals living in nursing homes d) Those entering the workforce

b) High school students

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? a) Volition b) Parasuicide c) Suicide attempt d) Copycat suicide

b) Parasuicide

After assessing a client, the nurse identifies that the client is at risk for suicide. Which would be the nurse's priority intervention? a) Determine the course of the client's suicidal thoughts. b) Remove means of suicide from the client's access. c) Provide mood-stabilizing medications per physician order. d) Communicate a desire to help the client.

b) Remove means of suicide from the client's access.

The nurse is working with an inpatient who has a history of suicide attempts. What action by the client should the nurse follow up on because it may constitute a suicide planning behavior? a) The client is consistently late in coming to the nurses' station to receive scheduled medications b) The client has requested extra bedding despite the warm weather c) The client states that the client is agitated and would like to be in the comfort room d) The client has begun stockpiling food in the room

b) The client has requested extra bedding despite the warm weather

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? a) The client has been treated with a variety of antidepressants over the years. b) The client overdosed on pills 2 years earlier c) The client sits silently after being asked several of the assessment questions d) The client states, "Everything just seems really dark right now."

b) The client overdosed on pills 2 years earlier

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? a) The client was recently prescribed lorazepam as a sleep aid b) The client was abused as a child by her stepfather c) The client is from a Latin American culture d) The client has been unsuccessful in her recent efforts to stop smoking

b) The client was abused as a child by her stepfather

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 ... a) provide distraction by organizing therapeutic recreation. b) help the client to identify and explore other options. c) organize a family meeting. d) encourage the client to identify and attend outpatient support groups.

b) help the client to identify and explore other options.

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: a) administer a PRN benzodiazepine as prescribed. b) provide the patient with meaningful and appropriate distraction. c) ask another patient to engage the patient in conversation. d) administer the patient's scheduled sustained serotonin reuptake inhibitor.

b) provide the patient with meaningful and appropriate distraction.

A client who lost a child as a result of an automobile accident by an 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? a) Expressing condolences over the loss of the child b) Assessing the client for feelings regarding the driver responsible for the death c) Assessing the client for suicidal ideations d) Encouraging the client to become an activist in organizations such as Mothers Against Drunk Driving (MADD)

c) Assessing the client for suicidal ideations

Which statement regarding gender and suicide is correct? a) Females are more likely to die by firearm than males. b) Females are more likely than males to die from suicide. c) Females engage in suicidal behaviors more frequently than males. d) Females choose more violent means of suicide than males.

c) Females engage in suicidal behaviors more frequently than males.

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? a) Angry outbursts at significant others b) Inquiry about doses of lethal drugs c) Giving away valued personal items d) Experiencing the loss of a boyfriend or girlfriend

c) Giving away valued personal items

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? a) Facilitating a referral for cognitive behavioral therapy b) Establishing a no-suicide contract with the client c) Performing vigilant assessment and close observation d) Administering the client's prescribed selective serotonin reuptake inhibitor

c) Performing vigilant assessment and close observation

After assessing a client, the nurse identifies that the client is at risk for suicide. Which would be the nurse's priority intervention? a) Provide mood-stabilizing medications per physician order. b) Determine the course of the client's suicidal thoughts. c) Remove means of suicide from the client's access. d) Communicate a desire to help the client.

c) Remove means of suicide from the client's access.

Which of the following is a primary risk factor for suicide? a) Unemployment b) Poverty c) Social isolation d) Economic deprivation

c) Social isolation

The nurse is assessing a 42-year-old client who is experiencing depression. The client's mother died by suicide 20 years ago. Which statement regarding this client's risk for suicide is correct? a) The client's risk is equivalent to that of the general population. b) The client's risk for suicide will increase when the client reaches the age of 50. c) The client has a greater risk for suicide than the general population. d) The client would have a greater risk for suicide if the client's father had died by suicide.

c) The client has a greater risk for suicide than the general population.

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? a) The nurse must refer the client to a physician who is authorized to assist the client with a suicide. b) The nurse is required to document the client's wishes and begin to facilitate an assisted suicide. c) The nurse is obliged to protect the client from self-harm. d) The nurse is ethically obliged to inform law enforcement.

c) The nurse is obliged to protect the client from self-harm.

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? a) diagnosed with an acute illness b) fears of growing older c) experiencing unemployment that has lasted a year d) starting a new business with friends

c) experiencing unemployment that has lasted a year

A nurse maintains a safe environment for a client who is suicidal by ... a) creating a stimulating environment. b) observing the client frequently. c) maintaining confidentiality at all times with the client. d) ensuring the client has access to all personal belongings to make the client feel at home.

c) maintaining confidentiality at all times with the client.

Which term describes a nonfatal, self-inflicted destructive act with an explicit or implicit intent to die? a) parasuicide b) suicidality c) suicide attempt d) suicidal ideation

c) suicide attempt

Which question by a depressed, inpatient, psychiatric-mental health client should the nurse interpret as a potential suicide clue? a) "Are we allowed to use the client kitchen whenever we want?" b) "When do you think the doctor will let me get my street clothes back?" c) "When is my next scheduled electroconvulsive therapy session?" d) "Are clients allowed to keep drugstore medications at their bedside?"

d) "Are clients allowed to keep drugstore medications at their bedside?"

Which question should the nurse ask to determine the intent to die when a client states, "Everyone would be better off if I just drove off the bridge into the ocean!"? a) "Have you done anything to put your plan into action?" b) "Is this thought increasing in frequency?" c) "How often do you have this thought?" d) "How seriously do you want to die?"

d) "How seriously do you want to die?"

A psychiatric-mental health nurse is conducting an in-service education program about suicide for a group of nurses working at a community mental health center. The nurse determines that the teaching was successful based on which statement by the group? a) "Suicide rates among older adults are low." b) "Suicide is more of a concern in countries other than the United States." c) "Suicide does not occur in affluent neighborhoods, indicating poverty is a factor." d) "Suicide has profound effects on those connected to the individual."

d) "Suicide has profound effects on those connected to the individual."

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) An adolescent client refuses to consume any more food b) A female client has several bottles of over-the-counter medications c) An older adult client verbalizes the desire to drown in the river d) A male client keeps a loaded firearm in the closet

d) A male client keeps a loaded firearm in the closet

After being diagnosed with a chronic disease, a client has been feeling depressed. Which diagnosis has the strongest association with an increased suicide risk? a) Congestive heart failure b) Coronary heart disease c) Chronic obstructive pulmonary disease d) Acquired immunodeficiency syndrome

d) Acquired immunodeficiency syndrome

The nurse is told by a client that the client is having suicidal thoughts. Which intervention has lowest priority? a) Determining the client's concerns and if the client has a plan b) Maintaining a safe, secure environment c) Assessing the client for past history of suicidal attempts d) Administering a mental status exam to assess for psychosis

d) Administering a mental status exam to assess for psychosis

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? a) Ensuring the client's room door remains locked at all times b) Administering medication to decrease acting out behaviors c) Observing the client at regular intervals d) Asking the client about diet preferences for meals

d) Asking the client about diet preferences for meals

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? a) Assume that the client had expressed suicidal ideations in the past b) Assume that the client had attempted suicide in the past c) Ask the client to sign a no-suicide contract d) Assess the client for indications of self-induced injuries

d) Assess the client for indications of self-induced injuries

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? a) Client will state that the client feels optimistic about the client's future b) Client will participate actively in cognitive behavioral therapy c) Client will implement strategies for managing stress d) Client will express that the client feels safe on the unit

d) Client will express that the client feels safe on the unit

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? a) Beginning a course of therapy with a nurse-therapist or psychologist b) Beginning treatment with a selective serotonin reuptake inhibitor c) Placing the woman on suicide precautions and establishing a no-suicide contract d) Establishing a support system for the woman and teaching her some coping measures

d) Establishing a support system for the woman and teaching her some coping measures

A 32-year-old client 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? a) Terminal illness b) Lack of conflict resolution skills c) Disengagement of family d) Genetic predisposition

d) 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 intervention should the nurse employ? a) Remind the client to make an outpatient appointment for follow-up care b) Discuss how the client's risk factors have decreased following the hospitalization c) Avoid inclusion of significant others to ensure confidentiality of client d) Include family members to provide a better understanding of symptoms of the illness

d) Include family members to provide a better understanding of symptoms of the illness

To care for an acutely suicidal client, which is the most effective initial mode of treatment? a) Group therapy b) Outpatient care c) Behavioral therapy d) Inpatient care

d) Inpatient care

The nurse is seeing an adolescent female client who has superficial cuts to both wrists and ankles. The client denies the desire to kill herself but reports recent family stress due to her parents recently separating. Which phenomena explains the client's response to stress? a) Suicide contagion b) Impulsivity c) Suicide attempt d) Parasuicide

d) Parasuicide

The primary nursing goal for a client who is admitted for suicidal ideation or attempt would be what? a) Develop rapport based on trust and understanding. b) Assist him or her in the expression of sad and helpless feelings. c) Assess the cause of his or her depression. d) Prevent self-destructive behavior.

d) Prevent self-destructive behavior.

The nurse has been caring for a 77-year-old client who was admitted to the psychiatric unit for depression and imminent suicide risk. Despite varying levels of intervention, the client continues to voice suicidal ideation with a lethal plan. Which intervention should the care team employ? a) Change the current antidepressant medication b) Apply physical restraints daily c) Keep the client secluded throughout the day d) Use electroconvulsive therapy

d) Use electroconvulsive therapy

Which is the greatest predictor of a future suicide attempt? a) suicide planning b) degree of hopelessness c) seriousness of suicidal ideation d) previous attempt

d) previous attempt