Mental Health Ch. 25_Suicide and Nonsuicidal Self-Injury

What are the most important characteristics for staff members who work with suicidal clients? a. Organization b. Problem-solving skills c. Warm, consistent interaction d. Effective interview and counseling skills

c. Warm, consistent interaction Crucial characteristics of staff members who work with suicidal clients include warmth, sensitivity, interest, and consistency since they support the nurse-client relationship. While helpful, none of the other options have the impact of a effective nurse-client relationship.REF: 482

A client on one-to-one supervision at arm's length indicates a need to go to the bathroom but reports, "I cannot 'go' with you standing there." How should the nurse respond to the client's concern? a. "I understand" and allow the client to close the door. b. Keep the door open, but step to the side out of the client's view. c. Leave the client's room and wait outside in the hall. d. "For your safety I can be no more than an arm's length away."

d. "For your safety I can be no more than an arm's length away." This level of suicide watch does not make adjustments based on client preference. The explanation quoting the protocol and the reason (your safety) is appropriate. The correct statement reinforces the basic need for client safety. The other options fail to provide for the degree of client safety required.REF: 482

The nurse observes the meal tray about to serve a suicidal client. Which item should be removed from the tray? a. Plastic plate b. Cloth napkin c. Styrofoam cup d. Metal utensils

d. Metal utensils In most health care agencies, suicidal clients receive plastic dinnerware on their meal trays since metal utensils can be used to cause physical harm. None of the other options carry that same degree of risk.REF: 484; (Box 25-4)

An assessment tool that is useful to nurses in rating suicide risk is the a. AIMS scale. b. SAFE-T. c. CAGE questionnaire. d. Mini-Mental Status Examination.

Evaluation of a suicide plan is extremely important in determining the degree of suicidal risk. The SAFE-T is short and easy to use and is focused on the risk for self-injury. That is not the focus of the other options.REF: 478

A client with a history of repeated suicidal attempts refuses to participate in a no-suicide contract. What intensity of nursing observation should be instituted? a. Constant 24-hour, one-to-one observation at arm's length b. One-to-one observation while client is awake c. Every 15-minute observation around the clock d. Seclusion with 15-minute observation

a. Constant 24-hour, one-to-one observation at arm's length A client who will not enter into a no-suicide contract should be placed on the highest level of suicide watch since the client is unable to commit to seeking help to resist suicidal ideations.REF: 484; Table 25-3

Unit practice requires inspection of all items being brought onto the unit by visitors. How can this be most effectively done? a. Having a staff member sit at the door and check packages as visitors enter. b. Having a staff member make frequent rounds during visiting hours to inspect gifts. c. Asking all visitors to report to the nurse's station before visiting a client. d. Asking clients to give staff any unsafe item that might have been left by a visitor.

a. Having a staff member sit at the door and check packages as visitors enter. A number of ways to inspect items are possible.Taking all potentially harmful gifts from visitors before allowing them to see clients, going through client's belongings (with client present) and removing all potentially harmful objects, ensuring that visitors do not leave potentially harmful objects in the client's room, and searching clients for harmful objects on return from pass are all effective methods to ensure a high rate of client safety. None of the other options provide a measure of control before clients and visitors meet. Self-reporting by the visitors is not reliable.REF: 484; (Box 25-4)

A client tells the nurse that he believes his situation is intolerable and is observed isolating socially. Which nursing diagnosis should be considered? a. Hopelessness b. Deficient knowledge c. Chronic low self-esteem d. Compromised family coping

a. Hopelessness The defining characteristics are present for the nursing diagnosis of hopelessness. The characteristics of the other options are not presented in the statement or behavior of the client.REF: 480; Table 25-2

While intoxicated a client unsuccessfully attempted suicide by using a gun. This method of using a gun to attempt suicide should be described in what terms? a. It is high risk, or a hard method. b. It is low risk, or a soft method. c. It was not an actual suicide attempt because the client was intoxicated. d. Considering the results, it is a nonlethal means.

a. It is high risk, or a hard method. Higher risk methods, also referred to as hard methods, include using a gun, jumping from a high place, hanging, and carbon monoxide poisoning. The other responses are incorrect.DIF: Cognitive Level: Understand (Comprehension)REF: page 15TOP: Nursing Process: AssessmentMSC: NCLEX: Safe and Effective Care Environment

Which is the greatest protective factor against the risk of suicide? a. One or more previous suicide attempts b. A sense of responsibility to family c. Fear of dying d. A cultural belief that suicide is a shameful resolution for a dilemma

b. A sense of responsibility to family Having family responsibilities makes a client less likely to commit suicide. Hopelessness is the greatest risk factor. Previous attempts are a high risk factor. None of the remaining options have the impact that support has on preventing suicide.REF: 478; Box 25-2

When a colleague committed suicide, the nurse stated "I do not understand why she would take her own life." This is an expression of which feeling? a. Anger b. Disbelief c. Confusion d. Sympathy

b. Disbelief Denial and the minimization of suicidal ideation or gestures is a defense against experiencing the feelings aroused by a suicidal person. Denial can be seen in such statements as "I cannot understand why anyone would want to take his own life." The statement doesn't demonstrate any of the other options as significantly.REF: 476

What is the focus of the SAFE-T assessment tool? a. Facilitate hospitalization. b. Identify level of suicidal risk. c. Development of client focused treatment. d. Introduce antidepressant medication therapy e. Stress collaboration with the client

b. Identify level of suicidal risk. c. Development of client focused treatment. e. Stress collaboration with the client The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) is an assessment tool that allows the clinician to benchmark relative risk (high, moderate, low) and to develop a treatment plan, in consultation with the patient, to reduce current risk. The tool does not provide for specific interventions.DIF: Cognitive Level: Apply (Application)REF: page 12TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment

Which of the following statements is true regarding culture and protective factors against suicide? a. Asian Americans have the highest rates of suicide. b. Religion and the importance of family are protective factors for Hispanic Americans. c. Older women have the highest risk for suicide among African Americans. d. American Indians and Pacific Islanders have the lowest rates of suicide.

b. Religion and the importance of family are protective factors for Hispanic Americans. Among Hispanic Americans, Roman Catholic religion (in which suicide is a sin) and the importance given to the extended family decrease the risk for suicide. The other options are all incorrect and are in fact the opposite of what is true.DIF: Cognitive Level: Comprehension (Understanding)REF: page 9TOP: Nursing Process: AssessmentMSC: NCLEX: Safe and Effective Care Environment

Nurses should assess the lethality of the client's plan for suicide. What factor would be irrelevant to that assessment? a. How long the client has been suicidal b. Whether the plan has specific details c. Whether the method is one that could cause death d. Whether the client has the means to implement the plan e. Has the client been suicidal in the past

b. Whether the plan has specific details c. Whether the method is one that could cause death d. Whether the client has the means to implement the plan Lethality refers to how deadly a plan is. The length of time a client has been suicidal or a history suicidal thoughts have nothing to do with the lethality of the plan. While the remaining options present important about the seriousness of the plan.REF: 479

Which neurotransmitter has been implicated as playing a part in the decision to commit suicide? a. γ-Amino-butyric acid b. Dopamine c. Serotonin d. Acetylcholine

c. Serotonin Low serotonin levels have been noted among individuals who have committed suicide. None of the other options are as directly related in the physiology of depression.REF: 477

A student nurse on the psychiatric unit expresses being uncomfortable about discussing possible suicidal ideations with clients because "It might put ideas in their head about suicide." What is the nurse's best response to this student's concern? a. "I'm glad you are thinking that way. They may not have thought of suicide before, and we don't want to introduce that." b. "You are right; however, because of professional liability, we have to ask that question." c. "Actually, it's a myth that asking about suicide puts ideas into someone's head." d. "If I were you, I'd ask the health provider to talk to the patient about that subject."

c. "Actually, it's a myth that asking about suicide puts ideas into someone's head." Asking about suicidal thoughts does not "give person ideas" and is, in fact, a professional responsibility similar to asking about chest pain in cardiac conditions. Talking openly leads to a decrease in isolation and can increase problem-solving alternatives for living. Patients have usually been already thinking about suicide; it is a myth that bringing up the topic will somehow cause someone to become suicidal. Liability is not the reason we ask patients about suicidal thoughts or plan; it is for patient safety. Asking the physician to speak to the patient on that subject does not educate the student regarding the need for asking about suicidal ideation and abdicates professional and ethical responsibility for keeping the patient safe.DIF: Cognitive Level: Analyze (Analysis)REF: page 13TOP: Nursing Process: AssessmentMSC: NCLEX: Safe and Effective Care Environment

Which suicide prevention intervention that has the greatest impact on a client's safety? a. Educating visitors about potentially dangerous gifts. b. Restricting the client from potentially dangerous areas of the unit. c. One-on-one observation by the staff. d. Removal of personal items that might prove harmful.

c. One-on-one observation by the staff. One-on-one observation allows for constant supervision, which minimizes the client's opportunities to cause self-harm. While the remaining options provide some protection, none have the impact of constant supervision.REF: 484; Table 25-3

The nursing diagnosis Risk for self-directed violence has been added to the care plan of a suicidal client. Which is the most appropriate short-term goal for this diagnosis? a. Will reclaim any prized possessions that were given away. b. Be able to name three personal strengths. c. Seek help when feeling self-destructive. d. Consistently participate in a self-help group.

c. Seek help when feeling self-destructive. Having the client cope with self-destructive impulses in a healthy way is the only appropriate short-term goal presented for Risk for self-directed violence since it focuses on client safety.REF: 481; Case Study and Nursing care Plan

Which statement, made by a patient admitted with a diagnosis of depression, indicates the need for further assessment? a. "I know a lot of people care about me and want me to get better." b. "I have suicidal thoughts at times, but I don't have any plan and don't think I would ever actually hurt myself." c. "I don't have a good support system, but I am planning on joining a recovery group." d. "I think things will be better soon."

d. "I think things will be better soon." This response may be a covert, or indirect, clue that the patient is thinking of suicide. The other options are all statements that, while they may be discussed further, are not clues to suicidality but rather clear communication.DIF: Cognitive Level: Analyze (Analysis)REF: page 2TOP: Nursing Process: AssessmentMSC: NCLEX: Safe and Effective Care Environment

Which statement factually describes the act of suicide? a. More women than men commit suicide. b. The Jewish culture has the lowest suicide rate. c. Suicide is the leading cause of death in the United States. d. A client diagnosed with schizophrenia is at great risk for attempting suicide.

d. A client diagnosed with schizophrenia is at great risk for attempting suicide. Individuals with schizophrenia are 8 times more likely to attempt suicide than is the general public. Suicide is the tenth leading cause of death in the United States. Protestants and the Jewish culture have a higher rate of suicide than do Catholics. More women attempt suicide, but more men are successful.REF: 476

When working with a client who may have made a covert reference to suicide, the nurse should base the response on what statement? a. Being careful not to mention the idea of suicide. b. Listening carefully to see whether the client mentions suicide more overtly. c. Asking about the possibility of suicidal thoughts in a covert way. d. Asking the client directly if they are thinking of attempting suicide.

d. Asking the client directly if they are thinking of attempting suicide. Covert references should be made overt. The nurse should directly address any suicidal hints given by the client. Self-destructive ideas are a personal decision. Talking openly about suicide leads to a decrease in isolation and can increase problem-solving alternatives for living. People who attempt suicide, even those who regret the failure of their attempt, are often extremely receptive to talking about their suicide crisis. None of the other options should direct this discussion.REF: 479