Suicide mental health

A nurse is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the discussion? "I can promote my client's sense of control by establishing a schedule. "I should encourage clients who have a schizoid personality disorder to increase socialization." "I should implement assertiveness training with clients who have antisocial personality disorder."

"I should encourage clients who have a schizoid personality disorder to increase socialization." "I should practice limit-setting to help prevent client manipulation." When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation. NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements should the nurse expect from a client who has this type of personality disorder? "I'm scared that you're going to leave me." "I'Il go to group therapy if you'll let me smoke." "I need to feel that everyone admires me." "I sometimes feel better if I cut myself."

"I'm scared that you're going to leave me." Clients who have avoidant personality disorder often have a fear of abandonment. This type of statement is expected. NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

A nurse is assisting in conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A client's verbal threat to oneself is attention-seeking behavior. Interventions are ineffective for clients who really want to commit suicide. Using the term suicide increases the client's risk for a suicide attempt. A no-suicide contract decreases the client's risk for suicide.

A no-suicide contract decreases the client's risk for suicide. The use of a no-suicide contract decreases the client's risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (Select all that apply.) Conducting a suicide risk screening on all new clients Creating a support group for family members of clients who died by suicide Informing high school teens about suicide prevention Initiating one-on-one observation for a client who has current suicidal ideation Reinforcing teaching middle-school educators about warning indicators of suicide

Conducting a suicide risk screening on all new clients Primary interventions include suicide prevention through the use of screenings to identify individuals at risk. Conducting a suicide risk screening on all new clients is an example of a primary intervention

A nurse is collecting data from a client who was in a motor-vehicle crash that killed her sibling. The client is shaking and asks, "What can I do now?" Which of the following questions is the nurse's priority? A. "Are you thinking about hurting yourself?" B. "Do you have someone who could come here to be with you?" C. "How will this situation affect your life?" D. "What qualities have helped you cope with a crisis in the past?"

Correct Answer: A. "Are you thinking about hurting yourself?" The client's statement and current emotional state indicate that the client's greatest risk is for self-harm. Therefore, the priority for the nurse is to ask the client about the possibility of suicide or self-harm.

A nurse is caring for a client who has excoriation disorder. Which of the following statements by the client should the nurse expect? A. "I pick my face when I am nervous." B. "I have bald patches from pulling out my hair." C. "I inspect my body in the mirror several times a day." D. "I am unable to part with any of my belongings."

Correct Answer: A. "I pick my face when I am nervous." The nurse should recognize that this statement is an indication of excoriation disorder. Clients who have excoriation disorder typically pick their faces when experiencing stress or anxiety.

A nurse in a mental health unit is contributing to the plan of care for a client who is receiving treatment for self-inflicted injuries. Which of the following interventions is the priority for this client? A. Promoting and maintaining client safety B. Discussing reasons for the client's behavior C.Helping the client recognize feelings D. Reinforcing teaching with the client about alternative coping strategies

Correct Answer: A. Promoting and maintaining client safety The nurse should recognize that this client who has self-inflicted injuries is at risk of further self-harm or suicide; therefore, the client's safety is the priority. The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.

A nurse is contributing to the plan of care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse recommend? A. Search the client and his belongings upon arrival B. Assign the client to a private room near the nurses' station C. Instruct assistive personnel to check on the client every 15 min D. Keep the door to the client's room closed

Correct Answer: A. Search the client and his belongings upon arrival The nurse should plan to search the client and all of his belongings upon arrival to the unit. This search is conducted for the client's safety so that the nurse can identify and remove any objects that increase the client's risk of injury or suicide. Potentially harmfully objects include razors, shoelaces, hygiene products, and tweezers.

A nurse is collecting data from a client who has major depressive disorder regarding suicide risk factors and protective factors. Which of the following client statements should the nurse identify as a protective factor that decreases the client's risk for suicide? A. "I am a college graduate and make a lot of money at my profession." B. " consider myself a good problem-solver." C. "My family lives out-of-state, and I spend my spare time at home." D. "I enjoy restoring antique weapons and have a nice collection."

Correct Answer: B. "I consider myself a good problem-solver." The ability to problem-solve and to think critically is a protective factor against suicide. Feelings of low self- esteem or hopelessness are risk factors for suicide.

A nurse in an acute care mental health facility is assisting with the evaluation of the plan of care for a client who has major depressive disorder and was admitted 1 week ago following a suicide attempt. Which of the following client statements should indicate to the nurse that the treatment plan has been effective? A. "I just don't want to talk about anything that happened before my admission." B. "I was feeling completely hopeless when I tried to kill myself." C. "I am feeling really great today, and I think I am ready to go home." D. "I want to punch the doctors who put me in this hospital."

Correct Answer: B. "I was feeling completely hopeless when I tried to kill myself." This statement should indicate to the nurse that the client is meeting a short-term goal of being willing to discuss painful feelings that occurred at the time of the suicide attempt. The nurse should also evaluate whether the client is now willing to seek help when feelings of self-harm occur.

A nurse delegates a newly licensed nurse to provide one-on-one observation for a client who requires suicide precautions. Which of the following actions by the newly licensed nurse indicates the need for further reinforcement of teaching? A. Accompanies the client to physical and occupational therapy B. Ambulates the client's roommate while the client sleeps C. Asks the nurse at lunch time to assign another newly licensed nurse to perform this task D. Remains with the client while family members are visiting

Correct Answer: B. Ambulates the client's roommate while the client sleeps One-on-one observation requires constant supervision of the client. The client might wake up and engage in self- injurious behavior while the newly licensed nurse is caring for the other client.

A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions is the nurse's priority? A. Offer the client finger foods every 2 hr B. Determine if the client is a danger to herself C. Monitor the client's vital signs every 2 hr D. Move the client to a quiet area

Correct Answer: B. Determine if the client is a danger to herself The greatest risk to this client is an injury from hyperactivity or life-threatening exhaustion. Therefore, the priority action is to determine whether the client has feelings of suicide or is showing manifestations of exhaustion.

A nurse in a provider's office is reviewing the medical history of a client who asks about the use of varenicline for smoking cessation. Which of the following items in the client's medical history indicates a precaution for the use of varenicline? A. The client has type I diabetes mellitus B. The client has a history of depression C. The client has rheumatoid arthritis D. The client has a history of GERD

Correct Answer: B. The client has a history of depression The nurse should recognize that varenicline can cause mood changes and thoughts of suicide. Precautions should be taken when prescribing this medication to clients who have a history of psychiatric disease such as depression.

A nurse in a clinic is collecting data from a client who asks for help with depression. Which of the following questions is the nurse's priority? A. "Is there anything in particular that makes you feel angry?" B. "Have you had difficulty falling asleep or staying asleep?" C. "Have you thought about harming yourself in any way?" D. "Do you have someone you can talk with at home?"

Correct Answer: C. "Have you thought about harming yourself in any way?" The greatest risk to this client is an injury from self-harm; therefore, the nurse's priority is to determine whether the client is at risk by asking about thoughts of self-harm or a suicide plan.

A nurse is collecting data from a client who has major depressive disorder. Which of the following questions is the priority for the nurse to ask the client? A. "Do you have any close friends?" B. "Can you describe how you feel about what's happening?" C. "Have you thought about hurting yourself?" D. "How are you dealing with being away from your family?"

Correct Answer: C. "Have you thought about hurting yourself?" The greatest risk to the client at this time is suicide. Therefore, the priority question the nurse should ask is if the client has any intent to self-harm.

A nurse is caring for a client who has tardive dyskinesia. Which of the following tools should the nurse use in performing an assessment on the client? A. CAGE Assessment B. Hamilton Anxiety Rating Scale C. Abnormal Involuntary Movement Scale (AIMS) D. SAFE.T Tool

Correct Answer: C. Abnormal Involuntary Movement Scale (AIMS) The AIMS is an assessment tool that identifies and tracks involuntary movements in clients who have tardive dyskinesia.

A nurse is collecting data from a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team? A. Calling family members B. Spending time alone C. Giving away possessions D. Excessive crying

Correct Answer: C. Giving away possessions Giving away possessions indicates that this adolescent client is at the greatest risk for suicide. The nurse should have a relationship with the adolescent built on trust and respect so that the nurse feels comfortable enough to ask the adolescent directly about suicidal thoughts and/or plans. Therefore, this is the priority finding for the nurse to report to the treatment team.

A nurse on an inpatient mental health unit is planning care for a client who was admitted following a suicide attempt. Which of the following actions should the nurse include in the plan? A. Keep the door of the client's room open while the client is awake B. Ensure that the client's meal tray contains no knives C. Observe the client swallow medications D. Have a staff member observe the client once every 30 minutes

Correct Answer: C. Observe the client swallow medications The nurse should plan to observe when the client swallows medications to ensure that he does not save the medications to take all at once.

A nurse in a provider's office is collecting data on a client who is taking paroxetine for the treatment of social anxiety. Which of the following information from the client should the nurse report to the provider immediately? A. The client reports a change in appetite. B. The client is experiencing insomnia C. The client reports being depressed D. The client is experiencing headaches

Correct Answer: C. The client reports being depressed A report of depression indicates that this client is at greatest risk for suicide. Therefore, this is the priority finding.

A nurse is assessing a client who has a new diagnosis of major depressive disorder. Which of the following questions is the priority for the nurse to ask? A. "How would you describe your mood?" B. "How are you sleeping?" C. "Do you drink alcohol or use other substances?" D. "Do you ever think about suicide?"

Correct Answer: D. "Do you ever think about suicide?" The diagnosis of major depressive disorder indicates that the greatest risk for this client is suicide. Therefore, the priority for the nurse to ask is about suicidal ideation. Research shows that clients who have depressive disorders are at high risk for suicide due to the common presence of recurring thoughts of death.

A client recently diagnosed with terminal cancer states to the nurse, "I wish I were dead. I have no reason to live." Which of the following responses should the nurse offer? A. "You still have a lot to live for." B. "Please don't talk about that." C. "Your prescribed medication will make you feel better." D. "Have you been thinking of hurting yourself?"

Correct Answer: D. "Have you been thinking of hurting yourself?" The nurse's response focuses on the client's underlying feelings and begins to examine the obvious verbal clues of suicidal thoughts. Asking the client about suicidal thoughts is an important intervention by the nurse because if the client is contemplating suicide, the client should be able to discuss these feelings with the nurse.

A nurse is talking with a client who has major depressive disorder. Which of the following client statements should the nurse identify as a covert statement of suicidal ideation? A. "I don't want to be alive any longer." B. "I think every day about killing myself." C. "My parents will be happier when I'm dead." D. "I won't have to deal with things much longer."

Correct Answer: D. "I won't have to deal with things much longer." The nurse should listen closely for overt and covert statements that can indicate a client's intent to commit suicide. Covert statements can indicate in an indirect way a client's plan for suicide or wish to no longer be alive. Covert statements are more difficult to identify because they do not openly express the client's suicidal thoughts like overt statements. The nurse should collect further data from the client for suicidal ideation and implement interventions to reduce the risk of a suicide attempt

A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client informs the nurse, "I do not want visitors today because I look and feel terrible." Which of the following responses should the nurse make? A. "That is silly. You look just fine to me." B. "Nobody expects you to look good in a hospital." C. "I understand. Would you like to wash your hair?" D. "Would you like to talk about why you feel this way?"

Correct Answer: D. "Would you like to talk about why you feel this way?" This response by the nurse acknowledges the client's feelings and conveys the ability to understand them, which promotes a trusting relationship between the client and the nurse.

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect? A. Hallucinations B. Impaired memory C. Dysphoria D. Social discomfort

Correct Answer: D. Social discomfort The absence of something that should be present is considered a negative symptom of schizophrenia. Social discomfort, the inability to enjoy activities, or a lack of goal-directed behavior are negative symptoms of schizophrenia.

A nurse is collecting data about the lethality of a client's plan for committing suicide. Which of the following plans should the nurse identify as a soft method of suicide? A. Jumping off a bridge B. Inhaling carbon monoxide C. Hanging with a rope D. Swallowing antidepressant pills

Correct Answer: D. Swallowing antidepressant pills The nurse should assess the lethality of a client's suicide plan and identify whether it is a hard or soft method. Ingesting antidepressants or other pills is considered a soft method because it has a lower risk of resulting in death than hard methods. Hard methods include jumping from a high place, carbon monoxide inhalation, hanging, and using a gun.

A nurse is assisting with the admission of a client to an acute-care mental health facility following a suicide attempt. Which of the following actions should the nurse take first? A. Assess the client's level of self-esteem B. Document the client's mood and affect C. Attend an interdisciplinary team meeting D. Search the client's belongings

D. Search the client's belongings

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse contribute to the plan of care? Assign the client to a private room. Document the client's behavior every hour. Allow the client to keep perfume in their room. Ensure that the client swallows medication.

Ensure that the client swallows medication. Ensure that the client swallows medication to prevent hoarding of medication for an attempt to exceed the prescribed dose. NCLEX® Connection: Psychosocial Integrity, Crisis Intervention

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following findings should the nurse identify as the priority? Client's educational and economic background Lethality of the method and availability of means Connection: Psychosocial Integrity, Crisis Intervention Ouality of the client's social support Client's insight into the reasons for the decision

Lethality of the method and availability of means The greatest risk to the client is self-harm as a result of carrying out a suicide plan. The priority finding is to determine how lethal the method is, how available the method is, and how detailed the plan is. NCLEX®

A nurse is collecting data from a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (Select all that apply.) "My family will be better off if I'm dead." "The stress in my life is too much to handle." "I wish my life was over." "I don't feel like I can ever be happy again." "If I kill myself then my problems will go away."

My family will be better off if I'm dead." This statement is an overt comment about suicide in which the client directly talks about their perception of an outcome of their death. Monitor the client further for a suicide plan