mental health chapter 23
A client tells the nurse that life became a mess after getting married a few months earlier and that there is no reason to continue living. What should the nurse ask the client initially?
"Do you have any plans to end your life right now?"
Which statement does the nurse know exemplifies suicidal ideation?
"I plan to kill myself by slitting my wrists."
A male client separated from his spouse works as a social worker. The client underwent an appendectomy 6 years ago. On examination the client is physically and mentally healthy and has no complaints. According to the SAD PERSONS scale, what is the client's score? Record your answer using a whole number.
2
Postvention for the family and friends who are survivors of a suicide is most successful when initiated within which time frame?
24 to 72 hours
A 27-year-old male client is unable to sleep after the loss of a parent. The client denies a history of or current issues with any physical or psychological illness. The client denies using either alcohol or tobacco but does report having, "no one to talk to about my problems." According to the SAD PERSONS scale, what is the score of this client?
4
The nurse responsible for the safety of a 10-year-old client diagnosed with impulse control disorder is most concerned about which of the following?
A notation in the child's medical history describing a previous suicide attempt.
What suicidal predictors does the nurse assess for in the client diagnosed with impulse disorder? Select all that apply.
Past suicidal attempts Family history of suicide attempt Feeling of hopelessness Drug or alcohol use
A client admitted to the hospital for radiation therapy for lung cancer wants to end his life. How should the nurse initially respond to this client?
Ask if the client has any plans to commit suicide.
The nurse is concerned when a depressed client presents another client with a favorite shirt as a "gift." What is the nurse's initial intervention?
Ask the client if he or she is experiencing suicidal ideations with a plan to hurt him or herself.
Which factors are considered when determining a client is at high risk for suicide? Select all that apply.
Attempted suicide two years ago Father committed suicide at age 45 Reports excessive reliance upon alcohol
Whom should the head nurse ask to sign the no-suicide contract?
Client
A client with a history of psychosis is admitted after a suicide attempt. During the initial assessment the client states, "The voices are still telling me to kill myself. Which is the priority nursing intervention for this patient?
Place the client on suicide precautions.
A community nurse is assessing the risk factors for suicide among a group of people. What are the factors that are associated with high risk of suicide? Select all that apply.
Family history of suicide
When a client in an outpatient program scores a 7 on the SAD PERSONS scale, what action should the nurse take?
Hospitalization of the client
Nurses should assess the lethality of the client's plan for suicide. What factor would be irrelevant to that assessment?
How long the client has been suicidal.
A client who had a stroke three days ago tearfully tells the nurse, "What's the use in living? I'm no good to anybody like this." What should be the nurse's priority action?
Implement the institutional protocol for suicide risk.
A pregnant woman seeks counseling after losing a parent. She informs the nurse that she has lost her job a few days ago and is aware of her responsibility for her family. Which factors put her at greater risk of suicide? Select all that apply.
Losing a job The death of her parent
Which neurobiological factor is the greatest predictor of suicide?
Low levels of 5-hydroxyindoleacetic
A client hospitalized after unsuccessfully attempting suicide had been adherent to antidepressant medication therapy for two weeks. The nurse observes the client is now brighter and more sociable. What is the nurse's highest priority intervention?
Maintain continuous supervision of the client.
Which provision should the nurse include in a client's no-suicide contract?
Not to attempt suicide in the next 24 hours.
Which states have legalized physician assisted suicide (PAS)/physician aid in dying (PAD)? Select all that apply.
Oregon Vermont California Washington
A client diagnosed with major depressive disorder was hospitalized for two weeks on an acute unit. One day after discharge, the client commits suicide. Which action should the nursing supervisor implement?
Provide a private setting for staff to talk about feelings associated with the event.
A single adult says to the nurse, "Both of my parents died several years ago and my only sibling committed suicide two weeks ago. I feel so alone." After determining this adult has no suicidal ideation, what should the nurse do?
Refer the adult to a self-help group for suicide survivors.
A client diagnosed with major depression successfully committed suicide while hospitalized. What appropriate action should the nurse manager take regarding the unit's staff? Select all that apply.
Review the events for the possible overlooked client clues. Provide adequate emotional support to the staff of the unit. Recommend conducting a psychological postmortem.
Which assessment tool is useful to nurses in rating suicide risk?
SAD PERSONS scale
A client scores 1 on the SAD PERSONS scale. What should the nurse's next step be?
Send the client home with follow-up
Which neurotransmitter has been implicated as playing a part in the decision to commit suicide?
Serotonin
The nurse is assessing a client with a history of attempted suicide. Which method used by the client in the previous suicide attempt would put the client at higher risk?
Staging a car crash
A nurse interacts with a depressive client. The client says, "Can you get me a sharp knife?" What conclusion is most appropriate for the nurse to make from the client's response?
The client is at higher risk of suicide.
If a client's SAD PERSONS score is 5, what does this indicate regarding care?
The client should be strongly considered for hospitalization.
