Mental Health

Which of the following are suicide risk factors that a nurse should assess for? Select all that apply. Age Gender Ethnicity Religion Education

Age Gender Ethnicity Religion

Mild Depression

Associated with grief process Symptoms include: anger, anxiety, helplessness, sadness, despondency, tearfulness, agitation, withdrawal, self-blame, eating too much/too little, sleeping too much/too little, headaches, body aches

If your patient has resiliency and support, then the risk of suicide

Decreases Resiliency and support systems are examples of protective factors associated with decreased potential for suicide.

The nurse is visiting with a client admitted to the psychiatric unit with depression and a history of suicide attempts. Which question by the nurse is appropriate? "How often do you feel sad?" "Are you having thoughts of harming yourself?" "Do you think you might go ahead and kill yourself?" "Are you attempting suicide for attention?"

"Are you having thoughts of harming yourself?" Assessing risk for suicide for a client with a history of attempts and admitted for depression is most important.

A client says, "I am just hopeless. I hate myself. I do not have any reason to live." Which would be the best response by the nurse to this client? "Don't feel that everyone will leave you. Your family will always be with you." "Don't feel that you cannot do anything. You can be independent." "Don't live in the past. I will be your friend." "Don't think that way. I will spend time with you because you matter."

"Don't think that way. I will spend time with you because you matter." A person who has a risk of suicide feels hopeless and worthless and has inward anger. Thus, while caring for this client, the nurse says, "I want to spend time with you because you matter."

Potential warning signs of suicide include which of the following? Select all that apply. Feeling trapped Expression of a suicide plan Hopelessness Social isolation Increasing substance use

Feeling trapped Expression of a suicide plan Hopelessness Social isolation Increasing substance use

Which statement made by the student nurse indicates an understanding of Joiner's theory of suicide? "The move from suicide ideation to attempts is viewed as an impulsive act." "Individuals work up to the act of suicide by first attempting self-harm." "Having a low feeling of burden increases suicidal thoughts." "Only psychological factors are critical to understanding suicide risk."

"Individuals work up to the act of suicide by first attempting self-harm." This statement is accurate and does not require correction. Individuals may become fearless by attempting self-harm first and then build up to suicide.

The nurse is caring for a group of clients. Which client would the nurse identify as being at highest risk for suicide? A divorced white middle-aged male A married Hispanic elderly female A single Asian young male A divorced black middle aged female

A divorced white middle-aged male The client is at highest risk for suicide. Being divorced, white, and being middle-aged are all high risk factors.

The nurse is reviewing statistics of leading causes of death among Americans ages 10 to 34 years. Which action is the second leading cause of death? Homicide Suicide Unintentional injury Heart disease

Suicide Suicide is the second leading cause of death among Americans 10-34 years of age.

Can you differentiate between the types of suicide risk factors and warning signs (low risk, high risk, very high risk) Feeling hopeless with suicidal ideation, a plan, and means

Very High Risk Suicidal ideation with a plan and means represents multiple high-risk warning signs for suicide. This person needs to seek immediate help from emergency medical or mental health professionals

Which statement made by a student nurse requires further teaching regarding religious beliefs and suicide? "My client identifies as an atheist, so I expect no religion-based opposition to physician-assisted suicide." "I think my client would have a religious opposition to physician-assisted suicide because she and her family are practicing Catholics." "My client does not believe physician-assisted suicide is a sin because he is a Hindu." "Suicide is considered a sin in the Jewish faith, so my client says physician-assisted suicide is not an option for them."

"My client does not believe physician-assisted suicide is a sin because he is a Hindu." This statement requires further teaching; Hinduism does condemn suicide.

Which of the following are appropriate assessment questions to elicit suicidal ideation or intent? Select all that apply. Have you wished you were dead or wished you could go to sleep and not wake up? Have you ever wanted to hurt yourself? Have you had any thoughts of killing yourself? Have you thought about how you would kill yourself? Are you not happy with living?

Have you wished you were dead or wished you could go to sleep and not wake up? Have you had any thoughts of killing yourself? Have you thought about how you would kill yourself?

Which scenario describes the cause of anomic suicide, according to Durkheim? A man's wife leaves him and his three children for her husband's best friend. A man is not accepted by his family or church community for his sexuality. A woman is extremely devoted to her religion and would give her life for their cause. A woman has been a victim of human trafficking for the past 4 years.

A man's wife leaves him and his three children for her husband's best friend. This describes an example of anomic suicide (divorce, loss of job).

Can you differentiate between the types of suicide risk factors and warning signs (low risk, high risk, very high risk) Withdrawing from friends, stating they feel trapped with no way out, and increased substance use

High Risk Withdrawing from others, feeling trapped, and increased substance use are maladaptive coping mechanisms in a crisis. The person has not stated they have suicidal ideation or a plan, but the nurse should be concerned about these symptoms as they are potential warning signs of suicide.

If your patient is between ages 55 and 64, then the risk of suicide

Decreases The highest rates of suicide occur in the 45- to 54-year-old age-group and among those 85 and older. Suicide is the third-leading cause of death in the adolescent population and the second-leading cause of death in children ages 10 to 14 years.

If your patient feels a lack of connectedness along with pain, then the risk of suicide

Increases Connectedness prevents suicidal ideation from increasing, but when pain and hopelessness are also present, suicidal ideation can become active.

If your patient has a family history of suicide, then the risk of suicide

Increases Higher risk is associated with a family history of suicide, especially in a same-gender parent. Individuals who have made previous suicide attempts are also at elevated risk. About one-half of individuals who die by suicide have previously attempted suicide and about half die on the first attempt. For this reason, all individuals with suicidal ideation should be assessed carefully.

If your patient is a male, then his risk of suicide

Increases More women than men attempt suicide, but men more often die by suicide (about 70% for men and 30% for women). These rates reflect the lethality of the means that men use.

If your patient is white, then the risk of suicide

Increases Whites have the highest age-adjusted suicide rates, and American Indians represent the second-highest rates.

The nurse is assisting a client and the client's friends in developing a safety plan. Which component would the nurse include in the plan? A dated signature agreeing not to harm self A promise to call 9-1-1 if thoughts of suicide are present A reminder that the individual agreed not to harm self Internal coping strategies the client can implement

Internal coping strategies the client can implement This component would be included on a safety plan for a client and friends/family members

Can you differentiate between the types of suicide risk factors and warning signs (low risk, high risk, very high risk) Social Isolation

Low Risk Social isolation is a warning sign, but by itself carries low suicide risk. The nurse should recommend counseling and monitor the person for other warning signs.

Severe Depression Major Depressive Disorder

Major distress or significant impairment in functioning for at least 2 weeks Symptoms include: depressed mood most of the day, diminished interest or pleasure in activities (anhedonia), weight loss/gain, sleep disturbances, psychomotor disturbances or retardation, worthlessness or guilt, decreased concentration, thoughts of death or suicidal ideation *Patient must have at least 5 symptoms including depressed mood or anhedonia

How many individuals who attempt or commit suicide have been diagnosed with a mental disorder? Very few About one-third Around half Most

Most More than 90% of individuals who commit or attempt suicide have a diagnosed mental disorder.

Transiet Depression

Normal response to stresses of everyday life Symptoms: sadness, crying, about what went wrong, feeling tired *These symptoms usually resolve on their own and resolve pretty quickly *Really no impairment in functioning

Other factors besides impulsivity elevate risk of suicidal ideation to an active risk for attempt. Which factors listed below are part of the three-step trajectory and increases a person's risk? Select all that apply. Pain Connectedness Suicidal ideation with no means Hopelessness Resiliency

Pain Hopelessness

Moderate Depression Dysthymia: Persistent Depressive Disorder

Persistent depressive disorder of depressed mood most of the day for at least 2 years Symptoms include: eating too much/too little, sleeping too much/too little, headaches, body aches, low energy, fatigue, low self-esteem, poor concentration, hopelessness *cause distress and impairment in functioning

The nurse is caring for a client with a high risk of suicide. Which intervention would be most effective for the nurse to implement? Monitor the client every 15 minutes Place the client in a private room Provide one-to-one observation Place the client in a room near the nurses' station

Provide one-to-one observation Providing 1:1 observation reduces likelihood that the client will commit suicide

The nurse is assessing a client's risk for suicide using the IS PATH WARM acronym. Which term does the "R" represent? Respect Responsibility Reaction Recklessness

Recklessness

Presenting symptoms that increase a person's risk for suicidal behavior include which of the following using the IS PATH WARM mnemonic? Select all that apply. Trapped Ideation Purpose Subjective data Anger

Trapped Ideation Anger

If the nurse asks the patient direct questions such as "Have you had any thoughts of killing yourself?" or "Have you been thinking about how you might do this?," then the risk of suicide

Stays the same The nurse needs to ask direct question about suicidal ideation, intent, plan, and means. Asking these questions will not trigger the patient to now think about suicide, but they may help the patient admit that there is a crisis and they need help. It is also important to use the correct terminology such as "suicide" and "death" rather than "not happy with living" or other indirect statements. Use of direct language also communicates to the client that these are acceptable topics to discuss.

A nurse is caring for a client with suicidal tendencies. Which client outcome would be the best indicator of the effectiveness of the nursing interventions? The client has avoided self-harm. The client sleeps without any difficulty. The client interacts appropriately with others. The client has good perceptions about himself or herself.

The client has avoided self-harm. If the client has avoided self-harm, then the nurse could evaluate that the nursing intervention was successful.

A client is depressed because he witnessed his friend dying in a fatal accident. Ever since the accident, the client has been saying that he could not save his friend from dying and nothing seems to be in his hands anymore. Which intervention would the nurse implement for this client? The nurse should teach the client about the use of "I" messages. The nurse should formulate a written contract with the client. The nurse should teach the importance of respecting human rights to the client. The nurse should encourage the verbalization of feelings related to the loss.

The nurse should encourage the verbalization of feelings related to the loss. The nurse should encourage the client to verbalize the feelings related to his or her inability to save the victim in an effort to deal with unresolved issues and accept what cannot be changed.

The nurse is caring for a client who has suicidal thoughts. Which would be the primary intervention by the nurse? The nurse would create a safe environment for the client. The nurse should make frequent rounds at irregular intervals. The nurse should take special care while administering medications. The nurse should take a promise from the client that he or she will seek out help from the staff members if thoughts of suicide emerge.

The nurse would create a safe environment for the client. Creating a safe environment for the client should be the primary intervention by the nurse. This helps decrease the risk of violence in the client.