Chapter 16: Suicide Prevention: Assessment and Screening

The nurse provides care for a client who is depressed and expresses hopelessness with the current situation. Which client statement indicates a need to implement safety precautions? "I haven't been able to sleep for the past week because I am anxious." "I just started my new medication and I hope to feel better soon." "I decided that I should stop drinking alcohol for a while." "I just started a new job so at least I have that."

"I haven't been able to sleep for the past week because I am anxious." Identification of clients who are considering suicide is a priority nursing action. The nurse can use the mnemonic IS PATH WARM to assess the client for warning signs for suicide. The A in this mnemonic stands for anxiety and may be manifested by an inability to sleep; therefore, the statement that indicates a need to explore the implementation of safety precautions is, "I haven't been able to sleep for the past week." Starting a new antidepressant and stating, "I hope I feel better soon; I decided that I should stop drinking alcohol for a while; I just started a new job so at least I have that." do not correspond with any of the warning signs for suicide.

The nurse is working with a patient who will be signing a commitment to treatment statement. After teaching the patient about this statement, the nurse determines the need for additional instruction when the patient states which of the following? A) "Signing this statement means that I will not commit suicide." B) "I am agreeing to get emergency treatment if I have suicidal thoughts." C) "I will be open and honest about my feelings about treatment." D) "I am agreeing to participate in the necessary treatment for my condition"

A) "Signing this statement means that I will not commit suicide."

A client comes to the clinic for an evaluation of headache, fatigue, and an overall feelings of being "down." When assessing the client, which statement by the client would alert the nurse to suspect possible suicide? Select all that apply. a) "I'm so tired that all I ever want to do is sleep all the time." b) "I'm looking for a new job because my job is so stressful." c) "Most times, I feel like I'm trapped with no way out." d) "I've been going out with my friends about once or twice a week." e) "I've been drinking about three or four more beers every night."

A) I'm so tired that all I ever want to do is sleep all the time C) most times, I feel like I'm trapped with no way out E) I've been drinking about three or four more beers every night Warning signs for suicide include increased substance use (drinking three or four more beers every night), an inability to sleep or sleeping all the time, and feeling trapped. Social isolation or withdrawal (rather than going out with friends or looking for a new job) would suggest suicide.

A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following? A) Use of substances 6 hours before the assessment B) Speech patterns C) Availability of support resources D) Amount of sleep in past 24 hours

A) Use of substances 6 hours before the assessment

The nurse is reviewing the medical records of several clients diagnosed with major depression. The nurse identifies which client as LEAST likely to commit suicide? a) Married man b) Widowed woman c) Single woman d) Divorced man

A) married man The nurse determines that the client least likely to commit suicide is the client who is married. Single, older men living in a rural area have the highest rates of suicide. Unmarried, unsociable men between the ages of 42 and 77 years with minimal social networks and no close relatives have a significantly increased risk for committing suicide. Women are less likely to complete a suicide but are more likely to attempt suicide. Marriage has been identified as a protective factor for mental disorders in older adults.

The nurse has been contacted by the parent of an adolescent who has posted a note on social media about the desire to kill oneself. Which additional sign is a warning that there is an acute risk of suicide for the client? A.) The client has been stealing prescription medication from home. B.) The client has been experiencing increased anxiety. C.) The client has appeared more angry lately. D.) The client has experience changes in sleep pattern.

A.) The client has been stealing prescription medication from home. According to the American Association for Suicidology, warning signs for acute risk for suicide include a threat to hurt or kill the self, and/ or looking for ways to kill the self such as with available pills or others means. The alternative answer options listed are also warning signs for suicide, however, they are considered expanded warning signs and are not captured within 'acute risk.' Nonetheless, the expanded factors must be taken into account when the acute factors are present as they serve to heighten the risk that the client will engage in a suicidal act.

Which statement is a myth regarding suicide? A. Most suicidal people are undecided about living or dying. B. Suicidal people are fully intent on dying. C. Many people who die by suicide have given definite warnings of their intentions. D. The suicide rate is lowest in December

ANS: B Suicidal people are fully intent on dying. Rationale: A myth regarding suicide is that suicidal people are fully intent on dying. Most suicidal people are undecided about living or dying. Facts about suicide include that the suicide rate is the lowest in December and that many people who die by suicide have given definite warnings of their intentions.

Which mental health disorder is the most significant risk factor for suicide? A. Mania B. Anxiety C. Depressive disorder D. Schizophrenia

ANS: depressive disorder Rationale: Depressive disorder is a major risk factor of suicide. Anxiety, schizophrenia, and mania are significant risk factors, but to a lesser degree than depression.

The majority of suicides in men are attributed to what means? A. Overdose B. Firearms C. Drowning D. Hanging

ANS: firearms Rationale: Men complete 78% of all suicides; 56% of these deaths are by firearms. The other means of suicide do not account for the majority of suicides in men.

The nurse is preparing a community education session on suicide awareness. Which point should the nurse include in the presentation? A.) Suicide is attributable solely to social and psychological factors. B.) A firearm in the home increases the risk that a person will complete suicide. C.) Being a Hispanic male poses the greatest risk for completing suicide. D.) Suicide rates are lowest among adolescent minorities who identify as bisexual.

Answer: B.) A firearm in the home increases the risk that a person will complete suicide.

A patient was admitted to the psychiatric unit 3 days ago because of suicidal ideation. His suicidal risk has lessened considerably, and he currently denies having any desire to kill himself. In addition, he is able to identify reasons why he wants to be alive. Which nursing intervention would be most appropriate at this time? A) Assigning nursing staff to stay with him during his suicidal crisis B) Developing a personal plan for managing suicidal thoughts when they occur C) Advising the patient that he should consider electroconvulsive therapy treatments D) Administering psychotropic drugs that decrease the patient's serotonin levels

B) Developing a personal plan for managing suicidal thoughts when they occur

After teaching a class about factors that enhance the risk of suicide, the instructor determines the need for ADDITIONAL TEACHING when the class identifies which of the following?A)Family member committing suicide B)Cautiousness C)Delusions D)Loss

B) cautiousness

Several questions can be used to assess a suicidal person's intent to die, severity of suicidal ideation, and degree of planning. Which question may be used to elicit information regarding the severity of SUICIDAL IDEATION? A. Have you made any plans to kill yourself? B. Can you dismiss thoughts of killing yourself, or do they tend to return? C. How seriously do you want to die? D. Have you done anything to put the plan into action?

B. can you dismiss thoughts of killing yourself, or do they tend to return? Rationale: A question to ask the person regarding severity of suicidal ideation may include, "Can you dismiss thoughts of killing yourself, or do they tend to return?" The other questions focus on the intent to die and the degree of planning.

A nurse is performing an assessment of a patient with suicidal ideation. Which question would the nurse most likely ask to determine the degree of planning? A) "How seriously do you want to die?" B) "Have you attempted suicide before?" C) "Could you stop yourself from killing yourself?" D) "How much do the thoughts distress you?"

C) "Could you stop yourself from killing yourself?"

A nurse determines that a patient has poor social skills that have interfered with his ability to engage others, which has contributed to his feelings of purposelessness, hopelessness, and withdrawal. Which of the following would be most important to assist the patient in beginning to social skills? A) Self-help group B) Recovery group C) Nurse—patient relationship D) Limit setting

C) Nurse—patient relationship

A nurse is presenting a discussion for a local community group about suicide. Which comment from an audience member indicates the need to CLARIFY clarify the information? A)"Warning signs about the person's intention often occur." B)"People who are suicidal are undecided about living or dying." C)"Suicides more often occur during the holiday seasons." D)"People who talk about suicide need to taken seriously."

C)"Suicides more often occur during the holiday seasons."

The nurse determines that a patient is at imminent risk for suicide. Which of the following would be least appropriate to include in the patient's plan of care? A)Listening intently and nonjudgmentally B)Validating the patient's feelings and experience C)Instituting strict restriction on the patient's activity D)Using cognitive interventions to foster hope

C)Instituting strict restriction on the patient's activity

Carrie, age 20, was admitted to the inpatient unit following a suicide attempt. She is disheveled, disorganized, and dehydrated. The priority for her care during the first 24 hours of her admission is ... a) assessing Carrie's recent suicide attempt and identifying factors that may have contributed to it. b) assisting Carrie with her activities of daily living, including a shower and clean clothing. c) assessing Carrie's current suicidal ideation and putting her on suicide precautions. d) rehydrating Carrie by forcing fluids.

C: assessing Carrie's current suicidal ideation and putting her on suicide precautions. The first step is to provide for Carrie's safety by assessing her risk for suicide. Because Carrie has attempted suicide, the nurse immediately places her on suicide precautions with frequent or continuous one-to-one observation and reassessment.

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

Case finding involves the identification of people who are at risk for suicide so that proper treatment can be initiated. Modifying the layout of the center would not be necessary in order to carry out the necessary assessments. Observation would not be a part of community-based care. The nurse should address the shame that often accompanies suicide, but this action is not a key component of case finding.

After teaching a group of students about the various concepts involving suicide, the instructor determines that the teaching was successful when the students describe parasuicide as which of the following? A) Voluntary act of killing oneself B) All suicide related behaviors and suicidal thoughts C) Nonfatal act with the intent to die D) Voluntary attempt without death as the aim

D) Voluntary attempt without death as the aim

Mark is a 43-year-old man whose wife JUST died by suicide. Which of the following is a common emotional response by family members of those who die by suicide? a) Unpredictable behavior and a potential for risk-taking behaviors b) The development of a panic disorder c) Turning toward alcohol or drugs d) Anger toward the loved one who committed suicide

D) anger towards the loved one who committed suicide Some of the emotional responses suicide survivors may experience include feelings of unreality, shock, disbelief, and emotional numbness; grief, sadness, and despair; confusion over not knowing why the loved one chose suicide; anger toward the mental health practitioner, another family member, or a friend for failing to prevent the suicide; self-anger and guilt for failing to prevent the suicide; feelings of anger toward and betrayal by the loved one who committed suicide; and social stigmatization and isolation.

A mental health nurse is caring for a depressed client, whose wife passed away 2 months ago. The client sates, "I'm going to kill myself." Which of the following is a BEHAVIORAL sign of suicide? a) Hopelessness b) Guilt c) Isolation d) Making a will

D) making a will Making a will is a behavioral sign of suicide. The other options are emotional/psychological signs.

A group of nursing students is reviewing information about suicide and associated concepts. The group demonstrates understanding of the information when they identify which of the following as the probability that a person will successfully complete suicide? A)Parasuicide B)Suicidal ideation C)Suicidality D)Lethality

D)Lethality Lethality refers to the probability that a person will successfully complete suicide. Parasuicide is a voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death (e.g., taking a sublethal drug). The term suicidalityrefers to all suicide-related behaviors and thoughts of completing or attempting suicide, and suicide ideation. Suicidal ideation is thinking about and planning one's own death.

Curtis is a psychiatric-mental health nurse who is conducting a suicide assessment with a client. Why is it important to conduct a LETHALITY ASSESSMENT? a) It may assist in evaluating the potential suicide protective factors of a client. b) It may assist in determining an individual's past suicide behaviors. c) It may assist in determining how long a client has been contemplating suicide. d) It may assist in predicting how likely a person is to die by suicide

It may assist in. predicting how likely a person is to die by suicide Lethality assessment is part of conducting a risk assessment. Once it is determined that someone is thinking of suicide, a lethality assessment is necessary. It is an attempt to predict how likely a person is to die by suicide.

What is the primary nursing concern related to a depressed client who has been taking amitriptyline 50 mg three times a day for the past 3 weeks? anxiety ineffective coping risk for self-injury chronic low self-esteem

Risk of injury Clients with depression are at increased risk for suicide when they have been on antidepressant medication for 2 weeks, because they are regaining some energy but may not have achieved full therapeutic effect with mood improvement. Poor coping is important but it is not the priority. Evidence of noncompliance is lacking. The medication is not prescribed for anxiety disorders.

The nurse is assessing a client for warning signs of suicide. Which would be a concern? The client has decreased substance use. The client is reaching out to family and friends. The client has forgiven those who have caused emotional pain. The client has engaged in risky behaviors and tends to be impulsive.

The client has engaged in risky behaviors and tends to be impulsive.

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?" Hopelessness is a significant risk factor for suicide among persons who are depressed. For an adult client, relationships with parents are significant but not among the major risk factors for suicide. Similarly, the client's perception of medication effectiveness is important but not a key risk factor. It is common for depressed individuals to lack firm plans for their days, and a lack of planning does not necessarily indicate a heightened suicide risk.

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."

While caring for a client in the hospital, you become concerned that the client may be having thoughts of suicide. Which of the following statements would be most therapeutic? a) "What is concerning you?" b) "Have you tried taking medication?" c) "Are you feeling sad?" d) "Do you have support at home?"

a) "what is concerning you?" Nurses start with open-ended questions that invite clients to convey what is concerning them most at this particular time. Sensitivity and empathy allow nurses to gather information, engage clients, and develop the therapeutic relationship.

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 Hanging is used in 75% of inpatient suicides. Consequently, efforts to eliminate the necessary equipment have the potential to reduce the risk. The described change in medication delivery is not relevant to suicide risk. Similarly, a buddy system for nurses will have no appreciable effect on suicide risk. For some patients, cognitive behavioral therapy may be useful, but this is not the case for all patients.

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 Following a suicide attempt, it is imperative that a plan be in place for continuity of care in the community. Arrangements such as advance directives and commitment to treatment statements are optional, not mandatory. Communication with the pharmacy is just one component of a discharge plan and is not necessary in every circumstance.

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

Which of the following statements regarding suicide is correct? a) Suicide has profound effects on those connected to the individual. b) Suicide is defined as the voluntary or unintentional act of taking one's own life. c) Suicide does not occur in affluent neighborhoods, indicating poverty is a factor. d) Suicide is more of a concern in countries other than the United States.

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

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 A CTS is a commitment to engage in treatment and access emergency care when necessary. It does not mean that the client waives his legal rights his ethical right to make decisions. A CTS is not a document that specifies which treatments the client desires.

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?" Parasuicide is a voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death (e.g., taking a sublethal drug). Parasuicidal behavior varies by intent. Some people truly wish to die, but others simply wish to feel nothing for a while. Still others want to send a message about their emotional state. Parasuicide behavior is never normal and should always be taken seriously. Parasuicide occurs frequently in younger age groups but declines after the age of 44 years. The nurse should discuss the observation of the parasuicidal behavior with the client by communicating that he or she understands the client may be attempting to communicate that there is some social or emotional stress. The nurse should ask the client if the assumption that stress has led to this way of coping is correct to offer the client a sense of control over the personal experience of parasuicide. Asking the client if his or her coping skills are ineffective can elicit defensiveness in the client due feeling blamed or inadequate. In this case the cuts are superficial, therefore, likely do not need to be dressed.By asking if the client would like the wounds dressed, the nurse has not addressed the fact that the client is seeking support by having the cuts visible. If it is determined that the cuts are deeper and at risk for infection, further assessment and treatment of the cuts is warranted. As stated previously, making assumptions risks eliciting a defensive response from the client. Asking if the counseling sessions are not working for the client may hinder the relationship and take away from the therapeutic relationship.

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. SAFETY is always first

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. A depressed client's request for extra sheets or blankets, especially during warm weather, should signal the nurse to the possibility of a hanging attempt. The nurse should address the client's food stockpiling and being late for medications, but these are less likely to be suicide planning behaviors. The nurse must always carefully assess clients' requests to be in a comfort room, but this is less likely to be a suicide planning behavior than an unwarranted request for bedding.

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 greatest predictor of suicide risk is a previous attempt. All of the other listed variables must be addressed, but none is as significant a risk factor as a previous suicide attempt.

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. Childhood abuse is linked to suicide. The use of sleep aids, being from a Latin American culture or being unable to quit smoking are not identified as independent risk factors for suicide.

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. Distraction can be beneficial in the short-term management of suicidal thoughts. Medications are not normally used for redirection of thinking in the short term. It is not appropriate to delegate care to another patient.

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 The suicidal individual may exhibit behaviors that provide clues to his or her intent, including the following:• Talking about death, suicide, and wanting to be dead• Talking or thinking about punishment, torture, and being persecuted• Hearing voices and suddenly seeming very happy after being very depressed for some time• Being very aggressive or very impulsive, and acting suddenly and unexpectedly• Showing an unusual amount of interest in getting his or her affairs in order• Giving away personal belongings

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 Assessment and observation are among the core nursing actions to prevent suicide. Medication is a cornerstone of treatment but does not prevent suicide in and of itself. No-suicide contracts have not been shown to be effective. Therapy is not always indicated for all clients and does not supersede assessment and observation as a safety measure.

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. Immediate interventions involve removing the means of suicide to reduce the risk of it happening. If the person is hospitalized, methods may include ensuring pills or medications are not available to clients or that they are not taking any measures to accumulate needed drugs. If in a community or home care setting, nurses may enlist the help of family or friends to remove the means and to provide immediate support.

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. Risk for suicide increases when there is a family history of suicide. Risk of suicide is two to eight times higher in first-degree (parents, siblings, or children) relatives of people who died by suicide than in 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. While the nurse is not obliged to inform law enforcement, he or she is ethically obligated to protect the client from self-harm. Participation or referral for assisted suicide has not been recognized as an acceptable component of nursing practice.

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.

The nurse is providing a presentation for a group of health professionals about suicide. Which of the following would the nurse address as a major contributing factor to the rising suicide rate among men? a) Lack of conflict resolution skills b) Parenting practices c) Substance abuse d) Media influences

c) substance abuse Substance abuse, aggression, hopelessness, emotion-focused coping, social isolation, and lack of purpose in life have been associated with suicidal behavior in men. In addition, just under 50% of suicide attempts in men between the ages of 42 and 77 years involve firearms. The media, lack of conflict resolution skills, and parenting practices can play a role, but are not considered major factors.

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 Rationale: A suicide attempt is a nonfatal, self-inflicted destructive act with explicit or implicit intent to die. Suicidal ideation is thinking about and planning one's own death. Suicidality refers to all suicide-related behaviors and thoughts of completing or attempting suicide and suicide ideation. Parasuicide is a voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death.

The nurse is facilitating a support group for people who have lost a family member or friend to suicide. When discussing strategies for coping with grief, which should the nurse include? Select all that apply completing a daily journal entry before bedtime writing out the events leading up to the loved one's suicide cognitive behavioral therapy encourage time spent in solitude take anti-anxiolytic medications as often as possible

completing a daily journal entry before bedtime writing out the events leading up to the loved one's suicide cognitive behavioral therapy The intensity and duration of the post-suicide grief process for many survivors has led to the development of family intervention programs. Although the evidence base for these interventions is still small, strategies that support a positive sense of self, enhance problem-solving such as that embedded within cognitive behavioral therapy, promote the formation of a suicide story, encourage social reintegration, reduce stigma, use journaling, or permit the survivor to debrief may be effective in reducing subjective distress and to resolve grief. Clients should be encouraged to spend time with others, not only to encourage social reintegration, but also because recovery from grief may be most effective when delivered in survivor peer help groups. Although clients may benefit from medications for relief of anxiety symptoms early in post-suicide, anti-anxiolytic medication is not an effective long term coping strategy and may delay an adaptive recovery process for survivors.

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 Rationale: In each of the answer options, the client has some level of personal risk for self-harm or suicide. However, the client who is at highest risk of lethality is the male client with direct access to a firearm. Lethality is determined by the seriousness of the person's intent and the likelihood that the planned method of death will succeed. A plan to use an accessible firearm to commit suicide has greater lethality than the other options listed. Males are also more likely to be successful with following through with a suicide plan than other groups.

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

d) A true psychiatric emergency exists when an individual presents with one or more symptoms associated with imminent risk for suicidal behavior. Immediate and focused action is needed to prevent the patient's death. The client who is depressed, using alcohol and has access to the most lethal means to commit suicide is the highest risk and requires imminent intervention. The client who is depressed, lives in poverty and has chronic pain meets criteria for someone at risk, however, the risk in this case is not imminent and would not warrant immediate intervention. The client who is depressed, withdrawn and spending most of the time playing video games would certainly warrant assessment and therapeutic intervention, however, based on the information provided the client would not be deemed an imminent risk. The grieving client who is tearful and does not want to be left alone is experiencing a normative response to death and does not meet the criteria for imminent suicide intervention.

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 About 50% to 80% of people who commit suicide have previously attempted suicide; the more violent and lethal the plan, the higher the potential for suicide. Assessment of past attempts and current plan (not psychosis) as well as maintaining client safety would be priorities. Maintaining a safe, secure environment is an important intervention by the nurse to prevent a suicide attempt.

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 Rationale: The initial care of a client who has had a suicide attempt focuses on helping the client feel safe and instilling the beginnings of hope. It would be premature to expect the client to learn and apply new stress management strategies after only 24 hours. Cognitive behavioral therapy would not begin during the acute stage of recovery. A sense of overall optimism will likely require long-term therapy to achieve it.

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 Primary prevention involves the identification and elimination of factors that cause or contribute to the development of an illness or disorder that could lead to suicide. Medication management, psychotherapy, and suicide precautions are more aggressive measures that would not be classified as primary prevention.

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 Suicide rates tend to be higher in families in which suicide has occurred, which are genetic and familial factors. First-degree relatives of individuals who have completed suicide have a two- to eight-times higher risk for suicide than do individuals in the general population.

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 Parasuicide is a voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death (e.g., taking a sublethal drug). Parasuicidal behavior varies by intent. Some people truly wish to die, but others simply wish to feel nothing for a while. Still others want to send a message about their emotional state. Parasuicide occurs frequently in younger age groups but declines after the age of 44 years. A suicide attempt is a nonfatal, self-inflicted destructive act with explicit or implicit intent to die. Social exposure to suicide is associated with an increased personal risk for suicidal behavior, particularly among adolescents. Suicide behavior that occurs after the suicide death of a known other is called suicide contagion or cluster suicide. Impulsivity is a risk factor for both parasuicide and suicide attempts. Impulsivity alone does not explain why the client engages in self-harming behaviors.

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. Preventing self-destructive behavior is the primary nursing goal. Other important goals, such as assisting the client in expressing feelings, assessing for causes of depression, and developing rapport, may be important for intervention after the primary goal of maintaining safety is met.

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 Rationale: The greatest predictor of a future suicide attempt is a previous attempt, partly because that individual already has broken the "taboo" around suicidal behavior. Assessing for risk includes determining the seriousness of the suicidal ideation, degree of hopelessness, and suicide planning.

The nurse is teaching about suicide prevention at the local high school. Which warning sign(s) of suicide would the nurse include in the education session? Select all that apply. illegal drug use writing about death insomnia wearing a seatbelt alcohol use assertive communication

illegal drug use writing about death insomnia alcohol use Warning signs to suicide include talking or writing about death, dying, or suicide; increased drug or alcohol use; sense of purposelessness; anxiety, agitation, insomnia, or hypersomnia; feeling trapped; hopelessness; social isolation from friends and family; anger, rage, or seeking revenge; and recklessness. Therefore, illegal drug use, writing about death, insomnia, and alcohol use would be included in the educational session about warning signs of suicide. Wearing a seatbelt and assertive communication are healthy behaviors and do not indicate possible warning signs of suicide.

When assessing risk of suicide, which assessment components are important? (Select all that apply.) A. Lethality of method B. Degree of hopelessness C. Previous attempt D. Seriousness of suicidal ideation E. Unemploymen

lethality of method degree of hopelessness previous attempt seriousness of suicidal ideation