Question 1

The nurse is assessing four patients for a risk for suicide. According to the Level of Suicidal Severity Index, which patient statement indicates the greatest risk for suicide?

Accepted Answer

1. The Level of Suicidal Severity Index is a tool used by nurses and clinicians in the comprehensive assessment of a patient's risk for suicide. This index categories the patient's thoughts of suicide into five various stages of severity. The patient who can no longer identify any protective measures or a reason for living is in Stage V, and is at greatest risk for suicide. The patient who states, "I have no reason to live anymore and suicide is my only option" is best demonstrating Stage V. The patient in Stage III is beginning to consider suicide as an option for problem solving. The patient who has a plan for suicide and method to carry out the strategy is in Stage IV. The patient who begins to have fleeting thoughts of suicide, followed by thoughts that dismiss suicide is in Stage II.

Question 2

A community health nurse is providing education to a group of mental health employees regarding the influence of the economy on the suicide rate within the community. What statement by the mental health employee indicates the need for further teaching?

Accepted Answer

1. Statistics are useful to understand trends in order to determine what population of individuals may be at risk for completion of suicide. Economic factors contribute to the suicide rate. Suicide rates decrease, not increase, during times of war. Suicide rates also increase during times of economic distress and decrease during times of economic growth.

Question 3

The nurse is performing an initial suicide risk assessment. What questions will the nurse include in this assessment? Select all that apply.

Accepted Answer

1. The nurse should ask patients explicitly if they feel as though they want to commit suicide and want to die. The nurse should inquire about whether patients have a means to harm themselves and what that means is (e.g., firearm, knife, overdose, hanging). The nurse should ask whether patients have fantasies about hurting themselves, such as jumping to their death. The nurse will not ask the patient about thoughts of consequences or how the patient's family would react to the patient's suicide; rather, the nurse is assessing the patient's risk for suicide on initial assessment. Once the patient's safety is established, the nurse will likely ask these questions.
2. The nurse should ask patients explicitly if they feel as though they want to commit suicide and want to die. The nurse should inquire about whether patients have a means to harm themselves and what that means is (e.g., firearm, knife, overdose, hanging). The nurse should ask whether patients have fantasies about hurting themselves, such as jumping to their death. The nurse will not ask the patient about thoughts of consequences or how the patient's family would react to the patient's suicide; rather, the nurse is assessing the patient's risk for suicide on initial assessment. Once the patient's safety is established, the nurse will likely ask these questions.
3. The nurse should ask patients explicitly if they feel as though they want to commit suicide and want to die. The nurse should inquire about whether patients have a means to harm themselves and what that means is (e.g., firearm, knife, overdose, hanging). The nurse should ask whether patients have fantasies about hurting themselves, such as jumping to their death. The nurse will not ask the patient about thoughts of consequences or how the patient's family would react to the patient's suicide; rather, the nurse is assessing the patient's risk for suicide on initial assessment. Once the patient's safety is established, the nurse will likely ask these questions.

Question 4

The nurse is caring for a patient who is active duty military. The nurse suspects the patient may be suicidal. According to current research on laboratory values and suicide, which action by the nurse would be most appropriate?

Accepted Answer

2. While further research is still needed, research has found a relationship between completed suicide and low vitamin D levels. While reviewing the other laboratory values are not inappropriate, these actions do not reflect the current research on laboratory values and suicide.

Question 5

The nurse is caring for a patient who is displaying hopelessness. The nurse wants to assess if the patient has any internal protective measures that could be used to assist the patient to overcome suicidal thoughts. Which question is most appropriate for this purpose?

Accepted Answer

4. Protective measures are factors that can help the individual to feel hopeful and worthy enough to begin problem solving, even when he or she feels that there are no answers to the presenting problem. There are internal and external protective measures. Internal factors are related to the ability to problem solve, think through conflict, and handle disputes without violence. The question, "How do you handle conflicts with others?" best assesses the presence of internal protective measures. The ability to relate to others, connect to family, and to request assistance address external, not internal, protective measures.

Question 6

When performing a suicide risk assessment, for which factors should the nurse assess based on an understanding of the psychiatric causal factor in suicide?

Accepted Answer

2. Anxiety has been implicated as a psychiatric causal factor in most research that has focused on the study of suicide. Specifically, anxiety that is fearful and filled with apprehension has been linked to high tendencies of suicide. Depression and decreased, not increased, productivity have been linked to an increased risk in suicide. Chronic disease, not acute disease, is linked to an increased risk for suicide. Anticipatory grief is not associated with increased risk for suicide.

Question 7

The nurse is caring for a patient in an outpatient clinic who has selected and obtained lethal measures to follow through with suicide completion. What nursing intervention is most appropriate for this patient?

Accepted Answer

4. The patient who has selected and obtained lethal measures to follow through with suicide completion is in Stage V of the Stage of Severity for Suicide Risk. This is the most severe stage, at which the nurse needs to intervene to ensure the patient's safety. This will include transportation to the emergency department for evaluation and planning for the patient to be admitted to the behavioral health unit. While the other answer choices are appropriate interventions for a patient displaying suicidal thoughts or actions, these interventions are only appropriate for those individuals with less severity of suicide risk, such as in stages I through IV.

Question 8

The nurse is caring for a patient who has expressed a desire to commit suicide. Which statement by the nurse is most appropriate?

Accepted Answer

4. For a patient who is expressing thoughts of suicide, it is important for the nurse to offer self and instill hope. The statement, "I am here for you. I know you want to hurt yourself, but there are things we can do to help you," best demonstrates offering self and instilling hope. The nurse should not provide false reassurance by stating, "Your problems will get better. Hurting yourself is not the answer." The nurse is acting in a judgmental way when stating, "Your family and friends will be very upset at you if you hurt yourself," or "I am shocked that you would consider hurting yourself. You have so much to live for." These statements are not therapeutic and not beneficial to a patient who is experiencing suicidal thoughts.

Question 9

The nurse is caring for the following patients. Which patient should the nurse assess most carefully for suicide risk?

Accepted Answer

2. According to the Centers for Disease Control (CDC) and the American Association for Suicidology, individuals ages 85 and older commit suicide at a rate 36% higher than adults younger than 85. Also, Caucasians have the highest rate of death by suicide in the United States.

Question 10

In order to prevent suicide, the nurse is learning about recognizing protective measures in patients displaying hopelessness. Which patient will the nurse recognize as displaying external protective measures?

Accepted Answer

2. Protective measures are factors that can help the individual to feel hopeful and worthy enough to begin problem solving, even when he or she feels that there are no answers to the presenting problem. There are internal and external protective measures. The patient with external protective measures relates to others and can request assistance when needed. The patient who is able to solve problems, think through conflict, and handle disputes without violence is displaying internal, not external protective measures.

Question 11

The nurse at a community health clinic is conducting a mental health assessment on a patient with a history of depression. Which environmental factor does the nurse recognize as a risk factor for suicide?

Accepted Answer

1. Sociological or environmental influences that increase risk for suicide include isolation from others, military status, and incarceration. Working two jobs is not a risk factor for suicide. Chronic illness is a biological risk factor. Apprehensive anxiety is a psychological risk factor.

Question 12

When assessing a patient's suicidal ideations and level of risk, which question most appropriately conveys empathy?

Accepted Answer

2. When assessing a patient's suicidal ideations and level of risk, the nurse will ask questions that either establish empathy or directly assess the patient's suicide ideation. Asking the patient, "What struggles in your life are upsetting you?" best conveys empathy by the nurse. Asking if patients own firearms, feel like they want to hurt themselves, or if there is anything that will make them feel better are appropriate questions to ask; however, these do not convey empathy.

Question 13

The nurse is planning care for a patient who is suspected of being at risk for suicide. Which question would be most appropriate for the nurse to ask the patient when determining the presence of protective measures?

Accepted Answer

4. Protective measures are factors that can help the individual to feel hopeful and worthy enough to begin problem solving, even when he or she feels that there are no answers to the presenting problem. Both religion and spirituality are protective measures that help reduce suffering and promote hope. Asking the patient, "Do you identify with a religious or spiritual group?" will help the nurse identify protective measures. Asking the patient if he or she has any thoughts of suicide, has a history of trauma, or has symptoms of depression, are appropriate questions; however, these questions assesses the patient's risk for suicide and do not address protective measures.

Question 14

The nurse manager is providing an in-service to the staff nurses regarding personality characteristics associated with increased rates of suicide. Which characteristics will the nurse include in the teaching? Select all that apply.

Accepted Answer

1. Research involving post-mortem studies and individuals who have attempted suicide and survived show decreased central serotonin activity in the ventromedial prefrontal cortex. This is exhibited in a higher level of aggression and impulsive behavior. Passivity, compulsivity, and assertiveness have not been associated with increased rates of suicide.
2. Research involving post-mortem studies and individuals who have attempted suicide and survived show decreased central serotonin activity in the ventromedial prefrontal cortex. This is exhibited in a higher level of aggression and impulsive behavior. Passivity, compulsivity, and assertiveness have not been associated with increased rates of suicide.

Question 15

The nurse is caring for a group of patients who are all active duty military. Which patient statement would the nurse identify as increasing the patient's risk for suicide?

Accepted Answer

1. Active duty military personnel are at increased risk for suicide. However, additional factors may further increase their risk. These include substance use, history of deployment to an active war zone, and not having attended or graduated from college. Those who have children are more likely to have protective measures against suicide, due to the fact that they are responsible for caring for another person's basic needs.

Question 16

The nurse is caring for a patient with a previous history of suicide attempt. The patient has been participating in the treatment plan, and while not actively suicidal, continues to express feelings of hopelessness. Which statements by the nurse would best promote hope for this patient? Select all that apply.

Accepted Answer

4. Hopelessness is a common emotion in individuals at risk for suicide. It is vital that nurse working with those at risk for suicide understands the best interventions to instill hope in these patients. Providing stress reduction techniques, such as exercise, help to encourage positive coping mechanisms, increasing hope. Providing encouraging words to the patient who is participating in his or her care instills hope. While the other statements are appropriate in the care of a patient at risk for suicide, these statements address establishing empathy and assessing suicidal ideation.
5. Hopelessness is a common emotion in individuals at risk for suicide. It is vital that nurse working with those at risk for suicide understands the best interventions to instill hope in these patients. Providing stress reduction techniques, such as exercise, help to encourage positive coping mechanisms, increasing hope. Providing encouraging words to the patient who is participating in his or her care instills hope. While the other statements are appropriate in the care of a patient at risk for suicide, these statements address establishing empathy and assessing suicidal ideation.

Question 17

While performing a suicide assessment, the nurse asks the patient, "Have you ever thought of taking your own life?" What is the rationale for the nurse's question? Select all that apply.

Accepted Answer

1. When the nurse asks a patient directly about thoughts of suicide, the nurse offers the opportunity to alleviate the patient's anxiety about considering suicide. Direct and clear communication helps patients open up about their feelings, and patients are more likely to discuss previous suicide attempts. Inquiring about suicidal thoughts does not cause an individual to contemplate suicide, nor does it provide the patient with ideas about suicide methods.
4. When the nurse asks a patient directly about thoughts of suicide, the nurse offers the opportunity to alleviate the patient's anxiety about considering suicide. Direct and clear communication helps patients open up about their feelings, and patients are more likely to discuss previous suicide attempts. Inquiring about suicidal thoughts does not cause an individual to contemplate suicide, nor does it provide the patient with ideas about suicide methods.
5. When the nurse asks a patient directly about thoughts of suicide, the nurse offers the opportunity to alleviate the patient's anxiety about considering suicide. Direct and clear communication helps patients open up about their feelings, and patients are more likely to discuss previous suicide attempts. Inquiring about suicidal thoughts does not cause an individual to contemplate suicide, nor does it provide the patient with ideas about suicide methods.

Question 18

The nurse manager is preparing a teaching session on suicide for a group of novice nurses. What will the nurse manager include in the teaching? Select all that apply.

Accepted Answer

2. According to the Centers for Disease Control (CDC) and the American Association for Suicidology (AAS), men commit suicide more than women, women have a higher rate of attempted suicide, and older adults commit suicide more than younger adults.
3. According to the Centers for Disease Control (CDC) and the American Association for Suicidology (AAS), men commit suicide more than women, women have a higher rate of attempted suicide, and older adults commit suicide more than younger adults.
4. According to the Centers for Disease Control (CDC) and the American Association for Suicidology (AAS), men commit suicide more than women, women have a higher rate of attempted suicide, and older adults commit suicide more than younger adults.

Question 19

The advanced practice nurse is caring for a patient in an outpatient clinic who has expressed thoughts of suicide, but who does not have a plan or means in place. The patient tells the nurse, "I sometimes think it would be easier for me to just go to sleep and never wake up. But I don't hurt myself because I love my children too much." Which nursing interventions are most appropriate for this patient? Select all that apply.

Accepted Answer

2. The patient is likely in Stage II of the Stage of Severity of Suicide Risk. Stage II is manifested by fleeting thoughts of suicide with no intent to carry out suicidal action. Also, the patient's love of his or her children is a protective measure. Appropriate nursing actions for a patient in Stage II include teaching the use of the National Suicide Prevention Lifeline and encouraging the patient to use internal and external support systems. Placing the patient on constant safety observation, admitting the patient to the behavioral health hospital immediately, and recognizing that the patient is likely to reject teaching are all interventions for patients who are in stages III, IV, and V of the Stage of Severity of Suicide Risk.
4. The patient is likely in Stage II of the Stage of Severity of Suicide Risk. Stage II is manifested by fleeting thoughts of suicide with no intent to carry out suicidal action. Also, the patient's love of his or her children is a protective measure. Appropriate nursing actions for a patient in Stage II include teaching the use of the National Suicide Prevention Lifeline and encouraging the patient to use internal and external support systems. Placing the patient on constant safety observation, admitting the patient to the behavioral health hospital immediately, and recognizing that the patient is likely to reject teaching are all interventions for patients who are in stages III, IV, and V of the Stage of Severity of Suicide Risk.

Question 20

The nurse in an emergency department is conducting mental health assessments. The nurse recognizes that which patients are at greatest risk for a suicide attempt? Select all that apply.

Accepted Answer

1. Individuals with schizophrenia are at increased risk for suicide if they are young, recently diagnosed, or have a history of hospitalization. Individuals with personality disorder are also at increased risk, as are active military personnel younger than 25 and who have a history of recent deployment to Iraq or Afghanistan. The working mother who is brought in by a co-worker has some level of external support, as does the teenager who sprained his ankle while camping with his church group. These patients are less likely to be at risk for suicide at this time.
2. Individuals with schizophrenia are at increased risk for suicide if they are young, recently diagnosed, or have a history of hospitalization. Individuals with personality disorder are also at increased risk, as are active military personnel younger than 25 and who have a history of recent deployment to Iraq or Afghanistan. The working mother who is brought in by a co-worker has some level of external support, as does the teenager who sprained his ankle while camping with his church group. These patients are less likely to be at risk for suicide at this time.
4. Individuals with schizophrenia are at increased risk for suicide if they are young, recently diagnosed, or have a history of hospitalization. Individuals with personality disorder are also at increased risk, as are active military personnel younger than 25 and who have a history of recent deployment to Iraq or Afghanistan. The working mother who is brought in by a co-worker has some level of external support, as does the teenager who sprained his ankle while camping with his church group. These patients are less likely to be at risk for suicide at this time.

Quiz 27: Preventing and Responding to Suicide