Question 1

A nurse is caring for four clients diagnosed with major depression. When considering the client's belief system, which client would potentially be at highest risk for suicide?

Accepted Answer

Research has shown that individuals who identify as atheist or have no religious affiliation have a higher risk for suicide compared to those who identify with a religion. This may be due to a lack of social support and perceived meaning/purpose in life. However, it's important to note that suicide risk is complex and multi-factorial, and should not be solely attributed to one's belief system.

Question 2

A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first?

Accepted Answer

Assessing suicide risk should be the first action taken when caring for a suicidal client. This involves asking about suicidal thoughts, intent, plan, and history of suicide attempts. This information is essential for developing an appropriate plan of care and ensuring the safety of the client.

Question 3

A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply?

Accepted Answer

The most appropriate nursing reply in this situation would be to reflect back to the client what they are expressing and validate their feelings. Option D does this by acknowledging that the client is feeling hopeless. Option A is not appropriate as it suggests a solution without addressing the client's current state of mind. Option B could potentially make the client feel worse by focusing on the negative aspects of their life. Option C is not helpful as it dismisses the client's current feelings and suggests they will disappear overnight.

Question 4

A stockbroker commits suicide after being convicted of insider trading. Which information should a nurse share with the grieving family?

Accepted Answer

The nurse should provide the grieving family with practical advice regarding coping strategies that may help in dealing with the death of their loved one. Option A is incorrect because the length of the grief process varies significantly among individuals and is subjective. Option C is inappropriate and not helpful at this time as emotions are running high. Option D is incorrect as avoidance is not an effective way to process grief.

Question 5

A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this client's risk for suicide?

Accepted Answer

Observing the client at intervals determined by assessed data is the best choice to lower the client's risk for suicide. This allows for ongoing monitoring of the client's mood and behavior, and can help to identify any potential suicidal ideation or risk factors. Encouraging participation in the milieu and developing a strong personal relationship are important aspects of care, but may not directly address the client's risk for suicide. Encouraging and redirecting the client to concentrate on happier times may be invalidating and ineffective in addressing the client's distress and risk for suicide.

Question 6

A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include?

Accepted Answer

Elderly individuals, while making up a smaller percentage of the population, account for a disproportionately higher percentage of suicides.

Question 7

A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred?

Accepted Answer

Option D accurately reflects a key statistic related to suicide, indicating that learning has occurred. Option A is incorrect and stigmatizing, as suicidal threats and gestures should always be taken seriously. Option B is also incorrect and stigmatizing, as not all individuals who die by suicide have a psychotic disorder. Option C is incorrect, as not all suicidal individuals have a diagnosable mental illness.

Question 8

The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the team's decision?

Accepted Answer

The ability to participate in a plan for safety and having the support of the family for constant observation are crucial factors in the decision to discharge a previously suicidal client. While stable vital signs and compliance with medication are important, they alone do not guarantee the client's safety upon discharge. The lack of previous major depressive disorder admissions may be a positive factor, but does not outweigh the importance of an effective safety plan.

Question 9

A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager's best reply?

Accepted Answer

Suicide is a behavior, not a diagnosis or a mental disorder. It refers to intentionally taking one's own life. It can be the result of various factors, including mental health disorders, substance abuse, chronic pain, relationship problems, financial difficulties, or cultural and social pressures. It is important to assess and manage suicide risk in patients who have suicidal ideation, plan, or attempt, and to provide appropriate support and treatment.

Question 10

Which nursing intervention strategy is most appropriate to implement initially with a suicidal client?

Accepted Answer

The risk of suicide is greatly increased if the client has suicidal ideations,if the client has developed a plan,and particularly if the means exist for the client to execute the plan.

Question 11

Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self?

Accepted Answer

Option A is important but it is not an appropriate outcome as it does not address the client's low self-esteem and isolation. Option C is a negative outcome that should be avoided. Option D focuses more on the relationship with the nurse than the client's actual issue. Option B provides a specific and measurable outcome for the client's low self-esteem by giving them a goal to work towards and a sign of improvement.

Question 12

After years of dialysis, an 84-year-old states, "I'm exhausted, depressed, and so over these attempts to keep me alive." Which question should the nurse ask the spouse when preparing a discharge plan of care?

Accepted Answer

The question that would be most relevant in this situation is how often the patient is left alone. This can help the nurse determine if the patient is at risk for falls, medication errors, or other safety issues if they were to be discharged home with hospice care. The other options may be relevant in other situations but do not specifically address the concerns expressed by the patient.

Question 13

A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, "I'm going to use a knotted shower curtain when no one is around." Which information would determine the nurse's plan of care for this client?

Accepted Answer

Clients who have specific plans are at greater risk for suicide.

Question 14

A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention, and the rationale for this action?

Accepted Answer

Placing the client on one-to-one suicide precautions is the priority nursing intervention because the client has a specific plan for committing suicide, which increases the risk of him/her carrying out the act. One-to-one suicide precautions involve constant supervision and monitoring of the client to prevent any attempts at self-harm. Administering Ativan would not be appropriate in this situation as the client is not displaying symptoms of anxiety or agitation. Room restrictions and calling an emergency treatment team meeting are appropriate actions, but they are not the priority at this time.

Question 15

The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide?

Accepted Answer

The nurse should be available to actively listen, support, and accept the feelings of the family members. This helps to promote an open and trusting relationship between the nurse and the family while also providing a safe space for the family to express their concerns and ask questions. Providing this type of support can help to prevent relapse and aid in the recovery process. The other options, such as addressing only serious suicide threats or promoting trust through promise-keeping, are not appropriate or effective methods for caring for a suicidal client after discharge. Offering a private environment for time alone may be helpful, but it is not the best choice for providing information to the family.

Question 16

In planning care for a suicidal client, which correctly written outcome should be a nurse's first priority?

Accepted Answer

The first priority in caring for a suicidal client is to ensure their safety. Therefore, the correct outcome for the nurse's first priority is that the client will remain safe during the hospital stay. A, B, and C are also important outcomes, but ensuring safety comes first.

Question 17

During a one-to-one session with a client, the client states, "Nothing will ever get better," and "Nobody can help me." Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time?

Accepted Answer

The client's statements indicate the problem of hopelessness.Prior to assigning either risk for injury or risk for suicide,a further evaluation of the client's suicidal ideations and intent would be necessary.

Question 18

A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time?

Accepted Answer

The sudden improvement in mood and affect, especially for a client with a history of suicide attempts, could be a sign of increased impulsivity and potential risk for self-harm. Increasing the frequency of client observation would allow for close monitoring and early intervention if needed. Giving off-unit privileges or encouraging group sharing may be appropriate for positive reinforcement, but safety should be the priority concern. Requesting a reevaluation of medication protocol may be necessary, but not the immediate priority in this scenario.

Question 19

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Accepted Answer

Placing the client on one-to-one observation while monitoring suicidal ideations is the priority intervention in this situation. The client is at high risk for self-harm due to their auditory hallucinations commanding them to do so. By providing constant observation, the nurse can intervene if necessary and ensure the client's safety. Obtaining an order for locked seclusion may be necessary if the client becomes actively suicidal, but it is not the priority intervention at this time. Conducting 15-minute checks may not be sufficient in ensuring the client's safety given their current risk level. Encouraging the client to express feelings related to suicide may be appropriate in other situations but is not the priority intervention in this case where the client is actively hearing commands to self-harm.

Question 20

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge?

Accepted Answer

Providing a 1-week supply of Elavil with refills contingent on follow-up appointments is the best option because it allows for regular follow-up with the healthcare provider, ensuring that the client is taking the medication correctly and monitoring for any adverse effects or potential toxicity. Additionally, it helps to minimize the risk of overdose or misuse of the medication. Providing a 6-month supply could lead to noncompliance or hoarding of the medication, which could be dangerous. Providing a pill dispenser may be helpful, but it is not the best intervention for maintaining the client's safety in relation to the medication. Education regarding the avoidance of foods containing tyramine is not necessary with amitriptyline.

Quiz 18: Intervention With a Suicidal Client