Question 1

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

A specific plan indicates a higher risk of suicide attempt, necessitating immediate and appropriate interventions to ensure the client's safety.

Question 2

A client is admitted to an inpatient unit after a suicide attempt. The health-care provider prescribes amitriptyline (Elavil) for the client. Which would the nurse expect to be initiated to maintain this client's safety upon discharge?

Accepted Answer

Providing a 3-day supply of Elavil with refills contingent on follow-up appointments allows for proper monitoring of the client's response to the medication and ensures compliance. A 6-month supply would not allow for proper monitoring and can increase the risk of overdose. Providing a pill dispenser may be helpful, but it is not essential in maintaining the client's safety. Education regarding the avoidance of foods containing tyramine is important for clients taking MAOIs, not amitriptyline.

Question 3

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 this client?

Accepted Answer

The client's statements "Nothing will ever get better" and "Nobody can help me" directly indicate a sense of hopelessness, making "Hopelessness R/T altered mood AEB client statements" the most appropriate nursing diagnosis.

Question 4

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

Accepted Answer

The best information for the nurse to provide is to be available to actively listen, support, and accept feelings. This conveys empathy and understanding, which are important for addressing the client's suicidal ideation and creating a therapeutic relationship. Promising to keep suicide attempt information within the family could limit the client's access to additional support and resources, such as mental health professionals. Addressing only serious suicide threats could lead to clients not disclosing ideation, which can prevent necessary interventions. Offering a private environment could be important, but it is not the most appropriate response to the family's request for more information.

Question 5

A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information?

Accepted Answer

Option B is the most appropriate and accurate response as it offers support through the availability of support groups and a willingness to assist the family in locating one. It also acknowledges the sensitive nature of suicide and demonstrates an empathetic approach to the family's grief. Option A is not appropriate as it assumes that the family will require antidepressants and is not based on individual needs. Option C is not appropriate as it suggests expressing anger towards the brokerage firm, which may not be an appropriate response for all families. Option D is not appropriate as it suggests avoiding discussion of the suicide, which may perpetuate stigmatization and prevent the family from seeking support.

Question 6

A nurse is caring for four clients diagnosed with major depressive disorder. When considering each client's belief system, the nurse would conclude which client would potentially be at higher risk for suicide than the other clients?

Accepted Answer

Research suggests that individuals who have a lack of religious belief or affiliation may be at higher risk for suicide compared to those with religious beliefs or affiliations. The other options do not provide enough information to conclude any potential higher risk for suicide.

Question 7

During the planning of care for a suicidal client, which correctly written outcome would be a nurse's first priority?

Accepted Answer

The first priority when caring for a suicidal client is to ensure their safety. Therefore, the most important outcome is for the client to remain safe during their hospital stay. While the other outcomes may also be important, they are secondary to the client's safety.

Question 8

Which client data indicates that a suicidal client is participating in a plan for safety?

Accepted Answer

Disclosing a plan for suicide to staff indicates that the client is participating in a plan for safety, as they are actively seeking help and support.

Question 9

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. Which would be the nurse's priority intervention at this time?

Accepted Answer

Placing the client on one-to-one observation while monitoring suicidal ideations would be the nurse's priority intervention at this time as the client is actively experiencing auditory hallucinations that are commanding self-harm and refusing to commit to developing a plan for safety. This intervention would ensure that the client is constantly monitored and kept safe until further interventions can be implemented. Conducting 15-minute checks may not be sufficient in ensuring the client's safety, especially as the client is actively experiencing psychotic symptoms. Obtaining an order for locked seclusion may be indicated if the client becomes actively suicidal and exhibits unsafe behavior, but it may not be necessary at this time. Encouraging the client to express feelings related to suicide may be important for therapeutic communication but would not necessarily address the immediate safety concern.

Question 10

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 fact that the client participates in a plan for safety and the family agrees to constant observation are important factors in determining the client's readiness for discharge. This indicates that the client has a support system in place and is taking steps to prevent future suicidal behavior. The other options are important information but do not necessarily speak to the client's readiness for discharge.

Question 11

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

Accepted Answer

Option D is a therapeutic response because it acknowledges the client's feelings and reflects back what they have said. It also shows empathy, which can help establish trust and rapport with the client. Option A is a distraction technique that may not address the client's underlying issues. Option B is not an appropriate response because it focuses on negativity rather than potential solutions. Option C minimizes the client's feelings and may not be helpful.

Question 12

The nurse discovers a client's suicide note that details the time, place, and means to commit suicide. Which would 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 intervention because the client has a clear and specific plan for suicide, which increases the likelihood of attempting suicide. This intervention will ensure that the client is always being monitored and kept safe until further interventions can be implemented. Administering lorazepam PRN would not address the client's risk for suicide and could potentially worsen the client's anger. Establishing room restrictions assumes that the client's threat is manipulative, which cannot be determined at this time. Calling an emergency treatment team meeting may be needed, but it is not the priority intervention.

Question 13

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 nursing intervention to lower the client's risk for suicide. This allows for close monitoring and detection of any possible suicidal ideation or plan, and prompt intervention can be implemented. Encouraging participation in the milieu may promote hope, but it may not necessarily lower the client's risk for suicide. Developing a strong personal relationship with the client and encouraging the client to concentrate on happier times are also important but may not be sufficient to address the immediate risk for suicide.

Question 14

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

Accepted Answer

The question about how often the client's spouse is left alone is important in determining if a caregiver will be needed in the discharge plan of care. This information could help ensure that the client's needs are being met when he is at home and may help prevent feelings of isolation or depression. The other answer choices are not as relevant to the client's current emotional and physical state.

Question 15

Which documented intervention would the nurse implement first when caring for a severely depressed client?

Accepted Answer

Assessing suicide risk is the priority intervention when caring for a severely depressed client. This is because depression is a significant risk factor for suicide, and the nurse needs to identify any suicidal ideations or plans to intervene appropriately to prevent harm to the client. Once the level of suicide risk is assessed, the nurse can then implement other interventions such as communicating therapeutically and providing a hazard-free environment.

Question 16

Which information would the nursing instructor include about suicide in the elderly population when teaching nursing students?

Accepted Answer

Elderly individuals, despite making up a smaller portion of the population, have a disproportionately higher rate of suicide. This fact highlights the importance of recognizing and addressing mental health and suicide risk among the elderly.

Question 17

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 would be the nurse's priority at this time?

Accepted Answer

The sudden improvement in mood and affect may indicate that the client is experiencing a lift in their depressive symptoms, which can increase the risk of suicidal behavior. The nurse's priority should be to ensure the safety of the client by increasing the frequency of observation. Options A and B may be appropriate interventions in other situations but do not address the immediate safety concern. Option D may be appropriate, but ensuring safety of the client is the priority in this situation.

Question 18

Which statement best describes the classification of suicide?

Accepted Answer

Suicide is classified as a behavior, not a mental disorder or DSM-5 diagnosis. While suicidal ideation may be a symptom or aspect of certain mental illnesses, the act of suicide itself is considered a behavior. It is not an affliction, antisocial or otherwise, as it does not simply affect one individual but has repercussions on their loved ones and the community as a whole.

Question 19

Which statement made by a nursing student indicates that learning regarding suicide has been successful?

Accepted Answer

This statement accurately reflects the statistic that between 50 and 80 percent of people who die by suicide have a history of previous attempts. Options A and B are myths that have been debunked by research, while option C is an overgeneralization that does not apply to all suicidal individuals.

Question 20

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 a safety outcome and not related to the client's self-esteem or isolation. Option C is a negative outcome and not appropriate or desirable. Option D is a process outcome and does not specify a change in behavior or symptom reduction. Option B is specific to the client's low self-esteem and isolation, and is measurable and achievable within a reasonable timeframe.

Quiz 11: Suicide Prevention