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MSC: Client Needs: Psychosocial Integrity a. “Why do you want to kill yourself?” b. “Do you have access to medications?” c. “Have you been taking drugs and alcohol?” d. “Did something happen with your parents?”

10. Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills.

ANS: B

The nurse must assess the patient’s access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the patient’s safety. The information in the other questions may be important to ask but are not the most critical.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 25-15, 16, 47 (Table 25-2), 52 (Box 25-2)

TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.

11. It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention.

ANS: A

The patient now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 25-14 TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment a. “I will not try to harm myself during the next 24 hours.” b. “I will not make a suicide attempt while I am hospitalized.” c. “For the next 24 hours, I will not in any way attempt to harm or kill myself.” d. “I will not kill myself until I call my primary nurse or a member of the staff.”

12. A nurse and patient construct a no-suicide contract. Select the preferable wording.

ANS: C

The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks “I am not going to harm myself, I am going to kill myself” or “I am not going to attempt suicide, I am going to commit suicide.” A patient may call a therapist and leave the telephone to carry out the suicidal plan.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 25-14 (Table 26-5) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

13. A tearful, anxious patient at the outpatient clinic reports, “I should be dead.” The initial task of the nurse conducting the assessment interview is to a. assess lethality of suicide plan. b. encourage expression of anger. c. establish trust with the patient. d. determine risk factors for suicide.

ANS: C

This scenario presents a potential crisis. Establishing trust facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 25-18 (Case Study and Nursing Care Plan), 24, 39

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

14. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, “I am considering committing suicide.” a. “I’m glad you shared this. Please do not worry. We will handle it together.” b. “I think you should admit yourself to the hospital to keep you safe.” c. “Bringing up these feelings is a very positive action on your part.” d. “We need to talk about the good things you have to live for.”

ANS: C

The correct response gives the patient reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as “You have a lot to live for.” It uses the patient’s ambivalence and sets the stage for more realistic problem solving.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 25-18 (Case Study and Nursing Care Plan), 24

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy

15. Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide?

ANS: C

Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 25-7, 31 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

16. Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy?

ANS: A

Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 25-14 TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment a. “I wish I were dead.” b. “Life is not worth living.” c. “I have a plan that will fix everything.” d. “My family will be better off without me.”

17. A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, “My business is bankrupt, and I was served with divorce papers.” Which subsequent statement by the patient alerts the nurse to a concealed suicidal message?

ANS: C

Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient’s suicide as being a way to “fix everything” but does not say it outright.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 25-12, 13, 47 (Table 25-2)

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment a. “Are you having thoughts of suicide?” b. “I am not sure I understand what you are trying to say.” c. “Try to stay hopeful. Things have a way of working out.” d. “Tell me more about what interested you before you became depressed.”

18. A depressed patient says, “Nothing matters anymore.” What is the most appropriate response by the nurse?

ANS: A

The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 25-12, 13, 18 (Case Study and Nursing Care Plan), 47 (Table 25-2)

TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment