Chapter 17 Flashcards
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?
Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide
During the planning of care for a suicidal client, which correctly written outcome should be a nurse’s first priority?
The client will remain safe during the hospital stay.
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?
Placing the client on one-to-one observation while monitoring suicidal ideations
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?
Increase frequency of client observation.
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?
Provide a 1-week supply of Elavil with refills contingent on follow-up appointments.
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?
Hopelessness R/T altered mood AEB client statements
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?
Able to participate in a plan for safety; family agrees to constant observation
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?
Be available to actively listen, support, and accept feelings.
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?
“Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area.”
After years of dialysis, an 84-year-old states, “I’m exhausted, depressed, and done with these attempts to keep me alive.” Which question should the nurse ask the spouse when preparing a discharge plan of care?
“How often is your spouse left alone?”
A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include?
Although the elderly make up less than 13% of the population, they account for 16% of all suicides.
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?
The more specific the plan is, the more likely the client will attempt suicide.
A suicidal client says to a nurse, “There’s nothing to live for anymore.” Which is the most appropriate nursing reply?
“It sounds like you are feeling pretty hopeless.”
A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager’s best reply?
“Suicide is a behavior.”
A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first?
Assess suicide risk.
