Chapter 17- T

Question 1

1. 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?
   A. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note
   B. Establishing room restrictions, because the client’s threat is an attempt to manipulate the staff
   C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide
   D. Calling an emergency treatment team meeting, because the client’s threat must be addressed

Answer 1

ANS: C
The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.

Question 2

2. During the planning of care for a suicidal client, which correctly written outcome should be a nurse’s first priority?
   A. The client will not physically harm self.
   B. The client will express hope for the future by day 3.
   C. The client will establish a trusting relationship with the nurse.
   D. The client will remain safe during the hospital stay.

Answer 2

ANS: D
The nurse’s priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse’s priority. The “A” answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, and realistic and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated.

Question 3

3. 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?
   A. Obtaining an order for locked seclusion until client is no longer suicidal
   B. Conducting 15-minute checks to ensure safety
   C. Placing the client on one-to-one observation while monitoring suicidal ideations
   D. Encouraging client to express feelings related to suicide

Answer 3

ANS: C
The nurse’s priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation.

Question 4

4. 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?
   A. Give the client off-unit privileges as positive reinforcement.
   B. Encourage the client to share mood improvement in group.
   C. Increase frequency of client observation.
   D. Request that the psychiatrist reevaluate the current medication protocol.

Answer 4

ANS: C
The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.

Question 5

5. 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?
   A. Provide a 6-month supply of Elavil to ensure long-term compliance.
   B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments.
   C. Provide a pill dispenser as a memory aid.
   D. Provide education regarding the avoidance of foods containing tyramine.

Answer 5

ANS: B
The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client’s safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential.

Question 6

6. 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?
   A. Powerlessness R/T altered mood AEB client statements
   B. Risk for injury R/T altered mood AEB client statements
   C. Risk for suicide R/T altered mood AEB client statements
   D. Hopelessness R/T altered mood AEB client statements

Answer 6

ANS: D
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 7

7. 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?
   A. No previous admissions for major depressive disorder
   B. Vital signs stable; no psychosis noted
   C. Able to comply with medication regimen; able to problem-solve life issues
   D. Able to participate in a plan for safety; family agrees to constant observation

Answer 7

ANS: D
Participation in a plan of safety and constant family observation will decrease the risk for self-harm. All other answer choices are not directly focused on suicide prevention and safety.

Question 8

8. 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?
   A. Address only serious suicide threats to avoid the possibility of secondary gain.
   B. Promote trust by verbalizing a promise to keep suicide attempt information within the family.
   C. Offer a private environment to provide needed time alone at least once a day.
   D. Be available to actively listen, support, and accept feelings.

Answer 8

ANS: D
Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.

Question 9

9. 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?
   A. “Your grieving will subside within 1 year; until then I recommend antidepressants.”
   B. “Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area.”
   C. “The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them.”
   D. “Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone.”

Answer 9

ANS: B
Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. Support groups for survivors can provide a meaningful resource for grief work.

Question 10

10. 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?
    A. “Have there been any changes in appetite or sleep?”
    B. “How often is your spouse left alone?”
    C. “Has your spouse been following a diet and exercise program consistently?”
    D. “How would you characterize your relationship with your spouse?”

Answer 10

ANS: B
This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.

Question 11

11. A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include?
    A. Elderly people use less lethal means to commit suicide.
    B. Although the elderly make up less than 13% of the population, they account for 16% of all suicides.
    C. Suicide is the second leading cause of death among the elderly.
    D. It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality.

Answer 11

ANS: B
This factual information should be included in the nursing instructor’s teaching plan. An expressed desire to die is not normal in any age group.

Question 12

12. 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?
    A. The more specific the plan is, the more likely the client will attempt suicide.
    B. Clients who talk about suicide never actually commit it.
    C. Clients who threaten suicide should be observed every 15 minutes.
    D. After a brief assessment, the nurse should avoid the topic of suicide.

Answer 12

ANS: A

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

Question 13

13. A suicidal client says to a nurse, “There’s nothing to live for anymore.” Which is the most appropriate nursing reply?
    A. “Why don’t you consider doing volunteer work in a homeless shelter?”
    B. “Let’s discuss the negative aspects of your life.”
    C. “Things will look better in the morning.”
    D. “It sounds like you are feeling pretty hopeless.”

Answer 13

ANS: D

This statement verbalizes the client’s implied feelings and allows him or her to validate and explore them.

Question 14

14. A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager’s best reply?
    A. “Suicide is a DSM-5 diagnosis.”
    B. “Suicide is a mental disorder.”
    C. “Suicide is a behavior.”
    D. “Suicide is an antisocial affliction.”

Answer 14

ANS: C

Suicide is not a diagnosis, disorder, or affliction. It is a behavior.

Question 15

15. A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? 
A. Communicate therapeutically. 
B. Observe the client.
C. Provide a hazard-free environment.
D. Assess suicide risk.

Answer 15

ANS: D
Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions.

Question 16

16. 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?
    A. The client will not physically harm self.
    B. The client will express three positive self-attributes by day 4.
    C. The client will reveal a suicide plan.
    D. The client will establish a trusting relationship.

Answer 16

ANS: B
Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client centered, specific, realistic, and measureable and contain a time frame.

Question 17

17. A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred?
    A. “Suicidal threats and gestures should be considered manipulative and/or attention-seeking.”
    B. “Suicide is the act of a psychotic person.”
    C. “All suicidal individuals are mentally ill.”
    D. “Fifty to eighty percent of all people who kill themselves have a history of a previous attempt.”

Answer 17

ANS: D
It is a fact that between 50% and 80% of all people who kill themselves have a history of a previous attempt. All other answer choices are myths about suicide.

Question 18

18. A nurse is caring for four clients diagnosed with major depressive disorder. When considering each client’s belief system, the nurse should conclude which client would potentially be at highest risk for suicide?
A. Roman Catholic
B. Protestant
C. Atheist
D. Muslim

Answer 18

ANS: C
Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts.

Question 19

19. Which nursing intervention strategy is most appropriate to implement initially with a suicidal client?
    A. Ask a direct question such as, “Do you ever think about killing yourself?”
    B. Ask client, “Please rate your mood on a scale from 1 to 10.”
    C. Establish a trusting nurse–client relationship.
    D. Apply the nursing process to the planning of client care.

Answer 19

ANS: A
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 20

20. A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this client’s risk for suicide?
    A. Encouraging participation in the milieu to promote hope
    B. Developing a strong personal relationship with the client
    C. Observing the client at intervals determined by assessed data
    D. Encouraging and redirecting the client to concentrate on happier times

Answer 20

ANS: C
The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors.

Question 21

21. Which client data indicate that a suicidal client is participating in a plan for safety?
    A. Compliance with antidepressant therapy
    B. A mood rating of 9/10
    C. Disclosing a plan for suicide to staff
    D. Expressing feelings of hopelessness to nurse

Answer 21

ANS: C
A degree of the responsibility for the suicidal client’s safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide.

Question 22

22. Which statement indicates that the nurse is acting as an advocate for a client who was hospitalized after a suicide attempt and is now nearing discharge?
    A. “I must observe you continually for 1 hour in order to keep you safe.”
    B. “Let’s confer with the treatment team about the resources that you may need after discharge.”
    C. “You must have been very upset to do what you did today.”
    D. “Are you currently thinking about harming yourself?”

Answer 22

ANS: B
The nurse is functioning in an advocacy role when collaborating with the client and treatment team to discuss client problems and needs.

Question 23

23. A client is newly admitted to an inpatient psychiatric unit. Which of the following is most critical to assess when determining risk for suicide?
    A. Family history of depression
    B. The client’s orientation to reality
    C. The client’s history of suicide attempts
    D. Family support systems

Answer 23

ANS: C
A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the client’s risk.

Question 24

24. A client has been brought to the emergency department for signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation?
    A. Assessing the client’s pulse oximetry and vital signs
    B. Developing a plan for safety for the client
    C. Assessing the client for suicidal ideations
    D. Establishing a trusting nurse–client relationship

Answer 24

ANS: A
It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslow’s hierarchy of needs. This client’s problems with oxygenation will take priority over assessing for current suicidal ideations.

Question 25

25. After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply.
    A. “I can’t believe this is happening.”
    B. “If only I had been more understanding.”
    C. “How dare he do this to me!”
    D. “I’m just going to have to accept that he was gay.”
    E. “Well, that was a selfish thing to do.”

Answer 25

ANS: A, B, C
Suicide of a family member can induce a whole gamut of feelings in the survivors. Shock, disbelief, guilt, remorse, anger, and resentment are all feelings that may be experienced by this father. The last two possible responses suggest acceptance and understanding. It is far more common for survivors of suicide to have a sense of feeling wounded and as if they will never get over it.

Question 26

26. A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? Select all that apply.
    A. In the Middle Ages, suicide was viewed as a selfish and criminal act.
    B. During the Roman Empire, suicide was followed by incineration of the body.
    C. Suicide was an offense in ancient Greece, and a common-site burial was denied.
    D. During the Renaissance, suicide was discussed and viewed more philosophically.
    E. Old Norse traditionally set a person who committed suicide adrift in the North Sea.

Answer 26

ANS: A, C, D

These are true historical facts about suicide and should be included in the student’s study guide.