Chapter 19: Self-Protective Responses and Suicidal Behavior

Question 1

1. A patient who _____ should be assessed as using indirect self-destructive behavior.
   a. scratches both wrists with safety pins
   b. drinks nearly 1 quart of whiskey per day
   c. took an overdose of sedative-hypnotic drugs
   d. calls a friend when contemplating suicide

Answer 1

ANS: B
Direct self-destructive behavior includes any form of suicidal threats, attempts, gestures, and completed suicide. Indirect self-destructive behavior is any behavior that is detrimental to the person’s physical well-being and that may potentially result in death.

Question 2

2. What nursing diagnosis should be considered when caring for a patient who has engaged in direct or indirect self-destructive behavior?
   a. Death anxiety
   b. Chronic low self-esteem
   c. Disturbed body image
   d. Disturbed personal identity

Answer 2

ANS: B

To think about or attempt self-destruction, the individual must have low self-regard.

Question 3

3. A nurse assessing a patient who has been noncompliant with the prescribed diabetic diet and exercise regimen should consider planning strategies to overcome patient use of:
   a. denial.
   b. projection.
   c. dissociation.
   d. displacement.

Answer 3

ANS: A
The most prominent behavior associated with noncompliance is refusal to admit the seriousness of the illness. This denial interferes with acceptance of treatment.

Question 4

4. A nurse is caring for a patient who has been noncompliant with the prescribed diabetic diet and exercise regimen. The nurse promotes compliance by enhancing the patient’s:
   a. sense of control.
   b. sense of well-being.
   c. fear of the sequelae of illness.
   d. dependence on health care workers.

Answer 4

ANS: A
Noncompliant people struggle for control. Serious illness is seen as a betrayal by the body. Patients wish to reassert control and prove mastery over their bodies.

Question 5

5. The major difference between self-injury and suicide lies in whether the patient has:
   a. a need to control or a need to be controlled.
   b. the wish to relieve tension or the wish to die.
   c. been diagnosed with a developmental disorder or psychosis.
   d. a tendency toward indirect or direct expression of self-destructive urges.

Answer 5

ANS: B
The lethality of self-injury is usually low, and patients who self-injure seek relief of tension. Suicide attempts are directed by the wish to die. Care-planning strategies will differ based on underlying patient motivation.

Question 6

6. A patient with depression tells a nurse, “I hope someone will make sure my family gets my jewelry when I’m gone.” This statement can be assessed as a suicide:
   a. attempt.
   b. gesture.
   c. threat.
   d. plan.

Answer 6

ANS: C

Suicide threats are warnings—indirect or direct, verbal or nonverbal—that the person plans to attempt suicide.

Question 7

7. The nursing diagnosis for a patient who is depressed and suicidal at admission is “risk for suicide.” The most appropriate outcome for this diagnosis at discharge from the hospital is, “The patient will:
   a. increase feelings of self-worth.”
   b. not harm self while hospitalized.”
   c. be able to problem solve effectively.”
   d. develop a trusting relationship with one staff member.”

Answer 7

ANS: B
The outcome concerning manifestation of self-harm is directly related to the diagnosis. The other outcomes are desirable but are more appropriate for other diagnoses.

Question 8

8. A person calls the crisis hotline and says, “Nobody can help me now. I just want to say goodbye to somebody before I do it.” The best response to this statement would be:
   a. “I can help you. Will you let me try?”
   b. “You’re still alive, so you can still get help.”
   c. “You sound very discouraged. What are you planning to do?”
   d. “I’ll arrange transportation so you can come here and tell me about the problem.”

Answer 8

ANS: C
This reply shows empathy, an important quality in developing a relationship. The reply also begins assessment of risk. It is important to determine whether the patient has a plan, the lethality of the method chosen, and whether the patient has the means to implement the plan.

Question 9

9. A person who has been fired from a job calls the mental health clinic and tells a nurse, “I feel so overwhelmed that I don’t see any other answer but to die.” Another voice can be heard in the background. Which action should the nurse take?
   a. Convince the caller to drive to the hospital.
   b. Get the caller’s address, go to the home, and take the caller to the hospital.
   c. Stay on the telephone and send the police to bring the caller to the hospital.
   d. Ask to speak to the other person and alert them to the caller’s suicide threat.

Answer 9

ANS: D
Most suicidal patients have some ambivalence. In this case the patient is most likely experiencing both a need to die and a desire to live. With this strategy the nurse is appealing to the patient’s desire to survive by procuring support through the intervention of the other person.

Question 10

10. Patients of which demographic group have the highest suicide rate in the United States?
    a. Female between the ages of 13 and 19 years
    b. Male between the ages of 19 and 27 years
    c. Female age 65 years or older
    d. Male age 50 years or older

Answer 10

ANS: D
The highest suicide rate for any group in the United States is among people over the age of 65 years, especially white men over the age of 85 years. Although this group constitutes 12.6% of the total U.S. population, it accounts for about 18.1% of suicide deaths. White males over the age of 50 years represent the greatest number of these deaths.

Question 11

11. A suicidal patient was found attempting to hang himself in the bathroom shower. What nursing intervention would best address the patient’s current need for safety while maintaining his self-esteem?
    a. Assign a staff member to remain with the patient at all times.
    b. Place the patient in the seclusion room with 15-minute checks.
    c. Request that the patient remain with the patient group at all times.
    d. Tell the patient that he may use the bathroom only with staff supervision.

Answer 11

ANS: A

One-to-one supervision communicates concern to the patient by offering help in controlling self-harm impulses.

Question 12

12. When evaluating the effectiveness of the care provided for a self-destructive patient, the best approach is to:
    a. identify maladaptive coping behaviors.
    b. involve the patient in the process of evaluation.
    c. make sure the staff has followed the original care plan.
    d. modify the plan as little as possible to avoid confusing the patient.

Answer 12

ANS: B

Patient involvement in evaluation of progress can provide reinforcement and incentive to work toward a goal.

Question 13

13. A psychiatric technician states, “This patient has frequently threatened suicide but has never attempted it. The patient should be sent home instead of encouraging the threats.” The nurse supports admitting the patient by responding:
    a. “There is no family to provide the social support that is vital to safety.”
    b. “Any suicide threat deserves serious attention and concern for safety.”
    c. “You seem to have a real problem when patients lose emotional control.”
    d. “Nursing staff are encouraged to share their concerns with the physician.”

Answer 13

ANS: B
The treatment plan must first address the goal of protecting the patient from self-harm, and no threat of suicide should be ignored, even if no attempt has occurred. Admission is the most appropriate action in this case. The remaining goals do not adequately address the patient’s risk for self-harm.

Question 14

14. A nurse performing an admission interview identifies a need for one-to-one supervision when the patient admits to having suicidal ideations with a plan. The best way to inform the patient of the planned intervention is to say:
    a. “We cannot trust you to remain safe, so someone will always be with you.”
    b. “It is our policy to have a staff member stay with all new admissions to the unit.”
    c. “The hospital can’t let you hurt yourself. Someone will stay with you at all times to protect you from self-harm.”
    d. “I understand your impulse to harm yourself. A staff member will stay with you to help you control that impulse.”

Answer 14

ANS: D
This explanation is honest and suggests caring as well as collaboration between the nurse and patient. The other choices are impersonal and do little to convey caring.

Question 15

15. During an admission a nurse suspects a patient is having suicidal ideations. The best course of action is to:
    a. ask the patient if thoughts of suicide have occurred.
    b. ask the patient’s significant other if the patient is suicidal.
    c. arrange for involuntary commitment to avoid harm to self or others.
    d. avoid the subject to avoid pushing the patient into further thoughts of self-harm.

Answer 15

ANS: A
The subject of suicide is not taboo. It should be approached matter-of-factly. If the patient is having suicidal thoughts, he or she is often relieved to be able to talk about them openly.

Question 16

16. A nurse is working with a patient with depression whose identical twin committed suicide. In assessing this patient for suicidal risk, the nurse should consider that this patient:
    a. is at increased risk for suicide.
    b. has the same risk as the general population.
    c. cannot be assigned a level of risk based on such limited data.
    d. is at low risk because the patient has experienced the trauma of suicide.

Answer 16

ANS: A
Family history of suicide is a significant risk factor for self-destructive behavior. In addition, monozygotic twins have a high concordance rate for suicide.

Question 17

17. A patient who was hospitalized after a serious suicide attempt is scheduled to be discharged to home. During the hospitalization the patient has been compliant with all aspects of the treatment plan. It is reasonable to believe the patient will continue to comply with treatment because the patient:
    a. is beginning to demonstrate positive behavioral changes.
    b. continues to need to seek praise from multidisciplinary team members.
    c. states, “I’m trying to change. I can’t do it all at once but I want to continue to try.”
    d. verbally promises to go to every meeting that the group schedules after the planned discharge.

Answer 17

ANS: A
Since the patient is now demonstrating positive behavioral changes and is compliant with the treatment plan, it would be reasonable to expect this change in behavior to continue and facilitate continued compliance. The remaining options lack tangible proof that the patient has experienced any true change in behavior that would facilitate compliance now or in the future since they lack positive action.

Question 18

18. An assessment has been made that a patient is highly suicidal. One-to-one constant supervision with unit restriction has been ordered. How will this order be implemented?
    a. By observing the patient while awake, both on and off the unit
    b. By observing the patient at all times while revoking any off-unit privileges
    c. By obtaining a no-suicide contract while removing all harmful objects from the environment
    d. By observing the patient every 15 minutes around the clock while documenting whereabouts and activity level

Answer 18

ANS: B
While under constant supervision the patient is never left alone, even momentarily. Unit restriction requires that the patient remain on the unit at all times.

Question 19

19. A nurse caring for a hospitalized suicidal patient on one-to-one supervision should initially focus on:
    a. mobilizing social support for the patient and family.
    b. facilitating awareness, expression, and labeling of feelings.
    c. helping the patient test new mechanisms for coping with stress.
    d. talking to the patient about the effect suicide would have on family members.

Answer 19

ANS: B
Nursing care of suicidal patients should initially be directed toward protection, increasing patient self-esteem, and helping patients to become aware of their feelings, to label them, and to express them appropriately.

Question 20

20. Which remark by a nurse best represents an attempt to assess the patient’s current ability to organize and enact a suicide wish?
    a. “What is your educational background?”
    b. “What plan do you have for committing suicide?”
    c. “Have you ever thought about or tried to hurt yourself?”
    d. “Are your self-destructive thoughts constant or intermittent?”

Answer 20

ANS: B
This question will give the nurse information as to whether a plan exists, the lethality of the method chosen, and the accessibility of the method.

Question 21

21. A patient who has recently lost a spouse calls the crisis line and reports suicidal ideations that involve jumping off a bridge over the river when no one is around. What level of lethality would a nurse assess for this plan?
    a. Low
    b. Moderate
    c. High
    d. Lethality cannot be determined from this data.

Answer 21

ANS: C

Jumping from a high place into water when no one is present to provide rescue is a highly lethal method.

Question 22

22. A patient was admitted after an unsuccessful suicide attempt. The patient is overheard saying, “Next time, I’ll make sure no one interrupts me.” Which level of suicide precautions should be ordered?
    a. Occasional safety checks
    b. Verbal contract for safety
    c. Every-15-minute safety checks
    d. One-to-one supervision for safety

Answer 22

ANS: D

One-to-one supervision is appropriate for suicidal patients who express details regarding plans to reattempt self-harm.

Question 23

MULTIPLE RESPONSE

1. A priority for nurses working with psychiatric patients would be the assessment of suicide risk for individuals who have the tendency to be: (Select all that apply.)
   a. blaming.
   b. hostile.
   c. hopeless.
   d. impulsive.
   e. controlling.

Answer 23

ANS: B, C, D
The three aspects of personality most closely associated with increased risk for suicide are hostility, impulsivity, and hopelessness. These traits cross diagnostic groups.