Chapter 25: Suicide

Question 1

An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patient’s history and diagnosis, which antidepressant medication would the nurse expect to be prescribed?

a. Amitriptyline (Elavil), a sedating tricyclic medication
b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor
c. Desipramine (Norpramin), a stimulating tricyclic medication
d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

Answer 1

ANS: B
Selective serotonin reuptake inhibitor antidepressants (SSRIs) are very safe in overdose situations, which is not true of the other medications listed. Lethal overdose is nearly impossible with SSRIs. Given this patient’s history of overdosing, it is important that the medication be as safe as possible in case she takes an overdose of her prescribed medication.

Question 2

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk?

a. Turning on the oven and letting gas escape into the apartment during the night
b. Cutting the wrists in the bathroom while the spouse reads in the next room
c. Overdosing on aspirin with codeine while the spouse is out with friends
d. Shooting in the head with a firearm that spouse keeps in the bedroom

Answer 2

ANS: D
This is a highly lethal method with little opportunity for rescue. A risk factor for suicide is easy access to firearms. The other options are lower lethality methods with higher rescue potential.

Question 3

Which measure would be considered a form of primary intervention for suicide?

a. Psychiatric hospitalization of a suicidal patient
b. Referral of a formerly suicidal patient to a support group
c. Suicide precautions for 24 hours for newly admitted patients
d. Helping school children learn to manage stress and be resilient

Answer 3

ANS: D
This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary intervention measures. Support group referral is a tertiary prevention measure.

Question 4

Which change in the brain’s biochemical function is most associated with suicidal behaviour?

a. Dopamine excess
b. Serotonin deficiency
c. Acetylcholine excess
d. Gamma-aminobutyric acid deficiency

Answer 4

ANS: B
Research suggests that low levels of serotonin may play a role in the decision to commit suicide. Evidence suggests a potentially causal association between suicidal behaviour and the serotonin neurotransmission system. The other neurotransmitter alterations have not been implicated in suicidality.

Question 5

A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behaviour provides the strongest clue of an impending suicide attempt?

a. Calling parents
b. Excessive crying
c. Remaining in a dorm room alone
d. Giving away sweaters to her roommate.

Answer 5

ANS: D
A behaviour such as giving away prized objects possibly indicates she is considering suicide. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.

Question 6

A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to which of the following?

a. Current stress level
b. Mood disturbance
c. Suicide potential
d. Level of anxiety

Answer 6

ANS: C
The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed.

Question 7

A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?

a. Powerlessness
b. Social isolation
c. Risk for suicide
d. Compromised family coping

Answer 7

ANS: C
This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options.

Question 8

A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will do which of the following?

a. Verbalize a will to live by the end of the second hospital day
b. Describe two new coping mechanisms by the end of the third hospital day
c. Accurately delineate personal strengths by the end of the first week of hospitalization
d. Refrain from attempts to harm self for 24 hours

Answer 8

ANS: D
Having the patient refrain from attempts to harm self most directly addresses the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

Question 9

A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, “We should have seen this coming. We did not do enough.” The parents’ reaction reflects which of the following?

a. Guilt
b. Denial
c. Shame
d. Rescue feelings

Answer 9

ANS: A
The parents’ statements indicate guilt. Guilt is evident from the parents’ self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario.

Question 10

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

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?”

Answer 10

ANS: B
The nurse must assess the patient’s access to a means to carry out the plan and, if there is access, alert the parents to remove the means 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.

Question 11

It has been 3 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.

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.

Answer 11

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.

Question 12

What is the key element when the nurse is providing follow-up counselling to a patient that has been discharged to home following a suicide attempt?

a. Maintain 24 hour observation.
b. Administer antidepressant medication as ordered.
c. Establish a working alliance to encourage realistic problem solving.
d. Offer solutions to problems related to the stigma associated with a suicide attempt.

Answer 12

ANS: C
The key element is establishing a working alliance to encourage the patient to engage in more realistic problem solving. Helpful staff characteristics include warmth, sensitivity, interest, and consistency.

Question 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 do which of the following?

a. Assess lethality of suicide plan
b. Encourage expression of anger
c. Establish rapport with the patient
d. Determine risk factors for suicide

Answer 13

ANS: C
The foundation of any intervention for suicide or suicidal behaviours is establishing a therapeutic relationship. Understanding and appreciating clients’ unique situations and treating individuals with respect and openness are essential. Establishing rapport facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of any plan, and the presence of risk factors for suicide.

Question 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.”

Answer 14

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.

Question 15

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

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

Answer 15

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.

Question 16

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

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.

Answer 16

ANS: A
Antidepressant medication has the objective of relieving depression. Risk for suicide is greater with dramatic mood changes, 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.

Question 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?

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.”

Answer 17

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.

Question 18

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

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.”

Answer 18

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.

Question 19

A nurse counsels a patient with recent suicidal ideation. Which is the nurse’s most therapeutic comment?

a. “Let’s make a list of all your problems and think of solutions for each one.”
b. “I’m happy you’re taking control of your problems and trying to find solutions.”
c. “When you have bad feelings, try to focus on positive experiences from your life.”
d. “Let’s consider which problems are very important and which are less important.”

Answer 19

ANS: D
The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. Talking openly leads to a decrease in isolation and can increase problem-solving alternatives for living. The incorrect options continue to present overwhelming approaches to problem solving.

Question 20

When assessing a patient’s plan for suicide, what aspect has priority?

a. Patient’s financial and educational status
b. Patient’s insight into suicidal motivation
c. Availability of means and lethality of method
d. Quality and availability of patient’s social support

Answer 20

ANS: C
If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question.

Question 21

The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is:

a. Hopelessness
b. Sadness
c. Elation
d. Anger

Answer 21

ANS: A
Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

Question 22

Which statement by a depressed patient will alert the nurse to the patient’s need for immediate, active intervention?

a. “I am mixed up, but I know I need help.”
b. “I have no one to turn to for help or support.”
c. “It is worse when you are a person of colour.”
d. “I tried to get attention before I cut myself last time.”

Answer 22

ANS: B
Hopelessness is evident. Lack of social support and social isolation increase the suicide risk. Willingness to seek help lowers risk. Being a person of colour does not suggest higher risk because more White people commit suicide than individuals of other racial groups do. Attention-seeking is not correlated with higher suicide risk.

Question 23

A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing measure will be most important regarding this event?

a. Ask the information technology manager to verify that the hospital information system is secure.
b. Hold a staff meeting to express feelings and plan care for the other patients.
c. Ask the patient’s roommate not to discuss the event with other patients.
d. Prepare a report of a sentinel event.

Answer 23

ANS: B
Interventions should help the staff and patients come to terms with the loss and grow because of the incident. Then, a community meeting should occur to allow other patients to express their feelings and request help. Staff should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. A sentinel event report can be prepared later. The other incorrect options will not control information or would result in unsafe care.

Question 24

After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide?

a. “Genetics are associated with suicide risk. Monitoring and support are important.”
b. “Apathy underlies suicide. Instilling motivation is the key to health maintenance.”
c. “Your child is unlikely to act out suicide when identifying with a suicide victim.”
d. “Fraternal twins are at higher risk for suicide than identical twins.”

Answer 24

ANS: A
Family history of suicide is a suicide risk factor. Therefore, the daughter would be at risk and should be monitored. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification

Question 25

Which individual in the emergency department should be considered at highest risk for completing suicide?

a. An adolescent girl with superior athletic and academic skills who has asthma
b. A 38-year-old single female church member with fibrocystic breast disease
c. A 60-year-old married man with twelve grandchildren who has type 2 diabetes
d. A 79-year-old single, White male diagnosed recently with terminal cancer of the prostate

Answer 25

ANS: D

High-risk factors include being an older adult, single, male, and having a co-occurring medical illness.

Question 26

A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply.

a. 82-year-old White male
b. 17-year-old White female
c. 22-year-old Hispanic male
d. 19-year-old Inuit male
e. 39-year-old African Canadian male

Answer 26

ANS: A, B, D
White people have suicide rates almost twice those of non-Whites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include Inuit and Aboriginal people.

Question 27

Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply.

a. Maintain arm’s-length, one-on-one direct observation at all times.
b. Check all items brought by visitors and remove risk items.
c. Use plastic eating utensils; count utensils upon collection.
d. Remove the patient’s eyeglasses to prevent self-injury.
e. Interact with the patient every 15 minutes.

Answer 27

ANS: A, B, C
One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; “no silver or glassware” orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm’s-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arm’s length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.

Question 28

A college student is extremely upset after failing two examinations. The student said, “No one understands how this will hurt my chances of getting into medical school.” The student then suspends access to his social networking Web site and turns off his cell phone. Which suicide risk factors are evident? Select all that apply.

a. Shame
b. Panic attack
c. Humiliation
d. Self-imposed isolation
e. Recent stressful life event

Answer 28

ANS: A, C, D, E
Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, “No one can understand,” can be seen as recent lack of social support. Terminating access to one’s social networking site and turning off the cell phone represent self-imposed isolation. The scenario does not provide evidence of panic attack