Question: Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk?
Answer Choices: a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends
Answer: a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night
Question: Which individual in the emergency department should be considered at the highest risk for completing suicide?
Answer Choices: a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland
Answer: d. A 79-year-old single white man with cancer of the prostate gland
Question: A nurse answers a suicide crisis line. A caller says, “I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I’m going to shoot myself in the heart.” How would the nurse assess the lethality of this plan?
Answer Choices: a. No risk b. Low level c. Moderate level d. High level
Answer: d. High level
Question: A staff nurse tells another nurse, “I evaluated a new patient using the modified SAD PERSONS scale and got a score of 10. I’m wondering if I should send the patient home.” Select the best reply by the second nurse.
Answer Choices: a. “That action would seem appropriate.” b. “A score over 8 requires immediate hospitalization.” c. “I think you should strongly consider hospitalization for this patient.” d. “Give the patient a follow-up appointment. Hospitalization may be needed soon.”
Answer: b. “A score over 8 requires immediate hospitalization.”
Question: A patient recently hospitalized for 2 weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event?
Answer Choices: a. Request the public information officer to address inquiries from the local media b. Hold a staff meeting to express feelings and plan the care for other patients c. Ask the patient’s roommate not to discuss the event with other patients d. Quickly discharge as many patients as possible to prevent panic
Answer: b. Hold a staff meeting to express feelings and plan the care for other patients
Question: A severely depressed patient who has been on suicide precautions tells the nurse, “I am feeling a lot better, so you can stop watching me. I have taken too much of your time already.” Which is the nurse’s best response?
Answer Choices: a. “I wonder what this sudden change is all about. Please tell me more.” b. “That’s great to hear. I will reduce the monitoring now.” c. “You have taken none of my time. It’s my job to keep you safe.” d. “I am glad you are feeling better. I will check on you later.”
Answer: a. “I wonder what this sudden change is all about. Please tell me more.”
Question: A new nurse says to a peer, “My new patient is diagnosed with bipolar disorder. At least I won’t have to worry about suicide risk.” Which response by the peer would be most helpful?
Answer Choices: a. “Let’s reconsider your plan. Suicide risk is high in patients diagnosed with bipolar disorder.” b. “Suicide is a risk for any patient diagnosed with bipolar disorder who uses alcohol or drugs.” c. “The thought processes of patients diagnosed with bipolar disorder are usually too disorganized to attempt suicide.” d. “Racing thoughts during mania often prompt suicide among patients diagnosed with bipolar disorder.”
Answer: a. “Let’s reconsider your plan. Suicide risk is high in patients diagnosed with bipolar disorder.”
Question: The parents of identical twins ask a nurse for advice when one twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate?
Answer Choices: 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: a. “Genetics are associated with suicide risk. Monitoring and support are important.”
Question: A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking website. Which suicide risk factors are present? (Select all that apply.)
Answer Choices: a. History of earlier suicide attempt b. Co-occurring medical illness c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation
Answer: c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation
Question: A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient’s plan of care? (Select all that apply.)
Answer Choices: a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient’s possession. c. Maintain arm’s length, one-on-one nursing observation around the clock. d. Check the patient’s whereabouts every 15 minutes and make frequent verbal contacts. e. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.
Answer: a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient’s possession. c. Maintain arm’s length, one-on-one nursing observation around the clock.
Question: A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? (Select all that apply.)
Answer Choices: a. An 82-year-old white man b. A 17-year-old white female adolescent c. A 39-year-old African-American man d. A 29-year-old African-American woman e. A 22-year-old man with a traumatic brain injury
Answer: a. An 82-year-old white man b. A 17-year-old white female adolescent e. A 22-year-old man with a traumatic brain injury
Question: A nurse assesses the health status of soldiers returning from a war zone. Screening for which health problems will be a priority? (Select all that apply.)
Answer Choices: a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Oppositional defiant disorder e. Posttraumatic stress disorder
Answer: c. Traumatic brain injury e. Posttraumatic stress disorder
Question: Which behavior best demonstrates aggression?
Answer Choices: a. Stomping away from the nurses’ station, darting to another room, and grabbing a snack from another patient b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing c. Telling the primary nurse, “I felt angry when you said I could not have a second helping at lunch” d. Telling the medication nurse, “I am not going to take that or any other medication you try to give me”
Answer: a. Stomping away from the nurses’ station, darting to another room, and grabbing a snack from another patient
Question: Which scenario predicts the highest risk for directing violent behavior toward others?
Answer Choices: a. Family ritualistic behaviors that trigger magical thinking b. Admitted yesterday with a history of diabetes and dementia c. Paranoid delusions of being followed by a military drone d. Completion of alcohol withdrawal and beginning a rehabilitation program
Answer: c. Paranoid delusions of being followed by a military drone
Question: A patient is hospitalized after an arrest for breaking windows in the home of a former intimate partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority?
Answer Choices: a. Risk for injury b. Post-trauma response c. Disturbed thought processes d. Risk for other-directed violence
Answer: d. Risk for other-directed violence
Question: A confused older adult patient in a skilled care facility is sleeping. A healthcare worker enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the healthcare worker in the face. Which statement best explains the patient’s action?
Answer Choices: a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the healthcare worker’s behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out.
Answer: c. The patient interpreted the healthcare worker’s behavior as potentially harmful.
Question: A patient is pacing the hall near the nurse’s station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say what?
Answer Choices: a. “What is going on here?” b. “Quiet down and sit down in this chair immediately.” c. “You seem upset. Tell me about it.” d. “You must go to your room and try to get control of yourself.”
Answer: c. “You seem upset. Tell me about it.”
Question: A patient has been responding to auditory hallucinations throughout the day. The patient approaches the nurse, shaking a fist and shouting, “Back off!” and then goes into the day room. As the nurse follows the patient into the day room, the nurse should take what precaution?
Answer Choices: a. Making sure adequate physical space exists between the nurse and the patient b. Moving into a position that allows the patient to be close to the door c. Maintaining one arm’s length distance from the patient d. Sitting down in a chair near the patient
Answer: a. Making sure adequate physical space exists between the nurse and the patient