Question: A nurse uses the modified SAD PERSONS scale to interview a patient. This tool provides data relevant to assessing what?
Answer Choices: a. Current stress level b. Mood disturbance c. Suicide potential d. Level of anxiety
Answer: c. Suicide potential
Question: When a person intentionally overdoses on antidepressant drugs, which nursing diagnosis has the highest priority?
Answer Choices: a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimen
Answer: c. Risk for suicide
Question: A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial patient outcome?
Answer Choices: a. Will verbalize a will to live by the end of the second hospital day. b. Can describe two new coping mechanisms by the end of the third hospital day. c. Accurately delineate personal strengths by the end of first week of hospitalization. d. Exercise suicide self-restraint by refraining from gestures or attempts to harm self for 24 hours.
Answer: d. Exercise suicide self-restraint by refraining from gestures or attempts to harm self for 24 hours.
Question: A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, “There must be a mistake. This could not have happened. We’ve given our child everything.” What emotional response does the parents’ reaction reflect?
Answer Choices: a. Denial b. Anger c. Anxiety d. Projection
Answer: a. Denial
Question: An adolescent tells the school nurse, “My friend threatened to take an overdose of pills.” The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?
Answer Choices: a. “What makes 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: b. “Do you have access to medications?”
Question: An adult after an attempted suicide is hospitalized and takes an antidepressant medication for 5 days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention.
Answer Choices: 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 the discontinuation of suicide precautions.
Answer: a. Supervise the patient 24 hours a day.
Question: A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract.
Answer Choices: a. “I will not try to harm myself during the next 24 hours.” b. “I will not make a suicide attempt while I am hospitalized.” c. “For the next 24 hours, I will discuss any thoughts of killing or harming myself with staff.” d. “I will not kill myself until I call my primary nurse or a member of the staff.”
Answer: c. “For the next 24 hours, I will discuss any thoughts of killing or harming myself with staff.”
Question: 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 focus on what?
Answer Choices: a. Assessing the lethality of any suicide plan b. Encouraging expression of anger c. Establishing a rapport with the patient d. Determining risk factors for suicide
Answer: c. Establishing a rapport with the patient
Question: What is the most helpful response for a nurse to make when a patient being treated as an outpatient states, “I am considering suicide.”?
Answer Choices: 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 get help.” c. “We need to talk about the good things you have to live for.” d. “Bringing this up is a very positive action on your part.”
Answer: d. “Bringing this up is a very positive action on your part.”
Question: Which intervention should a nurse recommend for the distressed family and friends of someone who has successfully committed suicide?
Answer Choices: a. Participating in reminiscence therapy b. Attending a self-help group for survivors c. Contracting for two sessions of group therapy d. Completing a psychological postmortem assessment
Answer: b. Attending a self-help group for survivors
Question: Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy?
Answer Choices: a. The patient may experience sudden lifts in mood, which can indicate an increased risk of suicidal behavior. b. Antidepressant medications can cause mood swings that make it difficult to predict a patient’s behavior. c. Patients may stop taking their medication as prescribed, leading to a return of severe depressive symptoms. d. The nurse must ensure that the patient understands the medication regimen and follows it correctly.
Answer: a. The patient may experience sudden lifts in mood, which can indicate an increased risk of suicidal behavior.
Question: A nurse assesses a patient who reports a 3-week history of depression and crying spells. 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?
Answer Choices: 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: c. “I have a plan that will fix everything.”
Question: A depressed patient says, “Nothing matters anymore.” What is the most appropriate response by the nurse?
Answer Choices: 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 began feeling depressed.”
Answer: a. “Are you having thoughts of suicide?”
Question: A nurse counsels a patient with recent suicidal ideation. Which is the nurse’s most therapeutic comment?
Answer Choices: 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 most important and focus on discussing them.”
Answer: d. “Let’s consider which problems are most important and focus on discussing them.”
Question: When assessing a patient’s plan for suicide, what aspect has priority?
Answer Choices: 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: c. Availability of means and lethality of method
Question: Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient?
Answer Choices: a. Every suicidal person is mentally ill b. Every suicidal person is intent on dying. c. Every suicidal person is cognitively impaired. d. Every suicidal person experiences hopelessness.
Answer: d. Every suicidal person experiences hopelessness.
Question: Which statement by a patient during an assessment interview should alert the nurse to the patient’s need for immediate, active intervention?
Answer Choices: a. “I am mixed up, but I know I need help.” b. “I have no one for help or support.” c. “It is worse when you are a person of color.” d. “I tried to get attention before I shot myself”
Answer: b. “I have no one for help or support.”
Question: What feeling experienced by a patient should be assessed by the nurse as most predictive of elevated suicide risk?
Answer Choices: a. Hopelessness b. Sadness c. Anxiety d. Anger
Answer: a. Hopelessness