Answer Options:
a. Implementing suicide precautions for a patient with depression
b. Teaching stress-reduction techniques to a beginning student nurse
c. Assessing coping strategies used by a patient who has attempted suicide
d. Referring a patient with schizophrenia to a partial hospitalization program
Answer: a. Implementing suicide precautions for a patient with depression
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 Options:
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: 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 Options:
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 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 Options:
a. “I wonder what this sudden change is all about. Please tell me more.”
b. “I am glad you are feeling better. The team will consider your request.”
c. “You should not try to direct your care. Leave that to the treatment team.”
d. “Because we are concerned about your safety, we will continue with our plan.”
Answer: d. “Because we are concerned about your safety, we will continue with our plan.”
Question: A patient newly diagnosed with pancreatic cancer says, “My father also died of pancreatic cancer. I took care of him during his illness. I can’t go through that.” Select the highest priority nursing diagnosis.
Answer Options:
a. Anticipatory grieving
b. Ineffective coping
c. Ineffective denial
d. Risk for suicide
Answer: d. Risk for suicide
Question: A nurse counsels a patient with recent suicidal ideation. Which is the nurse’s most therapeutic comment?
Answer Options:
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: Which intervention should a nurse recommend for the distressed family and friends of someone who has successfully committed suicide?
Answer Options:
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: A nurse uses the modified SAD PERSONS scale to interview a patient. This tool provides data relevant to assessing what?
Answer Options:
a. Current stress level
b. Mood disturbance
c. Suicide potential
d. Level of anxiety
Answer: c. Suicide potential
Question: A patient comes to the crisis center saying, “I’m in a terrible situation. I don’t know what to do.” The triage nurse can initially assume that the patient is experiencing what?
Answer Options:
a. Suicidal ideations
b. Anxiety and fear
c. Misperceived reality
d. Homicidal ideations
Answer: b. Anxiety and fear
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 Options:
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. Remove the patient’s shoelaces and belt.
e. Check the patient’s whereabouts every 15 minutes and give frequent verbal contacts.
f. 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.
d. Remove the patient’s shoelaces and belt.
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 web site. Which suicide risk factors are present? (Select all that apply.)
Answer Options:
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 person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial patient outcome?
Answer Options:
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 self-restraint by refraining from gestures or attempts to harm self for 24 hours.
Answer: d. Exercise 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 Options:
a. Denial
b. Anger
c. Anxiety
d. Projection
Answer: a. Denial
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 Options:
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 the antidepressant.
Answer: a. Supervise the patient 24 hours a day.
Question: When a person intentionally overdoses on antidepressant drugs, which nursing diagnosis has the highest priority?
Answer Options:
a. Powerlessness
b. Social isolation
c. Risk for suicide
d. Ineffective management of the therapeutic regimen
Answer: c. Risk for suicide
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 Options:
a. No risk
b. Low level
c. Moderate level
d. High level
Answer: d. High level
Question: A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? (Select all that apply.)
Answer Options:
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: Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk?
Answer Options:
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: 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 Options:
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: Which change in brain biochemical function is most associated with suicidal behavior?
Answer Options:
a. Dopamine excess
b. Serotonin deficiency
c. Acetylcholine excess
d. Gamma-aminobutyric acid deficiency
Answer: b. Serotonin deficiency
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 Options:
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: A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract.
Answer Options:
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 depressed patient says, “Nothing matters anymore.” What is the most appropriate response by the nurse?
Answer Options:
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: Which individual in the emergency department should be considered at the highest risk for completing suicide?
Answer Options:
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 wants to perform a preliminary assessment for suicidal ideation in an older adult patient. Which question would obtain the desired data?
a. “What thoughts do you have about a person’s right to take his or her own life?”
b. “If you felt suicidal, would you communicate your feelings to anyone?”
c. “Do you have any risk factors that potentially contribute to suicide?”
d. “Do you think you are vulnerable to developing a depressed mood?”
Answer: A