Ch 17. FaDavis student test bank NCLEX – Flashcards
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Tim is being assessed at the community mental health clinic where his sister brought him with concerns that he might be suicidal. He recently lost his teenage son in a tragic automobile accident and commented that he would rather be with his son than here on earth. He admits to thinking of killing himself but denies intent. Which of the following pieces of information shared by Tim during the assessment are considered protective factors that might reduce Tim's risk for suicide? Select all that apply. 1) Tim describes himself as very religious and according to his religious beliefs, suicide is an unforgivable sin. 2) Tim is 70 years old. 3) Tim describes his family as very supportive and his sister adds, "We would do anything to help Timmy get through this." 4) Tim is being treated for prostate cancer. 5) Tim worked for 20 years as a consultant for a company that teaches conflict resolution skills to corporations.
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1,3,5, Rationale Feedback 1: Adhering to religious beliefs that discourage suicide and encourage self-preservation reduces the potential for suicide. Feedback 2: Tim is actually in an age group and gender that has a risk for suicide four times the national average. Feedback 3: Having strong family support is identified as a protective factor in assessing risk for suicide. Feedback 4: Presence of a physical illness in an individual who is depressed and suicidal increases the risk for suicide. Feedback 5: Having strong problem-solving skills and conflict resolution skills are identified as protective factors that might reduce a person's risk for suicide.
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A soldier experienced the loss of all fellow platoon members during the Vietnam conflict. The soldier was recently admitted after a suicide attempt. According to Hendin, what has influenced this soldier's predisposition to suicide? 1) Anger turned inward 2) Hopelessness 3) Desperation and guilt 4) Developmental stressors
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3 Rationale Hendin identifies desperation and guilt as important factors in the predisposition to suicide. An individual feels helpless to change, but he or she also feels that life is impossible without such change. Guilt and self-recrimination are other aspects of desperation. These affective components were found to be prominent in Vietnam veterans with post-traumatic stress disorder exhibiting suicidal behaviors.
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Jane, a 25-year-old widow, is admitted after a failed suicide attempt. She states her beloved husband died 3 months ago. Currently, she cannot pay her bills. In the analysis of Jane's current suicidal crisis which of the following factors is present that would increase her risk for suicide? 1) Relevant history 2) A precipitating stressor 3) Life stage issues 4) Altered social interactions
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2 Rationale A precipitating stressor is an increase in emotional disturbance added to life's stress, such as the loss of a loved person either by death or by divorce, problems in major relationships, changes in roles, or serious physical illness. The client's husband's death 3 months ago and her subsequent financial difficulties can easily be seen as precipitating stressors.
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A client is discussing her suicide attempt with the nurse. Which nursing response is appropriate? 1) "Let's focus on the future instead of what already happened." 2) "Why did you try to kill yourself?" 3) "This is a sad topic. Let's talk about something more pleasant." 4) "Can you think of situations in which you have been in control?"
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4 Rationale Suicidal clients can feel powerless over life's stressors, leading to impulsive acts of self-harm. Encouraging the client to review areas of life that can be controlled may instill a sense of personal achievement and, therefore, increase self-worth.
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Which is a misconception about suicide? 1) Eight out of ten individuals who commit suicide give warnings about their intentions. 2) Most suicidal individuals are very ambivalent concerning their feelings about suicide. 3) Most individuals commit suicide by taking an overdose of drugs. 4) Initial mood improvement can precipitate suicide.
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3 Rationale It is a misconception that individuals usually commit suicide by taking an overdose of drugs. Gunshot wounds are the leading cause of death among suicide victims.
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When assessing suicidal risk, which nursing question is most appropriate? 1) "Can you tell me about your lifestyle?" 2) "You say that you won't be around much longer. Can you tell me what that means?" 3) "Have you written any suicide notes?" 4) "You seem desperate. Do you have a plan and a method for ending your life?"
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4 Rationale The nurse makes an observation related to potential suicidal ideations and questions the client about a plan and a means to carry out the plan. This is the most appropriate question to provide the nurse with the most complete information that will help determine the client's suicide risk.
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A nursing instructor is teaching about suicide risk statistics. Which statement by the student nurse indicates that learning has occurred? 1) "Males of very high socioeconomic status are predisposed to suicide." 2) "Females of Asian-American ethnicity are predisposed to suicide." 3) The majority of people who commit suicide do not have a diagnosable mental illness. 4) People of the Roman Catholic faith have higher suicide rates than rates among Protestants and Jews.
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1 Rationale Males are more likely to commit suicide than are females. Individuals of very high and very low socioeconomic status are more likely to commit suicide than are middle-class individuals.
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The nurse is caring for a client who is considered a suicide risk. Which client statement would require immediate nursing intervention? 1) "I don't want to talk with the psychiatrist about my feelings." 2) "I've thought about killing myself, but I don't know how I'd do it." 3) "My family won't need to worry about me in another day." 4) "My wife took away all the medications from our medicine cabinet."
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3 Rationale This statement indicates that the client has a suicide plan with an immediate time frame that would require the nurse to intervene by initiating suicide precautions immediately.
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Which of the following nursing interventions are appropriate when caring for a suicidal client? Select all that apply. 1) Initiate suicide precautions and provide a hazard-free environment. 2) Encourage the client to talk about his or her emotional pain. 3) Help the client identify areas of life that are within his or her control. 4) Provide the client with ample privacy. 5) Allow the client to isolate self.
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1, 2, 3 Rationale Feedback 1: Initiating suicide precautions and providing a hazard-free environment are priority nursing interventions when caring for a suicidal client, to maintain the client's safety. Feedback 2: Encouraging the client to talk about his or her emotional pain will help the client use a problem-solving approach to openly deal with hidden fears or anxieties rather than resorting to self-harm. Feedback 3: It is important for the client to feel some control over his or her life situation in order to perceive a measure of self-worth and hopefulness. Feedback 4: Providing the client with privacy would not be appropriate. A suicidal client must be under constant supervision so that if the client attempts self-injurious behaviors, interventions can quickly be implemented to prevent harm. Feedback 5: Allowing the client to isolate self would not be appropriate. A suicidal client must be under constant supervision so that if the client attempts self-injurious behaviors, interventions can quickly be implemented to prevent harm.
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The nurse is developing a care plan for Joe, who was admitted to the inpatient psychiatric unit after attempting to kill himself by hanging. He continues to express suicidal ideation and states "I'll try it again, the next chance I get." Which of the following nursing interventions are appropriate to include in Joe's immediate care plan for suicide risk? Select all that apply. 1) Maintain 15-minute checks at regular intervals throughout the day. 2) Maintain continuous one-to-one observation. 3) Make an agreement with the patient that if he signs a no-suicide contract, all other suicide precautions will be removed. 4) Remove belts, ties, sharp objects, and glass items from patient access. 5) Ensure that patient has swallowed any medication that is being administered.
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2, 4, 5 Rationale Feedback 1: Although 15-minute checks are an option in care plans for suicidal patients, Joe's expression of intent to make another attempt places him in a high-risk category and warrants closer observation than 15-minute checks would provide. Furthermore, checks should be done at irregular intervals to minimize patients' opportunity to predict when staff will not be checking on them. Feedback 2: Continuous observation is appropriate in this high-risk period, particularly when the patient is making threats of another attempt. Feedback 3: Whereas no-suicide contracts can be a useful adjunct to other safety plans, evidence does not support their reliability as the only intervention to protect a person's safety. Feedback 4: Items like belts, ties, sharp objects, and glass are at high risk for use in a suicide attempt and should be removed from patient access. Feedback 5: Hoarded medications can be used to attempt suicide, so it is essential to ensure that the patient is observed to have swallowed any medications administered.
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The nurse is assessing a Joshua, a 25-year-old, at the mental health clinic to determine his degree of risk for suicide. Which of the following statements support that he is in the high risk category for suicide? Select all that apply. 1) "I've been having panic anxiety attacks since last year." 2) "I drink alcohol daily and smoke pot 3 to 4 times per week." 3) "I've got a lot of close family that live nearby; there's only one or two that I can't count on." 4) "My girlfriend kicked me out and I moved in with a girl I met at the bar but she only let me stay for a month. I've been homeless since then." 5) "When I get angry I let it out by breaking objects or taking my car out for a race around the neighborhood."
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1, 2, 4, 5 Rationale Feedback 1: Panic level anxiety is associated with high risk for suicide. Feedback 2: This statement suggests continual substance abuse, which is associated with high risk for suicide. Feedback 3: This statement identifies several available significant others, which lessens the intensity of risk for suicide. Feedback 4: This statement suggests an unstable lifestyle, which is associated with high risk for suicide. Feedback 5: This statement suggests predominantly destructive coping skills, which is associated with high risk for suicide.
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The nurse is counseling an actively suicidal client. What is the nurse's priority intervention? 1) Discuss strategies for the management of anxiety, anger, and frustration. 2) Provide opportunities for increasing the client's self-worth, morale, and control. 3) Place client on suicide precautions with one-on-one observation. 4) Explore experiences that affirm self-worth and self-efficacy.
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3 Rationale Placing the client on suicide precautions with one-on-one observation provides a safe environment for an actively suicidal client. Maintaining client safety should always be a priority nursing intervention.
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The nurse is caring for four clients. On the basis of knowledge and statistics associated with suicidal risk, which client does the nurse recognize as more predisposed to a suicide attempt? 1) 15-year-old male who abuses substances 2) 48-year-old married Asian-American woman 3) 66-year-old Roman Catholic Hispanic woman 4) 80-year-old married Roman Catholic woman
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1 Rationale Adolescence is a prime age for suicidal attempts, especially among males. It is the third leading cause of death in this age group. Substance abuse increases suicidal risk because of its effect on inhibition and impulse control.
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The nurse is performing an assessment on a client who has been admitted after a suicide attempt. Which of the following questions would the nurse include in the initial interview? Select all that apply. 1) "What means did you use to attempt suicide?" 2) "Do you have a family history of any suicides?" 3) "Why did you choose suicide to solve your problems?" 4) "Was this your first suicide attempt?" 5) "How have you coped with stress in the past?"
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1, 2, 4, 5 Rationale Feedback 1: It is important for the nurse to assess how the client attempted suicide. Certain methods of suicide, such as hanging, historically present an increased risk during hospitalization. Feedback 2: A family history of suicide puts the client at higher risk. Feedback 3: Using the nontherapeutic block of requesting an explanation puts the client on the defensive and blocks the communication process. Feedback 4: If the client has a history of attempted suicide, there is an increased risk for future attempts. Feedback 5: Assessing previously successful coping mechanisms will enable the nurse to foster and encourage future use of appropriate problem-solving skills.
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A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. At this time, which is the most appropriate nursing intervention for this client? 1) Provide the client with a safe and structured environment. 2) Isolate the client from all stressful situations that may precipitate a suicide attempt. 3) Observe the client continuously to prevent self-harm. 4) Assist the client to develop more effective coping mechanisms.
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4 Rationale Assisting the client to develop more effective coping mechanisms is a nursing intervention that can and should be implemented in outpatient settings as ongoing follow-up.
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A physician writes discharge orders for a 30-day supply of imipramine (Tofranil) for a client who has a strong history of suicidal ideations. What is the priority nursing intervention? 1) Teach the client about side effects of antidepressants. 2) Direct the client to the hospital pharmacy to immediately fill the prescription. 3) Question the physician about the quantity of medication ordered. 4) Encourage the client to keep follow-up appointments.
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3 Rationale As depression lifts, clients can become energized and able to implement suicide plans. The nurse should question the physician's order for a 30-day supply of Tofranil. Tricyclic antidepressant medications can be lethal in overdose. Early in treatment, quantities of these medications should be limited to no more than a 3-day supply with no refills.
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Which individual is at lowest risk for suicide? 1) A single 65-year-old male dentist 2) A married middle-class woman 3) A male teenager who hunts 4) A 70-year-old Caucasian woman whose father committed suicide
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2 Rationale A married middle-class woman has the lowest risk for suicide. Single, divorced, and widowed individuals are at higher risk than are married persons. Individuals in the highest and lowest socioeconomic classes are at higher risk than are those in the middle class. Males are at higher risk than are females.
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Which client statement would indicate the most severe suicide risk? 1) "I really don't have much to live for, but I'd go to hell if I ended it all." 2) "I have been diagnosed with cancer. My wife is a great help and support." 3) "When I get home I am using my rifle to blow my brains out." 4) "I don't think anyone would care if I wasn't around anymore."
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3 Rationale Clients who have specific suicidal plans and easy access to lethal methods, especially guns, are at highest risk for suicide.
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Which of the following information would the nurse provide the caregivers of a client with a history of multiple suicide attempts who is being treated on an outpatient basis? Select all that apply. 1) Leave the client alone only for short periods of time. 2) Encourage open lines of communication within the family. 3) Prepare the home environment to be free from substances and firearms. 4) Provide an emergency contact number. 5) Schedule counseling appointments weekly to monitor safety risk.
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2, 3, 4 Rationale Feedback 1: It is important not to leave the client alone. Arrangements must be made for the client to stay with family or friends. If this is not possible, hospitalization should be reconsidered. Feedback 2: Open lines of communication within the family can help the family be aware of subtle clues that might be missed otherwise. Feedback 3: It is important for caregivers to ensure that the home environment is safe and does not harbor dangerous items, such as firearms or stockpiled drugs. Feedback 4: It is important that caregivers receive the telephone number of the counselor or an emergency contact person in the event the counselor is not available. Feedback 5: Counseling appointments need to be scheduled daily, not weekly, until the client is stabilized.
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Which statement is true about suicide? 1) People who talk about suicide do not commit suicide. 2) Suicidal behavior is inherited. 3) You cannot stop a suicidal individual. 4) Individuals who want to kill themselves are suicidal only for a limited time.
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4 Rationale It is true that individuals who want to kill themselves are suicidal only for a limited time. If they are saved from feelings of self-destruction they can go on to lead normal lives.
