Chapter 25: Suicide and Non-Suicidal Self-Injury

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

ANS: B

Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. 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.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 492 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

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.

Jumping from a railroad bridge located in a deserted area late at night

ANS: D

This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 486-487 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

3. Which measure would be considered a form of primary prevention 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

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 prevention measures. Support group referral is a tertiary prevention measure.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 487-488 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

4. Which change in the brain’s biochemical function is most associated with suicidal behavior?

a.

Dopamine excess

b.

Serotonin deficiency

c.

Acetylcholine excess

d.

Gamma-aminobutyric acid deficiency

ANS: B

Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 484-485 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity

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 behavior provides the strongest clue of an impending suicide attempt?

a.

Calling parents

b.

Excessive crying

c.

Giving away sweaters

d.

Staying alone in dorm room

ANS: C

Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 486-487 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

6. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to:

a.

current stress level.

b.

mood disturbance.

c.

suicide potential.

d.

level of anxiety.

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 486-487 (Table 25-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

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

ANS: C

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

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 487-490 (Table 25-3) TOP: Nursing Process: Diagnosis/Analysis

MSC: Client Needs: Psychosocial Integrity

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:

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 first week of hospitalization.

d.

exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

ANS: D

Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 487 | Page 492 (Table 25-4) TOP: Nursing Process: Outcomes Identification

MSC: Client Needs: Psychosocial Integrity

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:

a.

guilt.

b.

denial.

c.

shame.

d.

rescue feelings.

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 493-494 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

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?”

ANS: B

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

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 483 (Box 25-2) | Page 486-487

TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

11. It has been 5 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.

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 486-487 TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment

12. A nurse and patient construct a no-suicide contract. Select the preferable wording.

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 not in any way attempt to harm or kill myself.”

d.

“I will not kill myself until I call my primary nurse or a member of the staff.”

ANS: C

The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks “I am not going to harm myself, I am going to kill myself” or “I am not going to attempt suicide, I am going to commit suicide.” A patient may call a therapist and leave the telephone to carry out the suicidal plan.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 491-492 (Table 26-5) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

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:

a.

assess lethality of suicide plan.

b.

encourage expression of anger.

c.

establish rapport with the patient.

d.

determine risk factors for suicide.

ANS: C

This scenario presents a potential crisis. 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 plan, and presence of risk factors for suicide.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 488-491 (Nursing Care Plan 25-1)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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.”

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 484 | Page 488-491 (Nursing Care Plan 25-1)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 493-494 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

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.

ANS: A

Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, 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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 486-487 TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment

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.”

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 485-486 | Page 490 (Table 25-3)

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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.”

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 486-487 | Page 488-490 (Nursing Care Plan 25-1) and (Table 25-3)

TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

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.”

ANS: D

The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 484 | Page 488-489 (Nursing Care Plan 25-1) | Page 491-492

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 486-487 TOP: Nursing Process: Assessment

MSC: Client Needs: Safe, Effective Care Environment

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.

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 487-490 (Table 25-3) and (Nursing Care Plan 25-1)

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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 color.”

d.

“I tried to get attention before I cut myself last time.”

ANS: B

Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 487-490 (Table 25-3) and (Nursing Care Plan 25-1) TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment

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 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.

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 487-488 | Page 493-494 TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

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.”

ANS: A

Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 483-484 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

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

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 twelve grandchildren who has type 2 diabetes

d.

A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

ANS: D

High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 482-483 (Box 25-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

1. 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 Native American male

e.

39-year-old African American male

ANS: A, B, D

Whites 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 young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 481-485 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

2. 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.

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 491-492 (Table 25-5) and (Box 25-4)

TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

3. 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 website 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

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 represents self-imposed isolation. The scenario does not provide evidence of panic attack.

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