Chapter 21: Suicide Prevention: Screening, Assessment, and Intervention

1. The nurse is caring for a group of hospitalized patients with various psychiatric diagnoses. The nurse

identifies which patient as having the greatest risk for a suicide attempt?

A) Man with bipolar I disorder

B) Woman with acute stress disorder

C) Man with major depressive disorder

D) Woman with somatoform disorder

C) Man with major depressive disorder

2. The nurse is reviewing the medical records of several patients diagnosed with major depression. The

nurse identifies which patient as least likely to commit suicide?

A) Divorced man

B) Widowed woman

C) Single woman

D) Married man

D) Married man

3. A family member of an adolescent who has expressed a desire to commit suicide asks the nurse, What

might predict the possibility of future suicide attempts? Which of the following would the nurse include

in the response?

A) Unemployment

B) Death of a spouse

C) Previous suicide attempt

D) Polydrug use

C) Previous suicide attempt

4. A nurse is completing an admission assessment of a young adult woman who has a history of

depression and who was brought to the hospital by her boyfriend. In response to the nurse's question

regarding suicidal ideation, the patient discloses that the she is thinking about killing herself. Which

question would be most appropriate for the nurse to ask next?

A) What does your boyfriend think about your desire to kill yourself?

B) What are your spiritual beliefs about suicide?

C) What will killing yourself accomplish?

D) What thoughts have you had about how you would kill yourself?

D) What thoughts have you had about how you would kill yourself?

5. A nurse is with an adolescent who tells the nurse that she has nothing to live for and she just wishes she

was dead. Which nursing action would be the priority?

A) Going to the patient's psychiatrist to tell him of the girl's suicidal ideation

B) Staying with the patient to explore more of her thoughts about suicide

C) Putting the patient in seclusion with a staff assigned to watch her at all times

D) Ascertaining the client's beliefs about what happens when you die

B) Staying with the patient to explore more of her thoughts about suicide

6. The nurse is caring for a 30-year-old white man whose wife has recently died. The patient has been

diagnosed with clinical depression and is demonstrating insufficient coping skills. Which action by the

nurse would be most important?

A) Refer the patient for long-term psychotherapy.

B) Determine the patient's risk of psychosis.

C) Determine if anyone in the patient's family has had depression.

D) Ask the patient if he is thinking about killing himself.

D) Ask the patient if he is thinking about killing himself.

7. The nurse is providing a presentation for a group of health professionals about suicide. Which of the

following would the nurse address as a major contributing factor to the rising suicide rate among men?

A) Substance abuse

B) Media influences

C) Lack of conflict resolution skills

D) Parenting practices

A) Substance abuse

8. A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to

documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also

document which of the following?

A) Use of substances 6 hours before the assessment

B) Speech patterns

C) Availability of support resources

D) Amount of sleep in past 24 hours

A) Use of substances 6 hours before the assessment

9. A patient was admitted to the psychiatric unit 3 days ago because of suicidal ideation. His suicidal risk

has lessened considerably, and he currently denies having any desire to kill himself. In addition, he is able to identify reasons why he wants to be alive. Which nursing intervention would be most appropriate at this time?

A) Assigning nursing staff to stay with him during his suicidal crisis

B) Developing a personal plan for managing suicidal thoughts when they occur

C) Advising the patient that he should consider electroconvulsive therapy treatments

D) Administering psychotropic drugs that decrease the patient's serotonin levels

B) Developing a personal plan for managing suicidal thoughts when they occur

10. A nurse is presenting a discussion for a local community group about suicide. Which comment from an

audience member indicates the need to clarify the information?

A) Warning signs about the person's intention often occur.

B) People who are suicidal are undecided about living or dying.

C) Suicides more often occur during the holiday seasons.

D) People who talk about suicide need to taken seriously.

C) Suicides more often occur during the holiday seasons.

11. A group of nursing students is reviewing information about suicide and associated concepts. The group

demonstrates understanding of the information when they identify which of the following as the

probability that a person will successfully complete suicide?

A) Parasuicide

B) Suicidal ideation

C) Suicidality

D) Lethality

D) Lethality

12. After teaching a class about factors that enhance the risk of suicide, the instructor determines the need

for additional teaching when the class identifies which of the following?

A) Family member committing suicide

B) Cautiousness

C) Delusions

D) Loss

B) Cautiousness

13. A nurse is reviewing the medical record of a patient who has attempted suicide. Which of the following

would the nurse identify as relating to a psychological cause?

A) History of childhood trauma

B) Cluster B personality disorder

C) Social isolation

D) Suicide contagion

B) Cluster B personality disorder

14. A patient comes to the clinic for an evaluation of headache, fatigue, and an overall feelings of being down. When assessing the patient, which statement by the patient would alert the nurse to suspect possible suicide? Select all that apply.

A) I've been drinking about three or four more beers every night.

B) I've been going out with my friends about once or twice a week.

C) I'm so tired that all I ever want to do is sleep all the time.

D) Most times, I feel like I'm trapped with no way out.

E) I'm looking for a new job because my job is so stressful.

A) I've been drinking about three or four more beers every night.

C) I'm so tired that all I ever want to do is sleep all the time.

D) Most times, I feel like I'm trapped with no way out.

15. The nurse determines that a patient is at imminent risk for suicide. Which of the following would be least appropriate to include in the patient's plan of care?

A) Listening intently and nonjudgmentally

B) Validating the patient's feelings and experience

C) Instituting strict restriction on the patient's activity

D) Using cognitive interventions to foster hope

C) Instituting strict restriction on the patient's activity

16. A patient who has attempted suicide has an underlying diagnosis of depression. Which of the following

would the nurse anticipate being ordered for the patient?

A) Selective serotonin reuptake inhibitor

B) Mood stabilizer

C) Tricyclic antidepressant

D) Atypical antipsychotic

A) Selective serotonin reuptake inhibitor

17. The nurse is working with a patient who will be signing a commitment to treatment statement. After

teaching the patient about this statement, the nurse determines the need for additional instruction when

the patient states which of the following?

A) Signing this statement means that I will not commit suicide.

B) I am agreeing to get emergency treatment if I have suicidal thoughts.

C) I will be open and honest about my feelings about treatment.

D) I am agreeing to participate in the necessary treatment for my condition

A) Signing this statement means that I will not commit suicide.

18. A nurse is performing an assessment of a patient with suicidal ideation. Which question would the nurse most likely ask to determine the degree of planning?

A) How seriously do you want to die?

B) Have you attempted suicide before?

C) Could you stop yourself from killing yourself?

D) How much do the thoughts distress you?

C) Could you stop yourself from killing yourself?

19. A nurse determines that a patient has poor social skills that have interfered with his ability to engage

others, which has contributed to his feelings of purposelessness, hopelessness, and withdrawal. Which

of the following would be most important to assist the patient in beginning to social skills?

A) Self-help group

B) Recovery group

C) Nurse patient relationship

D) Limit setting

C) Nurse patient relationship

20. After teaching a group of students about the various concepts involving suicide, the instructor

determines that the teaching was successful when the students describe parasuicide as which of the

following?

A) Voluntary act of killing oneself

B) All suicide related behaviors and suicidal thoughts

C) Nonfatal act with the intent to die

D) Voluntary attempt without death as the aim

D) Voluntary attempt without death as the aim