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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 began feeling depressed.'
Correct Answer: A
Rationale: The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation.
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Which statement by a patient during an assessment interview should 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 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.'
Correct Answer: B
Rationale: Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide.
Which change in brain biochemical function is most associated with suicidal behavior?
- A. Dopamine excess
- B. Serotonin deficiency
- C. Acetylcholine excess
- D. Gamma-aminobutyric acid deficiency
Correct Answer: B
Rationale: 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 suicidal crises.
The parents of identical twins ask a nurse for advice when one twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate?
- 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.'
Correct Answer: A
Rationale: 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 the genetic load. The incorrect options are untrue statements or oversimplifications.
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?
- A. No risk
- B. Low level
- C. Moderate level
- D. High level
Correct Answer: D
Rationale: The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.
Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient?
- 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 experiencing hopelessness.
Correct Answer: D
Rationale: Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired.