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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.
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A nurse uses the modified SAD PERSONS scale to interview a patient. This tool provides data relevant to assessing what?
- A. Current stress level
- B. Mood disturbance
- C. Suicide potential
- D. Level of anxiety
Correct Answer: C
Rationale: The modified SAD PERSONS tool evaluates major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, stated future intent, organized plan, separated/widowed/divorced, and sickness. The tool does not have appropriate categories to provide information on the other options listed.
What is the most helpful response for a nurse to make when a patient being treated as an outpatient states, 'I am considering 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 get help.'
- C. We need to talk about the good things you have to live for.'
- D. Bringing this up is a very positive action on your part.'
Correct Answer: D
Rationale: This response gives the patient reinforcement 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 strategies.
A nurse assesses the health status of soldiers returning from a war zone. Screening for which health problems will be a priority?
- A. Schizophrenia
- B. Eating disorder
- C. Traumatic brain injury
- D. Oppositional defiant disorder
- E. Posttraumatic stress disorder
Correct Answer: C,E
Rationale: The incidence of TBI is very high in veterans and this problem is associated with an increased risk of dying by suicide compared with people without brain injuries. Many soldiers also have posttraumatic stress disorder, which contributes to increased suicide risk. The incidence of disorders identified in the distractors would be expected to parallel the general population.
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?
- 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. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift.
- E. Check the patient's whereabouts every 15 minutes and make 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.
Correct Answer: A,B,C
Rationale: One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions.
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?
- A. Denial
- B. Anger
- C. Anxiety
- D. Projection
Correct Answer: A
Rationale: The parents' statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distractors are not clearly described in the scenario.