Nokea
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.
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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.
A severely depressed patient who has been on suicide precautions tells the nurse, 'I am feeling a lot better, so you can stop watching me. I have taken too much of your time already.' Which is the nurse's best response?
- A. I wonder what this sudden change is all about. Please tell me more.'
- B. I am glad you are feeling better. The team will consider your request.'
- C. You should not try to direct your care. Leave that to the treatment team.'
- D. Because we are concerned about your safety, we will continue with our plan.'
Correct Answer: D
Rationale: When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. The incorrect options will not cause the patient to admit to a suicidal plan, do not convey concern for the patient, or suggest that the patient is not a partner in the care process.
What feeling experienced by a patient should be assessed by the nurse as most predictive of elevated suicide risk?
- A. Hopelessness
- B. Sadness
- C. Anxiety
- D. Anger
Correct Answer: A
Rationale: 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.
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 most important and focus on discussing them.'
Correct Answer: D
Rationale: The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.
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 focus on what?
- A. Assessing the lethality of any suicide plan
- B. Encouraging expression of anger
- C. Establishing a rapport with the patient
- D. Determining risk factors for suicide
Correct Answer: C
Rationale: Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.