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
Correct Answer: C
Rationale: The nurse-patient relationship (C) provides a safe, therapeutic environment to model and practice social skills, addressing the patient?s isolation and hopelessness. Self-help (A) and recovery groups (B) are beneficial but less individualized, while limit setting (D) is unrelated to social skill development.
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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
Correct Answer: B
Rationale: Cautiousness (B) is not a recognized risk factor for suicide; it may even be protective by reducing impulsivity. Family history of suicide (A), delusions (C), and loss (D) are established risk factors, as they contribute to genetic predisposition, altered thinking, and emotional distress, respectively.
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
Correct Answer: C
Rationale: Strict activity restriction (C) is least appropriate for a patient at imminent suicide risk unless there is an immediate safety threat requiring such measures. Listening (A), validating feelings (B), and cognitive interventions (D) are therapeutic and supportive, aligning with best practices for managing suicidal patients.
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
Correct Answer: B
Rationale: The priority is to ensure the patient?s safety by staying with her and exploring her suicidal thoughts (B), which allows for immediate risk assessment and therapeutic engagement. Notifying the psychiatrist (A) is important but secondary to direct patient contact. Seclusion (C) is inappropriate unless the patient poses an immediate danger, and exploring beliefs about death (D) is less urgent than assessing current risk.
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
Correct Answer: D
Rationale: Lethality (D) refers to the probability that a person will successfully complete suicide, based on the method?s potential to cause death. Parasuicide (A) involves nonfatal acts, suicidal ideation (B) is thoughts of suicide, and suicidality (C) is a broader term encompassing suicidal thoughts and behaviors.
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?
Correct Answer: C
Rationale: Asking if the patient could stop themselves from killing themselves (C) directly assesses the degree of control and planning, indicating the specificity of their suicidal intent. Other options (A, B, D) provide related information but do not specifically address the plan?s feasibility.
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