Nokea
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
Correct Answer: C
Rationale: Documenting the availability of support resources (C) is essential in a suicide risk assessment, as social support is a key protective factor that can mitigate risk. Substance use (A), speech patterns (B), and sleep (D) may be relevant but are less directly tied to risk assessment compared to support resources.
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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 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
Correct Answer: C
Rationale: A previous suicide attempt is the strongest predictor of future suicide attempts, as it indicates a history of engaging in life-threatening behavior and suggests persistent suicidal ideation or unresolved risk factors. While unemployment (A), death of a spouse (B), and polydrug use (D) are risk factors, they are less specific predictors compared to a documented prior attempt.
A patient comes??5comes to the clinic for an evaluation of headache, fatigue, and an overall feeling 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.
Correct Answer: C,D
Rationale: Statements indicating excessive sleepiness (C) and feeling trapped with no way out (D) are red flags for suicide risk, as they suggest severe depression and hopelessness, respectively. Increased alcohol use (A) is a risk factor but less specific without direct suicidal content. Socializing (B) and job stress (E) are not direct indicators of suicidal ideation.
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 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 be taken seriously.
Correct Answer: C
Rationale: The comment that suicides more often occur during the holiday seasons (C) is a common myth. Research shows no consistent increase in suicides during holidays; risk is more tied to individual factors. The other comments (A, B, D) are accurate: warning signs are common, suicidal individuals are often ambivalent, and suicide talk must be taken seriously.