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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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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.
A patient was admitted to the psychiatric unit 3 days ago because of suicidal ideation. His suicidal risk has lessened considerably, and he currently denies having any desire to kill himself. In addition, he is able to identify reasons why he wants to be alive. Which nursing intervention would be most appropriate at this time?
- A. Assigning nursing staff to stay with him during his suicidal crisis
- B. Developing a personal plan for managing suicidal thoughts when they occur
- C. Advising the patient that he should consider electroconvulsive therapy treatments
- D. Administering psychotropic drugs that decrease the patient?s serotonin levels
Correct Answer: B
Rationale: Since the patient?s risk has decreased and he is identifying reasons to live, developing a personal plan for managing suicidal thoughts (B) is appropriate to empower him and prevent future crises. Constant supervision (A) is unnecessary given the reduced risk. Electroconvulsive therapy (C) is not indicated without severe, treatment-resistant depression. Decreasing serotonin (D) would worsen depression.
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.
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.