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A nurse is completing an admission assessment of a young adult woman who has a history of depression and who was brought to the hospital by her boyfriend. In response to the nurse?s question regarding suicidal ideation, the patient discloses that she is thinking about killing herself. Which question would be most appropriate for the nurse to ask next?
- A. What does your boyfriend think about your desire to kill yourself?
- B. What are your spiritual beliefs about suicide?
- C. What will killing yourself accomplish?
- D. What thoughts have you had about how you would kill yourself?
Correct Answer: D
Rationale: When a patient expresses suicidal ideation, the nurse?s priority is to assess the specificity and immediacy of the risk by inquiring about a plan, as this indicates the degree of intent and potential lethality. Asking about specific thoughts on how the patient would kill herself (D) is critical for risk assessment. Options A, B, and C, while potentially relevant later, do not directly assess the immediate risk or plan.
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The nurse is caring for a group of hospitalized patients with various psychiatric diagnoses. The nurse identifies which patient as having the greatest risk for a suicide attempt?
- A. Man with bipolar I disorder
- B. Woman with acute stress disorder
- C. Man with major depressive disorder
- D. Woman with somatoform disorder
Correct Answer: C
Rationale: Major depressive disorder is strongly associated with a high risk of suicide due to persistent feelings of hopelessness, worthlessness, and despair, which are core symptoms. Studies indicate that individuals with major depressive disorder have a significantly higher suicide risk compared to other psychiatric conditions. Bipolar I disorder (A) carries a risk, particularly during depressive episodes, but the risk is generally lower than in major depressive disorder. Acute stress disorder (B) is typically short-term and less associated with suicide. Somatoform disorder (D) focuses on physical symptoms and has a lower direct link to suicide.
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.
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.
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 patient who has attempted suicide has an underlying diagnosis of depression. Which of the following would the nurse anticipate being ordered for the patient?
- A. Selective serotonin reuptake inhibitor
- B. Mood stabilizer
- C. Tricyclic antidepressant
- D. Atypical antipsychotic
Correct Answer: A
Rationale: Selective serotonin reuptake inhibitors (SSRIs) (A) are first-line treatments for depression due to their efficacy and favorable side-effect profile. Mood stabilizers (B) are used for bipolar disorder, tricyclic antidepressants (C) are less commonly used due to side effects, and atypical antipsychotics (D) are not primary treatments for depression.