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A nurse is reviewing the medical record of a patient who has attempted suicide. Which of the following would the nurse identify as relating to a psychological cause?
- A. History of childhood trauma
- B. Cluster B personality disorder
- C. Social isolation
- D. Suicide contagion
Correct Answer: B
Rationale: Cluster B personality disorder (B), such as borderline or antisocial personality disorder, is a psychological cause of suicide risk due to emotional instability and impulsivity. Childhood trauma (A) is a historical or environmental factor, social isolation (C) is a social factor, and suicide contagion (D) is an external influence, not a psychological cause.
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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.
The nurse is caring for a 30-year-old white man whose wife has recently died. The patient has been diagnosed with clinical depression and is demonstrating insufficient coping skills. Which action by the nurse would be most important?
- A. Refer the patient for long-term psychotherapy.
- B. Determine the patient?s risk of psychosis.
- C. Determine if anyone in the patient?s family has had depression.
- D. Ask the patient if he is thinking about killing himself.
Correct Answer: D
Rationale: Given the recent loss and diagnosis of clinical depression, assessing for suicidal ideation (D) is the most critical action to ensure patient safety, as loss and depression are significant suicide risk factors. Psychotherapy referral (A) is important but not immediate. Assessing for psychosis (B) or family history (C) is relevant but secondary to suicide risk assessment.
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.
The nurse is reviewing the medical records of several patients diagnosed with major depression. The nurse identifies which patient as least likely to commit suicide?
- A. Divorced man
- B. Widowed woman
- C. Single woman
- D. Married man
Correct Answer: D
Rationale: Social support, particularly from a stable marital relationship, is a protective factor against suicide. A married man (D) is likely to have more social and emotional support, reducing suicide risk compared to those who are divorced (A), widowed (B), or single (C), who may experience greater isolation or loss, increasing vulnerability to suicidal behavior in the context of major depression.
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.