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A nurse uses the modified SAD PERSONS scale to interview a patient. This tool provides data relevant to assessing what?
- A. Current stress level
- B. Mood disturbance
- C. Suicide potential
- D. Level of anxiety
Correct Answer: C
Rationale: The modified SAD PERSONS tool evaluates major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, stated future intent, organized plan, separated/widowed/divorced, and sickness. The tool does not have appropriate categories to provide information on the other options listed.
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A staff nurse tells another nurse, 'I evaluated a new patient using the modified SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home.' Select the best reply by the second nurse.
- A. That action would seem appropriate.'
- B. A score over 8 requires immediate hospitalization.'
- C. I think you should strongly consider hospitalization for this patient.'
- D. Give the patient a follow-up appointment. Hospitalization may be needed soon.'
Correct Answer: B
Rationale: The modified SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization.
After failing two tests, a college student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt?
- A. Calling parents
- B. Excessive crying
- C. Giving away sweaters
- D. Staying alone in a dorm room
Correct Answer: C
Rationale: Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the student has nowhere else to go.
A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care?
- A. Allow no glass or metal on meal trays.
- B. Remove all potentially harmful objects from the patient's possession.
- C. Maintain arm's length, one-on-one nursing observation around the clock.
- D. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift.
- E. Check the patient's whereabouts every 15 minutes and make frequent verbal contacts.
- F. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.
Correct Answer: A,B,C
Rationale: One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions.
A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, 'My business is bankrupt, and I was served with divorce papers.' Which subsequent statement by the patient alerts the nurse to a concealed suicidal message?
- A. I wish I were dead.'
- B. Life is not worth living.'
- C. I have a plan that will fix everything.'
- D. My family will be better off without me.'
Correct Answer: C
Rationale: Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to 'fix everything' but does not say it outright.
A depressed patient says, 'Nothing matters anymore.' What is the most appropriate response by the nurse?
- A. Are you having thoughts of suicide?'
- B. I am not sure I understand what you are trying to say.'
- C. Try to stay hopeful. Things have a way of working out.'
- D. Tell me more about what interested you before you began feeling depressed.'
Correct Answer: A
Rationale: The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation.