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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.
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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 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.
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.
The nurse is working with a patient who will be signing a commitment to treatment statement. After teaching the patient about this statement, the nurse determines the need for additional instruction when the patient states which of the following?
- A. Signing this statement means that I will not commit suicide.
- B. I am agreeing to get emergency treatment if I have suicidal thoughts.
- C. I will be open and honest about my feelings about treatment.
- D. I am agreeing to participate in the necessary treatment for my condition
Correct Answer: A
Rationale: A commitment to treatment statement is a collaborative agreement to engage in treatment and seek help, not a promise not to commit suicide (A), which is unrealistic and oversimplifies the patient?s responsibility. Options B, C, and D accurately reflect components of such a statement.
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.