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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.
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A nurse answers a suicide crisis line. A caller says, 'I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart.' How would the nurse assess the lethality of this plan?
- A. No risk
- B. Low level
- C. Moderate level
- D. High level
Correct Answer: D
Rationale: The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.
An adolescent tells the school nurse, 'My friend threatened to take an overdose of pills.' The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?
- A. What makes you want to kill yourself?'
- B. Do you have access to medications?'
- C. Have you been taking drugs and alcohol?'
- D. Did something happen with your parents?'
Correct Answer: B
Rationale: The nurse must assess the patient's access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical.
Which individual in the emergency department should be considered at the highest risk for completing suicide?
- A. An adolescent Asian-American girl with superior athletic and academic skills who has asthma
- B. A 38-year-old single African-American female church member with fibrocystic breast disease
- C. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes
- D. A 79-year-old single white man with cancer of the prostate gland
Correct Answer: D
Rationale: High risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.
A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present?
- A. History of earlier suicide attempt
- B. Co-occurring medical illness
- C. Recent stressful life event
- D. Self-imposed isolation
- E. Shame or humiliation
Correct Answer: C,D,E
Rationale: Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The inability to contact parents can be seen as a recent lack of social support, as can the roommate's absence from the dormitory. Terminating access to one's social networking site represents self-imposed isolation. This scenario does not provide data regarding a history of an earlier suicide attempt, a family history of suicide, or of co-occurring medical illness.
Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention?
- A. I am mixed up, but I know I need help.'
- B. I have no one for help or support.'
- C. It is worse when you are a person of color.'
- D. I tried to get attention before I shot myself.'
Correct Answer: B
Rationale: Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide.