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A tearful, anxious patient at the outpatient clinic reports, 'I should be dead.' The initial task of the nurse conducting the assessment interview is to focus on what?
- A. Assessing the lethality of any suicide plan
- B. Encouraging expression of anger
- C. Establishing a rapport with the patient
- D. Determining risk factors for suicide
Correct Answer: C
Rationale: Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.
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A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk?
- A. An 82-year-old white man
- B. A 17-year-old white female adolescent
- C. A 39-year-old African-American man
- D. A 29-year-old African-American woman
- E. A 22-year-old man with a traumatic brain injury
Correct Answer: A,B,E
Rationale: Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, adolescents, and young adults. Other high-risk groups include young African-American men, Native-American men, older Asian Americans, and persons with traumatic brain injury.
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.
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.
When assessing a patient's plan for suicide, what aspect has priority?
- A. Patient's financial and educational status
- B. Patient's insight into suicidal motivation
- C. Availability of means and lethality of method
- D. Quality and availability of patient's social support
Correct Answer: C
Rationale: If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.
The parents of identical twins ask a nurse for advice when one twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate?
- A. Genetics are associated with suicide risk. Monitoring and support are important.'
- B. Apathy underlies suicide. Instilling motivation is the key to health maintenance.'
- C. Your child is unlikely to act out suicide when identifying with a suicide victim.'
- D. Fraternal twins are at higher risk for suicide than identical twins.'
Correct Answer: A
Rationale: Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting the genetic load. The incorrect options are untrue statements or oversimplifications.