Nokea
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.
You may also like to solve these questions
A severely depressed patient who has been on suicide precautions tells the nurse, 'I am feeling a lot better, so you can stop watching me. I have taken too much of your time already.' Which is the nurse's best response?
- A. I wonder what this sudden change is all about. Please tell me more.'
- B. I am glad you are feeling better. The team will consider your request.'
- C. You should not try to direct your care. Leave that to the treatment team.'
- D. Because we are concerned about your safety, we will continue with our plan.'
Correct Answer: D
Rationale: When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. The incorrect options will not cause the patient to admit to a suicidal plan, do not convey concern for the patient, or suggest that the patient is not a partner in the care process.
When a person intentionally overdoses on antidepressant drugs, which nursing diagnosis has the highest priority?
- A. Powerlessness
- B. Social isolation
- C. Risk for suicide
- D. Ineffective management of the therapeutic regimen
Correct Answer: C
Rationale: This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.
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.
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.
A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment?
- A. Let's make a list of all your problems and think of solutions for each one.'
- B. I'm happy you're taking control of your problems and trying to find solutions.'
- C. When you have bad feelings, try to focus on positive experiences from your life.'
- D. Let's consider which problems are most important and focus on discussing them.'
Correct Answer: D
Rationale: The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.