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The nurse determines that a patient is at imminent risk for suicide. Which of the following would be least appropriate to include in the patient?s plan of care?
- A. Listening intently and nonjudgmentally
- B. Validating the patient?s feelings and experience
- C. Instituting strict restriction on the patient?s activity
- D. Using cognitive interventions to foster hope
Correct Answer: C
Rationale: Strict activity restriction (C) is least appropriate for a patient at imminent suicide risk unless there is an immediate safety threat requiring such measures. Listening (A), validating feelings (B), and cognitive interventions (D) are therapeutic and supportive, aligning with best practices for managing suicidal patients.
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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 nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
- A. Use of substances 6 hours before the assessment
- B. Speech patterns
- C. Availability of support resources
- D. Amount of sleep in past 24 hours
Correct Answer: C
Rationale: Documenting the availability of support resources (C) is essential in a suicide risk assessment, as social support is a key protective factor that can mitigate risk. Substance use (A), speech patterns (B), and sleep (D) may be relevant but are less directly tied to risk assessment compared to support resources.
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.
A nurse determines that a patient has poor social skills that have interfered with his ability to engage others, which has contributed to his feelings of purposelessness, hopelessness, and withdrawal. Which of the following would be most important to assist the patient in beginning to social skills?
- A. Self-help group
- B. Recovery group
- C. Nurse-patient relationship
- D. Limit setting
Correct Answer: C
Rationale: The nurse-patient relationship (C) provides a safe, therapeutic environment to model and practice social skills, addressing the patient?s isolation and hopelessness. Self-help (A) and recovery groups (B) are beneficial but less individualized, while limit setting (D) is unrelated to social skill development.
A patient who has attempted suicide has an underlying diagnosis of depression. Which of the following would the nurse anticipate being ordered for the patient?
- A. Selective serotonin reuptake inhibitor
- B. Mood stabilizer
- C. Tricyclic antidepressant
- D. Atypical antipsychotic
Correct Answer: A
Rationale: Selective serotonin reuptake inhibitors (SSRIs) (A) are first-line treatments for depression due to their efficacy and favorable side-effect profile. Mood stabilizers (B) are used for bipolar disorder, tricyclic antidepressants (C) are less commonly used due to side effects, and atypical antipsychotics (D) are not primary treatments for depression.