Nokea
The nurse is caring for a 30-year-old white man whose wife has recently died. The patient has been diagnosed with clinical depression and is demonstrating insufficient coping skills. Which action by the nurse would be most important?
- A. Refer the patient for long-term psychotherapy.
- B. Determine the patient?s risk of psychosis.
- C. Determine if anyone in the patient?s family has had depression.
- D. Ask the patient if he is thinking about killing himself.
Correct Answer: D
Rationale: Given the recent loss and diagnosis of clinical depression, assessing for suicidal ideation (D) is the most critical action to ensure patient safety, as loss and depression are significant suicide risk factors. Psychotherapy referral (A) is important but not immediate. Assessing for psychosis (B) or family history (C) is relevant but secondary to suicide risk assessment.
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A nurse is performing an assessment of a patient with suicidal ideation. Which question would the nurse most likely ask to determine the degree of planning?
- A. How seriously do you want to die?
- B. Have you attempted suicide before?
- C. Could you stop yourself from killing yourself?
- D. How much do the thoughts distress you?
Correct Answer: C
Rationale: Asking if the patient could stop themselves from killing themselves (C) directly assesses the degree of control and planning, indicating the specificity of their suicidal intent. Other options (A, B, D) provide related information but do not specifically address the plan?s feasibility.
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 with an adolescent who tells the nurse that she has nothing to live for and she just wishes she was dead. Which nursing action would be the priority?
- A. Going to the patient?s psychiatrist to tell him of the girl?s suicidal ideation
- B. Staying with the patient to explore more of her thoughts about suicide
- C. Putting the patient in seclusion with a staff assigned to watch her at all times
- D. Ascertaining the client?s beliefs about what happens when you die
Correct Answer: B
Rationale: The priority is to ensure the patient?s safety by staying with her and exploring her suicidal thoughts (B), which allows for immediate risk assessment and therapeutic engagement. Notifying the psychiatrist (A) is important but secondary to direct patient contact. Seclusion (C) is inappropriate unless the patient poses an immediate danger, and exploring beliefs about death (D) is less urgent than assessing current risk.
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.