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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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The nurse is working with a patient who will be signing a commitment to treatment statement. After teaching the patient about this statement, the nurse determines the need for additional instruction when the patient states which of the following?
- A. Signing this statement means that I will not commit suicide.
- B. I am agreeing to get emergency treatment if I have suicidal thoughts.
- C. I will be open and honest about my feelings about treatment.
- D. I am agreeing to participate in the necessary treatment for my condition
Correct Answer: A
Rationale: A commitment to treatment statement is a collaborative agreement to engage in treatment and seek help, not a promise not to commit suicide (A), which is unrealistic and oversimplifies the patient?s responsibility. Options B, C, and D accurately reflect components of such a statement.
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 family member of an adolescent who has expressed a desire to commit suicide asks the nurse, What might predict the possibility of future suicide attempts? Which of the following would the nurse include in the response?
- A. Unemployment
- B. Death of a spouse
- C. Previous suicide attempt
- D. Polydrug use
Correct Answer: C
Rationale: A previous suicide attempt is the strongest predictor of future suicide attempts, as it indicates a history of engaging in life-threatening behavior and suggests persistent suicidal ideation or unresolved risk factors. While unemployment (A), death of a spouse (B), and polydrug use (D) are risk factors, they are less specific predictors compared to a documented prior attempt.
A patient comes??5comes to the clinic for an evaluation of headache, fatigue, and an overall feeling of being down. When assessing the patient, which statement by the patient would alert the nurse to suspect possible suicide? Select all that apply.
- A. I?ve been drinking about three or four more beers every night.
- B. I?ve been going out with my friends about once or twice a week.
- C. I?m so tired that all I ever want to do is sleep all the time.
- D. Most times, I feel like I?m trapped with no way out.
- E. I?m looking for a new job because my job is so stressful.
Correct Answer: C,D
Rationale: Statements indicating excessive sleepiness (C) and feeling trapped with no way out (D) are red flags for suicide risk, as they suggest severe depression and hopelessness, respectively. Increased alcohol use (A) is a risk factor but less specific without direct suicidal content. Socializing (B) and job stress (E) are not direct indicators of suicidal ideation.
The nurse is reviewing the medical records of several patients diagnosed with major depression. The nurse identifies which patient as least likely to commit suicide?
- A. Divorced man
- B. Widowed woman
- C. Single woman
- D. Married man
Correct Answer: D
Rationale: Social support, particularly from a stable marital relationship, is a protective factor against suicide. A married man (D) is likely to have more social and emotional support, reducing suicide risk compared to those who are divorced (A), widowed (B), or single (C), who may experience greater isolation or loss, increasing vulnerability to suicidal behavior in the context of major depression.