Nokea
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.
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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.
Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy?
- A. As depression lifts, physical energy becomes available to carry out suicide.
- B. Suicide may be precipitated by a variety of internal and external events.
- C. Suicidal patients have difficulty using social supports.
- D. Suicide is an impulsive act.
Correct Answer: A
Rationale: Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.
A nurse assesses the health status of soldiers returning from a war zone. Screening for which health problems will be a priority?
- A. Schizophrenia
- B. Eating disorder
- C. Traumatic brain injury
- D. Oppositional defiant disorder
- E. Posttraumatic stress disorder
Correct Answer: C,E
Rationale: The incidence of TBI is very high in veterans and this problem is associated with an increased risk of dying by suicide compared with people without brain injuries. Many soldiers also have posttraumatic stress disorder, which contributes to increased suicide risk. The incidence of disorders identified in the distractors would be expected to parallel the general population.
Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk?
- A. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night
- B. Turning on the oven and letting gas escape into the apartment during the night
- C. Cutting the wrists in the bathroom while the spouse reads in the next room
- D. Overdosing on aspirin with codeine while the spouse is out with friends
Correct Answer: A
Rationale: This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.
A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, 'My business is bankrupt, and I was served with divorce papers.' Which subsequent statement by the patient alerts the nurse to a concealed suicidal message?
- A. I wish I were dead.'
- B. Life is not worth living.'
- C. I have a plan that will fix everything.'
- D. My family will be better off without me.'
Correct Answer: C
Rationale: Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to 'fix everything' but does not say it outright.