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Which is a possible explanation for the increased risk of suicide in persons who have had a relative who committed suicide?
- A. The relative's suicide offers a sense of permission or acceptance of suicide as a method of escaping a difficult situation.
- B. Many people with depression who have suicidal ideation lack the energy to implement suicide plans, but antidepressant treatment can actually give clients with depression the energy to act on suicidal ideation.
- C. Suicide is more likely to occur in April when natural energy from increased sunlight may give the client the energy to act on suicidal ideation.
- D. The relative's suicide caused the family members to realize that suicide is emotionally harmful to the ones left behind and vow not to consider suicide.
Correct Answer: A
Rationale: A relative's suicide may normalize the act, increasing risk by providing a sense of acceptability.
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A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which nursing intervention is most likely to help the client successfully participate?
- A. Allowing the client to direct her participation at her own pace.
- B. Giving the client several choices of projects, so she can choose her favorite.
- C. Staying away from the client during the session to encourage free expression.
- D. Structuring the activity to facilitate completion of one specific task.
Correct Answer: D
Rationale: Structuring the activity ensures success for a lethargic client, supporting engagement and achievement.
A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?
- A. Administering a sedative that has been prescribed to be used PRN.
- B. Insisting the client take a time-out in his room.
- C. Clearing the area of all other clients.
- D. Setting limits on aggressive and intimidating behavior.
Correct Answer: D
Rationale: Setting limits on aggressive behavior is the initial action to ensure safety while allowing the client to exercise self-control.
A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?
- A. Immediately after a family visit
- B. On the anniversary of significant life events in the client's life
- C. During the first few days after admission
- D. Approximately 2 weeks after starting antidepressant medication
Correct Answer: D
Rationale: The risk of self-harm increases about 2 weeks after starting antidepressants, as energy improves before mood stabilizes.
A visitor comes to see a client who is suicidal. Upon entering the unit, the nurse notices that the visitor has brought the client a can of his favorite soda. Which action should the nurse take at this time?
- A. Confiscate the soda can as a restricted item.
- B. Pour the soda into a plastic cup.
- C. Ask the visitor to place the soda can at the nurse's desk until he or she leaves.
- D. Ask the visitor not to bring outside items on the unit in the future.
Correct Answer: B
Rationale: Pouring the soda into a plastic cup ensures safety by removing a potential self-harm item while allowing the client to enjoy the drink.
A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time?
- A. Redirect the client to appropriate behavior.
- B. Place the client in seclusion for his or her own protection.
- C. Ignore the behavior to avoid reinforcing it.
- D. Tell the client that the behaviors have to stop right now.
Correct Answer: A
Rationale: Redirecting to appropriate behavior is effective and non-confrontational, preventing escalation of manic behavior.