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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.
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A tearful, anxious patient at the outpatient clinic reports, 'I should be dead.' The initial task of the nurse conducting the assessment interview is to focus on what?
- A. Assessing the lethality of any suicide plan
- B. Encouraging expression of anger
- C. Establishing a rapport with the patient
- D. Determining risk factors for suicide
Correct Answer: C
Rationale: Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.
When assessing a patient's plan for suicide, what aspect has priority?
- A. Patient's financial and educational status
- B. Patient's insight into suicidal motivation
- C. Availability of means and lethality of method
- D. Quality and availability of patient's social support
Correct Answer: C
Rationale: If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.
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.
A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care?
- A. Allow no glass or metal on meal trays.
- B. Remove all potentially harmful objects from the patient's possession.
- C. Maintain arm's length, one-on-one nursing observation around the clock.
- D. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift.
- E. Check the patient's whereabouts every 15 minutes and make frequent verbal contacts.
- F. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.
Correct Answer: A,B,C
Rationale: One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions.
A new nurse says to a peer, 'My new patient is diagnosed with bipolar disorder. At least I won't have to worry about suicide risk.' Which response by the peer would be most helpful?
- A. Let's reconsider your plan. Suicide risk is high in patients diagnosed with bipolar disorder.'
- B. Suicide is a risk for any patient diagnosed with bipolar disorder who uses alcohol or drugs.'
- C. The thought processes of patients diagnosed with bipolar disorder are usually too disorganized to attempt suicide.'
- D. Racing thoughts during mania often prompt suicide among patients diagnosed with bipolar disorder.'
Correct Answer: A
Rationale: Epidemiological surveys have demonstrated that 90% of suicide completers had a diagnosable psychiatric condition at the time of the event. People with mood disorders, especially major depressive disorder and bipolar disorder, are responsible for approximately 50% of completed suicides. The correct response is the most global answer.