Chapter 12 Suicide Prevention

Chapter 12  Suicide Prevention

Complete Chapter Questions And Answers
 

Sample Questions

____ 1. A nurse discovers a client’s suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action?
1.
Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note
2.
Establishing room restrictions, because the client’s threat is an attempt to manipulate the staff
3.
Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide
4.
Calling an emergency treatment team meeting, because the client’s threat must be addressed

____ 2. During the planning of care for a suicidal client, which correctly written outcome should be a nurse’s first priority?
1.
The client will not physically harm self.
2.
The client will express hope for the future by day three.
3.
The client will establish a trusting relationship with the nurse.
4.
The client will remain safe during the hospital stay.

____ 3. A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse’s priority intervention at this time?
1.
Obtaining an order for locked seclusion until client is no longer suicidal
2.
Conducting 15-minute checks to ensure safety
3.
Placing the client on one-to-one observation while monitoring suicidal ideations
4.
Encouraging client to express feelings related to suicide

____ 4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse’s priority at this time?
1.
Give the client off-unit privileges as positive reinforcement.
2.
Encourage the client to share mood improvement in group.
3.
Increase frequency of client observation.
4.
Request that the psychiatrist reevaluate the current medication protocol.

Answer Section

MULTIPLE CHOICE

1. ANS: 3
Chapter: Chapter 12, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Application of the Nursing Process with the Suicidal Client > Analysis of the Suicidal Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate

Feedback
1
This action would not be appropriate and could be considered a restraint.
2
Establishing room restrictions does not keep the client safe in the immediate situation.
3
The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.
4
The client’s immediate safety is a priority.

PTS: 1 CON: Stress

2. ANS: 4
Chapter: Chapter 12, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Application of the Nursing Process with the Suicidal Client > Analysis of the Suicidal Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate

Feedback
1
This answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, realistic, and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated.
2
This option may take longer to achieve.
3
This option is important, but safety must be established first.
4
The nurse’s priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse’s priority.

PTS: 1 CON: Stress

3. ANS: 3
Chapter: Chapter 12, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Application of the Nursing Process with the Suicidal Client > Analysis of the Suicidal Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate

Feedback
1
Seclusion may be excessive for this client.
2
Checks every 15 minutes would be inadequate for this client.
3
The nurse’s priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation.
4
The client’s physical safety is the priority.

PTS: 1 CON: Stress

4. ANS: 3
Chapter: Chapter 12, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 236
Heading: Application of the Nursing Process with the Suicidal Client > Analysis of the Suicidal Crisis
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Safety and Infection Control
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate

Feedback
1
The client should not be given off-unit privileges, as this could be unsafe.
2
Group involvement is important, but client safety must take priority.
3
The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.
4
Medication can be reevaluated after client safety has been established.

PTS: 1 CON: Stress