Chapter 22: Suicide Prevention: Screening, Assessment, and Intervention

Format: Multiple Choice

Client Needs: Psychosocial Integrity

Cognitive Level: Analyze

Integrated Process: Nursing Process

Objective: 4

Page and Header: 332, Adults and Older Adults

1. A nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse identifies which client as having the highest risk for a suicide attempt?

A) Man with bipolar I disorder

B) Woman with acute stress disorder

C) Man with major depressive disorder

D) Woman with somatoform disorder

Page and Header: 337, Social Distress

2. A nurse is reviewing the medical records of several clients diagnosed with major depression. The nurse identifies which client as least likely to commit suicide?

A) Divorced man

B) Widowed woman

C) Single woman

D) Married man

Page and Header: 340, Assessing Risk

3. 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 factor would the nurse include in the response?

A) Unemployment

B) Death of a family member

C) Previous suicide attempt

D) Polydrug use

Page and Header: 340, Assessing Risk

4. A nurse is completing an admission assessment of a young client who has a history of depression and who was brought to the hospital by the client’s partner. In response to the nurse’s question regarding suicidal ideation, the client discloses contemplation of suicide. Which question would be most appropriate for the nurse to ask next?

A) “What does your partner think about your desire to kill yourself?”

B) “What are your spiritual beliefs about suicide?”

C) “What will killing yourself accomplish?”

D) “What thoughts have you had about how you would kill yourself?”

Page and Header: 340, Interventions for Those at Imminent Risk

5. A nurse is with an adolescent who reports nothing to live for and wishes to be dead. Which nursing action would be the priority?

A) Going to the client’s psychiatrist to report the suicidal ideation

B) Staying with the client to explore more of the client’s thoughts about suicide

C) Putting the client in seclusion with a staff member assigned to watch the client at all times

D) Ascertaining the client’s beliefs about what happens when one dies

Page and Header: 340, Assessing Risk, Box 22.5

6. A nurse is caring for a 30-year-old man whose wife has recently died. The client has been diagnosed with clinical depression and is demonstrating insufficient coping skills. Which action by the nurse would be most important?

A) Refer the client for long-term psychotherapy.

B) Determine the client’s risk of psychosis.

C) Determine whether anyone in the client’s family has had depression.

D) Ask the client whether he is thinking about killing himself.

Page and Header: 332, Epidemiology and Risk Factors; 333, Box 22.2, Suicide Risk Factors

7. A nurse is providing a presentation about suicide for a group of health professionals. Which factor would the nurse address as a major contributor to the rising suicide rate among men?

A) Substance abuse

B) Media influences

C) Lack of conflict resolution skills

D) Parenting practices

Page and Header: 343, Documentation and Reporting

8. A nurse has just completed a suicide risk assessment of a widowed 76-year-old client. In addition to documenting the presence or absence of suicidal thoughts, a suicide plan, and the client’s available means, it would also be important for the nurse to document which other information?

A) Use of substances 6 hours before the assessment

B) Speech patterns

C) Availability of support resources

D) Amount of sleep in past 24 hours

Page and Header: 340, Ensuring Patient Safety

9. A client was admitted to the psychiatric unit 3 days ago because of suicidal ideation. The client’s suicidal risk has lessened considerably, and the client currently denies having any desire to inflect self-harm. In addition, the client is able to identify reasons to be alive. Which nursing intervention would be most appropriate at this time?

A) Assign nursing staff to stay with the client during the suicidal crisis.

B) Develop a personal plan for managing suicidal thoughts when they occur.

C) Advise the client to consider electroconvulsive therapy treatments.

D) Administer psychotropic drugs that decrease the client’s serotonin levels.

Page and Header: 330, Introduction; 331, Box 22.1, Myths and Facts about Suicide

10. A nurse is presenting a discussion about suicide for a local community group. 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 without warning during the holiday seasons.”

D) “People who talk about suicide need to be taken seriously.”

Page and Header: 330, Introduction

11. A group of nursing students is reviewing information about suicide and associated concepts. The group demonstrates understanding of the information when members identify which term as the probability that a person will successfully complete suicide?

A) Parasuicide

B) Suicidal ideation

C) Suicidality

D) Lethality

Page and Header: 333, Psychological Risk Factors

12. The nurse educates a class on factors that enhance the risk of suicide. The instructor determines the need for additional education when the class identifies which one as a factor?

A) Family member committing suicide

B) Cautiousness

C) Delusions

D) Loss

Page and Header: 340, Interventions for Those at Imminent Risk

13. A nurse determines that a client is at imminent risk for suicide. Which action would be least appropriate to include in the client’s plan of care?

A) Listening intently and nonjudgmentally

B) Validating the client’s feelings and experience

C) Instituting strict restriction on the client’s activity

D) Using cognitive interventions to foster hope

Page and Header: 341, Interventions for the Biologic Domain

14. A client who has attempted suicide has an underlying diagnosis of depression. Which medication would the nurse anticipate being ordered for the client?

A) Selective serotonin reuptake inhibitor

B) Mood stabilizer

C) Tricyclic antidepressant

D) Atypical antipsychotic

Page and Header: 342, Commitment to Treatment

15. A nurse is working with a client who will be signing a commitment to treatment statement. After teaching the client about this statement, the nurse determines the need for additional instruction when the client makes which statement?

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.”

Page and Header: 340, Assessing Risk, Box 22.5

16. A nurse is performing an assessment of a client with suicidal ideation. Which question would the nurse most likely ask to determine the degree of planning?

A) “How seriously do you want to die?”

B) “Have you attempted suicide before?”

C) “Could you stop yourself from killing yourself?”

D) “How much do the thoughts distress you?”

Page and Header: 342, Interventions for the Social Domain

17. A nurse determines that a client has poor social skills that have interfered with the ability to engage others, which has contributed to feelings of purposelessness, hopelessness, and withdrawal. Which engagement would be most important for the nurse to recommend in order to help the client develop social skills?

A) Self-help group

B) Recovery group

C) Nurse–client relationship

D) Limit setting

Page and Header: 330, Introduction

18. After educating a group of students on the various concepts involving suicide, the instructor determines that the education was successful when the students provide which description of parasuicide?

A) The voluntary act of killing oneself

B) All suicide-related behaviors and suicidal thoughts

C) A nonfatal act with the intent to die

D) A voluntary attempt without death as the aim

Page and Header: 338, Case Finding, Box 22.3

19. The nurse has been contacted by the parent of an adolescent who has posted a note on social media about the desire to kill oneself. Which additional sign is a warning that there is an acute risk of suicide for the client?

A) The client has been stealing prescription medication from home.

B) The client has been experiencing increased anxiety.

C) The client has appeared angrier lately.

D) The client has experience changes in sleep pattern.

Page and Header: 338, Case Finding, Box 22.3

20. A client comes to the clinic for an evaluation of headache, fatigue, and an overall feeling of being “down.” When assessing the client, which statement by the client 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.”