335 Exam 2
1) The nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse
identifies which client as having the greatest risk for a suicide attempt.
1. Man with bipolar I disorder
2. Woman with acute stress disorder
3. Man with major depressive disorder
4. Woman with somatoform disorder
ANS: 3
Feedback: Men have a higher suicide completion rate than women. For men, suicide occurs at a rate of
24.79 per 100,000, whereas in women it is 7.16 per 100,000. White men complete 78% of all suicides;
56% of these deaths are by firearms. Men are more likely to use means that have a higher rate of
success, such as firearms and hanging. Most suicide deaths occur in men with a psychiatric disorder,
primarily depression, in many cases complicated by substance abuse.
Chapter 16.
2) The nurse is reviewing the electronic health records of several clients diagnosed with major
depression. The nurse identifies which client as most likely to commit suicide?
1. Divorced man
2. Widowed man
3. Woman living with a roommate
4. Married woman
ANS: 2
Feedback: The nurse determines that the client most likely to commit suicide is the client who is
widowed. Single, older men living in a rural area have high rates of suicide. Unmarried, unsociable men
between the ages of 42 and 77 years with minimal social networks and no close relatives have a
significantly increased risk for committing suicide. Women are less likely to complete a suicide but are
more likely to attempt suicide. Marriage has been identified as a protective factor for mental disorders in
older adults.
,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 element would the nurse include
in the response?
1. Unemployment
2. Death of a spouse
3. Previous suicide attempt
4. Polydrug use
ANS: 3
Feedback: Although factors such as unemployment, death of a spouse, and polydrug use can contribute
to depression and suicidal ideation, one of the best predictors for suicide in adolescence is a
us attempt.
Chapter 16.
4) A nurse is completing an admission assessment of a young adult client who has a history of
depression, and who was brought to the hospital by a friend. In response to the nurse's question
regarding suicidal ideation, the client discloses that they often think about attempting suicide. Which
question is appropriate for the nurse to ask?
1. "What does your friend think about your desire to kill yourself?"
2. "What are your spiritual beliefs about suicide?"
3. "What will killing yourself accomplish?"
4. "What thoughts have you had about how you would kill yourself?"
ANS: 4
Feedback: Assessing for risk includes determining the seriousness of the suicidal ideation, degree of
hopelessness, disorders, previous attempt, suicide planning and implementation, and availability and
lethality of the suicide method. Risk assessment also includes the client's resources, including coping
skills and social supports, that can be used to counter suicidal impulses.
Chapter 16.
,5) The nurse is caring for a 30 year old white man whose wife 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?
1. Refer the client for long term psychotherapy.
2. Determine the client's risk of psychosis.
3. Determine whether anyone in the client's family has had depression.
4. Ask the client whether he is thinking about killing himself.
ANS: 4
Feedback: The nurse should first ask if the client is thinking about killing himself, because statistics show
that in young, recently widowed white men between the ages of 20 and 34 years, the suicide risk is 17
times higher than that of married men in that same age group. Social isolation and access to firearms
play important roles in this group. Information related to psychosis, psychotherapy, or family history
would be less of a priority at this time.
Chapter 16.
6) The nurse is providing a presentation for a group of health professionals about suicide. Which would
the nurse address as a major contributing factor to the rising suicide rate among men?
1. Substance abuse
2. Media influences
3. Lack of conflict resolution skills
4. Parenting practices
ANS: 1
Feedback: Substance abuse, aggression, hopelessness, emotion focused coping, social isolation, and lack
of purpose in life have been associated with suicidal behavior in men. In addition, 56% of suicide deaths
among men involve firearms. The media, lack of conflict resolution skills, and parenting practices can
play a role, but are not considered major factors.
Chapter 16.
, 7) A nurse has just completed a suicide risk assessment of a widowed client, 76 years of age. In addition
to documenting the presence or absence of suicidal thoughts, a suicide plan, and the client's available
means, the nurse would also document which information?
1. Use of substances 6 hours before the assessment
2. Speech patterns
3. Availability of support resources
4. Amount of sleep in past 24 hours
ANS: 1
Feedback: The nurse should document the presence or absence of suicidal thoughts, intent, plan, and
available means to illustrate current and ongoing suicide risk. If the client denies any suicidal ideation, it
is important that the denial is documented. Documentation must include any use of drugs, alcohol, or
prescription medications by the client during the 6 hours before the assessment. It should include the
use of antidepressants that are especially lethal (e.g., tricyclics), as well as any medication that might
impair the client's judgment (e.g., a sleep medication). Notes should reflect the level of the client's
judgment and ability to be a partner in treatment.
Chapter 16.
8) 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 perform
suicide. In addition, the client is able to identify reasons to be alive. Which nursing intervention is
appropriate?
1. Assigning nursing staff to stay with the client during this suicidal crisis
2. Developing a personal plan for managing suicidal thoughts when they occur
3. Advising the client to consider electroconvulsive therapy treatments
4. Administering psychotropic drugs that decrease the client's serotonin levels
ANS: 2
Feedback: The client's immediate suicidal crisis has subsided, and it is now appropriate for the nurse to
focus on working with the client on symptom management. Preventing suicidal behavior requires that
clients develop crisis management strategies, generate solutions to difficult life circumstances other than
suicide, engage in effective interpersonal interactions, and maintain hope.
1) The nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse
identifies which client as having the greatest risk for a suicide attempt.
1. Man with bipolar I disorder
2. Woman with acute stress disorder
3. Man with major depressive disorder
4. Woman with somatoform disorder
ANS: 3
Feedback: Men have a higher suicide completion rate than women. For men, suicide occurs at a rate of
24.79 per 100,000, whereas in women it is 7.16 per 100,000. White men complete 78% of all suicides;
56% of these deaths are by firearms. Men are more likely to use means that have a higher rate of
success, such as firearms and hanging. Most suicide deaths occur in men with a psychiatric disorder,
primarily depression, in many cases complicated by substance abuse.
Chapter 16.
2) The nurse is reviewing the electronic health records of several clients diagnosed with major
depression. The nurse identifies which client as most likely to commit suicide?
1. Divorced man
2. Widowed man
3. Woman living with a roommate
4. Married woman
ANS: 2
Feedback: The nurse determines that the client most likely to commit suicide is the client who is
widowed. Single, older men living in a rural area have high rates of suicide. Unmarried, unsociable men
between the ages of 42 and 77 years with minimal social networks and no close relatives have a
significantly increased risk for committing suicide. Women are less likely to complete a suicide but are
more likely to attempt suicide. Marriage has been identified as a protective factor for mental disorders in
older adults.
,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 element would the nurse include
in the response?
1. Unemployment
2. Death of a spouse
3. Previous suicide attempt
4. Polydrug use
ANS: 3
Feedback: Although factors such as unemployment, death of a spouse, and polydrug use can contribute
to depression and suicidal ideation, one of the best predictors for suicide in adolescence is a
us attempt.
Chapter 16.
4) A nurse is completing an admission assessment of a young adult client who has a history of
depression, and who was brought to the hospital by a friend. In response to the nurse's question
regarding suicidal ideation, the client discloses that they often think about attempting suicide. Which
question is appropriate for the nurse to ask?
1. "What does your friend think about your desire to kill yourself?"
2. "What are your spiritual beliefs about suicide?"
3. "What will killing yourself accomplish?"
4. "What thoughts have you had about how you would kill yourself?"
ANS: 4
Feedback: Assessing for risk includes determining the seriousness of the suicidal ideation, degree of
hopelessness, disorders, previous attempt, suicide planning and implementation, and availability and
lethality of the suicide method. Risk assessment also includes the client's resources, including coping
skills and social supports, that can be used to counter suicidal impulses.
Chapter 16.
,5) The nurse is caring for a 30 year old white man whose wife 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?
1. Refer the client for long term psychotherapy.
2. Determine the client's risk of psychosis.
3. Determine whether anyone in the client's family has had depression.
4. Ask the client whether he is thinking about killing himself.
ANS: 4
Feedback: The nurse should first ask if the client is thinking about killing himself, because statistics show
that in young, recently widowed white men between the ages of 20 and 34 years, the suicide risk is 17
times higher than that of married men in that same age group. Social isolation and access to firearms
play important roles in this group. Information related to psychosis, psychotherapy, or family history
would be less of a priority at this time.
Chapter 16.
6) The nurse is providing a presentation for a group of health professionals about suicide. Which would
the nurse address as a major contributing factor to the rising suicide rate among men?
1. Substance abuse
2. Media influences
3. Lack of conflict resolution skills
4. Parenting practices
ANS: 1
Feedback: Substance abuse, aggression, hopelessness, emotion focused coping, social isolation, and lack
of purpose in life have been associated with suicidal behavior in men. In addition, 56% of suicide deaths
among men involve firearms. The media, lack of conflict resolution skills, and parenting practices can
play a role, but are not considered major factors.
Chapter 16.
, 7) A nurse has just completed a suicide risk assessment of a widowed client, 76 years of age. In addition
to documenting the presence or absence of suicidal thoughts, a suicide plan, and the client's available
means, the nurse would also document which information?
1. Use of substances 6 hours before the assessment
2. Speech patterns
3. Availability of support resources
4. Amount of sleep in past 24 hours
ANS: 1
Feedback: The nurse should document the presence or absence of suicidal thoughts, intent, plan, and
available means to illustrate current and ongoing suicide risk. If the client denies any suicidal ideation, it
is important that the denial is documented. Documentation must include any use of drugs, alcohol, or
prescription medications by the client during the 6 hours before the assessment. It should include the
use of antidepressants that are especially lethal (e.g., tricyclics), as well as any medication that might
impair the client's judgment (e.g., a sleep medication). Notes should reflect the level of the client's
judgment and ability to be a partner in treatment.
Chapter 16.
8) 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 perform
suicide. In addition, the client is able to identify reasons to be alive. Which nursing intervention is
appropriate?
1. Assigning nursing staff to stay with the client during this suicidal crisis
2. Developing a personal plan for managing suicidal thoughts when they occur
3. Advising the client to consider electroconvulsive therapy treatments
4. Administering psychotropic drugs that decrease the client's serotonin levels
ANS: 2
Feedback: The client's immediate suicidal crisis has subsided, and it is now appropriate for the nurse to
focus on working with the client on symptom management. Preventing suicidal behavior requires that
clients develop crisis management strategies, generate solutions to difficult life circumstances other than
suicide, engage in effective interpersonal interactions, and maintain hope.
