1. Which assessment statement(s) would be appropriate for a patient who may be suicidal? Select all that apply.

    1. Do you ever think about suicide?
    2. Are you thinking of hurting yourself?
    3. Do you sometimes wish you were dead?
    4. Has it ever seemed like life is not worth living?
    5. If you were to kill yourself, how would you do it?
    6. Does it seem like others might be better off if you were dead?

    When assessing for risk of suicide it is helpful to be direct and open in one’s inquiries. Such questioning will not “give the patient the idea,” and by being frank, the clinician may increase the likelihood that the patient will respond with a similar degree of frankness. Inquiring about ideation, intent, and plans is essential to a suicide assessment, as is inquiring about death holding an attraction for the patient (by relieving his suffering or helping others).
  2. Which person is at the highest risk for suicide?

    B. A young, single white male who is alcohol dependent, hopeless, impulsive, has just been rejected by his girlfriend, and has ready access to a gun he has hidden.

    All of the persons described are potentially at risk for suicide. However, the person most likely to be at highest risk is the person who has the greatest number of risk factors, the fewest mitigating factors (factors which counter the tendency towards suicide, such as strong religious beliefs which hold suicide to be a sin), the most imminent intent, the most specific and lethal plan, and access to lethal means (especially if those means cannot be controlled in such a way that the patient’s access to them can be prevented). The young, single man who suffers from alcoholism is impulsive, feels hopeless, and has a lethal plan that he has partially enacted (by hiding the gun to prevent others from taking it from him). His isolation, alcoholism, recent loss, impulsiveness, specific plan, and ready access to a highly lethal means suggest a high degree of risk. The 50-year-old married male has a somewhat vague plan with intent that is dependent on how events at work play out. He is married as opposed to isolated, and his plan involves a relatively low-lethality means; relatively speaking, he is at lower risk. The woman with bipolar disorder who lost her parents and has a history of a suicide attempt as a teenager might seem to be at higher risk because of her significant loss, mood disorder, and history of a previous attempt, but her risk is somewhat mitigated by her ability to cope effectively for many years since that attempt. The older Hispanic man has experienced a very significant loss and does not have ready access to family support at a difficult time in his life, and his chronic illness is a risk factor as well. However, both his culture and his religion are mitigating factors in that Catholics typically hold suicide to be a mortal sin, and Hispanic persons tend to hold to a belief that one is fated to deal with certain burdens in life.
  3. Which intervention(s) maximize the safety of an actively suicidal patient on an inpatient
    mental health unit? Select all that apply.

    1. Place the patient on every-15-minute checks.
    2. Place the patient in a room near the nurses’ station.
    3. Assign the patient to a private room to facilitate monitoring.
    4. Install breakaway curtain rods, coat hooks, and shower rods.
    5. Search the patient, his room, and his belongings for dangerous items.
    6. Substitute blankets and thicker cloth items for sheets and thinner cloth items.
    7. Withhold visitation privileges to prevent the patient from obtaining dangerous items via

    Checks done on an every-15-minute basis are inadequate in that they still allow a patient more than enough time to enact a potentially lethal plan to harm himself (e.g., by hanging himself from a door-closing mechanism). For an actively suicidal patient, continuous direct observation, wherein a staff member is directly and actively observing the patient at all times, is indicated instead. A room near the nurses’ station reduces isolation and facilitates observation by staff and in some cases may inhibit suicidal behavior. Placing the patient in a private room would tend to increase isolation and perhaps worsen other symptoms that might be present (e.g., hallucinations), which in turn could increase the risk of suicide. The presence of a roommate can also serve to inhibit suicidal behavior or at least increase the likelihood of such behavior being reported. Hanging is the most frequently used means of completing suicide in inpatient settings and therefore requires significant milieu interventions designed to impede such actions. Eliminating fixtures that can be used for hanging is one key element of milieu management and can be accomplished via high ceilings, recessed fixtures, and fixtures designed to break away if a person’s weight is placed on them. Another intervention is to assure that the patient does not have access to cloth items that could be used for hanging. Thick items are more difficult to fashion into nooses and can be substituted (e.g., heavy blankets can replace standard sheets, and special “suicide blankets” made of thick, stiff material can be purchased). Searching for potentially dangerous items (including items brought by visitors) is essential. A patient intent on suicide may hide such items within his belongings on admission or may obtain them directly or indirectly after admission. Withhold visitation privileges is likely to increase isolation and despair and is not generally recommended unless there is reason to believe that visitors would attempt to bring dangerous items to the patient. Instead, all items brought by visitors are searched before the patient is allowed to access them. If in doubt, visitation can be monitored by staff.
  4. Which are accurate statements about no-suicide contracts? Select all that apply.

    1. Refusal to sign a no-suicide contract suggests higher risk.
    2. No-suicide contracts have been shown to reduce the risk of suicide.
    3. No-suicide contracts include alternate actions a patient should take if suicidal.
    4. Short lengths of stay tend to reduce the effectiveness of no-suicide contracts.
    5. Nurses should encourage ambivalent patients to sign a no-suicide contract.
    6. Such contracts may inhibit some suicidal behavior but cannot be relied upon for safety.

    No-suicide contracts include a list of alternate responses to suicidal thinking. They are used to help the patient consider other options when experiencing suicidal ideation, and in some cases they may lead some patients to reconsider or delay suicide attempts. Therefore, they can be used as one of multiple interventions designed to reduce suicide risk. However, they should never be relied upon as reason for reducing precautions; research does not indicate that no suicide contracts reliably reduce risk. Therefore, while patients who are ambivalent or who refuse to sign such contracts should be considered to be at higher risk, a person who readily signs a contract should NOT be assumed to be at lower risk. For example, a patient will sometimes sign such a contract simply to give the impression that he is at lower risk in order to get staff to reduce the level of suicide precautions. The patient in turn can attempt suicide more easily. Research has suggested that such contracts can give staff a false sense of security, causing them to relax their level of concern and in turn increase the risk to suicidal patients. Further, such contracts typically rely on the patient having a therapeutic relationship and bond with the staff with whom they contract. In cases where inpatient stays are short, there is often insufficient time available to develop such bonds, reducing the reliability of the patient’s commitment to remain safe. There is little value in persuading an ambivalent patient to sign such contracts, since they lack the commitment required to make the agreement meaningful.
  5. Which of the following represents the greatest protective factor against the risk of suicide?

    B. Sense of responsibility to family (e.g., spouse, children)

    Having family responsibility makes a client less likely to commit suicide. Hopelessness, however, is the greatest risk factor. Text page: 551
  6. An assessment tool that is useful to nurses in rating suicide risk is the

    A. Sad Persons scale.

    The evaluation of a suicide plan is extremely important in determining the degree of suicidal risk. The Sad Persons scale is short and easy to use. It thoroughly covers major risk factors and gives guidelines for action to meet patient needs. Text page: 553

    AIMS scale - Abnormal Involuntary Movement scale for detection of tardive dyskinesia and other involuntary movements.

    SAD PERSONS scale - Sex, Age, Depression, (space), PreviousĀ attempt, Ethanol use, Rational thinking loss, Social supports lacking, Organized plan, No spouse, Sickness.

    CAGE questionnaire - An alcohol/drug abuse screen mnemonic: Cut down?, People Annoyed you w/ critizism?, Felt Guilty?, Needed an Eye-opener? Use this in conjunction with MAST-G (Michigan Alcohol Screening Test -Geiatric version.

    Mini-Mental Status Examination.
  7. Which statement represents a fact about suicide?

    C. A schizophrenic client is at a great risk for attempting suicide.

    • Schizophrenics are 50 times more likely to attempt suicide than the general public.
    • Suicide is the eleventh leading cause of death in the United States
    • Native Americans and Alaskan Natives had high suicide rates
    • More women attempt suicide but more men are successful.

    Text page: 548
  8. A suicidal individual calls a suicide hot line. This represents the level of intervention classified as

    A. secondary.

    • Primary - provide suypport, inforation and education to prevent suicide, and this is always done for healthy patients.
    • Secondary - prevention is essentially treatment of a suicidal crisis, i.e. before the act.
    • Tertiary - interventions with family and friends of someone who has commited suicide.
    • Text page: 556
  9. Which neurotransmitter has been implicated as playing a part in the decision to commit suicide?

    B. Serotonin

    Low serotonin levels have been noted among individuals who have committed suicide. Text page: 551
  10. When working with a client that the nurse thinks may have made a covert reference to suicide, the nurse should

    A. ask the client directly if he or she is thinking of attempting suicide.

    Covert references should be made overt. The nurse should directly address any suicidal hints given by the client. Self-destructive ideas are a personal decision. Talking openly about suicide leads to a decrease in isolation and can increase problem-solving alternatives for living. People who attempt suicide, even those who regret the failure of their attempt, are often extremely receptive to talking about their suicide crisis. Text page: 553
  11. Nurses should assess the lethality of the client's plan for suicide. What factor would be irrelevant to that assessment?

    B. How long the client has been suicidal?

    Lethality refers to how deadly a plan is. Length of time has nothing to do with lethality of the plan. Text page: 553
  12. The suicide intervention that has the most impact on client safety is:

    B. one-on-one observation by staff.

    One-on-one observation allows for constant supervision thus minimizing the client's opportunity to self harm. Text pages: 556, 557
  13. Some of the most important characteristics that staff, working with suicidal clients, need to have areĀ 

    C. warmth and consistency when interacting.

    Helpful staff characteristics for individuals who work with suicidal clients include warmth, sensitivity, interest, and consistency. Text page: 557
  14. The nurse proposes that a suicidal client enter into a no-suicide contract. Such a contract would contain a provision that the client promises

    C. not to attempt suicide in the next 24 hours.

    A no-suicide contract is quite straightforward in seeking a promise not to attempt to harm oneself within a specified period. When that time expires, a new contract is negotiated. Text page: 558
  15. A woman of who recently lost one of her identical twin sons as a result of suicide, shares with the nurse, "Thank heavens suicide does not run in families. I won't have to worry about my other son." The nurse who hears this can make the assessment that the mother's optimism

    D. is not based on accurate knowledge because twin studies suggest the presence of genetic factors in suicide.

    Twin studies, in fact, show that a genetic component of suicide may be present. Text page: 551
  16. A client on one-to-one supervision at arm's length indicates a need to go to the bathroom. She tells the nurse "I cannot 'go' with you standing there." The nurse should

    B. say "For your safety I can be no more than an arm's length away."

    This level of suicide watch does not make adjustments based on client preference. The explanation quoting the protocol and the reason (your safety) is appropriate. Text page: 557
  17. Unit practice requires inspection of all items being brought onto the unit by visitors. This can be most effectively done by

    A. having a staff member sit at the door and check packages as visitors enter.

    A number of ways to inspect items are possible.

    Taking all potentially harmful gifts from visitors before allowing them to see clients,

    going through client's belongings (with client present) and removing all potentially harmful objects,

    ensuring that visitors do not leave potentially harmful objects in the client's room, and

    searching clients for harmful objects on return from pass are all effective methods to ensure a high rate of client safety. Text page: 557
  18. The morning after he was admitted, a suicidal client wishes to use the cordless electric razor the staff took from his suitcase the night before. The nurse should

    D. allow him to use the razor under staff supervision.

    Because the razor is cordless, independent use is relatively safe. Text page: 557
  19. When a colleague committed suicide, the nurse stated "I do not understand why she would take her own life." This is an expression of

    A. denial.

    Denial and the minimization of suicidal ideation or gestures is a defense against experiencing the feelings aroused by a suicidal person. Denial can be seen in such statements as "I cannot understand why anyone would want to take his own life." Text page: 554
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