NCLEX Suicide Preventions & Interventions

Question 1

Which suicide is an example of Durkheim’s anomic suicide?

a. A Muslim who was disgraced by a family member
b. A woman whose life savings were embezzled from her
c. A suicide bomber who blows up a bus in the middle East
d. A convicted rapist who has been given a life sentence

Answer 1

ANS: B
Anomic suicides are acts of self-destruction by individuals who have become alienated from important relationships in their groups, especially as this relates to their standard of living. Durkheim characterized egoistic suicides as the self-inflicted deaths of individuals who turn against their own conscience. Altruistic suicides are self-inflicted deaths on the basis of obedience to a group’s goals rather than reflecting the person’s own best interests. Durkheim defined fatalistic suicides as self-inflicted deaths that result from excessive regulation.

Question 2

The nurse administering an antidepressant to a suicidal patient understands that the brain abnormality the medication addresses is:

a. Atrophy of the brain
b. Enlarged lateral ventricles
c. Irregularities in the serotonin system
d. Abnormal electroencephalogram (EEG) readings

Answer 2

ANS: C
Antidepressants regulate serotonin levels, which is a chemical that is involved the development of depression. There is no research to support brain atrophy or enlarged lateral ventricles as being related to the development of depression. EEG readings are designed to assess the electrical activity of the brain.

Question 3

A family member of a suicidal patient asks, “Are there any medications that can prevent a person from committing suicide?” Which statement best answers the question?

a. If people want to harm themselves, they eventually will.
b. Antipsychotic medications are used primarily for suicide prevention.
c. Antidepressants treat mood disorders that accompany suicidal ideation.
d. There are no medications available that specifically affect suicidal behavior.

Answer 3

ANS: C
Although there is no medication to prevent suicide, the most constructive answer informs the family that mood disorders are often accompany by suicidal ideation, and antidepressants can treat these. Antipsychotic medications are not generally used for depression. The remaining option lacks empathy and does not accurately answer the question.

Question 4

Which intervention would the nurse implement when a patient’s frontal lobe is affected?

a. Educating the patient on the affects of dopamine
b. Helping the patient identify reasons for crying
c. Assessing the patient for any suicidal ideations
d. Evaluating the affects of medication on motivation

Answer 4

ANS: C
Researchers believe that frontal lobe dysfunction is related to feelings of hopelessness and worthlessness, both of which are signs of suicidal thoughts. The remaining options are related to symptoms that are associated with the limbic system.

Question 5

Which approach listed in the plan of care of a suicidal patient is considered a cognitive technique?

a. Intense psychotherapy to deal with childhood issues
b. Group therapy with patients with similar problems
c. Limitation of negative thought patterns and increase of realistic self-evaluation
d. Inclusion of significant others and family in the plan of care

Answer 5

ANS: C
Cognitive techniques use examination of thought patterns and challenges to irrational or negative thoughts. The remaining options are not interventions that are supported cognitive therapy.

Question 6

The nurse presenting a suicide prevention lecture would decide who the target population is based on what fact?

a. Females have the highest risk for suicide.
b. Children are considered a high-risk group for committing suicide.
c. The highest suicide rate is among the Caucasian middle-age population.
d. Rates of suicide are highest among the older population, age 80 and older.

Answer 6

ANS: D

The highest rate of suicide is among the older adult population. The remaining options are not true statements

Question 7

Which statement by a young adult would alert the nurse to increased suicide risk?

a. “I have a necktie in my room that I can use to hang myself.”
b. “If I fail one more class, I’m going to have to think about ending it.”
c. “When I leave home to live on my own, I’m going to buy myself a gun.”
d. “When I took two bottles of Mom’s pills, I had to have my stomach pumped.”

Answer 7

ANS: A
Only the correct option states an intended method and indicates immediacy and available means of enacting a successful suicide attack.

Question 8

An older adult is admitted to the hospital for severe depression. The nurse, gathering data for a medical and psychiatric history, learns of a suicide attempt 4 years ago after the death of a spouse. Based on this information, it is likely that the patient:

a. Will avoid attempting suicide again after the past experience
b. Will try to minimize the seriousness of the suicide attempt
c. May express suicidal ideation or make a suicide attempt
d. Will report that he has recently written a will

Answer 8

ANS: C
The majority of persons who complete suicides have made previous suicide attempts. The remaining options are not supported by research that indicates the increased risk of suicide associated with a history of such behaviors.

Question 9

The nurse asks a patient admitted with a diagnosis of major depression, “Do you feel like hurting yourself at this time?” What is the primary rationale for obtaining this information when nothing in the referral note implied that the patient was suicidal?

a. It is likely that he is hiding the desire to harm himself.
b. This information must be reported to the patient’s physician.
c. Specific safety measures must be implemented when self-harm is a danger.
d. Patient safety is always the primary responsibility of the unit’s nursing staff.

Answer 9

ANS: C
Depression is a disorder linked to suicidal behavior, so it is imperative to ask and then closely observe the patient if he says “Yes.” The remaining options although true are not the primary rationale for assessing a depressed patient for suicidal ideations.

Question 10

The nurse working at the crisis center received a call from a patient who stated he was depressed and wanted to die. Further investigation revealed that the patient had within reach all of the items listed below that he could use “to get the job done.” Which item would cause the nurse the most concern?

a. A garden hose
b. A loaded gun
c. Two bottles of Prozac
d. A bottle of an alcoholic beverage

Answer 10

ANS: B
Firearms are the most lethal form of weapons that are used to complete suicide, with 50.2% of all individuals who completed suicide in 2007 doing so with a firearm. Using a firearm is a more lethal method of suicide than are medications, a garden hose, or a bottle of alcohol. It does not allow time for rescue.

Question 11

Which statement made by a patient who attempted suicide 5 days ago would cause the nurse to observe his behavior more closely?

a. “When I’m discharged, maybe my son will let me stay with him.”
b. “I’m not sure I will ever really enjoy the things we did before I lost her.”
c. “It puzzles me that anyone would want to kill themselves but I certainly did.”
d. “My wife and I would have celebrated our thirty-sixth wedding anniversary today.”

Answer 11

ANS: D
Significant anniversary dates may be a time for future suicide attempts. The remaining options do not have the same level of risk since they are not expressing despair or indicate an available means.

Question 12

Which finding related to a teenager who has been diagnosed with depression is most significant when planning care?

a. Her father recently remarried.
b. Her mother died from suicide 1 year ago.
c. She has expressed a dislike for her new stepmother.
d. She ran away from home twice during the past month.

Answer 12

ANS: B
Option b is correct because suicidal behavior can become a learned familial adaptation to stressors. Running away, remarriage, and issues in stepfamilies can be important, but they are not of primary importance

Question 13

The nurse is planning care for a patient who was admitted to the hospital after threatening to harm himself when he was stopped by the police for speeding. He was intoxicated at the time of admission and was assessed as being depressed, anxious, and hostile. Which patient outcome is the priority?

a. Patient will remain free from self-harm although hospitalized.
b. Patient will report suicidal ideation or desire to harm self to the staff.
c. Patient will accept referral to the hospital-based substance abuse program.
d. Patient will recognize and interrupt unconscious intentions to harm self.

Answer 13

ANS: A
The primary outcome is for the patient to be free from self-harm because the primary issue for this patient is the high risk for self-harm. The remaining options are all actions that will support this outcome

Question 14

A patient was admitted and prescribed antidepressants for severe depression with feelings of hopelessness, helplessness, and suicidal ideation. When would the patient be at greatest risk for suicide during hospitalization?

a. Within the first hour after admission and when family leaves
b. At night after visitors leave and patients are allow in their room
c. Within the first 24 hours after admission and as discharge approaches
d. Within 48 hours of first expressing suicidal ideation and as therapy progresses

Answer 14

ANS: C
Statistics show that the most dangerous times for a hospitalized patient who has the potential for self-harm is within the first 24 hours after admission and as the associated stress of discharge nears.

Question 15

Which statement made by the patient who attempted suicide best indicates that the criterion for discharge has been met?

a. “I know who to call if I get depressed again.”
b. “I’ve learned that there is hope and I don’t have to hurt.”
c. “I have good friends who are willing to help me with my problems.”
d. “I do not feel like harming myself anymore and that feels so comforting.”

Answer 15

ANS: D
Denying a need to harm oneself is a clear statement from the patient that he or she is feeling more positive. The remaining options although positive are not as good an indicator for discharge because they do not address the issue of self-harm

Question 16

The Emergency Department nurses were discussing a patient who seeks help almost every holiday by expressing suicidal ideation or making a suicide gesture. One of the nurses stated, “I don’t think he is serious about hurting himself. Maybe we should not see him the next time he comes.” Which response from the charge nurse is accurate in dealing with the patient who may be using suicidal behavior as a ploy to enter the hospital?

a. “He obviously needs the support he gets at the hospital.”
b. “We should avoid showing any warmth the next time he comes in.”
c. “Telling him we cannot see him may be the answer to stop this behavior.”
d. “Each episode must be individually evaluated, and all options must be explored.”

Answer 16

ANS: D
A patient who has a history of suicide gestures or attempts is at greater risk for using this behavior style again. This is unsafe behavior that needs to be evaluated. It is true that the patient is in need of support but that answer does not address the issue of the misconception expressed by the nurse’s statement. The remaining options are unprofessional and totally lacking in therapeutic understanding of suicide.

Question 17

A patient diagnosed with cancer of the prostate was admitted after his wife reported he was trying to mix a lethal dose of medications and alcohol to drink. Which patient outcome is a priority to this situation?

a. Patient will participate in all unit activities.
b. Patient will recognize that depression is treatable.
c. Patient will learn ways to handle his unresolved anger.
d. Patient will admit to suicidal thoughts when asked by staff.

Answer 17

ANS: D
Notifying staff of suicidal ideations has priority since it is directly related to the patient’s safety. The other options lack the direct relationship to patient safety.

Question 18

On day 4 of hospitalization after a suicide attempt, the patient tells the nurse, “You don’t have to worry about me any longer. Today was the turning point. You can stop the suicide precautions.” Which action indicates the nurse’s use of intuition in responding to this patient?

a. Reporting the patient’s statements and the nurse’s own feelings to the staff and suggest increased vigilance
b. Reporting only the patient’s statements and evaluate the outcome, Patient will report lack of suicidal ideation as attained.
c. Conferring with the patient’s family members to obtain their evaluation of the patient and his behavior and follow their lead
d. Suggesting that the level of suicide precautions be lowered from one-to-one supervision to observing the patient every 30 minutes

Answer 18

ANS: A
It is unlikely that a highly suicidal patient would recover so quickly. Sometimes hospitalization and medication allow a renewal of energy, enough to increase suicidal resolve. The nurse should follow this intuition and suggest increased vigilance. Keeping this concern to oneself is not helpful. Taking the lead from the family is not appropriate, and lowering suicide precautions so soon is risky.

Question 19

A patient has been displaying advanced thought of suicide. Which action reflects this behavior?

a. Acknowledging thoughts of dying
b. Expresses verbal expressions of ‘severe sadness’
c. Wrists are bleeding from cuts with a butter knife
d. Found unconscious with empty pills bottles nearby

Answer 19

ANS: C
A nonlethal suicide gesture is characteristic of this degree of suicide risk. Having suicidal thoughts only is reflective of ideations although a verbal expression is a moderate risk gesture. An actual attempt that was potentially lethal is the ultimate risk behavior.

Question 20

A patient who is a policewoman tells the nurse she is depressed and can no longer deal with the stress of her job. She mentions that employee assistance counseling failed to change her hopeless attitude. She states that she will use her police revolver to shoot herself in the head during the day when no one is at home and the home is locked. Which formulation by the triage nurse is correct?

a. Plan explicit. Imminence high. Method highly lethal and accessible. Rescue potential low.
b. Plan vague. Imminence moderate. Method somewhat lethal and accessible. Rescue potential moderate.
c. Plan complete. Imminence low. Method low lethality but accessible. Rescue potential high.
d. Plan nebulous. Imminence low. Method low lethality but accessible. Rescue potential high.

Answer 20

ANS: A
The correct option identifies that the plan is well thought out; the imminence is high because the patient is ready to act; the gun is a highly lethal method, and she has the weapon; and the rescue potential is low because a gun is the chosen method. The remaining options do not show the proper assessment of these criteria

Question 21

The health care team is planning care for a patient hospitalized following a suicide attempt. Which statement by a team member should serve as a basis for planning?

a. “A patient who has made a recent suicide attempt is at low risk for another attempt.”
b. “A patient who has made a recent suicide attempt is at very high risk for another attempt.”
c. “A patient who has made a recent suicide attempt requires ongoing assessment to determine the level of risk.”
d. “A patient who has made a recent suicide attempt may be at risk for 24 hours until medication takes effect.”

Answer 21

ANS: C
The correct option shows an understanding of the need for additional assessment in order to develop an effective plan of care. Assessment is needed to determine whether a patient is at high risk for another suicide attempt. The remaining options are incorrect.

Question 22

A suicidal patient agreed on day 2 of hospitalization to write and sign a “no self-harm contract.” As a result of this contract, the health care team should plan to:

a. Discontinue suicide precautions.
b. Base the level of observation on staff assessment.
c. Reduce observation to observing the patient every hour.
d. Reduce one-to-one observation to observing the patient every 15 minutes.

Answer 22

ANS: B
Research suggests that no-harm contracts may not prevent self-harm; therefore any reduction in suicide precautions is incorrect. Staff assessment needs to be continued and based on observation

Question 23

When assigning the suicidal patient to a room on the unit, the nurse should select a:

a. Single room near the exit
b. Double room near the exit
c. Single room near the nurse’s station
d. Double room near the nurse’s station

Answer 23

ANS: D
The correct option implements the helpful practice if having a roommate for the suicidal patient and observation of the patient is easier if the room is close to the nurse’s station. The remaining options lack both of those interventions.

Question 24

There are several suicidal patients on the psychiatric unit. When meal trays are returned to the kitchen, a serrated-edge knife is missing. The nurse to whom the aide reports this should:

a. Acknowledge the information and be watchful for the remainder of the shift.
b. Ask each of the patients on suicide precautions where the knife is hidden.
c. Report the information to the charge nurse and suggest a unit search.
d. Report the information to security and let them handle the matter.

Answer 24

ANS: C
This is an important safety issue. Although being watchful is appropriate, it is not sufficient to ensure safety in this situation. Assuming that only the patients on suicide precautions would know about the knives is not a proper assumption. Security does not need to be called in at this time, so option d is incorrect. Searching the unit for the missing knife would be the safest option.

Question 25

To maximize therapeutic care to a newly admitted suicidal patient on days 1 and 2 of hospitalization, the nurse will:

a. Select appropriate community resources for referral.
b. Identify patient areas of weakness and deficiency.
c. Encourage the patient to express psychological pain.
d. Refute delusional thinking by logical argument and reinforcement.

Answer 25

ANS: C
With a newly admitted patient, listening to expressions of pain will be one of the first interventions for the nurse in order to support the assessment process. It is too soon to consider community resources. Identifying weaknesses is not a helpful intervention for a suicidal patient. There is no data supporting delusional thinking.

Question 26

A suicidal patient tells the nurse, “There’s no other way out for me. I have so many problems that there’s nothing to do but cash it in.” Which statement by the nurse would be a helpful approach?

a. “I can see that things are bad. It’s good you recognized your limitations.”
b. “Let’s look at the problem you consider most urgent to see about a solution.”
c. “We’ll begin problem-solving together as soon as you stop feeling suicidal.”
d. “Your thinking is flawed. I’ll teach you to think differently and be less depressed.”

Answer 26

ANS: B
The most effective intervention is to help the patient prioritize problems and work on them one at a time. To affirm the negative is not therapeutic. Although a change in thinking is appropriate, it does not deal with the patient’s statement about problems. The remaining option places unrealistic demands on the patient.

Question 27

A newly admitted patient with depression has been determined as suicidal and in need of one-to-one supervision. What is the best statement to inform the patient of the plan of care?

a. “A staff member will be with you at all times to watch you for suicide gestures.”
b. “On this unit, a staff member stays with each new admission for the first 24 hours.”
c. “We understand the impulse to attempt self-harm may be strong, so someone will stay with you to help you control the impulse.”
d. “We are not sure you would be willing to tell a staff member if the urge to commit suicide becomes strong, so to prevent hospital liability someone will stay with you.”

Answer 27

ANS: C
The correct option explains the intervention in terms of the patient’s needs. Basing the intervention on the patient’s suicidal gestures is too threatening and intrusive. It is not true that all patients are observed for 24 hours. Identifying liability indicates that the staff is mostly worried about the hospital.