,GCN|NUR 256 Exam 3 | Mental Health Nursing |
Galen College of Nursing | 26/27 Edition (PDF)
1. A nurse is assessing a client for suicide risk. According to current epidemiological data, which age
group has the highest risk for suicide?
A) Children aged 5 to 9 years
B) Adolescents aged 15 to 24 years
C) Adults aged 25 to 44 years
D) Older adults aged 65 years and older
Correct Answer: Adolescents aged 15 to 24 years
Rationale: Suicide is the third leading cause of death among individuals aged 15 to 24. While older
adults also have elevated rates, the 15–24 age group represents a significant peak in suicide mortality.
Children under 10 have lower rates, and the 25–44 age group is fourth leading.
2. A nurse is evaluating a client's risk factors for suicide. Which finding is the strongest biological
predictor of suicidal behavior?
A) History of childhood trauma
B) Low serotonin levels
C) Recent job loss
D) Family history of cancer
Correct Answer: Low serotonin levels
Rationale: Low serotonin levels are associated with depressed mood and increased suicide risk.
Childhood trauma and job loss are psychosocial factors, and family history of cancer is not a
recognized suicide predictor.
3. According to Beck's cognitive theory, which emotional state is the central factor in suicide risk?
A) Anger
,B) Guilt
C) Hopelessness
D) Anxiety
Correct Answer: Hopelessness
Rationale: Aaron Beck identified hopelessness as the central emotional factor in suicide risk. While
anger, guilt, and anxiety may coexist, hopelessness is the strongest cognitive predictor of suicidal
intent.
4. A nurse is caring for a client who recently attempted suicide. According to Menninger's theory,
which three wishes are present in suicidal behavior?
A) Wish to sleep, wish to escape, wish to be loved
B) Wish to kill, wish to be killed, wish to die
C) Wish to hurt, wish to be punished, wish to disappear
D) Wish to control, wish to be free, wish to rest
Correct Answer: Wish to kill, wish to be killed, wish to die
Rationale: Menninger proposed that suicide represents three intertwined wishes: the wish to kill
(aggression turned inward), the wish to be killed (guilt and punishment), and the wish to die
(cessation of pain). The other options do not reflect Menninger's theoretical framework.
5. A nurse is conducting a suicide risk assessment. Which question is the priority for determining
imminent risk?
A) "Have you ever thought about suicide before?"
B) "Do you have a specific plan and the means to carry it out?"
C) "How would you describe your mood today?"
D) "Do you have supportive family members?"
Correct Answer: "Do you have a specific plan and the means to carry it out?"
, Rationale: The presence of a specific plan with access to means is the strongest predictor of imminent
suicide risk. Previous thoughts, current mood, and social support are important but do not indicate
immediate danger as directly.
6. A nurse is implementing the SAFETY protocol for a client at risk for suicide. Which intervention is
included in the implementation phase?
A) Diagnosing the client with risk for injury
B) Performing a comprehensive nursing assessment
C) Assisting with proper health management
D) Evaluating the client's response to treatment
Correct Answer: Assisting with proper health management
Rationale: Implementation of the SAFETY protocol includes assisting with proper health management
to eradicate the underlying cause, using supportive measures to relieve distress, and preventing
physical harm. Diagnosis occurs in the assessment phase, and evaluation is a separate phase.
7. A client who recently lost a spouse reports feeling intense sadness, difficulty sleeping, and loss of
appetite. Which nursing intervention is the priority?
A) Encourage the client to attend a grief support group
B) Monitor the client's nutritional intake and sleep patterns
C) Teach the client about the stages of grief
D) Refer the client for psychiatric evaluation
Correct Answer: Monitor the client's nutritional intake and sleep patterns
Rationale: Addressing basic physiological needs is the priority in grief, as clients may neglect meals
and rest, leading to physical deterioration. While support groups, education, and psychiatric referral
are important, they are secondary to ensuring physical safety.
Galen College of Nursing | 26/27 Edition (PDF)
1. A nurse is assessing a client for suicide risk. According to current epidemiological data, which age
group has the highest risk for suicide?
A) Children aged 5 to 9 years
B) Adolescents aged 15 to 24 years
C) Adults aged 25 to 44 years
D) Older adults aged 65 years and older
Correct Answer: Adolescents aged 15 to 24 years
Rationale: Suicide is the third leading cause of death among individuals aged 15 to 24. While older
adults also have elevated rates, the 15–24 age group represents a significant peak in suicide mortality.
Children under 10 have lower rates, and the 25–44 age group is fourth leading.
2. A nurse is evaluating a client's risk factors for suicide. Which finding is the strongest biological
predictor of suicidal behavior?
A) History of childhood trauma
B) Low serotonin levels
C) Recent job loss
D) Family history of cancer
Correct Answer: Low serotonin levels
Rationale: Low serotonin levels are associated with depressed mood and increased suicide risk.
Childhood trauma and job loss are psychosocial factors, and family history of cancer is not a
recognized suicide predictor.
3. According to Beck's cognitive theory, which emotional state is the central factor in suicide risk?
A) Anger
,B) Guilt
C) Hopelessness
D) Anxiety
Correct Answer: Hopelessness
Rationale: Aaron Beck identified hopelessness as the central emotional factor in suicide risk. While
anger, guilt, and anxiety may coexist, hopelessness is the strongest cognitive predictor of suicidal
intent.
4. A nurse is caring for a client who recently attempted suicide. According to Menninger's theory,
which three wishes are present in suicidal behavior?
A) Wish to sleep, wish to escape, wish to be loved
B) Wish to kill, wish to be killed, wish to die
C) Wish to hurt, wish to be punished, wish to disappear
D) Wish to control, wish to be free, wish to rest
Correct Answer: Wish to kill, wish to be killed, wish to die
Rationale: Menninger proposed that suicide represents three intertwined wishes: the wish to kill
(aggression turned inward), the wish to be killed (guilt and punishment), and the wish to die
(cessation of pain). The other options do not reflect Menninger's theoretical framework.
5. A nurse is conducting a suicide risk assessment. Which question is the priority for determining
imminent risk?
A) "Have you ever thought about suicide before?"
B) "Do you have a specific plan and the means to carry it out?"
C) "How would you describe your mood today?"
D) "Do you have supportive family members?"
Correct Answer: "Do you have a specific plan and the means to carry it out?"
, Rationale: The presence of a specific plan with access to means is the strongest predictor of imminent
suicide risk. Previous thoughts, current mood, and social support are important but do not indicate
immediate danger as directly.
6. A nurse is implementing the SAFETY protocol for a client at risk for suicide. Which intervention is
included in the implementation phase?
A) Diagnosing the client with risk for injury
B) Performing a comprehensive nursing assessment
C) Assisting with proper health management
D) Evaluating the client's response to treatment
Correct Answer: Assisting with proper health management
Rationale: Implementation of the SAFETY protocol includes assisting with proper health management
to eradicate the underlying cause, using supportive measures to relieve distress, and preventing
physical harm. Diagnosis occurs in the assessment phase, and evaluation is a separate phase.
7. A client who recently lost a spouse reports feeling intense sadness, difficulty sleeping, and loss of
appetite. Which nursing intervention is the priority?
A) Encourage the client to attend a grief support group
B) Monitor the client's nutritional intake and sleep patterns
C) Teach the client about the stages of grief
D) Refer the client for psychiatric evaluation
Correct Answer: Monitor the client's nutritional intake and sleep patterns
Rationale: Addressing basic physiological needs is the priority in grief, as clients may neglect meals
and rest, leading to physical deterioration. While support groups, education, and psychiatric referral
are important, they are secondary to ensuring physical safety.
