Nightingale College BSN 346 – HESI Case Study:
Suicide & Nursing Care | Concepts of Nursing III
Study Guide & Case Study Review 2026/2027 |
Suicide Risk Assessment, Mental Health Nursing,
Patient Safety, Suicide Prevention, Therapeutic
Communication, Nursing Interventions, Sentinel
Events, Risk Factors, Assessment Findings, Care
Planning, Clinical Judgment, HESI Case Study
Practice & Detailed Explanations
Question 1: A nurse is caring for a client who is admitted to the psychiatric
unit following a suicide attempt by overdose. Which of the following actions
should the nurse prioritize during the initial assessment?
A. Completing a physical health history.
B. Establishing a therapeutic nurse-client relationship.
C. Performing a suicide risk assessment.
D. Contacting the client's family for collateral information.
CORRECT ANSWER: C. Performing a suicide risk assessment
Rationale: The priority action for a client who has recently attempted suicide is to
conduct a thorough and immediate suicide risk assessment. This involves evaluating the
client's current suicidal ideation, plan, intent, and means. While establishing a
therapeutic relationship (B) is important for long-term care, safety is the immediate
priority. A physical health history (A) and family contact (D) are important components
of care but come after the immediate risk has been evaluated.
Question 2: A nurse is evaluating a client's plan of care after a suicide attempt.
Which client statement indicates the plan is effective and the client is at a
lower risk for self-harm?
A. "I feel much better, so I don't think I need the medication anymore."
B. "My family has promised to watch me all the time, so I should be fine."
C. "I have developed a list of people I can call when I feel overwhelmed."
D. "I have a new plan for how to end things if the medication doesn't work."
CORRECT ANSWER: C. "I have developed a list of people I can call when I feel
overwhelmed."
Rationale: This statement demonstrates the development of a crucial coping strategy
and a safety plan. Identifying a support system and a plan for seeking help is a positive
indicator of reduced risk. Stopping medication against advice (A) indicates non-
adherence and increased risk. Placing sole responsibility on family (B) is not a
sustainable or effective safety plan and places undue burden on them. Expressing a new
plan (D) is a direct indicator of continued high risk and requires immediate intervention.
,Question 3: A client with major depressive disorder is prescribed a Selective
Serotonin Reuptake Inhibitor (SSRI). The nurse's education should include a
warning about which potential side effect that significantly increases suicide
risk?
A. Akathisia
B. Insomnia
C. Weight gain
D. Xerostomia
CORRECT ANSWER: A. Akathisia
Rationale: Akathisia is a severe, distressing side effect characterized by an intense
feeling of inner restlessness and a strong urge to move. It is associated with SSRIs and
other antidepressants and is a significant risk factor for suicidal ideation and impulsive
behavior. Insomnia (B) and weight gain (C) are common side effects but are not as
directly linked to an acute increase in suicide risk as akathisia. Xerostomia (D) is a dry
mouth side effect and is not a safety concern in this context.
Question 4: The nurse is preparing a client for discharge from an inpatient
psychiatric unit after a suicide attempt. Which of the following should be the
primary focus of the discharge plan?
A. Scheduling a follow-up appointment with a mental health provider.
B. Providing a list of all medications with potential side effects.
C. Removing access to all potential means of self-harm from the home.
D. Ensuring the client receives a written copy of their diagnosis.
CORRECT ANSWER: C. Removing access to all potential means of self-harm
from the home.
Rationale: The primary focus of discharge planning for a suicidal client is ensuring
safety. "Means restriction" or "lethal means counseling" is a critical evidence-based
intervention that directly reduces the risk of suicide by making it more difficult for the
client to act on impulses. While follow-up appointments (A) and medication education
(B) are important, they are secondary to the immediate safety measure of removing
means.
Question 5: A nurse is caring for an adolescent client who is hospitalized after
a suicide attempt. Which factor is the most significant predictor of adolescent
suicide?
A. A history of physical abuse.
B. A previous suicide attempt.
C. Poor performance in school.
D. The presence of a co-occurring anxiety disorder.
CORRECT ANSWER: B. A previous suicide attempt.
,Rationale: A history of a prior suicide attempt is the single strongest predictor of future
suicide completion and attempts in all age groups, including adolescents. While a
history of abuse (A), academic struggles (C), and anxiety disorders (D) are risk factors,
none are as statistically powerful as a prior attempt.
Question 6: A nurse is using the SAD PERSONS scale to assess a client's risk
for suicide. Which factor on this scale carries the highest specific predictive
weight for suicide?
A. Sex (Male)
B. Age (Older)
C. Depression
D. Previous attempt
CORRECT ANSWER: D. Previous attempt
Rationale: On the SAD PERSONS scale, "Previous Attempt" is assigned the highest
weight (2 points), while all other factors, including Sex (1 point), Age (1 point), and
Depression (1 point), are assigned only 1 point. This weighting reflects the significant
predictive power of a history of a prior suicide attempt.
Question 7: A client diagnosed with bipolar disorder is experiencing a
depressive episode and verbalizes suicidal ideation. Which is the most
appropriate nursing intervention to maintain client safety?
A. Place the client in a quiet room away from other clients.
B. Ask the client to sign a "no-suicide" contract.
C. Initiate one-to-one continuous observation.
D. Inform the client that they will be placed in seclusion if they do not stop talking about
suicide.
CORRECT ANSWER: C. Initiate one-to-one continuous observation.
Rationale: For a client actively expressing suicidal ideation, the most effective and
immediate intervention to ensure safety is continuous, one-to-one observation. This
allows the nurse to directly monitor the client's actions and prevent self-harm. "No-
suicide" contracts (B) are not considered a reliable intervention. Isolation (A) increases
risk, and threatening seclusion (D) is punitive and detrimental to the therapeutic
relationship.
Question 8: A nurse is providing education to a client's family about suicide
risk factors. Which statement by a family member indicates the need for
further teaching?
A. "I understand that treating his depression will help reduce the risk."
B. "We need to make sure we don't leave any alcohol or drugs in the house."
C. "I believe that talking about suicide will put the idea in his head."
D. "We should monitor for any signs of increased agitation or impulsivity."
, CORRECT ANSWER: C. "I believe that talking about suicide will put the idea in
his head."
Rationale: This is a common and dangerous myth. Openly discussing suicide with a
client does not "plant the idea" but instead provides a safe space for the client to express
their feelings and reduces the stigma, which can actually lower the risk. The other
statements demonstrate correct understanding of depression treatment (A), means
restriction (B), and monitoring for warning signs (D).
Question 9: A client with a history of suicide attempts is prescribed lithium
carbonate. The nurse is monitoring for toxicity and should report which
assessment finding?
A. Fine hand tremors.
B. Increased thirst.
C. Weight gain.
D. Persistent nausea and vomiting.
CORRECT ANSWER: D. Persistent nausea and vomiting.
Rationale: Persistent nausea and vomiting, along with diarrhea, are early signs of lithium
toxicity. Fine hand tremors (A) and increased thirst (B) are common side effects at
therapeutic levels and do not necessarily indicate toxicity. Weight gain (C) is a common
but not urgent side effect.
Question 10: The nurse is leading a group session for clients on a psychiatric
unit. One client expresses frustration and states, "No one here cares if I live or
die." What is the nurse's best therapeutic response?
A. "Why do you feel that no one cares?"
B. "I care about you, and I am here to help you."
C. "You shouldn't say things like that."
D. "Tell me more about your feelings of isolation."
CORRECT ANSWER: D. "Tell me more about your feelings of isolation."
Rationale: This response is therapeutic because it explores the client's feelings,
encouraging them to express their emotions and thoughts in a safe environment. While
a brief statement of care (B) is appropriate, exploring the underlying feelings is a more
effective intervention in a group setting. Asking "why" (A) can be perceived as
judgmental or confrontational, and "shouldn't say" (C) is a non-therapeutic, dismissive
response.
Question 11: A nurse is assessing a client for warning signs of suicide. Which
of the following behavioral cues is the most critical and requires immediate
action?
A. Talking about being a burden to others.
B. Withdrawing from family and friends.
Suicide & Nursing Care | Concepts of Nursing III
Study Guide & Case Study Review 2026/2027 |
Suicide Risk Assessment, Mental Health Nursing,
Patient Safety, Suicide Prevention, Therapeutic
Communication, Nursing Interventions, Sentinel
Events, Risk Factors, Assessment Findings, Care
Planning, Clinical Judgment, HESI Case Study
Practice & Detailed Explanations
Question 1: A nurse is caring for a client who is admitted to the psychiatric
unit following a suicide attempt by overdose. Which of the following actions
should the nurse prioritize during the initial assessment?
A. Completing a physical health history.
B. Establishing a therapeutic nurse-client relationship.
C. Performing a suicide risk assessment.
D. Contacting the client's family for collateral information.
CORRECT ANSWER: C. Performing a suicide risk assessment
Rationale: The priority action for a client who has recently attempted suicide is to
conduct a thorough and immediate suicide risk assessment. This involves evaluating the
client's current suicidal ideation, plan, intent, and means. While establishing a
therapeutic relationship (B) is important for long-term care, safety is the immediate
priority. A physical health history (A) and family contact (D) are important components
of care but come after the immediate risk has been evaluated.
Question 2: A nurse is evaluating a client's plan of care after a suicide attempt.
Which client statement indicates the plan is effective and the client is at a
lower risk for self-harm?
A. "I feel much better, so I don't think I need the medication anymore."
B. "My family has promised to watch me all the time, so I should be fine."
C. "I have developed a list of people I can call when I feel overwhelmed."
D. "I have a new plan for how to end things if the medication doesn't work."
CORRECT ANSWER: C. "I have developed a list of people I can call when I feel
overwhelmed."
Rationale: This statement demonstrates the development of a crucial coping strategy
and a safety plan. Identifying a support system and a plan for seeking help is a positive
indicator of reduced risk. Stopping medication against advice (A) indicates non-
adherence and increased risk. Placing sole responsibility on family (B) is not a
sustainable or effective safety plan and places undue burden on them. Expressing a new
plan (D) is a direct indicator of continued high risk and requires immediate intervention.
,Question 3: A client with major depressive disorder is prescribed a Selective
Serotonin Reuptake Inhibitor (SSRI). The nurse's education should include a
warning about which potential side effect that significantly increases suicide
risk?
A. Akathisia
B. Insomnia
C. Weight gain
D. Xerostomia
CORRECT ANSWER: A. Akathisia
Rationale: Akathisia is a severe, distressing side effect characterized by an intense
feeling of inner restlessness and a strong urge to move. It is associated with SSRIs and
other antidepressants and is a significant risk factor for suicidal ideation and impulsive
behavior. Insomnia (B) and weight gain (C) are common side effects but are not as
directly linked to an acute increase in suicide risk as akathisia. Xerostomia (D) is a dry
mouth side effect and is not a safety concern in this context.
Question 4: The nurse is preparing a client for discharge from an inpatient
psychiatric unit after a suicide attempt. Which of the following should be the
primary focus of the discharge plan?
A. Scheduling a follow-up appointment with a mental health provider.
B. Providing a list of all medications with potential side effects.
C. Removing access to all potential means of self-harm from the home.
D. Ensuring the client receives a written copy of their diagnosis.
CORRECT ANSWER: C. Removing access to all potential means of self-harm
from the home.
Rationale: The primary focus of discharge planning for a suicidal client is ensuring
safety. "Means restriction" or "lethal means counseling" is a critical evidence-based
intervention that directly reduces the risk of suicide by making it more difficult for the
client to act on impulses. While follow-up appointments (A) and medication education
(B) are important, they are secondary to the immediate safety measure of removing
means.
Question 5: A nurse is caring for an adolescent client who is hospitalized after
a suicide attempt. Which factor is the most significant predictor of adolescent
suicide?
A. A history of physical abuse.
B. A previous suicide attempt.
C. Poor performance in school.
D. The presence of a co-occurring anxiety disorder.
CORRECT ANSWER: B. A previous suicide attempt.
,Rationale: A history of a prior suicide attempt is the single strongest predictor of future
suicide completion and attempts in all age groups, including adolescents. While a
history of abuse (A), academic struggles (C), and anxiety disorders (D) are risk factors,
none are as statistically powerful as a prior attempt.
Question 6: A nurse is using the SAD PERSONS scale to assess a client's risk
for suicide. Which factor on this scale carries the highest specific predictive
weight for suicide?
A. Sex (Male)
B. Age (Older)
C. Depression
D. Previous attempt
CORRECT ANSWER: D. Previous attempt
Rationale: On the SAD PERSONS scale, "Previous Attempt" is assigned the highest
weight (2 points), while all other factors, including Sex (1 point), Age (1 point), and
Depression (1 point), are assigned only 1 point. This weighting reflects the significant
predictive power of a history of a prior suicide attempt.
Question 7: A client diagnosed with bipolar disorder is experiencing a
depressive episode and verbalizes suicidal ideation. Which is the most
appropriate nursing intervention to maintain client safety?
A. Place the client in a quiet room away from other clients.
B. Ask the client to sign a "no-suicide" contract.
C. Initiate one-to-one continuous observation.
D. Inform the client that they will be placed in seclusion if they do not stop talking about
suicide.
CORRECT ANSWER: C. Initiate one-to-one continuous observation.
Rationale: For a client actively expressing suicidal ideation, the most effective and
immediate intervention to ensure safety is continuous, one-to-one observation. This
allows the nurse to directly monitor the client's actions and prevent self-harm. "No-
suicide" contracts (B) are not considered a reliable intervention. Isolation (A) increases
risk, and threatening seclusion (D) is punitive and detrimental to the therapeutic
relationship.
Question 8: A nurse is providing education to a client's family about suicide
risk factors. Which statement by a family member indicates the need for
further teaching?
A. "I understand that treating his depression will help reduce the risk."
B. "We need to make sure we don't leave any alcohol or drugs in the house."
C. "I believe that talking about suicide will put the idea in his head."
D. "We should monitor for any signs of increased agitation or impulsivity."
, CORRECT ANSWER: C. "I believe that talking about suicide will put the idea in
his head."
Rationale: This is a common and dangerous myth. Openly discussing suicide with a
client does not "plant the idea" but instead provides a safe space for the client to express
their feelings and reduces the stigma, which can actually lower the risk. The other
statements demonstrate correct understanding of depression treatment (A), means
restriction (B), and monitoring for warning signs (D).
Question 9: A client with a history of suicide attempts is prescribed lithium
carbonate. The nurse is monitoring for toxicity and should report which
assessment finding?
A. Fine hand tremors.
B. Increased thirst.
C. Weight gain.
D. Persistent nausea and vomiting.
CORRECT ANSWER: D. Persistent nausea and vomiting.
Rationale: Persistent nausea and vomiting, along with diarrhea, are early signs of lithium
toxicity. Fine hand tremors (A) and increased thirst (B) are common side effects at
therapeutic levels and do not necessarily indicate toxicity. Weight gain (C) is a common
but not urgent side effect.
Question 10: The nurse is leading a group session for clients on a psychiatric
unit. One client expresses frustration and states, "No one here cares if I live or
die." What is the nurse's best therapeutic response?
A. "Why do you feel that no one cares?"
B. "I care about you, and I am here to help you."
C. "You shouldn't say things like that."
D. "Tell me more about your feelings of isolation."
CORRECT ANSWER: D. "Tell me more about your feelings of isolation."
Rationale: This response is therapeutic because it explores the client's feelings,
encouraging them to express their emotions and thoughts in a safe environment. While
a brief statement of care (B) is appropriate, exploring the underlying feelings is a more
effective intervention in a group setting. Asking "why" (A) can be perceived as
judgmental or confrontational, and "shouldn't say" (C) is a non-therapeutic, dismissive
response.
Question 11: A nurse is assessing a client for warning signs of suicide. Which
of the following behavioral cues is the most critical and requires immediate
action?
A. Talking about being a burden to others.
B. Withdrawing from family and friends.
