Chapter 16. Suicide Prevention
Multiple Choice
1. A nurse discovers a clients suicide note that details the time, place, and means to
commit suicide. What should be the priority nursing intervention and the rationale for
this action?
A. Administering lorazepam (Ativan) prn, because the client is angry about the
discovery of the note
B. Establishing room restrictions, because the clients threat is an attempt to
manipulate the staff
C. Placing this client on one-to-one suicide precautions, because the more specific the
plan, the more likely the client will attempt suicide
D. Calling an emergency treatment team meeting, because the clients threat must be
addressed
ANS: C
The priority nursing action should be to place this client on one-to-one suicide
precautions, because the more specific the plan, the more likely the client will attempt
suicide. The appropriate nursing diagnosis for this client would be risk for suicide.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process:
Implementation | Client Need:
Safe and Effective Care Environment: Management of Care
2. During the planning of care for a suicidal client, which correctly written outcome
should be a nurses first priority?
,A. The client will not physically harm self.
B. The client will express hope for the future by day 3.
C. The client will establish a trusting relationship with the nurse. D. The client will
remain safe during the hospital stay.
ANS: D
The nurses priority should be that the client will remain safe during the hospital stay.
Client safety should always be the nurses priority. The A answer choice is incorrectly
written. Correctly written outcomes must be client focused, measurable, and realistic
and contain a time frame. Without a time frame, an outcome cannot be correctly
evaluated.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning |
Client Need: Safe and Effective Care Environment
3. A client diagnosed with major depressive disorder with psychotic features hears
voices commanding self- harm. The client refuses to commit to developing a plan for
safety. What should be the nurses priority intervention at this time?
A. Obtaining an order for locked seclusion until client is no longer suicidal
B. Conducting 15-minute checks to ensure safety
C. Placing the client on one-to-one observation while monitoring suicidal ideations
D. Encouraging client to express feelings related to suicide
, ANS: C
The nurses priority intervention when a client hears voices commanding self-harm is
to place the client on one- to-one observation while continuing to monitor suicidal
ideation.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process:
Implementation | Client Need:
Safe and Effective Care Environment: Management of Care
4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac)
for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and
is much more communicative. Which action should be the nurses priority at this time?
A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client
to share mood improvement in group. C. Increase frequency of client observation.
D. Request that the psychiatrist reevaluate the current medication protocol.
ANS: C
The nurse should be aware that a sudden increase in mood rating and change in affect
could indicate that the client is at risk for suicide and client observation should be
more frequent. Suicide risk may occur early during treatment with antidepressants.
The return of energy may bring about an increased ability to act out self- destructive
behaviors prior to attaining the full therapeutic effect of the antidepressant medication.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process:
Implementation | Client Need:
Safe and Effective Care Environment: Management of Care
Multiple Choice
1. A nurse discovers a clients suicide note that details the time, place, and means to
commit suicide. What should be the priority nursing intervention and the rationale for
this action?
A. Administering lorazepam (Ativan) prn, because the client is angry about the
discovery of the note
B. Establishing room restrictions, because the clients threat is an attempt to
manipulate the staff
C. Placing this client on one-to-one suicide precautions, because the more specific the
plan, the more likely the client will attempt suicide
D. Calling an emergency treatment team meeting, because the clients threat must be
addressed
ANS: C
The priority nursing action should be to place this client on one-to-one suicide
precautions, because the more specific the plan, the more likely the client will attempt
suicide. The appropriate nursing diagnosis for this client would be risk for suicide.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process:
Implementation | Client Need:
Safe and Effective Care Environment: Management of Care
2. During the planning of care for a suicidal client, which correctly written outcome
should be a nurses first priority?
,A. The client will not physically harm self.
B. The client will express hope for the future by day 3.
C. The client will establish a trusting relationship with the nurse. D. The client will
remain safe during the hospital stay.
ANS: D
The nurses priority should be that the client will remain safe during the hospital stay.
Client safety should always be the nurses priority. The A answer choice is incorrectly
written. Correctly written outcomes must be client focused, measurable, and realistic
and contain a time frame. Without a time frame, an outcome cannot be correctly
evaluated.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning |
Client Need: Safe and Effective Care Environment
3. A client diagnosed with major depressive disorder with psychotic features hears
voices commanding self- harm. The client refuses to commit to developing a plan for
safety. What should be the nurses priority intervention at this time?
A. Obtaining an order for locked seclusion until client is no longer suicidal
B. Conducting 15-minute checks to ensure safety
C. Placing the client on one-to-one observation while monitoring suicidal ideations
D. Encouraging client to express feelings related to suicide
, ANS: C
The nurses priority intervention when a client hears voices commanding self-harm is
to place the client on one- to-one observation while continuing to monitor suicidal
ideation.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process:
Implementation | Client Need:
Safe and Effective Care Environment: Management of Care
4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac)
for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and
is much more communicative. Which action should be the nurses priority at this time?
A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client
to share mood improvement in group. C. Increase frequency of client observation.
D. Request that the psychiatrist reevaluate the current medication protocol.
ANS: C
The nurse should be aware that a sudden increase in mood rating and change in affect
could indicate that the client is at risk for suicide and client observation should be
more frequent. Suicide risk may occur early during treatment with antidepressants.
The return of energy may bring about an increased ability to act out self- destructive
behaviors prior to attaining the full therapeutic effect of the antidepressant medication.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process:
Implementation | Client Need:
Safe and Effective Care Environment: Management of Care
