ATI LPN
Psychiatric Nursing: Contemporary Practice 6th Edition
Chapter 21 : Suicide Prevention: Screening, Assessment, and Intervention Questions
Question 1 of 5
A nurse is completing an admission assessment of a young adult woman who has a history of depression and who was brought to the hospital by her boyfriend. In response to the nurse?s question regarding suicidal ideation, the patient discloses that she is thinking about killing herself. Which question would be most appropriate for the nurse to ask next?
Correct Answer: D
Rationale: When a patient expresses suicidal ideation, the nurse?s priority is to assess the specificity and immediacy of the risk by inquiring about a plan, as this indicates the degree of intent and potential lethality. Asking about specific thoughts on how the patient would kill herself (
D) is critical for risk assessment. Options A, B, and C, while potentially relevant later, do not directly assess the immediate risk or plan.
Question 2 of 5
A nurse is with an adolescent who tells the nurse that she has nothing to live for and she just wishes she was dead. Which nursing action would be the priority?
Correct Answer: B
Rationale: The priority is to ensure the patient?s safety by staying with her and exploring her suicidal thoughts (
B), which allows for immediate risk assessment and therapeutic engagement. Notifying the psychiatrist (
A) is important but secondary to direct patient contact. Seclusion (
C) is inappropriate unless the patient poses an immediate danger, and exploring beliefs about death (
D) is less urgent than assessing current risk.
Question 3 of 5
The nurse is caring for a 30-year-old white man whose wife has recently died. The patient has been diagnosed with clinical depression and is demonstrating insufficient coping skills. Which action by the nurse would be most important?
Correct Answer: D
Rationale: Given the recent loss and diagnosis of clinical depression, assessing for suicidal ideation (
D) is the most critical action to ensure patient safety, as loss and depression are significant suicide risk factors. Psychotherapy referral (
A) is important but not immediate. Assessing for psychosis (
B) or family history (
C) is relevant but secondary to suicide risk assessment.
Question 4 of 5
The nurse is providing a presentation for a group of health professionals about suicide. Which of the following would the nurse address as a major contributing factor to the rising suicide rate among men?
Correct Answer: A
Rationale: Substance abuse (
A) is a major contributing factor to the rising suicide rate among men, as it exacerbates mental health issues, impairs judgment, and increases impulsivity, all of which heighten suicide risk. Media influences (
B), lack of conflict resolution skills (
C), and parenting practices (
D) may contribute indirectly but are less significant compared to substance abuse.
Question 5 of 5
A nurse has just completed a suicide risk assessment of a 76-year-old widowed man. In addition to documenting the presence or absence of suicidal thoughts, plan, and means, the nurse would also document which of the following?
Correct Answer: C
Rationale: Documenting the availability of support resources (
C) is essential in a suicide risk assessment, as social support is a key protective factor that can mitigate risk. Substance use (
A), speech patterns (
B), and sleep (
D) may be relevant but are less directly tied to risk assessment compared to support resources.