Exam (elaborations)
Chapter 16. Suicide Prevention
- Course
- Psychology
- Institution
- Forest Institute Of Professional Psychology
Chapter 16. Suicide Prevention
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TownsendPMHN, 10e
Chapter 16 - ETB
Chapter 16. Suicide Prevention abirb.com/test
MULTIPLE CHOICE
1. A nurse discovers a client’s suicide note that details the time, place, and means to
commit suicide. What is the priority nursing intervention and accompanying rationale
for this action?
1. Administering lorazepam (Ativan) prn, because the client is angry about the discovery
of the note
2. Establishing room restrictions, because the client’s threat is manipulate
an a t te m p t t o
ab i rb .c om / e s t
the staff
3. Placing this client on one-to-one suicide precautions, because the more specific the
plan, the more likely the client will attempt suicide
4. Calling an emergency treatment team meeting, because the client’s threat must be
addressed
ANS: 3
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 276
Heading: Suicidal Ideas or Acts > Table 16–3, Care Plan for the Suicidal Client: Nursing
Diagnosis: Risk for Suicide
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Managementaboirfb.Ccoamr/etest
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
Feedback
1. This is incorrect. Administering Ativan does not address the client’s situation, and
there is no indication the client is upset about the note beinagbirdbi.csocmo/vteesrt ed.
2. This is incorrect. Room restrictions are not appropriate for the suicidal client and
there is no indication of manipulation.
3. This is correct. The priority nursing action is to place the calibeirnb.tcoomn/teosnt e-
to-one suicide precautions. A client with a specific plan is at very high risk of
attempting
4. suicide. The appropriate
This is incorrect. nursing team
An emergency diagnosis for this
meeting client is “risk
is unnecessary; theforclient’s
suicide.”
safety needs can be addressed with one-to-one precautions.
CON: Safety
,Townsend
PMHN, 10e
Chapter 16 - ETB
abirb.com/test
2. During the planning of care for a suicidal client, which correctly written outcome
should be the nurse’s priority?
1. The client will not physically harm self.
2. The client will express hope for the future by day 3.
3. The client will establish a trusting relationship.
4. The client will remain safe during the hospital stay.
ANS: 4
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting
suaibciribd.caolmb/tehstavior. Page: 276
Heading: Table 16–3, Care Plan for the Suicidal Client: Nursing Diagnosis: Risk for
Suicide
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: [Applying]
Concept: Safety
Difficulty: Easy
Feedback abirb.com/test
1. This is incorrect. This outcome is incorrectly addressed by not providing a
measurable time frame.
2. This is incorrect. Client safety is always the nurse’s priority. An expression of
abirb.com/test
hope does not address the priority of safety.
3. This is incorrect. Client safety is always the nurse’s priority. Establishing a trusting
relationship does not demonstrate the priority of safety, and there is no time frame
provided. abirb.com/test
4. This is correct. Client safety is always the nurse’s priority. The outcome to remain
safe during the hospital stay addresses the priority and provides a measurable time
frame.
CON: Safety
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. Which is the nurse’s priority intervention at this time?
1. Obtaining an order for locked seclusion until the client is no longer suicidal
2. Conducting 15-minute checks to ensure safety
3. Placing the client on one-to-one observation while monitoringasbuirbic.ciodma/tleisdt eations
4. Encouraging client to express feelings related to suicide
ANS: 3
Chapter: Chapter 16, Suicide Prevention
, Townsend
PMHN, 10e
Chapter 16 - ETB
abirb.com/test
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 276
Heading: Suicidal Ideas or Acts > Table 16–3, Care Plan for the Suicidal Client: Nursing
Diagnosis: Risk for Suicide
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
Feedback
1. This is incorrect. Client safety is always the nurse’s priority. Locked seclusion is not
appropriate for this situation; the client must be continuously monitored.
2. This is incorrect. Conducting checks every 15-minutes doeasbinrbo.ctompr/toesvtide
continuous monitoring of the client. Client safety must remain the nurse’s priority.
3. This is correct. Client safety is always the nurse’s priority. The nurse must place the
client on one-to-one observation and continue to monitor suicidal ideations.
4. This is incorrect. Encouraging communication with the clieabnirtbi.csomap/tepsrtopriate;
however, this does not provide continuous monitoring to maintain client safety,
which is the priority.
CON: Safety
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, is much more
communicative, and rates mood at 9/10. Which action should be atbhireb.ncoumr/st es’ts
priority at this time?
1. Give the client off-unit privileges as positive reinforcement.
2. Encourage the client to share mood improvement in group.
3. Increase frequency of client observation.
4. Request a medication reevaluation.
ANS: 3
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 276
Heading: Suicidal Ideas or Acts > Table 16–3, Care Plan for the Suicidal Client: Nursing
Diagnosis: Risk for Suicide
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Managementaboirfb.Ccoamr/etest
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
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