Nursing Suicide Risk Assessment Quiz

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Questions and Answers

What is the primary focus for nurses when dealing with a suicidal client?

Diagnosing mental disorders

Providing counseling services

Ensuring client safety (correct)

Administering medications

Which of these demonstrates a critical aspect of assessing a client's suicide potential?

The client's past history of substance use

The client's rational thinking, specific plan, and availability of means (correct)

The client's family history of mental illness

The client's socioeconomic status

According to the content, the rate of suicide is significantly higher in which of the following groups?

Elderly women in nursing homes

Divorced and separated men (correct)

Married women under 30

Adolescent girls from rural areas

Which action contradicts common myths surrounding suicide?

Actively talking to an individual about suicide to assess risk (D) Signup and view all the answers

On Guam, which age group experienced the highest number of suicide deaths in 2018?

30-40 year olds (A) Signup and view all the answers

What does the acronym 'SAD PERSONS' refer to in the context of suicide risk assessment?

A tool based on 10 suicide risk factors (A) Signup and view all the answers

What does the concept of 'means' refer to when assessing a client's suicide potential?

The methods available to the client to carry out their plan (C) Signup and view all the answers

Which of these statements is accurate, based on the content of the document?

Suicide is a preventable cause of death. (C) Signup and view all the answers

Which population is specifically identified as being at higher risk for suicide due to losses, alcohol use, and/or loneliness?

Elderly men over 75 (A) Signup and view all the answers

What is a common emotional response experienced by friends and families of individuals who have successfully committed suicide?

Anger and sadness (D) Signup and view all the answers

Which of the following nursing diagnoses is most related to feelings of a lack of control over one's life?

Powerlessness (C) Signup and view all the answers

What is the primary purpose of a suicide safety plan?

To guide a client through safe steps if thoughts of self-harm arise (A) Signup and view all the answers

Which of the following is an example of tertiary prevention in the context of suicide?

Crisis intervention after a suicide attempt (D) Signup and view all the answers

What is a crucial element in creating a safe and reduced-risk environment for someone at risk of suicide?

Controlling access to lethal means (A) Signup and view all the answers

What is a key component of evaluating the effectiveness of suicide prevention strategies?

Assessing the client's view of self and life situation (C) Signup and view all the answers

What is the main action in establishing a suicide contract with a client?

Helping the client to agree to specific self-harm precautions or actions (B) Signup and view all the answers

According to the SAD PERSONS scale, what is the recommended clinical action for a patient scoring 5 points?

Strongly consider hospitalization (A) Signup and view all the answers

Which demographic is most likely to have unsuccessful suicide attempts?

Women (A) Signup and view all the answers

According to the content, what percentage of those who commit suicide have a diagnosed psychiatric illness?

Around 90% (C) Signup and view all the answers

A client who was previously depressed suddenly appears cheerful and motivated. What is the most appropriate nursing action?

Recognize the increased risk for suicide and increase precautions. (D) Signup and view all the answers

Which of the following is LEAST likely to be a sign of an increased risk of suicide?

Improved mood after starting an antidepressant (A) Signup and view all the answers

Which item would be considered safe to be used by a client at risk for suicide?

Plastic spoon (C) Signup and view all the answers

Which action is most strongly associated with a person formulating a suicide plan?

Giving away possessions (D) Signup and view all the answers

Which of the following is NOT mentioned as a significant risk factor for suicide?

High social involvement (C) Signup and view all the answers

What is the primary focus of care when working with a client at risk for suicide?

Ensuring the client's safety (B) Signup and view all the answers

Which of these times is considered a 'danger time' for a hospitalized client at risk for suicide?

During shift change (C) Signup and view all the answers

When assessing the risk of suicide, which of these factors is MOST important to evaluate?

Availability of a means to carry out the plan (C) Signup and view all the answers

When a suicidal client is on the phone, what is the most appropriate action for the healthcare provider?

Keep the client talking whilst seeking assistance. (B) Signup and view all the answers

Which of the following is considered a high-risk diagnosis according to the given information?

Unipolar or Bipolar depression (A) Signup and view all the answers

According to the legal system, what is the healthcare provider's duty when they are aware a client is at risk of suicide?

To provide reasonable care to prevent the suicide. (A) Signup and view all the answers

What is 'cyberbullicide'?

Suicide due to cyberbullying. (A) Signup and view all the answers

What would be the most appropriate action to do when you know that a client has ingested some drugs?

Attempt to get as much information as possible about what was ingested. (D) Signup and view all the answers

Study Notes

Psychiatric Mental Health Nursing: The Client Who Is Suicidal

Suicide is the purposeful taking of one's own life, the ultimate form of self-destruction, involving intense feelings of fear, loss, anger, or despair.
The effects of suicide can be devastating and long-lasting.
Nurses must recognize suicidal risk, as suicide causes 11 deaths per 100,000 people per year.
Suicide is preventable.

Learning Outcomes

Identify conditions and circumstances that make individuals at high risk for suicide.
Describe a means of assessing suicide potential in a client.
Know the means of providing a safe environment for the suicidal client.

Guam's Suicide Rates

Suicide is the 8th leading cause of death on Guam.
Every 6 days, someone dies by suicide on Guam.
2019: 31 deaths (20-30 year olds)
2018: 44 deaths (30-40 year olds)
2010: 30 deaths from suicide
2011: 7 cases, 4 were 16-year-olds
Illicit drug use is a contributing factor.

Suicide Statistics

Suicide is the 10th leading cause of death for people aged 15 to 24.
The suicide rate for males over 75 years old is three times the national average.
The suicide rate is 40% higher among the elderly.
Suicide is more common in divorced and separated men.

Myths About Suicide

People who talk about suicide never commit it.
People who are suicidal only want to hurt themselves, not others.
There is no way to help someone who really wants to kill himself.
Mentioning the word suicide will cause the suicidal individual to actually commit suicide.

Main Priority: Safety

Safety is the highest priority when working with suicidal clients.
Suicide precautions are crucial to prevent self-inflicting injuries or death.

Suicide Potential Assessment

Suicide potential is assessed using the rationality of the client, their plan, and the means of carrying it out.
Table 16-1 Assessment of Suicide Potential is helpful.
The SAD PERSONS tool (Handout) is a useful assessment method. -A helpful website is https://qxmd.com/calculate/calculator_201/modified-sad-persons-scale

Suicide Risk Assessment (SAD PERSONS)

Details for the SAD PERSONS tool are included in page 9.

Clinical Action Based on SAD PERSONS

Clinical actions, like sending the client home with follow-up, close monitoring, or hospitalization, depend on the total points from the SAD PERSONS tool.
Details are included in page 10.

Suicide Attempts

Some accidents may be suicides.
Suicide attempts (unsuccessful) are more common in women.
Successful suicides are more common in men.
Suicidal ideation (thoughts of suicide) must not be ignored.
Many suicide attempts involve firearms and/or medication overdoses.

Suicide and Psychiatric Illnesses

90% of those who commit suicide have a psychiatric diagnosis.
Unipolar (persistent sadness) and bipolar depression are among the conditions at higher risk.
Schizophrenia increases suicide risk.
Alcohol and substance abuse increase suicide risk.

Recognizing Signs and Symptoms

Depression is the most common sign.
Look for sudden changes in behavior (reckless, withdrawn, talking about death).
Observe dramatic mood changes.
Monitor for improved mood post anti-depressant therapy (medication may not be therapeutic yet).

Formulation of a Suicide Plan

Look for signs like giving away possessions, accessing lethal means (weapons, pills), getting finances in order, and direct/indirect statements of suicidal intent.
Increased energy, a suicide note, and a plan for committing suicide are all significant signs to watch out for.

Risk Factors for Suicide

Males over 50 years old are at high risk.
Suicide is the 2nd leading cause of death for 15-19 year olds.
Social isolation is an important factor.
A history of previous suicide attempts is a high-risk indicator.
Terminal illness increases risk.
Job or financial loss can be a contributing factor.
Mental health issues, drug/alcohol abuse, and depression all significantly increase suicide risk.

NCLEX Considerations

To assess suicide risk, determine if a plan exists, the lethality of the plan, and the client's access to the means.
Evaluate the presence and lethality of the plan, and assessment of means will guide treatment.

Warning Signs

Clients emerging from depression may have increased energy to plan suicide.
A sudden change from depressed mood to cheerful or motivated behavior in a depressed client is a strong warning sign and indicates an increased risk for suicide.

Care of Suicidal Clients

The immediate focus is on client safety.
One-on-one supervision and support are critical.
Establish trust through non-judgmental communication.
Remove all potential means of self-harm in the environment (belts, razors).
Use caution in the use and prescription of pills to ensure safety.

Always 1:1 Supervision

Clients should be on 24/7 supervision to prevent self-harm.
Monitor client's access and use of harmful means.
Staff check on clients regularly (every hour) and document the monitoring.

Danger Times

Periods in a hospital environment when staff may be less available for observation (shift change, weekends, nightshifts)

If a Suicidal Client Calls

Keep the caller speaking with them while getting help for them.
Be sympathetic and non-judgmental.
Listen and keep calm.
Try to get details of any ingested substance and the amount.
Avoid advising, belittling, or making quick referrals.

Duty of Care

Healthcare professionals have a legal responsibility to ensure reasonable care in preventing a client from dying by suicide if aware of their risk.

Cyberbullying is a significant factor, increasing suicide risk among children and adolescents.
Cyberstalking is a similar contributing factor for adults.
In some cases, suicides are committed in reaction to cyberbullying.

Special Populations

Adolescents and young adults are at high risk for drug-related suicide attempts.
Elderly individuals, may have experienced losses, alcohol use, and loneliness.
Incarcerated individuals are at a higher risk for suicide compared to the general population.
Military combat veterans are also among those who are at risk for suicide.

Suicide Survivors

Friends and family members of those who committed suicide may have an increased burden of stress and experience grief in different ways.
They may experience anger and sadness, and need support after losing a loved one to suicide.
Nurses may need to support those who have lost loved ones to suicide.

Nursing Diagnosis

Spiritual well-being or distress
Hopelessness
Powerlessness

Outcome Identification

The goal is to prevent harm, develop a suicide safety plan, ensure client safety, and create a safe and reduced-risk environment.

Suicide Safety Plan

A written plan, developed with the client's help and support, offering specific steps the client should take if they feel suicidal.
A safety plan may include warning signs, steps to isolate themselves, reasons for living, and resources of contact.

Planning/Interventions

Prevention strategies should include primary (public awareness, especially in young people), secondary (early recognition of suicide risk factors), and tertiary (preventing additional suicide attempts and supporting survivors).
Control access to means of harming oneself or others.
Media responsibility must address harmful content.
Crisis intervention and maintaining communication with the client is crucial.

Further Planning and Interventions

Encourage hospitalization if necessary.
Help the client develop a suicide contract.
Decrease the client's social isolation.
Minimize psychological symptoms through measures to manage anxiety and stress.

Evaluation

Prevent harm through monitoring and support.
Assess the client's view of their self and life situation.
Evaluate the restoration of hope.
Involve family members and significant others to gain support and reinforce safety efforts.
Ensure evaluation of the client's care.

Case Study: Crisis Hotline Call

The best initial response by a nurse to a hotline caller stating "It's over" is to ask "Are you thinking of hurting yourself?"
This is the most important and direct question as it is the central concern and the highest priority.

Therapeutic Response

Nurses need to get to the point quickly when interacting with a client at risk of self-harm.
The crucial question to ascertain is whether a clear plan is present for harming oneself.

Studying That Suits You

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Description

Test your knowledge on the critical aspects of assessing suicide risk in clients. This quiz covers essential concepts such as the SAD PERSONS acronym, demographics, and common myths surrounding suicide. Ideal for nursing students and professionals looking to deepen their understanding of this sensitive topic.