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ANS: D

This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension) eBay: testbanks_and_xanax

REF: Pages 25-17, 18, 54 (Box 25-3) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. γ-aminobutyric acid deficiency

4. Which change in the brain’s biochemical function is most associated with suicidal behavior?

ANS: B

Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 25-7 TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

5. A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt?

ANS: C

Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 25-14 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

6. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

ANS: C

The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 25-17, 47 (Table 25-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

7. A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority?

ANS: C

This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 25-17, 47 (Table 25-2) TOP: Nursing Process: Diagnosis/Analysis

MSC: Client Needs: Psychosocial Integrity

8. A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

ANS: D

Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 25-18 (Case Study and Nursing Care Plan), 38, 47 (Table 25-2)

TOP: Nursing Process: Outcomes Identification

MSC: Client Needs: Psychosocial Integrity

9. A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, “We should have seen this coming. We did not do enough.” The parents’ reaction reflects a. guilt. b. denial. c. shame. d. rescue feelings.

ANS: A

The parents’ statements indicate guilt. Guilt is evident from the parents’ self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 25-7 TOP: Nursing Process: Assessment