Author Question: When risk factors to potential suicide have been identified, a nurse must further assess the actual ... (Read 41 times)

rosent76 · **on:** Jul 11, 2018

When risk factors to potential suicide have been identified, a nurse must further assess the actual risk for a suicide attempt.

Which of the following questions would be appropriate for initial assessment to determine the presence or absence of suicidal thoughts in an older adult with risk factors?

A) Under what circumstances would you take your life? Have you ever started to act on a plan to harm yourself?
B) Do you have a plan for taking your life? What action would you take if you were to harm yourself?
C) Does your life feel worthless? Do you ever think about escaping from your problems?
D) Do you think about harming yourself? Do you ever think about committing suicide?

Question 2

A nurse is reviewing the side effects of antidepressants with a group of older adults. Which of the following statements by a member of the group indicates that the nurse's teaching has been effective?

A) I will start on the dose that I will take for life.
B) Fluoxetine should be given in the evening because it may help me sleep.
C) I need to maintain my fluid intake while on antidepressant medication.
D) The length of antidepressant treatment is usually 3 months for a first-time depression.

smrerig · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

Ans: C
Suicide assessment is multilevel, and each level of questions depends on the response the client gives to the previous level's questions. Level 1 questions determine the presence or absence of suicidal thoughts. Level 1 questions are indirect; at level 2, they become more direct. Level 2 determines the presence or absence of thoughts about self-harm. Level 3 questions determine whether the client has a realistic suicide plan.

Answer to Question 2

Ans: C
An increase in fluid intake helps prevent the risk of postural hypotension. Dosages can be increased gradually until maximal therapeutic levels are reached, while observing for adverse effects. Fluoxetine should be given in the afternoon because of agitation. The length of treatment is usually 6 months for a first-time depression.