Chapter 19: Self-Protective Responses and Suicidal Behavior My Nursing Test Banks

Chapter 19: Self-Protective Responses and Suicidal Behavior

Test Bank

MULTIPLE CHOICE

1. A patient who _____ should be assessed as using indirect self-destructive behavior.

a.

scratches both wrists with safety pins

b.

drinks nearly 1 quart of whiskey per day

c.

took an overdose of sedative-hypnotic drugs

d.

calls a friend when contemplating suicide

ANS: B

Direct self-destructive behavior includes any form of suicidal threats, attempts, gestures, and completed suicide. Indirect self-destructive behavior is any behavior that is detrimental to the persons physical well-being and that may potentially result in death.

DIF: Cognitive Level: Application REF: Text Page: 324

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

2. What nursing diagnosis should be considered when caring for a patient who has engaged in direct or indirect self-destructive behavior?

a.

Death anxiety

b.

Chronic low self-esteem

c.

Disturbed body image

d.

Disturbed personal identity

ANS: B

To think about or attempt self-destruction, the individual must have low self-regard.

DIF: Cognitive Level: Analysis REF: Text Page: 324

TOP: Nursing Process: Nursing Diagnosis

MSC: NCLEX: Psychosocial Integrity

3. A nurse assessing a patient who has been noncompliant with the prescribed diabetic diet and exercise regimen should consider planning strategies to overcome patient use of:

a.

denial.

b.

projection.

c.

dissociation.

d.

displacement.

ANS: A

The most prominent behavior associated with noncompliance is refusal to admit the seriousness of the illness. This denial interferes with acceptance of treatment.

DIF: Cognitive Level: Application REF: Text Page: 325

TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

4. A nurse is caring for a patient who has been noncompliant with the prescribed diabetic diet and exercise regimen. The nurse promotes compliance by enhancing the patients:

a.

sense of control.

b.

sense of well-being.

c.

fear of the sequelae of illness.

d.

dependence on health care workers.

ANS: A

Noncompliant people struggle for control. Serious illness is seen as a betrayal by the body. Patients wish to reassert control and prove mastery over their bodies.

DIF: Cognitive Level: Analysis REF: Text Page: 325

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

5. The major difference between self-injury and suicide lies in whether the patient has:

a.

a need to control or a need to be controlled.

b.

the wish to relieve tension or the wish to die.

c.

been diagnosed with a developmental disorder or psychosis.

d.

a tendency toward indirect or direct expression of self-destructive urges.

ANS: B

The lethality of self-injury is usually low, and patients who self-injure seek relief of tension. Suicide attempts are directed by the wish to die. Care-planning strategies will differ based on underlying patient motivation.

DIF: Cognitive Level: Comprehension REF: Text Page: 326

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

6. A patient with depression tells a nurse, I hope someone will make sure my family gets my jewelry when Im gone. This statement can be assessed as a suicide:

a.

attempt.

b.

gesture.

c.

threat.

d.

plan.

ANS: C

Suicide threats are warningsindirect or direct, verbal or nonverbalthat the person plans to attempt suicide.

DIF: Cognitive Level: Application REF: Text Page: 326

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

7. The nursing diagnosis for a patient who is depressed and suicidal at admission is risk for suicide. The most appropriate outcome for this diagnosis at discharge from the hospital is, The patient will:

a.

increase feelings of self-worth.

b.

not harm self while hospitalized.

c.

be able to problem solve effectively.

d.

develop a trusting relationship with one staff member.

ANS: B

The outcome concerning manifestation of self-harm is directly related to the diagnosis. The other outcomes are desirable but are more appropriate for other diagnoses.

DIF: Cognitive Level: Application REF: Text Page: 333

TOP: Nursing Process: Outcome Identification

MSC: NCLEX: Psychosocial Integrity

8. A person calls the crisis hotline and says, Nobody can help me now. I just want to say goodbye to somebody before I do it. The best response to this statement would be:

a.

I can help you. Will you let me try?

b.

Youre still alive, so you can still get help.

c.

You sound very discouraged. What are you planning to do?

d.

Ill arrange transportation so you can come here and tell me about the problem.

ANS: C

This reply shows empathy, an important quality in developing a relationship. The reply also begins assessment of risk. It is important to determine whether the patient has a plan, the lethality of the method chosen, and whether the patient has the means to implement the plan.

DIF: Cognitive Level: Analysis REF: Text Page: 335

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

9. A person who has been fired from a job calls the mental health clinic and tells a nurse, I feel so overwhelmed that I dont see any other answer but to die. Another voice can be heard in the background. Which action should the nurse take?

a.

Convince the caller to drive to the hospital.

b.

Get the callers address, go to the home, and take the caller to the hospital.

c.

Stay on the telephone and send the police to bring the caller to the hospital.

d.

Ask to speak to the other person and alert them to the callers suicide threat.

ANS: D

Most suicidal patients have some ambivalence. In this case the patient is most likely experiencing both a need to die and a desire to live. With this strategy the nurse is appealing to the patients desire to survive by procuring support through the intervention of the other person.

DIF: Cognitive Level: Application REF: Text Page: 326

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

10. Patients of which demogra

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