17: Mood Disorders and Suicide

The nurse has been asked to assess a client to determine if the client has a suicide plan. Which question would assist the nurse in assessing this area?

"Are you thinking about killing yourself right now?" Explanation: Potential questions to assess a suicide plan include the following: Are you thinking about killing yourself right now? Are you feeling so badly that you have thought of taking your own life? Have things been so bad that you feel you can't go on? What have you thought about doing? Have you thought about a specific time or place? Do you have access to a firearm, pills, knife?

A client being counseled for depression reveals that they would like to develop a sense of connection and belonging within a support system. Which wellness strategy would be encouraged by the nurse for the client?

"Contact at least one friend or attend a religious service." Explanation: Wellness strategies are encouraged based on the wellness challenge that the client is experiencing. If the client is experiencing the challenge of developing a sense of connection, belonging, and a support system, the wellness strategy is to encourage the client to contact at least one friend, or attend a religious service. Therefore, the client in the scenario should be encouraged to contact at least one friend or attend a religious service. The encouragement of educating themselves about depression or joining a support group would be indicated for the wellness challenge of understanding the stigma of depression. The encouragement of praying, meditating, helping others, or volunteering would be indicated for the wellness challenge of expanding a sense of purpose and meaning in life. The encouragement of avoiding being a perfectionist, considering a massage or meditation would be indicated for the wellness challenge of stress management.

The nurse is interviewing a client with a diagnosis of depression and the client states, "Honestly, I know my family would be a lot better off if I wasn't around to be a burden on them. That's just between you and me, though, okay?" What is the nurse's best response?

"I'm obliged to share what we talk about with the other people on your care team." Explanation: The nurse has a binding obligation to communicate information suggesting a suicide risk to other members of the care team. The nurse should certainly assess the motivations for the client's desire for secrecy, but the priority is clearly communicating to the client that this is not possible. The nurse should avoid trite advice ("Nothing good ever comes ..."). The client's permission is not required to share this information, though the nurse should make efforts to preserve rapport and trust.

A client comes to the clinic for an evaluation of headache, fatigue, and an overall feeling of sadness. When assessing the client, which statement by the client would alert a nurse to suspect possible suicide? Select all that apply. "I've been drinking about three or four more beers every night." "I've been going out with my friends about once or twice a week." "I'm so tired that all I ever want to do is sleep all the time." "Most times, I feel like I'm trapped with no way out." "I'm looking for a new job because my job is so stressful."

"I've been drinking about three or four more beers every night." "I'm so tired that all I ever want to do is sleep all the time." "I'm looking for a new job because my job is so stressful." Warning signs for suicide include increased substance use (drinking three or four more beers every night), an inability to sleep or sleeping all the time, and feeling trapped. Social isolation or withdrawal (rather than going out with friends or looking for a new job) would suggest suicide.

A psychiatric-mental health nurse has learned about the treatment goals for clients diagnosed with depression. Which statement made by the nurse would indicate a need for further teaching?

"Psychiatrists are the primary discipline treating clients diagnosed with depression." Explanation: Interdisciplinary treatment of depressive disorders, which are lifelong, needs to include a wide array of health professionals in all areas. The specific goals of treatment are reducing or controlling symptoms, and, if possible, eliminating signs and symptoms of the depressive syndrome; improving occupational and psychosocial functioning as much as possible; and reducing the likelihood of relapse and recurrence through recovery-oriented strategies. Therefore, the nurse's statements, "Symptoms are aimed to be reduced in the client", "Occupational and psychosocial functioning should increase for the client with treatment", and "A focus of treatment is to decrease the likelihood of a recurrence depressive event for the client" indicate effective teaching. The nurse's statement, "Psychiatrists are the primary discipline treating clients diagnosed with depression" indicates a need for further teaching.

A psychiatric-mental health nurse is conducting an in-service education program about suicide for a group of nurses working at a community mental health center. The nurse determines that the teaching was successful based on which statement by the group?

"Suicide has profound effects on those connected to the individual." Explanation: Suicide is a major public health concern, both in the United States and around the world. Although certain factors may increase risk for suicide, suicide knows no bounds of person, age, class, race, or gender. It is an act that profoundly affects those left in its wake. Suicide among the older adult population has increased.

A client with a diagnosis of depression tells the nurse that the client's mood was especially bad this morning but that the client pushed through it to attend a support group. How can the nurse best validate the client?

"That shows an admirable level of perseverance on your part. Well done!" Explanation: Acknowledging the effort and perseverance that it took for the client to attend the support group is a good example of validation. Because the client has depression, the client likely had to battle hopelessness more than fear or anxiety. A statement about the benefits of support groups is irrelevant and does not validate the client. It is presumptuous to claim that the client has nearly recovered.

Research has shown that risk of suicide increases within which time frame for initiation of antidepressant therapy?

14 days Explanation: Studies have shown that the risk for suicide increases within the first 2 to 3 weeks after starting antidepressant medication, usually because the client's mood has not lifted as quickly as physical energy has returned.

Which sleep pattern is suggestive of a manic episode?

A client stays awake for several days and nights before "crashing" and sleeping for a long period. Explanation: During a manic episode, an individual will typically go several nights without sleep before collapsing from exhaustion.

Which client is most likely to benefit from electroconvulsive therapy (ECT)?

A client whose major depression has not responded appreciably to antidepressants Explanation: While ECT is used to treat an increasing range of psychiatric-mental health problems, individuals with major depression are often among the best candidates for the treatment. ECT would not be used as a response to noncompliance, and a person who is currently experiencing a manic episode is less commonly treated with ECT. Cyclothymic disorder is less severe than bipolar II disorder and is consequently less likely to warrant ECT.

A 46-year-old client comes to the community mental health center because the client thinks they might be suffering from depression. When assessing this client, which symptom would the nurse identify as being necessary for the diagnosis of major depressive disorder to be made?

A loss of interest or inability to derive pleasure for previously enjoyed activities Explanation: Clients with major depressive disorder must have either a depressed mood or a loss of interest or inability to derive pleasure from previously enjoyed activities for diagnosis..

A client was abandoned by the parents at age 3, resulting in the client's perception of the world as a hostile place and the subsequent development of rage against men. This statement is an example of what?

A psychodynamic interpretation of the client's major depressive disorder. Explanation: Psychodynamic theories postulate that clients with depression have unexpressed and unconscious anger about feeling helpless or dependent on others. Such anger begins in childhood when basic developmental needs are not met. Clients cannot express this anger toward the person or people on whom they feel dependent, so their anger turns inward.

After being diagnosed with a chronic disease, a client has been feeling depressed. Which diagnosis has the strongest association with an increased suicide risk?

Acquired immunodeficiency syndrome Explanation: The World Health Organization notes that chronic physical illness and certain physical illnesses contribute to higher suicide risk in some individuals. Neurologic diseases such as epilepsy and spinal and brain injury have been associated with increased suicide risk. HIV infection and AIDS also pose increased suicide risk, particularly at the time of diagnosis. Pain also has been identified as a significant contributing factor.

The nurse is seeing a 26-year-old client and the client's family. The client's family describes the client as being "very, very different." The family describes a history of periods of unpredictable behavior and disregard for consequences occurring a few times each year. The client has recently been diagnosed with bipolar I disorder, a condition that is characterized by what?

An elevated mood that lasts for at least 1 week Explanation: During manic episodes that characterize bipolar disorder, the individual exhibits an abnormal, persistently elevated, or irritable mood that lasts for at least 1 week. Failure to respond to treatment, the presence of signs of depression without anhedonia, and the client's admission of a mood disorder are neither diagnostic nor typical of bipolar disorder.

A loss of pleasure or interest in a client diagnosed with depression would be documented as what?

Anhedonia Explanation: A person with depression has a sustained period of feeling depressed, sad, or hopeless and may experience anhedonia (loss of interest or pleasure). The client may report "not caring anymore" or not feeling any enjoyment in activities that were previously considered pleasurable. Flat affect is the complete or near absence of affective expression. Hopelessness and discouragement would not be the correct documentation for this symptom.

A client with bipolar disorder has been ordered a medication that is classified as an anticonvulsant. Which drug does the nurse know falls within this class of medications?

Carbamazepine Explanation: Carbamazepine is an anticonvulsant with mood-stabilizing effects. Lithium is a mood stabilizer. Mannitol and methyldopa are not used in the treatment of bipolar disorder.

The client's spouse calls the health clinic stating that the client is having a manic episode. What information should alert the nurse to recommend that the client should go to the emergency room for treatment?

Client is avoiding eye contact and visibly shaking. Explanation: Clients with bipolar disorder need to be evaluated according to the continuum of care. Not all recurrent episodes of mania/depression will require emergency care or inpatient care. The client who is avoiding eye contact and visibly shaking should be referred to the emergency room for appropriate assessment to maintain safety and hydration. The other presented client information does not require emergent care and can be handled by going through established community resources.

A client has just been admitted to the inpatient psychiatry unit following a suicide attempt. During the client's first 24 hours of care, what outcome should be identified?

Client will express that the client feels safe on the unit Explanation: The initial care of a client who has had a suicide attempt focuses on helping the client feel safe and instilling the beginnings of hope. It would be premature to expect the client to learn and apply new stress management strategies after only 24 hours. Cognitive behavioral therapy would not begin during the acute stage of recovery. A sense of overall optimism will likely require long-term therapy to achieve it.

The major difference between bipolar I and bipolar II disorder is what?

Clients with bipolar II disorder do not have symptoms of mania that interfere enough to cause marked functional disturbances. Explanation: Bipolar II disorder is characterized by a major depressive episode (either current or past) and at least one hypomanic episode. Bipolar II disorder differs from bipolar I in that the client has never had a manic or mixed episode but may have had an episode in which he/she experienced a persistently elevated, expansive, or irritable mood. The hypomanic symptoms are not severe enough to cause marked social or occupational dysfunction.

When assessing a client immediately following electroconvulsive therapy (ECT), the nurse expects what in a client?

Confusion Explanation: After ECT treatment, the client may be mildly confused or briefly disoriented. He or she is very tired and often has a headache. The client will have some short-term memory impairment. Numbness and tingling in the extremities is not an expected symptom of ECT.

A client on the psychiatric mental health unit completed suicide. A nurse who cared for the client has been experiencing insomnia and anxiety attacks since the event. What is the nurse's first action?

Dialogue with a trusted colleague about these feelings Explanation: A nurse who has experienced secondary trauma may benefit from talking about his or her experience. It would be inappropriate to seek informal care from a psychiatrist on the unit, however. The nurse should likely try talking about the event and seeking outpatient treatment before taking a leave of absence. Interacting with other patients is unlikely to bring the nurse relief.

Before a client became depressed, the client was an active, involved parent with three children, often attending school functions and serving as a volunteer. The client is hospitalized for a major depressive episode and now reveals feeling like an unnecessary burden on the family. Which nursing diagnosis is most appropriate?

Disturbance of self-concept related to feelings of worthlessness Explanation: The client does not express anxiety, anger, or apathy. Instead, the client has experienced a change from being an involved, interested parent to feeling as though the client is a burden, which would be reflective of a disturbance of self-concept. The self-concept changes the client is experiencing are related to feelings of worthlessness brought on by the depressive episode.

A client has been successfully treated on the psychiatric mental health unit following a suicide attempt. In preparation for discharge, the nurse should prioritize what action?

Ensuring a plan is in place for the client's community-based care Explanation: Following a suicide attempt, it is imperative that a plan be in place for continuity of care in the community. Arrangements such as advance directives and commitment to treatment statements are optional, not mandatory. Communication with the pharmacy is just one component of a discharge plan and is not necessary in every circumstance.

Which behavior is the priority concern as the nurse begins a care plan for a client in the manic phase of bipolar disorder?

Hyperactivity, dismissing meals, and sleep disturbance Explanation: Safety needs are always the first priority in care planning. A client who has not eaten or slept for several days and has been extremely hyperactive may be at risk for exhaustion and malnutrition and the implications of those states. Although thought disorder, expansive mood, and dress are important assessment information, priority interventions must center on the basic needs of hyperactivity, dismissing meals, and sleep disturbance.

A nurse is preparing a client for discharge. As part of the discharge process, the nurse provides education to the client regarding safety from self-harm. Which intervention should the nurse employ?

Include family members to provide a better understanding of symptoms of the illness Explanation: In addition to trying to reduce the stigma that the client and family may associate with suicide, the nurse must educate them about depression, suicidal behavior, and treatments. When possible, the nurse should schedule educational sessions to include significant others so that they will better understand the client's illness and also learn what is necessary in providing outpatient care.

A 30-year-old woman has been brought to the emergency department after causing a disturbance. She is wearing a pair of tight, pink yoga pants, high heels, a sports bra, and a bright-colored hat. The woman's care providers would recognize that the woman's dress may suggest what?

Mania Explanation: Physical appearance is a factor that influences communication; the client with mania may dress in brightly colored clothes with several items of jewelry and excessive makeup.

Limit setting is most appropriate in which client population?

Manic Explanation: Most of the time, anxious, depressed, and suicidal clients do not test the limits of the caregiver.

A client has been diagnosed with major depression. The client reports of waking up during the night and has trouble returning to sleep. A nurse interprets this finding as suggesting what?

Middle insomnia Explanation: The most common sleep disturbance associated with major depression is insomnia, which is categorized according to three categories: initial insomnia (difficulty falling asleep), middle insomnia (waking up during the night and having difficulty returning to sleep), and terminal insomnia (waking too early and being unable to return to sleep). Less frequently, the sleep disturbance is hypersomnia (prolonged sleep episodes at night or increased daytime sleep).

Cognitive psychotherapy is most likely to be appropriate in the care of a client who has been diagnosed with what?

Moderate depression Explanation: Cognitive psychotherapy is as effective as antidepressant medication in the treatment of mild to moderate depression. It is less likely to address depression that has a demonstrated medical etiology. The primary treatment for postpartum psychosis is medication. Therapy is not relevant in cases of anaclitic depression since the problem occurs in infants.

A client in an acute manic phase is pacing the halls and talking in a loud voice with pressured speech. The client is overly involved with coclients and frequently threatens and disrupts others on the unit. After administering lithium treatment for the client, the nurse can expect the plan of care to include which additional intervention?

Monitoring blood levels of the medication. Explanation: Lithium is the drug of choice for clients with bipolar illness and has a high antimanic effectiveness. Lithium decreases the intensity, frequency, and duration of manic and depressive episodes. Blood levels need to be monitored for therapeutic levels during the acute phase (1.0-1.5 mEq/L) and during longer term maintenance. Other treatments that could be expected for clients during mania include sedatives or antipsychotics. Electroconvulsive therapy, phototherapy, and monoamine oxidase inhibitors are not typically indicated during manic phases.

A client has been diagnosed with major depression and placed on amitriptyline. Which is a side effect of amitriptyline?

Orthostatic hypotension Explanation: Side effects of amitriptyline include orthostatic hypotension, constipation, weight gain, and dry mouth.

A depressed older adult client is being treated with a tricyclic antidepressant (TCA). For which clinical manifestations should the nurse monitor the client?

Orthostatic hypotension and urinary retention Explanation: Orthostatic hypotension and urinary retention are common side effects of TCAs. Photosensitivity, skin rashes, pseudoparkinsonism, and tardive dyskinesia are common side effects of older antipsychotics. Diarrhea and electrolyte imbalances are side effects of lithium.

A client has admitted to the nurse that the client is "tempted to end it all." How can the nurse prevent a future malpractice lawsuit if the client makes a suicide attempt?

Promptly act on, and document, the client's statement. Explanation: Prompt action and documentation are the best defenses against a future lawsuit. Verbal communication does not constitute proof of the nurse's due diligence. A referral may be needed, but this in itself does not prove the timeline of the nurse's actions.

Which would be the priority diagnosis for the client in the manic phase of bipolar disorder who is exhibiting aggressive behavior?

Risk for other-directed violence Explanation: The priority nursing diagnosis is risk for other-directed violence. The other diagnoses are utilized for the client in the manic phase of bipolar disorder but are not the priority in this situation.

A nurse is caring for a client diagnosed with bipolar disorder. The client is experiencing a manic episode. The nurse would be especially alert for signs indicating what?

Self-injury Explanation: During a manic episode, client safety is a priority. Risk of suicide is always present for those having a depressive or manic episode. During a depressive episode, the client may believe that life is not worth living. During a manic episode, the client may believe that he or she has supernatural powers, such as the ability to fly. Although changes in sleep, fluid balance (such as dehydration), and inadequate nutrition manifested by weight loss would be important to assess, safety and prevention of self-injury are the priority.

A client taking lithium for bipolar disorder is having mild diarrhea. The nurse informs the client that this is an example of what?

Side effect Explanation: Lithium has many side effects that can be handled with interventions. For diarrhea, the nurse can instruct the client to take the medication with meals and provide for fluid replacement. The nurse should tell the client to notify the prescriber if the diarrhea becomes severe—this development can be an early sign of lithium toxicity, which would warrant a change in medication. Diarrhea is not a toxic or desired effect. The therapeutic effect is the intended effect of a drug.

The nurse is assessing a client who has presented to the emergency department in emotional distress. What client data represents the greatest risk for suicide?

The client overdosed on pills 2 years earlier Explanation: The greatest predictor of suicide risk is a previous attempt. All of the other listed variables must be addressed, but none is as significant a risk factor as a previous suicide attempt.

A client admitted to the inpatient psychiatric unit changes clothes eight or nine times a day, wears heavy eye makeup, is intrusive with other clients, and makes inappropriate sexual advances toward staff members. Which goal would be most appropriate for this client?

The client will refrain from being intrusive with others and change clothing only twice per day. Explanation: The focus should be on symptom management and containment until the client recovers enough to participate in more structured nursing interventions. Small limitations relative to hugging and wardrobe changes are realistic, offer a measure of change/stability, and help decrease overall hypomanic behaviors. Recording the number of clothing changes per day is not realistic. Having staff members of the opposite sex help the client choose appropriate dress is incorrect because this behavior will encourage continued inappropriate sexual advances. The client does not have difficulties with low self-esteem.

Which is a true statement regarding depressive disorders?

The neurotransmitters norepinephrine, dopamine, and serotonin have been implicated. Explanation: The neurotransmitters norepinephrine, dopamine, and serotonin have been associated with depression. Individuals between the ages of 18 to 29 years have a three times higher prevalence rate than those age 60 and older. The prevalence rates for females and males differ with females experiencing "a 1.5 - 3-fold higher rate than males beginning in early adolescence." Depressive symptomatology in older adults is more difficult to diagnose because it may be confused with symptoms of dementia or cerebrovascular accidents. Depression is the leading cause of years lost because of disability.

A 50-year-old client who has recently been diagnosed with a chronic degenerative illness has announced to the nurse the intention to commit suicide in order to prevent future suffering. Which fact should underlie the nurse's response to this client?

The nurse is obliged to protect the client from self-harm. Explanation: While the nurse is not obliged to inform law enforcement, he or she is ethically obligated to protect the client from self-harm. Participation or referral for assisted suicide has not been recognized as an acceptable component of nursing practice.

The client is taking a monoamine oxidase inhibitor (MAOI) for depression. The nurse educates the client to avoid foods containing what while taking this medication?

Tyramine Explanation: If coadministered with food or other substances containing tyramine, MAOIs can trigger a hypertensive crisis, which may be life threatening. MAOIs given with foods containing calcium, potassium, or sugar do not cause a hypertensive crisis.

When caring for a client with mania, which effect would a nurse most likely find during assessment?

Unusual self-confidence Explanation: Mania is easily recognized by the cognitive changes that occur. Elevated self-esteem is expressed as grandiosity (exaggerating personal importance) and may range from unusual self-confidence to grandiose delusions. Speech is pressured; the person is more talkative than usual and at times is difficult to interrupt. There is often a flight of ideas (illogical connections between thoughts) or racing thoughts. Distractibility increases.

The nurse is creating a plan of care for a client with depression and suicidal ideations. Which nursing action would be a protective factor in the prevention of suicide for this client?

incorporating therapy along with antidepressant medications Explanation: Protective factors buffer individuals from suicidal thoughts and behavior. Protective factors have not been studied as extensively as risk factors, but identifying and understanding them are very important. Protective factors include effective clinical care for mental, physical, and substance abuse disorders. Although medical interventions for depression are important, effective depression treatment is multitudinal and should incorporate psychosocial and spiritual care as well. Clients should not be told to avoid conflict; rather, the nurse should assist the client in building personal capacity to manage conflict in adaptive ways. Clients who are at risk for suicide would find social support to be a protective factor in mitigating or preventing self-harm. Client's should be encouraged to be connected to family and community support whenever possible.

A client experiencing acute mania from bipolar disorder refuses hospitalization. Which type of treatment would the nurse anticipate being prescribed for this client?

intensive outpatient program Explanation: Intensive outpatient programs for several weeks of acute-phase care during a manic or depressive episode are used when hospitalization is not necessary or to prevent or shorten hospitalization. These programs are usually called partial hospitalization. Close medication monitoring and milieu therapies that foster restoration of a client's previous adaptive abilities are the major nursing responsibilities in these settings. Community clinic visits would be appropriate for the client whose condition is stable. The use of telemedicine can be very effective for persons with bipolar disorder during periods of remission. Telephone contacts are a useful strategy for monitoring medication adherence. Collaborative care of mental health with primary care increases the likelihood that a person would be screened for bipolar disorder, resulting in an early diagnosis and effective treatment; however, this is not the treatment that would be prescribed first.