mental health lesson 2

A staff nurse tells another nurse, "I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse.

"A score over 8 requires immediate hospitalization."

A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response?

"Because we are concerned about your safety, we will continue with our plan."

Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering suicide."

"Bringing this up is a very positive action on your part."

A patient diagnosed with bipolar disorder is hyperactive and manic after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?

"Do not hit anyone. If you are unable to control yourself, we will help you."

A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract.q

"For the next 24 hours, I will not kill or harm myself in any way."

The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate?

"Genetics are associated with suicide risk. Monitoring and support are important."

A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message?

"I have a plan that will fix everything."

Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention?

"I have no one for help or support."

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention?

"I saw my best friend get killed by a roadside bomb. It should have been me instead."

A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful?

"I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."

A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment?

"Let's consider which problems are most important and which are less important."

A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." To assist the patient in reframing this overgeneralization, the nurse should respond:

"Let's look at one bad thing that happened to see if another explanation exists."

A new nurse says to a peer, "My newest patient is diagnosed with schizophrenia. At least I won't have to worry about suicide risk." Which response by the peer would be most helpful?

"Let's reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia."

A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response.

"Post-traumatic stress disorder often strains relationships. I will suggest some community resources for help and support."

A patient being treated for major depressive disorder has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse should advise the patient:

"Take one dose of the antidepressant. Come to the clinic to see the health care provider."

When assessing a patient's plan for suicide, what aspect has priority?

. Availability of means and lethality of method

A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply.

. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation

A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply.

82-year-old white man b. 17-year-old white female adolescent 22-year-old man with traumatic brain injury

Which individual in the emergency department should be considered at the highest risk for completing suicide?

A 79-year-old single white man with cancer of the prostate gland

A patient diagnosed with major depressive disorder will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment? Select all that apply.

Administer pretreatment medication 30 to 45 minutes before treatment. Withhold food and fluids for a minimum of 6 hours before treatment. Remove dentures, glasses, contact lenses, and hearing aids.

During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How should the nurse document the patient's affect and mood?

Affect flat; mood depressed

A nurse assesses soldiers in a combat zone in Afghanistan. When is it most important for the nurse to screen for signs and symptoms of traumatic brain injury (TBI)?

After a fall, vehicle crash, or exposure to a blast

Which experiences are most likely to precipitate post-traumatic stress disorder (PTSD)? Select all that apply.

An adolescent is kidnapped and held for 2 years in the home of a sexual predator. A passenger is in a bus that overturns on a sharp curve in the road, tumbling down an embankment. An adult is trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

A patient says to the nurse, "My life does not have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." How would the nurse document the complaint?

Anhedonia

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy?

As depression lifts, physical energy becomes available to carry out suicide.

Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide?

Attending a self-help group for survivors

A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with post-traumatic stress disorder (PTSD)?

Avoidance

When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy.

CBT

An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be:

Do you have access to the medications

A soldier returned 3 months ago from Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). Which social event would most likely be disturbing for this soldier?

Fireworks display on July 4th

A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described?

Flashback

A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event?

Hold a staff meeting to express feelings and plan the care for other patients.

A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system?

Hypothalamus

A student nurse caring for a patient diagnosed with major depressive disorder reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply.

Imbalanced nutrition: less than body requirements Sexual disfunction Self-care deficit Insomnia

The admission note indicates a patient diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? Select all that apply.

Instilling a sense of hopefulness Assisting with self-care activities Accommodating psychomotor retardation

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk?

Jumping from a 100-foot-high railroad bridge located in a deserted area late at night

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for which problem?

Major depressive disorder

A nurse teaching a patient about a tyramine-restricted diet would approve which meal?

Mashed potatoes, ground beef patty, corn, green beans, apple pie

A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply.

Offer laxatives, if needed. Monitor food and fluid intake. Provide a quiet sleep environment.

A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and now I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind." Which phenomenon associated with post-traumatic stress disorder (PTSD) is this soldier describing?

Re-experiencing

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?

Risk for injury

A soldier served in combat zones in Iraq in 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of post-traumatic stress disorder (PTSD)?

Screening should be ongoing

Which changes in brain biochemical function is most associated with suicidal behavior?

Serotonin deficiency

Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective?

Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?

Social skills training

A patient diagnosed with liver failure has been on the transplant waiting list 8 months. The patient says, "Why is it taking so long to have the surgery? Maybe I'm meant to die for all the bad things I've done." The nurse should document the patient's comment in which section of the assessment?

Spiritual

An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention.

Supervise the patient 24 hours a day.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment?

Supporting physiologic stability

A nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply.

TBI PTSD

nurse assesses the health status of soldiers returning from Afghanistan. Screening will be a priority for signs and symptoms of which health problems? Select all that apply.

TBI PTSD

A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.

Temporary memory impairments and confusion can be associated with electroconvulsive therapy.

A patient being treated with paroxetine (Paxil) 50 mg/day orally for major depressive disorder reports to the clinic nurse, "I took a few extra tablets earlier in the day and now I feel bad." Which aspects of the nursing assessment are most critical? Select all that apply.

VS Presence of abdominal pain and diarrhea Hyperactivity or feelings of restlessness

A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate?

You're wearing a new shirt

A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply.

a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient's possession. c. Maintain arm's length, one-on-one nursing observation around the clock.

A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse?

are you having thoughts of suicide

A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will:

bring hyperactivity under rapid control.

A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed?

carbamazepine (Tegretol)

A priority nursing intervention for a patient diagnosed with major depressive disorder is:

carefully and inconspicuously observing the patient around the clock.

A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient:

consults the pharmacist when selecting over-the-counter medications.

A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects:

denial

A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to:

establish a rapport with the patient.

A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will:

exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.

Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered:

experiencing hopelesness

A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse should:

explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks.

A patient was started on escitalopram (Lexapro) 5 days ago and now says, "This medicine isn't working." The nurse's best intervention would be to:

explain the time lag before antidepressants relieve symptoms.

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate?

eyes pointed downward

A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. The nurse should:

firmly and neutrally assist the patient with showering.

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

giving away sweaters

A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan?

high level

The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is:

hopelessness

A nurse talks with the caregiver of a combat veteran diagnosed with severe traumatic brain injuries. The caregiver says, "I don't know how much longer I can do it. My whole life is consumed with taking care of my partner." Select the nurse's best response.

how are you taking care of yourself

A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:

hypertensive crisis

A nurse worked with a patient diagnosed with major depressive disorder who was severely withdrawn and dependent on others. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of:

ineffectiveness and frustration

A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then the patient says gaily, "Do you like my scarves? Here...they are my gift to you." How should the nurse document the patient's mood?

labile and euphoric

A patient diagnosed with major depressive disorder does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurse's most effective approach to communication.

make observations

Which beverage should the nurse offer to a patient diagnosed with major depressive disorder who refuses solid food?

milk

A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. The person has not slept or eaten for 3 days. What features of mania are evident?

poor judgment and hyperactivitu

Which scenario best demonstrates an example of eustress?

prepares to take a 1 week vacation to a tropical island with a group of close friends.

A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to:

report increase in suicidal thoughts

This nursing diagnosis applies to a patient experiencing mania: Imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will:

rink six servings of a high-calorie, high-protein drink each day.

A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I feel like a failure. This baby is the root of my problems." The priority nursing diagnosis is:

risk for other-directed violence

A patient diagnosed with major depressive disorder repeatedly tells staff members, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.

risk for suicide

The cause of bipolar disorder has not been determined, but:

several factors, including genetics, are implicated.

A patient's employment is terminated and major depressive disorder results. The patient says to the nurse, "I'm not worth the time you spend with me. I'm the most useless person in the world." Which nursing diagnosis applies?

situational low self-esteem

A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to:

suicidal prevention

A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority?

suicide risk

A patient diagnosed with major depressive disorder is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?

urinary retention

A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, "No one cares about me anymore. I'm not worth anything." Select an appropriate initial outcome for the nursing diagnosis: Situational low self-esteem, related to feelings of abandonment. The patient will:

verbalize realistic positive characteristics about self by (date) .