120 Unit 3 (?)

delusions

fixed beliefs that are not amenable to change in light of conflicting evidence

conveying empathy and acknowledging the child's distress. explaining and reinforcing reality to avoid distortions. using a calm manner and low, comforting voice. staying with the child until the anxiety decreases. The child's symptoms and behavior suggest that he is exhibiting posttraumatic stress disorder. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child's distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.

A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend: (select all that apply) conveying empathy and acknowledging the child's distress. explaining and reinforcing reality to avoid distortions. using a calm manner and low, comforting voice. avoiding repetition in what is said to the child. staying with the child until the anxiety decreases. minimizing opportunities for exercise and play.

Neuroleptic malignant syndrome The symptoms are consistent with neuroleptic malignant syndrome, which is an adverse reaction to antipsychotic medication. While the other conditions listed in answers A and D may also be side effects of antipsychotic medication, the symptoms presented are not indicative of these conditions. Pneumonia may present with these vital signs; however, the diaphoresis and muscular rigidity are not.

A 20-year-old male patient diagnosed with chronic schizophrenia is placed on an antipsychotic, 20 mg twice a day. At the evening medication time, he expresses that he is not feeling well. The nurse assesses the patient and finds the following symptoms: oral temperature 103° F (39.4° C), pulse 110 beats/min, and respirations 24 breaths/min. The patient is diaphoretic and appears rigid. This patient is most likely suffering from which of the following? Tardive dyskinesia Pneumonia Neuroleptic malignant syndrome Pseudoparkinsonism

Allow opportunities for him to express his anger. Provide patient and family teaching regarding PTSD. Exhibit a nonjudgmental attitude. Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse-patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.

A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend's apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to this patient? (Select all that apply.) Allow opportunities for him to express his anger. Provide patient and family teaching regarding PTSD. Tell the patient that hurting himself will solve nothing. Report him to the authorities. Exhibit a nonjudgmental attitude. Reassure him that everything will be all right.

Consistently use the patient's name. The patient needs continuous reality-based orientation, so his name should be used in all interactions with the nurse and other staff. The nurse should not reinforce the delusion by agreeing with the patient. Logical arguments and PRN medication are not likely to change his thinking.

A 25-year-old man is admitted to the psychiatric unit after being found by the police walking naked down the middle of the street at 3:00 AM. He insists that he is the real Santa Claus. Which of the following nursing interventions should the nurse implement when working with this patient? Consistently use the patient's name. Point out to the patient why he cannot be Santa Claus. Agree that he is Santa Claus so as not to upset him further. Provide medication as needed (PRN).

Provide canned food while expressing reasonable doubt. Highly suspicious patients may refuse to eat food from an individually prepared tray. While not reinforcing the patient's delusion by agreeing with it, providing canned food may be an acceptable alternative to ensure proper nutrition. Challenging the delusion may increase the patient's anxiety. Dismissing her fears and insecurities invalidates the patient's emotional state.

A 50-year-old female patient is admitted to the psychiatric unit for an acute exacerbation of paranoid schizophrenia after she stopped taking her medications for several months. She tells the nurse that she believes her food is being poisoned, and she refuses to eat. What is the most appropriate intervention by the nurse? Provide canned food while expressing reasonable doubt. Agree with the patient's decision. Challenge the patient's delusion. Dismiss her fears and insecurities.

evidence of risks for suicide. The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.

A 79-year-old white male tells a nurse, "I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing." The nurse should analyze this comment as: normal pessimism of the elderly. evidence of risks for suicide. a call for sympathy. normal grieving.

throw flowers on the lake at each anniversary date of the accident. Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.

A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? The parents: visit their child's grave daily. maintain their child's room as the child left it 2 years ago. keep a place set for the dead child at the family dinner table. throw flowers on the lake at each anniversary date of the accident.

Bullying and abusing others Children who have been abused are at risk for abusing others, as well as for developing dysfunctional patterns in close interpersonal relationships. While the other characteristics may occur, none are as characteristic as the correct option.

A child who was physically and sexually abused is at great risk for demonstrating which characteristic? Depression Suicide attempts Bullying and abusing others Becoming active in a gang

Tricyclic antidepressant (TCA) TCAs or mirtazapine (Remeron) may be prescribed if SSRIs or SNRIs are not tolerated or do not work. None of the other options would be the next consideration.

A client diagnosed with post-traumatic stress disorder (PTSD) shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that which medication will be prescribed next? Beta blocker Barbiturate Tricyclic antidepressant (TCA) Sedative

"For your safety I can be no more than an arm's length away." This level of suicide watch does not make adjustments based on client preference. The explanation quoting the protocol and the reason (your safety) is appropriate. The correct statement reinforces the basic need for client safety. The other options fail to provide for the degree of client safety required.

A client on one-to-one supervision at arm's length indicates a need to go to the bathroom but reports, "I cannot 'go' with you standing there." How should the nurse respond to the client's concern? "I understand" and allow the client to close the door. Keep the door open, but step to the side out of the client's view. Leave the client's room and wait outside in the hall. "For your safety I can be no more than an arm's length away."

Explain the high possibility of an adverse reaction. Serotonin malignant syndrome is a possibility if St. John's wort is taken with other antidepressants. None of the other options are relevant to the situation.

A client prescribed a selective serotonin reuptake inhibitor mentions taking the medication along with the St. John's wort daily. The nurse should provide the client with what information regarding this practice? Agreeing that this will help the client to remember the medications. Caution the client to drink several glasses of water daily. Suggest that the client also use a sun lamp daily. Explain the high possibility of an adverse reaction.

express doubt that there are spiders on the wall. The client is experiencing visual hallucinations. Appropriate care for this client would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

A client previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. The nurse's best response to this behavior is to ignore his remarks. express doubt that there are spiders on the wall. ask the client if he also sees spiders in the day room. tell the client there are no spiders and he should stop worrying about it.

Hopelessness The defining characteristics are present for the nursing diagnosis of hopelessness. The characteristics of the other options are not presented in the statement or behavior of the client.

A client tells the nurse that he believes his situation is intolerable and is observed isolating socially. Which nursing diagnosis should be considered? Hopelessness Deficient knowledge Chronic low self-esteem Compromised family coping

Constant 24-hour, one-to-one observation at arm's length A client who will not enter into a no-suicide contract should be placed on the highest level of suicide watch since the client is unable to commit to seeking help to resist suicidal ideations.

A client with a history of repeated suicidal attempts refuses to participate in a no-suicide contract. What intensity of nursing observation should be instituted? Constant 24-hour, one-to-one observation at arm's length One-to-one observation while client is awake Every 15-minute observation around the clock Seclusion with 15-minute observation

Protecting the client against any suicidal impulses Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress; the client's safety is the focus of nursing interventions. Supporting the client's interest in the outside world is of very low priority. The client is focusing on the current personal situation, not the outside world. Helping the client manage the concern for family members is a secondary concern. Reassurance will not change the client's belief.

A client with major depression that includes psychotic features tells the nurse, "All of my relatives have been killed because I've been sinful and need to be punished." What is the primary focus of nursing interventions? Protecting the client against any suicidal impulses Supporting the client's interest in the outside world Helping the client manage the concern for family members Reassuring the client that past behaviors are not being punished

presence of hallucinations. Schizophrenic clients who relapse go through five stages. Correctly identifying which stage the relapsing client is in is important so that interventions can be specific to the behavior. Expressing feelings of anxiety would be part of stage two, expressing feelings of being overwhelmed would be part of stage one, and bizarre behaviors and speech would be part of stage three. Presence of hallucinations is consistent with stage four, psychotic disorganization.

A client with schizophrenia has relapsed and has been identified as being in stage four of relapse. Behavior which is most consistent with this stage of relapse would include expressing feelings of anxiety. expressing feelings of being overwhelmed. bizarre behaviors and speech. presence of hallucinations.

discontinuation syndrome

a cluster of symptoms resulting from withdrawl of SSRIs. includes, flulike feeling, difficulty concentrating, and GI symptoms. most commonly occurs with SSRIs with the shortest half-lives (citalopram, escitalopram, sertaline, paroxetine)

Allow the client to undress when ready to help maintain identity. Any approach other than allowing the client to undress when ready will probably be seen as threatening, increase anxiety, and result in a physical confrontation. Providing two outfits and helping the client make a simple decision will increase anxiety, not foster decision-making. Explaining that clean clothes will look more attractive and increase self-esteem will increase anxiety, not increase self-esteem. Getting assistance and removing the clothing to meet the client's basic hygiene needs will increase the client's anxiety and will probably result in a physical confrontation.

A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs? Allow the client to undress when ready to help maintain identity. Provide two outfits and help the client decide which one to wear. Explain that clean clothes will look more attractive and increase self-esteem. Get assistance and remove the clothing to meet the client's basic hygiene needs.

serotonin syndrome

A collection of symptoms, including delirium, sweating, and shivering, resulting from elevated levels of the neurotransmitter serotonin; may occur with the use of any psychotropic drug that enhances brain serotonin activity. to treat, give benzodiazepam, and stop current medication

Shame Humiliation Self-imposed isolation Recent stressful life event Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, "No one can understand," can be seen as recent lack of social support. Terminating access to one's social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack.

A college student is extremely upset after failing two examinations. The student said, "No one understands how this will hurt my chances of getting into medical school." The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? Select all that apply. Shame Panic attack Humiliation Self-imposed isolation Recent stressful life event

guilt. 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.

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: guilt. denial. shame. rescue feelings.

Giving away sweaters 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.

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? Calling parents Excessive crying Giving away sweaters Staying alone in dorm room

Learned helplessness Learned helplessness results in depression when the client feels no control over the outcome of a situation. None of the other options demonstrate these feelings.

A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse should identify this cognitive distortion as what response? Self-blame Catatonia Learned helplessness Discounting positive attributes

"Are you having thoughts of suicide?" The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation.

A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? "Are you having thoughts of suicide?" "I am not sure I understand what you are trying to say." "Try to stay hopeful. Things have a way of working out." "Tell me more about what interested you before you became depressed."

"Let's look at what you just said, that you can 'never do anything right.'" Cognitive distortions can be refuted by examining them, but to examine them the nurse must gain the client's willingness to participate. None of the other options examines the underlying cause of the feeling.

A depressed, socially withdrawn client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can best address this cognitive distortion with which response? "Let's look at what you just said, that you can 'never do anything right.'" "Tell me what things you think you are not able to do correctly." "Is this part of the reason you think no one likes you?" "That is the most unrealistic thing I have ever heard."

firmly and neutrally assist the patient with showering. When patients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.

A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: bring up the issue at the community meeting. calmly tell the patient, "You must bathe daily." avoid forcing the issue in order to minimize stress. firmly and neutrally assist the patient with showering.

"The person may have excess energy, talk a lot, feel restless, and spend too much money." Signs that a person is cycling into a manic phase include sleeping and eating less and having increased energy and racing thoughts, increased impulsivity, and increased spending behaviors. Blood pressure may increase related to increased activity, but increased blood pressure and food cravings alone are not indicative of mania. Increased sleep and poor appetite and hygiene are indicative of depression. Decreased energy in winter seasons is indicative of seasonal affective disorder related to decreased sunlight.

A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse? "The person may sleep more, have trouble completing hygiene needs, and have a poor appetite." "The person may have sudden spikes in blood pressure and crave foods that are sweet or salty." "The person may have excess energy, talk a lot, feel restless, and spend too much money." "The person may experience decreased energy and interest in activities beginning in the winter months."

mood spectrum

a continuum of all possible moods that any person may experience

"Depression is seen in people of all ages, from childhood to old age." Depression can occur at any age. Children, adolescents, adults, and the elderly may all experience depression.

A new psychiatric technician mentions to the nurse, "Depression seems to be a disease of old people. All the depressed clients on the unit are older than 60 years." How should the nurse respond to this statement? "That is a good observation. Depression does mostly strike people older than 50 years." "Depression is seen in people of all ages, from childhood to old age." "Depression is most often seen among the middle adult age group." "The age of onset for most depressive episodes is given as 18 years."

"For the next 24 hours, I will not in any way attempt to harm or kill myself." The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks "I am not going to harm myself, I am going to kill myself" or "I am not going to attempt suicide, I am going to commit suicide." A patient may call a therapist and leave the telephone to carry out the suicidal plan.

A nurse and patient construct a no-suicide contract. Select the preferable wording. "I will not try to harm myself during the next 24 hours." "I will not make a suicide attempt while I am hospitalized." "For the next 24 hours, I will not in any way attempt to harm or kill myself." "I will not kill myself until I call my primary nurse or a member of the staff."

"I have a plan that will fix everything." Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to "fix everything" but does not say it outright.

A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. 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 wish I were dead." "Life is not worth living." "I have a plan that will fix everything." "My family will be better off without me."

82-year-old white male 17-year-old white female 19-year-old Native American male Whites have suicide rates almost twice those of non-whites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males.

A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. 82-year-old white male 17-year-old white female 22-year-old Hispanic male 19-year-old Native American male 39-year-old African American male

anhedonia. sleep pattern changes. increased concerns with bodily functions. The correct responses relate to symptoms often noted in elderly patients with depression. Somatic symptoms are often present but missed by nurses as related to depression. Anorexia, rather than hyperphagia, occurs in major depression. Grandiosity is associated with bipolar disorder.

A nurse assessing an elderly patient for depression and suicide potential should include questions about mood as well as: (select all that apply) anhedonia. increased appetite. sleep pattern changes. evidence of grandiosity. increased concerns with bodily functions.

"Let's consider which problems are very important and which are less important." The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? "Let's make a list of all your problems and think of solutions for each one." "I'm happy you're taking control of your problems and trying to find solutions." "When you have bad feelings, try to focus on positive experiences from your life." "Let's consider which problems are very important and which are less important."

"You're crying. Let's talk about it." Noting that the client is crying and suggesting that the nurse and client talk about it addresses the behavior observed, and the offer by the nurse to spend time to help the client implies that the client is worthy. With "Let me get a cup of coffee; then we can talk" the nurse offers to help but places the client second by stating the desire to get coffee first. The nurse denies the client's feelings by focusing on getting ready for visitors. Assuring the client that the client will feel better soon and asking the client to come to the sitting room constitutes false reassurance. The nurse first recognizes the client's feelings and then moves away from discussing them.

A nurse enters a depressed client's room on the evening of admission and observes the client sitting in a chair crying. What is the most therapeutic response by the nurse? "You're crying. Let's talk about it." "Let me get a cup of coffee; then we can talk." "Visitors will be here soon; you'd better get ready." "You'll feel better soon. Come to the sitting room with me."

hypertensive crisis. Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: hypotensive shock. hypertensive crisis. cardiac dysrhythmia. cardiogenic shock.

"Bringing up these feelings is a very positive action on your part." The correct response gives the patient reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem solving.

A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, "I am considering committing suicide." "I'm glad you shared this. Please do not worry. We will handle it together." "I think you should admit yourself to the hospital to keep you safe." "Bringing up these feelings is a very positive action on your part." "We need to talk about the good things you have to live for."

Confusion immediately after the treatment The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Loss of appetite, postural hypotension, and total amnesia are not usual or expected side effects.

A nurse is assisting with the administration of electroconvulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate? Loss of appetite Postural hypotension Complete temporary loss of memory Confusion immediately after the treatment

Too busy to take the time to eat Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating? Feeling undeserving of the food Too busy to take the time to eat Wishes to avoid others in the dining room Believes that there is no need for food at this time

Paranoid Clients with paranoid schizophrenia tend to experience persecutory or grandiose delusions and auditory hallucinations and exhibit behavioral changes such as anger, hostility, or violence. Residual schizophrenia is characterized by the negative symptoms of schizophrenia, but the client does not experience delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior. Catatonia is a state in which the client displays extreme psychomotor retardation to the point of not talking or moving. There may be brief intermittent hyperactive episodes with catatonia. Disorganized schizophrenia is characterized by a disintegration of the personality and withdrawn behavior.

A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are saying that they are going to poison him because he is bad. What type of schizophrenic behavior does the nurse identify? Residual Paranoid Catatonic Disorganized

Eyes pointed downward Nonverbal communication is usually considered more powerful than verbal communication. Downward casted eyes suggest feelings of worthlessness or hopelessness.

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? Arms crossed Staring at the nurse Smiling inappropriately Eyes pointed downward

Risk for injury Imbalanced nutrition, less than body requirements Sleep deprivation Risk for injury, poor nutrition, and impaired sleep are priority needs of the patient experiencing mania related to their impulsivity, inability to attend to activities of daily living such as diet and hygiene, and disruption of sleep. Caregiver strain is important to be addressed but is not a priority need on admission for the patient. Verbal communication improves when the mania is managed, and racing thoughts return to normal patterns. Ineffective coping will require stabilization of the acute phase along with cognitive therapy over time.

A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic phase. Which nursing diagnoses address priority needs for the patient? (Select all that apply.) Risk for caregiver strain Impaired verbal communication Risk for injury Imbalanced nutrition, less than body requirements Ineffective coping Sleep deprivation

Depression and suicide Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide. Educating staff about signs and symptoms of high-risk patients and early intervention strategies will decrease morbidity and mortality. The other conditions have a lower prevalence.

A nurse plans a staff education program for employees of a senior living community. Which topic has priority? Late-onset schizophrenia Depression and suicide Dementia Delirium

confers with a pharmacist when selecting over-the-counter medications. Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: monitors sodium intake and weight daily. wears support stockings and elevates the legs when sitting. can identify foods with high selenium content that should be avoided. confers with a pharmacist when selecting over-the-counter medications.

Mashed potatoes, ground beef patty, corn, green beans, apple pie The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? Macaroni and cheese, hot dogs, banana bread, caffeinated coffee Mashed potatoes, ground beef patty, corn, green beans, apple pie Avocado salad, ham, creamed potatoes, asparagus, chocolate cake Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

suicide potential. 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.

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

"What are your beliefs about a person's right to take his or her own life?" This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion.

A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin this assessment. "Are there any things going on in your life that would cause you to consider suicide?" "What are your beliefs about a person's right to take his or her own life?" "Do you think you are vulnerable to developing a depressed mood?" "If you felt suicidal, would you tell someone about your feelings?"

ineffectiveness and frustration. Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with patients with depression because of the patient's resistance. Guilt and despair might be seen when the nurse experiences the patient's feelings because of empathy. Interest is possible, but not the most likely result.

A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: guilt and despair. over-involvement. interest and pleasure. ineffectiveness and frustration.

Explain that the physical symptoms are related to the psychological state. Persons with posttraumatic stress disorder often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body's responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for posttraumatic stress disorder is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.

A nurse works with a patient diagnosed with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? Trigger flashbacks intentionally in order to help the patient learn to cope with them. Explain that the physical symptoms are related to the psychological state. Encourage repression of memories associated with the traumatic event. Support "numbing" as a temporary way to manage intolerable feelings.

verbalize realistic positive characteristics about self by (date). Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best 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). agree to take an antidepressant medication regularly by (date). initiate social interaction with another person daily by (date). identify two personal behaviors that alienate others by (date).

"I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you." Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is "offering self." Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point.

A patient became severely depressed when the last of the family's 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? "Things will look brighter soon. Everyone feels down once in a while." "Our staff members care about you and want to try to help you get better." "It is difficult for others to care about you when you repeatedly say the same negative things." "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

"Take a dose of your antidepressant now and come to the clinic to see the health care provider." The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.

A patient being treated for depression 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 will advise the patient to: "Go to the nearest emergency department immediately." "Do not to be alarmed. Take two aspirin and drink plenty of fluids." "Take a dose of your antidepressant now and come to the clinic to see the health care provider." "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

Reexperiencing Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

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

Vital signs Presence of abdominal pain and diarrhea Hyperactivity or feelings of restlessness The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. The patient may have urinary retention, but frequency would not be expected.

A patient being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? Select all that apply. Vital signs Urinary frequency Psychomotor retardation Presence of abdominal pain and diarrhea Hyperactivity or feelings of restlessness

Seasonal affective disorder Decreased exposure to sunlight in winter months can reduce the production of serotonin in the brain, leading to a type of depression termed seasonal affective disorder; this tends to resolve with the longer days and increased exposure to sun of spring and summer. There are not enough data to identify anxiety or signs linked to medication, which also tend to not resolve with seasons. Antisocial traits include isolation but also include behaviors of manipulation and lack of remorse in interpersonal relationships.

A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? Anxiety Seasonal affective disorder Medication side effects Antisocial personality

reporting increased suicidal thoughts. Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: restricting sodium intake to 1 gram daily. minimizing exposure to bright sunlight. reporting increased suicidal thoughts. maintaining a tyramine-free diet.

There is a risk of toxicity when this medication is taken with alcohol. There is an increased risk of toxicity with TCAs when taken with alcohol and a high rate of morbidity.

A patient diagnosed with depression is being discharged with a prescription for TCAs after no improvement of symptoms on an SSRI. Which instruction should the nurse include about this new medication? This drug does not cause problems with sleep, constipation, or low blood pressure. Take St. John's wort every day to minimize the adverse effects of the medication. There is a risk of toxicity when this medication is taken with alcohol. There are no drug or food contraindications with this medication.

Urinary retention All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? Dry mouth Blurred vision Nasal congestion Urinary retention

Risk for suicide A patient diagnosed with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

A patient diagnosed with depression repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. Powerlessness Risk for suicide Stress overload Spiritual distress

teach the patient strategies to manage postural hypotension. Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication. Activity is an important aspect of the patient's treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.

A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today 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 will: limit the patient's activities to those that can be performed in a sitting position. withhold the drug, force oral fluids, and notify the health care provider. teach the patient strategies to manage postural hypotension. update the patient's mental status examination.

explain the time lag before antidepressants relieve symptoms. Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with patients.

A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to: discuss with the health care provider the need to increase the dose. reassure the patient that the medication will be effective soon. explain the time lag before antidepressants relieve symptoms. critically assess the patient for symptoms of improvement.

Make observations. Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations for answers on the patient. Acceptance and support are shown by the nurse's presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialogue. Platitudes are never acceptable. They minimize patient feelings and can increase feelings of worthlessness.

A patient diagnosed with major depression 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. Which communication technique will be effective? Make observations. Ask the patient direct questions. Phrase questions to require yes or no answers. Frequently reassure the patient to reduce guilt feelings.

Temporary memory impairments and confusion may occur with electroconvulsive therapy. Recent memory impairment and/or confusion is often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The patient needing time to reorient to a pressured work schedule is less relevant than the correct rationale.

A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. Temporary memory impairments and confusion may occur with electroconvulsive therapy. The patient needs time to readjust to a pressured work schedule.

Milk Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? Tomato juice Orange juice Hot tea Milk

"You're wearing a new shirt." Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as making an observation avoid negative interpretations. Saying, "You look nice" or "I like your shirt" gives approval (non-therapeutic techniques). Saying "You must be feeling better today" is an assumption, which is non-therapeutic.

A patient diagnosed with major depression says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? "You look nice this morning." "You're wearing a new shirt." "I like the shirt you are wearing." "You must be feeling better today."

Offer laxatives if needed. Monitor food and fluid intake. Provide a quiet sleep environment. The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted.

A patient diagnosed with major depression 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. Eliminate all daily caffeine intake. Restrict intake of processed foods.

"Let's look at one bad thing that happened to see if another explanation exists." By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement.

A patient diagnosed with major depression tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? "I really doubt that one person can be blamed for all the bad things that happen." "Let's look at one bad thing that happened to see if another explanation exists." "You are being extremely hard on yourself. Try to have a positive focus." "Are you saying that you don't have any good things happen?"

c. Cardiac dysrhythmias Tricyclic antidepressant overdoses are notoriously lethal. The primary organ systems affected are the central nervous system and the cardiovascular system, and death usually results from either seizures or dysrhythmias.

A patient has been admitted to the emergency department with a suspected overdose of a tricyclic antidepressant. The nurse will prepare for what immediate concern? a. Hypertension b. Renal failure c. Cardiac dysrhythmias d. Gastrointestinal bleeding

Poor eye contact Appetite changes Slowed speech Typical signs of depression include sleep disturbance; poor eye contact; loss of interest in events; guilt; decreased energy, speech, and concentration; appetite changes; and slowed motor movements. Increased fever and white blood cell count are indicative of infection, not depression.

A patient has been admitted with major depressive disorder. What typical signs and symptoms would the nurse expect to assess? Select all that apply. Poor eye contact Increased fever Appetite changes Increased white blood cell count Slowed speech

"It usually takes a few weeks for you to notice improvement from this medication." Seeing a response to antidepressants takes 3 to 6 weeks. No change in medication is indicated at this point of treatment, because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that his or her life is better does not acknowledge the patient's feelings.

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? "I will call your care provider. Perhaps you need a different medication." "Don't worry. We can try taking it at a different time of day to help it work better." "It usually takes a few weeks for you to notice improvement from this medication." "Your life is much better now. You will feel better soon."

Eating foods such as blue cheese or red wine will cause side effects. MAOIs have serious food interactions when ingested with tyramine-containing foods such as aged or processed foods. Serum levels are routinely monitored when mood stabilizers such as lithium carbonate are prescribed. It is not necessary to administer this class intramuscularly. This medication takes several weeks to show effectiveness and should not be stopped abruptly; short-term use will not be effective.

A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient? Serum blood levels must be regularly monitored to assess for toxicity. To prevent side effects, the medication should be administered as an intramuscular injection. Eating foods such as blue cheese or red wine will cause side effects. This medication class may only be used safely for a few days at a time.

perceptual disturbance

a disruption in sensory interpretations, including visual and auditory hallucinations and delusions (e.g., paranoia); often associated with mania

d. "You need to avoid all foods that contain tyramine, including beer, while taking this medication." Foods containing tyramine, such as beer and aged cheeses, should be avoided while a patient is taking an MAOI. Drinking beer while taking an MAOI may precipitate a dangerous hypertensive crisis. The other options are incorrect.

A patient has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil) for 6 months. The patient wants to go to a party and asks the nurse, "Will just one beer be a problem?" Which advice from the nurse is correct? a. "You can drink beer as long as you have a designated driver." b. "Now that you've had the last dose of that medication, there will be no further dietary restrictions." c. "If you begin to experience a throbbing headache, rapid pulse, or nausea, you'll need to stop drinking." d. "You need to avoid all foods that contain tyramine, including beer, while taking this medication."

d. "Taking St. John's wort with Zoloft may cause severe interactions and is not recommended." The herbal product St. John's wort must not be used with SSRIs. Potential interactions include confusion, agitation, muscle spasms, twitching, and tremors. The other responses by the nurse are inappropriate.

A patient has been taking the selective serotonin reuptake inhibitor (SSRI) sertraline (Zoloft) for about 6 months. At a recent visit, she tells the nurse that she has been interested in herbal therapies and wants to start taking St. John's wort. Which response by the nurse is appropriate? a. "That should be no problem." b. "Good idea! Hopefully you'll be able to stop taking the Zoloft." c. "Be sure to stop taking the herb if you notice a change in side effects." d. "Taking St. John's wort with Zoloft may cause severe interactions and is not recommended."

Hold a staff meeting to express feelings and plan care for the other patients. Interventions should help the staff and patients come to terms with the loss and grow because of the incident. Then, a community meeting should occur to allow other patients to express their feelings and request help. Staff should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. A sentinel event report can be prepared later. The other incorrect options will not control information or would result in unsafe care.

A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing measure will be most important regarding this event? Ask the information technology manager to verify the hospital information system is secure. Hold a staff meeting to express feelings and plan care for the other patients. Ask the patient's roommate not to discuss the event with other patients. Prepare a report of a sentinel event.

"Members of the same family may have the same biological predisposition to experiencing mood disorders." Research is showing a genetic or hereditary role in the predisposition of experiencing mood disorders. These tendencies can be inherited by family members. Fluid and electrolyte imbalances cause many problems, but neurotransmitters in the brain are more directly linked to mood disorders. Mood disorders are not a learned behavior, but are linked to neurotransmitters in the brain.

A patient newly diagnosed with depression states, "I have had other people in my family say that they have depression. Is this an inherited problem?" What is the nurse's best response? "There are a lot of mood disorders that are caused by many different causes. Inheriting these disorders is not likely." "Current research is focusing on fluid and electrolyte disorders as a cause for mood disorders." "All of your family members raised in the same area have probably learned to respond to problems in the same way." "Members of the same family may have the same biological predisposition to experiencing mood disorders."

Buspirone (BuSpar) Buspirone (BuSpar) has the advantage of having fewer adverse effects such as sedation and lack of dependency potential. All of the other options are sedatives as well as anxiolytics.

A patient prescribed lorazepam (Ativan) for the treatment of anxiety states, "I feel drowsy all the time, and it's interfering with every aspect of my life." The nurse knows that a better drug therapy option for this patient is which anxiolytic medication? Chlordiazepoxide (Librium) Hydroxyzine hydrochloride salt (Vistaril) Alprazolam (Xanax) Buspirone (BuSpar)

anhedonia. Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means "without energy."

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of: dysthymia. anhedonia. euphoria. anergia.

Depersonalization disorder Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.

A patient states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? Acute stress disorder Dissociative amnesia Depersonalization disorder Disinhibited social engagement disorder

January The days are short in January, so the patient would have the least exposure to sunlight. Seasonal affective disorder is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.

A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute? January April June September

Fireworks display on July 4th The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

A soldier returned 3 months ago from Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier? Halloween festival with neighborhood children Singing carols around a Christmas tree A family outing to the seashore Fireworks display on July 4th

melancholy

a feeling of quiet, stoic sadness, typically with no obvious cause.

"I will tell myself that I am a good person when things don't go well at work." Cognitive therapy helps patients restructure their patterns of thinking to various events or thoughts in a more healthy way. Medication alters neurotransmitters but does not make problems go away. Family support is important but is not the goal of cognitive therapy. Neurotransmitters are affected by medication and brain stimulation therapy, not by cognitive therapy.

A patient who has been diagnosed with depression is scheduled for cognitive therapy in addition to receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met when what is reported by the patient? "I will tell myself that I am a good person when things don't go well at work." "My medications will make my problems go away." "My family will help take care of my children while I am in the hospital." "This therapy will improve my response to neurotransmitter impulses."

a. Agitation c. Tremors e. Sweating Common symptoms of serotonin syndrome include delirium, agitation, tachycardia, sweating, hyperreflexia, shivering, coarse tremors, and others. See Box 16-1 for a full list of symptoms.

A patient who has been taking a selective serotonin reuptake inhibitor (SSRI) is complaining of "feeling so badly" when he started taking an over-the-counter St. John's wort herbal product at home. The nurse suspects that he is experiencing serotonin syndrome. Which of these are symptoms of serotonin syndrome? (Select all that apply.) a. Agitation b. Drowsiness c. Tremors d. Bradycardia e. Sweating f. Constipation

Secondary prevention Secondary prevention is aimed at early detection of problems, in this case, the identification of depression for early intervention. Primary prevention for mood disorders focuses on stress reduction and societal issues such as reducing poverty and racism. Tertiary prevention aims to reduce disability from a diagnosed condition; for mood disorders, this includes prevention of relapse and protection from harm. Modified prevention is not a recognized level of prevention, although prevention interventions may need to be adapted to meet specific individual situations.

A patient who is at a health clinic with complaints of a sore throat is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing? Primary prevention Secondary prevention Tertiary prevention Modified prevention

St. John's wort Serotonin syndrome may occur with SSRIs when they are combined with herbal products such as St. John's wort.

A patient who is prescribed duloxetine (Cymbalta) comes to the medical clinic complaining of restlessness, sweating, and tremors. The nurse suspects serotonin syndrome and questions the patient regarding concurrent use of which herbal product or dietary supplement? Zinc St. John's wort Glucosamine chondroitin Vitamin E

1.5 or higher mEq/L Diarrhea, blurred vision, ataxia, and polyuria are all signs of lithium toxicity, which generally occurs at serum levels above 1.5 mEq/L. Serum levels within the normal range of 0.8 to 1.4 mEq/L are not likely to cause signs of toxicity.

A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision, frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient? 0 to 0.5 mEq/L 0.6 to 0.9 mEq/L 1.0 to 1.4 mEq/L 1.5 or higher mEq/L

Specific assessment for suicide plan must be evaluated. Energy levels increase as depression lifts; this may increase the risk of completing a suicide plan. An increase in mood would not indicate a decrease or discontinuation of prescribed medication. The patient may be ready to return to work, but assessment for suicide risk in a patient who has had suicidal ideation is the priority assessment.

A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1 month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and talkative. What priority assessment must the nurse consider for this patient? The medication dose needs to be decreased. Treatment is successful, and medication can be stopped. The patient is ready to return to work. Specific assessment for suicide plan must be evaluated.

Avoid eating aged cheese. Eating foods high in tyramine, including aged cheese, can cause a hypertensive crisis in patients taking MAOIs.

A patient with a diagnosis of depression is being discharged with a prescription for an MAOI. Which instruction should the nurse include for this medication? Emphasize that tremors are a common adverse effect. Avoid eating aged cheese. Explain the symptoms of tardive dyskinesia. Encourage use of fiber supplements.

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

A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? Powerlessness Social isolation Risk for suicide Compromised family coping

exercise suicide self-restraint by refraining from attempts to harm self for 24 hours. 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.

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

Major depression Between 32% and 47% of patients who have major depression or bipolar disorder (during the depressed phase) will complete suicide. For the others, percentages of suicides are as follows: Personality disorders: 8% to 11%; Substance abuse: 3% to 17%; and schizophrenia: 15% to 20%.

A person with which psychiatric problem is most likely to complete suicide? Personality disorder Major depression Substance abuse Schizophrenia

posttraumatic stress disorder (PTSD)

A psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as a natural disaster or military combat.

Flashback Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.

A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with posttraumatic 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? Illusion Flashback Nightmare Auditory hallucination

"Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." Posttraumatic stress disorder precipitates changes that often lead to divorce. It's important to provide support to both the veteran and spouse. Confrontation will not be effective. While it's important to provide information, on-going support will be more effective.

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. "Posttraumatic stress disorder often changes a person's sexual functioning." "I encourage you to continue to participate in social activities where children are present." "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

depression. Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for: bipolar disorder. schizophrenia. depression. dementia.

Screening should be on-going PTSD can have a very long lag time, months to years. Screening should be on-going.

A soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)? Immediately upon return to the U.S. from Afghanistan Before departing Afghanistan to return to the U.S. One year after returning from Afghanistan Screening should be on-going

Avoidance Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individual's avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

A soldier who served in a combat zone returned to the U.S. 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 posttraumatic stress disorder (PTSD)? Reexperiencing Hyperarousal Avoidance Psychosis

"The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings." The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurse's priority intervention is to form a therapeutic alliance and support the patient's expression of feelings. Crying at 2 weeks after his death is expected and normal.

A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response. "Are you taking your medications the way they are prescribed?" "This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?" "I'm worried about how much you are crying. Your grief over your husband's death has gone on too long." "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

Imbalanced nutrition: less than body requirements Sexual dysfunction Self-care deficit Insomnia Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self. See relationship to audience response question.

A student nurse caring for a patient diagnosed with depression 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 Chronic low self-esteem Sexual dysfunction Self-care deficit Powerlessness Insomnia

establish rapport with the patient. This scenario presents a potential crisis. Establishing rapport facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.

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: assess lethality of suicide plan. encourage expression of anger. establish rapport with the patient. determine risk factors for suicide.

Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.

A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." Say to the wife, "I will call the health care provider to discuss this matter with you." Hold the wife's hand in silence until the family arrives.

misc. antidepressant note: mirtazapine can cause weight gain

drug class: mirtazapine

Anger is an expected emotion in an adjustment disorder. Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.

A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? The comment suggests potential allegations of malpractice. In some cultures, grief is expressed solely through anger. Anger is an expected emotion in an adjustment disorder. The patient had ambivalent feelings about her husband.

Acute stress disorder Depersonalization disorder Posttraumatic stress disorder Acute stress disorder, depersonalization disorder, and posttraumatic stress disorder can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patient's presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.

A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? Select all that apply. Acute stress disorder Depersonalization disorder Generalized anxiety disorder Posttraumatic stress disorder Reactive attachment disorder Disinhibited social engagement disorder

"Genetics are associated with suicide risk. Monitoring and support are important." Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification.

After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? "Genetics are associated with suicide risk. Monitoring and support are important." "Apathy underlies suicide. Instilling motivation is the key to health maintenance." "Your child is unlikely to act out suicide when identifying with a suicide victim." "Fraternal twins are at higher risk for suicide than identical twins."

"Her death is a terrible loss for you." Adjustment disorders may be associated with grief. A statement that validates a bereaved person's loss is more helpful than false reassurances and clichés. It signifies understanding.

After the sudden death of his wife, a man says, "I can't live without her...she was my whole life." Select the nurse's most therapeutic reply. "Each day will get a little better." "Her death is a terrible loss for you." "It's important to recognize that she is no longer suffering." "Your friends will help you cope with this change in your life."

Social skills training Social skill training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a patient's support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skill training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.

An adult diagnosed with major depression 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 Relaxation training classes Desensitization techniques Use of complementary therapy

Fluoxetine (Prozac), a selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patient's history of overdosing, it is important that the medication be as safe as possible in case she takes an overdose of her prescribed medication.

An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? Amitriptyline (Elavil), a sedating tricyclic medication Fluoxetine (Prozac), a selective serotonin reuptake inhibitor Desipramine (Norpramin), a stimulating tricyclic medication Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

St. John's Wort

An herbal supplement often used for treatment of depression and anxiety, can have serious interactions if taken with SSRIs or MAOIs

Common side effects include headache and short-term memory loss. Common side effects of ECT include headache, sleepiness, short-term memory loss, nausea, and muscle aches. Preparations before and after the procedure are the same as any operative procedure involving the patient receiving anesthesia. Treatment is typically three sessions a week for 4 weeks, not once. Patients are not unconscious after the procedure due to the use of precisely placed electrodes and the use of anesthesia.

An older adult has experienced severe depression for many years and is unable to tolerate most antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy (ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment? There are no special preparations needed before this treatment. Common side effects include headache and short-term memory loss. One treatment will be needed to cure the depression. This treatment will leave you unconscious for several hours.

Assess for depression and ask directly about suicidal thoughts. Assessing directly for thoughts of harm to self or others is a priority intervention for any patient exhibiting signs of a mental health disorder. It is estimated that 50% of individuals who succeed in suicide had visited a health care provider within the previous 24 hours. Currently there is no serum lab that identifies depression. The risk of self-harm is a priority safety issue that is monitored in all health care within the scope of the nurse. It is important to obtain information directly from the patient when possible, and then validate the information from family or other secondary sources.

As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient? Assess for depression and ask directly about suicidal thoughts. Ask the care provider to prescribe blood lab work to assess for depression. Focus on the presenting problems and refer the patient for a mental health evaluation. Interview the patient's family to identify their concerns about the patient's behaviors.

TCA

drug class: nortriptyline

SSRI

drug class: paroxetine

Provide emotional support while presenting a simple explanation of the ECT procedure. The nurse should offer support and use clear, simple terms to allay the client's anxiety. Having the client talk to ECT recipients may be too frightening or confusing to the client, and the nurse is responsible for educating the client. Severely depressed clients cannot retain long explanations. The client generally is kept on nothing-by-mouth status before ECT to prevent aspiration during the procedure.

Because a severely depressed client has not responded to any of the antidepressant medications, the primary healthcare provider decides to try electroconvulsive therapy (ECT). What should the nurse do before the treatment? Have the client speak with other clients undergoing ECT. Give a detailed explanation of what to expect after the procedure. Limit the client's intake to a light breakfast on the days of the treatment. Provide emotional support while presenting a simple explanation of the ECT procedure.

b. Anticoagulants Use of selective serotonin reuptake inhibitor (SSRI) antidepressants with warfarin results in an increased anticoagulant effect. SSRI antidepressants do not interact with the other drugs or drug classes listed. See Table 16-6 for important drug interactions with SSRIs.

Before beginning a patient's therapy with selective serotonin reuptake inhibitor (SSRI) antidepressants, the nurse will assess for concurrent use of which medications or medication class? a. Aspirin b. Anticoagulants c. Diuretics d. Nonsteroidal anti-inflammatory drugs

MAOI

drug class: phenalzine

MAOI

drug class: selegline

Hallucinations Delusions Agitation Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the client experiences hallucinations, delusions, or agitation. Negative symptoms are those that cause a loss of normal function, such as when the client exhibits disorganized speech and behavior and anhedonia.

Clients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in clients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) Hallucinations Disorganized speech and behavior Anhedonia Delusions Agitation

SSRI

drug class: sertraline

MAOI

drug class: tranyleypromine

Affect flat; mood depressed Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person's expression, the affect is flat.

During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? Affect depressed; mood flat Affect flat; mood depressed Affect labile; mood euphoric Affect and mood are incongruent.

affective disorder

Emotional disorders that are characterized by changes in mood.

Jumping from a railroad bridge located in a deserted area late at night This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? Turning on the oven and letting gas escape into the apartment during the night Cutting the wrists in the bathroom while the spouse reads in the next room Overdosing on aspirin with codeine while the spouse is out with friends Jumping from a railroad bridge located in a deserted area late at night

create a scholarship fund at their child's high school. Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.

Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who: visit their teenager's grave daily. return immediately to employment. discuss the accident within the family only. create a scholarship fund at their child's high school.

misc. antidepressant note: trazodone can cause priapism

drug class: trazodone

Risk for suicide related to recent deaths of significant others The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patient's social isolation is important, but the risk for suicide has higher priority.

In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse's priority is to determine whether which nursing diagnosis applies to this patient? Risk for suicide related to recent deaths of significant others Anxiety related to sudden and abrupt lifestyle changes Social isolation related to loss of existing family Spiritual distress related to anger with God

Father diagnosed with paranoid schizophrenia Recent immigration to the United States January birth date Physical abuse by the father Genetic predisposition has been identified as a risk factor for development of schizophrenia. Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.

In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) Father diagnosed with paranoid schizophrenia Rural residence Recent immigration to the United States Occasional cannabis use January birth date Physical abuse by the father

Supervise the patient 24 hours a day. The patient now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk.

It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. Supervise the patient 24 hours a day. Begin discharge planning for the patient. Refer the patient to art and music therapists. Consider discontinuation of suicide precautions.

Situational low self-esteem The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses.

Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? Powerlessness Defensive coping Situational low self-esteem Disturbed personal identity

disorganized thinking

Most commonly inferred from speech, defined by derailment, loose associations, tangentially, and incoherence

The imaginary friend is a coping mechanism the child is using. Often traumatized children feel responsible for what happened to them and are frightened by flashbacks, amnesia, or hallucinations that may be due to trauma. For example, a child may use imaginary friends as a coping mechanism. This option addresses the parents' concern most effectively.

Parents express concern when their 5-year-old child, who is receiving treatment for cancer, keeps referring to an imaginary friend, Candy. Which response should the nurse provide to best address the parent's concerns? Children of this age usually have imaginary friends. It is nothing to worry about unless the child starts to socially isolate. The child needs more of their one-on-one attention. The imaginary friend is a coping mechanism the child is using.

careful unobtrusive observation around the clock. Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit.

Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: distracting the patient from self-absorption. careful unobtrusive observation around the clock. allowing the patient to spend long periods alone in meditation. opportunities to assume a leadership role in the therapeutic milieu.

engage the parasympathetic nervous system. In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.

Relaxation techniques help patients who have experienced major traumas because they: engage the parasympathetic nervous system. increase sympathetic stimulation. increase the metabolic rate. release hormones.

Trazodone (Desyrel)

SSRI that is indicated for treatment of depression as well as insomnia due to its strongly sedative qualities. CAN CAUSE PRIAPISM

"Do you have access to medications?" The nurse must assess the patient's access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the patient's safety. The information in the other questions may be important to ask but are not the most critical.

Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. "Why do you want to kill yourself?" "Do you have access to medications?" "Have you been taking drugs and alcohol?" "Did something happen with your parents?"

SNRI

drug class: venlaxafine

neurotransmitters

endogenous chemicals in the body that serve to conduct nerve impulses between nerve cells

Block the reuptake of neurotransmitters at nerve endings The SSRIs block the reuptake of serotonin. The TCAs block the reuptake of norepinephrine and serotonin. The monoamine oxidase inhibitors (MAOIs) inhibit the MAO enzyme that stops the actions of neurotransmitters such as dopamine, serotonin, and norepinephrine. Amphetamines stimulate areas of the brain associated with mental alertness.

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) both function by which mechanism? Inhibit an enzyme that stops the action of neurotransmitters Block the reuptake of neurotransmitters at nerve endings Stimulate areas of the brain associated with mental alertness Decrease the catecholamine release into the blood

nonsuicidal self-injury

Self-injury directed to the surface of the body to induce relief from a negative feeling/cognitive state or to achieve a positive mood state

Instilling a sense of hopefulness Assisting with self-care activities Accommodating psychomotor retardation Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.

The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. Channeling excessive energy Reducing guilty ruminations Instilling a sense of hopefulness Assisting with self-care activities Accommodating psychomotor retardation

hopelessness. Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is hopelessness. sadness. elation. anger.

Flashbacks Cortisol is a hormone released in response to stress. Severe dissociation or "mindflight" occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol. The cortisol level may go up or down, so diuresis and/or weight gain may or may not occur. Answering this question correctly requires that the student apply prior learning regarding the effects of cortisol.

The gas pedal on a person's car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this person's cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? Weight gain Flashbacks Headache Diuresis

Fear of the other clients Because the client has paranoid feelings that other people are out to do harm, assignment to a four-bed room may be threatening. Concern about family at home seems unlikely, because the disruption appears to have started with the transfer to a four-bed room. Watching for an opportunity to escape is possible but unlikely; planning an escape is usually not part of a schizophrenic pattern of behavior. Trying to work out emotional problems is possible but not likely; clients with schizophrenia have difficulty solving problems.

The night nurse reports that a young client with paranoid schizophrenia has been awake for several nights. The day nurse reviews the client's record and finds that this client did not have an interrupted sleep pattern disorder before transfer from a private room to a four-bed room 3 days ago. What factor should the nurse identify as most likely related to the client's sleeplessness? Fear of the other clients Concern about family at home Watching for an opportunity to escape Trying to work out emotional problems

anticipatory grief

The normal mourning that occurs when a patient or family is expecting a death

avoids people and places that arouse painful memories. experiences flashbacks or reexperiences the trauma. experiences symptoms suggestive of a heart attack. demonstrates hypervigilance or distrusts others. feels detached, estranged, or empty inside. These assessment findings are consistent with the symptoms of posttraumatic stress disorder. Ritualistic behaviors are expected in obsessive-compulsive disorder.

The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: (select all that apply) avoids people and places that arouse painful memories. experiences flashbacks or reexperiences the trauma. experiences symptoms suggestive of a heart attack. feels driven to repeat selected ritualistic behaviors. demonstrates hypervigilance or distrusts others. feels detached, estranged, or empty inside.

Ideas of reference Thought insertion is a belief that others are placing thoughts in one's mind. Thought broadcasting is a belief that others can read one's thoughts. Magical thinking is a belief that one's thoughts can make an event happen. Ideas of reference refers to a person's belief that external events, like the evening news, have a direct personal reference to oneself.

The nurse is caring for a 32-year-old woman diagnosed with schizophrenia. The woman tells the nurse, "The news on TV last night was all about me." This is an example of what kind of thought content? Thought insertion Thought broadcasting Magical thinking Ideas of reference

mania

extremely elevated and excitable mood usually associated with bipolar disorder.

Reminder to call the clinic if fever, sore throat, or malaise develops Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

The nurse is planning discharge teaching for a patient taking clozapine (Clozaril). Which of the following is essential to include? Caution about sunlight exposure Reminder to call the clinic if fever, sore throat, or malaise develops Instructions regarding dietary restrictions A chart to record patient weight

c. Tricyclic antidepressants cause serious cardiac dysrhythmias if an overdose occurs. Death from overdose of tricyclic antidepressants usually results from either seizures or dysrhythmias. SSRIs are associated with significantly fewer and less severe systemic adverse effects, especially anticholinergic and cardiovascular adverse effects. The other options are incorrect.

The nurse is reviewing medications used for depression. Which of these statements is a reason that selective serotonin reuptake inhibitors (SSRIs) are more widely prescribed today than tricyclic antidepressants? a. SSRIs have fewer sexual side effects. b. Unlike tricyclic antidepressants, SSRIs do not have drug-food interactions. c. Tricyclic antidepressants cause serious cardiac dysrhythmias if an overdose occurs. d. SSRIs cause a therapeutic response faster than tricyclic antidepressants.

c. Salami and Swiss cheese sandwich Aged cheeses, such a Swiss or cheddar cheese, and Salami contain tyramine. Patients who are taking MAOIs need to avoid tyramine-containing foods because of a severe hypertensive reaction that may occur. Orange juice, eggs, biscuits, and honey do not contain tyramine.

The nurse is reviewing the food choices of a patient who is taking a monoamine oxidase inhibitor (MAOI). Which food choice would indicate the need for additional teaching? a. Orange juice b. Fried eggs over-easy c. Salami and Swiss cheese sandwich d. Biscuits and honey

Cheese, beer, and products with chocolate Cheese, beer, and products with chocolate are high in tyramine, which in the presence of a monoamine oxidase inhibitor can cause an excessive epinephrine-type response that can result in a hypertensive crisis. There is no relationship between monoamine oxidase inhibitors and pork, spinach, oysters, milk, grapes, meat tenderizers, leafy green vegetables, apples, or ice cream.

The nurse is teaching a client who is receiving a monoamine oxidase inhibitor about dietary restrictions. The nurse plans to caution the client to avoid which foods? Pork, spinach, and fresh oysters Milk, grapes, and meat tenderizers Cheese, beer, and products with chocolate Leafy green vegetables, fresh apples, and ice cream

a. Anxiety disorder Buspirone is indicated for the treatment of anxiety disorders, not depression, schizophrenia, or bipolar disorder.

The nurse reads in the patient's medication history that the patient is taking buspirone (BuSpar). The nurse interprets that the patient may have which disorder? a. Anxiety disorder b. Depression c. Schizophrenia d. Bipolar disorder

Seek help when feeling self-destructive. Having the client cope with self-destructive impulses in a healthy way is the only appropriate short-term goal presented for Risk for self-directed violence since it focuses on client safety.

The nursing diagnosis Risk for self-directed violence has been added to the care plan of a suicidal client. Which is the most appropriate short-term goal for this diagnosis? Will reclaim any prized possessions that were given away. Be able to name three personal strengths. Seek help when feeling self-destructive. Consistently participate in a self-help group.

b. "It may take up to 6 weeks to notice any therapeutic effects. Let's wait a little longer to see how he does." Patients and family members need to be told that antidepressant drugs commonly require several weeks before full therapeutic effects are noted. The other answers are incorrect.

The wife of a patient who has been diagnosed with depression calls the office and says, "It's been an entire week since he started that new medicine for his depression, and there's no change! What's wrong with him?" What is the nurse's best response? a. "The medication may not be effective for him. He may need to try another type." b. "It may take up to 6 weeks to notice any therapeutic effects. Let's wait a little longer to see how he does." c. "It sounds like the dose is not high enough. I'll check about increasing the dosage." d. "Some patients never recover from depression. He may not respond to this therapy."

"I might be a little dizzy or have a mild headache after each procedure." Transcranial Magnetic Stimulation (TCM) treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are awake and alert during the procedure. After the procedure, patients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The patient will be able to care for children.

Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? "They will put me to sleep during the procedure so I won't know what is happening." "I might be a little dizzy or have a mild headache after each procedure." "I will be unable to care for my children for about 2 months." "I will avoid eating foods that contain tyramine."

"I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." The correct response indicates the soldier is thinking about death and feeling survivor's guilt. These emotions may accompany suicidal ideation, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention? "It's good to be home. I missed my home, family, and friends." "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." "I want to continue my education, but I'm not sure how I will fit in with other college students."

Having a staff member sit at the door and check packages as visitors enter. A number of ways to inspect items are possible.Taking all potentially harmful gifts from visitors before allowing them to see clients, going through client's belongings (with client present) and removing all potentially harmful objects, ensuring that visitors do not leave potentially harmful objects in the client's room, and searching clients for harmful objects on return from pass are all effective methods to ensure a high rate of client safety. None of the other options provide a measure of control before clients and visitors meet. Self-reporting by the visitors is not reliable.

Unit practice requires inspection of all items being brought onto the unit by visitors. How can this be most effectively done? Having a staff member sit at the door and check packages as visitors enter. Having a staff member make frequent rounds during visiting hours to inspect gifts. Asking all visitors to report to the nurse's station before visiting a client. Asking clients to give staff any unsafe item that might have been left by a visitor.

Warm, consistent interaction Crucial characteristics of staff members who work with suicidal clients include warmth, sensitivity, interest, and consistency since they support the nurse-client relationship. While helpful, none of the other options have the impact of a effective nurse-client relationship.

What are the most important characteristics for staff members who work with suicidal clients? Organization Problem-solving skills Warm, consistent interaction Effective interview and counseling skills

Having suicidal ideation Exhibiting tearfulness Avoiding previously enjoyed activities and relationships Having suicidal ideation, exhibiting tearfulness, and avoiding previously enjoyed activities and relationships are characteristic features of depression. Having poor muscle tone and performing physical exercise routine are uncommon in depressed adolescents.

What characteristics are commonly associated with adolescent depression? Select all that apply. Exercising daily Having suicidal ideation Exhibiting tearfulness Having poor muscle tone Avoiding previously enjoyed activities and relationships

Dissociation is a method for coping with severe stress. Childhood physical, sexual, or emotional abuse and other traumatic events are associated with adults experiencing dissociative symptoms. None of the other options are true.

What information should the nurse give to the family of a client who has had a dissociative episode? Dissociation is a method for coping with severe stress. Dissociation suggests the possibility of early dementia. Brief periods of psychotic behavior may occur. Ways to intervene to prevent self-mutilation and suicide attempts.

Smoking cessation Zyban is a sustained-release form of bupropion that is useful in helping patients to quit smoking.

What is another approved and indicated use for the antidepressant bupropion (Zyban)? Tourette's syndrome Orthostatic hypotension Smoking cessation Nocturnal enuresis

Supporting physiological stability During the immediate post-treatment period, the patient is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? Nutrition and hydration Supporting physiological stability Reducing disorientation and confusion Assisting the patient to identify and test negative thoughts

Formal suicide plans increase the likelihood that a client will attempt suicide. A formal plan demonstrates determination, concentration, and effort, with conclusions already thought out. Failure to successfully complete the suicidal act can add to feelings of worthlessness and stimulate further acts. Verbalizing feelings may help reduce the client's need to act out. Many clients verbalize their suicidal thoughts as they are working on their decision and plan of action; a suicide attempt is not necessarily just to receive attention.

What should the nurse consider when caring for clients who are at risk for suicide? A client who fails in a suicide attempt will probably not try again. Formal suicide plans increase the likelihood that a client will attempt suicide. It is best not to talk to clients about suicide, because it may give them the idea. Clients who talk about suicide are not planning it; they are using the threat to gain attention.

Listen to what the client is saying. Listening to what the client is saying demonstrates that the nurse believes that what the client has to say is important; it also encourages verbalization of feelings. Ignoring the client's stories may increase the client's feelings of worthlessness and persecution. Explaining that no one can get through the door will accomplish little; a paranoid individual cannot be talked out of his or her feelings. These are feelings, not information, and they cannot always be explained; asking where the information came from forces the client to further develop the delusional system.

When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, what should the nurse do? Ignore the client's stories. Listen to what the client is saying. Explain that no one can get through the door. Ask for an explanation of where the information was obtained.

Availability of means and lethality of method If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question.

When assessing a patient's plan for suicide, what aspect has priority? Patient's financial and educational status Patient's insight into suicidal motivation Availability of means and lethality of method Quality and availability of patient's social support

After going to bed Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. Before meals, during group activities, and during television watching are all times of relatively high, competing environmental stimuli.

When being admitted to a mental health facility, a young male adult tells the nurse that the voices he hears frighten him. The nurse knows that clients tend to hallucinate more vividly at what point in their routine? Before meals After going to bed During group activities While watching television

Urban residence Recent immigration Ethnic and racial discrimination Urban residence, recent immigration, and ethnic and racial discrimination are social conditions that have been implicated as risk factors for developing schizophrenia. Although the other factors are also considered to be risk factors, they are not classified as social predictors.

When conducting a health history, the nurse identifies some of the following social risk factors as possible predictors of a diagnosis of schizophrenia. Select all that apply. Urban residence Recent immigration Impaired physical or mental health Older paternal age First-degree relative diagnosed with schizophrenia Ethnic and racial discrimination

cognitive behavioral therapy. Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.

When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: psychoanalytic therapy. desensitization therapy. cognitive behavioral therapy. alternative and complementary therapies.

Waiting quietly for the client to reply Depressed clients think slowly and take long periods to formulate answers and respond. The nurse must be prepared to wait for a reply.

When the nurse remarks to a depressed client, "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to implement which intervention? Waiting quietly for the client to reply Prompting the client if the reply is slow Repeating the question if the client does not answer promptly Reviewing the client's medical record to support the client's response

Selegiline Selegiline is a selective monoamine oxidase-B inhibitor. Phenelzine, isocarboxazid, and tranylcypromine are nonselective monoamine oxidase-A and monoamine oxidase-B inhibitors.

Which antidepressant drug is a selective monoamine oxidase-B inhibitor? Selegiline Phenelzine Isocarboxazid Tranylcypromine

Hypervigilance PTSD in preschool children may manifest as irritability, aggressive or self-destructive behavior, sleep disturbances, problems concentrating, and hypervigilance. None of the other options are characteristic of PTSD in a young child.

Which behavior best supports the diagnosis of posttraumatic stress disorder (PTSD) in a 4-year-old child? Overeating Hypervigilance A drive to be perfect Passivity

Serotonin deficiency 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.

Which change in the brain's biochemical function is most associated with suicidal behavior? Dopamine excess Serotonin deficiency Acetylcholine excess Gamma-aminobutyric acid deficiency

A 4-year-old female The developing brain is particularly vulnerable to adverse events because the most rapid brain development occurs in the first five years of life. The right hemisphere is involved in processing social-emotional information, promoting attachment functions, regulating body functions, and in supporting the individual in survival and in coping with stress. Since the right brain develops first and is involved with developing templates for relationships and regulation of emotion and bodily function, early attachment relationships are particularly important for healthy development and life-long health.

Which child is at greatest risk for developing attachment problems as a result of a neurobiological development? A 13-year-old male A 10-year-old female A 7-year-old male A 4-year-old female

Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. Sleeping 6 hours, participating with a group, and anticipating an event are all positive events. All the other options show at least one negative finding.

Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

Selegiline Selegiline is a selective monoamine oxidase inhibitor-B (MAOI-B) that comes in a transdermal dosage form; this drug is used in the management of major depression. Phenelzine, Isocarboxazid, and tranylcypromine are nonselective inhibitors of both MAOI type A and MAOI type B. These drugs are administered orally.

Which drug would the nurse administer transdermally to treat a client with major depression? Selegiline Phenelzine Isocarboxazid Tranylcypromine

"Lately I have had a lot of aches and pains and just haven't felt very well." "People are in and out of my room all day and all night taking my things." "Don't ask me to eat. I can't because my stomach is upset all the time." Any of the remarks listed as correct should be enough to trigger use of an assessment tool for depression. Somatic symptoms, delusions of persecution, and nihilistic delusions are more common in late-onset depression than in early-onset depression. The distracters do not suggest symptoms of depression.

Which remarks by a 72-year-old patient should prompt the nurse to assess for depression? Select all that apply. "Lately I have had a lot of aches and pains and just haven't felt very well." "People are in and out of my room all day and all night taking my things." "Don't ask me to eat. I can't because my stomach is upset all the time." "I'm eating more than usual, and I am sleeping about 6 hours a night." "Life seems more organized now that I don't live in my own home."

An adolescent was kidnapped and held for 2 years in the home of a sexual predator. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks. PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individual's extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.

Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? Select all that apply. A young adult bungee jumped from a bridge with a best friend. An 8-year-old child watched an R-rated movie with both parents. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

Bologna Bologna has a high tyramine content; tyramine should not be consumed by clients taking monoamine oxidase inhibitors (MAOIs) because the drug interaction may cause severe hypertension. Potatoes and citrus fruits do not contain tyramine. Grapefruit juice may cause a negative drug interaction in clients taking buspirone.

Which food should be avoided by a client who is prescribed monoamine oxidase inhibitors (MAOIs)? Bologna Potatoes Citrus fruit Grapefruit juice

A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

Which individual in the emergency department should be considered at highest risk for completing suicide? An adolescent Asian American girl with superior athletic and academic skills who has asthma A 38-year-old single, African American female church member with fibrocystic breast disease A 60-year-old married Hispanic man with twelve grandchildren who has type 2 diabetes A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

Attending a self-help group for survivors Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide.

Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? Participating in reminiscence therapy Psychological postmortem assessment Attending a self-help group for survivors Contracting for at least two sessions of group therapy

Citalopram Citalopram is an example of a second-generation antidepressant drug. Doxepin, protriptyline, and trimipramine are examples of first-generation antidepressant drugs.

Which is a second-generation antidepressant drug? Doxepin Citalopram Protriptyline Trimipramine

Helping school children learn to manage stress and be resilient 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.

Which measure would be considered a form of primary prevention for suicide? Psychiatric hospitalization of a suicidal patient Referral of a formerly suicidal patient to a support group Suicide precautions for 24 hours for newly admitted patients Helping school children learn to manage stress and be resilient

Self-inflicted gunshot wound A self-inflicted gunshot wound is considered a high-risk method, or "hard" method. The other examples listed here are lower-risk, or "soft" methods.

Which method of suicide has the highest lethality? Ingesting pills Cutting one's wrists Inhaling natural gas Self-inflicted gunshot wound

Maintain arm's-length, one-on-one direct observation at all times. Check all items brought by visitors and remove risk items. Use plastic eating utensils; count utensils upon collection. One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; "no silver or glassware" orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm's-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arm's length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.

Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply. Maintain arm's-length, one-on-one direct observation at all times. Check all items brought by visitors and remove risk items. Use plastic eating utensils; count utensils upon collection. Remove the patient's eyeglasses to prevent self-injury. Interact with the patient every 15 minutes.

Duloxetine Duloxetine can worsen uncontrolled angle-closure glaucoma. Trazodone is contraindicated in clients with a known drug allergy. Bupropion is contraindicated for clients with seizures. Mirtazapine is contraindicated in cases of known drug allergy and concurrent use of monoamine oxidase inhibitors.

Which second-generation antidepressant can worsen uncontrolled angle closure glaucoma? Trazodone Bupropion Duloxetine Mirtazapine

Onset of action is from 1 to 3 weeks or longer. A drawback of antidepressant drugs is that improvement in mood may take 1 to 3 weeks or longer. None of the other options provide correct information regarding antidepressant medications.

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? Onset of action is from 1 to 3 weeks or longer. They tend to be more effective for men. Recent memory impairment is commonly observed. They often cause the client to have diurnal variation.

This disorder results in a split in the personality causing a lack of integration. The theory of structural dissociation of the personality proposes that patients with complex trauma have different parts of their personality, the apparently normal part and the emotional part, that are not fully integrated with each other. Each part has its own responses, feelings, thoughts, perceptions, physical sensations, and behaviors. These different parts may not be aware of each other, with only one dominant personality operating depending on the situation and circumstance of the moment. None of the other options are accurate statements regarding this disorder.

Which statement about structural dissociation of the personality is true? An organic basis exists for this type of disorder. Nurses perceive clients with this disorder as easy to care for. No known link exists between this disorder and early childhood loss or trauma. This disorder results in a split in the personality causing a lack of integration.

"I have no one to turn to for help or support." Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk.

Which statement by a depressed patient will alert the nurse to the patient's need for immediate, active intervention? "I am mixed up, but I know I need help." "I have no one to turn to for help or support." "It is worse when you are a person of color." "I tried to get attention before I cut myself last time."

As depression lifts, physical energy becomes available to carry out suicide. Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? As depression lifts, physical energy becomes available to carry out suicide. Patients who previously had suicidal thoughts need to discuss their feelings. For most patients, antidepressant medication results in increased suicidal thinking. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

"I would like to sit with you for 15 minutes now and again this afternoon." Spending time with the client without making demands is a good way to show acceptance. While not inappropriate, the other options are less accepting.

Which statement would best show acceptance of a depressed, mute client? "I will be spending time with you each day to try to improve your mood." "I would like to sit with you for 15 minutes now and again this afternoon." "Each day we will spend time together to talk about things that are bothering you." "It is important for you to share your thoughts with someone who can help you evaluate your thinking."

c. Therapeutic effects may not be seen for about 4 to 6 weeks after the medication is started. d. If the patient has been on an MAOI, a 2- to 5-week or longer time span is required before beginning an SSRI medication. During SSRI medication, therapeutic effects may not be seen for 4 to 6 weeks. To prevent the potentially fatal pharmacodynamic interactions that can occur between the SSRIs and the MAOIs, a 2- to 5-week washout period is recommended between uses of these two classes of medications. The other options apply to other classes of psychotherapeutic drugs, not SSRIs.

Which statements are true regarding the selective serotonin reuptake inhibitors (SSRIs)? (Select all that apply.) a. Avoid foods and beverages that contain tyramine. b. Monitor the patient for extrapyramidal symptoms. c. Therapeutic effects may not be seen for about 4 to 6 weeks after the medication is started. d. If the patient has been on an MAOI, a 2- to 5-week or longer time span is required before beginning an SSRI medication. e. These drugs have anticholinergic effects, including constipation, urinary retention, dry mouth, and blurred vision. f. Cogentin is often also prescribed to reduce the adverse effects that may occur.

One-on-one observation by the staff. One-on-one observation allows for constant supervision, which minimizes the client's opportunities to cause self-harm. While the remaining options provide some protection, none have the impact of constant supervision.

Which suicide prevention intervention that has the greatest impact on a client's safety? Educating visitors about potentially dangerous gifts. Restricting the client from potentially dangerous areas of the unit. One-on-one observation by the staff. Removal of personal items that might prove harmful.

b. Self-injury or suicidal tendencies In 2005, the U.S. Food and Drug Administration (FDA) issued special black-box warnings regarding the use of all classes of antidepressants in both adult and pediatric patient populations. Data from the FDA indicated a higher risk for suicide in patients receiving these medications. As a result, current recommendations for all patients receiving antidepressants include regular monitoring for signs of worsening depressive symptoms, especially when the medication is started or the dosage is changed. The other options are incorrect.

While monitoring a depressed patient who has just started SSRI antidepressant therapy, the nurse will observe for which problem during the early time frame of this therapy? a. Hypertensive crisis b. Self-injury or suicidal tendencies c. Extrapyramidal symptoms d. Loss of appetite

Acknowledge the presence of the hallucinations. Reassure the patient that he is not in any danger. Give simple commands in a calm voice. Using a calm voice and giving simple commands, the nurse should reassure the patient that he is not in any danger. It is not appropriate to tell the patient to stop the behavior, and ignoring the behavior will not reduce his agitation.

While watching television, a 28-year-old male patient appears to be hallucinating. He is swearing loudly at the television and is becoming increasingly agitated. Which of the following nursing interventions would be appropriate in dealing with this patient? Select all that apply. In a firm voice, tell the patient to stop this behavior. Acknowledge the presence of the hallucinations. Instruct other team members to ignore the patient's behavior. Reassure the patient that he is not in any danger. Give simple commands in a calm voice.

Diazepam (Valium)

a long-acting (≈12-24 hr) benzodiazepine, indicated for the relief of anxiety, management of alcohol withdrawl, reversal of status epilepticus, preoperative sedation, and for the relief of skeletal muscle spasms. Should be avoided in patients with major hepatic compromise. Adverse effects include headache, confusion, and slurred speech.

electroconvulsive therapy (ECT)

a medical treatment most commonly used in patients with severe major depression or bipolar disorder that has not responded to other treatments; involves a brief electrical stimulation of the brain while the patient is under anesthesia.

depression

a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning

euthymia

a normal, tranquil mental state; It is often used to describe a stable mental state in those affected with bipolar disorder that is neither manic nor depressive

grief

a person's individual response to bereavement that occurs after the loss of a loved one

blunting

a reduction in the intensity of an individual's emotional response; a classic symptom of psychosis

Bupropion (Wellbutrin)

a second-generation antidepressant that is also indicated as an aid for SMOKING CESSATION. sometimes added as an adjuct antidepressant for patients experiencing sexual adverse effects secondary to SSRI therapy. contraindicated in those with a seizure disorder. common adverse effects include dizziness, confusion, tachycardia, agitation, tremor, and dry mouth

Selegline (Eldepryl)

a selective MAO-B inhibitor currently indicated for major depression. patients need to avoid exposing the patch to external sources of heat or prolonged direct sunlight.

complicated grief

a state of grief in which painful emotions are so long lasting (≈ 1 year in adults, 6 months in children) and severe that the person has trouble recovering from the loss and resuming their own life

dysphoria

a state of unease or generalized dissatisfaction with life

Anosognosia

a symptom of severe mental illness experienced by some that impairs a person's ability to understand and perceive his or her illness. It is the single largest reason why people with schizophrenia or bipolar disorder refuse medications or do not seek treatment.

psychosis

a syndrome of neurocognitive symptoms that impairs cognitive capacity leading to deficits of perception, functioning, and social relatedness. a neurotoxic state

MAOIs (monoamine oxidase inhibitors)

along with TCAs, represent the first generation of antidepressant drug therapy. currently most commonly used to treat Parkinson's. a serious disadvantage of this class of drug is their potential to cause a hypertensive crisis (BP >180/110) when taken with stimulant medications or with substances containing tyramine. use with SSRIs also carries risk for serotonin syndrome.

Duloxetine (Cymbalta)

an SNRI indicated for depression, GAD, and pain resulting from diabetic peripheral neuropathy or fibromyalgia. can worsen uncontrolled angle-colsure glaucoma. adverse effects include dizziness, drowsiness, headache, GI upset, anorexia, hepatotoxicity. alcohol consumption can create increased risk of liver injury. notable side effects include hyperhidrosis, tachycardia, and urinary retention.

anergia

an abnormal lack of energy

Buspirone (Buspar)

an anxiolytic drug that is different both chemically and pharmacologically from the benzodiazepines, that is indicated for anxiety. Needs to be administered on a SCHEDULE, and lacks the sedative properties and dependency potential of benzodiazepines. Adverse effects include paradoxical anxiety, dizziness, blurred vision, headache, and nausea. A waiting period of at least 2 weeks after discontinuation of MAOI therapy must be allowed before this drug is started.

hypervigilance

an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect activity

functional status

an individual's ability to perform activities of daily living and to realistically solve problems of daily living

acute stress disorder

an intense, unpleasant, and dysfunctional reaction beginning shortly after an overwhelming traumatic event and lasting less than a month. If symptoms persist longer than a month, people are diagnosed as having posttraumatic stress disorder

Lorazepam (Ativan)

an intermediate-acting (≈8 hr) benzodiazepine, available PO, IV, or IM, and often administered to agitated patients undergoing mechanical ventilation. also used to treat or prevent alcohol withdrawl. indications, contraindications, and adverse effects are similar to those of xanax.

vegetative functioning

bodily processes most directly concerned with maintenance of life. includes sleep, appetite, energy, and libido

anxiolytic drugs

commonly used for acute and chronic anxiety disorders, includes benzodiazepine and buspirone.

BZD

drug class: alprazolam

TCA

drug class: amitriptyline

misc. antidepressant note: buproprion can also be used for smoking cessation

drug class: bupropion

misc. anxiolytic note: buspirone must be scheduled

drug class: buspirone

SSRI

drug class: citalopram

BZD

drug class: diazepam

SNRI

drug class: duloxetine

SSRI

drug class: escitalopram

SSRI

drug class: fluoxetine

BZD

drug class: lorazepam

second-generation antidepressants (SSRIs/SNRIs)

generally considered superior to TCAs and MAOIs in terms of their adverse-effect profiles, these drugs primarily inhibit serotonin and possibly norepinephrine uptake. Depression is their primary indiction, although they also benefit treatment of bipolar disorder, obesity, eating disorders, OCD, panic attacks or disorders, social anxiety disorder, PTSD, and alcoholism. contraindictions include use of MAOIs in the previous 2 weeks, and therapy with thioridazine or mesoridazine (antipsychotics). common adverse effects are insomnia, weight gain, and sexual dysfunction. St. John's wort can interact and is best avoided.

disenfranchised grief

grief that is not acknowledged by society

Citalopram (Celexa)

one of the most commonly used SSRIs, approved for treatment of depression and OCD. short half-life (1-2 days), and commonly associated with discontinuation syndrome. adverse effects include anxiety, dizziness, drowsiness, and insomnia.

hallucinations

perception-like experiences that occur without an external stimulus

Mirtazapine (Remeron)

promotes the presynaptic release of serotonin and norepinephrine in the brain. usually dosed once daily at bedtime due to its strong association with sedation. helpful in reducing the sexual adverse effects of SSRIs of male patients. known to be an appetite stimulant. adverse effects include drowsiness, abnormal dreams, dry mouth, constipation, WEIGHT GAIN, and asthenia.

affective instability

repeated, rapid, and abrupt shifts in mood, behavior, or both

positive symptoms

symptoms that are not generally seen in healthy people; a symptom that is present that normally would not be

negative symptoms

symptoms that reflect an absence or deficit in normal functions

mourning

the actions of a person in relation to coping with grief; a process of coming to terms with a loss

Fluoxetine (Prozac)

the first SSRI marketed for the treatment of depression, although it also treats bulimia, OCD, panic disorder, and premenstrual dysphoric disorder. adverse effects include anxiety, dizziness, drowsiness, and insomnia.

alogia

the inability to speak because of mental defect, or mental confusion. a classic symptom of psychosis

suicide

the intentional act of killing oneself by any means

asociality

the lack of motivation to engage in social interaction, or a preference for solitary activities; a classic symptom of psychosis

benzodiazepines

the largest and most commonly prescribed anxiolytic drug class that works by depressing activity in the brainstem and the limbic system. Potentially habit-forming and addictive (schedule IV), and when combined with alcohol can result in death.

anhedonia

the loss of interest in previously rewarding or enjoyable activities; a classic symptom of psychosis

affect

the observable response a person has to his or her own feelings; external

Amitriptyline (Elavil)

the oldest and most widely used TCA, commonly used to treat insomnia and neuropathic pain. contraindications include pregnancy and recent MI. adverse effects include dry mouth, constipation, blurred vision, urinary retention, and dysrhythmias.

TCAs (tricyclic antidepressants)

the original first-generation antidepressant drug class, which works by correcting serotonin and norepinephrine imbalances in the CNS. currently used to treat neuropathic pain syndromes, insomnia, and anorexia. contraindications include use of MAOIs within 2 weeks, and pregnancy, and the most common adverse effects are constipation and urinary retention. overdoses are notoriously lethal.

bereavement

the period of grieving following a death

Antidepressants

the pharmacologic treatment of choice for major depressive disorders, as well as dysthymia, schizophrenia, eating disorders, and personality disorders.

GAD-7

the primary screening tool used for anxiety

PHQ-9

the primary screening tool used for depression

PANSS (Positive and Negative Syndrome Scale)

the primary screening tool used for psychosis

avolition

the severe lack of initiative to accomplish purposeful tasks; a classic symptom of psychosis

Alprazolam (Xanax)

the shortest-acting (≈6 hr) benzodiazepine, indicated for GAD, short-term relief of anxiety symptoms, panic disorder, and anxiety associated with depression; adverse effects include confusion, ataxia, and headache.

comorbidity

the simultaneous presence of two chronic diseases or conditions in a patient

anxiety

the unpleasant state of mind in which real or imagined dangers are anticipated and/or exaggerated

mood

the way a person feels; internal

suicidal ideation

thinking about or planning suicide

secondary psyhosis

type of psychosis that is caused by a specific medical condition (e.g., HIV)

primary psychosis

type of psychosis that is symptomatic of a psychiatric disorder (e.g., schizophrenia)