Chapter 17: Mood disorders and Suicide
Following the failure of a woman's recent in vitro fertilization (IVF), the nurse recognizes that she may be at risk of depression. Which intervention is considered a primary suicide prevention measure?
Establishing a support system for the woman and teaching her some coping measures Explanation: Primary prevention involves the identification and elimination of factors that cause or contribute to the development of an illness or disorder that could lead to suicide. Medication management, psychotherapy, and suicide precautions are more aggressive measures that would not be classified as primary prevention.
Which medication classification is considered first-line drug therapy for bipolar disorder?
Mood stabilizers Explanation: Mood stabilizers are first-line drugs for bipolar disorders. They stabilize depressive and manic cycles.
The nurse is assessing a client who gave birth to a baby 1 week ago. She has been feeling sad, fatigued, and has been crying often. The client is most likely experiencing what?
Postpartum blues Explanation: Following childbirth, many women experience hormonal fluctuations that result in transitory mood disturbances. This is sometimes called "postpartum blues" and usually resolves by the end of the second or third postpartum week. For postpartum depression to be diagnosed, the client must report experiencing these and other symptoms for at least 4 weeks.
A family member of an adolescent who has expressed a desire to commit suicid e asks the nurse, "What might predict the possibility of future suicide attempts?" Which would the nurse include in the response?
Previous suicide attempt Explanation: Although factors such as unemployment, death of a spouse, and polydrug use can contribute to depression and suicidal ideation, one of the best predictors for suicide during adolescence is a previous attempt.
When teaching a group of new mental health nurses about the major difference between bipolar I and bipolar II disorders, which would be most appropriate for the nurse to include?
The mania symptoms of bipolar II disorder have little effect on functioning. Explanation: With bipolar I, at least one manic episode or mixed episode and a depressive episode have to occur. Bipolar II is not as easily recognized as bipolar I because the symptoms are less dramatic. Hypomania, a mild form of mania, is characteristic of bipolar II. A hypomanic episode is less intense, and there is little impairment in social or occupational functioning. The risk for suicide is present with both disorders.
A 50-year-old client who has recently been diagnosed with a chronic degenerative illness has announced to the nurse the intention to commit suicide in order to prevent future suffering. Which fact should underlie the nurse's response to this client?
The nurse is obliged to protect the client from self-harm. Explanation: While the nurse is not obliged to inform law enforcement, he or she is ethically obligated to protect the client from self-harm. Participation or referral for assisted suicide has not been recognized as an acceptable component of nursing practice.
Which mental health disorder has the most significant risk factor for suicide?
depression Explanation: Depression is a major risk factor of suicide. Anxiety, schizophrenia, and mania are significant risk factors but to a lesser degree than depression.
The nurse assesses a client who reports being depressed for over 2 weeks. Which question does the nurse include in the interview portion of the assessment process to determine if the client meets the criteria for major depressive disorder (MDD)? Select all that apply.
"Are you experiencing insomnia every day?" "Have you recently lost weight without dieting?" "Have you experienced difficulty with concentration when working?" Explanation: To diagnose MDD, the client must present with either (1) depressed mood or (2) loss of interest or pleasure for a 2-week period in addition to five (or more) specific symptoms, including weight loss or gain or an increase or decrease is appetite nearly every day, insomnia or hypersomnia nearly every day, psychomotor changes (either increased or decreased) nearly every day, fatigue or loss of energy nearly every day, feelings of worthlessness or inappropriate/excessive guilt nearly every day, diminished ability to think or concentrate or indecisiveness nearly every day, and recurrent thoughts of death and/or suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide. Based on this information, the questions the nurse asks to determine if the client meets the criteria for MDD include "Are you experiencing insomnia every day?" and "Have you recently loss weight without dieting?" and "Have you experienced difficulty with concentration when working?" The remaining questions are not appropriate because the client must have recurrent thought of death and not just a fear of dying and an increase in energy does not support a diagnosis of MDD.
A bipolar client presents to the clinic with reports of headaches and feeling more irritable than usual. What is the best nursing response?
"Can you tell me more about these symptoms?" Explanation: Additional assessment is needed for the bipolar client at this time. By asking an open-ended question, the nurse will be able to determine if the symptoms described by the client are examples of a depressive episode. Telling the client to continue taking medication as prescribed may be warranted, but telling the client that the symptoms are minor minimizes the expressed concern. Asking the client whether or not they have been taking their medication correctly may be needed but it is not the best response at the time because it can be construed as implicit bias. There may be a need for bloodwork, but more information is needed before an order should be obtained.
The nurse is conducting an interview with an adult client who is being treated for major depression. What question should the nurse prioritize in an effort to determine the client's risk for suicide?
"Do you ever feel like your situation is hopeless?" Explanation: Hopelessness is a significant risk factor for suicide among persons who are depressed. For an adult client, relationships with parents are significant but not among the major risk factors for suicide. Similarly, the client's perception of medication effectiveness is important but not a key risk factor. It is common for depressed individuals to lack firm plans for their days, and a lack of planning does not necessarily indicate a heightened suicide risk.
The nurse provides care for a client who is depressed and expresses hopelessness with the current situation. Which client statement indicates a need to implement safety precautions?
"I haven't been able to sleep for the past week because I am anxious." Explanation: Identification of clients who are considering suicide is a priority nursing action. The nurse can use the mnemonic IS PATH WARM to assess the client for warning signs for suicide. The A in this mnemonic stands for anxiety and may be manifested by an inability to sleep; therefore, the statement that indicates a need to explore the implementation of safety precautions is, "I haven't been able to sleep for the past week." Starting a new antidepressant and stating, "I hope I feel better soon; I decided that I should stop drinking alcohol for a while; I just started a new job so at least I have that." do not correspond with any of the warning signs for suicide.
The nurse is interviewing a client with a diagnosis of depression and the client states, "Honestly, I know my family would be a lot better off if I wasn't around to be a burden on them. That's just between you and me, though, okay?" What is the nurse's best response?
"I'm obliged to share what we talk about with the other people on your care team." Explanation: The nurse has a binding obligation to communicate information suggesting a suicide risk to other members of the care team. The nurse should certainly assess the motivations for the client's desire for secrecy, but the priority is clearly communicating to the client that this is not possible. The nurse should avoid trite advice ("Nothing good ever comes ..."). The client's permission is not required to share this information, though the nurse should make efforts to preserve rapport and trust.
A client is to receive three treatments of electroconvulsive therapy (ECT) per week for 3 weeks. After the third treatment, the client is forgetful and confused. When the client's spouse arrives to take the client home, the nurse discusses the client's condition with the spouse. Which statement is best?
"Some people experience mild confusion after ECT. Generally it clears in a few days, though it may take longer." Explanation: A frequent consequence of ECT is memory impairment, ranging from mild forgetfulness of details to severe confusion. This may persist for weeks or months after treatment but usually resolves.
The nurse working on a mental health unit is teaching a nursing student. The student asks the nurse about what constitutes a diagnosis for major depressive disorder. What is the nurse's best response?
"The primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present." Explanation: Normal variations in mood (such as sadness, euphoria, and anxiety) occur in response to life events; they are time limited and not usually associated with significant functional impairment. The primary diagnostic criterion for major depressive disorder is one or more major depressive episodes (either a depressed mood or a loss of interest of pleasure in nearly all activities) for at least 2 weeks. Four of seven other symptoms must be present. Thus, the best response from the nurse is "the primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present."
The nurse provides teaching to the family of a client who is hospitalized after a suicide attempt. Which family member statement indicates a need for additional teaching?
"There is no sense discouraging suicidal thoughts because it doesn't help." Explanation: It is essential that the nurse teach the client and family about suicide and its prevention. Once the teaching is complete, it is important to evaluate understanding. The family member statement that indicates a need to provide additional teaching is, "This is no sense discouraging suicidal thoughts because it doesn't help." It is essential that suicidal ideation, rumination, and self-harm behaviors be discouraged. The other family member statements indicate a correct understanding of the teaching provided.
A client has just been diagnosed with bipolar disorder and is upset with the diagnosis. The client tells the nurse, "It is probably my mother's fault, she has bipolar too." Which is the best response by the nurse?
"While bipolar disorders are genetic, there are other causes as well." Explanation: Although a single definitive cause has not been pinpointed, scientists agree that a combination or interaction of genes, neurobiology, environment, life history, and development can result in bipolar disorders. Bipolar disorders are highly inheritable.
A client has experienced a first episode of major depression and has received medication and treatment, which has led to a complete remission of the symptoms. The client asks the nurse, "How much longer will I need to take the medication?" Which response by the nurse would be most appropriate?
"You'll need to continue the medication for about 6 to 12 months to see how things go." Explanation: Even after the first episode of major depression, medication should be continued for at least 6 months to 1 year after the client achieves complete remission of symptoms. If the client experiences a recurrence after tapering the first course of treatment, the regimen should be reinstituted for at least another year, and if the illness reoccurs, medication should be continued indefinitely.
A client with bipolar disorder is receiving lithium therapy. The nurse is reviewing the client's serum plasma drug levels and determines that the client's level is therapeutic based on what?
1.0 mEq/L Explanation: Serum plasma lithium levels should range from 0.6 to 1.2 mEq/L. Levels above that suggest toxicity (moderate toxicity for levels 1.5 to 2.5 mEq/L; severe toxicity for levels greater than 2.5 mEq/L).
Which client is most likely to benefit from electroconvulsive therapy (ECT)?
A client whose major depression has not responded appreciably to antidepressants Explanation: While ECT is used to treat an increasing range of psychiatric-mental health problems, individuals with major depression are often among the best candidates for the treatment. ECT would not be used as a response to noncompliance, and a person who is currently experiencing a manic episode is less commonly treated with ECT. Cyclothymic disorder is less severe than bipolar II disorder and is consequently less likely to warrant ECT.
A nurse is providing psycho-education to a client who has been admitted to the inpatient mental health unit for a manic episode. In order to ensure the teaching is effective, the nurse must first determine which regarding the client?
Ability to concentrate and process the information Explanation: To best assure successful outcomes related to client education of an individual experiencing a manic episode, the nurse's initial assessment is focused on the client's ability to concentrate and process the information.
The nurse is seeing a 26-year-old client and the client's family. The client's family describes the client as being "very, very different." The family describes a history of periods of unpredictable behavior and disregard for consequences occurring a few times each year. The client has recently been diagnosed with bipolar I disorder, a condition that is characterized by what?
An elevated mood that lasts for at least 1 week Explanation: During manic episodes that characterize bipolar disorder, the individual exhibits an abnormal, persistently elevated, or irritable mood that lasts for at least 1 week. Failure to respond to treatment, the presence of signs of depression without anhedonia, and the client's admission of a mood disorder are neither diagnostic nor typical of bipolar disorder.
A 34-year-old client with depression is admitted to an inpatient psychiatric unit. The nurse enters the client's room and initiates interaction with the client. When talking with the client, which approach would be least appropriate?
Animated and cheerful manner Explanation: When communicating with clients who are depressed, the nurse should never use an overly enthusiastic approach. This approach can lead to irritation and block communication.
A psychiatric-mental health nurse can best prevent suicide by performing what action?
Assess clients carefully for the warning signs of suicide Explanation: Vigilant assessment for the risk factors and warning signs of suicide is a key preventative measure. The administration of medications does not replace the need for careful assessment and monitoring. Education about epidemiological trends is not an effective preventative action.
The nurse provides care to a hospitalized client who is diagnosed with major depressive disorder (MDD). Which is the priority when planning care for this client?
Assess the client's risk for suicide. Explanation: Although all these actions should be included by the nurse in the client's plan of care, the possibility of suicide should always be a priority for clients who experience MDD. Assessment and documentation of suicide risk should always be included in the client's plan of care and prioritize for safety.
The policies and procedures at a community psychiatric-mental health center include an emphasis on case finding. How can a nurse at the center best perform case finding?
Assessing all clients carefully to identify those at risk for suicide Explanation: Case finding involves the identification of people who are at risk for suicide so that proper treatment can be initiated. Modifying the layout of the center would not be necessary in order to carry out the necessary assessments. Observation would not be a part of community-based care. The nurse should address the shame that often accompanies suicide, but this action is not a key component of case finding.
A client is admitted to the unit in an acute manic episode. The client has had three major depressive episodes in the past 10 years and two other hospitalizations for mania. Which disorders would reflect the client's symptom profile?
Bipolar I Explanation: Bipolar I disorder is characterized by one or more manic episodes, usually alternating with major depressive episodes.
A nursing instructor is reviewing a case study with students about a client with mania who was admitted to a mental health unit. The instructor asks the students what medical diagnosis is most likely responsible for the mania. Which would be the best answer by a student?
Bipolar disorder Explanation: In most cases, mania is a symptom that manifests in people with underlying bipolar disorder. Mania is reflected in periods of euphoria, exuberant activity, grandiosity, and a false sense of well-being. There can be periods of mood instability and irritability as well.
A psychiatric-mental health nurse is conducting a refresher class for a group of psychiatric-mental health nurses returning to the field. After teaching about depressive disorders, the nurse determines a need for additional teaching when the class identifies which physical or psychological symptom as being associated with depression?
Catatonia Explanation: Catatonia is a state of motor or physical activity associated with manic states in bipolar illness. Catatonia is also seen in clients with schizophrenia who have periods of immobility interrupted by episodes of extreme agitation. Fatigue is a lack of energy common during a severely depressed state. Severely depressed clients frequently have difficulty falling asleep or wake early in the morning and are unable to go back to sleep as with insomnia. Feelings of worthlessness or excessive/inappropriate guilt are commonly associated with depression.
A client has just been admitted to the inpatient psychiatry unit following a suicide attempt. During the client's first 24 hours of care, what outcome should be identified?
Client will express that the client feels safe on the unit Explanation: The initial care of a client who has had a suicide attempt focuses on helping the client feel safe and instilling the beginnings of hope. It would be premature to expect the client to learn and apply new stress management strategies after only 24 hours. Cognitive behavioral therapy would not begin during the acute stage of recovery. A sense of overall optimism will likely require long-term therapy to achieve it.
When assessing a client immediately following electroconvulsive therapy (ECT), the nurse expects what in a client?
Confusion Explanation: After ECT treatment, the client may be mildly confused or briefly disoriented. He or she is very tired and often has a headache. The client will have some short-term memory impairment. Numbness and tingling in the extremities is not an expected symptom of ECT.
A client who otherwise is healthy is admitted for depression and reports feeling "all alone" following a recent divorce. The client admits to drinking at least 12 beers every day. The client has which risk factors for the depression? Select all that apply.
Current substance use or abuse Life and environmental stressors Lack of coping abilities Explanation: Risk factors for depression include prior history of depression, family history of depressive disorder, lack of social support, lack of coping abilities, presence of life and environmental stressors, current substance use or abuse, and medical comorbidity. This client's assessment findings include a recent life stressor in the form of divorce and excessive use of alcohol. In addition, the client's social isolation and heavy drinking indicate lack of healthy coping abilities. The client's data do not include a family history or prior history of depression or any other health issues.
A client who otherwise is healthy is admitted for depression and reports feeling "all alone." The client reports recently losing a spouse to divorce. The client admits to drinking at least 12 beers every day. The client has which risk factors for the depression? Select all that apply.
Current substance use or abuse Life and environmental stressors Lack of coping abilities Explanation: Risk factors for depression include prior history of depression, family history of depressive disorder, lack of social support, lack of coping abilities, presence of life and environmental stressors, current substance use or abuse, and medical comorbidity. This client's assessment findings include a recent life stressor in the form of divorce and excessive use of alcohol. In addition, the client's social isolation and heavy drinking indicate lack of healthy coping abilities. The client's data do not include a family history or prior history of depression or any other health issues.
An elderly client is admitted to the hospital with fatigue and weight loss of 20 pounds in 1 month. Upon further assessment, the client is diagnosed with depression. What other thing should the nurse assess this client for based on the weight loss?
Dehydration Explanation: When there is a significant wight loss in older adults with moderate to severe depression, they need to be assessed for dehydration as well as weight changes. They also need to be monitored for suicide, sleep disturbance, and decreased energy, but they are not related to nutrition and the weight loss.
After teaching a group of nursing students about major depression, the instructor determines that the education was successful when the group identifies which information is accurate?
Depression is twice as common in women than in men Explanation: Depression is twice as common in women than in men. The onset of depression can happen at any age; onset is more commonly seen in the 20s. Depression is not correlated with low intellectual ability.
A client on the psychiatric mental health unit completed suicide. A nurse who cared for the client has been experiencing insomnia and anxiety attacks since the event. What is the nurse's first action?
Dialogue with a trusted colleague about these feelings Explanation: A nurse who has experienced secondary trauma may benefit from talking about his or her experience. It would be inappropriate to seek informal care from a psychiatrist on the unit, however. The nurse should likely try talking about the event and seeking outpatient treatment before taking a leave of absence. Interacting with other patients is unlikely to bring the nurse relief.
Which is an anticonvulsant used as a mood stabilizer?
Divalproex Explanation: Divalproex is an anticonvulsant that may be used as a mood stabilizer. Venlafaxine, bupropion, and phenelzine are antidepressants.
A client with a diagnosis of bipolar disorder is described by a family member as "flip-flopping between being happy and loving to irritable and hostile." Which characteristic symptoms of this disorder is the family member referring to?
Emotional lability Explanation: Emotional lability is alterations in moods with little or no change in external events. It is a term used for the rapid shifts in moods that often occur in bipolar disorder.
A client is prescribed a selective serotonin reuptake inhibitor (SSRI) as treatment for depression. Which would the nurse most likely administer?
Escitalopram Explanation: Escitalopram is classified as an SSRI. Venlafaxine is classified as a serotonin norepinephrine reuptake inhibitor. Maprotiline is a cyclic antidepressant. Phenelzine is a monoamine oxidase inhibitor.
On admission to the psychiatric unit, a client is dressed in a red leotard and exercise bra, with an assortment of chains and brightly colored scarves on the client's head, waist, wrists, and ankles. The client's first words to the nurse are, "I'll punch you, munch you, crunch you," as the client dances into the room, shadow boxing. The client shakes the nurse's hand and says cheerfully, "We need to become better acquainted. I have the world's greatest intellect, and you are probably an intellectual midget." How can the nurse document the client's mood?
Expansive and grandiose. Explanation: The client is demonstrating an expansive and grandiose mood state. Although the client also exhibits aspects of belligerence, the client does not have a blunted affect. The client is not demonstrating anxious or unpredictable behavior, suspicion, or paranoia.
A client has been diagnosed with depression and states that the client is reluctant to receive treatment, stating that the client "would prefer to just wait this out." What is the nurse's most appropriate action?
Explain to the client that untreated depression often becomes increasingly severe and frequent over time Explanation: Untreated depression tends to increase in severity and in the frequency of episodes. The client's statement does not necessarily indicate noncompliance, but rather the client's initial preference. Similarly, the client's statement does not necessarily suggest denial. Assessing the client's knowledge of depression is necessary, but describing the risks of suicide does not directly address the client's expressed preference.
Which statement regarding gender and suicide is correct?
Females engage in suicidal behaviors more frequently than males. Explanation: While females engage in suicidal behaviors approximately three times more frequently than males, males are at least four times more likely to die from suicide. This outcome may be because men generally tend to choose more violent methods. In the United States, two thirds of male suicide victims die by firearm. The most common cause of death by suicide in women is overdose or poisoning.
The nurse is conducting an admission assessment with a 45-year-old client who has been demonstrating signs of bipolar disorder. While conducting the assessment, the client starts speaking in illogical rhymes and using word associations. What is the name for this thought pattern?
Flight of ideas Explanation: Rapid "flights of ideas" lead to excessive and illogical rhyming, punning, and word associations, along with pressured speech.
A 32-year-old client is admitted to the inpatient unit for depression with suicidal thoughts. During the nursing assessment, why it is important for the nurse to assess and explore if there is any family member who has committed suicide?
Genetic predisposition Explanation: Suicide rates tend to be higher in families in which suicide has occurred, which are genetic and familial factors. First-degree relatives of individuals who have completed suicide have a two- to eight-times higher risk for suicide than do individuals in the general population.
When teaching prevention to the parents of a 15-year-old client who recently attempted suicide by taking an overdose of alprazolam, the nurse describes which behavioral clue?
Giving away valued personal items Explanation: The suicidal individual may exhibit behaviors that provide clues to his or her intent, including the following:• Talking about death, suicide, and wanting to be dead• Talking or thinking about punishment, torture, and being persecuted• Hearing voices and suddenly seeming very happy after being very depressed for some time• Being very aggressive or very impulsive, and acting suddenly and unexpectedly• Showing an unusual amount of interest in getting his or her affairs in order• Giving away personal belongings
Which would be a finding related to perceptual disturbances during the mental status exam in the client with mania?
Hallucinations Explanation: Perceptual disturbances include hallucinations and delusions, anxiety, and grandiose delusions involving power, wealth, fame, or knowledge. Increased motor activity is assessed in appearance and general behavior. Inappropriate affect is assessed in mood and affect. Limited insight is part of the judgment and insight assessment.
A client taking lithium therapy has a serum therapeutic level of 0.8 mEq/L. What priority dietary instruction should the nurse include in the teaching plan?
Maintain daily sodium intake. Explanation: Consistent sodium intake is critical with lithium therapy. A serum therapeutic level of 0.8mEq/L is within the therapeutic range of 0.6-1.2 mEq/L. Fluid intake on lithium therapy should be increased to 2 L/day. Switching to a DASH diet is used to treat HTN. Monitoring weight pattern should be included but it is not the current priority.
A 30-year-old woman has been brought to the emergency department after causing a disturbance. She is wearing a pair of tight, pink yoga pants, high heels, a sports bra, and a bright-colored hat. The woman's care providers would recognize that the woman's dress may suggest what?
Mania Explanation: Physical appearance is a factor that influences communication; the client with mania may dress in brightly colored clothes with several items of jewelry and excessive makeup.
A client has been diagnosed with major depression. The client reports that the client often wakes up during the night and has trouble returning to sleep. The nurse interprets this finding as suggesting what?
Middle insomnia Explanation: The most common sleep disturbance associated with major depression is insomnia, which is categorized according to three categories: initial insomnia (difficulty falling asleep), middle insomnia (waking up during the night and having difficulty returning to sleep), and terminal insomnia (waking too early and being unable to return to sleep). Less frequently, the sleep disturbance is hypersomnia (prolonged sleep episodes at night or increased daytime sleep).
Cognitive psychotherapy is most likely to be appropriate in the care of a client who has been diagnosed with what?
Moderate depression Explanation: Cognitive psychotherapy is as effective as antidepressant medication in the treatment of mild to moderate depression. It is less likely to address depression that has a demonstrated medical etiology. The primary treatment for postpartum psychosis is medication. Therapy is not relevant in cases of anaclitic depression since the problem occurs in infants.
A client on a medical unit has a comorbid diagnosis of depression and has been taking mirtazapine for several months prior to the current admission. When providing care to the client, which action would be most appropriate for the nurse to do? Select all that apply.
Monitor the client's mood and affect over the course of the admission. Ensure that the client is not cheeking or stockpiling the medication. Explanation: With any antidepressant, the nurse should monitor the client's mood and ensure that he or she is not stockpiling medication for a suicide attempt. Antidepressants do not have a short-term affect on mood, so assessment 30 minutes after administration is unnecessary. Mirtazapine is not associated with hypertensive crises and dietary modifications are unnecessary.
Which biogenic amines have been implicated in depression?
Norepinephrine and serotonin Explanation: The monoamines that have been implicated in depression are norepinephrine (NE), dopamine (DA), and serotonin (5-HT). Disturbances in mood may result when absolute concentrations of NE, 5-HT, or both are deficient.
For which reason is depression in older adults often undiagnosed and untreated?
Older adult depression is often seen as "normal aging." Explanation: Depression is often considered normal in light of the multiple losses common to aging. Older clients, their families, or health care providers mistakenly confuse signs and symptoms of depression with "normal aging." Older adults are not less likely to express sadness or die prior to the onset of depression. Older adults enter the health care system more than do younger adults.
A client is being treated for bipolar disorder and the health care provider has ordered milieu therapy. What best practice method should the nurse use?
Place the client in a private room away from the nurse's station. Explanation: The nurse is responsible for setting a calm therapeutic environment that will prevent overstimulation for the bipolar client. Placing the client in a private room away from the nurse's station will accomplish this. The other options place the focus on stimulation and participation, which would detract from the milieu environment.
A client on the inpatient psychiatric-mental health unit was discovered attempting to asphyxiate himself or herself using a blanket. Which measure should the care team prioritize in the client's immediate care?
Placing the client under constant observation Explanation: The need for safety and suicide prevention supersedes the importance of client education, anxiety management, and assessment of the client's motivations. To prevent further suicide attempts, the safest approach is to monitor the client constantly until stabilized.
A client with major depression and a suicide attempt is admitted to the inpatient facility. The client is started on antidepressant therapy. The next day, the client demonstrates significantly higher energy and says, "I'll feel much better." The nurse would interpret this behavior as suggesting what?
Possible decision to complete a suicide attempt Explanation: In many cases, clients are admitted to the psychiatric hospital because of a suicide attempt. Suicidality should continually be evaluated, and the client should be protected from self-harm. During the depths of depression, clients may not have the energy to complete a suicide. As clients begin to feel better and have increased energy, they may be at a greater risk for suicide. If a previously depressed client appears to become energized overnight, he or she may have made a decision to commit suicide and thus may be relieved that the decision is finally made. The nurse may misinterpret the mood improvement as a positive move toward recovery; however, this client may be very intent on suicide. These individuals should be carefully monitored to maintain their safety. Antidepressants take several weeks to become effective.
A client was admitted to the psychiatric unit after being picked up by police officers who found the client frantically running back and forth across the freeway. The client's spouse reports that the client stayed up all night, ate very little, and talked incessantly. Additional assessment findings that indicate a manic episode include what?
Pressured speech, combative behavior, and impaired judgment Explanation: A manic episode would be characterized by pressured speech, potentially combative behavior, and impaired judgment. Neither psychomotor retardation is present nor are recurrent illusions. Self-destructive behavior is not a classic symptom of mania; more often, clients may have accidents caused by their lack of judgment and psychomotor agitation.
After observing a bipolar client on the mental health unit, the nurse determines that the client is at risk for violence. Which would be an appropriate intervention?
Restrict the client to the client's room until the client can calm down. Explanation: If clients are determined to be at risk for violence, establishing geographic boundaries, such as room or half-hall restriction, is part of ongoing monitoring. Other environmental approaches include reducing stimuli and opportunities for interaction with other clients. Nurses remove all dangerous items from client rooms and monitor closely for use of any dangerous items. A pen or pencil that is used to write a letter can be a dangerous object.
A client has been admitted to a psychiatric-mental health facility in a manic state. The client's spouse accompanies the client to the facility and informs the nurse that the client has been displaying manic symptoms for the past 2 weeks. The spouse reports that the client has not slept for the past 2 days and that the client has not eaten anything for at least 3 days. Which would be the priority nursing diagnosis for this client?
Risk for imbalanced nutrition Explanation: A primary concern for clients with bipolar disorders is physiologic integrity and function. Mania causes hyperactivity, resulting in an inability to sit still for the time needed to eat a meal. Clients with mania often neglect nutritional and fluid needs. While all listed nursing diagnoses are appropriate for the client, restoring nutritional balance is the highest priority.
Which would be the priority diagnosis for the client in the manic phase of bipolar disorder who is exhibiting aggressive behavior?
Risk for other-directed violence Explanation: The priority nursing diagnosis is risk for other-directed violence. The other diagnoses are utilized for the client in the manic phase of bipolar disorder but are not the priority in this situation.
A client is receiving lithium carbonate for the treatment of mania. The nurse would reinforce which teaching component regarding lithium treatment?
Schedule bloodwork for lithium levels. Explanation: There is a narrow range between therapeutic lithium levels and lithium toxicity. It is important to obtain scheduled drug levels to prevent toxicity from occurring. The nurse should monitor for polyuria. Teaching includes taking the medication with food or milk after meals and ensuring an adequate daily intake of fluid (2,500 to 3,000 mL) daily.
Family education concerning the safe care of a client with a history of suicide attempts includes what? Select all that apply.
Signs and symptoms that indicate a mood change that could indicate the client is suicidal Information regarding the stressors that trigger the client's suicidal ideations Techniques to help the client cope with known triggers List of emergency service telephone numbers Explanation: Family education should include information regarding recognizing changes in mood or behavior that could indicate a plan for self-injury (e.g., irritability, anger, agitation, withdrawal, or self-deprecating comments) and notify the client's health care provider. It should also include how to anticipate future stressors that trigger the client, along with information regarding how to assist the client with coping skills. Also important to family education is information regarding a 24-hour emergency hotline phone number—and the need to keep the information readily available.
A nurse is with an adolescent who reports nothing to live for and wishing to be dead. Which nursing action would be the priority?
Staying with the client to explore more of the client's thoughts about suicide Explanation: A true psychiatric emergency exists when an individual presents with one or more symptoms associated with imminent risk for suicidal behavior. The first priority is to provide for the client's safety while initiating the least restrictive care possible. Staying with the client and further exploring the client's thoughts about suicide will enhance safety and allow the nurse to more thoroughly understand the extent of the client's suicidal risk. It would not be appropriate to leave the client alone while the nurse goes to talk with the psychiatrist. Seclusion would be used only as a last resort because it is a highly restrictive environment. Determining the client's beliefs about death would be a topic to be addressed much later in the process.
A nurse is providing a presentation about suicide for a group of health professionals. Which would the nurse address as a major contributor to the rising suicide rate among men?
Substance abuse Explanation: Substance abuse, aggression, hopelessness, emotion-focused coping, social isolation, and lack of purpose in life have been associated with suicidal behavior in men. In addition, just under 50% of suicide attempts among men between the ages of 42 and 77 years involve firearms. The media, lack of conflict resolution skills, and parenting practices can play a role but are not considered major factors.
To confirm that a client is experiencing a manic episode, the nurse must eliminate the possibility that the client's symptoms are related to which problem?
Substance use Explanation: The effects of illicit substance use can mimic the symptoms of mania. The use of substances must be ruled out through the use of blood and urine diagnostics. Once determined that the signs and symptoms are not the result of substances, the client can be further investigated for mania.
The nurse is assessing a 42-year-old client who is experiencing depression. The client's mother died by suicide 20 years ago. Which statement regarding this client's risk for suicide is correct?
The client has a greater risk for suicide than the general population. Explanation: Risk for suicide increases when there is a family history of suicide. Risk of suicide is two to eight times higher in first-degree (parents, siblings, or children) relatives of people who died by suicide than in the general population.
The nurse is working with an outpatient who has a history of depression and suicide attempts. What assessment finding should the nurse interpret as indicating a high degree of planning for a future attempt?
The client recently purchased a large bottle of over-the-counter analgesics Explanation: Acquisition of a large amount of medication strongly suggests planning of a suicide attempt. The client's referral to being a burden suggests suicidality but does not directly indicate a specific plan. Withdrawing from a support group and expressing skepticism about psychopharmacology suggest a worsening of the client's condition but not necessarily a suicide plan.
A 29-year-old first-time mother has been diagnosed with postpartum psychosis after her partner reported the client was hearing voices and told the partner she "saw someone trying to steal the baby." In the planning of this client's care, which outcome should the nurse prioritize?
The client will demonstrate the ability to differentiate between perceptual disturbances and reality. Explanation: An inability to differentiate perceptual disturbances from reality is a hallmark of psychosis, and the ability to do so should be a priority goal in the care of a client with postpartum psychosis. Fatigue, nutrition, and self-expression are less likely to be central issues.
A mental health nurse has identified a nursing diagnosis of hopelessness related to poor self-concept for a client with depression. Which outcome would be most appropriate for this nursing diagnosis?
The client will reframe negative thoughts in a more positive way. Explanation: An appropriate outcome for hopelessness would be for the client to reframe and redefine an event positively rather than negatively, which can help the client view the situation in an alternative way, thereby fostering hope. Discussing the cause of fatigue is unrelated to hopelessness. Identifying factors contributing to depression would reflect a knowledge deficit. The ability to differentiate reality from fantasy would be inappropriate for this client. There is nothing to support that the client is not focused in the here and now.
When completing a baseline assessment of a client with depression, which diagnostic tests would the nurse anticipate?
Thyroid function tests Explanation: A physical examination is recommended with baseline vital signs and baseline laboratory tests, including a comprehensive blood chemistry panel, complete blood counts, liver function tests, thyroid function tests, urinalysis, and electrocardiograms. These physical examinations can help to rule out any underlying medical conditions that may be causing or exacerbating an existing depression. The other diagnostic tests indicated in the options are not related to identifying underlying medical conditions that are commonly found comorbid to depression.
A nurse taking an admission history from a client suspects that the physician will diagnose major depression. For the physician to make this diagnosis, the client will have to demonstrate specific symptoms. What are some of these symptoms? Select all that apply.
disruption in sleep disruption in appetite disruption in concentration excessive guilt Explanation: Four of seven symptoms must be present along with the episodes of depressed mood to qualify for a diagnosis of major depressive disorder. Symptoms include disruption in sleep, appetite, concentration, or energy; psychomotor agitation or retardation; excessive guilt or feelings of worthlessness; and suicidal ideation.
Which is the greatest predictor of a future suicide attempt?
previous attempt Explanation: The greatest predictor of a future suicide attempt is a previous attempt, in part because that individual already has broken the "taboo" around suicidal behavior. Assessing for risk includes determining the seriousness of the suicidal ideation, degree of hopelessness, and suicide planning.
