Mental Health Nursing

Tricyclic Antidepressants

* Raise the level of epinephrine and serotonin in the brain by slowing the rate at which they are reabsorbed by nerve cells. * SIDE EFFECTS: anticholinergic in nature (dry mouth, constipation), blurred vision, dizziness, drowsiness, tachycardia, dysrhythmias, hypotension, increased suicide risks the first few weeks of therapy THE MEDS: Amitriptyline (Elavil) Nortriptyline (Pamelor) Imipramine (Tofranil)

The nurse is preparing to administer lithium (Eskalith), an antimania medication, to a client diagnosed with bipolar disorder. The lithium level is 1.4 mEq/L. Which action should the nurse implement? 1. Administer the medication 2. Hold the medication 3. Notify the health-care provider 4. Verify the lithium level

1. Administer the medication The therapeutic serum level is 0.6 to 1.5 mEq/L. Because the lithium level is within those parameters, the nurse should administer the medication.

The client admitted to the psychiatric unit for major depressive disorder with an attempted suicide is prescribed an antidepressant medication. Which interventions should the psychiatric nurse implement? SELECT ALL THAT APPLY. 1. Assess the client's apical pulse and blood pressure 2. Check the client's serum antidepressant level 3. Monitor the client's liver function status 4. Provide for and ensure the client's safety 5. Evaluate the effectiveness of the medication

1. Assess the client's apical pulse and blood pressure 3. Monitor the client's liver function status 4. Provide for and ensure the client's safety Antidepressant medications may cause orthostatic hypotension, and the nurse should question administering the medication if the blood pressure is less than 90/60. Many antidepressants may cause hepatotoxicity; therefore, the nurse should monitor the client's liver function tests. The nurse should ensure the client's safety. Many antidepressants may cause orthostatic hypotension and increase the risk for dizziness, falls, and injuries

The male client is diagnosed with narcolepsy. Which over-the-counter preparations should the nurse teach the client about? 1. Caffeinated beverages and diphenhydramine (Benadryl) 2. Flavored water and beta carotene 3. Milk with added vitamin D and saw palmetto 4. Carbonated sodas and black cohosh

1. Caffeinated beverages and diphenhydramine (Benadryl) Caffeine may help the client to achieve some measure of alertness, whereas products containing diphenhydramine can increase the client's problem because this medication is used in over-the-counter sleep aids. The client should be taught about both

The client who is a chronic alcoholic is admitted to the medical unit for pneumonia. Which medication would the nurse expect the health-care provider to prescribe to prevent delirium tremens? 1. Chlordizaepoxide (Librium), a benzodiazepine 2. Thiamine (vitabine B1), a vitamin 3. Disulfiram (Antabuse), an abstinence medication 4. Fluoxetine (Prozac), an antidepressant

1. Chlordizaepoxide (Librium), a benzodiazepine Librium diminishes anxiety and has anticonvulsant qualities to provide safe withdrawal from alcohol. It may be ordered every 4 hours or PRN to manage adverse effects from withdrawal, after which the dose is tapered to zero

The client with major depressive disorder is suicidal. The client was prescribed the tricyclic antidepressant imipramine (Tofranil) 3 weeks ago. Which priority intervention should the nurse implement? 1. Determine if the client has a plan to commit suicide 2. Assess if the client is sleeping better at night 3. Ask the family if the client still wants to kill himself or herself 4. Observe the client for signs of wanting to commit suicide

1. Determine if the client has a plan to commit suicide The nurse should ask if the client has a plan to commit suicide. As the client begins to recover from both psychological and physical depression, the client's energy level increases, making the client more prone to commit suicide during this time. It takes 2-6 weeks for therapeutic effects of tricyclic antidepressants to be effective

The elderly client being prepared for major abdominal surgery has been taking alprazolam (Xanax), a benzodiazepine, PRN for many years for nerves. Which information should the nurse discuss with the HCP? 1. Discuss prescribing another benzodiazepine medication postoperatively 2. Make sure that the alprazolam (Xanax) is ordered after surgery 3. Taper the medication to prevent complications 4. Change the alprazolam (Xanax) to a medication for sleep

1. Discuss prescribing another benzodiazepine medication postoperatively The client is having abdominal surgery so the client will be NPO for a while. Xanax is only manufactured for an oral medication. Therefore, the client will need a similar medication postoperatively. The nurse should discuss this with the HCP.

The client diagnosed with schizophrenia is prescribed clozapine (Clozaril), an atypical antipsychotic. Which information should the nurse discuss with the client concerning this medication? 1. Discuss the need for regular exercise 2. Instruct the client to monitor for weight loss 3. Tell the client to take the medication with food 4. Explain to the client the need to decrease alcohol intake

1. Discuss the need for regular exercise Clozaril can promote significant weight gain; therefore, the client should exercise regularly, monitor weight, and reduce caloric intake

The health-care provider has prescribed lorazepam (Ativan), a benzodiazepine, for a female client receiving chemotherapy who complains of inability to sleep. Which information should the nurse teach the client? 1. Do not attempt to become pregnant while taking Ativan 2. Avoid consuming too much alcohol while taking Ativan 3. Try exercising to tire yourself just before bedtime 4. Do not take the medication too long to avoid addiction

1. Do not attempt to become pregnant while taking Ativan The client should be instructed not to attempt to get pregnant while receiving chemotherapy or taking Ativan. Ativan is a pregnancy category D drug. Ativan is very useful in controlling chemotherapy-induced nausea and vomiting, so the HCP is attempting to achieve a dual use for the medication--improved sleep and relief of chemotherapy-induced nausea

Which information should the nurse discuss with the client diagnosed with schizophrenia who is prescribed an antipsychotic medication? 1. Drink decaffeinated coffee and tea 2. Decrease the dietary intake of salt 3. Eat six small, high-protein meals a day 4. Limit alcohol intake to one glass of wine a day

1. Drink decaffeinated coffee and tea Caffeine-containing substances will negate the effects of antipsychotic medication; therefore, the client should drink caffeine-free beverages such as decaffeinated coffee and tea and caffeine-free colas

Which pharmacologic intervention should the nurse discuss with the client who is requesting help to quit smoking marijuana? 1. Explain that there is no specific pharmacologic intervention 2. Instruct the client to use a nicotine patch or chew nicotine gum 3. Encourage the client to have the HCP prescribe an antianxiety medication 4. Discuss tapering dronabinol (Marinol) over a 2-week time period

1. Explain that there is no specific pharmacologic intervention Marijuana is psychologically addicting, not physically addicting. There is no medication that can help the client to quit smoking marijuana.

The client diagnosed with a general anxiety disorder is prescribed alprazolam (Xanax), a benzodiazepine. Which information should the clinic nurse discuss with the client? 1. Explain to the client that this medication is for short-term use. 2. Inform the client that rage and excitement are expected side effects 3. Tell the client to avoid foods that are high in vitamin K 4. Instruct the client to take the medication with at least 8 ounces of water

1. Explain to the client that this medication is for short-term use Xanax has the potential for dependency, but that potential can be minimized by using the lowest effective dosage for the shortest time necessary.

The client diagnosed with bipolar disorder is prescribed lithium (Eskalith), an antimania medication. Which interventions should the nurse discuss with the client? SELECT ALL THAT APPLY. 1. Monitor serum therapeutic levels 2. Maintain an adequate fluid intake 3. Decrease sodium intake in diet 4. Do not take medication if the radial pulse is <60 5. Explain ways to prevent orthostatic hypotension

1. Monitor serum therapeutic levels 2. Maintain an adequate fluid intake Lithium has a narrow therapeutic serum level. The level is monitored every 3-5 days initially and every 2-3 months thereafter. Lithium is a salt and may cause dehydration; therefore, the client should maintain an adequate fluid intake of at least 2000 mL or more a day

The client has been taking alprazolam (Xanax), a benzodiazepine, daily for the last 2 years. Which signs or symptoms would warrant intervention by the nurse? 1. Nausea, vomiting, and agitation 2. Yawning, rhinorrhea, and cramps 3. Disorientation, lethargy, and craving 4. Ataxia, hyperpyrexia, and respiratory distress

1. Nausea, vomiting, and agitation Nausea, vomiting, and agitation, along with tachycardia, diaphoresis, tremors, and marked insomnia, are adverse effects of central nervous system depressants, such as benzodiazepines.

The conscious client was admitted to the emergency department with an overdose of the anxiolytic alpraxolam (Xanax). Which intervention should the nurse implement first? 1. Prepare to administer an emetic with activated charcoal 2. Request a mental health consultation for the client 3. Prepare to administer the antidote flumazenil (Romazicon) IV 4. Determine why the client chose to overdose on the medication

1. Prepare to administer an emetic with activated charcoal The first intervention in a case of Xanax overdose is to encourage vomiting--to remove the medication from the stomach before the medication is metabolized and absorbed into the system. Administering an emetic with activated charcoal would induce vomiting

Nonverbal cues include... (3)

1. Sudden brightening of mood 2. Giving away of ones belongings 3. Organizing financial affairs

The client diagnosed with narcolepsy is prescribed methylphenidate (Ritalin), an amphetamine. Which information should the nurse teach the client? 1. Take the medication early in the day 2. The medication should be taken at bedtime 3. Keep the medication in a locked cabinet 4. Notify the HCP if there is a decrease in appetite

1. Take the medication early in the day Ritalin is a stimulant and should be taken early in the day to prevent insomnia at night

The client with bipolar disorder is prescribed carbamazepine (Tegretol), an anticonvulsant. Which data indicates the medication is effective? 1. The client is able to control extremes between mania and depression 2. The client's serum Tegretol level is within the therapeutic range 3. The client reports a "3" on a depression scale of 1-10, with 10 indicating severely depressed 4. The client has a decrease in delusional thoughts and hallucinations

1. The client is able to control extremes between mania and depression Tegretol is an anticonvulsant medication that is prescribed as a mood stabilizer. Mood stabilizers are prescribed because they have the ability to moderate extreme shifts in emotions between mania and depression. Therefore, this data indicates the medication is effective.

The client diagnosed with pneumonia is admitted to the medical unit. The nurse notes the client is taking an antidepressant medication. Which data best indicate the antidepressant therapy is effective? 1. The client reports a "2" on a 1-10 scale, with 10 being very depressed 2. The client reports not feeling very depressed today 3. The client gets out of bed and completes activities of daily living 4. The client eats 90% of all meals that are served during the shift

1. The client reports a "2" on a 1-10 scale, with 10 being very depressed Depression is subjective and the nurse does not know this client; therefore, asking the client to rate the depression on a scale best indicates the effectiveness of the medication. Any subjective data can be put on a scale to make it objective

The 24-year-old female client with bipolar disorder is prescribed valproic acid (Depakote), an anticonvulsant medication. Which question should the nurse ask the client? 1. "Have you ever had a migraine headache?" 2. "Are you taking any type of birth control?" 3. "When was the last time you had a seizure?" 4. "How long since you have had a manic episode?"

2. "Are you taking any type of birth control?" Depakote is a category D drug, which means it will cause harm to the fetus and should not be prescribed to a female of childbearing age who is not taking the birth control pill

The client diagnosed with bipolar disorder is taking lithium (Eskalith), an anti mania medication. Which statement by the client warrants further clarification by the nurse? 1. "I will limit the amount of caffeine I drink." 2. "I really enjoy playing soccer on weekends." 3. "I will drink at least 2000 mL of water a day." 4. "I need to call my HCP if I develop diarrhea."

2. "I really enjoy playing soccer on weekends." Playing soccer or any sport that includes running can lead to dehydration, and the nurse must make sure the client understands the need to stay well-hydrated during the activity. Therefore, this comment indicates the need for further clarification by the nurse.

Which statement indicates the client diagnosed with bipolar disorder who is taking lithium (Eskalith), an anti mania medication, understands the medication teaching? 1. "I will monitor my daily lithium level." 2. "I will make sure I do not get dehydrated." 3. "I need to taper the dose if I quit taking it." 4. "I need to take the medication on an empty stomach."

2. "I will make sure I do not get dehydrated" Lithium acts like sodium in the body so dehydration can cause lithium toxicity; therefore, the client should not become dehydrated

The client with major depressive disorder is prescribed nefazodone (Serzone), an atypical antidepressant. The client tells the nurse, "I am going to take my medication at night instead of in the morning." Which statement would be the nurse's best response? 1. "You really should take the medication in the morning for the best results" 2. "It is all right to take the medication at night. It may help you sleep at night" 3. "The medication should be taken with food so you should not take it at night" 4. "Have you discussed taking the medication at night with your psychiatrist?"

2. "It is all right to take the medication at night. It may help you sleep at night" Antidepressants may cause central nervous depression, which causes drowsiness. Therefore, taking the medication at night may help the client sleep at night and relieve daytime sedation. This is the nurse's best response.

The client diagnosed with obsessive-compulsive disorder is prescribed the selective serotonin reuptake inhibitor (SSRI) sertraline (Zoloft). Which statement indicates the client understands the medication teaching? 1. "If I get a headache or become nauseated, I will notify my HCP." 2. "It will take a couple of months before I see a change in my behavior." 3. "I need to be careful because SSRIs may cause physical addiction." 4. "I am glad I do not need to go to my psychologist's appointments."

2. "It will take a couple of months before I see a change in my behavior" The beneficial effects of SSRIs develop slowly, taking several months to become maximal when used to treat obsessive-compulsive disorder. The client understands this.

For which client would the nurse expect the health-care provider to prescribe methadone, an abstinence medication? 1. A client addicted to cocaine 2. A client addicted to heroin 3. A client addicted to amphetamines 4. A client addicted to hallucinogens

2. A client addicted to heroin Methadone blocks the craving for heroin

To which client would it be most appropriate to prescribe disulfiram (Antabuse), an abstinence medication? 1. A client with chronic alcoholism admitted to the medical unit 2. A highly motivated client who wants to quit drinking alcohol 3. A client who has been taking amphetamines for more than 1 year 4. A highly motivated client who wants to quit taking heroin

2. A highly motivated client who wants to quit drinking alcohol Disulfiram is only effective in highly motivated clients because the success of pharmacotherapy is entirely dependent on client compliance. This client is highly motivated to quit drinking alcohol

The client is having a CT scan and starts having a severe anxiety attack. The HCP prescribed the anxiolytic diazepam (Valium), intravenous push. Which action should the nurse implement? 1. Dilute the Valium with normal saline and administer IVP 2. Do not dilute the Valium and inject in a port closest to the client 3. Inject the Valium into a 50-mL normal saline bag and infuse 4. Question the order because Valium should not be administered IV

2. Do not dilute the Valium and inject in a port closest to the client The nurse should administer the Valium undiluted over 2-3 minutes in the IV port closest to the client's hand so the medication can get to the client's blood stream faster

The client with a major depressive disorder taking the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac) calls the psychiatric clinic and reports feeling confused and restless and having an elevated temperature. Which action should the psychiatric nurse take? 1. Determine if the client has flulike symptoms 2. Instruct the client to stop taking the SSRI 3. Recommend the client take the medication at night. 4. Explain that these are expected side effects

2. Instruct the client to stop taking the SSRI Serotonin syndrome is a serious complication of SSRIs that produces mental changes (confusion, anxiety, and restlessness), hypertension, tremors, sweating, hyperpyrexia (elevated temperature), and ataxia. Conservation treatment includes stopping the SSRI and supportive treatment. If untreated, ESE can lead to death

The 10-year-old client has begun to sleepwalk, a parasomnia disorder. Which information should the nurse provide the parents of the child? SELECT ALL THAT APPLY. 1. Give the child a mild sedative 2 hours before bedtime 2. Place a lock on the outer door out of the child's reach 3. Make the child wake up when an episode occurs. 4. Have the child practice guided imagery before bedtime 5. Administer atomoxetine (Strattera) every morning

2. Place a lock on the outer door out of the child's reach This is a safety measure to keep the child from exiting the house during the night

The male client with chronic alcoholism comes to the emergency department (ED) reporting he has not had an alcoholic drink in more than 1 week. Which action should the ED nurse implement first? 1. Implement seizure precautions according to hospital policy 2. Rehydrate the client with large amounts of intravenous fluids 3. Discuss withdrawal treatment in a hospital environment 4. Administer thiamine (Vitamin B1) through an intravenous route

2. Rehydrate the client with large amounts of intravenous fluids Immediately on arrival to a hospital the client should be rehydrated with large amounts of intravenous physiological fluids. This is the first intervention.

The client diagnosed with insomnia is scheduled for sleep studies. Which medication should the nurse instruct the client not to take? 1. The ACE inhibitor captopril. 2. The antihistamine diphenhydramine 3. The loop diuretic furosemide 4. The thyroid medication levothyroxine

2. The antihistamine diphenhydramine Antihistamines such as diphenhydramine (Benadryl) can cause drowsiness in many clients; the client should not take any medication that would interfere with the test being interpreted correctly

The client admitted to the psychiatric unit diagnosed with schizophrenia is prescribed clozapine (Clozaril), an atypical antipsychotic. Which laboratory data should the nurse evaluate? 1. The client's clozapine therapeutic level 2. The client's white blood cell count 3. THe client's red blood cell count 4. The client's arterial blood gases

2. The client's white blood cell count Weekly WBCs are taken because the client is at risk for fatal agranulocytosis. Initially the medication will not be administered if the WBC is not available

The client diagnosed with paranoid schizophrenia has been taking haloperidol (Haldol), a conventional antipsychotic, for several years. Which statement indicates the client needs additional teaching concerning this medication? 1. "I know that if I have any rigidity or tremors I must call my HCP." 2. "I eat high-fiber foods and drink extra water during the day." 3. "I am more susceptible to colds and the flu when taking this medication." 4. "This medication will make my hallucinations and delusions go away."

3. "I am more susceptible to colds and the flu when taking this medication." Haldol causes agranulocytosis, which diminishes the client's ability to fight infection, but the medication (if the client does not develop the adverse effect of agranulocytosis) does not cause the client to have increased susceptibility to colds and the flu. If the client has a fever or sore throat, the HCP should be notified, and if the white blood cell count is elevated, the medication will be discontinued

The client diagnosed with a major depressive disorder asks the nurse, "Why did my psychiatrist prescribe an SSRI medication rather than one of the other types of anti-depressants?" Which statement by the nurse would be most appropriate? 1. "Probably it is the medication that your insurance will pay for" 2. "You should ask your psychiatrist why the SSRI was ordered" 3. "SSRIs have fewer side effects than the other classifications" 4. "The SSRI medications work faster than the other medications"

3. "SSRIs have fewer side effects than the other classifications." SSRIs have the same efficacy as MAO inhibitors and tricyclics, but SSRIs are safer because they do not have the sympathomimetic effects (tachycardia and hypertension) and anticholinergic effects (dry mouth, blurred vision, urinary retention, and constipation) of the MAO inhibitors and tricyclics.

The nurse is preparing to administer the benzodiazepine alprazolam (Xanax) to a client who has a generalized anxiety disorder. Which intervention should the nurse implement prior to administering the medication? 1. Assess the client's apical pulse 2. Assess the client's respiratory rate 3. Assess the client's anxiety level 4. Assess the client's blood pressure

3. Assess the client's anxiety level The nurse must assess the client's anxiety level on a scale of 1 to 10, with 10 being the most anxious, before administering the Xanax. If the nurse does not do this, there is no way to evaluate the effectiveness of the medication later

The female client taking lorazepam (Ativan), a benzodiazepine, for panic attacks tells the clinic nurse that she is trying to get pregnant. Which action should the nurse take first? 1. Tell the client to inform the obstetrician of taking Ativan. 2. Instruct the client to quit taking the medication 3. Determine how long the client has been taking the medication 4. Encourage the client to stop taking Ativan prior to getting pregnant

3. Determine how long the client has been taking the medication The nurse should first determine how long the client has been taking Ativan and what dosage (or how many pills) to determine if the medication can be discontinued abruptly or if it must be gradually decreased

The client diagnosed with major depression who attempted suicide is being discharged from the psychiatric facility after a 2-week stay. Which discharge intervention is most important for the nurse to implement? 1. Provide the family with the phone number to call if the client needs assistance 2. Encourage the client to keep all follow-up appointments with the psychiatric clinic 3. Ensure the client has no more than a 7-day supply of antidepressants 4. Instruct the client not to take any over-the-counter medications without consulting with the HCP

3. Ensure the client has no more than a 7-day supply of antidepressants Ensuring the psychological and physical safety of the client is priority. As antidepressant medications become more effective, the client is at a higher risk for suicide. Therefore, the nurse should ensure that the client cannot take an overdose of medication

The client with bipolar disorder who is prescribed lithium (Eskalith), an anti mania medication, is admitted to the psychiatric unit in an acute manic state. Which intervention should the nurse implement first? 1. Determine the client's serum lithium level 2. Assess why the client quit taking the lithium 3. Implement care for the client's physiological needs 4. Administer a stat dose of lithium to the client

3. Implement care for the client's physiological needs This is the first intervention because the client is in an acute manic state and the client's physiological need is priority

The client is discussing wanting to quit smoking cigarettes with the clinic nurse. Which intervention is most successful in helping the client to quit smoking cigarettes? 1. Encourage the client to attend a smoking cessation support group 2. Discuss tapering the number of cigarettes smoked daily 3. Instruct the client to use nicotine replacement therapy, such as a patch 4. Explain that clonidine can be taken daily to help decrease withdrawal symptoms

3. Instruct the client to use nicotine replacement therapy, such as a patch Using a nicotine patch or chewing nicotine gum is the most successful way to help with the nicotine withdrawal symptoms

The client admitted to the psychiatric unit experiencing hallucinations and delusions is prescribed risperidone (Risperdal), an atypical antipsychotic. Which intervention should the nurse implement? 1. Provide the client with a low tyramine diet 2. Assess the client's respiration for 1 full minute 3. Instruct the client to change positions slowly 4. Monitor the client's intake and output

3. Instruct the client's respiration for 1 full minute A side effect of all types of antipsychotics is orthostatic hypotension (lightheadedness, dizziness), which can be minimized by moving slowly when assuming an erect posture.

The client with paranoid schizophrenia is prescribed aripiprazole (Abilify), a dopamine system stabilizer (DDS). Which statement best describes the scientific rationale for administering this medication? 1. It decreases the anxiety associated with hallucinations and delusions 2. It increases the dopamine secretion in the brain tissue to improve speech 3. It reduces positive symptoms of schizophrenia and improves negative symptoms 4. It blocks the cholinergic receptor sites in the diseased brain tissue

3. It reduces positive symptoms of schizophrenia and improves negative symptoms Like other antipsychotics, Abilify treats the positive and negative symptoms of schizophrenia--but it does so with fewer side effects than other antipsychotics. This medication does not cause significant weight gain, hypotension, or prolactin release, and it poses no risk of anticholinergic effects or dysrhythmias

The client has Pickwickian syndrome and falls asleep at inappropriate times. Which medication should the nurse prepare to administer? 1. Maximum Strength NoDoz, a caffeine drug 2. An inhaled steroid in a bi-pap machine for nighttime sleep 3. Modafinil (Provigil), a central nervous system stimulant 4. Amitriptyline (Elavil), a tricyclic antidepressant

3. Modafinil (Provigil), a central nervous system stimulant A central nervous system stimulant would be ordered to prevent somnolence

The client with bipolar disorder who is taking lithium (Eskalith), an anti mania medication, has a lithium level of 3.1 mEq/L. Which treatment would the nurse expect the health-care provider to prescribe? 1. No treatment because this is within the therapeutic range. 2. Intravenous therapy with an 18-gauge angiocath 3. Preparation for immediate hemodialysis 4. The antidote for lithium toxicity

3. Preparation for immediate hemodialysis Extremely high toxic levels of lithium require hemodialysis and supportive care

The elderly client diagnosed with a panic attack disorder is in the busy day room of a long-term care facility and appears anxious, is starting to hyperventilate, is trembling, and is sweating. Which action should the nurse implement first? 1. Administer the benzodiazepine alprazolam (Xanax) 2. Assess the client's vital signs 3. Remove the client from the day room 4. Administer the selective serotonin reuptake inhibitor (SSRI) sertraline (Zoloft)

3. Remove the client from the day room This is the most appropriate intervention; the nurse should remove the client from the busy day room to help decrease the anxiety attack

To which client would the nurse question administering lithium (Eskalish), an antimania medication? 1. The 54-year-old client on a 4-g sodium diet 2. The 23-year-old client taking an antidepressant medication 3. The 42-year-old client taking a loop diuretic 4. The 30-year-old client with a urine output of 40 mL/hour

3. The 42-year-old client taking a loop diuretic Diuretics increase the excretion of lithium from the kidneys; therefore, the nurse would question administering lithium to this client

The client diagnosed with depression is prescribed phenelzine (Nardil), a monoamine oxidase (MAO) inhibitor. Which statement by the client indicates to the nurse the medication teaching is effective? 1. "I am taking the herb ginseng to help my attention span" 2. "I drink extra fluids, especially coffee and iced tea" 3. "I am eating three well-balanced meals a day" 4. "At a family cookout I had chicken instead of a hotdog"

4. "At a family cookout I had chicken instead of a hotdog." Taking MAOIs requires adherence to strict dietary restrictions concerning tyramine-containing foods, such as processed meat (hot dogs, bologna, and salami), yeast products, beer, and red wines. Eating these foods can cause a life-threatening hypertensive crisis

The client who returned from the war 1 month ago is diagnosed with posttraumatic stress disorder (PTSD) and prescribed paroxetine (Paxil), an SSRI. The client asks the nurse, "Will this medication really help me? I don't like feeling this way." Which statement is the nurse's best response? 1. "The medication will make you feel better within a couple of days." 2. "Why do you think the medication won't help you feel better?" 3. "Nothing really helps PTSD unless you go to counseling weekly." 4. "Because the traumatic event was within 1 month, the Paxil should be helpful."

4. "Because the traumatic event was within 1 month, the Paxil should be helpful." SSRIs reduce the three core symptoms of PTSD: re-experiencing, avoidance/ emotional numbing, and hyperarousal. The medication is most effective if taken within 3 months of the traumatic event and may take up to 2 or 3 months for maximal response

A client in the medical unit has been NPO for 3 days and is complaining of a headache. Which question should the nurse ask the client in regard to determining the reason for the headache? 1. "Do you eat a diet high in glucose?" 2. "How often do you drink alcohol?" 3. "Do you take sleeping pills regularly?" 4. "How often do you drink caffeinated beverages?"

4. "How often do you drink caffeinated beverages?" A hallmark symptom of caffeine withdrawal is a headache, along with fatigue, depression, and impaired performance of daily activities. This question would be most appropriate for the nurse to ask the client.

The male client diagnosed with schizophrenia is prescibed ziprasidone (Geodon), an atypical antipsychotic. Which statement to the nurse indicates the client understands the medication teaching? 1. "I need to keep taking this medication even if I become impotent." 2. "I should not go out in the sun without wearing protective clothing." 3. "This medication may cause my breast size to increase." 4. "I may have trouble sleeping when I take this medication"

4. "I may have trouble sleeping when I take this medication" Geodon is well-tolerated, but the most common side effect is difficulty in sleeping, perhaps because of the histamine antagonist blockade effect of the drug. This comment indicates the client understands the teaching.

The client prescribed an antidepressant 1 week ago tells the psychiatric clinic nurse, "I really don't think this medication is helping me." Which statement by the psychiatric nurse would be most appropriate? 1. "Why do you think the medication is not helping you?" 2. "You think your medication is not helping you?" 3. "You need to come to the clinic so we can discuss this." 4. "It takes about 3 weeks for your medication to work"

4. "It takes about 3 weeks for your medication to work" The client probably was told this information but may have forgotten it, or the client may not have been told, but the most appropriate response is to provide information so that the client realizes it takes 3 weeks for the medication to work and that he or she may not feel better until that time has elapsed.

The client with a staggering gait is brought to the emergency department by a friend. The client is short of breath and has an oral temperature of 104 degrees. Which question should the nurse ask the client's friend? 1. "How many alcohol drinks has your friend had today?" 2. "When was the last time your friend took amphetamines?" 3. "Has your friend been inhaling any type of paint thinner?" 4. "Through which route and at what time did your friend take cocaine?"

4. "Through which route and at what time did your friend take cocaine?" Respiratory distress, ataxia, hyperpyrexia, convulsions, coma, or stroke are signs and symptoms of cocaine overdose. This question would be most appropriate for the nurse to ask based on the client's signs and symptoms

The male client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the medical unit. During the admission process the client tells the nurse that he cannot sleep without Valium, a benzodiazepine, every night. Which action should the nurse take? 1. Inform the client that clients with COPD should not take Valium 2. Ask the client when was the last time he had any seizure activity 3. Determine what effect the Valium has on the client when he takes it 4. Ask the health-care provider for an order for Valium

4. Ask the health-care provider for an order for Valium Benzodiazepines should be tapered off when the client is trying to stop taking them. The nurse should request an order for the Valium

The client with an anxiety disorder is prescribed the anxiolytic alprazolam (Xanax). The client calls the clinic and reports a dizzy, weak feeling when getting out of the chair. Which action should the nurse take? 1. Instruct the client to quit taking the medication 2. Make an appointment for the client to come to the clinic 3. Determine if the client is drinking enough fluids 4. Discuss ways to prevent orthostatic hypotension

4. Discuss ways to prevent orthostatic hypotension Feeling dizzy and weak when getting out of a chair is indicative of orthostatic hypotension, which is a common side effect of anti anxiety medications. The nurse should instruct the client to rise slowly from the sitting to standing position to avoid dizziness

The client with major depressive disorder has been taking amitriptyline (Elavil), a tricyclic antidepressant, for more than 1 year. The client tells the psychiatric clinic nurse that the client wants to quit taking the antidepressant. Which intervention is most important for the nurse to discuss with the client? 1. Ask questions to determine if the client is still depressed 2. Ask the client why he or she wants to stop taking the medication 3. Tell the client to notify the HCP before stopping medication 4. Explain the importance of tapering off the medication

4. Explain the importance of tapering off the medication The client must first know the importance of needing to taper off the medication because rebound dysphoria, irritability, or sleepiness may occur if the medication is discontinued abruptly. Then the client should see the HCP to determine what action doesn't want to take the medication.

The client is prescribed methadone, an opiate agonist. Which intervention should the nurse discuss with the client? 1. Take the medication on an empty stomach 2. Decrease the fiber in the diet while taking the medication 3. Do not take methadone if the radial pulse is less than 60 4. Learn how to prevent orthostatic hypotension

4. Learn how to prevent orthostatic hypotension Methadone causes drowsiness, light-headedness, dizziness, and a transient drop in blood pressure. Therefore, the nurse should discuss how to prevent orthostatic hypotension. Methadone is used to treat heroin withdrawal.

The nurse is discussing the prescribed antipsychotic medication with a family member of a client diagnosed with schizophrenia. Which information should the nurse discuss with the family member? 1. Explain the need for the family member to give the client the medication 2. Encourage the family member to learn cardiopulmonary resuscitation (CPR0. 3. Discuss the need for the client to participate in a community support group 4. Teach the family member what to do in case the client has a seizure

4. Teach the family member what to do in case the client has a seizure Antipsychotic medications lower the seizures threshold, even if the client does not have a seizure disorder. Therefore, the nurse should discuss what to do if the client has a seizure

Which information should the nurse discuss with the client diagnosed with bipolar disorder who is taking the anticonvulsant carbamazepine (Tegretol)? 1. Instruct the client to use a soft-bristled toothbrush 2. Encourage the client to get ophthalmic examinations annually. 3. Teach the client to monitor the blood pressure daily. 4. Tell the client to avoid hazardous activities

4. Tell the client to avoid hazardous activities The client should avoid driving and other hazardous activities until the effects of Tegretol are known because this medication may cause sedation and drowsiness

Which assessment data indicates the atypical antipsychotic quetiapine (Seroquel) is effective for the client diagnosed with paranoid schizophrenia? 1. The client does not exhibit any tremors or rigidity 2. The client reports a "2" on an anxiety scale of 1-10 3. The family reports the client is sleeping all night 4. The client denies having auditory hallucinations

4. The client denies having auditory hallucinations Antipsychotic medications are prescribed to decrease the signs or symptoms of schizophrenia. If the client denies auditory hallucinations, the medication is effective.

The 43-year-old female client diagnosed with schizophrenia has been taking the conventional antipsychotic medication chlorpromazine (Thorazine) for 20 years. Which assessment data would warrant discontinuing the medication? 1. The client has had menstrual irregularities for the last year 2. The client has to get up very slowly from a sitting position 3. The client complains of having a dry mouth and blurred vision 4. The client has fine, wormlike movements of the tongue

4. The client has fine, wormlike movements of the tongue Exhibiting fine, wormlike movements of the tongue is a symptom of tardive dyskinesia, which is an adverse effect that may develop after months or years of continuous therapy with a conventional antipsychotic medication. The medication should be discontinued, and a benzodiazepine should be administered

The client is receiving the anxiolytic alprazolam (Xanax) for a generalized anxiety disorder. Which assessment data best indicates the medication is effective? 1. The client reports not feeling anxious 2. The client's pulse is not greater than 100 3. The client's respiratory rate is not greater than 22 4. The client reports a "1" on a 1-10 anxiety scale

4. The client reports a "1" on a 1-10 anxiety scale The best indicator of the medication's effectiveness is the client's objective report of his or her anxiety level

A patient in a support group says, "I'm tired of being sick. Everyone always helps me, but I will be glad when I can help someone else." This statement reflects: a. altruism. b. universality. c. cohesiveness. d. corrective recapitulation.

ANS: A Altruism refers to the experience of being helpful or useful to others, a condition that the patient anticipates will happen. The other options are also therapeutic factors identified by Yalom.

A therapy group adds new members as others leave. What type of group is evident? a. Open b. Closed c. Homogeneous d. Heterogeneous

ANS: A An open group is a group that adds members throughout the life of the group as other members leave and as more persons who would benefit from the group become available. A closed group does not add new members; the membership is established at the beginning and, except for the occasional losses as some members leave, does not change thereafter. A homogeneous group includes members who are similar, and a heterogeneous group includes dissimilar members; not enough data are provided here to determine which applies in this case.

A leader plans to start a new self-esteem building group. Which intervention would be most helpful for assuring mutual respect within the group? a. Describe the importance of mutual respect in the first session and make it a group norm. b. Exclude potential members whose behavior suggests they are likely to be disrespectful. c. Give members a brochure describing the purpose, norms, and expectations of the group. d. Explain that mutual respect is expected and confront those who are not respectful.

ANS: A It is helpful to motivate members to behave respectfully by describing how mutual respect benefits all members and is necessary for the group to be fully therapeutic. Setting a tone and expectation of mutual respect from the outset is the most helpful intervention listed. Excluding members because of how they might behave could exclude members who would have been appropriate, depriving them of the potential benefits of the group. Conveying expectations by brochure is less effective than doing so orally, because it lacks the connection to each member a skilled leader can create to motivate members and impart the expectation of respect. Confronting inappropriate behavior is therapeutic but only addresses existing behavior rather than preventing all such undesired behavior.

A nurse leads a psychoeducational group for patients in the community diagnosed with schizophrenia. A realistic outcome for group members is that they will: a. discuss ways to manage their illness. b. develop a high level of trust and cohesiveness. c. understand unconscious motivation for behavior. d. demonstrate insight about development of their illness.

ANS: A Patients with schizophrenia almost universally have problems associated with everyday living in the community, so discussing ways to manage the illness would be an important aspect of psychoeducation. Discussing concerns about daily life would be a goal to which each could relate. Developing trust and cohesion is desirable but is not the priority outcome of a psychoeducational group. Understanding unconscious motivation would not be addressed. Insight would be difficult for a patient with residual schizophrenia because of the tendency toward concrete thinking.

A group begins the working phase. One member has a childhood history of neglect and ridicule by parents. Which comment would the group leader expect from this member? a. "My boss is always expecting more of me than the others, but talking to him would only make it worse." b. "I'm sorry for talking all the time, but there is so much going on in my life. I can't remember what I already said." c. "Thanks for the suggestions everyone. Maybe some of them will help. It won't hurt to give them a try." d. "This group is stupid. Nobody here can help anybody else because we are all so confused. It's a waste."

ANS: A People who frequently complain, yet reject help or suggestions when offered, tend to have histories of severe deprivation as children, often accompanied by neglect or abuse. The other comments reflect dynamics other than the help-rejecting complainer, such as the monopolizer who apologizes for talking too much, the person who is insightful and agrees to try a peer's suggestion, and the demoralizing member.

During a therapy group that uses existential/Gestalt theory, patients shared feelings that occurred at the time of their admission. After a brief silence, one member says, "Several people have described feeling angry. I would like to hear from members who had other feelings." Which group role is evident by this comment? a. Energizer b. Encourager c. Compromiser d. Self-confessor

ANS: B The member is filling the role of encourager by acknowledging those who have contributed and encouraging input from others. An energizer encourages the group to make decisions or take an action. The compromiser focuses on reducing or resolving conflict to preserve harmony. A self-confessor verbalizes feelings or observations unrelated to the group.

Three members of a therapy group share covert glances as other members of the group describe problems. When one makes a statement that subtly criticizes another speaker, the others nod in agreement. Which group dynamic should the leader suspect? a. Some members are acting as a subgroup instead of as members of the main group. b. Some of the members have become bored and are disregarding others. c. Three members are showing their frustration with slower members. d. The leadership of the group has been ineffective.

ANS: A Subgroups, small groups isolated within a larger group and functioning separately from it, sometimes form within therapy groups. When this occurs, subgroup members are cohesive with other subgroup members but not with the members of the larger group. Members of the subgroup may be bored or frustrated or expressing passive aggression, but the primary dynamic is the splitting off from the main group.

A patient has talked constantly throughout the group therapy session, often repeating the same comments. Other members were initially attentive then became bored, inattentive, and finally sullen. Which comment by the nurse leader would be most effective? a. Say to everyone, "Most of you have become quiet. I wonder if it might be related to concerns you may have about how the group is progressing today." b. Say to everyone, "One person has done most of the talking. I think it would be helpful for everyone to say how that has affected your experience of the group." c. Say to everyone, "I noticed that as our group progressed, most members became quiet, then disinterested, and now seem almost angry. What is going on?" d. Say to the talkative patient, "You have been doing most of the talking, and others have not had a chance to speak as a result. Could you please yield to others now?"

ANS: A The most effective action the nurse leader can take will be the one that encourages the group to solve its own problem. Pointing out changes in the group and asking members to respond to them lays the foundation for a discussion of group dynamics. Asking members to respond to the talkative patient puts that patient in an awkward position, likely increasing her anxiety. As anxiety increases, monopolizing behavior tends to increase as well, so this response would be self-defeating. Asking members what is going on is a broader opening and might lead to responses unrelated to the issue that bears addressing; narrowing the focus to the group process more directly addresses what is occurring in the group. Focusing on the talkative patient would be less effective and involves the leader addressing the issue instead of members first attempting to do so themselves (giving them a chance to practice skills such as assertive communication).

During group therapy, one patient says to another, "When I first started in this group, you were unable to make a decision, but now you can. You've made a lot of progress. I am beginning to think that maybe I can conquer my fears too." Which therapeutic factor is evident by this statement? a. Hope b. Altruism c. Catharsis d. Cohesiveness

ANS: A The patient's profession that he may be able to learn to cope more effectively reflects hope. Groups can instill hope in individuals who are demoralized or pessimistic. Altruism refers to doing good for others, which can result in positive feelings about oneself. Catharsis refers to venting of strong emotions. Cohesion refers to coming together and developing a connection with other group members.

A group has two more sessions before it ends. One member was previously vocal and has shown much progress but has now grown silent. What explanation most likely underlies this behavior? The silent member: a. has participated in the group and now has nothing more to offer. b. is having trouble dealing with feelings about termination of this group. c. wants to give quieter members a chance to talk in the remaining sessions. d. is engaging in attention-seeking behavior aimed at continuation of the group.

ANS: B A chief task during the termination phase of a group is to take what has been learned in group and transition to life without the group. The end of a group can be a significant loss for members, who may experience loss and grief and respond with sadness or anger. It is unlikely he would have nothing to say; at the very least, he could be responding to the comments of others even if not focusing on his own issues. He may wish to give quieter members a chance to talk, but again, this would not require or explain his complete silence. Some members, faced with only two remaining sessions, may be becoming more dominant under this pressure of time, but here too this is unlikely to lead a previously active participant to fall completely silent. The member is not attention-seeking.

Which type of group is a staff nurse with 2 months' psychiatric experience best qualified to conduct? a. Psychodynamic/psychoanalytic group b. Medication education group c. Existential/Gestalt group d. Family therapy group

ANS: B All nurses receive information about patient teaching strategies and basic information about psychotropic medications, making a medication education group a logical group for a beginner to conduct. The other groups would need a leader with more education and experience.

During a support group, a patient diagnosed with schizophrenia says, "Sometimes I feel sad that I will never have a good job like my brother. Then I dwell on it and maybe I should not." Select the nurse leader's best comment to facilitate discussion of this issue. a. "It is often better to focus on our successes rather than our failures." b. "How have others in the group handled painful feelings like these?" c. "Grieving for what is lost is a normal part of having a mental disorder." d. "I wonder if you might also experience feelings of anger and helplessness."

ANS: B Asking others to share their experiences will facilitate discussion of an issue. Giving information may serve to close discussion of the issue because it sounds final. Suggesting a focus on the positives implies a discussion of the issue is not appropriate. Suggesting other possible feelings is inappropriate at this point, considering the patient has identified feelings of sadness and seems to have a desire to explore this feeling. Focusing on other feelings will derail discussion of the patient's grief for his perceived lost potential.

The nurse is planning a new sexuality group for patients. Which location would best enhance the effectiveness of this group? a. The hospital auditorium b. A small conference room c. A common area, such as a day room d. The corner of the music therapy room

ANS: B The conference room would provide a quiet, private area with few distractions, separate from other patient areas and effective for teaching and learning about a private topic. The auditorium is too large, and members' anxiety or lack of trust might lead them to spread out too far from each other, interfering with group process. The day room and the music therapy room are too busy and exposed, reducing privacy and increasing distractions.

A patient in a detoxification unit asks, "What good it will do to go to Alcoholics Anonymous and talk to other people with the same problem?" The nurse's best response would be to explain that self-help groups such as AA provide opportunities for: a. newly discharged alcoholics to learn about the disease of alcoholism. b. people with common problems to share their experiences with alcoholism and recovery. c. patients with alcoholism to receive insight-oriented treatment about the etiology of their disease. d. professional counselors to provide guidance to individuals recovering from alcoholism.

ANS: B The patient needs basic information about the purpose of a self-help group. The basis of self-help groups is sharing by individuals with similar problems. Self-help is based on the belief that an individual with a problem can be truly understood and helped only by others who have the same problem. The other options fail to address this or provide incorrect information.

The next-to-last meeting of an interpersonal therapy group is taking place. The leader should take which actions? Select all that apply. a. Support appropriate expressions of disagreement by the group's members. b. Facilitate discussion and resolution of feelings about the end of the group. c. Encourage members to reflect on their progress and that of the group itself. d. Remind members of the group's norms and rules, emphasizing confidentiality. e. Help members identify goals they would like to accomplish after the group ends. f. Promote the identification and development of new options for solving problems.

ANS: B, C, E The goals for the termination phase of groups are to prepare the group for separation, resolve related feelings, and prepare each member for the future. Contributions and accomplishments of members are elicited, post-group goals are identified, and feelings about the group's ending are discussed. Group norms are the focus of the orientation phase, and conflict and problem solving are emphasized in the working phase.

A leader begins the discussion at the first meeting of a new group. Which comments should be included? Select all that apply. a. "We use groups to provide treatment because it's a more cost-effective use of staff in this time of budget constraints." b. "When someone shares a personal experience, it's important to keep the information confidential." c. "Talking to family members about our group discussions will help us achieve our goals." d. "Everyone is expected to share a personal experience at each group meeting." e. "It is important for everyone to arrive on time for our group."

ANS: B, E The leader must set ground rules for the group before members can effectively participate. Confidentiality of personal experiences should be maintained. Arriving on time is important to the group process. Talking to family members would jeopardize confidentiality. While groups are cost-effective, blaming the budget would not help members feel valued. Setting an expectation to share may be intimidating for a withdrawn patient.

A group is in the working phase. One member states, "That is the stupidest thing I've ever heard. Everyone whines and tells everyone else what to do. This group is a waste of my time." Which initial action by the group leader would be most therapeutic? a. Advise the member that hostility is inappropriate. Remove the member if it continues. b. Keep the group's focus on this member so the person can express the anger. c. Meet privately with the member outside of group to discuss the anger. d. Change to a more positive topic of discussion in this group session.

ANS: C Meeting privately with the member can convey interest and help defuse the anger so that it is less disruptive to the group. Removing the member would be a last resort and used only when the behavior is intolerably disruptive to the group process and all other interventions have failed. Decreasing the focus on the hostile member and focusing more on positive members can help soften the anger. Angry members often hide considerable vulnerability by using anger to keep others at a distance and intimidated. Changing the subject fails to respond to the behavior.

A patient in a group therapy session listens to others and then remarks, "I used to think I was the only one who felt afraid. I guess I'm not as alone as I thought." This comment is an example of: a. altruism. b. ventilation. c. universality. d. group cohesiveness.

ANS: C Realizing that one is not alone and that others share the same problems and feelings is called universality. Ventilation refers to expressing emotions. Altruism refers to benefitting by being of help to others. Group cohesiveness refers to the degree of bonding among members of the group.

A group is in the working phase. One member says, "That is the stupidest thing I've ever heard. Everyone whines and tells everyone else what to do. This group is a total waste of my time." Which comment by the group leader would be most therapeutic? a. "You seem to think you know a lot already. Since you know so much, perhaps you can tell everyone why you are back in the hospital?" b. "I think you have made your views clear, but I wonder if others feel the same way. How does everyone else feel about our group?" c. "It must be hard to be so angry." Direct this comment to another group member, "You were also angry at first but not now. What has helped you?" d. "I would like to remind you that one of our group rules is that everyone is to offer only positive responses to the comments of others."

ANS: C The member's comments demean the group and its members and suggest that the member is very angry. Labeling the emotion and conveying empathy would be therapeutic. Focusing on members who are likely to be more positive can balance the influence of demoralizing members. "You seem to know a lot..." conveys hostility from the leader, who confronts and challenges the member to explain how he came to be readmitted if he was so knowledgeable, implying that he is less knowledgeable than he claims. This comment suggests countertransference and is non-therapeutic. Shifting away from the complaining member to see if others agree seeks to have others express disagreement with this member, but that might not happen. In the face of his anger, they might be quiet or afraid to oppose him, or they could respond in kind by expressing hostility themselves. A rule that only positive exchanges are permitted would suppress conflict, reducing the effectiveness of the therapy group.

A nurse at the well child clinic realizes that many parents have misconceptions about effective ways of disciplining their children. The nurse decides to form a group to address this problem. What should be the focus of the group? a. Support b. Socialization c. Health education d. Symptom management

ANS: C The nurse has diagnosed a knowledge deficit. The focus of the group should be education. Support and socialization are beneficial but should not be the primary focus of the group, and symptoms are not identified for intervention here.

During a group therapy session, a newly admitted patient suddenly says to the nurse, "How old are you? You seem too young to be leading a group." Select the nurse's most appropriate response. a. "I am wondering what leads you to ask. Please tell me more." b. "I am old enough to be a nurse, which qualifies me to lead this group." c. "My age is not pertinent to why we are here and should not concern you." d. "You are wondering whether I have enough experience to lead this group?"

ANS: D A question such as this is common in the initial phase of group development when members are getting to know one another, dealing with trust issues, and testing the leader. Making explicit the implied serves to role model more effective communication and prompts further discussion of the patient's concern. Asking the patient to tell the leader more about the question focuses on the reason for the member's concern rather than on the issue raised (the experience and ability of the leader) and is a less helpful response. "I am old enough to be a nurse" and "age is not pertinent" are defensive responses and fail to address the patient's valid concern.

Which outcome would be most appropriate for a symptom-management group for persons with schizophrenia? Group members will: a. state the names of their medications. b. resolve conflicts within their families. c. rate anxiety at least two points lower. d. describe ways to cope with their illness.

ANS: D An appropriate psychoeducational focus for patients with schizophrenia is managing their symptoms; coping with symptoms such as impaired memory or impaired reality testing can improve functioning and enhance their quality of life. Names of medications might be appropriate for a medication education group but would be a low priority for symptom management. Addressing intra-family issues would be more appropriate within a family therapy group or possibly a support group. Rating anxiety lower would be an expected outcome for a stress-management group.

A patient tells members of a therapy group, "I hear voices saying my doctor is poisoning me." Another patient replies, "I used to hear voices too. They sounded real, but I found out later they were not. The voices you hear are not real either." Which therapeutic factor is exemplified in this interchange? a. Catharsis b. Universality c. Imitative behavior d. Interpersonal learning

ANS: D Here a member gains insight into his own experiences from hearing about the experiences of others through interpersonal learning. Catharsis refers to a therapeutic discharge of emotions. Universality refers to members realizing their feelings are common to most people and not abnormal. Imitative behavior involves copying or borrowing the adaptive behavior of others.

Which remark by a group participant would the nurse expect during the working stage of group therapy? a. "My problems are very personal and private. How do I know people in this group will not tell others what you hear?" b. "I have enjoyed this group. It's hard to believe that a few weeks ago I couldn't even bring myself to talk here." c. "One thing everyone seems to have in common is that sometimes it's hard to be honest with those you love most." d. "I don't think I agree with your action. It might help you, but it seems like it would upset your family."

ANS: D In the working stage, members actively interact to help each other accomplish goals, and because trust has developed, conflict and disagreement can be expressed. Focusing on trust and confidentiality typically occur in the orientation phase as part of establishing group norms. Commonality and universality are also themes typically expressed in the orientation phase, whereas reflecting on progress is a task addressed in the termination phase.

Guidelines followed by the leader of a therapeutic group include focusing on recognizing dysfunctional behavior and thinking patterns, followed by identifying and practicing more adaptive alternate behaviors and thinking. Which theory is evident by this approach? a. Behavioral b. Interpersonal c. Psychodynamic d. Cognitive-behavioral

ANS: D The characteristics described are those of cognitive-behavioral therapy, in which patients learn to reframe dysfunctional thoughts and extinguish maladaptive behaviors. Behavioral therapy focuses solely on changing behavior rather than thoughts, feelings, and behaviors together. Interpersonal theory focuses on interactions and relationships. Psychodynamic groups focus on developing insight to resolve unconscious conflicts.

A young female member in a therapy group says to an older female member, "You are just like my mother, always trying to control me with your observations and suggestions." Which therapeutic factor of a group is evident by this behavior? a. Instillation of hope b. Existential resolution c. Development of socializing techniques d. Corrective recapitulation of the primary family group

ANS: D The younger patient is demonstrating an emotional attachment to the older patient that mirrors patterns within her own family of origin, a phenomenon called corrective recapitulation of the primary family group. Feedback from the group then helps the member gain insight about this behavior and leads to more effective ways of relating to her family members. Instillation of hope involves conveying optimism and sharing progress. Existential resolution refers to the realization that certain existential experiences such as death are part of life, aiding the adjustment to such realities. Development of socializing techniques involves gaining social skills through the group's feedback and practice within the group.

Anticonvulsants

Action not clear. Affects GABA receptors, which casuses a calming effect. Are used to stabilize the manic episodes in bipolar disorder. The Meds: Carbamazepine (Tegretol) Lamotrigine (Lamictal) Valporic Acid (Depakote) Side effects: nausea, vomiting, indigestion, drowsiness, dizziness, prolonged bleeding, headache, confusion These meds should NOT be stopped abruptly These patients should avoid ETOH (ALCOHOL!) Therapeutic Blood Levels: +Tegretol: 6-12 mcg/ml +Depakene & Depakote: 50-100 mcg/ml

_____ is the primary, chronic disease of brain reward, motivation, memory, and related circuitry. Along with the loss of ability to identify problematic behaviors and relationships.

Addiction

A in SAD PERSONS...

Age: 15-24 are at an elevated risk, and elderly 65 and older are at a higher risk.

The most effective treatment for alcohol abuse is _____ _____.

Alcoholics anonymous

Atypical Antipsychotics

Block multiple dopamine & serotonin receptors. The MEDS: clozapine (Clozaril) (lowers WBC count (agranulocytosis), monitor blood work every 1-2 weeks) risperidone (Risperdal) planzapine (Zyprexa) aripiprazole (Abilify) Paliperidone (Invenga) *Treatment-resistant PTSD*

Beta Blockers

Another type of anti-anxiety medication. Not a benzo. USED PRN. PROPRANOLOL (Inderal) (common one) *Typically used to treat heart conditions and hypertension, but sometimes used to control "performance anxiety" CHECK PATIENT'S BP and PULSE before administering

_____ makes you deathly ill if you drink alcohol. Patients who take this medication need to be careful for alcohol in vinegar, preservatives, and food.

Antabuse medications

Selective Serotonin Reuptake Inhibitors (SSRIs)

Antidepressant. Blocks the reabsorption of serotonin. THE MEDS: fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) escitalopram (Lexapro) citalopram (Celexa) fluvoxamine (Luvox) Side effects: excitation, n & v, decreased libido, anorexia & weight loss, increased suicide risk first few weeks of therapy Intrusive experiences (flashbacks, avoidance, and numbing)

Suicidal _____ is the manifestation of inner pain, hopelessness, and helplessness suffered by individuals.

Ideation

_____ are gradually being recognized as addictive.

Behaviors

If you achieve a certain score on the CIWA scale, you can be given a long-acting _____.

Benzodiazepine

_____ act on the same receptors as alcohol.

Benzodiazepines

Monoamine Oxidase Inhibitors (MAOIs)

Block the action of monoamine oxidase and prevent breakdown of norepinephrine and serotonin. The MEDS: Phenelzine (Nardil) tranylcypromine (Parnate) isocarboxazid (Marplan) Side effects: anticholinergic effects, dry mouth, orthostatic hypotension, headache DO NOT TAKE THESE MEDS WITH NASAL DECONGESTANTS or with FOOD CONTAINING high levels of TYRAMINE (a precursor to norepinephrine) AVOID THESE FOODS: AGED CHEESE, AVACADOS, YOGURT, SOUR CREAM, CHICKEN & BEEF LIVERS (DAMMIT!), pickled herring, corned beef, bean pods, bananas, raisins, figs, smoked & processed meat, yeast supplements, chocolate (NOOOOOOOOO!), MSG, soy sauce, beer, red wines, & caffeine (depressed just reading these!) Hypertensive crisis & DEATH can occur if patient cosumes these foods. Signs: stiff neck, nausea, vomiting When this med is stopped, wait @ WEEKS before starting any new meds. *Panic attacks*

Continuous substance use results in actual changes in _____ _____ and function of an area of the brain referred to as the reward or pleasure center.

Brain Structure

You assess alcohol withdrawal using a _____ scale.

CIWA scale

Psychodynamics such as chronic _____ and _____ have been identified in the histories of individuals with both substance abuse and mood disorders.

Chronic stress and trauma

Symptoms of _____ is valuing oneself by what one does, what one looks like, and what one has, rather than by who one is. They define their self worth in terms of caring for others to the exclusion of their own needs.

Codependence

Addiction is characterized by an individual's compulsive seeking of drugs and use despite the harmful _____.

Consequences

_____ suicide follows a highly publicized suicide of a public figure, an idol, or a peer in the community.

Copycat suicide

D in SAD PERSONS...

Depression: Hopelessness and depression put the patient at a 20x higher risk for suicide.

_____ is warranted when an individual quits a psychoactive substance that is known to cause withdrawal or when the individual is already in withdrawal.

Detoxification

Stimulants

Directly stimulate the CNS, used to promote alertness, diminish appetite, combat narcolepsy. Also used to treat ADHD The Meds: methylphenidate (Ritalin) Side effects: increased or irregular heart rate, hypertension, hyperactivity, dry mouth, hand tremor, rapid speech, diaphoresis, confusion, depression, seizures, suicidal ideation, insomnia DO NOT GIVE TO PATIENTS WITH ALCOHOLISM, MANIA or display suicidal or homicidal thoughts DO NOT USE with heart disease or glaucoma MAY impair judgement, drive with caution DO NOT USE with MAOIs ( may cause hypertensive crisis) Take at least 6 hours before sleep to avoid sleep disturbances

anticholinergic side effects

Dizziness, headaches, excitement, cough, urinary retention, dry mouth, irritability, delayed GI motility

E in SAD PERSONS...

Ethanol abuse: Alcohol and or drug abuse increases risk.

Brief intervention is discussing with the patient the risk associated with substance use while providing _____ and _____.

Feedback and advice

SSRIs

First-line treatment for anxiety disorders, OCD, and BDD

From alcohol withdrawal you can develop _____ _____ seizures which can be deadly.

Grand mal seizures

_____ _____ purposes are designed for extending the period of sobriety.

Halfway houses

_____ is when people are in the process of using a substance to excess. These substances can be uppers, downers, or all arounders.

Intoxication

_____ is how quickly a person would die from an attempt.

Lethality

Antipsychotics/ neuroleptics

MAJOR TRANQUILIZERS Used to treat bipolar, psychoses, agitation, schizophrenia The Meds: chlorpromazine (Thorazine) Haloperidol (Haldol) Fluphenazine (Prolixin) thioridazine (Mellaril) thiothixine (Navane) trifluoperazine (Trilafon) trifluoperazine (Stelazine) ****They block DOPAMINE RECEPTORS in the brain (which are the immediate precursors to norepinephrine). These affect neurotransmitters that allow for communication between nerve cells. Adverse reactions: hypotension, dizziness, fainting, dry mouth, possible impotence in men, photosensitivity, blood dyscrasias (abnormal values) THERE ARE MORE ADVERSE REACTIONS! SEE NEXT CARD!

Benzodiazepines

Main type of anti-anxiety medication. Relieves symptoms of anxiety-related disorders quickly. Most popular ones: *Clonazepam (Klonopin) *Alprazolam (Xanax) *Diazepam (Valium) *Lorazepam (Ativan) All addictive. For short term use only. DO NOT STOP ABRUPTLY, patients must be weaned off these meds or they will have SEIZURES.

Buspirone:

Management of anxiety disorders. Non-addictive; excellent for long-term relief of anxiety symptoms, e.g. GAD (e.g. BuSpar) Buspirone hydrochloride (BuSpar) Alleviates anxiety, but works best before benzodiazepines have been tried. Less sedating than benzodiazepines. Does not appear to produce physical or psychological dependence. Requires 3 or more weeks to be effective.

_____ does nothing but block cravings for medication.

Methadone

Long-Term Pharmacologic Management of Opioid Use Disorder

Methadone (Dolophine) Most effective; opioid agonist that blocks the craving. Buprenorphine (Subutex) Blocks the signs and symptoms of opioid withdrawal. Naltrexone (ReVia, Vivitrol) Antagonist that blocks the euphoric effects of opioids. Clonidine (Catapres) Is an effective somatic treatment when combined with naltrexone.

Treatment of Alcoholism

N.A.D-now alcohol dies Naltrexone (ReVia, Vivitrol) Reduces or eliminates alcohol craving. Acamprosate (Campral) Helps patient abstain from alcohol. Disulfiram (Antabuse) Alcohol-disulfiram reaction causes unpleasant physical effects. Most reactions last about 30 minutes and are self-limited Occasionally, can be severe included marked tachycardia, hypotension, bradycardia, and cardiac arrest

Opioid Addiction

Naloxone (Narcan) First choice to treat opioid toxicity Disadvantage: short-acting Nalmefene (Revex) Longer half-life, but prolongs withdrawal Methadone (Dolophine) Detox tool; synthetic opiate that blocks the craving for and effects of heroin.

_____ is a short acting medication and most substances usually are long acting, so observations for respiratory depression is important.

Narcan

N in SAD PERSONS...

No Significant Other

_____-_____ _____ is when the patient agrees not to harm themselves but to take an alternate action if feeling suicidal.

No-Suicide Contract

Antidepressants

Not uppers *6-8 weeks to take effect, continued for 6-12 months (or more) THREE main groups of antidepressants: 1.Tricyclic 2.Monoamine Oxidase Inhibitors (MAOIs) MY FAVE!!!!!!!!! 3.Selective Serotonin reuptake inhibitors (SSRIs) Treats Hyperarousal

O in SAD PERSONS...

Organized Plan: Having a method increases the risk.

Prazosin (minipress)

PTSD treatment For Nightmares

SNRIs:

Panic disorder (PD), generalized anxiety disorder (GAD), and social affective disorder (SAD)

Benzodiazepines (anxiolytics):

Prescribed for short-term treatment only; not for patients with substance use problems (see p.148)

_____ intervention includes activities that provide support, information, and education to prevent suicide.

Primary intervention

P in SAD PERSONS...

Prior History: 80% of suicides were preceded by a prior attempts.

_____ disorders accompany 90% of completed suicide.

Psychiatric disorders

R in SAD PERSONS...

Rational Thinking Loss: Psychosis ('I hear a voice telling me I should kill myself') increases risk.

_____ offers professionally directed evaluation and treatment in short-term settings for those with chronic distress or severe impairment.

Rehabilitation

_____ is returning to previous behavior.

Relapse

Beta blockers:

Relieve the physical symptoms, as in performance anxiety. Act by attaching to sensors that direct arousal message.

MAOIs:

Reserved for treatment-resistant conditions due to risk of life-threatening hypertensive crisis. Recently being used in people with social anxiety disorder (SAD) and rejection sensitivity

_____ is assessing a patient for substance use problems using standardized screening tools.

Screening

Tricyclic antidepressants:

Second- or third-line use for PD, GAD, and SAD; clomipramine is effective in obsessive-compulsive disorder (OCD)

_____ intervention includes treatment of the actual suicide crisis such as suicide hotlines.

Secondary intervention

Buspirone (BuSpar)

Secondary type of Anti-Anxiety med. NOT A BENZO! This med does NOT give the tranquilizer effect that the benzodiazepines do. BuSpar's action is unknown. *Takes 2 weeks to take effect *Side effects are slurred speech and dizziness

S in SAD PERSONS...

Sex: Males are more successful at completing suicide, but females make more attempts.

S in SAD PERSONS...

Sickness: Terminal Illnesses in a patient increases the risk of suicide more than the general population.

_____ use disorder is the pathological use of a substance that leads to a disorder of use, intoxication, and, often, withdrawal if taken away

Substance

_____ is the intentional act of killing oneself by any means.

Suicide

S in SAD PERSONS...

Support System Loss

_____ intervention includes interventions with the circle of survivors of a person who has completed suicide.

Tertiary intervention

Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

The MEDS: Effexor Cymbalta Pristiq Side Effects: anxiety, abnormal dreams, dizziness, nervousness

Anti-Manic Agent (calms patients in manic phase) Episodes of Bipolar 1 Disorder

The Med: LITHIUM used for bipolar disorder, calms patient in manic phase Controls flight of ideas, restlessness, etc LITIUM IS A SALT, maintain a diet with NORMAL sodium intake, restricting sodium INCREASES Litium toxicity. Have patients monitor selves for edema, regular weights! Side effects: Thirst, nausea, vomiting, hair loss, tremors, weight gain, hypothyroidism NARROW THERAPEUTIC RANGE INCREASES LIKELIHOOD OF TOXICITY! ******THERAPEUTIC RANGE OF LITHIUM: .5-1.5 mEq/L******

Extrapyramidal Symptoms (EPS) (more adverse reactions from antipsychotics/neuroleptics)

These types of symptoms appear to be dose related and are the most frightening to patient: 1. Dystonia: difficult or bad muscle tone in head & neck, swallowing problems, tongue sticks out 2.Akathisia- inability to sit down. restlessness. 3. Pseudo-Parkinsonism: side effects like tremors & "stiff face" that resemble Parkinson's disease. Occur a few weeks to a few months after therapy. May be controlled by anti-Parkinsonism med. 4.Tardive Dyskinesia: rhythimical, involuntary movements of tongue, face, mouth, jaw, trunk, extremities. No effective tratment. 5.NEUROLEPTIC MALIGNANT SYNDROME (NMS): uncommon reaction to neuroleptics, but could cause death. Muscle rigidity, hyperpyrexia (fever), fluctuations in BP, altered or loss of consciousness. NEEDS IMMEDIATE MEDICAL CARE!

_____ takes more to get to the same level of intoxication.

Tolerance

Referral to _____ is suggesting a referral for brief therapy or treatment for patients who screen positively.

Treatment

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

c. Risk for suicide

_____ is a set of physiological symptoms that begin to occur as the concentration of the chemical decreases in an individual's bloodstream.

Withdrawal

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

a. "Are you having thoughts of suicide?"

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? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

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

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

a. 82-year-old white male b. 17-year-old female d. 19-year-old African American male

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

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

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

a. Maintain arm's-length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection.

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. a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

a. Shame c. Humiliation d. Self-imposed isolation e. Recent stressful life event

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. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.

a. Supervise the patient 24 hours a day.

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: a. guilt. b. denial. c. shame. d. rescue feelings.

a. guilt.

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

a. hopelessness.

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

b. "I have no one to turn to for help or support."

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? a. Amitriptyline (Elavil), a sedating tricyclic medication b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor c. Desipramine (Norpramin), a stimulating tricyclic medication d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor

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

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

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

b. Serotonin deficiency

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

b."Do you have access to medication?"

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." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to keep you safe." c. "Bringing up these feelings is a very positive action on your part." d. "We need to talk about the good things you have to live for."

c "Bringing up these feelings is a very positive action on your part."

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

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

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? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

c. "I have a plan that will fix everything."

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

c. Attending a self-help group for survivors

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

c. Availability of means and lethality of method

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? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

c. Giving away sweaters

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

c. establish rapport with the patient.

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

c. suicide potential.

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

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

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

d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

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

d. Helping school children learn to manage stress and be rsilient

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

d. Jumping from a railroad bridge located in a deserted area late at night

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

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