PN120 PrepU Chapter 17

A 20-year-old client was admitted to the inpatient unit following a suicide attempt. The client is disheveled, disorganized, and dehydrated. The priority for the client's care during the first 24 hours of admission will be what?

Assessing the client's current suicidal ideation and putting the client on suicide precautions.

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

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?"

The nurse is providing care for a client who deliberately overdosed on acetaminophen several days ago. The nurse should assess the current severity of the client's suicidal ideation by asking what question?

"How often are you having thoughts about suicide this morning?"

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."

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."

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."

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."

A 38-year-old client has been diagnosed with major depressive disorder. The client is being placed on an antidepressant and the nurse is providing medication teaching. Which would be appropriate information to provide to the client?

"You may not notice an improvement in your symptoms for 2 to 6 weeks."

A client's depression is being treated in the community with phenelzine. The client has presented to the clinic stating, "I had a few beers and I'm feeling absolutely miserable." What is the nurse's best action?

Assess the client's blood pressure

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."

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

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

14 days

Which sleep pattern is suggestive of a manic episode?

A client stays awake for several days and nights before "crashing" and sleeping for a long period.

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

A client whose major depression has not responded appreciably to antidepressants

A 46-year-old client has been diagnosed with major depressive disorder. The client is seeing a nurse practitioner who is deciding on an appropriate treatment regimen. The nurse practitioner knows that which will be the most effective treatment for this client's depressive disorder?

A combination of psychotherapy and medication

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

A psychodynamic interpretation of the client's major depressive disorder.

The nurse is told by a client that the client is having suicidal thoughts. Which intervention has lowest priority?

Administering a mental status exam to assess for psychosis

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

The nurse is seeing a 43-year-old client whose spouse just died by suicide. Which is a common emotional response that the nurse should anticipate from this client?

Anger toward the loved one who committed suicide

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

Anhedonia

During assessment of a client with depression, the client states, "I just feel so sad and hopeless. I just don't care anymore. I don't even enjoy doing the crossword puzzles like I used to." The nurse documents this finding as indicative of what?

Anhedonia

A client is admitted to the psychiatric unit after taking various medications and illegal substances to get "high." In addition to the underlying diagnosis of bipolar disorder, the client is diagnosed with delirium. Currently the client is experiencing mild hallucinations and confusion. Which intervention should the nurse do first?

Arrange for an unlicensed assistant to sit with the client.

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

Carbamazepine

The nurse educates a class on factors that enhance the risk of suicide. The instructor determines the need for additional education when the class identifies which as one of these factors?

Cautiousness

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

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

Clients with bipolar II disorder do not have symptoms of mania that interfere enough to cause marked functional disturbances.

An adult client was admitted to the psychiatric mental health unit following a suicide attempt. The client has responded well to treatment, so discharge is being considered. In anticipation of the client's discharge, the nurse should:

Collaborate with the family to make sure the client's home environment is safe.

When a nurse assesses prior self-harm behavior, this can provide information about the motivation behind the client's actions and allows the nurse to do what?

Communicate concern and empathy to the client

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

Confusion

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

Which mental health disorder has the most significant risk factor for suicide?

Depression

A client was admitted to the psychiatric unit 3 days ago because of suicidal ideation. The client's suicidal risk has lessened considerably, and the client currently denies having any desire to kill himself or herself. In addition, the client is able to identify reasons why the client wants to be alive. Which nursing intervention would be most appropriate at this time?

Developing a personal plan for managing suicidal thoughts when they occur

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. The nurse knows that some of these symptoms include what? Select all that apply.

Disruption in sleep Disruption in appetite Disruption in concentration Excessive guilt

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

Disturbance of self-concept related to feelings of worthlessness

Which is an anticonvulsant used as a mood stabilizer?

Divalproex

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

Ensuring a plan is in place for the client's community-based care

A client diagnosed with bipolar disorder is admitted to an inpatient psychiatric facility with acute mania and threats of attacking others in the household. Which would be the priority?

Ensuring safety

A client who has experienced the recent loss of an infant child and recent immigration to the United States is admitted to the inpatient psychiatric unit with severe symptoms of depression. The client has expressed thoughts of suicide. Which is the nurse's priority intervention for this client?

Ensuring that the client is not permitted to use anything that would be potentially dangerous.

A client is prescribed a selective serotonin reuptake inhibitor (SSRI) as treatment for depression. Which would the nurse most likely administer?

Escitalopram

Which statement regarding gender and suicide is correct?

Females engage in suicidal behaviors more frequently than males.

The nurse knows that the most dangerous time period following a previous suicide attempt is what?

First 3 months

Following a change in job position, a minister asks a client how the client likes the new job. The client states, "Oh everything is great. I can really see myself going far in this new position." However, the client's voice is monotone and the client's face is nearly absent of affective expression. The minister is worried about this client and describes this facial expression as what?

Flat

Which antidepressant medication is classified as a selective serotonin reuptake inhibitor (SSRI)?

Fluoxetine

A nurse is caring for a client diagnosed with bipolar disorder who has been prescribed divalproex. The nurse knows that the client should have which test completed before initiation of drug therapy?

Liver function

A client has been on lithium for 3 weeks now. The client approaches the nurse, saying, "I feel like I'm going to throw up, and I can't even hold this cup of coffee straight. Why can't I do the crossword puzzle? I usually can do them in about 5 minutes." What is the appropriate nursing intervention at this time?

Further assess the client's symptoms, call the physician, hold the client's next dose of lithium, and have a blood level drawn because the client is showing symptoms of toxicity.

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

A client in the clinic appears to have elevated self-esteem, is more talkative than usual, and is easily distracted. This client is exhibiting symptoms of what?

Grandiosity

A nurse is caring for a client with major depression. The client tells the nurse that the client "just isn't sure that life is worth living." The nurse documents which nursing diagnosis as the priority?

Hopelessness related to symptoms of depression

While caring for a client in the hospital, the nurse becomes concerned that the client may be having thoughts of suicide. Which statement would be most therapeutic?

I've noticed something is bothering you. Please share you thoughts with me."

To care for an acutely suicidal client, which is the most effective initial mode of treatment?

Inpatient care

A client with severe depression has experienced anhedonia for the past 3 months. The nurse caring for this client understands that this term describes what?

Loss of interest or pleasure

A nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse identifies which client as having the highest risk for a suicide attempt?

Man with major depressive disorder

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

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

A client who has been taking lithium for bipolar disorder is admitted to the hospital with the following symptoms: dry mouth, nausea and vomiting, blurred vision, dizziness, and muscle twitching. What should the nurse suspect?

Moderate lithium toxicity

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

Monitoring blood levels of the medication.

Which medication classification is considered first-line drug therapy for bipolar disorder?

Mood stabilizers

For which reason is depression in older adults often undiagnosed and untreated?

Older adult depression is often seen as "normal aging."

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

Orthostatic hypotension

A newly admitted client's history includes multiple suicide attempts. How can the nurse on the psychiatric-mental health unit best protect the client's safety?

Performing vigilant assessment and close observation

A client is admitted to a mental health unit with reports of fatigue, poor appetite, and difficulty making decisions. The client also states feeling unhappy most of the time for "as long as the client can remember." Which diagnosis should the nurse anticipate for this client?

Persistent depressive disorder

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

Police officers bring a client to the mental health unit for admission. The client had been directing traffic on a busy city street, shouting rhymes such as "to work, you jerk, for perks" and making obscene gestures at cars that came close to the client. When the client's spouse is contacted at work, the spouse reports that the client stopped taking lithium 3 weeks ago and has not slept or eaten for 3 days. With which two features characteristic of the manic phase of bipolar disorder can the nurse identify?

Poor judgment and hyperactivity

`The primary nursing goal for a client who is admitted for suicidal ideation or attempt would be what?

Prevent self-destructive behavior.

Which is the greatest predictor of a future suicide attempt?

Previous attempt

A family member of an adolescent who has expressed a desire to commit suicide asks the nurse, "What might predict the possibility of future suicide attempts?" Which would the nurse include in the response?

Previous suicide attempt

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

Promptly act on, and document, the client's statement.

Pharmacotherapy is essential to the management of the client with bipolar disorder. The nurse understands that the goals for such therapy are what? Select all that apply.

Rapid control of symptoms Decreased frequency of manic episodes Prevention of future episodes Decreased severity of manic episodes

A client with bipolar disorder is currently experiencing mania. The nurse identifies a nursing diagnosis of sleep deprivation related to the effects of the mania. Which would be most appropriate for the nurse to include in the client's plan of care?

Reducing environmental stimuli

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

A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has priority?

Risk for suicide related to highly lethal plan

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.

A client who has attempted suicide has an underlying diagnosis of depression. Which would the nurse anticipate being ordered for the client?

Selective serotonin reuptake inhibitor

A nursing student is caring for an elderly client who is taking sertraline for depression. The instructor quizzes the student about the medication and its actions. To what classification of drugs should the student assign sertraline?

Selective serotonin reuptake inhibitor

A client with major depression is prescribed paroxetine. The nurse develops an education plan for the client based on the understanding that this drug belongs to which class of drugs?

Selective serotonin reuptake inhibitors

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

Self-injury

When assessing risk of suicide, which are important assessment components? Select all that apply.

Seriousness of suicidal ideation Degree of hopelessness Previous attempt Lethality of method

A client hospitalized for uncontrolled manic behavior constantly belittles other clients on the general ward and is demanding special favors from the nurses. Which is the most effective nursing intervention for this client?

Set limits with specific and consistent consequences for belittling or demanding behavior.

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

Side effect

A client receiving lithium therapy has a plasma blood concentration of 2.2 mEq/L. Which would the nurse expect to assess?

Slurred speech

Which is a primary risk factor for suicide?

Social isolation

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

A nurse is providing a presentation about suicide for a group of health professionals. Which would the nurse address as a major contributing factor to the rising suicide rate among men?

Substance abuse

A parent of four small children lost a spouse in an automobile accident 3 months ago and is admitted to the hospital with severe depression. Since the spouse's death, the client's mood has been somber; until now, the client has refused treatment. What is this client at high risk for?

Suicide

The nurse is assessing a client for warning signs of suicide. Which would be a concern?

The client has engaged in risky behaviors and tends to be impulsive.

The nurse is working with an inpatient who has a history of suicide attempts. What action by the client should the nurse follow up on because it may constitute a suicide planning behavior?

The client has requested extra bedding despite the warm weather

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

The client overdosed on pills 2 years earlier

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

A mental health nurse has formed a nursing diagnosis of hopelessness related to poor self-concept for a client with depression. An appropriate outcome for this nursing diagnosis would include what?

The client will demonstrate improved ability to express self.

A mental health nurse has formed a nursing diagnosis of hopelessness related to poor self-concept for a client with depression. An appropriate outcome for this nursing diagnosis would include what?

The client will reframe negative thoughts in a more positive way.

A client who has just been prescribed lithium for bipolar disorder is being given education from the nurse about this medication. Which is important for the nurse to include in teaching?

The higher the sodium level, the lower the lithium level will be.

Which is a true statement regarding depressive disorders?

The neurotransmitters norepinephrine, dopamine, and serotonin have been implicated.

Which is an accurate statement regarding women and suicide?

They are less likely to complete suicide than men.

Which best defines the term suicide?

Thinking about and planning one's own death

When caring for a client with mania, which would the nurse most likely assess?

Unusual self-confidence

When conducting a suicide risk assessment, the nurse understands that which method has the least lethality?

Wrist slashing

The genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should ...

assess for depression in the client's family history.

A client who is depressed tells the nurse, "If I'm honest, I really see suicide as the only way out." In order to challenge the client's belief, the nurse should ...

help the client to identify and explore other options.

When assessing a client who reports mild symptoms of depression, the nurse expects that the diagnostic tests ordered will include:

thyroid stimulating hormone (TSH).