MH 3 (mine)

overt statements

"I don't want to live anymore." "Life isn't worth living anymore." Open statements, straightforward, specific to ending life

covert statements

"It's okay, now. Soon everything will be fine." Absolutes- never, always, everything

suicide precautions

1 to 1 observation 15min documentation Nothing to harm self with -no glass/silverware or forks, ensure count and apple to after use Hands always in view- not under covers Observe patient swallow meds All belongings kept separate from pt

A nurse is assessing a client who was in a motor vehicle crash that killed her sibling. The client is shaking and asks, "What can I do now?' Which of the following questions is the nurse's priority?

Are you thinking about hurting yourself?

Euthanasia

Assisted death for patients with terminal illness and in significant pain

A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make?

Attending group therapy, even if you're tired, is an important part of your treatment.

Acceptance of death

Closure, reminiscing, remembering good memories

A nurse is assessing a client who has a new diagnosis of major depressive disorder. Which of the following questions is the priority for the nurse to ask?

Do you ever think about suicide?

What should you ask a suicidal patient?

Do you have thoughts of suicide? Do you have a plan? -asses lethality

Complicated grief

Extended time and stuck in anger or denial phase Ex. Mutiple family deaths 4mo apart

Ziprasidone

Geodon Atypical Antipsychotic (2nd Generation) QT prolongation -monitor EKG and potassium low risk for metabolic syndrome (diabetes, dyslipidemia, weight gain)

A nurse is assessing a client who has major depressive disorder. Which of the following questions should the nurse prioritize when speaking with the client?

Have you thought about hurting yourself?

A nurse is caring for a client who has major depressive disorder and recently started taking an antidepressant. The nurse should identify which of the following client statements as the priority?

I have it all figured out. Everything is going to be okay now.

A nurse is caring for a client who has excoriation disorder. Which of the following statements by the client should the nurse expect?

I pick my face when I am nervous

A nurse in an acute care mental health facility is evaluating the plan of care for a client who has major depressive disorder and was admitted 1 week ago following a suicide attempt. Which of the following client statements should indicate to the nurse that the treatment plan has been effective?

I was feeling completely hopeless when I tried to kill myself.

A nurse is talking with a client who has major depressive disorder. Which of the following client statements should the nurse identify as a covert statement of suicidal ideation?

I won't have to deal with things much longer.

Disenfranchised grieving

Intense loss that may not be socially acceptable or you may not feel is acceptable, causing you not to share or discuss loss, extending grieving process

A nurse is planning a teaching session at a community center about preventing suicide. Which of the following groups should the nurse recognize is most at risk for suicide?

Older adult male clients ages 75 to 90 years old

Hospice

Provide care through pain management, transition to dying and providing dignity. No cure for pt, comfort measures only

Antidepressants

SSRIs drugs that combat depression by affecting the levels or activity of neurotransmitters in the brain take time to have effect monitor for indications of increased depression or intent of suicide sudden mood changes from sad to happy and peaceful (intent to end life soon)

close family loss

Statement that grieving is effective

A nurse receives a call on a crisis intervention hotline from a client. Which of the following statements should the nurse identify as an overt statement indicating the client's risk for suicide?

There's no point in living any longer.

A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client states, "I do not want visitors today because I look and feel terrible." Which of the following responses should the nurse make?

Would you like to talk about why you feel this way?

A nurse is teaching a client who has major depressive disorder and is scheduled to begin electroconvulsive therapy (ECT). Which of the following pieces of information should the nurse include?

You can expect to wake up about 15min after the procedure.

A nurse is caring for a client who has depression. The nurse. observed that the client has not come to breakfast and is still in bed. The client states "I'm not worth your time. Leave me alone and go help someone else." Which of the following responses should the nurse make?

You seem to be saying that you feel unworthy of help.

A nurse is caring for a client who has depression and started taking paroxetine 1 week ago. The client states "My family would be better off without me." Which of the following responses should the nurse make?

You sound upset. Are you thinking of hurting yourself?

serotonin syndrome

a serious drug reaction caused by medications that build up high levels of serotonin in the body negative symptoms: agitation or restlessness, insomnia, confusion, rapid HR, high BP, dilated pupils, loss of muscle coordination or twitching muscles, muscle rigidity, heavy sweating, diarrhea, headache, shivering, goosebumps.

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depression. Following the procedure, which of the following actions should the nurse take?

administer oxygen

A nurse in a mental health clinic is assessing an older adult client who is tearful and reports sleep disturbances. The client tells the nurse, "All of my friends have died, and my children are too busy for me." Which of the following actions should the nurse take first?

administer the Geriatric Depression Scale

disenfranchised grief

an experienced loss which that cannot be publicly shared or not socially accepted (suicide and abortion)

SADS PERSONS Scale

assessment tool to determine risk for suicide Sex - male (1pt) Age- <20 or >44 years old (1pt) Depression or hopelessness (2pt) Previous suicide attempts or psych care (1pt) Excessive alcohol or drug use (1pt) Rational thinking loss (2pt) Separated, divorced or widowed (1pt) Organized or serious attempt (2pt) No social supports (1pt) States future intent (2pt) 0-2 send home w follow up 3-4 close follow up, consider hospitalization 5-6 strongly consider hospitalization 7-10 hospitalize or commit

A nurse on a mental health unit is caring for a client who has depression. which of the following actions should the nurse take to foster a therapeutic environment for this client?

build trust with the client by sitting quietly with him

A nurse is obtaining a client's medical history prior to scheduling the client for electroconvulsive therapy (ECT). Which of the following findings should the nurse identify as a potential complication of the procedure?

cardiac arrhythmia

vegetative signs of depression

change in eating patterns and bowel habits, sleep disturbances and decreased interest in sexual activity

A school nurse is caring for an adolescent patient with a history of a depressive episode 1 year ago. He appears withdrawn from social activities, and his school performance is declining. Which of the following actions should the nurse take first?

conduct a suicide risk assessment

A nurse is caring for a client who just received a terminal diagnosis of cancer. Which of the following initial reactions should the nurse expect from the client?

denial

A nurse is caring for a client who was newly diagnosed with breast cancer that has metastasized into the spine. The client refuses to discuss treatment options. The nurse should identify that the client is experiencing which of the following stages of Kubler-Ross' grief theory?

denial

A nurse is providing support for the parents of a child who has a new diagnosis of a terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief first?

denial

s/s of depression

depressed mood, insomnia, excessive sleeping, indecisiveness, decreased ability to concentrate, suicidal ideation, increase or decrease in motor activity, increase or decrease in wt. and agnosia.

low serotonin

depression and anxiety can cause inability to eat or sleep, basic needs which need to be addressed by nurse

overt

done or shown openly "there is just no reason for me to go on living"

A nurse is updating the plan of care for a client who has major depression and a new prescription for amitriptyline. The nurse should plan to monitor the client for which of the following adverse effects?

drowsiness

A nurse is assessing the a client who takes phenelzine for the treatment of depression. Which of the following findings is the priority for the nurse to report to the provider?

elevated blood pressure

light therapy

first line therapy for Seasonal Affective Disorder (SAD) inhibits nocturnal secretion of melatonin

A nurse is assessing a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team?

giving away possessions

A nurse in a clinic is assessing a client who states that she needs help with depression. Which of the following questions is the nurse's priority?

have you thought about harming yourself in any way?

suicidal ideation

having thoughts about committing suicide

A nurse in a provider's office is reviewing the medical history of a client who asks about the use of varenicline for smoking cessation. Which of the following items in the client's medical history indicates a precaution for the use of varenicline?

history of depression

A nurse is caring for a client who has end-stage lung cancer. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of Kubler-Ross' stages of grief?

i would give anything to live to see my grandchild born

complicated grieving

in an ongoing, heightened state of mourning that keeps you from healing delayed/inhibited grief, distorted or exaggerated grief response, chronic or prolonged grief, disenfranchised grief.

light therapy

inhibits nocturnal secretion of melatonin exposure in light box 30min a day

anergia

lack of energy

anthedonia

lack of pleasure or joy

A nurse is teaching a client who has seasonal affective disorder (SAD) about light therapy. Which of the following statements should the nurse make?

light therapy suppresses the natural nighttime release of melatonin

who is more likely to complete suicide?

males, adolescents, middle and older adult

who is at increased risk for suicide?

military personnel, lgbtqia+ comorbid mental illness

covert

not openly acknowledged or displayed "everything is looking pretty grim for me"

affect

objective expression of mood

major depressive disorder (MDD)

persistently depressed mood or loss of interest in activities, causing significant impairment in daily life

A nurse is caring for a client who attempted suicide and refuses to sign a no-suicide contract. Which of the following actions should the nurse take when implementing suicide precautions?

place client on 1 to 1 observation

euthanasia

practice of intentionally ending life to relieve pain and suffering

Pt is admitted with history of depression, what is the nurse's priority?

prevent patient injuring themselves

hospice / palliative care

prioritizes comfort and quality of life by reducing pain and suffering

A nurse in a mental health unit is planning care for a client who is receiving treatment for self-inflicted injuries. Which of the following interventions is the priority when planning care for this client?

promoting and maintaining client safety

A nurse is planning care for a client who has vegetative signs of depression. Which of the following actions should the nurse include in the plan?

provide decaffeinated beverages

tertiary interventions

providing support and assistance to survivors of a pt who completed suicide

A nurse is planning care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse include in the client's plan of care?

search the client and his belongings upon arrival

A nurse is teaching a client who has depression and is scheduled for transcranial magnetic stimulation (TMS). The nurse should inform the client that TMS can cause which of the following adverse effects?

seizures

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect?

social discomfort

levels of lethality

soft suicide- overdose hard suicide- self inflicted gsw

secondary interventions

suicide prevention for an individual patient who is having an acute suicidal crisis; suicide precautions begin

primary interventions

suicide prevention through community education and screening to identify individuals at risk

A nurse is assessing the lethality of a client's plan for committing suicide. Which of the following plans should the nurse identify as a soft method of suicide?

swallowing antidepressant pills

A nurse is teaching a parent who has admitted to verbally abusing his children about stress management techniques. Which of the following strategies is the nurse providing?

tertiary prevention

anticapatory grieving

the 'letting go' of an object or person before the loss; allows opportunity to grieve before the actual loss

lethality

the capacity to cause death or serious harm or damage

A nurse is completing an admission assessment for an adolescent client who has depression. The nurse should identify which of the following findings as the priority?

the client gave his favorite possessions to friends

A nurse is reviewing the health history of a young adult client who has a depressive disorder. Which of the following factors increases the cilent's risk of depression?

the client is female

grieving

the inner emotional response to loss and is exhibited is as many ways as there are individuals

A nurse in a mental health facility is meeting with a client who has a diagnosis of major depression. During the conversation, the client stops speaking, and the nurse sits silently next to the client for several minutes. The nurse should identify that the therapeutic communication technique of silence is used for which of the following purposes?

to encourage the client to express feelings or concerns.

non-suicide contract

verbal or written agreement made not to harm themselves and to seek help instead develop trust between nurse and patient, in turn allowing pt to feel more comfortable disclosing feelings of self harm

who is more likely to attempt suicide?

white females