These operate in both healthy and unhealthy ways to protect a person from conflict and emotional discomfort.
What are defense mechanisms?
100
"I can't take it any more"
What is an overt statement of a verbal cue to suicide risk?
100
Primarily assessed through the client's speech, it can also be assessed in their writing, their artwork and occupational tasks.
What are thought processes?
100
Restlessness, or a subjective experience of not being able to sit still.
What is akathisia
100
Shifting of moods or feelings.
What is lability?
200
The is unable to follow directions, preoccupied with a minute detail, says time feels longer than usual, and that he feels as if he is going to die.
What are signs and symptoms of severe anxiety?
200
Older adult (>65), males.
Who is at highest risk for suicide?
200
A false belief, despite contrary evidence and not unique to one's culture.
What is a delusion?
200
The Mini-Mental Status (MMSE) or Mini-Cog.
What are tools for assessing cognition?
200
The nurse assesses this by observing facial expression, tone of voice, and body language.
What is affect?
300
The counter server who is disgusted by fat people adds extra whipped cream to the milkshake she serves to the obese customer is using this defense mechanism.
What is Reaction Formation?
300
Detail of a plan for suicide, lethality of method, access to means, opportunity for rescue and whether or not any action to implement the plan has been taken.
What is evaluation of a suicide plan?
300
Logical, goal directed, and organized.
What is normal though process?
300
The determines how well a client can solve problems, choose among alternatives and anticipate consequences.
How does the nurse assess judgment?
300
Pervasive and sustained emotion.
What is mood?
400
The nurse should speak in firm, short and simple statements.
What is an effective communication pattern in severe to panic levels of anxiety?
400
"Those who talk about it, don't do it"
What is a myth about suicide? / Always take threats seriously.
400
What a person is thinking about, for example an obsession is an abnormality of this parameter.
What is thought content.
400
Refers to a client's level of consciousness and responsiveness to environmental stimuli.
What is sensorium?
400
Elevated mood accompanied by poor judgment, and impairment in functioning.
What is mania?
500
Problem solving, clarification,demonstration of interest and encouraging the patient to express feelings.
What are effective interventions in mild to moderate anxiety?
500
Risk for suicide
What is the priority nursing diagnosis for the acutely suicidal client?
500
When thinking becomes disorganized, the logical connection between thoughts erodes.