Suicide Risk
Typically a nonlethal, repetitive act used to reduce distress rather than end one’s life is known as?
Nonsuicidal self-injuring behavior (NSSIB)
For a heavy alcoholic, what is the length of time after the last drink that alcohol withdrawal symptoms usually start?
Bonus 200 pts: Alcohol withdrawal delirium can occur during what time frame?
3-12 hours.
2-3 days after cessation of alcohol
T or F: Clients diagnosed with Bulimia Nervosa have eroded tooth enamel, whereas clients with Anorexia Nervosa do not.
False. Both of these clients would as the emesis from purging corrodes tooth enamel.
Mild, Moderate, Severe, or Profound IDD?
May need some support with complex activities of daily living. As an adult is generally capable of independent living with assistance during times of stress.
Mild
A nurse is caring for a client who states, “I plan to commit suicide.” Which of the following assessments should the nurse identify as priority?
B. Lethality of the method and availability of means. The greatest risk to the client is self-harm as a result of carrying out a suicide plan.
This medication works by blocking the breakdown of alcohol in the body, leading to the buildup of a toxic compound that causes symptoms such as flushing, headache, nausea, vomiting, chest pain, and anxiety.
Disulfiram
T or F: Behavior modification is used as a treatment plan in order to increase the client's motivation to gain weight.
False. Behavior modification is used to attempt to give the client some control over their life / behavior choices.
A nurse is assessing a 4-year-old for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess?
B. repetitive actions and strict routines are an indication of autism spectrum disorder.
A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care?
C. Ensure that the client swallows all of their medication to prevent hoarding and taking a higher dose at a later time.
What is Wernicke’s encephalopathy a deficiency of?
Thiamine. Wernicke’s encephalopathy is the most serious form of thiamine deficiency in clients diagnosed with alcoholism. If thiamine replacement therapy is not undertaken quickly, death will ensue.
A nurse is planning care for a client who has anorexia nervosa with binge eating and purging behavior. Which of the following actions should the nurse include in the client’s plan of care?
D. Implement one to one observation during meal times. Closely monitoring is important, especially early in treatment.
Mild, Moderate, Severe, or Profound IDD?
Requires support for all activities of daily living. Requires complete supervision. Minimal verbal skills. Wants and needs often communicated by acting-out behaviors.
Severe
Opioid withdrawal... what are 3 sx a nurse might see / the pt might describe
Nausea, vomiting, diarrhea, anxiety, sweating, rhinorrhea, piloerection, tremors, irritability, weakness, insomnia, pupil dilation, pain in muscles and bones, muscle spasms.
Suicide screening usually asks the patient 2 questions:
What is the third question a nurse will ask if either of these are a yes answer?
“Are you having thoughts of suicide right now?”
What are the CAGE questions?
•Have you ever felt you should Cut down on your drinking?
•Have people Annoyed you by criticizing your drinking?
•Have you ever felt bad or Guilty about your drinking?
•Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)?
T or F: Family dynamics are thought to be a big influence on the development of anorexia nervosa and the overemphasis of attention to food can be a part of this.
False. More than that - the home environment that is overprotective, demanding perfection is more of a concern for the development of anorexia.
Mild, Moderate, Severe or Profound IDD?
Can perform some activities independently. Requires supervision. May experience some limitation in speech communication. Difficulty adhering to social convention may interfere with peer relationships.
Moderate
SATA: A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide?
A, C, E. The other 2 statements identify a problem, but do not talk about suicide. You would assess further to gain more information with those 2 questions.
Alcohol detoxification / withdrawal ... what are 3 signs / symptoms should the nurse expect
Nausea and vomiting
Gross tremor
Paroxysmal sweats
Anxiety
Agitation / Hyperactivity
Tactile disturbances
Auditory disturbances
Visual disturbances
Headache
Orientation and clouded sensorium, delirium
Hypertension
SATA: A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding?
The other options are expected findings of anorexia
SATA: A nurse is teaching a group of guardians about manifestations of conduct disorder. Which of the following findings should the nurse include?
A, C, D. Low self-esteem, rather than narcissistic bx, and irritability/temper outbursts rather than flat affect are expected findings.