SUICIDE ALERT
A client says, "I don't want to live anymore." What is the nurse's best response?
Have you had thoughts of harming yourself or others?
Which therapeutic communication technique is being used when the nurse says, “Tell me more about how you’re feeling”?
Open-ended question
What is the priority nursing action for a client experiencing a panic attack?
Stay with the client and provide reassurance
Which nursing intervention is appropriate for a client with dementia who is disoriented?
Reinforce orientation to time, place, and person.
Clients taking MAOIs should avoid foods containing this substance.
Tyramine
This environmental intervention is most important for a suicidal client.
Remove harmful objects from the room
This type of milieu environment promotes mental health recovery.
Calm and structured atmosphere
Which disorder is characterized by alternating periods of depression and mania?
Bipolar disorder
What is a hallmark sign of schizophrenia?
Which adverse effect is life-threatening and requires immediate discontinuation of antipsychotic medication?
Neuroleptic malignant syndrome (NMS) - high fever, rigidity, altered mental status
“Everyone will be better off when I’m gone” is what type of suicidal statement?
Covert suicidal statement
The goal of the therapeutic nurse-client relationship is this.
Optimal personal growth
Persistent defiance and hostile behavior in school-age children describes this disorder.
Oppositional Defiant Disorder (ODD)
These fluctuating symptoms help distinguish delirium from Alzheimer’s disease.
Acute confusion and changing levels of consciousness
When a patient diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine), a conventional (first generation) antipsychotic medication, 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a “zombie.” What other common side effects should the nurse determine if the patient experienced?
What is sedation, tremor, and muscle stiffness
A client with severe depression should receive these to improve nutritional intake.
Frequent high calorie small snacks
Helping a depressed client sit up and put on slippers is an example of this communication approach.
Offering assistance/support
Easily startled by loud noises after trauma is commonly seen in this disorder.
Post traumatic stress disorder
A nurse should review these first when delirium is suspected.
Current medications
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient’s skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient’s recent presentation. The patient is likely experiencing ________ , and the nurse should ___________.
What is anticholinergic toxicity…check vital signs and prepare to use a cooling blanket?
Asking directly about suicide plans helps the nurse determine this.
Suicide risk level
Asking about stress related to headaches demonstrates this nursing approach.
Holistic nursing
A patient has been taking sertraline for 2 weeks. During his follow up appointment, the patient presents with agitation, tremors, and hallucinations. What condition should the nurse consider?
Serotonin syndrome
a)"You have forgotten that this is your home"
b)"I am your nurse. Let's walk to your room"
c)"You cannot go outside without a staff member."
b)"I am your nurse. Let's walk to your room"
This herbal supplement may improve symptoms of depression.
St. John's Wort