Depression/Suicide
What is the first nursing action when a patient expresses suicidal thoughts?
Ask if they have a plan or intent to harm themselves.
Which symptom indicates early alcohol withdrawal?
Tremors or “the shakes.”
What distinguishes delirium from dementia?
Delirium has an acute onset and fluctuating course.
Hearing voices others cannot hear is what type of symptom?
auditory hallucinations
Which Kübler-Ross stage is shown when a patient says, “This can’t be happening”?
Denial
Which neurotransmitter is primarily decreased in depression?
Serotonin
Which medication reverses opioid overdose?
Naloxone (Narcan).
Which assessment finding is most consistent with early Alzheimer’s disease?
Short-term memory loss with preserved long-term memory.
A patient with schizophrenia sits motionless, speaks in a monotone voice, and shows no facial expression even when discussing emotional topics. Which type of symptom is the nurse observing?
flat affect
What is the main goal of palliative care?
Relief of symptoms and improvement of quality of life.
A nurse learns that a patient has a detailed suicide plan and access to means. What is the next nursing action?
Initiate one-to-one observation and remove potential means of self-harm.
A patient taking disulfiram drinks alcohol and experiences vomiting and headache. What is the nurse’s interpretation?
A disulfiram-alcohol reaction has occurred.
A patient with delirium becomes agitated during the night. Which intervention is most effective?
Provide a calm, well-lit environment and frequent reassurance.
A patient says, “The government implanted a chip in my brain.” What is the therapeutic nursing response?
“I don’t share that belief, but I can see it feels very real and frightening to you.”
A patient nearing death has mottled skin and irregular breathing. What should the nurse do?
Provide comfort and reassure the family that these are expected signs.
A patient taking MAOIs should avoid which type of food?
Tyramine-rich foods such as aged cheese and cured meats.
A patient in withdrawal shows hypertension, diaphoresis, and hallucinations. What is the nurse’s priority?
Implement seizure precautions and administer prescribed benzodiazepines.
The nurse notes that a dementia patient begins wandering and entering other rooms. Which intervention is best?
Install door alarms and provide structured activities during the day.
A patient on risperidone develops restlessness, pacing, and inability to sit still. What should the nurse do?
Suspect akathisia and notify the provider for medication adjustment.
Which legal document outlines the patient’s wishes for medical treatment at end of life?
Advance directive or living will.
A patient with treatment-resistant depression begins ECT. Post-procedure, the patient is disoriented and tries to stand. What is the nurse’s priority?
Maintain airway and safety until orientation returns, then reorient the patient.
A patient on long-term opioid therapy is transitioning to recovery. Which medication reduces cravings?
Methadone or buprenorphine.
A patient with advanced dementia becomes combative during hygiene care. Which nursing action reflects the best clinical reasoning?
Pause the activity, approach calmly, use validation techniques, and try again later.
A patient with schizophrenia suddenly develops fever, muscle rigidity, and confusion. What is the nurse’s priority sequence of actions?
Stop antipsychotic medication, assess vital signs, notify provider, and prepare to transfer to higher level of care, suspect NMS.
After death, the family requests to perform a cultural ritual involving anointing the body. Which nursing action would show cultural competence?
Collaborate with the charge nurse and spiritual care to facilitate the ritual promptly while maintaining infection control and institutional policy.