Mental Health Final (Other 33%)

The nursing intervention that demonstrates false imprisonment is when the nurse escorts the irritating and attention-seeking patient down the hall and threatens them with seclusion if they don't stay in their room. False imprisonment refers to the intentional confinement or restraint of a person without proper legal authority. In this situation, the nurse is using the threat of seclusion to restrict the patient's movement, which is a form of false imprisonment.

The correct answer is to withhold the medication and confer with the healthcare provider. This is because the dose of the antidepressant is more than the usual geriatric dose, which could potentially lead to adverse effects or side effects in the elderly patient. It is important for the nurse to consult with the healthcare provider before administering the medication to ensure the safety and well-being of the patient.

The answer provides a detailed account of the patient's behavior leading up to the incident, including the administration of medication and the lack of effect. It also describes the patient's aggressive behavior and the action taken to physically place them in seclusion. Additionally, it mentions that a seclusion order was obtained from a physician after the incident. This documentation accurately captures the sequence of events and the necessary interventions taken, providing a comprehensive record of the situation.

The patient's statement suggests a disturbance in their thought processes, as they are expressing confusion and questioning their beliefs in the face of their recent cancer diagnosis. This diagnosis is focused on the patient's cognitive processes and how they are processing and making sense of their situation, rather than directly addressing their feelings of hopelessness or spiritual distress.

This nursing documentation best meets the requirement for problem-oriented charting because it follows the SOAP (Subjective, Objective, Assessment, Plan) format. The documentation includes the patient's subjective statement ("S: States 'I feel like I'm ready to blow up.'"), objective observations ("O: Pacing hall, mumbling to self"), assessment of the problem ("A: Auditory hallucinations"), plan of action ("P: Offer haloperidol 2 mg PO"), intervention performed ("I: Haloperidol 2 mg PO given at 0900"), and evaluation of the intervention ("E: Returned to lounge at 0930 and quietly watched TV"). This format provides a clear and organized structure for documenting the patient's problem and the nursing actions taken.

The nurse should document the confusion and obtain other assessment data from the grandchild. This is the appropriate next action because the patient is confused and unable to answer questions, indicating a cognitive impairment. By documenting the confusion, the nurse can provide an accurate record of the patient's condition. Obtaining other assessment data from the grandchild can help provide additional information about the patient's medical history, recent events, and potential causes of the confusion. This information will assist the healthcare team in determining the appropriate course of action for the patient's care.

The nurse's best reply is "Anything you say about feelings is private, but some things like suicidal thinking must be reported to the treatment team." This response acknowledges the adolescent's concern about confidentiality while also explaining the limitations to confidentiality when it comes to safety concerns such as suicidal thoughts. It shows that the nurse respects the adolescent's privacy but also prioritizes their well-being and safety.

The nurse is assessing the patient's understanding of the concept of abstraction. The saying "You can't judge a book by looking at the cover" implies that one cannot make accurate judgments about something or someone based solely on their outward appearance. This requires the ability to think abstractly and understand that there may be more to a person or situation than what is immediately apparent.

The nurse should ask the question "Are you having difficulty hearing when I speak?" because the patient's vague or unrelated answers, leaning forward, and frowning indicate potential hearing difficulties. By asking this question, the nurse can gather more information about the patient's hearing abilities and adjust their communication approach accordingly.

The nurse has fulfilled the aspect of care coordination known as milieu management. Milieu management refers to creating and maintaining a therapeutic environment for patients. In this scenario, the nurse is taking the patient on a tour, explaining the rules of the unit, and explaining the daily schedule, all of which contribute to creating a structured and supportive environment for the patient's care.

The nurse should respond by assuring the patient that their information will not be shared with their family or friends without their permission, but it will be shared with other staff members. This response respects the patient's privacy while also acknowledging the need for collaboration and communication among the healthcare team. It maintains confidentiality within the boundaries of the therapeutic relationship.

The desirable outcome for the initial stage of a nurse-patient relationship is for the patient to demonstrate behaviors that indicate rapport and trust with the nurse. This is important because establishing a strong rapport and trust is the foundation for effective communication and collaboration between the nurse and patient. It allows the patient to feel comfortable, safe, and supported, which in turn promotes a positive therapeutic relationship and enhances the overall quality of care provided.

In the nurse-patient relationship, the orientation phase is the initial stage where the nurse and patient establish rapport and set goals for the therapeutic relationship. It is important for the nurse to address termination during this phase because it allows the patient to understand that the relationship will eventually come to an end. This helps to prevent any feelings of abandonment or confusion that may arise when the relationship concludes. By discussing termination early on, the nurse can ensure a smooth and gradual transition out of the therapeutic relationship.

During the first session with a new patient, a nurse should introduce the matter of a contract because contracts spell out the participation and responsibilities of both parties. This helps establish clear expectations and boundaries for the therapeutic relationship between the nurse and the patient. By discussing and agreeing upon these terms, both parties can have a mutual understanding of their roles and responsibilities, which can contribute to effective communication and collaboration throughout the treatment process.

The nurse's best response is "I’m glad you’ve made progress and that I helped, but I cannot accept the gift." This response acknowledges the patient's progress and gratitude while also adhering to the agency's policies and procedures regarding accepting gifts. It demonstrates professionalism and ethical behavior on the part of the nurse.

The nurse's best action in this situation is to recognize the patient's thoughtfulness, express appreciation, and accept the card. This response shows gratitude towards the patient for their kind gesture and helps maintain a positive and supportive relationship between the nurse and the patient.

The correct answer is "I’d like to sit with you for a while to help you get comfortable talking to me." This statement demonstrates offering self because the nurse is expressing a willingness to spend time with the patient to establish a comfortable and trusting relationship. By offering to sit with the patient, the nurse is showing support and creating an environment where the patient feels safe to open up and communicate.

Silence provides meaningful moments for reflection during patient interview sessions. This principle suggests that allowing periods of silence can give patients the opportunity to process and reflect on their thoughts and feelings. It can also encourage them to share more information and provide deeper insights into their concerns and experiences. By creating a space for silence, the nurse respects the patient's need for reflection and allows for a more meaningful and therapeutic conversation.

The most appropriate remark would be "You’ve combed your hair and are wearing a new dress." This statement acknowledges the improvement in the patient's personal appearance and reinforces her self-esteem. It shows that the nurse noticed and appreciated the effort the patient put into her appearance, which can help boost her self-esteem and sense of worth.

The patient's symptoms suggest that he is experiencing severe depression, which can lead to weight loss and lack of self-care. Providing the patient with nutrient-dense finger foods and weighing him daily would address the unintentional weight loss and help monitor his nutritional status. This intervention would be important in the initial care plan to ensure the patient's physical health is being addressed.

Cognitive-behavioral therapy would best address a presentation of this type because it focuses on identifying and changing negative thought patterns and beliefs. The student's belief that everything he does is wrong and that nothing he tries ever works is an example of negative thinking. Cognitive-behavioral therapy can help the student challenge and reframe these negative thoughts, leading to more positive and realistic beliefs.

The nurse's response explains that the tricyclic antidepressant can affect the patient's blood pressure and cause dizziness, especially when changing positions. The nurse suggests drinking more fluids and changing position slowly as ways to alleviate this side effect. This response shows the nurse's understanding of the medication's effects and provides practical solutions for the patient's concern.

Imipramine is a tricyclic antidepressant that can cause anticholinergic side effects. Urinary retention is a serious side effect that requires immediate medical attention as it can lead to bladder distention and urinary tract infections. Dry mouth, blurred vision, and nasal congestion are common side effects of imipramine but do not require immediate medical attention.

The priority nursing focus immediately after electroconvulsive therapy treatment should be on assessing the level of consciousness and normal body functions. Electroconvulsive therapy can cause temporary confusion and disorientation, so it is important to monitor the patient's level of consciousness to ensure they are recovering well from the procedure. Additionally, assessing normal body functions such as vital signs and neurological status is crucial to identify any potential complications or adverse reactions to the treatment.

The progress note that suggests the treatment plan has been effective for the severely depressed and withdrawn patient is the one that mentions positive changes in mood and engagement with activities. The note states that the patient slept for 6 hours straight, participated in an activity group by singing, and expressed eagerness to see their grandchild. These behaviors indicate an improvement in mood, increased motivation, and a desire for social interaction, which are positive signs of the treatment plan's effectiveness.

The nurse should inform the patient about the risk of a serious reaction if she starts taking the MAOIs on her own. MAOIs should not be taken concurrently with SSRIs due to the risk of serotonin syndrome, a potentially life-threatening condition. Therefore, it is crucial for the nurse to emphasize the importance of following the prescribed treatment plan and not making any changes without consulting a healthcare professional.

The rationale for counseling the patient not to make a major business decision for a month is that ECT often causes temporary memory impairment.

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The best response would be to inform the patient that without an antidepressant, the depression is more likely to reoccur, but there are other medications that do not interfere as much with sex. This response addresses the patient's concern about the sexual side effects while also emphasizing the importance of continuing medication to prevent a recurrence of depression. It also offers a potential solution by mentioning that there are other medications available that may have fewer sexual side effects.

The patient's symptoms of cold sweats, nausea, rapid heartbeat, and terrible nightmares are consistent with withdrawal symptoms from abruptly stopping amitriptyline. The nurse should explain to the patient that these symptoms are likely due to withdrawal and advise her to take one dose of Elavil and contact her doctor for further guidance. This response acknowledges the patient's concerns, provides a possible explanation for her symptoms, and directs her to seek medical advice for appropriate management.

The nurse should respond by suggesting to the patient to examine one specific bad thing that happened in order to explore other possible explanations. This response encourages the patient to challenge their overgeneralization and consider alternative perspectives. By examining one specific event, the patient may be able to recognize that there are factors outside of their control that contribute to negative outcomes.

A severely depressed patient with psychomotor retardation may benefit from a rest period during the hour block from 11 AM to noon. This can help the patient conserve energy and reduce fatigue, which are common symptoms of depression. Rest periods can also provide an opportunity for the patient to relax and recharge, which may improve their overall well-being and ability to engage in therapy activities later in the day.

In preparing a depressed patient for their first electroconvulsive therapy (ECT) session, it is important to advise the patient that memory loss is usually transient. This is because memory loss is a common side effect of ECT, but it is typically temporary and improves over time. By informing the patient about this potential side effect, they can be mentally prepared and have realistic expectations about the treatment. This can help alleviate any anxiety or concerns they may have about memory loss and increase their overall comfort and readiness for the procedure.

The correct answer is to hold all medications and call 911 for transportation to the hospital. This is because the patient experienced a grand mal seizure, which is a medical emergency. The confusion and hot forehead could be signs of increased intracranial pressure, indicating a potentially serious condition. Holding all medications is important to prevent any potential interactions or adverse effects during transportation to the hospital. Calling 911 ensures that the patient receives immediate medical attention and appropriate care.

The priority concern for this patient's plan of care is hyperactivity, as well as not eating and sleeping. These symptoms suggest a manic episode, which can be indicative of a serious mental health condition such as bipolar disorder. Hyperactivity can lead to potential harm for the patient and others, while not eating and sleeping can have detrimental effects on their physical and mental well-being. Therefore, addressing these symptoms and ensuring the patient's safety and basic needs are met should be the priority in their plan of care.

A patient with mania who has not eaten or slept for 3 days is at high risk for injury. Mania is characterized by hyperactivity, impulsivity, and poor judgment, which can increase the likelihood of accidents or self-harm. The patient's lack of sleep and proper nutrition further exacerbates these risks. Therefore, the priority nursing diagnosis should be "Risk for injury" to ensure the patient's safety and prevent any potential harm.

The appropriate response by the nurse is to acknowledge the patient's behavior and provide support and assistance. This response shows empathy and understanding while also setting clear boundaries. It offers the patient help in controlling their impulses rather than immediately resorting to punishment or confrontation.

The rationale for adding olanzapine to the lithium regime is to bring hyperactivity under rapid control. Olanzapine is an antipsychotic medication that is commonly used to treat manic episodes in bipolar disorder. It works by balancing the levels of certain chemicals in the brain, which helps to reduce symptoms of mania, including hyperactivity. By combining olanzapine with lithium, the healthcare provider can provide a more comprehensive treatment approach that targets both the mood stabilization effects of lithium and the rapid control of hyperactivity provided by olanzapine.

Rapid cycling is a characteristic of bipolar disorder where a person experiences four or more mood episodes (either manic or depressive) within a year. Carbamazepine (Tegretol) is commonly prescribed for rapid cycling bipolar disorder as it has mood-stabilizing properties and can help to reduce the frequency and severity of mood episodes. Clonidine (Catapres) is primarily used for hypertension, Phenytoin (Dilantin) is an anticonvulsant used for seizures, and Chlorpromazine (Thorazine) is an antipsychotic used for various psychiatric conditions but not specifically for rapid cycling bipolar disorder.

The question asks for a drug that belongs to the same group as divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). The correct answer, lamotrigine (Lamictal), is an anticonvulsant medication commonly used to treat epilepsy and bipolar disorder, just like the other drugs mentioned. Clonazepam (Klonopin), risperidone (Risperdal), and aripiprazole (Abilify) are not in the same group and are used to treat different conditions.

The rationale for escorting the patient to their room to dine alone is to reduce environmental stimuli that negatively affect the patient. By removing the patient from the dining room where there is chaos and potential triggers, the staff can create a more calm and controlled environment for the patient. This can help to minimize the patient's hyperactivity, restlessness, and disorganization, and reduce the risk of harm to others.

The best intervention for the nurse in this situation is to invite the patient to sit with the nurse and look at new fashion magazines. This intervention acknowledges the patient's interest in fashion and redirects their focus in a more appropriate and therapeutic way. It provides a distraction from the impulsive desire to make excessive purchases and allows the nurse to engage with the patient in a therapeutic manner.

Lithium is a medication commonly used to treat bipolar disorder. It works by stabilizing mood swings. One of the potential side effects of lithium is dehydration, as it can increase urine output. Therefore, it is important for patients taking lithium to maintain normal salt and fluids in their diet to prevent dehydration. This means they should not restrict their salt intake and should drink an adequate amount of fluids to stay hydrated. The other options mentioned in the question, such as drinking twice the usual daily amount of fluid or avoiding certain foods, are not specifically related to lithium use. Regular laboratory studies of liver function are important for patients taking certain medications, but it is not specifically mentioned in the question stem.

Both patients with depression and acute mania may experience disturbed sleep patterns. Depression can cause insomnia or excessive sleepiness, while acute mania can cause decreased need for sleep. Addressing the disturbed sleep pattern is a priority for both patients as it can negatively impact their overall well-being and exacerbate their symptoms.

The menu option of broiled chicken breast on a roll, ear of corn, and apple is the best suited for a patient with acute mania. This option includes lean protein from the chicken breast, fiber from the roll and corn, and essential vitamins and minerals from the apple. This combination provides a balanced meal that can help stabilize the patient's mood and energy levels.

The given answer indicates that the treatment plan for a patient with acute mania was effective because the patient is able to converse without interrupting, their clothing matches, and they are participating in activities. These behaviors suggest that the patient's irritability and distractibility have decreased, and they are able to engage in social interactions and daily activities more effectively.

The patient is exhibiting symptoms of mania, which may be caused by a subtherapeutic lithium level. By considering the need to measure the serum lithium level, the nurse can determine if the patient is not swallowing the medication or if the dose needs to be adjusted. This action is important in order to ensure the patient's safety and well-being.

The correct answer is to clear the room of all other patients. This intervention is necessary to ensure the safety of both the patient with acute mania and the other patients in the room. By removing the other patients from the room, the nurse reduces the risk of any potential harm or escalation of the situation. This intervention prioritizes the safety and well-being of all individuals involved.

Lithium is a medication commonly used to treat bipolar disorder. It works by stabilizing mood and preventing episodes of mania or depression. However, it can also cause certain side effects. Diaphoresis, which is excessive sweating, weakness, and nausea are common side effects of lithium. Monitoring for these symptoms is important to ensure the patient's safety and to make any necessary adjustments to their medication regimen. The other options listed do not represent common side effects of lithium.

The patient's symptoms, including diarrhea, weakness, unsteadiness, and worsening hand tremor, may indicate lithium toxicity. Lithium toxicity can cause gastrointestinal symptoms, neurologic symptoms, and dehydration. Therefore, it is appropriate for the nurse to instruct the patient to have someone bring them to the clinic immediately for further evaluation and management of their symptoms.

A patient diagnosed with bipolar I disorder would be expected to experience episodes of major depression and acute mania. Bipolar I disorder is characterized by the presence of at least one manic episode, which is a distinct period of abnormally elevated, expansive, or irritable mood. These manic episodes are often accompanied by symptoms such as increased energy, decreased need for sleep, racing thoughts, and impulsive behavior. In addition to manic episodes, individuals with bipolar I disorder may also experience episodes of major depression, which is characterized by persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities.

The patient with paranoid delusions of being followed by the Mafia should be assessed as being at highest risk for directing violent behavior toward others. Paranoid delusions involve a belief that one is being persecuted or threatened, which can lead to feelings of fear and anger. In this case, the delusion specifically involves the Mafia, which is associated with criminal and violent behavior. The patient's belief that they are being followed by a dangerous and violent organization increases the likelihood that they may act out aggressively or violently towards others.

The behavior of creating a scholarship fund at their child's high school indicates adaptive mourning because it shows that the parents are finding a positive and constructive way to remember and honor their child's memory. By creating a scholarship fund, they are not only keeping their child's legacy alive but also helping other students in their child's school to pursue their education. This behavior demonstrates resilience and the ability to channel grief into something meaningful and beneficial for others.

The widower's statement indicates that he is making an effort to engage in social activities again, specifically by taking his neighbor out for dinner. This demonstrates a reorganization of behavior, as he is redirecting his focus and energy towards a new object or activity (spending time with his neighbor) as a way to cope with his bereavement.

The nurse's most therapeutic reply is "Her death is a terrible loss for you." This response acknowledges the man's grief and validates his feelings of loss. It shows empathy and understanding, which can help him feel heard and supported during this difficult time.

The nurse's best response in this situation is to acknowledge and validate the wife's feelings of anger and upset. By saying "I understand you are feeling upset. I will stay with you until your family comes," the nurse shows empathy and offers support to the wife during her time of distress. This response demonstrates the nurse's understanding of the wife's emotions and willingness to provide comfort and companionship in a difficult moment.

Experiencing many previous losses in life can make the grieving process more difficult because each loss adds to the emotional burden and can make it harder to cope with the current loss. This individual may have accumulated unresolved grief and may be more susceptible to feelings of sadness, anger, and despair. The cumulative effect of multiple losses can make it challenging to navigate through the grieving process and find healing and closure.

The patient's statement about having epigastric discomfort and thinking they have developed an ulcer suggests that they are experiencing somatic distress. Somatic distress refers to physical symptoms that are caused or worsened by psychological factors, such as stress or grief. In this case, the patient's recent loss of their spouse may be causing them to experience physical symptoms, even though diagnostic tests are negative. This is a common phenomenon in bereavement, where emotional distress can manifest as physical symptoms.

The nurse's reply, "Your mind and spirit are healthy, although your body is frail," shows active listening because it acknowledges the patient's statement about wanting to be in control and validates their feelings. It demonstrates that the nurse is actively listening and understanding the patient's perspective, while also providing a supportive and empathetic response.

The nurse should support the patient in sharing their request with their parents and sister and suggest that they inform the patient's friends of the request. This is the appropriate action because the patient has expressed their desire to limit visitors due to lack of energy and feeling embarrassed about their appearance. By involving the parents and sister, the patient's wishes can be communicated effectively to their friends, allowing the patient to have the support they need while respecting their preferences.

The spouse's comment about having to do everything themselves suggests that they may be feeling overwhelmed and frustrated with the situation. By providing teaching about anticipatory grieving, the nurse can help the spouse understand and cope with the emotions and challenges that often arise when caring for a terminally ill loved one. This can help the spouse feel more supported and may alleviate some of their feelings of anger and helplessness. Assigning new personnel or referring for crisis intervention may not address the underlying issue of the spouse's emotional needs, and hospitalization may not be necessary if the patient's condition is being managed effectively at home.

The event that is most likely to precipitate grief across a community is when an adolescent shoots the principal of a local high school. This type of tragedy involves the loss of a respected figure in the community and affects not only the students and staff of the high school but also the entire community as a whole. It is a shocking and traumatic event that can lead to widespread grief and mourning.

The nurse should identify this behavior as an "idea of reference" because the patient's belief that the doctors were plotting to kill him is a delusion that is specifically related to himself. This behavior is characterized by the individual attributing personal significance to unrelated events or objects in their environment.

The phenomenon that most likely underlies this presentation is that the illness itself is preventing the patient from realizing he is ill. Schizophrenia can affect a person's perception and cognition, leading to impaired insight and an inability to recognize their own illness. This lack of awareness is known as anosognosia and is a common symptom in schizophrenia. The patient's refusal to take medication may be due to their genuine belief that they are not ill, rather than denial or stigma. Additionally, there is no mention of command hallucinations instructing the patient to deny the illness, making this answer less likely.

The nurse's response should be predicated on the neurobiological-genetic model because paranoid schizophrenia has been found to have a strong genetic component. This model suggests that the illness is caused by a combination of genetic factors and abnormalities in brain structure and function. It focuses on understanding the biological and genetic mechanisms that contribute to the development of the illness, rather than external factors such as stress or family dynamics. By explaining this model to the family members, the nurse can help them understand that the patient's illness is not their fault or caused by any specific external factor.

The patient stopped taking chlorpromazine (Thorazine) because it made him feel like a "zombie." This suggests that he experienced sedation, which is a common side effect of antipsychotic medications. Additionally, the patient may have experienced tremor and muscle stiffness, which are also common side effects of conventional antipsychotics.

The indicators mentioned in the answer choice, darting eyes, distracted, and mumbling to self, suggest that the patient may be experiencing auditory hallucinations. Darting eyes and being distracted could indicate that the patient is responding to auditory stimuli that others cannot hear, and mumbling to self could suggest that the patient is hearing voices or sounds that are not actually present. These symptoms are commonly associated with auditory hallucinations.

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The most appropriate response by the nurse would be to remind the physician that schizophrenia usually develops earlier in life, that such presentations may be caused by medical problems, and suggest a medical work-up. This is because the patient's age and lack of previous history of mental illness raise concerns about the accuracy of the diagnosis. It is important to rule out any potential medical causes for the patient's symptoms before jumping to a psychiatric diagnosis. A thorough medical work-up will help ensure that the correct diagnosis is made and appropriate treatment is initiated.

The patient is experiencing a dystonic reaction, which is characterized by abnormal muscle contractions and spasms. This is evident by the patient's head rotated to one side in a stiffly fixed position and his lower jaw thrust forward. The nurse should administer PRN IM benztropine (Cogentin) to alleviate the symptoms of the dystonic reaction.

The patient's symptoms of restlessness, disorganized movement, nonsensical verbal responses, disorientation, hot and dry skin, and dilated pupils are consistent with anticholinergic toxicity. Anticholinergic toxicity is caused by an overdose or adverse reaction to medications that block the action of acetylcholine in the central and peripheral nervous systems. The nurse should check the patient's vital signs to assess for any further complications and prepare to use a cooling blanket to help reduce the patient's elevated body temperature.

The patient's verbalization demonstrates clanging, which is a thought disorder commonly seen in schizophrenia. Clanging refers to the use of words that are chosen based on sound rather than meaning. In this case, the patient's words "beat," "eat," and "doom" are connected by their rhyming sound rather than any logical or meaningful association. This is a characteristic symptom of disorganized type schizophrenia.

The patient has been receiving typical antipsychotics for a year, which have helped with his hallucinations but have not improved his apathy, poverty of thought, inability to work, and social isolation. These symptoms suggest negative symptoms of schizophrenia, which are often not effectively treated with typical antipsychotics. Olanzapine (Zyprexa), an atypical antipsychotic, is known to be effective in treating negative symptoms and may be a more suitable option for the patient.

The patient's symptoms, including severe muscle stiffness, difficulty swallowing and speaking, stupor, diaphoresis, and elevated temperature, pulse, and blood pressure, are consistent with neuroleptic malignant syndrome (NMS). NMS is a potentially life-threatening condition that can occur as a side effect of antipsychotic medications like risperidone. The appropriate nursing intervention for NMS is to place the patient in a cooling blanket to lower their body temperature and transfer them to the intensive care unit (ICU) for further management and monitoring.

A suicide can have a significant impact on the mental health and well-being of the individuals left behind, known as survivors. All survivors are at increased risk of experiencing mental health issues and should be assessed for risk at intervals to ensure their well-being. Ongoing support and primary intervention are crucial in reducing their risk and providing them with the necessary support to cope with the loss. It is important to acknowledge the impact of suicide on survivors and provide them with the necessary resources and support to help them heal.

Placing the adolescent on direct one-to-one observation 24 hours a day would be the most appropriate nursing action to ensure his safety during his first few days in the hospital. This level of observation would provide constant supervision and support, minimizing the risk of self-harm. Every-15-minute checks, searching for dangerous material, and having the patient sign a no-suicide contract may not provide sufficient monitoring and support for someone at high risk for self-harm.

The correct answer is that the majority of persons who attempt suicide have given overt or covert indications of their intentions to others. This means that most individuals who are contemplating suicide often show signs or give hints to others about their intentions, whether it be through their behavior, words, or actions. This statement highlights the importance of recognizing these signs and intervening to prevent suicide.

The observation that the adolescent is focusing on problem solving and hope for the future indicates that he may be ready for discharge to outpatient care. This suggests that he has developed coping skills and a positive outlook, which are important factors in preventing future self-harm. The other options, such as denying suicide ideation, family observation, and a decrease in SAD PERSONS score, are also important considerations, but they do not provide as reliable an indication of readiness for discharge as the focus on problem solving and hope for the future.

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Given the patient's history of suicide attempts and diagnosis of major depression, the nurse would expect fluoxetine (Prozac), a selective serotonin reuptake inhibitor (SSRI), to be ordered. SSRIs are commonly prescribed for the treatment of major depression due to their effectiveness in improving mood and reducing the risk of suicide. They work by increasing the levels of serotonin in the brain, which helps regulate mood. Additionally, fluoxetine is often preferred over tricyclic antidepressants or monoamine oxidase inhibitors due to its lower risk of side effects and overdose.

The nurse believes that brain biochemical dysfunction contributes to suicidal behavior. Serotonin is a neurotransmitter that plays a crucial role in regulating mood and emotions. Low levels of serotonin have been associated with depression and an increased risk of suicidal behavior. Therefore, identifying a probable neurotransmitter alteration of serotonin deficiency will help the nurse in planning necessary health teaching for the college student who attempted suicide.

The nurse uses the SAD PERSONS scale to assess the patient's suicide potential. This tool helps to evaluate various risk factors that contribute to the likelihood of a person attempting suicide. It provides valuable data that helps the nurse determine the severity of the patient's suicidal ideation and develop an appropriate intervention plan.

Given the scenario of a college student who attempted suicide by overdose and the decision to hospitalize her due to her living situation, the nursing diagnosis of highest priority would be "Risk for self-directed violence." This is because the patient has already demonstrated a significant risk for self-harm, and it is crucial to ensure her safety and provide appropriate interventions to prevent any further harm to herself. Powerlessness, social isolation, and compromised family coping may also be relevant concerns, but they are not the highest priority in this situation.

Monitoring the severely depressed patient closely as treatment proceeds is important because as depression lifts, the patient may experience an increase in physical energy and cognitive organization. This improvement in functioning can enable the patient to carry out a plan for suicide, making close monitoring crucial to prevent any potential harm.

The correct answer is disclosing a plan for suicide to staff. This indicates that the patient is actively considering suicide and has taken the step of sharing their plan with the staff. This is a critical piece of information that should be taken seriously and addressed immediately to ensure the patient's safety. Adherence to antidepressant therapy and signing a no-suicide contract may indicate some level of engagement in treatment, but they do not necessarily indicate immediate risk. Expressing feelings of hopelessness is concerning but does not provide specific information about the patient's intent or plan for suicide.

The priority areas to consider when assessing a patient's plan for suicide include the availability of means and lethality of the method. This means evaluating whether the patient has access to the necessary tools or substances to carry out their plan, as well as how likely the chosen method is to result in death. Understanding these factors is crucial in determining the level of risk and developing an appropriate intervention plan. Assessing the patient's financial and educational status, insight into their motivation, and social support are also important, but they are not the priority areas in this context.

This answer suggests that every person who thinks about suicide is likely experiencing pain and hopelessness. It implies that suicidal thoughts can be a result of emotional distress and despair.

Jumping from a high, deserted bridge late at night is considered the most lethal suicide plan because it involves a high risk of fatal injuries due to the height and impact of the fall. Additionally, the deserted nature of the bridge and the late-night timing may reduce the chances of someone intervening or providing immediate medical assistance. The other options, while still dangerous, may have a higher likelihood of being interrupted or not resulting in immediate death.

The second nurse suggests that a score of 7 or higher on the SAD PERSONS scale usually requires immediate hospitalization. This implies that the patient's score of 8 indicates a high risk for suicide and that hospitalization would be the most appropriate course of action.

Holding a staff meeting to express feelings and plan care for other patients would be helpful to staff and patients in dealing with the event of a patient committing suicide. This allows the staff to address their emotions and concerns, provide support to each other, and discuss any necessary changes in the care and treatment of other patients. It also allows the patients to express their feelings and receive reassurance and support from the staff. This approach promotes open communication, teamwork, and a supportive environment for everyone involved.

The correct answer is “People with schizophrenia are at high risk, especially early in their illness.” This response is the most helpful because it provides accurate information about the risk of suicide in individuals with schizophrenia, emphasizing the importance of monitoring and support, particularly during the early stages of the illness. It acknowledges the potential for suicidal behavior in this population and highlights the need for vigilance and appropriate assessment.

Based on the information provided, the child is home alone taking care of his younger siblings, indicating a lack of supervision and neglect. The house being cluttered and dirty further supports the assessment of neglect. There is no information provided about sexual or physical abuse, so these options can be ruled out. Therefore, the preliminary assessment is that the child and his siblings are experiencing neglect.

The given scenario suggests emotional abuse. The child's father constantly calling him "stupid" and saying he can never do anything right indicates a pattern of belittlement and undermining the child's self-esteem. Emotional abuse involves any behavior that causes emotional harm or distress, such as constant criticism, humiliation, or rejection. The fact that the child is staying home from school to care for his siblings due to financial constraints also suggests a possible element of economic abuse, but the primary focus in this scenario is on the emotional abuse inflicted by the father.

Asking the question "Do you or your husband ever beat the children?" may interfere with the nurse's goals because it is a direct and confrontational question that could potentially make the parents defensive and less likely to trust the nurse. Building trust is important in order to gather accurate assessment data, and asking about physical abuse may create a hostile environment that hinders the nurse's ability to gather information effectively.

The correct answer is to report her suspicions of abuse or neglect according to state regulations. In this scenario, the nurse is visiting the child's home and observing a cluttered and dirty environment, which may indicate neglect. As a mandated reporter, the nurse has a legal responsibility to report any suspicions of child abuse or neglect to the appropriate authorities, as outlined by state regulations. It is important for the nurse to take action to ensure the safety and well-being of the child and their siblings.

The intervention of meeting with elected officials to lobby for subsidized childcare and increasing the minimum wage is the best option for primary prevention of problems like the one described. By advocating for subsidized childcare, it can help alleviate the financial burden on families and provide them with affordable options for childcare. Increasing the minimum wage can also help improve the family's financial situation, reducing the need for the child to stay home and care for their siblings. This intervention addresses the root causes of the problem and aims to create systemic changes that can benefit not only this family but also others in similar situations.

The nursing diagnosis that should be the priority for the child is chronic low self-esteem. This is indicated by the child's belief that his father does not like him and calls him "stupid" all the time, leading to feelings of inadequacy and worthlessness. This diagnosis is important to address as it can significantly impact the child's overall well-being and development. By addressing and addressing the child's low self-esteem, the nurse can help promote a positive self-image and improve the child's emotional and social functioning.

The indicator that suggests nursing interventions are succeeding is that the child attends school regularly. This indicates that the child is able to prioritize their own education and well-being, rather than being forced to stay home and care for their siblings. Attending school regularly also suggests that the child feels safe and supported enough to leave their home environment, where they may be demeaned by their father and have negative self-perceptions.

The nurse should first focus on establishing trust and building rapport with the patient. This is important in order to create a safe and supportive environment for the patient to disclose any potential abuse. It is crucial for the nurse to gain the patient's trust before discussing sensitive and potentially traumatic topics such as domestic violence. By establishing trust and building rapport, the nurse can ensure that the patient feels comfortable and supported, increasing the likelihood of open communication and providing appropriate care.

The most important initial inquiry for the nurse to make in this situation is to ask the woman to "Tell me what has happened to you." This open-ended question allows the woman to share her experiences and disclose any incidents of abuse she may be experiencing. It shows empathy and concern for her well-being, and allows the nurse to gather important information to assess the situation and provide appropriate support and resources. The other options are more accusatory or judgmental, which may discourage the woman from opening up about her situation.

The nurse's response is considered unprofessional because it imposes the nurse's own beliefs and values onto the patient. Instead of providing support and understanding, the nurse is being judgmental and not considering the cultural and personal factors that may influence the patient's decision to stay in the abusive relationship. This response may not be helpful as it may further isolate the patient and discourage her from seeking help or confiding in healthcare professionals.

The evidence that the husband is at risk of becoming a perpetrator of physical abuse is that he was an abused child. This suggests that he may have learned violent behavior from his own father and is likely to repeat the same pattern of abuse in his own relationships. The fact that he is apologetic and remorseful after incidents does not necessarily indicate that he is not at risk of becoming an abuser, as this behavior can be part of a cycle of abuse. The other options of being unable to make lasting behavioral changes and being without a job do not directly indicate a risk of becoming a perpetrator of physical abuse.

The most important nursing diagnosis to address for this patient is "Risk for injury related to impaired cognition, judgment, and coordination and lack of caregiver supervision." This is because the patient has Alzheimer's disease, which affects her cognition and judgment. The bruises on her body indicate that she is at risk of injury, possibly due to falls or accidents. The daughter's statement also suggests that there is a lack of caregiver supervision, which further increases the risk of injury for the patient. Therefore, addressing this nursing diagnosis is crucial to ensure the patient's safety and well-being.

The nurse is likely to establish the nursing diagnosis of "Ineffective coping related to poor anger management" because the perpetrator has a long history of violent rages when frustrated. This suggests that the individual has difficulty managing their anger in a healthy and appropriate way, leading to ineffective coping mechanisms.