MH Exam #2
The priority nursing intervention and rationale when a nurse discovers a client's suicide
note that details the time, place and means to commit suicide. - Placing this client on
one-to-one suicide precautions because the more specific the plan, the more likely the
client will attempt suicide
The nurse's priority when writing a written outcome in the plan of care for a suicidal
client. - The client will remain safe during the hospital stay.
The nurse's priority intervention for a patient diagnosed with Major Depressive Disorder
that hears voices commanding self-harm and refuses to commit to a safety contract. -
Placing the client on one-to-one observation while monitoring suicidal ideations
The nurse's priority action when observes a patient who has history of (3) suicide
attempt, has been taking an antidepressant for 4 weeks and suddenly is talkative,
happy, with a bright affect. - Increase frequency of client observation.
The nurse's priority intervention and safety precautions that should be given that is
related to taking an (Elavil) amitriptyline prior to discharge. - Provide a 1-week supply of
Elavil with refills contingent on follow-up appointments.
The most appropriate nursing diagnosis if a patient states, "Nothing will ever get better"
or "Nobody in my can help me." - Hopelessness R/T altered mood AEB client
statements
What assessment information is a contributing factor, for a previously suicidal p to
interdisciplinary team's decision to discharge. - Able to participate in a plan for safety;
family agrees to constant observation
The nurse's best information that should be given to the family that is supportive and
request more facts in caring for the patient after discharge. - Be available to actively
listen, support, and accept feelings.
The information that should include when teaching a student about suicide in the elderly
population. - Although the elderly make up less than 13% of the population, they
account for 16% of all suicides.
What information is needed to determine the nurse's plan of care when a patient is
threatening to commit suicide by hanging and states, I'm going to use a knotted sheet
when no one is around." - The more specific the plan is, the more likely the client will
attempt suicide.
The best nursing reply when talking to a suicidal patient that states, "There's nothing to
live for anymore." - It sounds like you are feeling pretty hopeless.
The best reply when asked by a student nurse to classify suicide. - Suicide is a
behavior.
, MH Exam #2
The first nursing interventions that should be implemented when developing a plan of
care for a suicidal patient. - Assess for Suicide Risk
If teaching about suicide, what statement are made that indicates learning has occurred.
- Fifty to eighty percent of all people who kill themselves have a history of a previous
attempt.
The priority nursing action to maintain client safety for paranoid patient that presents
with bizarre behaviors, neologisms, and thought insertion. - Note escalating behaviors
and intervene immediately
The appropriate nursing reply to the parents of 16-year-old diagnosed with a mental
illness experiences command hallucination to harm others and the parents ask "Where
do the voices come from." - "Your child has a chemical imbalance of the brain which
leads to altered thoughts."
The appropriate nursing reply to tell parents when they ask about their child that is
diagnosed with Schizophrenia, tells him that the voices command him to harm others. -
"Focus on the feelings generated by the hallucinations and present reality."
What potential symptom is the nurse assessing for when asking a patient with
Schizophrenia, "Do you received special messages from the television or radio. -
Delusions of reference
The most appropriate nursing reply for a patient that is diagnosed with Schizophrenia
and states, "Can't you hear him? "It's the devil and he is telling me I'm going to hell." -
"I'm sure the voices sound scary. The devil is not talking to you. This is part of your
illness."
The priority nursing diagnosis with a patient with brief psychotic disorder tells the nurse,
"The voices are telling me to kill the president." - Risk for violence: directed toward
others
The most appropriate nursing intervention when caring for an acutely agitated client with
paranoia. - Provide personal space to respect the client's boundaries.
The nursing behavior that will enhance the establishment of a trusting relationship with
client diagnosed with Schizophrenia. - Being reliable, honest, and consistent during
interactions.
The presenting symptom and nurse's legal responsibilities related to that symptoms for
a patient diagnosed with Schizophrenia that states, "My doctor is out to get me" and "I'm
sad that the voice is telling me to stop him." - Command hallucinations; warn the
psychiatrist
The priority nursing intervention and rationale when a nurse discovers a client's suicide
note that details the time, place and means to commit suicide. - Placing this client on
one-to-one suicide precautions because the more specific the plan, the more likely the
client will attempt suicide
The nurse's priority when writing a written outcome in the plan of care for a suicidal
client. - The client will remain safe during the hospital stay.
The nurse's priority intervention for a patient diagnosed with Major Depressive Disorder
that hears voices commanding self-harm and refuses to commit to a safety contract. -
Placing the client on one-to-one observation while monitoring suicidal ideations
The nurse's priority action when observes a patient who has history of (3) suicide
attempt, has been taking an antidepressant for 4 weeks and suddenly is talkative,
happy, with a bright affect. - Increase frequency of client observation.
The nurse's priority intervention and safety precautions that should be given that is
related to taking an (Elavil) amitriptyline prior to discharge. - Provide a 1-week supply of
Elavil with refills contingent on follow-up appointments.
The most appropriate nursing diagnosis if a patient states, "Nothing will ever get better"
or "Nobody in my can help me." - Hopelessness R/T altered mood AEB client
statements
What assessment information is a contributing factor, for a previously suicidal p to
interdisciplinary team's decision to discharge. - Able to participate in a plan for safety;
family agrees to constant observation
The nurse's best information that should be given to the family that is supportive and
request more facts in caring for the patient after discharge. - Be available to actively
listen, support, and accept feelings.
The information that should include when teaching a student about suicide in the elderly
population. - Although the elderly make up less than 13% of the population, they
account for 16% of all suicides.
What information is needed to determine the nurse's plan of care when a patient is
threatening to commit suicide by hanging and states, I'm going to use a knotted sheet
when no one is around." - The more specific the plan is, the more likely the client will
attempt suicide.
The best nursing reply when talking to a suicidal patient that states, "There's nothing to
live for anymore." - It sounds like you are feeling pretty hopeless.
The best reply when asked by a student nurse to classify suicide. - Suicide is a
behavior.
, MH Exam #2
The first nursing interventions that should be implemented when developing a plan of
care for a suicidal patient. - Assess for Suicide Risk
If teaching about suicide, what statement are made that indicates learning has occurred.
- Fifty to eighty percent of all people who kill themselves have a history of a previous
attempt.
The priority nursing action to maintain client safety for paranoid patient that presents
with bizarre behaviors, neologisms, and thought insertion. - Note escalating behaviors
and intervene immediately
The appropriate nursing reply to the parents of 16-year-old diagnosed with a mental
illness experiences command hallucination to harm others and the parents ask "Where
do the voices come from." - "Your child has a chemical imbalance of the brain which
leads to altered thoughts."
The appropriate nursing reply to tell parents when they ask about their child that is
diagnosed with Schizophrenia, tells him that the voices command him to harm others. -
"Focus on the feelings generated by the hallucinations and present reality."
What potential symptom is the nurse assessing for when asking a patient with
Schizophrenia, "Do you received special messages from the television or radio. -
Delusions of reference
The most appropriate nursing reply for a patient that is diagnosed with Schizophrenia
and states, "Can't you hear him? "It's the devil and he is telling me I'm going to hell." -
"I'm sure the voices sound scary. The devil is not talking to you. This is part of your
illness."
The priority nursing diagnosis with a patient with brief psychotic disorder tells the nurse,
"The voices are telling me to kill the president." - Risk for violence: directed toward
others
The most appropriate nursing intervention when caring for an acutely agitated client with
paranoia. - Provide personal space to respect the client's boundaries.
The nursing behavior that will enhance the establishment of a trusting relationship with
client diagnosed with Schizophrenia. - Being reliable, honest, and consistent during
interactions.
The presenting symptom and nurse's legal responsibilities related to that symptoms for
a patient diagnosed with Schizophrenia that states, "My doctor is out to get me" and "I'm
sad that the voice is telling me to stop him." - Command hallucinations; warn the
psychiatrist
