Rasmussen Mental Health Exam #2
Common symptoms of depression - Answer Anergia, feelings of worthlessness, lack of
self esteem, guilt, helplessness, hopelessness, anger and irritability, changes in eating
patterns, changes in sleeping patterns, insomnia, hyper insomnia, constipation,
decreased libido, chronic pain, lack of concentration and indecisiveness.
Beck's Cognitive Triad - Answer Believed that people develop depression through
psychological predisposition of early life experiences. Even in positive circumstances,
Beck believed that depressed people still process things in a negative way. He believed
there are three automatic negative thoughts (Becks Cognitive triad).
1. A negative, self depreciating view of self.
2. A pessimistic view of the world.
3. The belief that negative reinforcement will continue.
How Cognitive Behavioral therapy works. - Answer Changing the way a patient thinks
will help relieve depression syndrome.
1. Identifying and testing negative cognition.
2. Developing alternative thinking patterns.
3. Rehearsing new cognitive and behavioral responses.
Risk for suicide- questions to ask - Answer Ask directly-Are you thinking of or have you
been thinking of killing yourself?
Ask if the person has a plan- When you think about suicide, do you have a way that you
might do this?
Determine the lethality of the plan- How detailed is the plan? How lethal is the proposed
method? Do they have a gun?
Gather information about risk factors- age, sex, medical problems, unemployment, lives
alone.
Is there a history of a suicide attempt?
Collaborate with other staff involved and come up with a safety plan?
Is there anyone that can stay with patient at home?
Does this person know the signs of suicidal ideations?
Suicide high risk - Answer Psychiatric disorder, potentially lethal suicide attempt or
persistent ideations with strong intent or suicide rehearsal.-Suicide precautions
Suicide moderate risk - Answer Multiple risk factors, suicidal ideations with plan but no
intent or behavior. -Develop crisis plan and give emergency crisis numbers
Suicide low risk - Answer Modified risk factors, thoughts of death, no plan, no intent or
behavior.- Outpatient referral, give emergency crisis numbers.
Nursing Diagnosis for depression - Answer Risk for suicide
Risk for self-mutilation
, Ineffective coping
Hopeless
Chronic low self-esteem
Impaired social interaction
Imbalanced nutrition
Constipation
Disturbed sleep pattern
Spiritual distress
Decisional conflict
Social isolation
Risk for loneliness
Self-neglect
Sexual dysfunction
Interventions for depression: Communication - Answer 1. Help the patient question
assumptions and beliefs to reconstruct a healthier and more hopeful attitude about the
future.
2.Help the patient identify cognitive distortions that encourage negative self appraisal:
overgeneralization (I have....He always), self-blame (blames self for everything
perceived as negative), mind reading (assumes other do not like him without any
evidence) discounting of positive attributes ( focuses on the negative).
3.Encourage activities that raise self esteem (problem solving skills, coping skills,
assertiveness skills).
4. Encourage physical activity- can reduce tension, alleviate depression/anxiety and
improve self concept.
5. Encourage formation of supportive relationships- support groups, therapy, peer
support.
6. Provide information referrals, when needed, spiritual.
Interventions for depression: Physical-Nutrition/Anorexia - Answer 1. Offer small, high
calorie and high protein snacks and or fluids frequently throughout the day and evening.
2. Encourage family or friends to remain with patient during meals.
3. Ask the patient which food or drink she likes- offer choices, involve dietician
4. Weigh the patient weekly and observe eating patterns.
Interventions for depression: Physical- Sleep/Insomnia - Answer 1. Provide periods of
rest after activities (fatigue can intensify feelings of depression)
2. Encourage the patient to get up and dressed and to stay out of bed during the day.
3. Encourage the use of relaxation measures in the evening.
4. Reduce environmental and physical stimulants in the evening- soft lights, soft music,
quiet activities
Interventions for depression: Self care deficits - Answer 1. Encourage the use of
toothbrush, washcloth, soap, makeup, shaving equipment (can increase self esteem)
2. When appropriate give step by step reminders (slowed thinking and difficulty
concentrating can make organizing simple tasks difficult).
Common symptoms of depression - Answer Anergia, feelings of worthlessness, lack of
self esteem, guilt, helplessness, hopelessness, anger and irritability, changes in eating
patterns, changes in sleeping patterns, insomnia, hyper insomnia, constipation,
decreased libido, chronic pain, lack of concentration and indecisiveness.
Beck's Cognitive Triad - Answer Believed that people develop depression through
psychological predisposition of early life experiences. Even in positive circumstances,
Beck believed that depressed people still process things in a negative way. He believed
there are three automatic negative thoughts (Becks Cognitive triad).
1. A negative, self depreciating view of self.
2. A pessimistic view of the world.
3. The belief that negative reinforcement will continue.
How Cognitive Behavioral therapy works. - Answer Changing the way a patient thinks
will help relieve depression syndrome.
1. Identifying and testing negative cognition.
2. Developing alternative thinking patterns.
3. Rehearsing new cognitive and behavioral responses.
Risk for suicide- questions to ask - Answer Ask directly-Are you thinking of or have you
been thinking of killing yourself?
Ask if the person has a plan- When you think about suicide, do you have a way that you
might do this?
Determine the lethality of the plan- How detailed is the plan? How lethal is the proposed
method? Do they have a gun?
Gather information about risk factors- age, sex, medical problems, unemployment, lives
alone.
Is there a history of a suicide attempt?
Collaborate with other staff involved and come up with a safety plan?
Is there anyone that can stay with patient at home?
Does this person know the signs of suicidal ideations?
Suicide high risk - Answer Psychiatric disorder, potentially lethal suicide attempt or
persistent ideations with strong intent or suicide rehearsal.-Suicide precautions
Suicide moderate risk - Answer Multiple risk factors, suicidal ideations with plan but no
intent or behavior. -Develop crisis plan and give emergency crisis numbers
Suicide low risk - Answer Modified risk factors, thoughts of death, no plan, no intent or
behavior.- Outpatient referral, give emergency crisis numbers.
Nursing Diagnosis for depression - Answer Risk for suicide
Risk for self-mutilation
, Ineffective coping
Hopeless
Chronic low self-esteem
Impaired social interaction
Imbalanced nutrition
Constipation
Disturbed sleep pattern
Spiritual distress
Decisional conflict
Social isolation
Risk for loneliness
Self-neglect
Sexual dysfunction
Interventions for depression: Communication - Answer 1. Help the patient question
assumptions and beliefs to reconstruct a healthier and more hopeful attitude about the
future.
2.Help the patient identify cognitive distortions that encourage negative self appraisal:
overgeneralization (I have....He always), self-blame (blames self for everything
perceived as negative), mind reading (assumes other do not like him without any
evidence) discounting of positive attributes ( focuses on the negative).
3.Encourage activities that raise self esteem (problem solving skills, coping skills,
assertiveness skills).
4. Encourage physical activity- can reduce tension, alleviate depression/anxiety and
improve self concept.
5. Encourage formation of supportive relationships- support groups, therapy, peer
support.
6. Provide information referrals, when needed, spiritual.
Interventions for depression: Physical-Nutrition/Anorexia - Answer 1. Offer small, high
calorie and high protein snacks and or fluids frequently throughout the day and evening.
2. Encourage family or friends to remain with patient during meals.
3. Ask the patient which food or drink she likes- offer choices, involve dietician
4. Weigh the patient weekly and observe eating patterns.
Interventions for depression: Physical- Sleep/Insomnia - Answer 1. Provide periods of
rest after activities (fatigue can intensify feelings of depression)
2. Encourage the patient to get up and dressed and to stay out of bed during the day.
3. Encourage the use of relaxation measures in the evening.
4. Reduce environmental and physical stimulants in the evening- soft lights, soft music,
quiet activities
Interventions for depression: Self care deficits - Answer 1. Encourage the use of
toothbrush, washcloth, soap, makeup, shaving equipment (can increase self esteem)
2. When appropriate give step by step reminders (slowed thinking and difficulty
concentrating can make organizing simple tasks difficult).
