A nurse in a mental health facility is caring for a client who has major depressive disorder.

Progress Notes

Week 1

Client is experiencing major depressive disorder following the unexpected death of their partner 6 months ago. Has been unable to proceed through stages of grief. Has been on anti-depressant therapy for 5 months.

Admits to having thoughts of self-harm. Reports increasing anxiety levels. Loss of 15 lb over past months due to anorexia and anxiety. Reports insomnia, sleeping only 4 to 5 hr/night with frequent nightmares. Reports feelings of extreme fatigue.

Plan: Admit for group and individual therapy. Suicide precautions. Will add alprazolam to medication regimen.

Week 2

Client remains depressed, continues to have thoughts of self-harm. Not responding to group or individual therapy. States no improvement in mood or energy level. Admits to less anxiety and increased hours and quality of nightly sleep with addition of alprazolam. Anorexia still present.

Plan: Due to ineffectiveness of antidepressant regimen and psychotherapy, suggest addition of electroconvulsive therapy (ECT).

Medication Administration Record

Bupropion 100 mg PO TID

Escitalopram 20 mg PO daily

Alprazolam 0.25 PO BID PRN anxiety

Which of the following items in the client's medical record indicate that they are a candidate for electroconvulsive therapy (ECT)?

(Select all that apply.)

Energy level

Clinical response to antidepressant therapy

Sleep changes

Appetite

Clinical response to alprazolam therapy

Answer and Explanation

Correct Answer : A,B,D

A.   Indication for ECT. The client reports extreme fatigue despite treatment, suggesting a lack of improvement in energy levels with medication and therapy.
B.   Indication for ECT. The client has not shown significant improvement in response to antidepressant therapy, as stated in the progress notes.
C.   Not an indication since the client reports increased hours and better quality of sleep.
D.   Potential indication for ECT. The client has anorexia, which indicates a persistent lack of appetite despite the treatment received.
E.   Mixed indication. While alprazolam has helped with anxiety and improved sleep, it hasn't resolved the underlying depressive symptoms or suicidal thoughts. Therefore, it might contribute to considering ECT as an alternative or additional therapy option.

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Correct Answer is B

Explanation

A. This is more aligned with the evaluation phase of the nursing process, ensuring that interventions are achieving the intended results.
B. During implementation, nurses execute the care plan, carry out interventions, and coordinate care with other healthcare team members to meet the patient's needs.
C. This is primarily part of the assessment phase, ensuring a thorough understanding of the patient's situation.
D. This involves collaborative goal-setting and is more aligned with the planning phase, ensuring that patient goals are agreed upon and relevant.

A. Every client will be questioned concerning the impact the suicide had on him or her personally. B. All group therapy sessions will be held on the unit for at least a 72-hour period. C. Suicide precautions for a full 24 hours will be implemented for all clients. D. A client-focused psychological postmortem assessment will be conducted immediately.

Correct Answer is C

Explanation

A. While assessing the impact of a suicide attempt on others is important, the immediate focus following a successful suicide attempt in a mental health unit is to ensure the safety of all clients.
B. Restricting group therapy for 72 hours might impede the therapeutic process and does not directly address the safety of clients after a suicide attempt.
C. Following a suicide attempt, it's standard practice to heighten monitoring and implement suicide precautions for all clients to ensure their safety.
D. While assessing the situation is important, immediate intervention to prevent further harm to other clients is a priority following a suicide attempt. The psychological assessment might occur but would not be the primary intervention in this immediate crisis situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Nursing behaviors associated with the implementation phase of the nursing process are concerned with the responsibilities of the psychiatric mental health nurse?

Correct Answer is B

Explanation

A client has made a successful suicide attempt while hospitalized on a unit that specializes in the treatment of depression. When considering both milieu control and crisis management, which intervention will the nursing staff implement?

Correct Answer is C

Explanation

A nurse teaching a patient about a tyramine-restricted diet would approve which meal?

A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?

What is the primary difference between somatic system disorders and dissociative disorders?

Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? (Select all that apply.)

A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? (Select all that apply.)

A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hr hold is over for which of the following conditions?

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager?