A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. What is the likely conclusion regarding the patient's behavior?

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?

A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to do what?

A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?

A nurse is providing teaching for a client who has a recent diagnosis of depression. Which of the following should the nurse identify as a primary risk factor for this disorder?

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.)

A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan?

After failing two tests, a college student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt?

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

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?

A nurse caring for a patient prescribed a selective serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to what outcome?