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 is discussing the process of evidence-based practice (EBP) with a newly licensed nurse. Which of the following statements made by the newly licensed nurse indicates an understanding of the process?

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.)

Which institution-specific clinical practice resource will the nurse use to integrate evidence- based practice (EBP) into the care of a client hospitalized for the purpose of the evaluation of his or her current therapy plan?

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

When assessing a patient's plan for suicide, what aspect has priority?

A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.

A patient states, "I'm starting cognitive behavioral therapy. What can I expect from the sessions? Which responses by the nurse are appropriate? (Select all that apply.)

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 nurse in an acute mental health facility is caring for a client who has major depressive disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make?