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

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 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 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 in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?

In a team meeting, a nurse says, "I'm concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision." Which ethical principle most clearly applies to this situation?

A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response?

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 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 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 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.)