Exam 2: PRN 1562/ PRN1562 (Latest 2024/ 2025 Update) Principles of Mental Health Nursing Review| Questions and Verified Answers|100% Correct| Grade A- Rasmussen

Exam 2: PRN 1562/ PRN1562 (Latest 2024/
2025 Update) Principles of Mental Health
Nursing Review| Questions and Verified
Answers|100% Correct| Grade A- Rasmussen
Q: OCD Nursing Considerations
Answer:
Allow time for client to complete ritual.
Discuss behavioral techniques for managing anxiety and decreasing OCD symp- toms.
Help the client learn ways to interrupt obsessive thoughts
Q: PTSD and flashbacks
Answer:
Post-traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD) are two stress related
disorders, which impact a person’s ability to function after a traumatic event. The signs and
symptoms of the disorders are the same. The difference between them is time. A person
diagnosed with Acute Stress Disorder will have symptoms resolve within a month. If the person
continues to have symptoms after one month, it will then move into the diagnosis of PTSD.
Q: Flashback
Answer:
acting or feeling as though the traumatic event is happening again
who have been diagnosed with PTSD may also experience dissociative symptoms, or recurrent
feelings of being detached. This can include a flashback, feeling you are losing touch with events
going on around you, and “blanking out,” or being unable to remember a period of time.
Q: Mania symptoms

Answer:
Inflated self-esteem or grandiosity
Decreased need for sleep
Increased talkativeness
Flights of idea or racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Increase in risky behavior
Q: Major Depressive Disorder
Answer:
The most common of the depressive disorders
MDD) is a medical illness that affects how you feel, think, and behave, causing persistent
feelings of sadness and loss of interest in previously enjoyed activities. MDD represents the
classic condition in this group of disorders.
Q: seasonal affective disorder (SAD)
Answer:
Mood is impacted by changes in weath- er/environment; light therapy is 1st line treatment.
Q: Bipolar I disorder
Answer:
At least one manic episode and one clearly defined depres- sive episode
Bipolar I disorder is characterized by at least one episode of “persistent or ele- vated, expansive
or irritable mood” (mania), accompanied by changes in activity and energy. The diagnosis
frequently includes a major depressive episode as part of a person’s psychiatric history. (Refer to
Chapter 15 on depressive disorders.) There is marked impairment in social and occupational
functioning. Psychosis may accompany the manic episode or the depressive episode, and
hospitalization may be warranted
Q: Bipolar II disorder

Answer:
Periods of depression alternating with hypomanic episodes
4 days.
The criteria for bipolar II disorder include at least one period of hypomania alternating with one
or more periods of depression. Those with a bipolar II disorder never experience a full manic
episode. Typically, an individual seeks treatment during
a depressive episode. The brief periods of hypomania may be missed. When a person is
experiencing a hypomanic episode, they have a decreased need for sleep, possibly inflated selfesteem, increased energy or activity, and distractibility and engage in activities that can cause
harm such as overspending, sexual indiscretions, and impulsive business decisions. This is
different from mania in that risks and consequences are less severe and are less likely to cause
marked impairment in function (Harvard University, 2019). Those with bipolar II disorder tend
to have more severe depressive symptoms and spend more time in a depressive state.
Q: CAM assessment (confusion assessment method)
Answer:
The CAM short form
(SF) and 3D-CAM are shortened versions of the assessment.
=instruments/confusion-assessment The particular tool used is dependent on the treatment team’s
needs and goals and the population being assessed
Use the following memory tool (MINDSPACES) to screen for risk factors associated with
delirium
M-Medications: polypharmacy, multiple classes of medications, medication weaning/withdrawal (refer to “Beers Criteria” for drugs to avoid a )
I—Infection and advanced illness
N—Number of cooccurring conditions/comorbidities (hypertension, heart failure, chronic
obstructive pulmonary disease [COPD], obstructive sleep apnea [OSA])
D—Disorders of substance or alcohol use (including withdrawal) S—Surgery and/or invasive
procedures (including anesthesia medications) P—Pain (uncontrolled), perfusion problems
A—Age: young children and older adults are most at risk but may occur at any age
C—Cognitive impairment and/or dementia
E—Emotional or mental illness (depression, anxiety) S—Sleep disturbances and altered patterns
of sleep
Cognitive and Perceptual Disturbances
Q: Mini-Mental State Examination (MMSE)
Answer:
Powered by https://learnexams.com/search/study?query=NR

Antidepressants: SSRIs
serotonin within the brain

Antidepressants (SSRIs) medications
Sertraline
Fluvoxamine

Antidepressants (SSRIs) medications note
Report suicidal thoughts; educate re sexual dysfunction

Watch for serotonin syndrome (abd pain, diarrhea, sweating, fever, tachycardia, elevated B/P)

Monoamine Oxidase Inhibitors (MAOIs)
MAOIs cause the inability to break down tyramine, requiring clients to be educated regarding proper diet to avoid foods rich in tyramine

Monoamine Oxidase Inhibitors (MAOIs) medication
Phenelzine

Monoamine Oxidase Inhibitors (MAOIs) note
Avoid foods rich in Tyramine (figs, avocados, bananas…)

Watch for hypertensive crisis

Mood Stabilizers
treat Bipolar disorder

Mood Stabilizers medication
Lithium Carbonate

Mood Stabilizers note
Therapeutic Range 1.0-1.5 mEq/L Maintenance 0.6-1.2 mEq/L

Lithium Toxicity occurs in serum levels above 1.5 mEq/L

Monitor sodium (when sodium ↓, lithium level ↑)

Anticonvulsants
Treat Bipolar disorder

Anticonvulsants medication
Valproic Acid
Lamotrigine
Carbamazepine

Anticonvulsants note
Causes birth defects; get baseline LFT

Watch for Stevens-Johnson Syndrome

Monitor WBCs

Anxiolytics
Benzodiazepines (use short-term)

Anxiolytics medication
Alprazolam
Diazepam
Lorazepam

Anxiolytics note
Do not take with other CNS depressants or alcohol

Less sedating compared to benzodiazepines

Educate that it may take more than 3 weeks for effect

Medications for Neurocognitive Disorders
(dementia)

Medications for Neurocognitive Disorders medications
Donepezil
Menantine

Medications for Neurocognitive Disorders note
Used in all stages of Alzheimer’s disease

Used in moderate to severe Alzheimer’s disease

OCD (Obsessive Compulsive Disorder)
OCD is a combination of obsessions (unreasonable fears, repetitive thoughts) and compulsions (repetitive or irresistible behaviors.

Obsessions vs compulsions
Obsessions are what the person thinks about;

compulsion is what they do. The intent of the compulsion is to temporarily reduce the anxiety associated with the obsessive thought; however, as the thought continues, the anxiety rises again, causing the compulsion to occur. The dysfunction of the disorder can be displayed through the time-consuming nature of the compulsion impacting the ability to complete daily activities/responsibilities

Obsessions

are what the person thinks about

compulsion

is what they do

Common Compulsions
Checking rituals
Counting rituals
Washing/scrubbing
Praying/chanting
Touching/rubbing/tapping
Ordering (arranging and rearranging)

OCD Nursing Considerations:
Allow time for client to complete ritual.

Discuss behavioral techniques for managing anxiety and decreasing OCD symptoms.

Help the client learn ways to interrupt obsessive thoughts

PTSD and flashbacks
Post-traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD) are two stress related disorders, which impact a person’s ability to function after a traumatic event. The signs and symptoms of the disorders are the same. The difference between them is time. A person diagnosed with Acute Stress Disorder will have symptoms resolve within a month. If the person continues to have symptoms after one month, it will then move into the diagnosis of PTSD.

Flashback
acting or feeling as though the traumatic event is happening again

who have been diagnosed with PTSD may also experience dissociative symptoms, or recurrent feelings of being detached. This can include a flashback, feeling you are losing touch with events going on around you, and “blanking out,” or being unable to remember a period of time.

Mania symptoms
Inflated self-esteem or grandiosity

Decreased need for sleep
Increased talkativeness

Flights of idea or racing thoughts

Distractibility

Increase in goal-directed activity or psychomotor
agitation

Increase in risky behavior

Major Depressive Disorder
The most common of the depressive disorders

MDD) is a medical illness that affects how you feel, think, and behave, causing persistent feelings of sadness and loss of interest in previously enjoyed activities. MDD represents the classic condition in this group of disorders.

seasonal affective disorder (SAD)
Mood is impacted by changes in weather/environment; light therapy is 1st line treatment.

Bipolar I disorder

At least one manic episode and one clearly defined depressive episode

Bipolar I disorder is characterized by at least one episode of “persistent or elevated, expansive or irritable mood” (mania), accompanied by changes in activity and energy. The diagnosis frequently includes a major depressive episode as part of a person’s psychiatric history. (Refer to Chapter 15 on depressive disorders.) There is marked impairment in social and occupational functioning. Psychosis may accompany the manic episode or the depressive episode, and hospitalization may be warranted

Bipolar II disorder

Periods of depression alternating with hypomanic episodes 4 days.

The criteria for bipolar II disorder include at least one period of hypomania alternating with one or more periods of depression. Those with a bipolar II disorder never experience a full manic episode. Typically, an individual seeks treatment during a depressive episode. The brief periods of hypomania may be missed. When a person is experiencing a hypomanic episode, they have a decreased need for sleep, possibly inflated self-esteem, increased energy or activity, and distractibility and engage in activities that can cause harm such as overspending, sexual indiscretions, and impulsive business decisions. This is different from mania in that risks and consequences are less severe and are less likely to cause marked impairment in function (Harvard University, 2019). Those with bipolar II disorder tend to have more severe depressive symptoms and spend more time in a depressive state.

CAM assessment (confusion assessment method)
The CAM short form (SF) and 3D-CAM are shortened versions of the assessment.
=instruments/confusion-assessment The particular tool used is dependent on the treatment team’s needs and goals and the population being assessed

Use the following memory tool (MINDSPACES) to screen for risk factors associated with delirium

M-Medications: polypharmacy, multiple classes of medications, medication weaning/withdrawal (refer to “Beers Criteria” for drugs to avoid a )

I—Infection and advanced illness

N—Number of cooccurring conditions/comorbidities (hypertension, heart failure, chronic obstructive pulmonary disease [COPD], obstructive sleep apnea [OSA])

D—Disorders of substance or alcohol use (including withdrawal)

S—Surgery and/or invasive procedures (including anesthesia medications)

P—Pain (uncontrolled), perfusion problems

A—Age: young children and older adults are most at risk but may occur at any age

C—Cognitive impairment and/or dementia
E—Emotional or mental illness (depression, anxiety)

S—Sleep disturbances and altered patterns of sleep

Cognitive and Perceptual Disturbances

Mini-Mental State Examination (MMSE)
1) ability to show attention, 2) immediate recall ability, 3) level of orientation

The tools focus on the client’s current cognitive status through a series of questions including ability to complete a word recall and follow directions, such as drawing a clock face.

(MMSE): a series of questions designed to test a range of everyday mental skills, including attention and memory and simple psychomotor skills.

Denial

Ignoring unpleasant realities

Projection

Attributing one’s own negative features onto others

Rationalization

Justifying actions with an acceptable explanation

Displacement

Shifting the focus of feelings on to someone or something of lesser significance

Humor

Looking for amusing or ironic nature of the stressor

Suicide Precautions
*Suicide Precautions: Suicide assessment should be done on all clients to assess for the possible risk.

If the client responds in the affirmative and tells you that he or she has been having these thoughts, you need to ask, “Do you have a plan?” If the answer is yes, determine the lethality of method (for example, high lethality includes guns, carbon monoxide and lower lethality includes cutting wrist and ingesting pills) and evaluate access, such as availability of firearm or access to large amounts of medications. Please note: A plan is a problem even if they do not have means or access; they have given considerable thought to how they would harm themselves and must be taken seriously.

When a client has been identified as a suicidal risk, communication with the care team will become priority. Implementing safe practices as established by the facility to keep them safe should occur.

Typically, these interventions include:

Remove potentially harmful objects including sharps, straps, belts, ties, glass items, shoelaces, electrical cords, and plastic bags. Search client belongings in the client’s presence to find and remove objects.
Close observation – may include 1:1 observation vs. 15-minute checks depending on facility.
Have client use plastic eating utensil.
Do not assign private room – keep the door open
Ensure that the client swallows all medication (may hoard for overdose).
Make rounds at irregular intervals.
Restrict visitors from bringing harmful items.
Search all items delivered to the client.

Other possible signs of suicide risk:

Verbal communication with overt statements such as “I wish I were dead,” or covert statements such as, “Things are all going to be okay now.”
Sudden change in behavior- if a client has been withdrawn and suddenly appears happy and engaged, this could be a possible indication of a suicidal plan as they have “figured” it out.
Giving away possessions.
Writing farewell letters.

Dementia Safe Environmental Interventions
Wandering: Consider the use of GPS device, complex locks, and a medical alert bracelet. Keep a recent photo and make neighbors aware of possible wandering.
If they drive, gradually restrict the use of the car. Remove throw rugs to allow them to ambulate safely. Have shower bars installed in bathroom. Label commonly used things, such as the utensil drawer or where plates are kept.

Compassion Fatigue symptoms:
: also know as secondary traumatic stress. These terms describe a phenomenon in which nurses and other health care workers become indirectly traumatized when trying to help a person who has experienced primary traumatic stress. The American Bar Organization (2018) summarizes some of the symptoms of secondary traumatic stress:

Feeling overwhelmed, physically and mentally exhausted

Primary prevention examples
(promote health and prevent development of disease)

Immunizations, pollution control, nutrition, exercise

immunization and taking regular exercise to prevent health problems developing in the future

immunization, birth control and condom usage, regular dental cleanings and care, and hand-washing.

Secondary prevention examples
Screenings, redirectional therapies, medications

(goal is to identify illness, reverse or reduce its severity, or cure)
examples

exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer)

Tertiary Prevention
actions taken to contain damage once a disease or disability has progressed beyond its early stages

(focus is on people who are already affected by disease. Goal is to improve quality of life by reducing disability, limiting or developing complications, and restoring function)

cardiac or stroke rehabilitation programs,

chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.)

support groups that allow members to share strategies for living well.

orientation phase
the patient may begin to express thoughts and feelings, identify problems, and discuss realistic goals. Therefore mutual agreement on goals is also part of the contract:

Working Phase
Maintain the relationship.

Gather further data.
Promote the patient’s problem-solving skills, self-esteem, and use of language.
Facilitate behavioral change.
Overcome resistance behaviors.
Evaluate problems and goals, and redefine them as necessary.
Promote practice and expression of alternative adaptive behavior,

Termination Phase:
is the final, integral phase of the nurse-patient relationship. Termination is discussed during the first interview and again during the working stage at appropriate times. Termination may occur when the patient is discharged or when the student’s clinical rotation ends. Basically, the tasks of termination are as follows:

Summarizing the goals and objectives achieved in the relationship
Discussing ways for the patient to incorporate into daily life any new coping strategies learned during the time spent with the nurse
Reviewing situations that occurred during the time spent together
Exchanging memories, which can help validate the experience for both nurse and patient and facilitate closure of that relationship

Give examples of safety things to do for a suicidal patient on suicide precautions
Remove potentially harmful objects including sharps, straps, belts, ties, glass items, shoelaces, electrical cords, and plastic bags. Search client belongings in the client’s presence to find and remove objects.
Close observation – may include 1:1 observation vs. 15-minute checks depending on facility.
Have clients use plastic eating utensils.
Do not assign private room – keep the door open
Ensure that the client swallows all medication (may hoard for overdose).
Make rounds at irregular intervals.
Restrict visitors from bringing harmful items.
Search all items delivered to the client.

List symptoms of a Bipolar I Disorder patient in a manic state
Inflated self-esteem or grandiosity
Decreased need for sleep
Increased talkativeness
Flights of idea or racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Increase in risky behavior

When completing a mini-mental status examination on a patient with dementia:
Which items do we want to include? (think.. memory, orientation, etc..)
Assessment of dementia is completed through a variety of tools such as the Mini-Mental Status Exam (MMSE), the Mini-Cog, and the Saint Louis University Mental Status (SLUMS) Examination. The tools focus on the client’s current cognitive status through a series of questions including ability to complete a word recall and follow directions, such as drawing a clock face.

a simple pen‐and‐paper test of cognitive function based on a total possible score of 30 points; it includes tests of orientation, concentration, attention, verbal memory, naming and visuospatial skills.

Understand vascular dementia client experience agnosia
The loss of sensory ability to recognize objects.

What items may indicate an increased risk for suicide?
Have you ever felt that life is not worth living?

Have you been thinking about death recently?

Do you ever think about suicide?

Have you ever attempted suicide?

Are you thinking of, or have you been thinking of harming yourself?

Other possible signs of suicide risk:

Verbal communication with overt statements such as “I wish I were dead,” or covert statements such as, “Things are all going to be okay now.”

Sudden change in behavior- if a client has been withdrawn and suddenly appears happy and engaged, this could be a possible indication of a suicidal plan as they have “figured” it out.

Giving away possessions.

Writing farewell letters.

Symptoms of compassion fatigue
sometimes also called secondary traumatic stress. These terms describe a phenomenon in which nurses and other health care workers become indirectly traumatized when trying to help a person who has experienced primary traumatic stress. The American Bar Organization (2018) summarizes some of the symptoms of secondary traumatic stress:

Feeling overwhelmed, physically and mentally exhausted

Reasons to justify the use of restraints or seclusion?
Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Symptoms of panic level anxiety:
Mild – normal every day-to-day tensions.
Moderate – may experience selective inattention.
Severe – may experience somatic symptoms such as headache, trembling, increase heart rate.
Panic – unable to perceive the environment around them, may dissociate, experience terror/dread.

Reorientating a client with delirium
Be short and concise with communication. ◦ Always identify yourself. ◦ If verbal abuse occurs, set limits on the behavior and redirect

Neurocognitive disorder patient is disoriented and wanders: Priority nursing concern?
Safety becomes a priority concern for nursing care with neurocognitive disorders. Risk for injury and falls will need to be evaluated.
Interventions:
Decrease stimulation (limit excessive noise, light)
Have family stay with the client
Verbally orient to time, place and situations several times daily
Use orientation aids, such as clocks and calendars
Place in a room close to the nursing station
Maintain a calm, structured environment
Involve family members in care

Buspirone
take for awhile before seeing how well it works

Lithium
dehydration

Phenelzine: understand dietary needs; Serotonin Syndrome
MAOIs cause the inability to break down tyramine, requiring clients to be educated regarding proper diet to avoid foods rich in tyramine. This strict diet of non-tyramine foods must be followed, or the client may experience a hypertensive crisis, which can be fatal. Additionally, majority of medications are listed as a contraindication when taking MAOIs, and clients must be educated to speak with their provider before starting any medication, prescribed or over-the-counter.

Tyramine Rich Foods to Avoid:
Figs
Avocados
Bananas
Fermented or aged meats
Smoked fish
Cheese
Foods with yeast
Imported beers
Chianti wine
Chocolate
Fava beans
Caffeinated beverages

Valproic Acid
LFTs; preventive measures when sexually active

Lamotrigine
Clients must be educated to report development of rash as there is an association with this medication and Stevens-Johnson Syndrome.

Donepezil
(Aricept) cholinesterase inhibitor- able to use in all stages

Understand Serotonin Syndrome, symptoms, and associated medications
Selective Serotonin Reuptake Inhibitors (SSRIs)
These medications focus on increasing the available serotonin within the brain.
Sertraline (Zoloft)
Fluoxetine (Prozac)
Escitalopram (Lexapro)
Citalopram (Celexa)
Fluvoxamine (Luvox)- treats OCD

Common side effects and client education should include:
Sexual dysfunction
Report increase of any suicidal thinking

One rare and life-threatening event associated with SSRIs is Serotonin Syndrome. This is thought to be related to over activation of the serotonin receptors by too high a dose or interaction with other drugs, especially those medications also affecting serotonin such as MAOIs. Before switching medications, there is typically a cross over period to help minimize the risk of Serotonin Syndrome. Symptoms include abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure and delirium. Severe manifestations can induce hyperpyrexia, cardiovascular shock, or death

Define Anhedonia
(lack of joy or pleasure in normal activities)

Side effects of Fluvoxamine:
Headaches
Gastrointestinal disturbance
Insomnia, fatigue
Initial anxiety
Sexual problems: reduces sexual drive; problems having and enjoying sex
Agitation, feeling jittery and nervous
Increased bleeding risk
Can also treat anxiety disorders
Risk of serotonin syndrome:
Shivering
Hyperreflexia
Increased temperature
Vital sign changes
Encephalopathy
Restlessness
Sweating
Hyponatremia
Increased bleeding tendencies
Avoid alcohol and herbal medications

Common side effects and client education should include:
Sexual dysfunction
Report increase of any suicidal thinking

Review redirecting and engaging in a calming activity with manic patients
communication

Use a firm and calm approach

Use short and concise explanations

Be consistent in approach and expectations

Identify expectations in simple and concrete terms with consequences

Hear and act on legitimate complaints

Redirect energy into more appropriate behavior/actions

Therapeutic Milieu

Low level stimulus

Provide structured/solitary activities (assist as needed)

Provide high calorie fluids

Encourage rest periods

Redirect aggressive behaviors

Use lease restrictive measures to ensure safety

Encourage adequate diet

Finger foods may be necessary (hand held on the go type foods)

Additional Treatment Options

Electroconvulsive Therapy (ECT) – Induces a grand mal seizure and through mechanism of action is unknown, improvement of mood occurs. Typically reserved for severe cases of depression or treatment resistant depression.

Vagus Nerve Stimulation – Used for treatment-resistant depression, involves surgically implanting a decide, which wills end electrical impulses through the vagus nerve.

Understand and give example of Defense Mechanism: Rationalization
Justifying actions with an acceptable explanation example doing something wrong but saying everyone is doing it.

Understand and give example of Defense Mechanism: Humor
Looking for amusing or ironic nature of the stressor example making a joke about something like at least I don’t have to wait in line for the restroom because I have a ostomy bag.

Understand and give example of Defense Mechanism: Denial
Ignoring unpleasant realities example denying they are obese even Tho they weigh 400 pounds

Difference between Acute Stress Disorder and Post-Traumatic Stress Disorder
Post-traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD) are two stress related disorders, which impact a person’s ability to function after a traumatic event. The signs and symptoms of the disorders are the same. The difference between them is time. A person diagnosed with Acute Stress Disorder will have symptoms resolve within a month. If the person continues to have symptoms after one month, it will then move into the diagnosis of PTSD.

Difference between Obsessions and Compulsions
OCD is a combination of obsessions (unreasonable fears, repetitive thoughts) and compulsions (repetitive or irresistible behaviors). Obsessions are what the person thinks about; compulsion is what they do. The intent of the compulsion is to temporarily reduce the anxiety associated with the obsessive thought; however, as the thought continues, the anxiety rises again, causing the compulsion to occur. The dysfunction of the disorder can be displayed through the time-consuming nature of the compulsion impacting the ability to complete daily activities/responsibilities.

Differences between Bipolar I and II
Bipolar I disorder – At least one manic episode and one clearly defined depressive episode.

Bipolar II disorder – Periods of depression alternating with hypomanic episodes.

Different duration and type of mania
manic is sudden and hypomanic has to be at least 4 days delirious mania or Depressive Episode it is rapid and acute onset

Lithium therapeutic levels
range of therapeutic serum concentration:
Acute mania 1.0-1.5 mEq/L
Maintenance 0.6-1.2 mEq/L
Lithium toxicity:
Serum levels above 1.5 mEq/L

Early symptoms include vomiting, diarrhea, thirst, slurred speech, and muscle weakness. Symptoms will get worse as the level increases. Severe toxicity >2.0 mEq/L symptoms include coma, cardiac dysrhythmias, and death.

Benefits of using EMDR therapy with PTSD
EMDR helps to change the way those with PTSD react to memories of their trauma. While thinking of or talking about the traumatic memories, the individual focuses on other stimuli, such as eye movements, hand taps, and sounds.

Define hypervigilance with a PTSD client
The experience of being in a state of high alert, constantly tense and ‘on guard’ and always on the lookout for hidden dangers, both real and presumed

Possible PTSD symptoms intrusive thoughts
Nightmares
Night terrors
Hallucinations
Intrusive traumatic thoughts and memories
Flashbacks
Avoidance behaviors from possible triggers

Assessing suicidal patients and safety measures to implement
The licensed practical nurse should approach the client in a non-judgmental and empathetic manner. This will create a therapeutic environment with the client to allow them the opportunity to be honest. Be direct in asking the questions.

hen a client has been identified as a suicidal risk, communication with the care team will become priority. Implementing safe practices as established by the facility to keep them safe should occur.

Typically, these interventions include:
Remove potentially harmful objects including sharps, straps, belts, ties, glass items, shoelaces, electrical cords, and plastic bags. Search client belongings in the client’s presence to find and remove objects.
Close observation – may include 1:1 observation vs. 15-minute checks depending on facility.
Have client use plastic eating utensil.
Do not assign private room – keep the door open
Ensure that the client swallows all medication (may hoard for overdose).
Make rounds at irregular intervals.
Restrict visitors from bringing harmful items.
Search all items delivered to the client.

Anxiety symptoms
Mild- normal every day to day tensions.
Moderate – may experience selective inattention.
Severe – may experience somatic symptoms such as headache, trembling, increase heart rate.
Panic – unable to perceive the environment around them, may dissociate, experience terror/dread.

Difference between Major Depressive Disorder and Persistent Depressive Disorder
Major Depressive Disorder – The most common of the depressive disorders.

Persistent Depressive Disorder (Dysthymic disorder) – Depressive mood lasting over two years; this is a chronic form of depression.

Examples of stress reduction techniques
Stress management courses, mindfulness, yoga, exercise, creative activities, and humor are all examples of stress reduction techniques to help nurses keep a healthy balance in their personal lives.

lb to kg conversion
Multiple 2.2 for pounds and dived 2.2 for kg

How many mL in 1 oz
30 mL=1 oz

How many mL in 1 Tbsp
15mL= 1Tbsp

How many mg in a 1 g
1000mg=1g

offer high calorie protein drink for patient who is
constantly pacing and unable to sit for meals

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