Adrian Knight An 18-year-old depressed person treated as an inpatient after an attempted suicide.

After about 15 minutes of being with Ad, he stops responding and stares into space with no affect. What is the best way to proceed?
Hint
Sit with Ad for 20 minutes more and then leave
Tell Ad that you will stay with him for a few more minutes and then return in another hour
Tell Ad that you will leave now and return to see him in the afternoon
Continue to sit with Ad until he feels more comfortable with you and starts talking
Tell Ad that you will stay with him for a few more minutes and then return in another hour

Based on Ad’s psychosocial summary, you suspect that his major issue may be loss. Many of the major events in Ad’s life have been losses.

Ad lost the stability of a relationship with both parents through divorce. He recently lost his brother. Ad may also be experiencing loss of self-esteem or self-worth in not being able to find a job.
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You decide to meet with Ad frequently for the remainder of the day. Returning frequently, as promised, will help convey that you are committed to a relationship with him and that you accept him for himself.

Ad has suffered multiple losses and may be fearful of establishing new relationships. He may fear that all relationships end in loss.

As you meet with Ad and try to develop a relationship, what factors will you assess to monitor his depression?
Select all that apply (there are 3 correct answers).
Hint
Ad’s food and fluid intake
Ad’s pulse, respirations, and blood pressure
Ad’s bladder and bowel elimination patterns
Ad’s activity level
Ad’s food and fluid intake
Ad’s bladder and bowel elimination patterns
Ad’s activity level

s promised, you sit with Ad frequently throughout the day. In addition, suicide checks are done every fifteen minutes.

Ad’s behavior and verbal responses remain slow and minimal. He occasionally nods in response to your greetings and statements, but offers little more. He gives no information in response to your attempts to do a mental status assessment or assess his degree of lethality.

In trying to understand Ad, you consider early and ongoing developmental issues

Ad was 11 years old when his parents were divorced. He is now 18 years old. According to Erikson, the developmental task for Ad at age 11 was:
Hint
Identity vs. Role Diffusion
Intimacy vs. Isolation
Industry vs. Inferiority
Industry vs. Inferiority Correct
Between the ages of 6 and 12 years old, Ad was learning how to use his knowledge and skills to master his environment through persistence and relationships with peers. This is the task of Industry vs. Inferiority. Ad currently is attempting to solidify his self-concept, including self-image, values, and beliefs. This is the task of Identity vs. Role Diffusion (ages 12-20).

After your first several sessions with Ad, he agrees to your turning on the lights in the room and opening the curtains. Ad refuses to walk with you into the hall, however, and naps at intervals.

At each visit, you bring Ad something to eat or drink: 100 mL of water, juice, milkshake, or soda; half of a cheeseburger and a piece of pizza; oatmeal cookies; fruit and cooked vegetables. He picks at the food and drinks little.

Ad voids 320 mL of concentrated urine for your entire 8-hour shift. He does not have a bowel movement.
The symptoms which Ad is experiencing are classic diagnostic clues of depression. These are called vegetative signs.

Fatigue, lack of initiative, lack of interest in being with other people, and diminished interest in eating, are signs that a person with depression is just existing, or in a vegetative state

4.
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You determine that the following nursing diagnoses apply to Ad. Which takes highest priority?
Hint
Imbalanced Nutrition: Less than Body Requirements related to fatigue and lack of interest in eating
Risk for Constipation related to immobility and decreased food and fluid intake
Disturbed Sleep Pattern related to inadequate coping with losses and altered circadian rhythms
Risk for Self-Harm related to previous suicide attempt and unresolved grief
Risk for Self-Harm related to previous suicide attempt and unresolved grief Correct
Since admission, Ad has neither confirmed nor denied whether or not he is still suicidal. His safety is a priority concern. Risk for Self-Harm is the nursing diagnosis that takes highest priority at this time.

Many variables place Ad in a high-risk category for suicide. Which of the following factors increase Ad’s risk for suicide?
Select all that apply (there are 6 correct answers).
His African-American heritage
His single lifestyle
The fact that Ad is male
The fact that Ad is unemployed
His state of depression
The fact that Ad is 18 years old
His history of losses
B, C, D, E, F, G,

His single lifestyle Correct
Being single places Ad in a slightly higher risk category for suicide than if he was married.
The fact that Ad is male Correct
Males are three times more likely to complete suicide than females. Ad’s male gender increases his risk for suicide.
The fact that Ad is unemployed Correct
Employment increases opportunity for self-esteem, social contacts, and meaningful contributions to society. Unemployment typically contributes to diminished self-esteem which can lead to feelings of hopelessness. This can increase risk of suicide.
His state of depression Correct
Ad’s depression and associated hopelessness increase his risk for suicide.
The fact that Ad is 18 years old Correct
As a late adolescent, Ad is at increased risk for suicide. Suicide is the third leading cause of death in adolescents and the age group of 18-24 years.
His history of losses Correct
Ad’s history of losses makes him vulnerable to hopelessness, and subsequently at risk for suicide.

Ad has been placed on suicide precautions. Suicide precautions involve:
Select all that apply (there are 4 correct answers).
Hint
having visual contact with Ad once an hour
assessing Ad’s suicidal risk and lethality once a day
removing belts, glass objects, coat hangers, razors, and other sharp items from Ad’s environment
checking to be sure that Ad swallows his medication
monitoring meal trays for missing utensils
searching gifts and other items brought by visitors
C, D, E, F

emoving belts, glass objects, coat hangers, razors, and other sharp items from Ad’s environment Correct
For a depressed person on suicide precautions, removing obvious articles that could be used in a suicide attempt is critical. These items are stimuli for suicidal thoughts and attempts. Staff members should also be alert to the availability of shoe strings, craft and cleaning supplies, light bulbs, and metal cans, all of which could be used to commit suicide.
checking to be sure that Ad swallows his medication Correct
For a depressed person on suicide precautions, checking whether or not the person is swallowing his medications is imperative. Depressed persons may “cheek” their medications, hoard them, and then attempt suicide by overdose.
monitoring meal trays for missing utensils Correct
To help maintain self-respect and self-esteem, depressed persons usually receive meal trays with metal silverware and the standard plastic plates and glasses. Silverware could potentially be used in a suicide attempt. For this reason, it is imperative that meal trays be checked for missing items.
searching gifts and other items brought by visitors Correct
Gifts and other items brought by visitors can potentially be dangerous to a suicidal person. Any items brought by visitors should be carefully scrutinized and assessed for the threat they might pose.

While Ad is on suicide precautions, visual contact should be made with him at least every 15 minutes. Checks should be done at slightly irregular intervals so that he would not be able to predict exactly when he would be observed.

If Ad began to actively express suicidal thoughts, he would be kept within eyesight of a staff member at ALL times.

Ad’s suicidal risk and degree of lethality should be assessed at least every eight hours while he is awake. In a structured environment with therapeutic staff, it is likely that Ad’s despair and need for suicide will decrease.

You recognize the need to develop a meaningful relationship with Ad, so that he might disclose the source of his distress. Over the course of the next two days, you continue to meet with Ad hourly.

Ad gradually responds by first glancing at you more frequently, then shifting his position to match yours, then elaborating more in responding to your questions and statements.

Finally, Ad initiates conversation with you. He describes the world “as a place where I don’t know what is going to happen next … everybody’s gone. I’m all by myself, without a job, worthless. Everybody’s left me … and I didn’t do anything to stop them. I deserve to be punished …”

7.
Before answering Ad, you consider several possible responses. Which of the following responses would help?
Select all that apply (there are 3 correct answers).
Hint
“It’s a burden to feel responsible for people leaving you.”
“You deserve to be punished?”
“It’s all right to feel so guilty.”
“You’re feeling all alone and as if you have nothing?”A
A, B, D

“It’s a burden to feel responsible for people leaving you.” Correct
Ad’s mood and behaviors of the past several days indicate that he may feel burdened. His words, “I didn’t do anything to stop them” suggest he feels responsible for his losses. This response would reflect Ad’s feelings back to him and give him an opportunity to confirm or deny your perception. This would be a therapeutic approach.
“You deserve to be punished?” Correct
Therapeutic communication is generally enhanced when the nurse restates a client’s thoughts or feelings. Restating Ad’s words in a questioning tone of voice would encourage him to elaborate on his belief that he should be punished. This would be a therapeutic response.
“You’re feeling all alone and as if you have nothing?” Correct
This response paraphrases Ad’s statements of, “Everybody’s gone. I’m all by myself, without a job, worthless.” Paraphrasing would allow Ad to reflect on his feelings and thoughts in a new way. This would be therapeutic.

Ad’s family and girlfriend pressure the treatment team to “do something quickly.” They are afraid that Ad will remain depressed and complete an attempt at suicide, even while in the hospital. Ad’s mother wants him to have electroconvulsive therapy (ECT). Ad himself hesitantly also mentions this treatment request

Electroconvulsive therapy (ECT) involves artificially inducing a grand mal seizure. This is achieved by passing an electrical current through electrodes that are applied to the patient’s head.

B,C, DE

Preparation for ECT treatments require that the patient be NPO
Written consent is required for treatments
The patient is asleep during ECT treatments
Memory impairment is common with ECT treatments

Usually, at least six ECT treatments are needed to achieve relief from depression. Often, a series of 12-15 treatments are administered to assure long-term improvement.

ECT is usually administered no more than three times a week, either in an inpatient or outpatient setting

Electroconvulsive therapy (ECT) is not risk-free. You are sure to tell Ad and his family about risks associated with ECT.

Precautions are taken to avoid patient injury during electroconvulsive therapy (ECT) treatments.

A,B, D, E, F

Use of a bite block
Administration of an IV muscle relaxant

Pulse oximetry monitoring
Blood pressure monitoring
Electrocardiogram (ECG) monitoring

Ad says he wants to have electroconvulsive therapy (ECT) treatments. The treatment team feels Ad would have a good response to treatments.

Preparations are made for Ad’s first treatment

Ad has signed a consent form, and it is the morning of his first electroconvulsive therapy (ECT) treatment. He has been NPO since midnight. His watch and rings have been removed, he has changed into a patient gown, and he has voided.

Ad’s affect is flat. He shows signs of nervousness and irritability, but declines to talk.

Ad’s psychiatrist and an anesthesiologist are already in the treatment room. Equipment has been tested and is ready.

Suddenly Ad says, “I’m not going to do this. I’m not going through with the treatments.” Ad refuses to talk about his reasons for changing his mind. From the tone of his voice, the clench of his fists, and his body posture, you can tell that he is serious.

10.
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Which response to Ad is indicated?
Hint
“Ad, everything is ready. You need to have the treatment.”
Even though everything is ready for Ad’s treatment, he has the right to change his mind. Another response is indicated.
“Ad, you have signed the consent form, and you need to have the treatment.”
Even though Ad has signed consent for treatment, he has the right to change his mind at any time. Another response is indicated.
“It sounds like you have made a firm decision and changed your mind.” Correct
This response is a good response. It acknowledges Ad’s right to change his mind while reflecting what he has verbally and nonverbally said to you. After discussion with Ad, his family and treatment team accept his decision to not have treatments, at least for now.
“It sounds like someone has influenced you to change your mind.”
This response does not address what Ad has stated. And, there is no evidence that someone has influenced Ad to change his mind about taking electroconvulsive therapy (ECT) treatments. Another response is indicated.
C

“It sounds like you have made a firm decision and changed your mind.” Correct
This response is a good response. It acknowledges Ad’s right to change his mind while reflecting what he has verbally and nonverbally said to you. After discussion with Ad, his family and treatment team accept his decision to not have treatments, at least for now.

Five days after Ad’s admission, Ad has begun to process information and is more communicative.

11.
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You need to determine administration times for Ad’s Prozac (fluoxetine). Which administration schedule is best?
Hint
6 PM and 10 PM
Insomnia, restlessness, and nightmares commonly occur with Prozac (fluoxetine), especially when it is taken in the evening. Another administration schedule is better.
8 AM and 12 noon Correct
Insomnia, restlessness, and nightmares commonly occur with Prozac (fluoxetine). These occur less frequently when Prozac is administered during morning hours.
10 AM and 6 PM
Insomnia, restlessness, and nightmares commonly occur with Prozac (fluoxetine), especially when it is taken in the evening. Another administration schedule is better.
12 noon and 8 PM
Insomnia, restlessness, and nightmares commonly occur with Prozac (fluoxetine), especially when it is taken in the evening. Another administration schedule is better.
8 AM and 12 noon Correct
Insomnia, restlessness, and nightmares commonly occur with Prozac (fluoxetine). These occur less frequently when Prozac is administered during morning hours.

12.
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Ad grumbles to you about “all the blood they’re taking.” What explanation would be best?
Hint
“The doctor has ordered tests to see what’s causing your depression.”
As stated, this explanation is too simplistic. Ad has begun to process information better and is able to understand a more specific explanation.
“The doctor has ordered thyroid and other tests to see if your feelings have a physical basis.” Correct
This response gives simple, specific, and accurate information. Ad is entitled to know as much as he is ready and willing to learn, without having to feel overwhelmed with too much information or patronized with too little.
“The doctor wants to find out if you have any physical problems.”
As stated, this explanation is too simplistic. Ad has begun to process information better and is able to understand a more specific explanation.
“T3, T4, and TSH all help measure the amount of hormones released from your thyroid gland.”
There are too many details in this explanation, and the details are medical terms he would not understand. Ad would probably be overwhelmed and confused.
“The doctor has ordered thyroid and other tests to see if your feelings have a physical basis.” Correct
This response gives simple, specific, and accurate information. Ad is entitled to know as much as he is ready and willing to learn, without having to feel overwhelmed with too much information or patronized with too little.

Some of the mental health technicians and nurses stay away from Ad.

One technician reports “Ad isn’t approaching us. If he wants help, let him come and ask. He needs to be more assertive if he’s going to get any better. Besides, he’s so quiet and depressed, it makes us depressed just to be near him.”

13.
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The staff members’ reaction to Ad’s isolated, introspective behavior is known as:
Hint
dissociation
The staff member’s reaction is not dissociation. Dissociation is a defense mechanism that involves disruption in the usually integrated functions of consciousness, memory, identity, and perception of the environment.
withdrawal Correct
Reacting to an isolated patient with similar behavior is called withdrawal. This a nontherapeutic response that needs to be changed.
rationalization
The staff member’s reaction is not rationalization. Rationalization is a defense mechanism that involves use of justification that has some element of truth to explain a deficit or problematic behavior.
suppression
The staff member’s reaction is not suppression. Suppression is a defense mechanism that involves the conscious denial of a disturbing situation or feeling.
withdrawal Correct
Reacting to an isolated patient with similar behavior is called withdrawal. This a nontherapeutic response that needs to be changed.

Despite the fact that Ad is verbalizing more of his feelings and thoughts, he still does not initiate eating, showering, or sitting in the milieu.

Ad does respond cooperatively to direction from staff members to sit in the unit’s living room, eat his meals in the kitchen, take a shower, or choose what to wear if he is given several choices of clothing.

When family members visit, Ad usually remains silent and does not join in conversation. However, he smiles and nods when his sister Yolanda comes. He is sullen and angry when his girlfriend Jackie visits.

In your individual sessions with Ad, which have now been changed to 20 minutes each in the morning and afternoon, he has shared that everything that has happened to him since his parents’ divorce seems to be his fault. He desperately wants things to change so that he will feel bette

You determine that Ad is dealing with Dysfunctional Grieving related to experiencing multiple losses, the sudden nature of his brother’s death, and inadequate coping.

14.
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Which of the following goals is most appropriate with regard to the nursing diagnosis Dysfunctional Grieving?
Hint
By the time of discharge, Ad will no longer be grieving
It would be unrealistic to expect that Ad would complete the grieving process by the time of his discharge. He has many issues and feelings to resolve. Acute symptoms of grieving are common for 4-8 weeks. Active symptoms of grieving may be present from 3-6 months. The complete work of mourning takes 1-2 years.
By the time of discharge, Ad will begin to grieve in a direct and open manner Correct
Ad needs assistance in learning how to express his feelings and thoughts honestly and directly. It would be realistic to expect that Ad could grieve in a direct and open manner by discharge. Ad will need to identify his losses and share feelings about his brother’s death. Acute symptoms of grieving are common for 4-8 weeks. Active symptoms of grieving may be present from 3-6 months. The complete work of mourning takes 1-2 years.
At the end of three weeks, Ad will have experienced almost all of the grieving process
It would be unrealistic to expect that Ad would experience most of the grieving process after three weeks. Acute symptoms of grieving are common for 4-8 weeks. Active symptoms of grieving may be present from 3-6 months. The complete work of mourning takes 1-2 years.
By the time of discharge, Ad will begin to grieve in a direct and open manner Correct
Ad needs assistance in learning how to express his feelings and thoughts honestly and directly. It would be realistic to expect that Ad could grieve in a direct and open manner by discharge. Ad will need to identify his losses and share feelings about his brother’s death. Acute symptoms of grieving are common for 4-8 weeks. Active symptoms of grieving may be present from 3-6 months. The complete work of mourning takes 1-2 years.

Activity Intolerance is another nursing diagnosis that applies to Ad. What is the best way to help Ad become active and motivated?
Hint
Remind Ad ten minutes before each activity he is expected to participate in
Walk with Ad to the bathroom, kitchen, and milieu when he indicates he wants to go to these areas
Allow Ad to stay in his room except for your individual sessions with him, when you meet in the interview room
Assist Ad in preparing a structured activity schedule so that he knows what is expected

Activity Intolerance is another nursing diagnosis that applies to Ad. What is the best way to help Ad become active and motivated?
Hint
Remind Ad ten minutes before each activity he is expected to participate in
Walk with Ad to the bathroom, kitchen, and milieu when he indicates he wants to go to these areas
Allow Ad to stay in his room except for your individual sessions with him, when you meet in the interview room
Assist Ad in preparing a structured activity schedule so that he knows what is expected
Assist Ad in preparing a structured activity schedule so that he knows what is expected Correct
Assisting Ad in preparing a structured activity schedule would allow him to anticipate activities and plan for his day. Meals, medication times, therapy sessions, time to sit in the milieu, visiting hours, and rest periods are some of the items to be included on Ad’s activity schedule.

After repeated short therapeutic visits and fulfilled promises to return, Ad begins to trust you and forms an emotional connection. This is called transference in psychoanalytic terms, and forms a bond upon which you can guide Ad toward greater freedom from depression.

As part of a therapeutic relationship you focus on Ad’s concerns. As a human being, your own personal feelings may be activated as you work with Ad.

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As you work with Ad, you realize that his descriptions of loss in his life remind you of losses in your own. This process is called:
countertransference
splitting
denial
undoing
countertransference Correct
When a client’s descriptions or feelings remind you of events or feelings in your own life, the process is referred to as countertransference. Feelings of countertransference need to be recognized and personally acknowledged, and possibly discussed with a colleague. It is important that personal feelings not interfere with judgments about a client.

Ad is able to make some constructive suggestions to his activity schedule. The two of you plan a schedule that accounts for half-hour periods of Ad’s time all day and all evening.

However, when it comes to following the schedule, Ad prefers instead to stay in his room or sit in the hall by his door.

What approach would be best in getting Ad to follow his expected routine?
Kind but firm
Passive but friendly
Matter-of-fact
Kind but firm Correct
A kind but firm approach uses words, voice tone, body stance, and gestures to communicate expectations. It would be the best approach to use to get Ad to follow his expected routine.

Ad slowly begins to initiate activities on his own and no longer needs reminders or direction to follow his schedule. Although he does not try to engage his peers in conversation, he watches what others are doing with interest. He responds in a friendly, yet brief way when he is spoken to.

Visiting with his mother, sister, girlfriend, and father has become more comfortable for Ad, and his family.

One day, while Ad is in the milieu, you notice him tapping his foot to some music that a small group of patients are playing.

Reflect to Ad that he seems to be enjoying the music and suggest that he join the music group Correct
Reflecting to Ad that he seems to be enjoying the music and suggesting that he join the music group would allow him opportunity for validation of his feelings as well as provide opportunity for interpersonal interaction.

19.
As Ad begins to talk more with you, you make a no-suicide contract with him. The goal of the contract is to prevent Ad from harming himself or committing suicide. The elements of the contract include:
Select all that apply (there are 3 correct answers).
a promise to contact you or another staff member if he is tempted to act on destructive impulses
giving personal items to friends and family
surrendering of items such as sharps or pills
willingness to manage several days medication on his own
participation of family and friends in the contract
A C E

a promise to contact you or another staff member if he is tempted to act on destructive impulses

surrendering of items such as sharps or pills

participation of family and friends in the contract

Ten days later, Ad has made considerable progress. Suicide precautions have been discontinued for several days. Ad has agreed to speak to you or another staff member if he thinks he wants to hurt himself. Ad is eating, working out in the exercise room daily, sleeping nine hours every night, waking refreshed, and has no problems with constipation.

When Ad’s girlfriend Jackie visits, he is affectionate and pleasant to her. You have overheard him apologizing to her, saying, “I know I needed to be here. I’m glad you made me come here.”

In all of the activity groups, such as music, art, and assertiveness, Ad shares his thoughts and reactions and often suggests new projects.
The treatment team is planning to discharge Ad in two days.

Considering Ad’s continued difficulty in sharing his thoughts and feelings about loss, how can you best help him deal with the loss of your relationship?
Hint
Wait for him to raise the issue, once he knows he will be discharged
Listen for his allusions to loss and words which symbolize loss of your relationship
Say to him, “If our relationship has meant anything, you should be able to tell me what the loss of our working together means to you.”
Say to him, “You’ll be leaving in a few days. How are you feeling about ending our relationship?”
Say to him, “You’ll be leaving in a few days. How are you feeling about ending our relationship?”

Correct
Initiating the topic of ending your relationship would give Ad permission to talk about his thoughts and feelings in a time frame that would encourage closure. Important areas to explore with Ad would include what he has learned from the work you’ve done together, how he feels about it, and what regrets he may have. It would also be important for him to determine if there is anything he wants to tell you in the time that is left.

Ad has continued to have difficulty being open and direct in his grief. Which of Ad’s statements indicates the best hope for his progress after discharge?
Hint
“I think I know what I need to do once I leave here.”
“I’m going to try to cry and get angry more openly.”
“It’s hard; but, I’m going to work on sharing my feelings a little bit at a time with my new therapist.”
“Nobody knows how difficult it is. My feelings are inside me and I can’t show them to anyone.”
It’s hard; but, I’m going to work on sharing my feelings a little bit at a time with my new therapist.” Correct
This statement sounds positive and realistic. In it, Ad acknowledges that although progress may be slow, he is committed.

In your final sessions together, Ad thanks you for listening to him and for helping him to feel “much better.” Ad says he feels less sad and wants to be with his friends again. He continues to deny any suicidal thoughts.

In all your sessions together, Ad has expressed little emotion. But, as Ad is discharged, he says good-bye to you, smiling, but with tears in his eyes.
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