Category: Uncategorized

(1/2) TJ is a 54-year-old (though appears older than her stated age) Caucasian female brought in by the police after she was found walking down the street in her pajamas and a parka at 0100 on a hot summer night. Her hair is disheveled and appears unkempt.  Although cooperative with the interview, her responses consist of one to two word answers. She appears guarded. Posture is slumped with head tilting to the right side. Eye contact is minimal. Patient admits to feeling fearful and anxious. Affect is blunted. Patient denies suicidal/homicidal ideation or intent.  Patient looks up and intermittently whispers softly to herself.  When questioned states “At night, God talks to me through the television telling me to leave my house and repent or die. I do not know if dogs can die, but dying Easter eggs at Christmas is what I do best. Are you the best?” The patient’s verbal expression provides an opportunity to assess:

Upon admission to a locked inpatient unit, the registered nurse conducts a variety of assessments to determine the current status and needs of the newly admitted patient . Completing a suicide risk and lethality assessment allows the nurse to:

What does it mean to be “trauma-informed” in the way you care for everyone? Select all that apply.

Walking down the aisle of a local grocery store, a nurse encounters a patient she has recently cared for on an inpatient mental health unit. What is the most respectful response the nurse can make?

This process refers to the increased responsiveness of a medication that results in denervation following administration of that medication ( example: Chlorpromazine, the generic form of Thorazine: a receptor antagonist) for a prolonged period. It may be responsible for the process associated with tardive dyskinesia.  This pharmacological concept is known as:

A nurse is engaged in a therapeutic conversation with a patient on a locked inpatient mental health unit. The patient states: “Please don’t tell anyone about what we talked about I don’t want anyone to know about what we talked about.” How should the nurse respond to this request?

Patients expect a nurse to act in their best interests and to respect their dignity. This means that a nurse abstains from attaining personal gain at the patient’s expense and refrains from jeopardizing the therapeutic nurse–patient relationship. At times, boundaries are crossed while attempting to meet a special therapeutic need of the patient. Which of the following scenarios are considered boundary violations?  Select all that apply.

A group of nurses in the emergency department are discussing a patient who has presented on at least five occasions with suicidal ideation and intent resulting in admission to the inpatient psychiatric unit. They determine that the patient is merely seeking attention from his parents and should not be taken seriously. Which response by the charge nurse demonstrates patient focused care?

(3/6) JT was found in his dorm unresponsive with a bottle of Vicodin on the floor.  He was taken to an emergency room, stabilized and admitted to the medical floor for 24-hour observation.  When questioned, he denied suicidal thoughts and continually requested discharge stating: “Everything is fine. I need to go to school in the morning. I have a test.” Concerned for his safety, the RN requests a consultation with the Psychiatric Emergency Team (P.E.T.) clinician.  The P.E.T. RN assesses JT and determines that he is in imminent danger of harming himself.  Collateral data shows a recent break-up with his girlfriend and failing grades in school. His appetite is poor and he finds it difficult to fall asleep and stay asleep. His relationship with his parents is “strained” at best, as they require “perfect behavior and excellent grades.” The P.E.T. Team RN places him on a 5150 with a plan to transfer to an inpatient behavioral health facility in the morning. Upon arrival to the behavioral health unit, what should the RN do to ensure the patient is aware of his involuntary admission status?

RJ is a 43-year-old man with a history of depression. He worked for an insurance company until last week when he was fired for excessive absences. During his intake assessment, he states: “I am going to blow his (his boss’s) head off. He has no idea what he has done to my life. How dare he let me go.  I have been with the company for 10 years! He does not deserve to live if he is allowed to treat people with such disrespect. The first chance I get; his family will learn what it is like to feel alone and scared.” As an RN, you are obligated to: