RASMUSSEN MENTAL HEALTH EXAM 2
CRISIS SUICIDE RISK MANAGEMENT
PROTOCOL AUTHORITY RESOURCE
INVENTORY 2026.
⫸ Prolonged stress. Ans: Maladaptive response
When stress is prolonged or people are not able to relax, they remain
in chronic low levels of stress. The body stays alert for a prolonged
period of time. A sustained increase in the chemicals produced by the
stress response (cortisol, adrenaline, and other catecholamines) can
have damaging effects on the body, causing physical diseases
including a substantial negative effect on the immune system, leaving
individuals vulnerable to autoimmune diseases.
Prolonged stress causes:
-Chronic anxiety or panic attacks
-Depression, chronic pain, sleep disturbances
-Weight gain or loss
-Increased risk for MI and stroke
-Poor diabetes control, hypertension, fatigue, irritability, decreased
ability to concentrate
-Increased risk for infection
,⫸ Nursing interventions for stress. Ans: **Cognitave behavioral
therapy and SSRI's are first line of treatment
Do not abruptly discontinue medication; can cause suicidal ideations
Assess risk for suicide and implement safety precautions
Monitor pt's ability to perform ADL's and encourage independence
Therapeutic communication develop nurse-client relationship
Counseling
⫸ Posttraumatic Stress Disorder (PTSD). Ans: People who
experience/witness any traumatic event. Will feel extraordinary
helplessness or powerlessness in the face of stressors; lack of energy;
sad with blunted affect; poor grooming/lack of hygiene; slow speech,
decreased verbalization, delayed responses.
⫸ Four cardinal symptoms of PTSD. Ans: • Intrusive reexperiencing
of the initial trauma (flashbacks, nightmares, unwanted distressing
memories of the event, feelings of unreality)
• Avoidance (avoid all memories and feelings as well as people or
places that might recall the event)
,• Persistent negative alterations in cognitions and mood (distorted
cognitions about themselves and others [fear, guilt] and feelings of
detachment)
• Alteration and arousal and activity (irritability, angry outbursts, self-
destructive behavior, exaggerated startle response, hypervigilance,
sleep difficulties)
⫸ Optimal outcomes for PTSD patients. Ans: • Patient and others
will remain safe.
• Patient will receive treatment for co-occurring conditions.
• Patient will attend support group meetings.
• Patient will expand social support network.
• Patient will exhibit an increase in restful sleep periods.
• Patient will have fewer nightmares and flashbacks.
• Patient will express decreased irritability.
• Patient will be able to demonstrate effective anxiety reduction
techniques
, ⫸ Pharmacotherapy for PTSD. Ans: Depression -> Antidepressants
Flashbacks -> SSRI antidepressants (fluoxetine), buspirone
augmentation of SSRI, second-generation antipsychotics
Panic attacks -> Antidepressants, MAOI's, high-potency
benzodiazepines
Hyperarousal -> Antidepressants, benzodiazepines, α2-adrenergic
agonists, anticonvulsants
Nightmares -> prazosin (Minipress)
⫸ Nursing diagnosis for PTSD. Ans: Disturbed thought process
Sleep deprivation r/t nightmares associated with traumatic event
Post-trauma syndrome r/t exposure to traumatic event
***Prioritize nursing diagnoses for PTSD related to safety/violence
and self-harm
⫸ Cognitive behavioral therapy. Ans: Uses cognitive reframing to
help the patient identify negative thoughts that produce anxiety,
CRISIS SUICIDE RISK MANAGEMENT
PROTOCOL AUTHORITY RESOURCE
INVENTORY 2026.
⫸ Prolonged stress. Ans: Maladaptive response
When stress is prolonged or people are not able to relax, they remain
in chronic low levels of stress. The body stays alert for a prolonged
period of time. A sustained increase in the chemicals produced by the
stress response (cortisol, adrenaline, and other catecholamines) can
have damaging effects on the body, causing physical diseases
including a substantial negative effect on the immune system, leaving
individuals vulnerable to autoimmune diseases.
Prolonged stress causes:
-Chronic anxiety or panic attacks
-Depression, chronic pain, sleep disturbances
-Weight gain or loss
-Increased risk for MI and stroke
-Poor diabetes control, hypertension, fatigue, irritability, decreased
ability to concentrate
-Increased risk for infection
,⫸ Nursing interventions for stress. Ans: **Cognitave behavioral
therapy and SSRI's are first line of treatment
Do not abruptly discontinue medication; can cause suicidal ideations
Assess risk for suicide and implement safety precautions
Monitor pt's ability to perform ADL's and encourage independence
Therapeutic communication develop nurse-client relationship
Counseling
⫸ Posttraumatic Stress Disorder (PTSD). Ans: People who
experience/witness any traumatic event. Will feel extraordinary
helplessness or powerlessness in the face of stressors; lack of energy;
sad with blunted affect; poor grooming/lack of hygiene; slow speech,
decreased verbalization, delayed responses.
⫸ Four cardinal symptoms of PTSD. Ans: • Intrusive reexperiencing
of the initial trauma (flashbacks, nightmares, unwanted distressing
memories of the event, feelings of unreality)
• Avoidance (avoid all memories and feelings as well as people or
places that might recall the event)
,• Persistent negative alterations in cognitions and mood (distorted
cognitions about themselves and others [fear, guilt] and feelings of
detachment)
• Alteration and arousal and activity (irritability, angry outbursts, self-
destructive behavior, exaggerated startle response, hypervigilance,
sleep difficulties)
⫸ Optimal outcomes for PTSD patients. Ans: • Patient and others
will remain safe.
• Patient will receive treatment for co-occurring conditions.
• Patient will attend support group meetings.
• Patient will expand social support network.
• Patient will exhibit an increase in restful sleep periods.
• Patient will have fewer nightmares and flashbacks.
• Patient will express decreased irritability.
• Patient will be able to demonstrate effective anxiety reduction
techniques
, ⫸ Pharmacotherapy for PTSD. Ans: Depression -> Antidepressants
Flashbacks -> SSRI antidepressants (fluoxetine), buspirone
augmentation of SSRI, second-generation antipsychotics
Panic attacks -> Antidepressants, MAOI's, high-potency
benzodiazepines
Hyperarousal -> Antidepressants, benzodiazepines, α2-adrenergic
agonists, anticonvulsants
Nightmares -> prazosin (Minipress)
⫸ Nursing diagnosis for PTSD. Ans: Disturbed thought process
Sleep deprivation r/t nightmares associated with traumatic event
Post-trauma syndrome r/t exposure to traumatic event
***Prioritize nursing diagnoses for PTSD related to safety/violence
and self-harm
⫸ Cognitive behavioral therapy. Ans: Uses cognitive reframing to
help the patient identify negative thoughts that produce anxiety,
