NUR 326 Final Exam Spring 2023 ASU
Lee/Murphy-Graded A
Provide appropriate nursing and collaborative interventions to minimize the impact of
depression. - ANS--see medication section
-clients with depression need a structured plan that encourages them to get up, get
dressed, be with other clients, etc.
-should not be allowed to ruminate about past traumas
-increase fiber and fluids to help with bowel movements
-safety, expressing feelings, instill hope, promote self esteem, antidepressants,
education, behavior change, socialization
-Cognitive behavioral therapy→ assists client to identify and change negative behavior
and thought patterns
-Interpersonal therapy→ encourages client to focus on personal relationships that
contribute to the depressive disorder
-ECT (electroconvulsive therapy)
Nurse responsibilities:
-Education on procedure: will be asleep and stimulate seizures, does not last longer
than 30 mins, will have multiple sessions
-monitoring of vitals and mental status before and after
-assess pt and family understanding and knowledge of procedure
-Reorientation, safety, personal cares
-benzos should be discontinued prior
-IM injection of nerve block/smooth muscle relaxant to decrease secretions and
counteract vagal stimulation effects (bradycardia)
-muscle relaxant given to paralyze muscles during seizure activity, paralyzes respiratory
muscles so O2 is necessary
-IV access and electrodes on scalp
-continuous monitoring of BP, ECG, and pulse ox
-Transcranial magnetic stimulation→ MRI pulsation to stimulate focal areas of cerebral
cortex; used only for disordered resistant to other forms of treatment
-Light therapy→ used for SAD, inhibits nocturnal secretion of melatonin (30 min/day)
-St John's Wort→potentially fatal serotonin syndrome when taken with SSRIs or
otherantidepressants; avoid tyramine
Recognize clinical manifestations of depression. - ANS--Anergia (lack of energy)
-Anhedonia (lack of pleasure in normal activities)
-Anxiety
-Reports of sluggishness or restlessness
-Vegetative findings - change in eating patterns, bowel habits, sleep disturbances
-The client most often looks sad with blunted affect
,-The client exhibits poor grooming and lack of hygiene
-Psychomotor retardation (slowed physical movement, slumped posture) is more
common, but psychomotor agitation (restlessness, pacing, finger tapping) can also
occur
-The client becomes socially isolated, showing little or no effort to interact
-Slowed speech, decreased verbalization, delayed response: The client might seem too
tired to speak and can sigh often
Identify priority assessments to identify whether a client is at risk for suicide. - ANS--C-
SSRS (short form)
Have you wished you were dead or wished you could go to sleep and not wake up?
Have you actually had any thoughts of killing yourself? If YES to 2, ask questions 3, 4,
5, and 6. If NO to 2, go directly to question 6.
Have you been thinking about how you might do this? (E.g. "I thought about taking an
overdose but I never made a specific plan as to when, where, or how I would actually do
it....and I would never go through with it.")
Have you had these thoughts and had some intention of acting on them? (As opposed
to "I have the thoughts but I definitely will not do anything about them.")
Have you started to work out or worked out the details of how to kill yourself? Do you
intend to carry out this plan?
Have you ever done anything, started to do anything, or prepared to do anything to end
your life? (ex. collected pills, obtained a gun, etc.) If YES, ask: Was this within the past
three months?
-SAFET-E
-males more likely to complete, females more likely to attempt
Demonstrate ability to prioritize clients at risk for suicide by assessing risk and
protective factors. - ANS-Risk factors:
-stating they want to die or kill themselves
-they feel hopeless or empty with no reason to live
-they feel trapped without solutions to problems
-they feel physical and emotional pain that is unbearable
-they feel like a burden to others
-social withdrawal
-giving away loved possessions
-bidding goodbye to friends and family (arranging affairs)
-engage in risky behavior (ex. fast driving)
-obsessively thinking and talking about death
-sudden euthymia (relief of making the decision to commit) "everything will be okay
soon"
-experiencing mania (energy to commit) important to watch immediately after starting
antidepressants
-individual → previous self harm attempts, mental illness, lacking social support,
legalproblems, financial problems, risky and impulsive behaviors, loss of job serious
medicalillness, use of substances, few protective factors, starting antidepressants
, -relationship → history of abuse/neglect, bullying, family history of suicide,
personalrelationship problems, sexual violence
-community → barriers to access health care, cultural/religious beliefs,
communitycluster of suicides
-societal → stigma with mental illness or help-seeking, access to
lethalweapons/medications, media portrayals of suicide
-populations at risk→ People over the age of 60, 2nd leading cause of death among
ages10-34, especially in 20s, health care workers, first responders, and military have
higherrates than general population, native americans, those identifying as lesbian or
gay
-Low mood, high energy and cognition=high risk
Protective factors:
-Current pregnancy
-Religious and cultural beliefs
-Overall satisfaction with life
-Presence of adequate social support
-Effective coping and problem‐solving skills
-Access to adequate medical care
-Feelings of responsibility toward partner and children
Recognize when a client is experiencing mania. - ANS--MSE example
-General appearance→ ex. bikini in a bank
-Behavior→ restlessness; dislike of interference or intolerance of criticism;demanding
and manipulative behavior; distractibility and decreased attentionspan
-Mood→labile mood with euphoria
-Affect→ agitation and irritability; labile mood with euphoria
-Speech→increase in talking and activity; clang activity
-Thought Process→ flight ideas, rapid continuous speech with sudden andfrequent topic
change
-Thought Content→ grandiose
-Perceptions→ delusions and hallucinations
-Cognition→ AxO?; sharp vs dull
-Insight→ what they think is happening to them (do they know why they arethere?)
-Judgment→ impulsivity (giving away money or possessions); demanding
andmanipulative behavior; poor judgment
-elevated expansive mood
-high inflated self esteem
-risky impulsive behaviors
-participate in activities that they did not previously (dangerous activities)
-delusions and hallucinations
-euphoria
-grandiosities→ inflated sense of self
-persecutory delusions→ paranoia
-anger, rage, agitated
-social intrusiveness
-increased sexual desire
Lee/Murphy-Graded A
Provide appropriate nursing and collaborative interventions to minimize the impact of
depression. - ANS--see medication section
-clients with depression need a structured plan that encourages them to get up, get
dressed, be with other clients, etc.
-should not be allowed to ruminate about past traumas
-increase fiber and fluids to help with bowel movements
-safety, expressing feelings, instill hope, promote self esteem, antidepressants,
education, behavior change, socialization
-Cognitive behavioral therapy→ assists client to identify and change negative behavior
and thought patterns
-Interpersonal therapy→ encourages client to focus on personal relationships that
contribute to the depressive disorder
-ECT (electroconvulsive therapy)
Nurse responsibilities:
-Education on procedure: will be asleep and stimulate seizures, does not last longer
than 30 mins, will have multiple sessions
-monitoring of vitals and mental status before and after
-assess pt and family understanding and knowledge of procedure
-Reorientation, safety, personal cares
-benzos should be discontinued prior
-IM injection of nerve block/smooth muscle relaxant to decrease secretions and
counteract vagal stimulation effects (bradycardia)
-muscle relaxant given to paralyze muscles during seizure activity, paralyzes respiratory
muscles so O2 is necessary
-IV access and electrodes on scalp
-continuous monitoring of BP, ECG, and pulse ox
-Transcranial magnetic stimulation→ MRI pulsation to stimulate focal areas of cerebral
cortex; used only for disordered resistant to other forms of treatment
-Light therapy→ used for SAD, inhibits nocturnal secretion of melatonin (30 min/day)
-St John's Wort→potentially fatal serotonin syndrome when taken with SSRIs or
otherantidepressants; avoid tyramine
Recognize clinical manifestations of depression. - ANS--Anergia (lack of energy)
-Anhedonia (lack of pleasure in normal activities)
-Anxiety
-Reports of sluggishness or restlessness
-Vegetative findings - change in eating patterns, bowel habits, sleep disturbances
-The client most often looks sad with blunted affect
,-The client exhibits poor grooming and lack of hygiene
-Psychomotor retardation (slowed physical movement, slumped posture) is more
common, but psychomotor agitation (restlessness, pacing, finger tapping) can also
occur
-The client becomes socially isolated, showing little or no effort to interact
-Slowed speech, decreased verbalization, delayed response: The client might seem too
tired to speak and can sigh often
Identify priority assessments to identify whether a client is at risk for suicide. - ANS--C-
SSRS (short form)
Have you wished you were dead or wished you could go to sleep and not wake up?
Have you actually had any thoughts of killing yourself? If YES to 2, ask questions 3, 4,
5, and 6. If NO to 2, go directly to question 6.
Have you been thinking about how you might do this? (E.g. "I thought about taking an
overdose but I never made a specific plan as to when, where, or how I would actually do
it....and I would never go through with it.")
Have you had these thoughts and had some intention of acting on them? (As opposed
to "I have the thoughts but I definitely will not do anything about them.")
Have you started to work out or worked out the details of how to kill yourself? Do you
intend to carry out this plan?
Have you ever done anything, started to do anything, or prepared to do anything to end
your life? (ex. collected pills, obtained a gun, etc.) If YES, ask: Was this within the past
three months?
-SAFET-E
-males more likely to complete, females more likely to attempt
Demonstrate ability to prioritize clients at risk for suicide by assessing risk and
protective factors. - ANS-Risk factors:
-stating they want to die or kill themselves
-they feel hopeless or empty with no reason to live
-they feel trapped without solutions to problems
-they feel physical and emotional pain that is unbearable
-they feel like a burden to others
-social withdrawal
-giving away loved possessions
-bidding goodbye to friends and family (arranging affairs)
-engage in risky behavior (ex. fast driving)
-obsessively thinking and talking about death
-sudden euthymia (relief of making the decision to commit) "everything will be okay
soon"
-experiencing mania (energy to commit) important to watch immediately after starting
antidepressants
-individual → previous self harm attempts, mental illness, lacking social support,
legalproblems, financial problems, risky and impulsive behaviors, loss of job serious
medicalillness, use of substances, few protective factors, starting antidepressants
, -relationship → history of abuse/neglect, bullying, family history of suicide,
personalrelationship problems, sexual violence
-community → barriers to access health care, cultural/religious beliefs,
communitycluster of suicides
-societal → stigma with mental illness or help-seeking, access to
lethalweapons/medications, media portrayals of suicide
-populations at risk→ People over the age of 60, 2nd leading cause of death among
ages10-34, especially in 20s, health care workers, first responders, and military have
higherrates than general population, native americans, those identifying as lesbian or
gay
-Low mood, high energy and cognition=high risk
Protective factors:
-Current pregnancy
-Religious and cultural beliefs
-Overall satisfaction with life
-Presence of adequate social support
-Effective coping and problem‐solving skills
-Access to adequate medical care
-Feelings of responsibility toward partner and children
Recognize when a client is experiencing mania. - ANS--MSE example
-General appearance→ ex. bikini in a bank
-Behavior→ restlessness; dislike of interference or intolerance of criticism;demanding
and manipulative behavior; distractibility and decreased attentionspan
-Mood→labile mood with euphoria
-Affect→ agitation and irritability; labile mood with euphoria
-Speech→increase in talking and activity; clang activity
-Thought Process→ flight ideas, rapid continuous speech with sudden andfrequent topic
change
-Thought Content→ grandiose
-Perceptions→ delusions and hallucinations
-Cognition→ AxO?; sharp vs dull
-Insight→ what they think is happening to them (do they know why they arethere?)
-Judgment→ impulsivity (giving away money or possessions); demanding
andmanipulative behavior; poor judgment
-elevated expansive mood
-high inflated self esteem
-risky impulsive behaviors
-participate in activities that they did not previously (dangerous activities)
-delusions and hallucinations
-euphoria
-grandiosities→ inflated sense of self
-persecutory delusions→ paranoia
-anger, rage, agitated
-social intrusiveness
-increased sexual desire
