,Mental Health Exam #2 -Rasmussen EXAM
QUESTIONS AND ANSWERS 100%
ACCURATE AND UPDATED!
Immature defenses - ANSWER
Beck's Cognitive Triad - ANSWER o Beck proposed that people acquire a psychological
predisposition to depression through early life experiences
o Three autonomic (uncontrollable and repetitive) negative thoughts (triad) are
responsible for development of depression
Three autonomic (uncontrollable and repetitive) negative thoughts (triad) are
responsible for development of depression - ANSWER ▪ Negative, self-deprecating view
of self
• "I really never do anything well; everyone else seems smarter."
▪ Pessimistic view of the world
• "Once you're down, you can't get up." • "Bad things everywhere you look."
▪ Belief that negative reinforcement (no validation for the self) will continue
• "It doesn't matter what you do, nothing will get better."
• "I'll be at this stupid job for the rest of my life."
Risk for suicide; Questions - ANSWER ▪ SADPERSONS scale
• S- sex- 1 male
• A- age- 1 if <19 or >45
• D- depression/hopelessness- 2
• P- previous attempts/psychiatric care- 1
• E- excessive alcohol or drug use- 1
• R- rational thinking loss (psychotic or organic illness- 1
• S- separated/widowed/divorced- 1
• O- organized plan or serious attempt- 2
• N- no social support- 1
• S- stated future intent- 1
• Guidelines
o 0-5: may be safe to discharge- discharge with family or friend
o 6-8: probably requires psych consult
o >8: probably requires hospital admission, voluntary or involuntary
, Overt statements- RISK FOR SUICIDE - ANSWER • I can't take it anymore
• Life isn't worth living anymore
• I wish I were dead
• Everyone would be better off if I were dead
Behaviors: RISK FOR SUICIDE - ANSWER ▪ Giving away possessions
▪ Writing farewell notes
▪ Making out a will
▪ Putting personal affairs in order
▪ Having global insomnia
▪ Sudden improvements in mood after being depressed or withdrawn
▪ Neglecting personal hygiene
Protective factors from suicide: Internal - ANSWER • Ability to cope with stress
• Religious beliefs
• Frustration tolerance
Protective factors from suicide: External - ANSWER • Responsibility to children or
beloved pets
• Positive therapeutic relationships
• Social supports
What do you inquire about Suicide - ANSWER ▪ Ideation: frequency, intensity, duration
▪ Plan: timing, location, lethality, availability, prep acts
▪ Behavior: past attempts, aborted attempts, rehearsals, non-suicidal self-injury
▪ Intent: extent to which patient expects to carry out plan and believes that plan to be
lethal
▪ Explore ambivalence: reasons to die vs. reasons to live
NURSING DIAGNOSIS: Risk for suicide; risk for self-mutilation - ANSWER ▪ Previous
suicide attempts, putting affairs in order, giving away prized possessions, suicidal
ideation, overt or covert statements regarding killing self, feelings of worthlessness,
hopelessness, helplessness
NURSING DIAGNOSIS: Decisional conflict, impaired memory, acute confusion -
ANSWER Lack of judgement, memory difficulty, poor concentration, inaccurate
interpretation of environment, negative ruminations, cognitive distortions
NURSING DIAGNOSIS:Ineffective coping, interrupted family process, risk for impaired
parent/infant/child attachment, ineffective role performance - ANSWER ▪ Difficulty with
QUESTIONS AND ANSWERS 100%
ACCURATE AND UPDATED!
Immature defenses - ANSWER
Beck's Cognitive Triad - ANSWER o Beck proposed that people acquire a psychological
predisposition to depression through early life experiences
o Three autonomic (uncontrollable and repetitive) negative thoughts (triad) are
responsible for development of depression
Three autonomic (uncontrollable and repetitive) negative thoughts (triad) are
responsible for development of depression - ANSWER ▪ Negative, self-deprecating view
of self
• "I really never do anything well; everyone else seems smarter."
▪ Pessimistic view of the world
• "Once you're down, you can't get up." • "Bad things everywhere you look."
▪ Belief that negative reinforcement (no validation for the self) will continue
• "It doesn't matter what you do, nothing will get better."
• "I'll be at this stupid job for the rest of my life."
Risk for suicide; Questions - ANSWER ▪ SADPERSONS scale
• S- sex- 1 male
• A- age- 1 if <19 or >45
• D- depression/hopelessness- 2
• P- previous attempts/psychiatric care- 1
• E- excessive alcohol or drug use- 1
• R- rational thinking loss (psychotic or organic illness- 1
• S- separated/widowed/divorced- 1
• O- organized plan or serious attempt- 2
• N- no social support- 1
• S- stated future intent- 1
• Guidelines
o 0-5: may be safe to discharge- discharge with family or friend
o 6-8: probably requires psych consult
o >8: probably requires hospital admission, voluntary or involuntary
, Overt statements- RISK FOR SUICIDE - ANSWER • I can't take it anymore
• Life isn't worth living anymore
• I wish I were dead
• Everyone would be better off if I were dead
Behaviors: RISK FOR SUICIDE - ANSWER ▪ Giving away possessions
▪ Writing farewell notes
▪ Making out a will
▪ Putting personal affairs in order
▪ Having global insomnia
▪ Sudden improvements in mood after being depressed or withdrawn
▪ Neglecting personal hygiene
Protective factors from suicide: Internal - ANSWER • Ability to cope with stress
• Religious beliefs
• Frustration tolerance
Protective factors from suicide: External - ANSWER • Responsibility to children or
beloved pets
• Positive therapeutic relationships
• Social supports
What do you inquire about Suicide - ANSWER ▪ Ideation: frequency, intensity, duration
▪ Plan: timing, location, lethality, availability, prep acts
▪ Behavior: past attempts, aborted attempts, rehearsals, non-suicidal self-injury
▪ Intent: extent to which patient expects to carry out plan and believes that plan to be
lethal
▪ Explore ambivalence: reasons to die vs. reasons to live
NURSING DIAGNOSIS: Risk for suicide; risk for self-mutilation - ANSWER ▪ Previous
suicide attempts, putting affairs in order, giving away prized possessions, suicidal
ideation, overt or covert statements regarding killing self, feelings of worthlessness,
hopelessness, helplessness
NURSING DIAGNOSIS: Decisional conflict, impaired memory, acute confusion -
ANSWER Lack of judgement, memory difficulty, poor concentration, inaccurate
interpretation of environment, negative ruminations, cognitive distortions
NURSING DIAGNOSIS:Ineffective coping, interrupted family process, risk for impaired
parent/infant/child attachment, ineffective role performance - ANSWER ▪ Difficulty with
