NSG 121 Health Assessment – Herzing Final Exam
Reviewer (Complete Solutions, Grade A+)
1. Recognizing the Highest Potential for Completing Suicide:
Answer>
Immediate Risk Indicators:
-Specific Plan
-Access to Means
-Intent
Behavioral Indicators:
-Recent social withdrawal
-giving away possessions.
-Sudden calmness after severe distress
-Increased substance use or reckless behaviors. Psychological and
Demographic Risk Factors:
-Hopelessness
-Major depressive disorder
-bipolar disorde
-schizophrenia with command hallucinations.
-Previous Attempts
-Male gender
-older adults
-LGBTQ
2. Examples of Covert statements for suicide
Answer>
It's okay now; Everything will be fine
-Things will never work out
-I won't be a problem much longer
,-Life isn't worth living anymore
-I wish I were dead
-Everyone would be better off if I died
4. What are the criteria for involuntary admission?
Answer>
Harm to Self
-Harm to Others
-Inability to Care for Self
5. unstable affective states in clients
Answer>
Emotional Lability
-Dysphoria:
-Agitation
-Irritability
-Flat or Blunted Affect
6. The Need for Further Assessment in Emergency Situations:
Answer> Suicidal Ideation:
-Ask directly about thoughts of suicide, plans, and means.
-Look for statements of hopelessness, worthlessness, or feeling like a burden. Homicidal Ideation:
-Assess for threats or plans to harm others.
-Evaluate the presence of anger, paranoia, or psychosis. Impulsivity:
-Assess the client's ability to control emotions and actions
-increases the risk of self-harm or violence. Psychotic
Features:
-Delusions
-Hallucinations
-severe disorientation.
-Command hallucinations (e.g., "Kill yourself") demand immediate intervention. Substance Use:
-Screen for recent drug or alcohol use Trauma History:
-recent or past traumatic events that may trigger emotional crises.
7. Behavioral cues for suicide
,-Neglecting personal hygiene
8. Nursing interventions for suicide
Answer>
Specific Suicide Plan
-Lethality of proposed method
-Access to means
-Intent
-Ask: "Are you thinking of hurting or killing yourself"
-Focus on safety
-stay with pt
9. educational points for clients diagnosed with MDD and taking anti-depres- sants:
Answer>
Purpose & Expectations:
-Balances brain chemicals to improve mood and functioning.
-May take 4-6 weeks for full effect; physical symptoms improve first.
-Antidepressants manage symptoms but don't cure depression.
Proper Use:
-Take consistently at the same time daily.
-Don't skip doses or stop abruptly. Side Effects:
-nausea
-headache
-dizziness
-dry mouth
-drowsiness
Report worsening symptoms:
-suicidal thoughts Lifestyle Tips:
-Combine medication with therapy (e.g., CBT).
-Maintain a healthy routine: exercise, eat well, sleep adequately.
-Build a support system with trusted people or groups. Substance
Cautions:
-Avoid alcohol, recreational drugs, and certain OTC meds.
-Inform providers of other medications or supplements.
Follow-Up:
-Regularly check in with the provider to monitor progress and adjust treatment.
-Communicate any concerns about side effects or effectiveness.
, Reduce Stimuli
-Limit Setting: Firm, direct, concrete terms
-Structured Environment
-Redirect Topic of Conversation: Get their attention when they have flight of ideas
-Redirect Activities
-Fluids
-finger foods
-Encourage naps
12. educational points regarding Lithium treatment
Answer>
mood stabilizer
-treats bipolar disorder
-Therapeutic effects may take 6 weeks
-Take Lithium exactly as prescribed, at the same time every day.
-therapeutic range: 0.4 - 1 mEq/L
-do not limit water or sodium
13. educational points regarding Lithium monitoring
Answer>
therapeutic range: 0.4 - 1 mEq/L
Reviewer (Complete Solutions, Grade A+)
1. Recognizing the Highest Potential for Completing Suicide:
Answer>
Immediate Risk Indicators:
-Specific Plan
-Access to Means
-Intent
Behavioral Indicators:
-Recent social withdrawal
-giving away possessions.
-Sudden calmness after severe distress
-Increased substance use or reckless behaviors. Psychological and
Demographic Risk Factors:
-Hopelessness
-Major depressive disorder
-bipolar disorde
-schizophrenia with command hallucinations.
-Previous Attempts
-Male gender
-older adults
-LGBTQ
2. Examples of Covert statements for suicide
Answer>
It's okay now; Everything will be fine
-Things will never work out
-I won't be a problem much longer
,-Life isn't worth living anymore
-I wish I were dead
-Everyone would be better off if I died
4. What are the criteria for involuntary admission?
Answer>
Harm to Self
-Harm to Others
-Inability to Care for Self
5. unstable affective states in clients
Answer>
Emotional Lability
-Dysphoria:
-Agitation
-Irritability
-Flat or Blunted Affect
6. The Need for Further Assessment in Emergency Situations:
Answer> Suicidal Ideation:
-Ask directly about thoughts of suicide, plans, and means.
-Look for statements of hopelessness, worthlessness, or feeling like a burden. Homicidal Ideation:
-Assess for threats or plans to harm others.
-Evaluate the presence of anger, paranoia, or psychosis. Impulsivity:
-Assess the client's ability to control emotions and actions
-increases the risk of self-harm or violence. Psychotic
Features:
-Delusions
-Hallucinations
-severe disorientation.
-Command hallucinations (e.g., "Kill yourself") demand immediate intervention. Substance Use:
-Screen for recent drug or alcohol use Trauma History:
-recent or past traumatic events that may trigger emotional crises.
7. Behavioral cues for suicide
,-Neglecting personal hygiene
8. Nursing interventions for suicide
Answer>
Specific Suicide Plan
-Lethality of proposed method
-Access to means
-Intent
-Ask: "Are you thinking of hurting or killing yourself"
-Focus on safety
-stay with pt
9. educational points for clients diagnosed with MDD and taking anti-depres- sants:
Answer>
Purpose & Expectations:
-Balances brain chemicals to improve mood and functioning.
-May take 4-6 weeks for full effect; physical symptoms improve first.
-Antidepressants manage symptoms but don't cure depression.
Proper Use:
-Take consistently at the same time daily.
-Don't skip doses or stop abruptly. Side Effects:
-nausea
-headache
-dizziness
-dry mouth
-drowsiness
Report worsening symptoms:
-suicidal thoughts Lifestyle Tips:
-Combine medication with therapy (e.g., CBT).
-Maintain a healthy routine: exercise, eat well, sleep adequately.
-Build a support system with trusted people or groups. Substance
Cautions:
-Avoid alcohol, recreational drugs, and certain OTC meds.
-Inform providers of other medications or supplements.
Follow-Up:
-Regularly check in with the provider to monitor progress and adjust treatment.
-Communicate any concerns about side effects or effectiveness.
, Reduce Stimuli
-Limit Setting: Firm, direct, concrete terms
-Structured Environment
-Redirect Topic of Conversation: Get their attention when they have flight of ideas
-Redirect Activities
-Fluids
-finger foods
-Encourage naps
12. educational points regarding Lithium treatment
Answer>
mood stabilizer
-treats bipolar disorder
-Therapeutic effects may take 6 weeks
-Take Lithium exactly as prescribed, at the same time every day.
-therapeutic range: 0.4 - 1 mEq/L
-do not limit water or sodium
13. educational points regarding Lithium monitoring
Answer>
therapeutic range: 0.4 - 1 mEq/L
