Nokea
Which time periods during antidepressant therapy are persons most likely to commit suicide? Select all that apply.
- A. After starting antidepressant therapy but not having reached the therapeutic level
- B. After having reached the therapeutic level of antidepressants and maintained it for several years
- C. If the client has made a choice to discontinue antidepressant therapy without medical supervision and is becoming gradually more depressed
- D. If the client does not adhere to the medication regimen and takes antidepressant medications irregularly
- E. Prior to initiating antidepressant therapy but before the depression results in lack of energy
Correct Answer: A,C,D,E
Rationale: Suicide risk is highest when energy increases before mood stabilizes, or during untreated or poorly managed depression.
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A concerned family member tells the nurse, 'I am concerned about my brother. He has been acting very different lately.' Knowing the family has a history of bipolar disorder, the nurse inquiries further about this. Which behavior during the past week might indicate that the brother has bipolar disorder?
- A. Taking unnecessary risks
- B. Sleeping more
- C. Intense focus
- D. Showing low self-esteem
Correct Answer: A
Rationale: Taking unnecessary risks is a symptom of mania, characteristic of bipolar disorder, unlike the other options.
Which client is at highest risk for carrying out a suicide plan?
- A. A client who plans to take a bottle of sleeping pills.
- B. A client who says, 'My life is over.'
- C. A client who has a private gun collection.
- D. A client who says, 'I'm going to jump off the next bridge I see.'
Correct Answer: C
Rationale: Access to a lethal means like a gun collection significantly increases the likelihood of completing a suicide plan.
A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale?
- A. As soon as lunch is over, the client will calm down.
- B. Other clients need to be protected from the intrusive behavior.
- C. The client's behavior is not an imminent threat to anyone's physical safety.
- D. The client needs food and fluids in any way possible.
Correct Answer: B
Rationale: Protecting other clients from intrusive behavior upholds their rights and maintains a safe environment.
The nurse is planning care for a client with major depression. Which is an appropriate expected outcome?
- A. The client will avoid causing harm to others.
- B. The client will be free from stress.
- C. The client will independently carry out activities of daily living.
- D. The client will not experience agitation.
Correct Answer: C
Rationale: Independently performing activities of daily living is a realistic and appropriate outcome for a client with depression.
A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?
- A. Immediately after a family visit
- B. On the anniversary of significant life events in the client's life
- C. During the first few days after admission
- D. Approximately 2 weeks after starting antidepressant medication
Correct Answer: D
Rationale: The risk of self-harm increases about 2 weeks after starting antidepressants, as energy improves before mood stabilizes.