It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention.

Correct Answer: A

Rationale: In this scenario, the highest priority nursing intervention is option A) Supervise the patient 24 hours a day. This is crucial because the patient's increased talkativeness and energy after initiating antidepressant medication could indicate a shift from a low-energy depressive state to a more active and potentially impulsive phase. This change in behavior poses an increased risk of acting on suicidal thoughts. Supervising the patient continuously allows the healthcare team to closely monitor for any signs of worsening mental state or emergence of suicidal ideation. It also enables prompt intervention if the patient's condition deteriorates, ensuring their safety. The other options are incorrect: - B) Beginning discharge planning prematurely could overlook the immediate need for intensive monitoring and potentially place the patient at risk. - C) Referring the patient to art and music therapists is beneficial for holistic care but not the highest priority when safety is a concern. - D) Considering discontinuation of suicide precautions is inappropriate at this stage, as the patient's behavior change warrants continued vigilance. Educationally, this question highlights the importance of ongoing assessment and monitoring in psychiatric emergencies, emphasizing the need for vigilant observation even when initial signs may seem positive. It underscores the critical role of nursing interventions in ensuring patient safety and well-being in mental health care settings.

Correct Answer: D

Rationale: The correct answer is D) Risk for other-directed violence. In a situation where a patient has been arrested for breaking windows, the priority nursing diagnosis is identifying the risk for other-directed violence. This is crucial for ensuring the safety of not only the patient but also others around them. It is important to assess the potential for the patient to cause harm to others, especially considering their behavior of breaking windows, which could escalate to physical harm towards individuals. Option A) Risk for injury is not the priority in this scenario because the focus is on the risk the patient poses to others rather than self-injury. Option B) Ineffective coping may be relevant, but it is secondary to the immediate concern of potential violence towards others. Option C) Impaired social interaction is not the priority at this moment because the main concern is the safety and well-being of those around the patient. Educationally, understanding the prioritization of nursing diagnoses in psychiatric emergencies is vital for providing effective and timely care. Recognizing and addressing the risk for violence is crucial in ensuring the safety of all individuals involved and preventing potential harm. By prioritizing this nursing diagnosis, nurses can implement appropriate interventions to manage and mitigate the risk of other-directed violence.

Correct Answer: B

Rationale: In psychiatric emergencies, administering medication safely and effectively is crucial in managing acute symptoms. Option B, accompanied by 3 staff, is the correct choice because it prioritizes safety for both the patient and staff. The presence of multiple staff members ensures that the medication administration process is conducted securely and reduces the risk of potential harm. Option A is incorrect as it lacks the necessary support and supervision for a potentially agitated or uncooperative patient. Option C is inappropriate as using physical restraint like a basket-hold should only be considered as a last resort in extreme cases due to the risk of escalation and harm. Option D is also incorrect as involving a guard may further escalate the situation and compromise the therapeutic relationship between the patient and healthcare provider. Educationally, this question highlights the importance of proper medication administration procedures in psychiatric settings. It emphasizes the significance of teamwork, communication, and safety measures when dealing with patients experiencing psychiatric emergencies. By choosing option B, nurses can ensure the well-being of both the patient and themselves while delivering timely and appropriate care.

Correct Answer: A

Rationale: In psychiatric emergencies, managing angry patients without resorting to violence is crucial for ensuring both patient and staff safety. Option A, which suggests helping the patient identify and challenge anger-inducing thoughts, is the correct choice. This intervention is rooted in cognitive-behavioral strategies, which aim to modify maladaptive thought patterns. By assisting the patient in evaluating and replacing irrational thoughts with more rational ones, nurses can help de-escalate the situation and promote self-awareness and self-regulation skills in the patient. Options B and C, advocating for negative reinforcement and aversive conditioning, respectively, are not appropriate in this context. These approaches can escalate aggression, violate ethical principles, and potentially lead to further distress or trauma for the patient. Restraint and seclusion should only be used as a last resort when imminent harm is likely. Aversive conditioning techniques are not recommended in mental health care due to their potential for harm and lack of evidence-based support. Option D, administering medication, may be necessary in some cases, but it should not be the first-line intervention for managing anger in psychiatric emergencies. Medications should be prescribed based on a thorough assessment by a qualified healthcare provider and in conjunction with other therapeutic interventions. Educationally, understanding the principles of de-escalation techniques, cognitive-behavioral strategies, and ethical considerations in psychiatric care is essential for nurses working in mental health settings. This question highlights the importance of using evidence-based, patient-centered approaches to manage challenging behaviors and promote positive outcomes for individuals experiencing psychiatric emergencies.

Correct Answer: C

Rationale: In a psychiatric emergency scenario involving a patient with multi-infarct dementia displaying aggression, the most appropriate initial intervention is option C) Saying to the patient, “This is a safe place.” This response acknowledges the patient's feelings of distress and helps create a sense of safety and security, potentially de-escalating the situation. Option A) Gently touching the patient’s arm could escalate the situation by invading their personal space and triggering a defensive response. Option B) Asking the patient, “What do you need?” may be too direct and overwhelming for a patient experiencing heightened agitation, potentially escalating the situation further. Option D) Directing the patient to cease the behavior is confrontational and may lead to increased aggression or resistance. Educationally, understanding the importance of creating a safe environment and using calming, reassuring language in managing psychiatric emergencies is crucial for healthcare providers. By prioritizing de-escalation techniques and communication skills, healthcare professionals can better address challenging behaviors in patients with psychiatric conditions, ensuring both patient and staff safety.