A nurse is performing a mental health assessment on an adult ...

[Frost2351]

A nurse is performing a mental health assessment on an adult client. According to Maslow's hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?
 
  1. Maintaining a long-term, faithful, intimate relationship.2. Achieving a sense of self-confidence.3. Possessing a feeling of self-fulfillment and realizing full potential.4. Developing a sense of purpose and the ability to direct activities.

Question 2

A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative.
 
  Which action should be the nurse's priority at this time? 1. Give the client off-unit privileges as positive reinforcement.
  2. Encourage the client to share mood improvement in group.
  3. Increase the level of this client's suicide precautions.
  4. Request that the psychiatrist reevaluate the current medication protocol.

[aruss1303]

Answer to Question 1

3
Rationale: The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow's hierarchy of needs.

Answer to Question 2

3
Rationale: The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behavior.

[Frost2351]

Excellent

[helenmarkerine]

TYSM