Author Question: A client diagnosed with major depressive disorder with psychotic features hears voices commanding ... (Read 84 times)

nautica902 · **on:** Jul 19, 2018

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

A. Obtaining an order for locked seclusion until client is no longer suicidal
B. Conducting 15-minute checks to ensure safety
C. Placing the client on one-to-one observation while monitoring suicidal ideations
D. Encouraging client to express feelings related to suicide

Question 2

A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative.

Which action should be the nurse's priority at this time?

A. Give the client off-unit privileges as positive reinforcement.
B. Encourage the client to share mood improvement in group.
C. Increase frequency of client observation.
D. Request that the psychiatrist reevaluate the current medication protocol.

stano32 · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: C
The nurse's priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation.

Answer to Question 2

ANS: C
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 and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.