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Mr. Jones is a 55-year-old divorced white male who was recently fired from his job. He lives alone in an apartment, and his sister, who lives nearby, called the police when she found no food in his refrigerator, his house was in shambles, and he threatened “to shoot himself.” When the police arrived, they placed him on an involuntary hold 5150 for danger to self (DTS). In the ambulance, his blood pressure is 180/96, his pulse is 96, respirations are 20 with pulse ox at 99%, and his temperature is 98.6. He looks down and is moving around a lot in his chair.When conducting an admission assessment for Mr. Jones on the psychiatric unit, your first nursing priority is (select the best answer):

Mr. Jones is a 35-year-old male with severe depression and has had failed treatment with SSRIs such as Citalopram (Celexa) and Fluoxetine (Prozac). He has a passive suicide ideation and has recently been unemployed after his anergia, poor concentration, and anhedonia. He has also lost 20 lbs in the last 3 months and has a poor appetite. He is scheduled for ECT tomorrow, and you are his nurse.If ECT is contraindicated for Mr. Jones because of his history of intracranial pressure and cardiac arrest, Repetitive Transcranial Magnetic Stimulation (rTMS) may be an alternative if (choose the best answer):

Greene is an 85-year-old male placed on a 5150 by the crisis team after his nurse called them. He has taken a fall in his driveway after his dialysis. He has end-stage kidney disease, diabetes, and a history of myocardial infarction 4 years ago. He was living alone until his home health nurse found him crying out in pain, clutching onto his leg in the kitchen. “I’m so tired,” he says.Nortriptyline and some tricyclic antidepressants may be helpful with neuropathic pain but are often contraindicated in elderly clients such as Mr. Greene because (select the best answer)

Mr. Jones is a 55-year-old divorced white male who was recently fired from his job. He lives alone in an apartment, and his sister, who lives nearby, called the police when she found no food in his refrigerator, his house was in shambles, and he threatened to shoot himself. When the police arrived, they placed him on an involuntary hold 5150 for danger to self (DTS). In the ambulance, his blood pressure is 180/96, his pulse is 96, respirations are 20 with pulse ox at 99%, and his temperature is 98.6. He looks down and is moving around a lot in his chair.Priority discharge planning for Mr. Jones should include: (select all that apply)

Mr. Greene is an 85-year-old male placed on a 5150 by the crisis team after his nurse called them. He was living alone until his home health nurse found him crying out in pain, clutching onto his leg in the kitchen. “I’m so tired,” he says.Some yes or no questions on the geriatric depression scale may include (select all that apply)

Edward is a 20-year-old college student. The student’s roommates tell the school nurse that their friend has seemed more moody than usual since a grandparent died of a COVID-19 infection last month. They also report that the patient sleeps all day and sometimes doesn’t wake up until noon or later. They tell the nurse that they invite the patient to go with them to the dining hall most meals, but he declines most of the time and, when he does go, he will only eat a few bites. Edward admits to feeling “empty most days” in the last month and has skipped many of his classes due to feeling “too tired to attend.” Edward reports that he “doesn’t do much most days” and that “nothing is really fun anymore.”The nonverbal cues that therapy and medication are working for Edward include (select all that apply):

Edward is a 20-year-old college student. The student’s roommates tell the school nurse that their friend has seemed more moody than usual since a grandparent died of a COVID-19 infection last month. They also report that the patient sleeps all day and sometimes doesn’t wake up until noon or later. They tell the nurse that they invite the patient to go with them to the dining hall most meals, but he declines most of the time and, when he does go, he will only eat a few bites. Edward admits to feeling “empty most days” and “doesn’t do much most days” and that “nothing is really fun anymore.”Edward states he “abandoned his grandfather who died alone in the ICU.” The nurse determines his depressive symptoms may be complicated due to “survivor’s guilt” and identifies his grief as (choose the best answer):

Mr. Greene is an 85-year-old male placed on a 5150 by the crisis team after his nurse called them. He has taken a fall in his driveway after his dialysis. He has end-stage kidney disease, diabetes, and a history of myocardial infarction 4 years ago. He was living alone until his home health nurse found him crying out in pain, clutching onto his leg in the kitchen. “I’m so tired,” he says.Some yes or no questions on the geriatric depression scale may include (select all that apply):

Edward is a 20-year-old college student. The student’s roommates tell the school nurse that their friend has seemed more moody than usual since a grandparent died of a COVID-19 infection last month. They also report that the patient sleeps all day and sometimes doesn’t wake up until noon or later. They tell the nurse that they invite the patient to go with them to the dining hall most meals, but he declines most of the time and, when he does go, he will only eat a few bites. Edward admits to feeling “empty most days” in the last month and has skipped many of his classes due to feeling “too tired to attend.” Edward reports that he “doesn’t do much most days” and that “nothing is really fun anymore.”When Edward enters the “Grief Support Group,” he discusses how frustrating it is and says, “I would like to punch my aunt for not calling me first and letting me know what was happening.” This statement can reflect what stage of grief according to Kubler-Ross (select the best answer):

Edward is a 20-year-old college student. The student’s roommates tell the school nurse that their friend has seemed more moody than usual since a grandparent died of a COVID-19 infection last month. They also report that the patient sleeps all day and sometimes doesn’t wake up until noon or later. They tell the nurse that they invite the patient to go with them to the dining hall most meals, but he declines most of the time and, when he does go, he will only eat a few bites. Edward admits to feeling “empty most days in the last month” and has skipped many of his classes due to feeling “too tired to attend.” Edward reports that he “doesn’t do much most days” and that “nothing is really fun anymore.”In California, Edward meets the criteria for a 5150 involuntary hold for “Danger to Self” when: (choose the best answer)

Mr. Jones is a 35-year-old male with severe depression and has had failed treatment with SSRIs such as Citalopram (Celexa) and Fluoxetine (Prozac). He has a passive concentration and anhedonia. He has also lost 20 lbs in the last 3 months and has a poor appetite. He is scheduled for ECT tomorrow, and you are his nurse.Some important considerations prior to ECT may be on a Pre-Op checklist that the nurse completes and some interventions include (select all that apply):