NR607 Final Exam Best Answers 2024 2025, Exams of Health sciences

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The PMHNP (Psychiatric Mental Health Nurse Practitioner) is providing care to a 29- year-old client who presents with persistent sadness and hopelessness for the last two months. She is having difficulty sleeping and has a decreased appetite. This is the patient's first contact with with the healthcare system about her concerns. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Primary Care Rationale: This is the client's initial contact with the healthcare system about her concerns The client has experienced depressive symptoms. The PMHNP prescribes a selective serotonin reuptake inhibitor (SSRI). PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Pharmacologic Intervention Rationale: The PMHNP is prescribing psychopharmacotherapy for the client The PMHNP provides the client with some mindfulness techniques to try at home. PMHNP role:

Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Psychotherapy Rationale: The PMHNP is utilizing a psychotherapeutic approach to help the client gain insight Two weeks after starting on the SSRI, the client begins to experience suicidal ideations and develops a plan to kill herself. A friend brings the client to the emergency room. The PMHNP meets the client at the emergency room and collaborates with the physician to coordinate care. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Crisis Intervention Rationale: Suicidal ideation with a plan is a psychiatric emergency requiring immediate intervention. The client is admitted to the psychiatric and behavioral health unit at the local hospital for a 72-hour observation where the PMHNP works with her team providing treatment. The client remains hospitalized for a week while her medications are managed. The client attends individual and group therapy sessions. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention

Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Acute PMHNP Care Rationale: Acute inpatient care occurs in an intensive hospital or psychiatric facility setting. Following hospitalization, the client returns home but commutes to a treatment center for 4 hours a day 5 days per week for ongoing therapy, medication management, and psychoeducation. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Partial Hospitalization/Intensive Outpatient Treatment Rationale: Partial Hospitalization/Intensive Outpatient Treatment occurs when a client receives intensive therapy on an outpatient basis, often used when a client do not require 24-hour care but still require intense treatment. The PMHNP serves as the point of contact person, coordinating the treatment team, which consists of the PMHNP, a social worker, and possibly a psychologist and psychiatrist. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Case Management Rationale: Case management involves oversight and/or coordination of care.

Over the course of 2 months, the client's condition improves. She is discharged from intensive outpatient treatment and begins weekly appointments with the PMHNP at the PMHNP's clinic. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Community-Based Care Rationale: Community-based care is provided in a non-hospital community setting. A global pandemic limits face-to-face mental health visits, the PMHNP determines that the patient requires ongoing mental health treatment. The PMHNP arranges to meet with the client via weekly interactive video sessions. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Telehealth Rationale: Telehealth services utilize telecommunication technology to deliver treatment to clients. The PMHNP owns the private practice that is providing services to the client. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention

Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy Self-Employment Rationale: The PMHNP is providing direct services through her own private practice. Code of Ethics for Nurses

• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice
• Duties to Self and Others
• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession How the PMHNP does Code of Ethics: Respect for the Individual
• approaches professional relationships with compassion, caring, & respect, acknowledging the dignity & worth of each individual.
• helps instill hope & empowers those with PMH disorders.
• affirms the worth & dignity of those with PMH disorders by advocating to overcome (-) stigmas towards PMH diagnoses to ensure access to care. How the PMHNP does Code of Ethics: Commitment to the Healthcare Consumer
• recognizes & addresses personal attitudes & behaviors that could interfere with meeting ethical guidelines for care.
• maintains proper boundaries. participates in self, peer, & supervisory oversight of clinical skills & practice.
• recognizes that those with brain-based mental health disorders may have maladaptive coping behaviors, which impact the individual, family, & society.
• Maladaptive behavior may continue in spite of (-) consequences.
• Behavioral change may involve setbacks.
• is aware of the need to balance human rights with safety, including coercive measures or forced tx when individuals are unable to maintain their own safety. How the PMHNP does Code of Ethics: Advocacy for the Healthcare Consumer
• strives to protect the rights, health, & safety of clients.
• maintains confidentiality according to HIPAA requirements & professional boundaries in all interactions
• recognizes the power differential in the therapeutic relationship & understands that any sort of sexual activity or intimacies with current clients, their close family members, guardians, or significant others is unethical. How the PMHNP does Code of Ethics: Responsibility and Accountability for Practice
• must be responsible & accountable for their own practice.
• must be able to articulate competencies & be aware of scope of practice professional standards guiding their own practice.

• must understand the scope of other team members' practice in order to delegate appropriately. How the PMHNP does Code of Ethics: Duties to Self and Others
• owes the same duties to self as to others.
• accords moral worth & dignity to oneself & others, including colleagues.
• is committed to practicing self-care, managing stress, & maintaining supportive relationships to meet personal needs outside of therapeutic relationships.
• identifies & addresses moral distress. How the PMHNP does Code of Ethics: Contributions to Healthcare Environments
• helps maintain & improve healthcare environments and conditions of employment.
• recognizes signs & symptoms of psychiatric disorders in the workplace & reports peer observations or concerns to leadership.
• helps address problems faced by colleagues that may impact patient safety or violate public trust, including substance abuse. How the PMHNP does Code of Ethics: Advancement of the Nursing Profession
• contributes to advancing the professing through practice, education, administration, & knowledge development.
• maintains knowledge of & apply evidence-based practice guidelines, including risk assessment & management.
• participates in continuous quality improvement.
• pursues continuing education. How the PMHNP does Code of Ethics: Collaboration to Meet Health Needs
• promotes community, national, & international efforts to meet health needs through collaboration with other healthcare professionals.
• engages in partnerships with other specialty nurses, government agencies, professional nursing organizations, & mental health organizations to promote prevention, treatment, & recovery. How the PMHNP does Code of Ethics: Promotion of the Nursing Profession
• advocates for environments that respect human rights, customs, & spiritual beliefs of individuals, families, & communities.
• engages in interactions & collaborations to articulate nursing values & maintain the integrity of the profession.
• participates in policy development & implementation that recognizes PMH disorders as treatable & ensures that nursing care is delivered with respect to human needs & values without prejudice. Person A: "I can't believe you deal with these people every day. Schizophrenics would drive ME crazy!" PMHNP: "Actually, schizophrenia is a chronic treatable disease, much like diabetes or other physical illnesses. Patients who have mental illness deserve compassion and care." How the PMHNP applied ethical principles:
• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice

• Duties to Self and Others
• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession Respect for the Individual Rationale: Respect for the individual affirms the worth and dignity of those with PMH disorders by advocating to overcome negative stigmas towards PMH diagnoses to ensure access to care. The client presents to the emergency department with hallucinations and is threatening self-harm. The PMHNP signs an involuntary admission order for emergent psychiatric care. How the PMHNP applied ethical principles:
• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice
• Duties to Self and Others
• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession Commitment to the Healthcare Consumer Rationale: The PMHNP demonstrates a commitment to the healthcare consumer by balancing the client's human rights with safety, including coercive measures when the client was unable to maintain their own safety. The PMHNP is sharing sexually explicit memes with a client that she saw earlier today in a group session. How the PMHNP applied ethical principles:
• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice
• Duties to Self and Others
• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession Advocacy for the Healthcare Consumer Rationale: This is an unethical scenario. The PMHNP recognizes the power differential in the therapeutic relationship and understands that any sort of sexual activity or

intimacies with current clients, their close family members, guardians, or significant others is unethical. The PMHNP has overbooked her sessions today, so she asks the registered nurse (RN) who works in her office to conduct one of her phone therapy sessions today. How the PMHNP applied ethical principles:

• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice
• Duties to Self and Others
• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession Responsibility and Accountability for Practice Rationale: This is an unethical scenario. The PMHNP must understand the scope of other team members' practice in order to delegate appropriately. Conducting a counseling session is outside of the RN's scope of practice. The PMHNP takes time for daily meditation to improve mindfulness and ease stress. How the PMHNP applied ethical principles:
• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice
• Duties to Self and Others
• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession Duties to Self and Others Rationale: The PMHNP is committed to practicing self-care, managing stress, and maintaining supportive relationships to meet personal needs outside of therapeutic relationships. A PMHNP discovers her colleague is diverting scheduled medications to self-medicate anxiety. The PMHNP reports the concerns to the colleagues supervisor. How the PMHNP applied ethical principles:
• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice
• Duties to Self and Others

• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession Contributions to Healthcare Environments Rationale: The PMHNP recognizes signs/symptoms of psychiatric disorders in the workplace reporting peer observations to leadership. The PMHNP helps address problems faced by colleagues that impact client safety or violate public trust, including substance abuse. The PMHNP gives a presentation at a national conference on best practices in depression treatment. How the PMHNP applied ethical principles:
• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice
• Duties to Self and Others
• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession Advancement of the Nursing Profession Rationale: The PMHNP contributes to advancing the professing through practice, education, administration, and knowledge development. The PMHNP is a member of the American Nurses Association (ANA) and National Alliance on Mental Illness (NAMI) and regularly participates in workgroups that seek to expand access to care for healthcare consumers with PMH disorders. How the PMHNP applied ethical principles:
• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice
• Duties to Self and Others
• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession Collaboration to meet health needs Rationale: The PMHNP promotes community, national, and international efforts to meet health needs through collaboration with other healthcare professionals to promote prevention, treatment, and recovery.

A PMHNP speaks at a school board meeting about the need develop policies to expand mental health services for underserved students. How the PMHNP applied ethical principles:

• Respect for the Individual
• Commitment to the Healthcare Consumer
• Advocacy for the Healthcare Consumer
• Responsibility and Accountability for Practice
• Duties to Self and Others
• Contributions to Healthcare Environments
• Advancement of the Nursing Profession
• Collaboration to Meet Health Needs
• Promotion of the Nursing Profession Promotion of the Nursing Profession Rationale: The PMHNP participates in policy development and implementation that recognizes PMH disorders as treatable and ensures that nursing care is delivered with respect to human needs and values without prejudice. Informed Consent
• for care & tx is a fundamental ethical & legal principle that respects the client's autonomy in medical decision-making.
• Clients have the right to receive information & ask Qs about recommended txs to make decisions about their care that are consistent with their beliefs, values, & tx goals
• The Joint Commission requires providers to conduct informed consent discussions steps required to obtain informed consent, according to the American Medical Association
• Assess client ability to understand medical info. & tx options & to make a voluntary decision.
• Present relevant info. with accuracy & sensitivity. Include:
• diagnosis
• nature & purpose of tx options
• benefits, risks, & burdens of all tx options, including forgoing tx
• Document informed consent conversation in the medical record, including all consent forms. exceptions to informed consent
• incapacitation
• situations involving life-threatening emergencies in which there is no time for informed consent
• client's voluntary waiver of informed consent
• When a client is incapable of informed consent due to the nature or severity of their mental illness
• PMHNP must determine if a client has the capacity to make medical decisions steps in evaluating a client's capacity for decision-making.

1. Assess for communication barriers: language, hearing or vision impairments, dysarthria
2. Evaluate for reversible causes of incapacity: infection, medications or other

substances, acute neurologic & psychiatric disorders

3. Identify values & cultural influences that may impact client decision making
4. Ask questions: determine the client's ability to understand the tx & how tx applies to their situation.
5. Identify a surrogate if needed: healthcare advance directive, medical power of attorney, spouse, adult children, other close relatives
6. Document formal assessment tool to assist in determining capacity Aid To Capacity Evaluation (ACE) Practice Settings for complex mental health care

• mental health settings
• primary care
• pediatrics
• family and internal medicine
• home health care
• hospitals
• schools
• prisons Legal & Ethical Implications in the Tx of Clients with Complex Disorders
• mental illness can impair a client's capacity to make informed decisions for themselves
• side effects of some mental health txs may lead clients to choose nonadherence to tx recommendations
• client's psychiatric symptoms may compromise their safety or the safety of others.
• ethical dilemmas may arise when clients' wishes differ from treatment recommendations or when interprofessional team members disagree about the best course of action in the treatment of a client Mental Health Amercia's 2015 position statement stipulates that: professionals must respect the client's fundamental rights of the client for dignity, autonomy, & self-determination while addressing concerns about the safety & well- being of the client & others. six key core skills that are critical to ethical decision-making in mental health care

1. Ability to identify ethical issues
2. Ability to understand how one's values, beliefs, & sense of self, including implicit biases, impact client care
3. Ability to recognize personal limits to knowledge & expertise & willingness to practice within limits
4. Ability to recognize situations that present a high risk for ethical dilemmas
5. Willingness to seek information & consultation in difficult ethical or clinical situations
6. Ability to build ethical safeguards into one's practice Unrepresented clients clients without advance directives and available family or friends to make decisions

• State laws and institutional policies typically take one of three approaches in choosing a decision-maker
• the physician or provider
• an ethics committee
• court-appointed guardian

Yolanda is a 20-year-old client who was referred to the PMHNP by her college health clinic for symptoms consistent with bipolar II disorder. She initiates the interview by stating that she is not willing to take any medications but is willing to engage in counseling or other therapies. Which of the following is the most appropriate action? provide additional education document refusal of treatment initiate treatment without informed consent provide additional education Rationale: The client should receive education about the risks, benefits, and appropriateness of pharmacological treatment. If, after receiving education, the client still refuses medication therapy, it is important to document the education provided and the client's refusal of treatment. Kevin is a 48-year-old with a 20-year history of schizophrenia. He has decided to stop pharmacological treatment due to the intolerable adverse effects of his medications. Kevin and the provider have discussed the benefits and drawbacks of ceasing treatment, and he has agreed to weekly telephone check-ins to ensure his well-being. Which of the following is the most appropriate action? provide additional education document refusal of treatment initiate treatment without informed consent document refusal of treatment Rationale: The client has the capacity to consent, and the situation is not emergent. The ethic of autonomy provides for the client to refuse treatment. Ashlei is a 19-year-old who presents to the clinic with severe anxiety symptoms. As the PMHNP begins reviewing treatment options, Ashlei interrupts and states, "Hearing about these medications increases my anxiety. Please prescribe what you think is best for me, and I will take it." Which of the following is the most appropriate action? provide additional education document refusal of treatment initiate treatment without informed consent initiate treatment without informed consent Rationale: Clients may choose to waive their right to informed consent. The PMHNP should clearly document the client's waiver. Geoff is a 32-year-old who presents to the clinic with anhedonia, fatigue, feelings of worthlessness, and a lack of focus. He admits to thinking about death but denies suicidal ideations or a plan. He has been taking sertraline 50 mg daily and wishes to stop taking the medication as it does not seem to be helping. Which of the following is the most appropriate action?

provide additional education document refusal of treatment initiate treatment without informed consent provide additional education Rationale: The client has the capacity to provide consent and the situation is not emergent; however, the client should receive education about the risks, benefits, and appropriateness of pharmacological treatment. At this time, the dose should be increased to achieve efficacy. If, after receiving education, the client still refuses medication therapy, the PMHNP should document the education provided and the client's refusal of treatment. Fritz is a 25-year-old who has been brought to the emergency department by the police after threatening a server at a restaurant. The PMHNP on call has treated Fritz for schizophrenia in the past. He has a history of poor treatment adherence. While in the emergency department, he admits to auditory hallucinations. He becomes agitated and begins throwing items around the examination room. Which of the following is the most appropriate action? provide additional education document refusal of treatment initiate treatment without informed consent initiate treatment without informed consent Rationale: The client does not have the capacity to provide consent at this time due to active hallucinations and agitation. For the safety of the client and staff, treatment should be initiated without obtaining informed consent. Acute inpatient care short-term treatment to provide care for acutely ill clients who are unable to meet basic needs due to a mental health condition or are at risk of harming themselves or others

• focus is crisis stabilization
• may be voluntary or involuntary Voluntary Admission
• when a client & provider agree that client's symptoms meet criteria for inpatient hospitalization & the client may benefit from admission
• client will sign consent form agreeing to a hospital stay in a locked unit
• not require a psychiatric hold
• if client requests discharge & provider determines the client is not yet safe, the provider may initiate an emergency involuntary hold Involuntary Admission
• when a client does not agree to hospitalization
• an evaluation by a mental health professional indicates that the client may be at high risk of harming themselves or others
• Other terms denoting an involuntary admission include involuntary commitment, psychiatric hold, or civil admission
• most states, clients can be held for up to 72 hours involuntary if deemed an imminent

threat

• Providers must perform & document a detailed eval & a risk assessment. Involuntary civil commitment
• legal intervention directed by a judge to order a person with serious symptoms of continued danger to self or others, grave disability, or serious deterioration to either remain in a psychiatric hospital or attend supervised outpatient treatment for a period of time
• maximum length of inpatient commitment varies by state
• Outpatient commitment, or assisted outpatient treatment (AOT), may consist of supported housing, intensive case management, medications, and frequent therapy
• tx may last for 6 to 12 months. Approximately ____% of clients with serious mental illness are committed involuntarily each year after a psychiatric hold 0.1% Standards for Involuntary Commitment (Assisted Treatment) State-by-State https://mentalillnesspolicy.org/national-studies/state-standards-involuntary- treatment.html Keith is a 35-year-old who presents to the crisis clinic with his wife, who is very concerned about Keith's recent behavior. He believes his neighbors have been spying on him using technology acquired from a secret government source. He is agitated and states, "I just have to take them out. I can't have them looking at us anymore. I'm going to have to build a blaster to take them out." Keith's wife confirms that there are no weapons in the home. Keith is willing to initiate treatment but does not want to be admitted as an inpatient at this time. Does Keith require an emergency psychiatric hold? yes no varies according to state legislation no Rationale: Keith does not meet the criteria for an emergency psychiatric hold. Although he is experiencing active delusions, his behavior does not threaten the safety of himself or others. Education, resources, and a plan for follow-up care should be established. Dakota is a 24-year-old who presents to the emergency department with his sister. He endorses taking a "handful" of pills after a fight with his boyfriend. He states that he regrets taking the pills, and he does not want to end his life. He denies active suicidal ideations or a plan. Dakota plans to stay with his sister for the next few days. Does Dakota require an emergency psychiatric hold? yes no varies according to state legislation no Rationale: Dakota does not meet the criteria for an emergency psychiatric hold. He

does not have active thoughts of killing himself. He should be provided with resources for follow-up as well as information for the National Suicide Prevention Lifeline. Rudy is a 42-year-old who was brought to the emergency department by his social worker. He was lethargic and disoriented when she found him at his "regular" spot in an encampment of unhoused individuals. Rudy was admitted for dehydration and his labs indicated severe malnutrition. Rudy has a history of schizophrenia with poor treatment adherence. He has no family in the area and has been living without housing for several years; his social worker endorsed that before this point, he had appeared healthy and had utilized available services for meals. Once medically stable, Rudy stated that he did not remember where to get food, and he was not sure how he got so sick. He does not wish to remain in the hospital. Does Rudy require an emergency psychiatric hold? yes no varies according to state legislation varies according to state legislation Rationale: Rudy meets the criteria for a psychiatric hold in most states. He has a history of mental illness with poor treatment adherence, has no family support, and has been unable to care for himself; he meets the criteria for a gravely disabled individual and may be detained involuntarily for further evaluation. Nnenna is a 22-year-old who was brought to the emergency department by the police after a car crash. The police officers state that Nnenna was crying and repeating, "just let me die" and the officers were concerned for her mental wellbeing. Nnenna's blood alcohol content is 0.12 g/mL. Upon interview, Nnenna has gross motor impairment and impaired judgment. She denies suicidal ideations, but she states it might be better for her to just die because her parents are going to be so upset after they find out about the accident. Nnenna's boyfriend met her in the emergency department and reported that she frequently drinks excessive amounts of alcohol. He plans to stay with her in her apartment overnight if she is released. Does Nnenna require an emergency psychiatric hold? yes no varies according to state legislation varies according to state legislation Rationale: Nnenna meets the criteria for a psychiatric hold in some states. She is legally impaired due to alcohol consumption, and her boyfriend reports that she frequently drinks excessive amounts of alcohol. She also crashed her vehicle and states that she wants to die. Miguel is a 64-year-old who was arrested at a nearby supermarket after pulling a knife out of his jacket pocket and threatening an employee who refused to allow him to enter without a mask. After finding a prescription bottle for lithium in his belongings, police requested a psychiatric evaluation to determine if he should be transferred to a

psychiatric facility. During the interview, Miguel is alert, oriented, and calm. He appears focused and his speech is measured and clear. He states that he has been living with bipolar 2 disorder for about 30 years, takes his medications regularly, and sees a mental health professional every month. Does Miguel require an emergency psychiatric hold? yes no varies according to state legislation no Rationale: Miguel does not meet the criteria for an emergency psychiatric hold. Although Miguel exhibited dangerous behavior in the supermarket, he does not display symptoms of mania that would indicate that his behavior is related to his mental health diagnosis. Bart is a 39-year-old client with no known medical or psychiatric history who was brought to the emergency department by the police after assaulting two people in a parking lot. He states that the people he attacked were demons sent to hurt him, and he was acting in self-defense when he attacked them. Bart endorses that he has been receiving messages from God for the past few days and, although he has tried to ignore the communication, he was forced to follow the commands in the messages. He states that he continues to receive messages; he becomes agitated when a phlebotomist enters the room and strikes at her, stating, "look! There's another demon! Why don't you believe me?" Does Bart require an emergency psychiatric hold? yes no varies according to state legislation yes Rationale: Bart meets the criteria for an emergency psychiatric hold. He presents a danger to others. Khoudia is a 34-year-old who delivered her second child one month ago. She presents to the emergency department with her husband and newborn. Her obstetrician called a referral to the emergency department after completing the Ask Suicide-Screening Questions tool which indicated an acute positive screen. Khoudia endorses frequent thoughts about killing herself in the past week and states she has been overwhelmed by the baby's care. She states she has a plan to wait until the baby is asleep and then sit inside the garage with the car running. Khoudia refuses to be admitted to the hospital because she is breastfeeding; her husband voices a plan to hide the car keys and stay awake all night to keep her safe. Does Khoudia require an emergency psychiatric hold? yes

no varies according to state legislation yes Rationale: Khoudia meets the criteria for an emergency psychiatric hold. She presents a danger to herself; her husband's safety plan, while admirable, is not realistic to keep her safe. The client should be provided with a breast pump and storage for breastmilk so that she may continue to breastfeed. Psychiatric Advance Directives (PAD)

• unique legal documents that guide a client's treatment preferences if they are having a mental health crisis and are unable to make decisions
• may contain advance instructions, a health care power of attorney, or both
• help protect a client's autonomy by detailing their preferred medications and treatment modalities, and by giving advance consent for treatment or admission
• useful for clients who experience episodes of acute psychosis, catatonia, mania, or delirium state laws regarding Psychiatric Advance Directives (PAD) https://nrc-pad.org/states/ Ethical Use of Restraints and Seclusion
• Clients at risk of imminent harm to themselves or others may require temporary seclusion or restraint until their condition is stabilized
• Laws differ from state to state
• Seclusion: involuntary confinement of an individual alone in a room or area from which the ind is prevented from leaving
• Restraints can be both chemical and physical
• Chemical restraints: any substance used to control a client's behaviors
• physical restraints: devices that restrict a client's movement, both soft and leather limb restraints, Mittens.
• should only be used to ensure the immediate physical safety of the client and others
• Restraints, used as a last resort when less restrictive interventions have been ineffective Restraints carry a risk of injury including: extremity fractures, suffocation, and even death Ordering Restraints and Seclusion
• face-to-face evaluation and written order are required to initiate
• evaluation must be completed within one hour of the application
• Restraints cannot be ordered PRN
• q24 hr, an authorized licensed practitioner responsible for the client's care orders must evaluate & document the continued need for restraints
• should be discontinued as soon as safely possible. Severe mental illness afflicts __% of all U.S. adults 6% of all U.S. adults
• higher among females, young adults aged 18-25, and minority populations Mental health professionals must respect the client's fundamental rights of the client for _______, _________, and ________________ while addressing concerns about the safety and well-being of the client and others.

dignity, autonomy, and self-determination _____________________ for care and treatment is a fundamental ethical and legal principle Informed consent Clients _____________________________ may require temporary seclusion or restraint until their condition is stabilized. at risk of imminent harm to themselves or others Over _______ of Americans live in a mental health professional shortage area one-third

• those that live outside of a shortage area often report access & utilization barriers to mental health care All clients experiencing psychiatric symptoms must be
• evaluated and screened with a validated suicide assessment tool
• Stabilization must be attempted
• using the least restrictive interventions. Psychiatric Emergencies situations that involve acute disturbances in thought, mood, behavior, or social interactions that negatively impact a client's ability to function in their environment and require immediate intervention to keep the client and others from harm Types of Psychiatric Emergencies
• Risk of harm to others
• Risk of harm to self
• unable to meet their own basic needs for food, clothing, or shelter due to a psychological impairment
• Serotonin syndrome
• Neuroleptic malignant syndrome (NMS)
• Agranulocytosis
• Lithium toxicity
• Suicidality
• Acute psychosis
• Agitation and aggression
• Mania
• Substance-related concerns
• Decompensation r/t personality disorders
• Severe anxiety
• Medication-related emergencies Risk factors for suicide
• Hx of substance abuse
• Physical disability or illness
• Losing a friend or family member to suicide
• Ongoing exposure to bullying behavior
• Mental health condition
• Recent death of a family member or a close friend
• Access to harmful means
• Relationship problems
• Previous suicide attempts

Ask suicide-screening questions (ASQ) suicide risk screening tool https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at- nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf Assessment During a Psychiatric Emergency

• gather info about pt before the exam to facilitate a rapid assessment; from family, medical records, emergency medical technicians or law enforcement, nursing staff.
• PMHNP may need to collaborate with emergency medicine team to determine if theres a physical cause for acute psychiatric symptoms
• psychiatric history
• Risk assessment
• Physical risk
• Risk of harm to others
• Deficiency needs
• De-escalation
• Risk of harm to self psychiatric history: Risk assessment
• quickly determine level of risk to client & others
• minimize as much as possible psychiatric history: Physical risk
• quick visual exam
• skin color, sweating, pupil size, LOC, or obvious injuries to ensure adequate airway, breathing, & circulation. Vital signs if able psychiatric history: Risk of harm to others
• PMHNP should not be alone while examining a client who is acutely disturbed or agitation
• Security personnel should be aware of the client's behavior
• door should be kept open
• provider positioned between client & the door for safe exit if necessary.
• early warning signs of violence
• threatening comments
• clenched fists
• shifts in body position towards a fighting stance
• loud vocalizations
• agitated movements
• striking inanimate objects.
• Risk assessment tools, help early identification and intervention.
• AEIO (agitation/arousal, environment, intent, objects) psychiatric history: Deficiency needs
• Pts with deficiency needs may req additional support to offset aggression
• Similar to Maslow's hierarchy, the needs may include:
• physiological (food, hydration, sleep, ability to see/hear normally)
• safety (access to personal items, pain medication)

• belonging (family members, physician-client relationship)
• esteem (clarifying the client's wishes) psychiatric history: De-escalation
• first-line response to potential violence or aggression in healthcare settings
• AKA conflict resolution or crisis management
• strategies and techniques to reduce a client's agitation or aggression
• Clear, calm, empathetic, nonjudgmental communication
• Respect for personal space
• Non-confrontational approach
• Non-threatening nonverbal communication
• Response to client's expressed problem or condition
• Clear limits
• Environmental controls such as minimizing light, noise, and loud conversations psychiatric history: Risk of harm to self
• suicide warning signs
• sense of hopelessness or no hope for the future
• Isolation or feeling alone
• Aggressiveness & irritability
• Possessing lethal means
• Feeling like a burden to others
• Drastic changes in mood & behavior
• Frequently talking about death
• Self-harm, like cutting behaviors
• Engaging in "risky" behaviors
• Making funeral arrangements
• Giving things away
• Substance abuse
• Making suicide threats
• Negative view of self
• at risk of suicide; suicide assessment & risk eval necessary using a valid tool
• Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) tool Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) tool

1. Identify risk factors

• Note those that can be modified to reduce risk

2. Identify protective factors

• Note those that can be enhanced

3. Conduct suicide inquiry

• Suicidal thoughts, plans, behavior, & intent

4. Determine risk level/intervention

• Determine risk
• Choose appropriate intervention to address & reduce risk

5. Document

• Assessment of risk, rationale, intervention, and follow-up Art is a 52-year-old who presents to the clinic for a routine follow-up appointment. He has a history of schizophrenia with a lack of insight, impulsivity, and previous violent behavior. As the interview begins, Art states that he has had homicidal ideations toward his brother and nephew. He states that the two men have "disrupted his thinking" by "creating a new theory of family," and he is worried that the only solution is to kill them both. Currently, Art is calm and cooperative with disorganized thought content and fixed delusions; his appearance is slightly disheveled. He denies substance use and does not appear inebriated. He denies a specific plan to kill his brother and nephew and denies access to firearms. He endorses that he stopped taking his medications two weeks ago because he no longer needs them and does not think he needs additional assistance at this time. Which of the following is the most a begin the involuntary admission process Rationale: The most appropriate management strategy for Art is to begin the involuntary admission process. Art has homicidal ideations and a history of impulsivity and prior violence. He does not recognize the need for treatment. Therefore, the process for involuntary admission should be implemented. Consideration should also be made as to whether Art's family should be notified of his threats. Because Art is currently calm and cooperative, de-escalation techniques are not necessary. Amir is a 28-year-old who was brought to the ED by law enforcement after his mother called 911 due to his bizarre behaviors. When the police arrived, Amir was agitated and wandering the street naked. He refused to follow directions and became combative with officers when approached. He was handcuffed and transported by a squad car. Before transfer, his mother told police that Amir had a history of schizophrenia with treatment nonadherence and marijuana use. During the ride to the ED, Amir was calm and cooperative. He was transferred to a gurney in the triage area without incident, but after transfer to an exam room, Amir began screaming and threatening the PMHNP and staff member. Amir tried to punch and spit at them when they approached the bedside. Which of the following are the most appropriate management strategies for Amir? Select all that apply.
• begin the involuntary admission process
• use de-escalation techni
• use de-escalation techniques
• request additional staff support
• medicate with intramuscular lorazepam 0.5 mg
• remove objects from the room, such as monitors, tray tables, or other equipment, that the client may use to injure himself or others Rationale: Amir presents a risk of harm to self and others due to his combative behavior; therefore, the most appropriate management strategies for Amir include the use of de-escalation techniques, request for additional staff support, intramuscular lorazepam 0.5 mg, and the removal of objects from the room, such as monitors, tray

tables, or other equipment, that he may use to injure himself or others. Chemical restraint may be necessary. Additional staff should be requested to provide support, and de-escalation techniques should be attempted. Items the client may be used to injure himself or others should be secured or removed. Physical restraints may be necessary and should be applied by the emergency department team, not law enforcement. Madison is a 30-year-old who was brought to the ED by police. She was apprehended at a local shopping center after several drivers called the police to report that she was shouting and making crude gestures at their cars. Madison is alert, oriented, and cooperative; she denies any past medical or psychiatric history, and no medical records are found in the system. She admits that she does not have a home, and he has been panhandling with little success. When the emergency department attending physician asked her to submit a blood and urine sample, she became agitated and verbally threatened the phlebotomist. A psychiatric consult is initiated. Which of the following are the most appropriate management strategies for Madison? Select all that apply.

• begin the involuntary admission process
• use de-escalation techniques
• request additional staff support
• medicate with intramuscular lorazepam 0.5 mg
• remove objects from
• ask Madison if she would like a meal or snack
• use de-escalation techniques
• request additional staff support most common psychiatric emergencies PMHNPs may encounter: Suicide Hailey is a 20-year-old brought to the emergency department by EMS to evaluate a laceration. Her roommate found her sitting on their sofa with blood streaming down her arms and a knife beside her. Her roommate immediately called 911 and applied pressure to the wound. The triage nurse assessed the wound as superficial. After dressing the wound, the PMHNP was called to perform a psychiatric evaluation. On exam, she is awake and alert but appears withdrawn and hesitant to speak. She continues to repeat, "I don't know why this keeps happening." Hailey denies medical or psychiatric history; the PMHNP notes bilaterally linear scarring on her arms. Hailey admits to self-injury behaviors and states she has been using cutting as a coping mechanism for years. She confirms that she did not intend to kill herself today and has never experienced suicidal ideations. Which of the following is the most appropriate recommendati discharge to home with resources for crisis care and recommendations for outpatient psychiatric services Rationale: The client did not have suicidal thoughts during the self-harm episode. The self-harm episode was not lethal in nature, nor was there intent for lethality. The client should be provided psychiatric care resources for follow-up. Mary Ellen is a 42-year-old who presents to the clinic with low energy and "feeling down." She states she has been increasingly fatigued for the past two months since she was laid off from her job due to downsizing. She reports that she presented for care

because she felt "down in the dumps" as it was her sister's death anniversary. She had thoughts about harming herself somehow over the past few days but denied specific plans, stating, "sometimes it just seems like it would be easier not to be here." She has a previous history of a suicide attempt as a teenager, after which she received several years of therapy; she has not received mental treatment for about 20 years. She also reports using occasional marijuana and alcohol socially; she currently appears sober. Mary Ellen lives with her husband with whom she states she has a poor relationship; he has not been supportive of her mental health needs in t recommend voluntary admission Rationale: Mary Ellen has had suicidal thoughts, and she does not have a plan; she has a history of suicide attempts and has a lack of support resources. Currently, she may benefit from voluntary admission for evaluation and treatment. Deshawn is a 32-year-old who presents to a rural ED with symptoms of worsening depression, insomnia, reduced appetite, and thoughts of jumping off a tall bridge. Deshawn has a history of major depressive disorder (MDD) and has been treated by his primary care provider for two years with sertraline 50 mg daily. Because the rural hospital has no psychiatric staff on call, the PMHNP was asked to provide a telemedicine consult. Deshawn was agreeable to meeting with the PMHNP via video conference. On the call, Deshawn endorsed depressive symptoms but stated that he did not want to die and that "jumping off a bridge would be a terrible way to go." He denied other active plans for suicide. Which of the following are the most appropriate recommendations to the care team for Deshawn's treatment and disposition? Select all that apply.

• discharge to home with resources for crisis care
• increase sertraline to 75 mg daily
• discharge to home with resources for crisis care
• increase sertraline to 75 mg daily
• recommend follow-up with telepsychiatry Rationale: The client is not having active suicidal thoughts and does not have a plan; therefore, the most appropriate recommendations for Deshawn include discharge to home with resources for crisis care, increasing his sertraline dose to 75-100 mg daily, and due to the limited resources in Deshawn's area, it is appropriate to recommend follow-up with telepsychiatry. Antonia is a 26-year-old who presents to the ED with acute suicidal thoughts for several days. She denies a plan at this time. She has a history of major depressive disorder (MDD) and generalized anxiety disorder (GAD), for which she takes paroxetine 20 mg daily and clonazepam 0.5 mg as needed. She endorses a suicide attempt by taking "a handful" of medications at age 16. Antonia reports recent stress in her life, including a breakup with her girlfriend and an unstable work environment. She states that she came to the ED tonight because she "wasn't feeling like I could trust myself 100%." Which of the following is the most appropriate recommendation to the care team for Antonia's treatment and disposition? Select all that apply.

• discharge to home with resources for crisis care & recommendation for follow-up
• increase sertraline to 75 mg daily
• 23 - hour observation in the ED with Q15 minute checks
• recom recommend voluntary admission Rationale: Antonia has had suicidal thoughts, and she does not have a plan; she has a history of suicide attempt and MDD and GAD. She is also under acute stress. At this time, she may benefit from voluntary admission for evaluation and treatment. Antonia agrees to voluntary admission for evaluation and treatment. After searching the hospital system, the PMHNP finds that there is not an available inpatient bed for Antonia and that a bed may not be available for 24 hours or longer. Antonia states that she is not willing to remain in the emergency department for that long, and she instead wants to schedule an appointment with her counselor for the next day. Antonia states that she is willing to stay with her brother and his family in their home and will give him her prescriptions so that she does not have access to the bottles. Which of the following is the most appropriate recommendation for Antonia?
• discharge to home with resources for crisis care and recommendation for follow-up
• increase sertraline to 75 mg daily
• 23 - hour observation in the ED with Q15 minute checks
• involuntary admission discharge to home with resources for crisis care and recommendation for follow-up Rationale: Antonia's symptoms indicate that she might benefit from voluntary admission; however, since there is no appropriate inpatient bed, keeping her indefinitely in the ED for observation is not appropriate. Antonia can be discharged to the care of her brother with a safety plan, crisis resources, and a follow-up plan. Antonia is discharged to the care of her adult brother and his family. Her girlfriend broke up with her by text that night and posted comments about Antonia's mental illness on social media. Antonia took her brother's car and left his house unnoticed. After hours of binge drinking, she parked her car on the expressway ramp and laid down on the highway. She took a video of herself lying on the highway and sent it to her girlfriend just as she was fatally struck by two cars. The care team is notified of the death by suicide, and the PMHNP is asked to lead a crisis debriefing and postvention or intervention after the suicide to support Antonia's family and friends. ... postvention
• Responding to Grief, Trauma, and Distress after a Suicide https://sprc.org/wp- content/uploads/2022/12/Spotlight_Postvention_ResourceSheetv03.pdf Serotonin Syndrome
• medications cause excessive levels of serotonin to build up in the body.
• antidepressants, illicit drugs, lithium, antibiotics.
• Clinical symptoms typically occur within several hours of beginning a new med or

increasing dose of an existing med: Symptoms:

• Neuromuscular abnormalities (greater in lower extremities)
• Clonus
• Hyperreflexia
• Tremor
• Seizure
• Mental changes
• Agitation
• Pressured speech
• Autonomic instability
• Mydriasis
• Tachycardia
• Hypertension
• Shivering
• Diaphoresis
• Diarrhea Serotonin Syndrome Tx
• discontinuing the causative medication
• intensity of supportive tx depends on severity of symptoms
• Mild cases typically resolve within 24 hrs
• severe cases may require hospitalization for stabilization Neuroleptic Malignant Syndrome (NMS)
• rare, life-threatening adverse effect caused by antipsychotic meds
• may occur due to:
• disruption of dopamine receptors in the anterior hypothalamus
• direct toxicity to muscle cells
• Psychological stressors that activate the ANS may also play a role in triggering NMS
• onset of symptoms may occur 1-2 weeks after starting or changing the causative medication
• Symptoms:
• mental status changes
• agitation
• confusion
• catatonia
• muscle rigidity ("lead pipe" rigidity)
• hyperthermia
• excessive salivation
• autonomic instability (labile blood pressure & heart rate)
• elevated Serum creatine kinase (CK) levels Neuroleptic Malignant Syndrome (NMS) Tx
• immediate intervention to stabilize vital signs, reduce fever, and control agitation
• frequently admitted to ICU