NR607 FINAL EXAM QUESTIONS WITH COMPLETE SOLUTIONS., Exams of Nursing

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NR607 FINAL EXAM QUESTIONS WITH COMPLETE

SOLUTIONS

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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-Self-Employment Rationale: The PMHNP is providing direct services through her own private practice. Code of Ethics for Nurses - ANSWER--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 - ANSWER--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 - ANSWER-- 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 - ANSWER--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 - ANSWER-- 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 - ANSWER--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 - ANSWER-- 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 - ANSWER-- 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 - ANSWER-- 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 - ANSWER-- 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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER--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 - ANSWER--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 - ANSWER--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. - ANSWER-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 - ANSWER-Aid To Capacity Evaluation (ACE) Practice Settings for complex mental health care - ANSWER--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 - ANSWER--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: - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER--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 - ANSWER--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 - ANSWER--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 - ANSWER-0.1%

Standards for Involuntary Commitment (Assisted Treatment) State-by-State - ANSWER- 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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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 - ANSWER-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) - ANSWER--unique legal documents that guide a client's treatment preferences if they are having a mental health crisis and are unable to make decisions