A patient is coming to the Emergency Department via ambulanc…

A patient is coming to the Emergency Department via ambulance for an overdose of Benadryl. The patient has taken in excess of 100 pills. After emergency intervention, the Emergency Room staff has requested the patient to transfer to the critical care unit for ongoing medical stabilization with intent to transfer to mental health inpatient upon stabilization. The Emergency Room nurse provides the following report:   S: 22-year old female presented to the ED in respiratory distress via ambulance. Patient is vocalizing desire to harm herself. B: Patient has significant history of Post-Traumatic Stress Disorder, multiple previous  suicide attempts, current and history of self-harm via cutting. Multiple open wounds on arms and legs. A: Patient is stable for transfer. IV of NS running at 100ml/hr, activated charcoal treatment completed. Updated labs pending, O2 via nasal cannula 2L. R: Suicide precautions, continue with 1:1 attendant. Attendant enroute with patient. Monitor labs, airway protection protocol, psychiatric evaluation upon stabilization.   The team is preparing the room for the patient. Which of the following items should be removed for the safety of the patient on suicide precautions? One or all of these answers may be correct: Select all that apply.

A patient’s spouse approaches the nurses’ station and asks t…

A patient’s spouse approaches the nurses’ station and asks to speak to the patient’s nurse. The spouse states, “I just don’t get it. He must check the stove 40 times before he leaves the house. Then we have to check all the locks at least 6 times. What is going on here?” What is the best response for the nurse to give?

A 46-year-old female has presented to the Emergency Room wit…

A 46-year-old female has presented to the Emergency Room with a friend. The triage nurse charted as follows:   S: Patient is 46-year-old female arrives at ED with complaints of headache and feeling “strange.” B: Past medical history: Depression, hypothyroidism, brain injury at age 5, started a new medication (MAOI) Nardil about 2 weeks ago for depression. A: Patient being taken back immediate due to critically high blood pressure and symptoms indicative of stroke. R: Continue to monitor BP, immediate physician assessment, cardiac monitoring, labs, VS. Dietary assessment/consult.   VS: BP: 246/122, R -22, P-135, T-99.4, Pain 10/10   Which condition is the accepting nurse considering for this patient?

The nurse has placed a 1:1 staff member with a patient who h…

The nurse has placed a 1:1 staff member with a patient who has the intent to act on suicidal feelings. The patient asks the 1:1 attendant to leave the room to use the bathroom in private. The nurse has provided directions to the 1:1 attendant if the patient requests to be alone. Which of the following statements will the 1:1 attendant say based on the direction of the nurse?

A nurse is talking with a patient who is struggling to quit…

A nurse is talking with a patient who is struggling to quit smoking. The patient states, “I know I should. Sometimes it feels like it is my only way to deal with stress.” The nurse responds with using a motivational interviewing technique of “developing discrepancy”. Which of the following responses most represents this technique?