A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative
Which action should be the nurse's priority at this time?
A. Give the client off-unit privileges as positive reinforcement.
B. Encourage the client to share mood improvement in group.
C. Increase frequency of client observation.
D. Request that the psychiatrist reevaluate the current medication protocol.
ANS: C
The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.
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