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Mental Health Nursing Exam 1 - Jersey College

Terms in this set (103)

at the same time each evening
A client's medication sheet contains a prescription for Sertraline (Zoloft). To ensure safe administration of the med, how should the nurse administer the drug?
crackers and tossed salad
A hospitalized client is started on phenalzine for the tx of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? SATA
-figs
-yogurt
-crackers
-aged cheese
-tossed salad
-oatmeal raisin cookies
white blood cell count
A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication?
avoid alcohol while taking this medication
A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place the highest priority on teaching the client which point that directly relates to client safety?
constipation
Side effect of oxazepam:
get up slowly when changing positions
avoid sunlight
2nd generation/atypical anti-psychotic
Discharge instructions for a patient taking risperidone?
2-3 weeks
TCA - trycyclic antidepressant
The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication?
tardive dyskinesia
The nurse notes that the client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication?
GI dysfunction
CNS dysfunction
Sleeplessness and/or drowsiness during day
SSRI
The nurse is performing a follow up teaching session with a client discharged one month ago. The client is taking fluoxetine (Prozac). Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of this medication?
rapid heartbeat or anxiety
A client who has been taking busprione for 1 month returns to the clinic for a follow up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred?
toxic
A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. The nurse plans the care based on which representation of this level?
< 0.4 to 1 mEq/L
Therapeutic level of lithium?
frequent hand washing with hot, soapy water.
TCA used to treat OCD
A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?
seizures
Excessive amounts of bupropion (Wellbutrin) can cause ________?
the death of a loved one
Example of a situational crisis?
-witnessing a murder
-the death of a loved one
-a fire that destroyed the client's home
-a recent rape episode experienced by the client
A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?
overt - obvious and direct statements
covert - indirect statements
Difference between overt and covert statements?
SAD PERSONS Scale
0-5 may be safe to discharge
6-8 probably requires psychiatric consultation
>8 probably requires hospital admission, voluntary or involuntary (need 2 psychiatrists)
Commonly used in emergency departments and helps staff to quickly evaluate the urgency of referral to mental health sources or protective care?
information regarding shelters
The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions?
"Tell me more about the incident that causes you to feel like the rape just occurred."
A female victim of sexual assault is being seen in the crisis center. The client states that she feels "as though the rape just happened yesterday", even though it has been a few months since the incident. Which is the most appropriate nursing response?
-monitor vital signs
-provide a safe environment
-address hallucinations therapeutically
-provide reality orientation as appropriate
Which interventions are most appropriate for caring for a client in alcohol withdrawal? SATA
-monitor vital signs
-provide a safe environment
-address hallucinations therapeutically
-provide stimulation in the environment
-provide reality orientation as appropriate
-maintain NPO status
-dental decay
-loss of tooth enamel
-electrolyte imbalances
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note?
-dental decay
-moist, oily skin
-loss of tooth enamel
-electrolyte imbalances
-body weight well below ideal range
-hyeprtension -anxiety -isomnia -anorexia
-disorientation, changes in LOC
-agitation -fever -delusions
Symptoms of alcohol withdrawal delirium (10)?
use an indirect light source and turn off the tv
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially.
identifying anxiety producing situations
Most appropriate maintenance goal for maintaining client safety at home upon discharge for a client with chronic anxiety?
Avoidant
A client is unwilling to go to his church because his ex gf goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains housebound. The home care nurse develops a plan of care that address which personality disorder?
conversion disorder
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult?
Heights
Acrophobia is a fear of ?
Open spaces
Agoraphobia is a fear of ?
Electrical Storms
Astraphobia is a fear of ?
Talking
Glossophobia is a fear of ?
Blood
Hematophobia is a fear of ?
Water
Hydrophobia is a fear of ?
Being alone
Monophobia is a fear of ?
Germs or dirt
Mysophobia is a fear of ?
Darkness
Nyctophobia is a fear of ?
Fire
Pyrophobia is a fear of ?
Strangers
Xenophobia is a fear of ?
Animals
Zoophobia is a fear of ?
To return to at least the pre-crisis level of functioning.
What is the goal of crisis intervention?
4-6 weeks
A crisis is self-limiting and is usually resolved within what time frame?
healthy
A person in crisis is assumed to be mentally ________________.
Introductory phase
The purpose and overview of the debriefing process is presented. Confidentiality is assured, team members are identified, and questions are answered. What phase of critical incident stress debriefing is this?
Fact phase
Participants are assisted in discussing the facts of the incident from their perspectives. What phase of critical incident stress debriefing is this?
Thought phase
All participants are asked to discuss their initial thoughts about the incident. What phase of critical incident stress debriefing is this?
Reaction phase
Participants engage in freewheeling discussion about the worst, most painful parts of the incident. What phase of critical incident stress debriefing is this?
Symptom phase
Participants describe cognitive, physical, emotional, or behavioral experiences at the time of the incident and ongoing. What phase of critical incident stress debriefing is this?
Teaching phae
The feelings of the participants are affirmed. Guidance is provided regarding future symptoms and stress management techniques. What phase of critical incident stress debriefing is this?
Reentry phase
The debriefing process thus far is reviewed, and any new topics are discussed. Team members provide encouragement and resources for additional help, and summarize the experience.
physical, emotional, sexual, neglect
What are the four types of abuse?
short term memory loss, decreased motivation
Damage to the hippocampus results in ?
OCD, decreased ability to experience pleasure
Damage to the thalamus results in ?
problems with circulation and respirations
Damage to the medulla results in ?
rage, violence, loss of emotional control
Damage to the frontal lobe results in ?
hyperreflexia, hyperthermia, diarrhea
Symptoms of serotonin syndrome (3)?
denial and blame, emotional abuse, control through isolation, control through intimidation, control through economic abuse, control through power
Characteristics of violent partner (6)?
Tension, batter, honeymoon
Three phases of the cycle of violence ?
physical, psychological, financial/exploitation, neglect, sexual
What are the five kinds of elder abuse?
Aaron Beck
Who pioneered the type of therapy we now know as Cognitive Behavioral Therapy?
narrative is a descriptive statement of patient status written in chronological order throughout a shift.

problem-oriented charting - SOAPIE
Explain the difference between narrative and problem-oriented charting?
used in problem-oriented charting
s - subjective data
o - objective data
a - assessment
p - plan
i - interventions
e - evaluation
What is SOAPIE ?
relaxation, reframing, sleep, exercise (aerobic), lower/eliminate caffeine intake,
What are 5 stress reduction techniques?
H - home environment
E - education and employment
A - activities
D - drugs, alcohol, tobacco use
S - sexuality
S - suicide risk/symptoms of depression
S - savagery (acts of violence in environment)
HEADSSS - What do the letters stand for?
antidepressants
What is the most common type of drug prescribed in the US?
MAOIs
Avoid tryamine with which class of antidepressants?
SSRI, SNRI, MAOI
Which classes of antidepressants should not be stopped abruptly (3)?
SNRI
With which class of antidepressants should liver enzymes be checked?
cant see, cant pee, cant spit, cant shit
Side effects of antidepressants? (fun rhyme)
good stress
What is eustress?
stress that causes emotional and physical problems
What is distress?
ASD resolves within one month
What is the difference between ASD and PTSD?
altruism
emotional conflicts and stressors are addressed by meeting the needs of others - healthy defense mechanism ?
sublimation
an unconscious process of substituting constructive and socially acceptable activity for strong impulses that are not acceptable in their original form. i.e., boxing, butcher, etc - healthy defense mechanism ?
suppression
the denial of a disturbing situation or feeling ("I can't worry about paying my rent because I have a test tomorrow.") - healthy defense mechanism ?
repression
the exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness - intermediate defense mechanism ?
displacement
transfer of emotions associated with a particular person, object, or situation to another person, object or situation that is nonthreatening - intermediate defense mechanism ?
reaction formation/overcompensation
unacceptable feelings or behaviors that are kept out of awareness by developing the opposite behavior or emotion ("I don't like kids so I think I'll go be a boy scout leader.") - intermediate defense mechanism ?
somatization
occurs when anxiety is repressed to an unconscious level but is revealed on a physical level in the form of physical symptoms that have no organic cause (making excuses) - intermediate defense mechanism ?
undoing
compensates for an act or communication (gifts after beatings) - intermediate defense mechanism ?
rationalization
justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener - intermediate defense mechanism ?
dissociation
a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment (can't remember) - immature defense mechanism
devaluation
occurs when emotional conflicts or stressors are handled by attributing negative qualities to self or others. the individual appears good by contrast (that award didn't mean anything anyway) - immature defense mechanism
anosignosia
The inability to recognize you are mentally ill because you are mentally ill is called ?
bipolar disorder and depression
Name the two affective disorders ?
thorazine
First psychotropic drug was called ?
-putting the client down
-calling the client names
-making the client feel guilty
The nurse is concerned that a client may be experiencing emotional abuse. The nurse observes an interaction between the client and a family member. Which assessment findings related to the actions of the family member toward the client led the nurse to make this clinical determination? Select all that apply.
-making all the decisions
-calling the client names
-limiting contact with others
-putting the client down
-making the client feel guilty
use of alcohol and other drugs and experiencing role reversal in childhood
Factors that are related to revictimization include?
(1) bruises involving no breaks in skin integrity, (2) burns, usually due to immersion in hot water, contact with cigarettes, tying with a rope, or the application of a hot iron, (3) lacerations, abrasions, welts, and scars noted on the lips, eyes, face, and external genitalia, (4) missing or loosened teeth, and (5) skeletal injuries such as fractured bones, epiphyseal separation, or stiff, swollen, enlarged joints.
What are the 5 most common indicators of physical abuse of a child?
ideas of reference
beliefs that external events have personal significance?
magical thinking
the belief that thinking about something will make it happen?
thought broadcasting
the belief that others can hear or know what the client is thinking?
obsession
unwanted repetitive thoughts?
ideas of reference
A psychiatric-mental health client informs the nurse that a tornado that hit a neighboring town was the client's fault because the client dislikes a neighbor. This disturbance of thought content is known as what?
circumstantial thinking
When a client gives excessive and unnecessary details and then gives the answer it is known as?
Flight of ideas
This type of speech is characterized by an excessive amount and rate of speech composed of fragmented or unrelated ideas?
Loose association
This type of speech is characterized by jumping from one idea to another with little or no evident relation between the thoughts?
It is a standardized, reliable depression tool.
What is the most significant benefit of using Beck's Depression Inventory to the practice of evidence-based nursing practice?
impassive
A(n) _________ face is frozen into an emotionless deadpan expression similar to a mask.
Data collection
_______________ refers to the objective data that nurses observe and the subjective data that clients report
incongruent
How should the nurse describe the mood and affect of a client who has a mask-like facial expression but states, "I'm really happy"?
Conversion
__________ disorder is part of a group of illnesses called Somatoform disorders, in which there is no physical or laboratory evidence to support the physical manifestations that the client presents.
Body identity integrity disorder
A client who feels alienated from a part of the body and is desiring amputation is identified as having _______________________. Clients with this disorder often want to have limbs removed.
benzodiazipines
Discontinuation of this class of drug, such as lorazepam, places the client at risk for withdrawal symptoms?
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