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Psych

Terms in this set (60)

A client in the emergency department was successfully treated for an overdose of heroin with Naloxone (Narcan). Which of the following, if the client was responsive to the treatment, would the nurse expect to observe?
Increased respiratory rate
A client states to the nurse, "I see headless people walking down the hall at night. Which nursing response is appropriate?
It must be frightening. I realize this is real to you, but I see no headless people
A client with a history of alcohol and prescription pain medication dependence is two days post-op for a bowel resection. What problem would be of most concern for nursing care?
Maintenance of adequate pain control
A woman in the last trimester of pregnancy seeks treatment for alcoholism. She admits to drinking a pint of whiskey a day. For planning purposes, what must the nurse know about the women's risk of delivering a baby?
The baby will have deformities
A new graduate has been assigned four clients whom he must perform an assessment on. His assessment reveals several client complaints. Which client complaint should receive priority?
The client receiving clozapine (Clorazil), who states, "I feel like I am getting the flu. My throat is sore and i am really tired.
A client in the outpatient clinic is found to be non-adherent to taking prescribed antipsychotic medication on a consistent basis. Of the medications listed, what would the nurse anticipate the physician to order?
Risperidone (risperdal consta)
A client admitted with catatonia is starting to perform self-care tasks with assistance from the mental health assistant. One day the nurse observes the client is standing immobile facing the wall with one arm bent behind his back and the other extended in a Naz-like salute. He remains immobile, in that position for 10 minutes, moving only when the nurse gently lowers his arm. What is the term for this behavior?
Wavy flexibility
The nurse admits a client to the in-patient psychiatric unit who is exhibiting bizarre delusions, auditory hallucinations and incoherent speech. The client is experiencing suicidal ideation and rates mood as a "2 out of 10" (based on a scale of 0 being extremely depressed to 10 being extremely euphoric). Based on these signs and symptoms, what DSM-5 diagnosis would the nurse suspect?
Schizoaffective
A client is in the active phase of paranoid schizophrenia. What is the priority nursing intervention?
Assign consistent staff members to establish trust
A nurse is working with a client with schizophrenia to develop a plan to prevent relapse of symptoms. What information should be included? (SATA)
Identify personal early warning signs of relapse
Involve a family member or friend
Agree to contact the doctor or case manager if warning signs occur
A client is admitted to the psychiatric unit in an acutely disturbed, violent state. SHe is given several doses of haloperidol (haldol) and becomes calm and approachable. During rounds, the nurse notes that the client has her head rotated to one side in a stiffly fixed position. Her lower jaw is thrust forward and she is drooling. She appears severely anxious. What is the correct assessment of what the client is experiencing?
Acute dystonic reaction
A client diagnosed with schizophrenia has auditory hallucinations. The client anxiously tells the nurse, " the voices are telling me to do things." select the nurse's priority assessment question.
What are the voice telling you to do?
What assessment findings Mark the prodromal stage of schizophrenia?
Social withdrawal and depressive mood
a client with schizophrenia is being discharged from an acute care hospital for the third time in a year. His admissions are due to lack of support and non-compliance with medication regimen. what type of community treatment would best assist the patient to remain stable in the community?
Assertive community treatment
What barriers are there for individuals seeking treatment for mental health disorders? Select all that apply.
Stigma of having a mental illness
Health care not available
Lack of access to care
Increase cost of health insurance
The nurse is preparing a presentation on the mental health system. what information would the nurse include regarding the purpose of mental health parity laws?
They ensure insurance coverage for mental illness is equal to that of coverage for physical illnesses
The psychiatrist prescribes olanzapine (zyprexa) for a client who displays delusions, hallucinations, apathy, and social isolation. which of the following symptoms are targeted by this medication?
Both positive and negative symptoms
A nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in mid-sentence, and listens intently. the nurse recognizes these behaviors as a symptom of the client's illness. What is the most appropriate nursing intervention for the symptom?
Ask the client to describe what he is hearing
A client is newly diagnosed with paranoid schizophrenia. He is suspicious and aloof. One of this nursing diagnoses is diversional activity deficit. What activity would be appropriate to plan for this client?
Color by number
A tense, jittery client with dilated pupils as seen in the 24-hour crisis clinic stating," I've been speeding with my mind racing and my thoughts are all over the place. I was at a party, I'm burning up. Help me." The clients temperature is 104 degrees. suddenly she becomes paranoid and moves away from the staff, refusing to allow further examination, shouting, " you are all out to kill me!" What are the signs, symptoms and behaviors indicative of?
Amphetamines
Which of the following strategies would show that a nurse is using motivational interviewing strategies to increase the chances of Behavioral change? Select all that apply.
Ask the client how they think substance abuse affects his/her family life
Mutually explore methods with the client that he/she thinks might work
A nurse is a case manager for a Home Care Agency and has a caseload made up of clients were mentally ill and who require periodic hospitalization. What does the nurse be considered a member of the multidisciplinary team?
...
A client diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, lack of energy, poor personal hygiene, and poor motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?
Anergia and poor personal hygiene
Which oral medication is the nurse most likely to see prescribed as part of the treatment plan for both both a client in an alcoholic treatment program and a client in a program for the treatment of opioid addiction?
Naltrexone (revia)
A client with a history of alcohol dependence has been diagnosed with Wernicke Korsakoff syndrome. Which member of the mental health Team would the nurse collaborate with to meet the clients described need?
The nutritionist to help the client increase consumption of thiamine-rich (Vitamin B1) foods
what signs would the nurse expect to observe in an individual who has injected heroin?
Drowsiness, constricted pupils, slurred speech
a client who has been diagnosed as an alcoholic is admitted to the Alcohol Rehabilitation Unit after being fired for drinking on the job. He States, " I don't have a problem with alcohol. I can handle my booze better than anyone I know. I can go days without even having a drink." What defense mechanism is the client using?
Denial
For the client who is in alcohol withdrawal, what will the nurse anticipate that the primary provider will order?
A benzodiazepine for its sedative and anticonvulsant effect
The nurse attempting to establish a relationship with a severely withdrawn client who is diagnosed with schizophrenia, tells a perceptor that her frustration level is rising daily because the client turns his head away each time she sits down near him. The nurse States, " I'm beginning to wonder what's wrong with me as a nurse." What should the perceptor teach the nurse about client's with schizophrenia who are withdrawn?
They avoid relationships because they become anxious with emotional distress
A client who was prescribed chlorpromazine (thorazine) is seen in the out-patient clinic. He tells the nurse he stopped taking his pills because he hated the way they made him feel. WHat common side effects is the client most likely referring to
Dry mouth, stiffness, shuffling gait
A student nurse is working in a community-based methadone clinic where clients receive their methadone on a daily basis. What comment, if made by the student, indicates to the supervising nurse that the student has accurate knowledge of methadone?
This medication replaces another potent opioid drug
A nursing instructor is teaching about the etiology of schizophrenia. What statement by the nursing student indicates an understanding of the content presented?
There are several theories, but an exact cause is not known.
When teaching clients and their families evidence-based strategies for the stabilization and maintenance phases of schizophrenia, what principle should these strategies be based on? SATA
Teaching clients and their families strategies for medication management will reduce relapse
Encouraging establishment of social relationships help to increase self-esteem
Decreasing triggers for stress and anxiety can assist in preventing a relapse
Which initial short-term outcome would be appropriate for a client who was admitted expressing delusional thoughts?
Engage in reality-oriented conversation
A client diagnosed with schizophrenia is having positive symptoms. Which of the symptoms below are classified as positive? Sata
Seeing spiders crawling on his bed sheets
Belief that the government has tapped his phone
Hearing the voice of his dead mother
Several weeks into treatment for opioid abuse, the nurse learns that a client is routinely using marijuana and alcohol to mellow out and a benzodiazepine every night to help with sleep. What is this assessment indicative of?
Polysubstance use disorder
A client admitted for a heroin overdose received naloxone (narcan) which improve the clients breathing pattern. However, he reports muscle aches and a domino cramping, stating, I feel terrible. He sniffles and points to the Goosebumps on his arms. Which assessment can be made?
Symptoms of opioid withdrawal are present
A client has been on a first-generation antipsychotic for the past 10 years. The nurse observes the client constantly smacking her lips in her neck and shoulders seem to twist in a slow, snake-like motion. What should I suspect?
Tardive dyskinesia
a client comes to the emergency room stating, I feel Restless. Everything I look at Weavers. Sometimes I'm outside my body looking at myself. I can hear colors. I think I'm losing my mind. Vital signs are slightly elevated. What does the nurse expect the client is experiencing?
Methamphetamine overdose
A client diagnosed with schizophrenia is admitted to the hospital, and haloperidol (haldol) was begun. The nurse would assess for neuroleptic malignant syndrome (NMS) if the client displayed which of these symptoms?
Temperature reading of 104
A client is experiencing labile emotions and expresses concern over nervousness, sleep disturbances, and cravings for nicotine. What is the priority nursing intervention for this client?
Obtain an order for a nicotine patch
When teaching a group of health professionals about managed care and mental health, the nurse is asked by a participant, why is it just those who are presenting their danger to themselves or others the only ones that are accepted for inpatient care? What is the nurses best reply to get the point across about Managed Care in mental health Delivery Systems?
The cost of inpatient hospitalization is reserved for those specific clients, other places are available in the community centers in many areas.
Which of the following interventions would the nurse omit if the client was in stabilization or maintenance phase of schizophrenia?
Limit setting
Which of the following is appropriate when giving care to a client who is withdrawing from psychostimulant drugs such as cocaine or Methamphetamine?
Observe for depression or suicidal ideation
Well meeting with a nurse, a client who is alcoholic ass what Alcoholic Anonymous is all about. Which reply by the nurse best describes this?
Its a self-help group where the norm is maintaining sobriety
A client has been taking fluphenazine (prolixin) for the past 2 weeks. He drools, has hand tremors, and walks with a shuffling gait. What would these behaviors be assessed as?
pseudoparkinsonism
When teaching a client who is to receive methadone therapy for opioid addiction, the nurse should instruct the client that methadone is useful primarily for which of the following reasons?
Its meant to have the client lead a more normal lifestyle
What intervention should the nurse plan to use to reduce the client's focus on delusional thinking?
Focus on feelings suggested by the delusion
The following observations of a client were identified in a shift report to a nurse who is to care for a teenage client who was admitted with a dual diagnosis. The report included suspicions of anabolic steroid abuse. Which observation supports substance abuse?
Throwing a chair when it was time to turn off the television
A nurse plans to teach an adolescent health class about the dangers of inhalant abuse. What important danger would be included in the teaching plan?
Cardiac Arrest
A client brought to the emergency room after an automobile accident tells the nurse that she attended a cocktail party and consumed a few drinks over the last hour. Her blood alcohol level is 0.15%, She describes herself as "tipsy." what conclusion can the nurse draw?
The clients blood alcohol level is over the legal limit and she is intoxicated
A nurse worked at a hospital for several months, resigned and then took a position at another hospital. In the new position, the nurse often volunteered to be the medication nurse. After several serious medication errors, an investigation revealed that the nurse was diverting client narcotics for self use. What is an early indicator of nurses abusing substances?
Seeking to be assigned as a float nurse on different floors.
The nurse is preparing to delegate assignments to a mental health assistant on a psychiatric unit. Which of the following assignments is an appropriate delegation to this level of health care worker?
Assist the client with a chemical dependency to the group therapy room
Using principles of biological theory, what contributing factor puts a client at risk for alcoholism?
The client is a child of an alcoholic parent
A client in the medical surgical setting is experiencing withdrawal from alcohol. Which of the following does the nurse evaluate as a subjective clinical manifestation?
Feelings of restlessness
Which of the following is a priority for the nurse to include in the discharge instructions given to a client who has been chemically dependent on opioids?
Explore attitudes and behaviors that may precipitate a relapse
The nurse is planning a teaching session for a client who has recently been prescribed disulfiram (Antabuse) as deterrent therapy for alcoholism. What statement indicates that the client has accurate knowledge of this subject matter?
"I'll have to stop using my alcohol-based aftershave while I am taking the disulfiram ."
A client is admitted with a compound fracture of the femur after falling while intoxicated. She is shaky, irritable and anxious and her pulse rate is 130. She cries out, "There are bugs crawling on my bed. I've got to get out of here."The client then begins thrashing about. What is the most accurate assessment of the situation?
The client is experiencing symptoms consistent with withdrawal delirium
Risperidone (Risperdal) is to delusions as alprazolam (Xanax) is to:
Anxiety
During a one-to-one session with a client, the nurse notes that the client is unable to stop moving. He frequently stands up and begins pacing while answering the nurse's questions. The nurse assesses the client's need to be in constant motion as which of the following?
Akathisia
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