N129 Exam #2

A nurse prepares to administer a scheduled intramuscular (IM) injection of antipsychotic medication to an out-patient diagnosed with schizophrenia. As the nurse swabs the site, the client shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." What is the nurse's best action?

a. Proceed with the injection but explain to the client that there are medications that will help reduce the unpleasant side effects.

b. Say to the client, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose."

c. Assemble other staff for a show of force and proceed with the injection, using restraint if necessary.

d. Stop the medication administration procedure and say to the client, "Tell me more about the side effects you've been having."
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A nurse prepares to administer a scheduled intramuscular (IM) injection of antipsychotic medication to an out-patient diagnosed with schizophrenia. As the nurse swabs the site, the client shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." What is the nurse's best action?

a. Proceed with the injection but explain to the client that there are medications that will help reduce the unpleasant side effects.

b. Say to the client, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose."

c. Assemble other staff for a show of force and proceed with the injection, using restraint if necessary.

d. Stop the medication administration procedure and say to the client, "Tell me more about the side effects you've been having."
d. Stop the medication administration procedure and say to the client, "Tell me more about the side effects you've been having."

Clients diagnosed with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The client in this situation presents no evidence of dangerousness. The nurse, as an advocate and educator, should seek more information about the client's decision and not force the medication.
The purpose of the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has been diagnosed with schizophrenia is early detection of

a. Acute dystonia
b. tardive dyskinesia
c. pseudoparkinsonism
d. cholestatic jaundice
b. tardive dyskinesia

An AIMS assessment should be performed periodically on clients who are being treated with antipsychotic medication known to cause tardive dyskinesia. This tool is not used to assess or monitor any of the other options.
Chlorpromazine or Thorazine best treats what symptoms of schizophrenia

a. positive symptoms of AVH
b. blunted affect
c. negative symptoms of depression
d. restless leg syndrome
a. positive symptoms of AVH
After 5 doses of Haloperidol 5 mg, John comes to the nurses station with a thick tongue and has difficulty talking and breathing. The nurse suspects:

a. acute dystonia
b. Worsening psychosis
c. Malingering
d. Parkinson's Disease
...
T/F: Diphenhydramine IM or Benadryl is often given for acute dystonia
True
Weight gain and diabetes are monitored closely with which medication

a. Fluphenazine (Prolixin)
b. Haloperidol (Haldol)
c. Lorazepam (Ativan)
d. Olanzapine (Zyprexa)
d. Olanzapine (Zyprexa)
After a week of Haldol (Haldolperidol) medication, used for severe manic symptoms. John still can not sit still and is very jumpy. After ruling out manic symptoms, the psychiatrist gives him Lorezapam and holds Haldol because he suspects:

a. Tourette's Syndrome
b. Post-Traumatic Stress Syndrome
c. Akathisia
d. Tardive Dyskinesia
c. Akathisia
A 31-year-old client admitted with acute mania tells the staff and the other clients that he is on a secret mission for the President of the United States. He states, "I am the only one he trusts because I am the best!" What term will the nurse use when documenting this behavior?

a. Flight of ideas
b. Unpredictability
c. Grandiosity
d. Rapid Cycling
c. Grandiosity
A client hospitalized for a psychotic relapse is being discharged home to family. Which topic is important to address when teaching both the client and the family to recognize possible signs of impending mania?

a. Decreased social interaction
b. Increased attention to bodily functions
c. Decreased sleep
d. Increased appetite
c. Decreased sleep
A patient is impulsive, has self-destructive thoughts, and is not taking lithium or bathing. What is your first priority nursing diagnosis?

a. Risk for Injury
b. Medication non-compliance
c. Family Conflict
d. Self-care deficit
a. Risk for Injury
Joe is 17 with pressured speech and auditory hallucinations. He has assaulted his mother prior to admission and hearing voices of the "devil" talking to him. He also attempted to assault police and nursing staff and received an IM injection of Olanzapine in Highland ER before arrival at your unit. Which nursing diagnosis is of highest priority upon arrival to the unit? a. Financial stress b. Social Isolation c. Family Stress d. Assault Riskd. Assault RiskTwo days later Joe has been taking Olanzapine consistently. He is Alert and orientated x3 but sometimes is whispering to himself in the room. what's an important question to ask Joe? a. If he is hearing voices and what they are saying b. When he wants to be discharged c. If he would like to go for a walk d. If he is hungrya. If he is hearing voices and what they are sayingA patient with Bipolar disorder has been prescribed Lithium. Good patient teaching includes: (Select all that apply) a. "High sodium levels can increase risk of Lithium toxicity" b. "It is not important to monitor medication levels after doing so for a month" c. "Low sodium levels can increase risk of Lithium toxicity" d. "It's important to have your kidneys checked periodically"c. "Low sodium levels can increase risk of Lithium toxicity" d. "It's important to have your kidneys checked periodically"Characteristics of mania include the following: (Select all that apply) a. Racing thoughts b. Drastically reduced sleep requirements c. Inflated sense of self-importance d. Easily distracted and poor concentrationa,b,c,d (all of the above)You're assessing a client with chronic schizophrenia. As a nurse, which effects will you most likely observe in the client? (Select all that apply) a. Apathy b. Flatness c. Pressure speech d. Euphoria e. Auditory hallucinationsa. Apathy b. Flatness e. Auditory hallucinationsMultiple doses of first-generation antipsychotics such as Haldol are discouraged because they often can cause which of the following side effects? (Select all that apply) a. Tardive dyskinesia b. Akathisa c. Metabolic syndrome d. Acute dystoniaa. Tardive dyskinesia b. Akathisa d. Acute dystoniaA client with schizophrenia sees a group of visitors sitting and talking together. The client tells the nurse, "I know they're talking about me." Which altered thought process does the nurse identify? a. grandiosity b. Hallucinations c. Ideas of reference d. Maniac. Ideas of referenceWhen talking to a schizophrenic patient who is hearing voices, what is the first priority nursing intervention for safety? a. Explain that the voices they are hearing are all in their head b. Explain that you don't hear voices so they must not be real c. Ask the patient directly if they are hearing voices and what the voices are saying d. Comfort the patient by acknowledging the voices as realc. Ask the patient directly if they are hearing voices and what the voices are sayingYou are evaluating the effectiveness of clozaril. What symptom would decrease if the drug was working? a. Auditory hallucinations b. Itching c. Constipation d. Droolinga. Auditory hallucinationsWhat kinds of behaviors show that a patient's schizophrenia is stabilized and he may be ready for discharge from the hospital? a. He is pacing in his room and yells at those who pass by b. He lifts up a chair and smashes it in the day room c. He is disheveled and refuses all his meds d. He hears an occasional voice but is able to groom self, and carry on a conversation with no thoughts of harming self or othersd. He hears an occasional voice but is able to groom self, and carry on a conversation with no thoughts of harming self or othersYou're the charge nurse on the unit and you observe another nurse trying to argue with a patient about shaking her finger at him regarding his meds, " If you don't take these meds, you're going to end up in the quiet room!" What should you do? a. Take the nurse to a private area and schedule some teaching and corrective action b. Let her do her job and continue your work c. call security d. Stand beside her and force the patient to take his medsa. Take the nurse to a private area and schedule some teaching and corrective actionT/F: A patient on a 5150 must take antipsychotic medication at all timesFalse Pt must sign consent for medication- involuntary meds can only be given in an emergency ( DTS or DTO or court-ordered REISE)Gladys has chronic schizoaffective disorder she doesn't like taking pills every day for her schizophrenia, what could the nurse recommend to the doctor for her improved medication compliance? a. Long acting injectable such as Risperadal consta b. Lithium capsules c. Clozaril. tabs d. ZYprexa tabsa. Long acting injectable such as Risperadal constaThe plan of care for a patient in the manic state of bipolar disorder should include which interventions? (Select all that apply.) a. Touch the patient and provide assurance b. Provide a structured environment for the patient c. Design activities that require a lot of concentration. and have her lead a group. d. Ensure that the patient's nutritional needs are met.b. Provide structured environment for the patient d. Ensure that the patient's nutritional needs are met.A client on the behavioral health unit bursts out in a verbal tirade in the dayroom. The client has a history of poor impulse control and is lifting up chairs and may throw them. Which de-escalation actions are necessary: ( select all that apply) a. Acknowledge the client's anger and ask if there is something that is triggering the anger presently b. Threaten to use the physical restraints c. First remove other clients from the day room d. Approach the client using a calm tone of voicea. Acknowledge the client's anger and ask if there is something that is triggering the anger presently c. First remove other clients from the day room d. Approach the client using a calm tone of voiceAn adult client who lives in a residential facility is developmentally delayed and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently engages in exposure to other residents. Which action should the nurse take first? a. Restrict all interactions with others in the facility for the rest of the week b. Have extensive one to one relationships to discuss behaviors c. Encourage the client to verbalize feelings d. Redirect client away from residents and engage them in activity in their own roomd. Redirect client away from residents and engaging them in an activity in their own roomA nurse gives her first dose of Zyprexa to a patient who will be taking this longterm for Bipolar and knows that if often can lead to "metabolic syndrome". What teaching can assist in preventing this side effect? a. Observe for urinary frequency b. Maintain a balanced diet and adequate exercise c. Watch out for abnormal facial reactions d. Monitor sleep patternb. Maintain a balanced diet and adequate exerciseOn admission, a highly anxious client is described as delusional. Delusions often occur with which disorders? a. Schizophrenia and bipolar b. Personality disorders c. Anxiety disorders d. dissociative disordersa. Schizophrenia and bipolarA nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. With which patient should the nurse be most alert for problems associated with fluid and electrolyte imbalance? The patient receiving a. Fluoxetine b. Lithium c. Clozapine d. Venlafaxineb. LithiumThe client experiences extrapyramidal symptoms (EPS) during therapy with phenothiazines and complains of a thick tongue and tight jaw- what medication can the nurse ask for? a. (Haldol ) Haloperdol b. Lorezepam (Ativan) c. Diphenhydramine (Benadryl) d. Diazepam (Valium)c. Diphenhydramine (Benadryl)The most serious side effect of Lamictal is______? a. insomnia b. Steven Johnsons Syndrome c. Hearing voices d. Euphoriab. Steven Johnsons SyndromeA normal lithium level is: a. 0.6-1.2 b. 2.0-3.0 c. 2.1-3.0 d. 4.0-5.0a. 0.6-1.2Betty is 80-year-old woman with Alzheimer's who was combative in assisted living and went she went to the ER. She received multiple IV push Haldol to calm her. When you encountered her on the inpatient unit she had a fever, of 104 F. confusion, rigid muscles, variable blood pressure, sweating, and fast heart rate. The nurse should immediately: a. Watch her respirations before the next dose b. Hold further Haldol and alert physician for possible Neuroleptic Malignant Syndrome c. Tie her down tightly on gurney she may hurt someone d. Chart that she is calm and cooperativeb. Hold further Haldol and alert physician for possible Neuroleptic Malignant SyndromeA client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? a. Venflaxine b. Risperdone c. Clonazepam d. Prozacb. RisperdoneWhich of the following describe the symptoms of the manic phase of bipolar disorder? (Select all that apply.) a. distractibility b. racing thoughts c. pressured speech d. Purposeless movement e. Excessive energya,b,c,d,e (all of the above)A patient diagnosed with paranoid schizophrenia believes that evil spirits are being stirred by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. What is the basis for this action? a. No action can violate the patient's confidentiality b. There is a duty to warn and protect c. information cannot be released without proper authorization d. Charges of malpractice must be avoidedb. There is a duty to warn and protectGreg is paranoid and suspicious when you enter his room with Zyprexa zydis. What is your prioties? ( select all that apply) a. Watch for increasing voices and agitation b. Leave a tablet at bedside in a paper cup c. Simple clear instructions with meds d. Wide personal spacea. Watch for increasing voices and agitation c. Simple clear instructions with meds d. Wide personal spaceAn adult diagnosed with schizophrenia lives with elderly parents. The client was recently hospitalized with acute psychosis. One parent is very anxious, and the other is ill because of the stress. Which nursing diagnosis is most applicable to this scenario? a. Ineffective family coping related to parental role conflict b. Caregiver role strain related to the stress of chronic illness c. Interrupted family processes related to relapse of acute psychosis d. Impaired parenting related to client's repeated hospitalizationsb. Caregiver role strain related to the stress of chronic illnessA newly hospitalized client experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad b. Anhedonia c. Echolalia d. Neologisma. Word saladA nurse finds a psychiatric advance directive in the medical record of a client currently experiencing psychosis. The directive was executed during a period when the client was stable and competent. What is the appropriate nursing action? a. Respect the directive in treatment planning and consult with hospital legal services if there are concerns b. review the directive with the client to ensure it is current. c. consider the directive only if there is a cardiac or respiratory arrest. d. encourage the client to revise the directive in light of the current health problem.a. Respect the directive in treatment planning and consult with hospital legal services if there are concernsA client with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the client's behavior? a. Consider the need to check the lithium level. The client may not be swallowing medications. b. Continue to monitor and document the client's speech patterns and motor activity. c. Educate the client about the proper ways to perform personal hygiene and coordinate clothing. d. Ask the health care provider to prescribe an increased dose and frequency of lithium.a. Consider the need to check the lithium level. The client may not be swallowing medications.A client diagnosed with bipolar disorder is in the maintenance phase of treatment. The client asks, "Do I have to keep taking this lithium even though my mood is stable now?" What is the nurse's most appropriate response? a. "Most clients take medication for approximately 6 months after discharge." b. "It's unusual that the health care provider hasn't already stopped your medication." c. Taking the medication every day helps reduce the risk of a relapse."c. Taking the medication every day helps reduce the risk of a relapse."Which action would the nurse take first when a patient receiving antipsychotic medication for 6 weeks with positive results repots flulike symptoms, including fever and sore throat? a. consider recommending a change of antipsychotic medication b. Arrange for the patient to have blood drawn for a WBC c. Suggest that the patient take something for the fever and get extra rest d. Advise the HCP that the patient should be admitted to the hospitalb. Arrange for the patient to have blood drawn for a WBC