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75 Cards in this Set
- Front
- Back
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A client hospitalized in an acute care mentalhealth facility ritualistically cleans the sink in her bathroom multiple timesdaily. The outcome identified by the treatment team is that the client shoulduse more effective coping measures. To achieve the desired outcome the nurseshould… |
Encourage the client to participate in avariety of unit activities |
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The client has recently begun taking SSRIparoxetine (Paxil) what should the nurse teach the client and spouse abouttaking this medication concurrently with St. Johns wort… |
Combining any SSRI antidepressant with St.John’s Wort can cause serotonin syndrome . Serotonin syndrome is a serious condition thatincludes high fever, hypertension and delirium The client should not continue to take St.Johns wort concurrently with paroxetine |
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Which communication principles should the nursemanger review with the staff regarding a client with bipolar disorder |
All ofthe above. |
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Nurse knows that teaching has been effective ifa client is taking benzo to treat anxiety states |
“I will not stop taking the drug abruptly” |
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A nurse is caring for aclient who is taking phenelzine (Nardil). For which of the following adverseeffects should the nurse observe? a. elevated blood glucoselevel b. orthostatic hypotension c. priapism d. headache e. bruxism |
Orthostatic hypotension and Headache |
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Client is starting on valproic acid (Depakote)for treatment of bipolar disorder what laboratory studies should be monitored regularly? |
AST/ALT and LDH |
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Identify factors that put client at risk fordysfunctional grieving… |
Her husband died suddenly and violently in amotor vehicle crash while under the influence of alcohol. There is a lack of social support, as theclient has stopped seeing her friends, and her daughter lives far away. |
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Which of the following is a risk factor forsuicide? |
Single, young adult male Disturbed thought process during admissionLack of family support |
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A nurse, who leads group therapy for a group ofdepressed patients, plans to implement a plan of exercise for each pt. … |
Has an antidepressant effect comparableto selective serotonin reuptake inhibitors |
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A Pt reports that financial problems arestressing his marriage. Today he heard of rumors about impending cutbacks atwork and he fears he will be laid off. He is wringing his hands, pulse rate of 112/min.RR 26 BP 166/88 instead of normal 110-120/76-84. Nursing intervention orrecommendation should be used first? |
Slow and deepen breathing via use of positiverepeated word |
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A pt. tells the nurse, “I’m told that I shouldreduce stress in my life but I have no idea where to start” Which best initialnursing response… |
“Let’s talk about what is going on in yourlife and then look at possible options” |
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Pt complains of tension, indigestion, anddifficulty concentrating; his resting pulse is 110/min. Nursing response… |
“It might help to talk. Tell me about what hasbeen going on today.” |
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An anxious pt. that receives anxiolytic meds isin the corridor pacing. He grass arms of anyone and ask, “When can I havemedication?” His voice high pithed and shaky… nurse should intervene by… |
Checking when his medication is due andinforming him. |
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A pt. that has been unable to leave his home formore than a month because of s/s of severe anxiety tells the nurse “I feel likea stupid a grown man not being able to leave his house” therapeutic reply |
“You feel stupid because you’re afraid to leavehome?” |
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Nurse is caring for pt. that has been diagnosedwith having generalized anxiety disorder tells a preceptor. “I find myselffeeling uncomfortable and anxious around the patient. When he states tremblingperspiring and pacing. … |
Increased anxiety. |
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The medical-surgical nurse working with patient whohas a somatoform disorder will find the understanding that the patients willprobably facilitates planning … |
Be resistant to seeking psychiatrichelp |
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Pt who is concerned that she may have seriousheart disease seeks help at the mental health center after her internistexamined her and told her that she has no physical illness. She wants staff totell her internist it’s not all in her head. The pt. reports she has hadtightness in her chest and the sensation of her heart is missing a beat. Herconcern over… caused her to miss much time from work … |
Hypochondriasis |
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Pt lives with her roommate leaving the condowearing seductive clothing quite different from her usual wardrobe andreturning 12-24 hrs. later, she sleeps for 8-12 hrs. Episodes have alsooccurred in which the pt. and her roommate argued about household matters andthe pt. have gone to sit the floor in the corner of the kitchen…. |
Dissociative identity disorder |
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Which physician orders would be most likely …pain? |
Relaxation techniques and antidepressantmedications |
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Poorly differentiated and determines that familymembers have little sense of individuality. A desirable outcome is that memberswill… |
Develop their own values and beliefsinstead of simply adopting those of others |
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A friend brings a teenager to Emergencydepartment. Pt is unconscious in a bedroom at a party. Semen is observed on pt.underclothes. Priority action by nurse… |
Maintaining the patient’s airway |
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After death of his wife, a man says “I cant livewithout her she was my whole life” select most therapeutic reply. |
Her death is a terrible loss for you” |
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A recently widowed pt. tells the nurse. ”I amhaving epigastric discomfort. I think I have developed an ulcer” Diagnostic labcame out negative. Which phenomenon of bereavement is evident? |
Sensations of somatic distress |
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45 yr. old married woman who works full time ina factory has recently been absent for 3-day period on several occasions. Eachtime returned to work wearing black glasses. Facial and body bruises wereapparent. Her supervisor becomes suspicious that she was a victim of batteringand referred her to the occupational health nurse. What nurse first focus on asshe meets the pt.? |
Establishing trust and building rapport |
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A depressed pt. that is taking a tricyclicantidepressant tells the nurse, I don’t think I can keep taking these pills.They make me very dizzy esp. when I stand up” Best nursing response… |
“The medicine can slow the bod’sadjustment of blood pressure when changing position: drinking more fluids andchanging positions slowly can help” |
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Information given to depressed pt. and familywhen pt. beginning SSRI antidepressant therapy includes the directive to |
Report increased suicidal thoughts |
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A depressed pt. repeatedly tells staff he’s eviland his insides are rotting because God is punishing him what priority nursingdiagnosis for this pt. be? |
Disturbed thought process |
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A pt. with bipolar disorder, mania, relapsedafter discontinuing lithium. HC provider prescribes lithium 600 BID andolanzapine (Zyprexa) 10 mg Bid. What is the rationale for addition ofolanzapine to the lithium regime? It will |
Bring hyperactivity under rapid control |
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Pt withbipolar disorder was hospitalized 5 days ago and received lithium 600 mg TID.The staff now observes agitation pressured speech, poor personal hygiene, hyperactivity, and bizarreclothing. Best nursing action… |
Consider the need to measure theserum lithium level. The patient may not be swallowing the medication. |
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A staff nurse tells another nurse, “I just usedthe SAD PERSONS to evaluate a man who sometimes thinks about suicide his sadperson was 8. I was wondering if I should send him home after arranges. Followup. Best reply by the second nurse is… |
A scale of 7 or higher usuallyrequires immediate hospitalization |
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Pt says “I never know the answers and “Myopinion doesn’t count” The nurse correctly assess that this pt. had difficultyresolving which psychosocial crisis? |
Autonomy versus shame and doubt |
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Parent of child with schizo tearfully ask thenurse. “What could I have done differently to prevent this illness? Select thebest response… |
Schizo is a biological illness resulting fromchanges in how the brain and nervous system functions you are not to blame foryour child’s illness” |
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When assessing pt. plan for suicide, thepriority areas to consider include |
Availability of means and lethality of method |
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Which symptom is an example of physiologicalalterations exhibited by client’s diagnosis with moderate depression? |
Decreased libido |
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Which nursing intervention takes priority whenworking with a newly admitted client experiencing suicidal ideations? |
Monitor the client at close, but irregularintervals |
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Using psychodynamic therapy, which interventionwould be appropriate for a client diagnosed with panic disorder? |
Discuss the overuse of ego defense mechanism andtheir impact on anxiety |
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Tony a 45 y/o pt. with schizo sometimes moveshis kips silently or murmurs when he does not realize others are watching.Sometimes when talking to others he suddenly spears distracted for a moment andthen resumes. |
Auditory hallucinations |
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The information that is least relevant whenassuming pt. with a suspected somatization disorder is |
Potential for violence |
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Shelly is having menstrual problems and asks youwhich supplement should you suggest for the patient to discuss with her primarycare provider? |
Black Cohosh |
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Nurse on an in-patient psychiatric unit isassessing client at risk for acting out behaviors. Which behavior system wouldnurse expect to be exhibited? |
Invasion of personal space |
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Which assessment data would support a physician’sdiagnosis of an anxiety disorder in client? |
A client experiences increased levelsof anxiety that affects functioning in more than one area of life over a 6-monthperiod |
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Client is diagnosed with obsessive- compulsivepersonality disorder is a highly agitated state. The physician prescribes abenzo. What expect to administer? |
Clonazepam (Klonephin) |
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A young male pt tells you that somehow he feelsthat he should not be a man and that inside he is a woman. This is an exampleof |
Gender dysphyria |
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Pt continues to dominate the group conversiondespite having been asked to allow others to speak. What is the mostappropriate nursing response? |
“When you speak out of turn. I feel concernedthat others cannot participate equally.” |
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Client diagnosed withobsessive-compulsive disorder commonly uses which defense mechanism? |
undoing |
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A client diagnosed with hypochondriasiscomplains to the nurse about others doubting the seriousness of the client’sdisease. The client is angry, frustrated and anxious. Which nursingintervention is priority? |
Acknowledge the clients frustrationwithout fostering continued focus on physical illness |
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A client diagnosed with an obsessive compulsivepersonality disorder has a nursing diagnosis of anxiety R/T interference withhand washing AEB “Ill go crazy if you don’t let me do that.” term outcome isappropriate for the client? |
Within 72 hours of administration the clientwill notify staff when s/s of anxiety escalate. |
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A 65 y/o women with history of prostitution isseen in emergency department and the recent onset of auditory hallucinationsand bizarre behavior? What diagnosis to document? a. schizophrenia b. tertiary syphilis c. gonorrhea d. schizotypal personalitydisorder |
Tertiary syphilis |
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Which client statement is evidence of theetiology of major depressive disorder from a genetic perspective? |
My maternal grandmother wasdiagnosed with bipolar affective disorder |
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Which is the key to understanding whether achild or adolescent is experiencing an underlying depressive disorder? |
A change in behavior over a 2-weekperiod |
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A nurse on an in-patient psychiatric unitreceives report at 1500 hours. Which client is to be assessed first? |
A client pacing the hallexperiencing irritability and flight of ideas |
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A nurse wants to use democratic leadership witha group whose purpose is to learn appropriate conflict resolution techniques.The nurse is correct in implementing this form of group leadership when shedemonstrates which of the following actions? |
Asks for group suggestions of techniques and then supports discussion |
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A nurse is caring for an adult client who is thevictim of abuse. The client does not wish to report violence enforcementauthorizes which of the following is highest priority? a. Advise the client about locations of women’s shelter b. Encourage the client to participate in asupport group for victims of abuse c. Implement case management to coordinatecommunity and social services d. Educate the client about the use of stressmanagement techniques. |
Advise the client about locations of women’s shelter |
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Which of the following are behaviors to help individuals mediate orlessen the stressors. Select all apply. a. Spiritually and/or religious beliefs b. Social support c. Culture d. wealth e. higher education |
Spiritually and/or religiousbeliefs Social support Culture |
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. Pt with severedepression...what med? |
Zoloft |
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A nurse caring for pt. taking SSRI will develop outcome criteriarelated to… |
Mood improvement |
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Pt tells nurse my docprescribed me Paxil for depression... paxil is what category of meds |
SSRI |
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Which nursing dx is a priority for both a pt.with depression and one with acute mania? |
DISTURBED SLEEP PATTERN. |
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An 11-year-old child…daddy calls him “stupid |
EMOTIONAL ABUSE |
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1. A victimof physical abuse by her domestic partner is being treated for a broken humerus.Which indicator for the outcome of abuse protection is most important toachieve before the pt. leaves the ED? |
THE PT HAS COMPLETED AND REVIEWED A WORKABLESAFETY PLAN. |
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1. Pt has outburst of physical violence against… |
EXPRESSES FRUSTRATION VERBALLY INSTEAD OFPHYSICALLY. |
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A woman was bound, taken to a remote location,and raped at gunpoint |
THE THREAT TO HER LIFE. |
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1. When avictim of sexual assault is discharged from the emergency department, the nurseshould: |
PROVIDE REFERRAL INFORMATION VERBALLY AND INWRITING. |
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Which assessment data would support aphysician’s dx of an anxiety disorder in a pt.? |
PT EXPERIENCES INCREASED LEVELS OF ANXIETY THATAFFECT FUNCTIONING IN MORE THAN ONE AREA FO LIFE OVER A 6-MONTH PERIODS. |
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1. You arecaring for a pt. that has been dx with dissociative identity disorder. She wasrecently hospitalized after coming the emergency room with deep cuts on herarms with no memory of how this occurred. The priority nursing intervention forthis pt. is: |
MAINTAIN 1:1 OBSERVATION |
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1. Which ofthe following is an appropriate nursing strategy when trying to give necessaryinformation to a pt. with moderate anxiety? |
DEMONSTRATE A CALM MANNER WHILE USING SIMPLE ANDCLEAR LANGUAGE. |
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1. Whichcommunication principles should the nurse manager review with the staffregarding a pt. with bipolar disorder? |
- USE FIRM, CALM APPROACH - EXPLAIN THINGS IN A SHORT, CONCISE MANNER. - TALK WITH OTHER STAFF MEMBER ABOUT WHATTECHNIQUES WORK AND DO NOT WORK- ADHERE TO AGREED UPON LIMITS. - ALL OF THE ABOVE. |
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1. Mrs.Smith dies at age 82. Mr. Smith has begun to pay less attention to his hygieneand seems less alert to his surroundings. He complains of difficultyconcentrating and sleeping and reports that he lacks energy. |
- ARRANGE FOR AN APPOINTMENT WITH A THERAPISTFOR EVALUATION AND TREATMENT OF SUSPECTED DEPRESSION. |
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A nurse is assessing pt. 4hr after receiving aninitial dose of fluoxetine (Prozac). Which of the following findings should thenurse report to the provider as an indication of serotonin syndrome? |
- HALLUCINATIONS- DIAPHORESIS-AGITATION |
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which of the following statements are correct regarding ocd? select all that apply a. obsessions are repetitive thoughts, whereas compulsions are ritualistic behaviors b. symptoms can start as early as 3 years old c. ocd patients often have difficulty sleeping d. schizophrenia often occurs comorbidly with ocd e. there is a tool (scale) to measure compulsive behaviors f. patients diagnosed with ocd are at higher risk for suicide than patients with depression |
a, b, c, e |
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since learning what he will have a trail pass to a new group home tomorrow, luke's usual behavior has become distracted and is breathing rapidly. he has trouble focusing on anything other than the group home issue ad complains that he suddenly feels nauseated. which initial nursing response is most appropriate for luke's level of anxiety? a. "you seem anxious. would you like to talk about how you are feeling?" b. if you don't calm down, i will have to give you pre med to help you c. luke, slow down. listen to me. you are safe. take a deep breath, and let's go to a quieter place. d. we can delay the visit to the group home if that would help you calm down |
c |
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michael seems to be angry when his family fails to visit him in the hospital as promised. however, he tells you that he is fine and that the visit wasn't important to him. when you suggest that perhaps he might be disappointed or even a little angry that the family has again let him down, the patient responds that it is his family that is angry not him, or else they would have visited. what defense mechanisms is this patient using to deal with his feelings? select all that apply a. rationalization b. projection c. regression d. denial e. dissociation |
a,b,d |
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a variety of meds are used in the treatment of severe anxiety disorders. which class of meds used to treat anxiety is potentially addictive? a. ssri b. beta blockers c. antihistamines d. buspirone e. benzos |
e |
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a disorder in which one experiences fear of being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurs is called |
agoraphobia |
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Client has a nursing diagnosis of knowledge deficit r/t relationship of anxiety to hypertension. Which intervention addresses this client’s problem? |
Teach the client about themind body connections |
