ATI #1 Flashcards
Schizophrenic patient with command hallucinations
Priority?
Determining what the ‘voices’ are saying After this, the triggers should be identified,
Schizophrenic patient
Clang association?
Word rthtm
I’m red, in the head and I’m going to bed!
Echolalia
consistent repeating!!
Word salad
A mixture of phrases and words strung together without meaning
質問に答えてるけど、全然話が嚙み合わずにとにかく永遠と話し続ける
Magical thinking
Thoughts or behaviors have control over specific people and situations
Not hallucinations
Anhedonia
Inability to receive pleasure from things
A Hate Doing
Anergia
abnormal lack of energy.
Seen in the depressive stage of bipolar disorder
An energy
Sexual assault pt in ER
Assess self-harm thought
Don’t shower or change clothing until after exam and evidence collection.
Sexual assault is what crisis?
an adventitious crisis
pt reaches new stage of development is what crisis?
Maturation crisis
During mania, pt needs what?
quiet, solitary(孤独な) activities and decreased stimulation
For pt with Obsessive-compulsive disorder (OCD)
schedule time for them to perform rituals
(しばしば同じ形式で繰り返される儀式)
This will decrease anxiety
Negative reinforcement can decrease pt self
-Isolation would inc of a panic attack.
-Keep the environmental stimuli low
What is Obsessive-compulsive disorder (OCD)?
A person has uncontrollable, reoccurring thoughts (“obsessions”) and/or behaviors (“compulsions”) that he or she feels the urge to repeat over and over.
OCD repetitive behaviors relieve what?
Anxiety
They do NOT have hallucinations
Alcohol withdrawal symptoms
Hand tremors
several days after the last intake of alcohol
Seizures
Antisocial characteristic?
Manipulation others
Aggressive
Do not seek isolation
Set realistic limits on the client’s behavior
反社会的人格異常
Dealing with an antisocial pt?
Use clear, calm statements
Limits should also be set
Confronting the patient will escalate the risk of violence
The nurse should stay out of reach of the client
Cognitive behavioral therapy helps?
When experiencing mania, the client tends to view the future unrealistically. CBT assists the client in recognizing and challenging unrealistic or “automatic” thoughts.
Also helps recognize early trends toward mania.
CBT does NOT replace medication. It is an individual therapy, and lifestyle interventions (rest and nutrition) still need to be followed.
Dementia is associated with?
Alzheimer’s disease,
chronic alcohol use disorder
head trauma
Progresses over time!!!
Delirium is?
Reversible
Occurs suddenly over hours or days
Could be caused by a reaction to a new med or a med toxicity
During the orientation phase, nurse should inform?
The client about confidentiality
This helps to establish trust.
Child abuse sing?
Inconsistent stories about a child’s injury
一貫性がない
Delaying medical care
The parent leaving the treatment area, or child showing fear of the parent.
During orientation phase, the nurse should determine?
The rules that apply to the group and ensure that all members understand.
Discuss confidentially and meeting times.
During working phase nurse should address?
Disagreements
The nurse should transition from the role of group leader to group facilitator. Clients are expected to experience grief during termination.
For a bipolar client having a manic episode, provide frequent?
High calorie snacks and meals
Pts will use excessive physical energy
Finger foods are easier than requiring the client to sit and focus on a meal
OCD?
Bipolar?
repetitive behavior
flight of ideas
Sitting a)_______ builds trust
Anorexia can cause b)______ on back and face
a) quietly
b) lanugo
OCD treatments?
SSRIs, behavior therapy, and deep-brain stimulation
For a domestic abuse victim, greatest risk is?
Further injury
The priority is to help client develop a safety plan for rapid escape.
Alcohol is a major risk for?
Cancers in
oral cavity, pharynx, and larynx.
Also association with liver, breast, and colorectal cancers.
What is a heavy drinking? man and women
14+ drinks is heavy drinking (male); 8+ for female
-Genetic risk for alcoholism is 40%-60%.
binge drinking? how many man and women
短時間での大量の飲酒
5 or more drinks (male) and 4 or more (women) within 2 hours
ECT is good for? wake quickly once treatment is completed.
severe depression, bipolar disorder, and Parkin?son’s disease. Reorient the client following ECT. Client should be NPO 6-8 hours before procedure and can eat after treatment. Client should wake about 15 minutes after treatment. Short-acting general anesthetic and muscle relaxant will be given PRIOR to treatment. This allows client to
ECT is good for?
Can’t do ECT for a client with?
severe depression, bipolar disorder, and Parkinson’s disease.
The client should be NPO 6-8 hours before the procedure and can eat after treatment
Short-acting general anesthetic and muscle relaxant will be given PRIOR to treatment.
cardiac arrhythmias. The greatest risk of death is cardiac complications
Caring for Anorexia pt?
Watch the pt one hour before and after meals
Weigh client daily in the AM
don’t discuss food during meals,
do NOT let them exercise until goal weight is reached.
Mild Alzheimer’s sign?
Forgetting something that was just read. Difficulty controlling the bladder and bowels. Difficult time with ADLs.
Changes in ability to walk, sit, and swallow.
If a depressed patient is suddenly happy and has “everything worked out” sing is?
They are at high risk for suicide.
When suicidal pt is admitted?
search all belongings on arrival
Give the client a semi-private room and put them on 1-on-1 observation
Keep the door open at all times
Cocaine use causes for bodies are?
dilated pupils and elevated BP and elevated body temp
Opioid withdrawal can cause?
rhinorrhea, insomnia, tachycardia, and hyperthermia
AIMS scale?
Helps assess with tardive dyskinesia
CAGE?
Assessment for diagnosis of alcohol disorder
Cut-Annoyed-Guilty-Eye-opener
phobia
恐怖症
Which are correct?
a) To assess cognitive ability, I should ask the pt to count backward by sevens
b) TO assess the effect, I should observe the pt facial expression
c) TO assess language ability, I should instruct the pt to write sentence
d) TO asses remote memory, I should have the pt repeat a list of objects
e) To assess the pt abstract thinking, I should asl to identify our most recent presidents
a, b, c
d= immediate memory
e= knowledge
