Exam 2 Flashcards
What should be included in the plan of care for a client who has bipolar disorder and is experiencing a manic episode?
- offer concise explanations
- establish consistent limits
- use a firm approach with communication
What would indicate that the nursing student has correct understanding of ECT for treatment in bipolar disorder?
“ECT is effective for clients who are experiencing severe mania”
What is a priority nursing action for a client who has bipolar disorder?
monitor the client for escalating behavior
What education should the nurse provide about relapse prevention in a client who has bipolar disorder?
- difficulty sleeping can indicate a relapse
- participating in psychotherapy can help prevent a relapse
- anhedonia is a manifestation of depressive relapse (lack of interest)
If a client with a psychotic disorder is experiencing auditory hallucinations and says “the voices won’t leave me alone!,” what are some things the nurse should say?
- when did you start hearing these things?
- it must be scary to hear these voices
- are the voices telling you to hurt yourself
what should the nurse consider as positive symptoms in a patient who has schizophrenia?
- auditory hallucinations
- use of clang association
- delusion of perception
- delusion of persecution
- constantly waving arms
What are some examples of negative symptoms?
lack of motivation and flat affect
A client hears voices saying, “kill your doctor,” what action should the nurse take first?
initiate one-to-one observation of the client
what should be included in the patient teaching for a client prescribed donepezil for Alzheimer’s?
take this medication at the end of the day before bed
what are some findings that can be expected in a client with delirium related to an acute UTI?
- family report of personality changes
- hallucinations
- restlessness
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal, what are some findings that the nurse may expect?
- fine tremors of both hands
- vomiting
- restlessness
what is the priority intervention for a client who is experiencing benzodiazepine withdrawal?
implement seizure precautions
what is preferred for osteoarthritis pain relief for a patient taking lithium therapy?
aspirin instead of ibuprofen (decreases risk for lithium toxicity)
What are some manifestations of early lithium toxicity?
- polyuria
- muscle weakness
A client who has had their last drink at 1100, when are they most likely to experience withdrawal?
1500- 2300 (withdrawal symptoms are most likely to appear 4-12 hours within cessation)
A client admitted to the inpatient detoxification program for alcohol withdrawal approaches the nurse complaining of nausea and feeling shaky. The nurse notices that the client has hand tremors and appears diaphoretic. Which of these nursing interventions is a priority?
Administer prn benzodiazepine that was ordered for management of withdrawal symptoms.
A client who has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job states to the nurse, “I don’t have a problem with alcohol. My boss is a jerk! I haven’t missed any more days than my coworkers.” What is the nurse’s best response?
“You are here because your drinking was interfering with your work.”
Which medication is the physician most likely to order for a client experiencing alcohol withdrawal syndrome?
chlordiazepoxide
Symptoms of alcohol withdrawal include:
Diaphoresis, nausea and vomiting, and tremors.
A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should expect prescriptions for which of the following medications to promote long-term abstinence from alcohol?
disulfiram, naltrexone, and acamprosate
A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority?
implement seizure precautions
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?
fine tremors, vomiting, restlessness
A home health nurse is making a visit to a client who has Alzheimer’s disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client’s risk for injury?
install extra locks at the top of exit doors
A nurse is completing an admission for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms
- auditory hallucinations
- use of clang association
- constantly waving arms
- delusion of persecution
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should expect a prescription for which of the following medication?
risperidone (atypical antipsychotics)
A charge nurse is discussing manifestation of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first-generation antipsychotics
Auditory hallucinations, delusions of grandeur, and severe agitation
A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)?
drooling, involuntary arm movements, and continual pacing
what may hallucinations, diaphoresis, and agitation indicate in a client who took an initial dose of fluoxetine (SSRI) 4 hrs ago?
serotonin syndrome
What is common for a client to experience following ECT?
confusion and disorientation
What should the nurse provide following ECT until the client has a stable respiratory status?
oxygen
Due to the risk for confusion after ECT, what intervention should the nurse implement?
reorient the client to their environment
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome?
stop taking the herbal supplement while taking this med
If a patient is taking selegilline, why should they notify the provider of drowsiness?
this may indicate a manifestation of serotonin syndrome
Which brain structures are most associated with the drive for compulsive substance use?
prefrontal cortex, basal ganglia, and amygdala
A CNS depressant such as a sedative works on which areas of the body?
muscles, brain, nerves, and heart
A client is experiencing withdrawal symptoms from alcohol use. Which of the following medications is most appropriate?
diazepam
Withdrawal from this substance requires a quiet atmosphere, sleep, food, and antidepressants. Name the substance.
stimulants
what is avolition?
lack of motivation (this may present as poor hygiene)
what is anergia?
lack of energy
what is anhedonia?
lack of pleasure
what is alogia?
lack of thoughts/speech
What medications may cause tardive dyskinesia, EPS, dystonia, NMS?
typical antipsychotics (haloperidol)
What type of medications may cause increase metabolic syndrome symptoms?
atypical antipsychotics
What are tyramine foods?
Raisin, smoked meats, pickles, chocolate cake, aged cheese
What may be found in schizoaffective disorder?
Hallucinations and depression
What intervention may be used for someone who has hallucinations?
distract them with a TV
What is a side effect of inhalant intoxication?
slurred speech
what is the purpose of the MMSE?
assess for neurocognitive disorders
