final exam

Question 1

what are examples of NMS s/s?

Answer 1

• severe muscle spasms
  -elevated HR
  -elevated BP
• elevated temp

Question 1

what interventions should be implemented at home for an individual who has dementia?

Answer 1

• store cleaning supplies in a lock cabinet/elevate to a level that is not easily accessible (NOT under kitchen sink)
• put mattress on floor

Question 2

what are nursing interventions for NMS?

Answer 2

• crash cart, dantrolene, cooling blankets, antipyretics

Question 3

what should the nurse teach the nursing student about application/care of a selegiline patch?

Answer 3

• apply at the same time every day
• if a patch falls off, apply a new one (call provider)
• it can go anywhere on skin (avoid hairy and open places)
• rotate patch site
• avoid direct heat
• wear gloves

Question 4

what cues would be indicative of chronic alcohol use?

Answer 4

• elevated blood alcohol concentration (>0)
• elevated HR
• hallucinations
• dark, concentrated urine
• ascites

Question 5

what can not be eaten with MAOIs?

Answer 5

pickles, raisins, chocolate cake, pepperoni pizza

Question 6

interventions for disturbed sensory perceptions

Answer 6

• ask if they are seeing something (NOT, “are you having hallucinations?”)
• warn before you touch
• share contents of their hallucinations
• tv or radio to distract them from hallucinations

Question 7

what are some manifestations of borderline personality disorder?

Answer 7

self-mutilation* suicidality, separation anxiety, and splitting behaviors

Question 8

what should the nurse encourage to a client with BPD who has been engaging in self-mutilation?

Answer 8

dialectal behavior treatment group

Question 9

what is a nursing priority for a client with BPD who self mutilates?

Answer 9

maintain close observation

Question 10

How would the nurse document instances when a client with BPD is trying to play one staff member against another one?

Answer 10

splitting

Question 11

If a client with BPD exhibits manipulative behaviors, which intervention should be implemented to address limit-setting?

Answer 11

establish and explain consequences for the client’s behavior

Question 12

after providing first aid, what action should the nurse take for their client with BPD who was cutting into their flesh with a paperclip?

Answer 12

identify the client’s feelings that led to self-injurious behaviors

Question 13

which action should the nurse take once they identify that a client is playing a staff member against another?

Answer 13

explore with the client his use of clinging and distancing behaviors

Question 14

what type of behaviors are seen in those with antisocial personality disorder?

Answer 14

lack of remorse, guilt, or empathy

Question 15

what is an expected findings in those with conduct disorder?

Answer 15

aggressive behavior toward other

Question 16

what type of scenarios would put a client at an increased risk for maladaptive grieving?

Answer 16

death that was result of violence, traumatic, or unexpected (they do not have the opportunity to say goodbye)