final exam (class review) Flashcards
what is an intervention that a nurse should implement for a hospitalized child with autism spectrum disorder to help reduce anxiety and make the client feel more comfortable?
maintain the clients routine
Which personality disorder cluster would a fresh two-inch cut on arms and legs be indicative of?
cluster B
“wild”
How can the nurse best respond to a client with a personality disorder who is using defensive coping?
*deliver consequences in a matter-of-fact manner
- use positive reinforcement to encourage desired behaviors
- recognize that the behavior is unacceptable, instead of saying the client is unacceptable
what is a trademark of all personality disorders?
they are comfortable with their altered behaviors (they think that other people are the ones who have something wrong)
How would someone with avoidant personality disorder receive a compliment?
fear rejection and humiliation afterwards
which personality disorder is implicated by a client who is dramatic, attention seeking, and seductive?
histrionic
How may a client with obsessive compulsive personality disorder respond to nurses alternating weekend shifts?
“you can’t just make these kinds of changes? what about rules?”
rule driven
how should the nurse reinforce positive behaviors in a client with borderline personality disorder?
give unit privileges for positive behaviors
what intervention should be made for a client with paranoid personality disorder who becomes very violent?
use clear, calm statements and a confident stance
what should a nurse say to a client who has antisocial personality disorder who exhibits angry outbursts?
“during group , you raised your voice and slammed the door”
- state facts without accusation
why do patients with schizoid personality disorder exhibit self isolation?
due to an inability to relate to others
what are the cluster A personality disorders?
weird
- schizoid, paranoid, schizotypal
what communication technique should be used for a client with intellectual disability disorder?
provide simple directions and praise independence
what is an appropriate step for a client who is having opioid toxication?
administer naloxone
A recovering alcoholic patient who is using medication to promote abstinence presents with headaches, tachycardia, flushing, and dyspnea after a glass of wine; what do you suspect is happening?
a disulfiram reaction
what are expected symptoms during alcohol detoxification?
- tremors
- delirium
- hypertension
- hyperactivity
what is the beginning step for a client to become successful in an alcohol recovery process?
they are able to correlate alcohol use with stress (what emotions/factors led to them drinking)
what is a priority nursing intervention during the first 24 hr of a client’s alcohol detoxification?
administering benzodiazepines; chlordiazepoxide due to risk for seizures
how should a nurse best respond to a client who has antisocial personality disorder who is spitting, cursing and refusing to answer questions?
recognize that you understand they are upset but behavior is not tolerated
-“I understand, but this will not be tolerated”
describe an example of tangentiality?
a client with schizophrenia is unable to stay focused on the topic of discussion
- never gets to main point
what is expected during the prodromal stage of schizophrenia?
significant deterioration of function
What would be indicated for a client who has complicated grief but states, “I started exercising to release tension?”
resolution of grief
- they have return to usual function
What is an appropriate goal for a client who has anorexia nervosa?
they can verbalize adequate nutritional intake in 2 weeks
what client education should be given for bulimia nervosa?
- purging can leas to tooth loss
- laxatives can cause dehydration
- depressed mood follows binging behavior
If a client who is grieving reports feelings of worthlessness, what would this indicate?
maladaptive grieving
describe a cognitive approach to fear.
ex. client refuses to go on vacation due to fear of cruise ship sinking
distorted and unrealistic appraisals of the situation
what dietary intake education should the nurse give a client taking lithium?
maintain a normal salt intake
why may oxygen therapy be used after ECT?
to prevent anoxia
- paralytic agent given may decrease SpO2
what is an example of flooding in the treatment of a phobia?
accompanying a client with arachnophobia to an exhibit full of spiders
what should the nurse do if a client scores as a 1 on a CAGE assessment?
further assess the client
what lab should be obtained before diagnosing a geriatric client with mild depression and anxiety?
CMP (complete metabolic panel)
what parameters should be monitored for a client recently admitted for benzodiazepine withdrawal?
blood pressure, fall risk score, duration of seizures
A client says they take “sleeping pills” and drinks a quart of vodka a day, what 2 assessments should be performed?
- urine drug screen
- CAGE questionnaire
what is seen with borderline personality disorder?
- self harm/ body mutilation
- difficulty with interpersonal relationships
which personality disorder has a preference for company of animals over people?
schizoid personality disorder
which personality disorder has a disregard for the rights of others?
antisocial personality diosrder
what is a trademark of narcissistic personality disorder?
grandiose perception of self
what baseline test should be anticipated for a client who is prescribed a CNS stimulant for treatment of ADHD in pediatric patients?
electrocardiogram
methylphenidate
what risk is associated to decreased appetite that may be seen in those taking methylphenidate?
nutritional deficits
what are 3 interventions that should be implemented for a client with ADHD?
- break large tasks into smaller goals
- provide a safe environment
- hold meds when not enrolled in school
what type of client would benefit from providing memory aids to maintain orientation and promote recognition?
diagnosis of neurocognitive disorder
what would indicate development of delirium after surgery?
changes that came on very quickly
what should a nurse assess in a client who states, “I have difficulty finding food and shelter since losing my job?”
the client’s access to care
what diagnosis is suspected with the following these cues?
- more common in males
- may resist minor changes in environment
- impairment in social interaction
- genes are linked to schizophrenia
ASD (autism spectrum disorder)
what does domestic violence increase a client’s risk for?
homelessness
what percentage of the homeless population has a comorbid mental illness?
33%
what is a priority action for a 35 yr old client who has schizophrenia and has been non-compliant with their meds?
complete a mental status examination
what does a CAGE assessment score of 1 indicate?
the client needs further assessment
What does CAGE stand for?
Cut down
Annoyed
Guilty
Eye-opener
what lab should be reviewed prior to diagnosing a geriatric client with mild depression and anxiety?
CMP (complete metabolic panel)
what 3 parameters should a nurse monitor for an elderly client who has recently been admitted for benzodiazepine withdrawal?
- duration of seizures
- blood pressure
- fall risk score
what are 4 behaviors that may be seen of a child of a military parent?
- failure to thrive
- sleep disturbances
- substance/alcohol misuse
- regressive behaviors
what is a factor impeding/delaying diagnosis of a pediatric mental health client?
acceptable behaviors vary with client age
what is a characteristic of conduct disorder?
lack of remorse
what should the nurse tell the parent of a pediatric client about atomoxetine?
use a digital scale to weigh weekly
what education should be provided for a pediatric patient taking methylphenidate?
- administer before 4pm
- avoid caffeine
- may cause growth suppression
- give with/after breakfast
what may be seen in a pediatric client experiencing PTSD regarding their interaction with sibling?
irritable with sibling
what behavior manifestation may be observed with a pediatric client who has reactive attachment disorder?
- rarely seeks comfort when distressed
which disorder would be implicated for a pediatric client who experiences excessive anxiety when separated from a parent?
separation anxiety disorder
what would this indicate:
- pediatric client has the ability to appropriately interpret reality?
the client is in good mental health
what finding would indicate the pediatric client may have a depressive disorder?
daily irritability
What is a simple intervention for a pediatric client with ADHD?
walking outdoors
what would be an example of a client with dependant personality disorder?
adult client who lives with parents and has no car
which 2 personality disorder are most likely to be encountered in a psych setting?
borderline and antiscoial
what nursing intervention is appropriate for violation of a “no physical contact” restriction?
clarify limits and communicate consequences of continuing actions
