Mental Health

Question 1

Personality disorders: Cluster A

Answer 1

paranoid, schizoid, schizotypal

Question 2

Personality disorders: cluster B

Answer 2

Antisocial, borderline, narcissistic, histrionic

Question 3

Personality disorders: Cluster C

Answer 3

Dependent, obsessive-compulsive, avoidant

Question 4

Nursing interventions: Paranoid

Answer 4

avoid being too nice or too friendly; give clear explanations; warn about changes in tx plan and explain reasons for delay

Question 5

Nursing interventions: schizoid

Answer 5

not impacted by approval or rejection of others; do not try to increase socialization

Question 6

Nursing interventions: schizotypal (may exhibit extreme anxiety in social situations r/t severe social and interpersonal deficits

Answer 6

Respect client’s need for social isolation; be aware of client’s suspicious behavior; be aware that superstition and magical thinking is common

Question 7

Nursing interventions: antisocial

Answer 7

be aware of and assess for substance abuse; set clear limits on specific behavior; be cautious of manipulation through guilt when client doesn’t get what he wants.

Question 8

Nursing interventions: borderline

Answer 8

provide clear and consistent boundaries; use clear communication; review therapeutic goals and boundaries when behavior issues are evident; assess for self-manipulating behaviors.

Question 9

Nursing interventions: narcissistic

Answer 9

remain neutral and avoid power struggle; convey unassuming confidence

Question 10

Nursing interventions; histrionic

Answer 10

understand seductive behavior as a response to stress; assess for suicidal behavior if admiration is withdrawn; model concrete, descriptive vs. vague language.

Question 11

Nursing interventions: dependent

Answer 11

be aware of counter transference that can occur d/t client’s clinging behavior; identify current stresses; satisfy client’s needs when setting limits.

Question 12

Nursing interventions: obsessive-compulsive

Answer 12

guard against power struggles w/ client as need to control is high; assess for use of intellectualization, rationalization, and reaction formation as defense mechanisms; be aware of client’s critical nature toward self and others.

Question 13

Nursing interventions: Avoidant

Answer 13

maintain a friendly, accepting, reassuring approach; do not push client into social situations.

Question 14

signs of w/d with CNS depressants (alcohol, barbiturates, benzos)

Answer 14

N/V, tachycardia, diaphoresis, tremors, grand mal seizures, restlessness, irritability

Question 15

signs of w/d with CNS stimulants (cocaine, amphetamines, methamphetamines)

Answer 15

fatigue, depression, agitation, apathy, anxiety, craving, increased appetite.

Question 16

signs of w/d with opiates (heroin, meperidine, fentanyl, hydromorphone).

Answer 16

yawning, insomnia, panic, diaphoresis, cramps, N/V, chills, fever, diarrhea.

Question 17

Delirum vs. dementia

Answer 17

Delirium is characterized by disturbance of consciousness and change in cognition that develop over a SHORT period of time; whereas, Dementia is progressive deterioration of cognitive functioning and global impairment of intellect with no change in consciousness and has an onset of months to years.

Question 18

Characteristics of Severe Stage (Stage 3) alzheimers

Answer 18

losing ability to converse with others; assistance required for ADL’s, incontinence, losing awareness of ones’ envir’t, progressing difficulty with physical abilities, eventually losses all ability to move - can develop stupor and coma; death frequently r/t choking or infection.

Question 19

Characteristics of Stage 2 alzheimers (Moderate)

Answer 19

incontinence, can wander and get lost, changes in sleep patterns, difficulty performing tasks that require planning and organizing (pay bills, manage $)

Question 20

Nursing interventions for delirium

Answer 20

1. establish baseline LOC by interviewing family;
2. asses VS and do neuro checks
3. assess for acute onset and fluctuating LOC
4. assess ability to function in immediate env’t
5. determine physiologic reason delirium is occurring
6. maintain safety