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Passpoint Fundamentals Flashcards

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1
Q

Involuntary committed for depression & suicide ideation. When planning care, what legal parameters of care should the nurse be aware of

  1. Client is able to refuse meds
  2. Client is able to obtain release against medical advice
  3. Client needs a public guardian
  4. Client is considered to be incompetent
A
  1. Client is able to refuse meds

Competent clients have right to refuse meds. Even though involuntarily committed nothing in scenario indicates client is not competent.

A guardian will be provided by the court if found incompetent

Involuntarily admitted cannot obtain release

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2
Q

Client with somatization disorder has nausea problems. Past symptoms include back pain, chest pain, problems urination. Client states that nausea began when spouse asked for divorce.

Which is most appropriate

  1. Ask client to describe problem with nausea
  2. Directing client to describe feelings about impending divorce
  3. Allowing client to talk about HCP they seen & meds they have taken
  4. Informing client of different medications for nausea.
A
  1. Directing client to describe feelings about impending divorce

Focusing on feelings about impending divorce will decrease clients anxiety & physical aliments.

The other answers are Counter Productive, they reinforce the focus on the “somatoform” symptoms

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3
Q

Name the phases of the Therapeutic Nurse-Client relationship (Not in Sequential Order)

  1. Evaluate & Refine established goals
  2. Formulating contract, exploring feelings, establishing expectations about relationship
  3. Prepares for separation and explores clients feelings about end of the relationship
A

Working
1. Evaluate & Refine established goals

Orientation
2. Formulating contract, exploring feelings, establishing expectations about relationship

Termination
3. Prepares for separation and explores clients feelings about end of the relationship

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4
Q

Short stature

Whole body: high blood pressure or osteoporosis

Heart: congenital heart defect or narrowing of the aorta

Mouth: failure of teeth to develop normally or abnormally raised roof of the mouth

Also common: absence of menstruation, dysplastic nail, female infertility, recurrent ear infections, widely spaced nipples, celiac disease, elbow deformity, hearing loss, increased number of moles, kidney malformation, obesity, puffy hands and feet at birth, scoliosis, underactive thyroid, vision disorder, or webbed neck

Name Syndrome & Interventions

A

Turners syndrome

Treatment: HGH & Estrogen therapy

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5
Q

Define
Refractive errors

Strabismus

amblyopia

(ptosis)

A

Refractive errors = near / far sightedness
strabismus = cross eyes
Amblyopia = lazy eye
Ptosis = Drooping eye lid

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6
Q

Client with Buerger’s disease smokes 2 packs a day. When helping the client change smoking behavior, the nurse should understand what about the clients needs?

  1. Ability to attend support groups
  2. Goals of treatment
  3. Perception of the negative behavior
  4. Motivation
A
  1. Perception of the negative behavior

1st learn how client perceives situation or problem.

Client is more likely to change behavior if they realize there is a problem.

Other options valid but come after understanding clients perception of the problem

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7
Q

Client with persistent depression is undecided about undergoing ECT, clients familia ask Nurse to convince client that treatment would be helpful.

In education of the family, which statement about clients rights should the nurse make?

  1. I recommend the family obtain legal counsel
  2. The client, family, & treatment team can meet to discuss treatment options
  3. If client declines treatment after learning pros & cons, there is a form to sign
  4. You must make the client aware of the moral aspect of refusing treatment
A
  1. The client, family, & treatment team can meet to discuss treatment options

When a client is undecided about treatment best solution is to have meeting with patient, family, care team.

Client has right to refuse & no need for legal counsel or Signing Refusal Form

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8
Q

Nurses self disclosure (talking about themselves-related to clients medical problem) should be brief, vague, and to the point, so that the focus can be shifted back onto the clients experience.

T or F

A

True

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9
Q

Most important to evaluate the understanding in a discharged patient with a lobectomy

  1. Support available at home
  2. Distance client lives from hospital
  3. Ability to do home BP monitoring
  4. Knowledge of causes of lung cancer
A

Support available at home

Essential to evaluate support they have at home

No data supporting BP monitoring

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10
Q

Client vulnerable to panic attacks has RR 28 & HR 110. Best first action

  1. STAT cardiac monitoring
  2. Coach on performing slow, deep breaths
  3. Administer antianxiety meds
  4. Performance of focused resp assessment
A
  1. Coach on performing slow, deep breaths

This may immediately help situation.

Always start with least invasive intervention first.

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11
Q

Treats depression, panic, social anxiety, and bipolar disorder.

Examples:
isocarboxazid
phenelzine
selegiline
tranylcypromine

Name type of medication

SE & Serious side effects

Contradictions

How long does it take to be effective

A

SE: Dry mouth, insomnia, Sexual Dysfunction, Weight gain, Nausea

Serious SE:
Hypertensive Crisis ( taken with Tyramine)
Serotonin syndrome (OD, Combine with SSRI, Starting new med)
Liver Damage
Suicide

Contradictions:

Tyramine rich foods: Aged cheese, Fermented Foods, Alcohol, Nuts, Pickled, Soy (Hypertensive Crisis)

Pheochromocytoma - A rare tumor of the adrenal glands that can lead to high blood pressure.

Liver disease

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12
Q

OCD client complains that night light wasn’t used during the previous evening shift. What is the best course of action

  1. Document & make a incident report
  2. Instruct night nurse to more carefully follow care plan
  3. Place sign at end of bed stating clients needs for night light
  4. Ask the previous night nurse about the experience of caring for the client the previous night.
A
  1. Ask the previous night nurse about the experience of caring for the client the previous night.

The dialogue will create a collaborative communication - creating healthier work environment

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13
Q

Diagnosis Functional Neurological Symptom Disorder. Occurred after witnessing a beating. What action should the nurse initially focus on when planning client care.

  1. Help client ID and verbalize feelings about the incident
  2. Helping the client ID stressors or psychological conflicts
  3. Teaching client to deal with any limitations of paralysis
  4. Exploring personal relationships that maybe related to the paralysis
A
  1. Help client ID and verbalize feelings about the incident

Functional Neurological Symptom Disorder- Clientnl represses and converts emotional conflicts into motor, sensory, or visceral Symptoms with No physiological cause

All interventions are correct but

First client needs to express feelings- reduce anxiety & anger

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14
Q

First question for a nurse to ask a client who suffers from anxiety attacks in effort to learn how they can help the client?

  1. Have you tried walking to ease anxiety
  2. What are you thinking about before anxiety attack starts
  3. Do you think taking slow deep breaths may help
  4. What do you do when anxious to feel better
A
  1. What are you thinking about before anxiety attack starts

To help client nurses understand triggers to anxiety attacks to prevent them.

Then assess coping strategies

Then educate Then regarding adaptive coping

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15
Q

Newly admitted client with OCD. Is it ever appropriate to allow them to do their rituals?

A

Yes, not allowing them to preform rituals will cause great anxiety

Initially allow them to preform full rituals but gradually limit time allowed.

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16
Q

Buspirone 5mg 3qDaily is prescribed for anxiety. Which medication would be Contradicted.

Beta-blockers
Antineoplastic
Antiparkinsonian
MAOI

A

MAOI

Buspirone (BusBar) is an anxiolytic (antianxiety) medication that isn’t a Benzodiazepine.

It will react with MAOI & cause Hypertensive Crisis

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17
Q

Buspirone dosage / use

A

Install 5 mg 3qDaily

Increase to 15 - 30 mg 2/3qDaily

Max 60mg

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18
Q

Agoraphobia without panic disorder. Type of therapy would nurse expect to see in plan of care.

  1. Insight
  2. Group
  3. Behavior
  4. Psychoanalysis
A
  1. Behavior (Most effective in treating phobias)

Includes: Systematic desensition, flooding, exposure, self-exposure.

Insight: how past experiences shapped their mental problems

Group: Social skills, Eating disorders, Gambling, Drugs, Greif, Self-Esteem, Isolation

Psychoanalysis: Depression, Personality disorders, relationship

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19
Q

PTSD hears loud boom come from a car during an interview and jumps onto a chair, wide eyed and frantic. Which is most therapeutic response

  1. Loud noises cause you to become very upset
  2. Take my hand I will help you down
  3. Have you experienced this kind of thing before
  4. What kinds of feelings are you experiencing?
A
  1. What kinds of feelings are you experiencing?

Response is out of proportion with the situation. Characteristic of PTSD, reliving a traumatic event.

Asking what they are experiencing provides opportunity for therapeutic ventilation of emotions allowing client to express triggered feelings.

Offering to help client down from chair doesn’t address clients current personal reality

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20
Q

Client spends several hours daily organizing the closet. What term is used to describe this behavior

  1. Obsession
  2. Compulsion
  3. Exhibitionism
  4. Transference
A
  1. Compulsion
    (Performing repetitive behaviors that interfers with ADL, relieves anxiety that occurs when action is not performed. )

Obsession = recurrent / intrusive thought.

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21
Q

___ is the process of projecting ones feelings and thoughts onto the therapist, who symbolically represents a significant person from the clients past

A

Transference

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22
Q

OCD receiving cognitive behavioral therapy. Which describes cognitive behavioral therapy?

  1. I’m learning to manage my behavior by being gradually exposed to increasingly fearful situations
  2. I’m working on changing my thinking and behavior to be more realistic and reduce my fears and anxieties
  3. I’m learning that my underlying beliefs are unreasonable and need to be changed
  4. Whenever I don’t engage in compulsive behavior I reward myself
A
  1. I’m working on changing my thinking and behavior to be more realistic and reduce my fears and anxieties

Not

  1. I’m learning to manage my behavior by being gradually exposed to increasingly fearful situations
    (Systematic desensition)
  2. I’m learning that my underlying beliefs are unreasonable and need to be changed (Rational Emotive Therapy)
  3. Whenever I don’t engage in compulsive behavior I reward myself
    (Operant conditioning)
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23
Q

Vaginismus is….

Causes…

A

Involuntary muscle spasm interferes with intercourse

Pain with attempts at sex.

Causes: Fear / Sexual Abuse

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24
Q

The following are risk factors for…

Severe anhedonia (What does anhedonia mean?)

Hopeless
Medical illness
Male
White / Native American
Living alone
>60 older
Unemployed
Financial distress
Previous suicide attempts

A

Suicide

Anhedonia = loss of ability to feel pleasure

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25
Q

What are the following herbs used for

St. Johns Wort
Ginko biloba
Echinacea
Ephedra

A

St. Johns Wort: Depression
Ginko biloba: Mental Acuity
Echinacea: Immune System
Ephedra: Ephedrine-like properties

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26
Q

Carbamazepine

Class

Use

SE

Contradictions

A

Anticonvulsant (antiepileptic)
Mood stabilizer

Uses:

Epilepsy (partial seizures, generalized tonic-clonic seizures)
Bipolar disorder (manic and mixed episodes)
Trigeminal neuralgia (nerve pain)
Certain types of neuropathic pain

SE

Aplastic anemia or agranulocytosis (severe blood disorders)

Stevens-Johnson syndrome (severe skin reaction)

Liver toxicity (hepatitis, jaundice)

Severe allergic reactions (e.g., swelling, difficulty breathing)

Hyponatremia (low sodium levels)

Suicidal thoughts or behavior

Contradictions

History of bone marrow suppression or blood disorders

Severe liver impairment

MAOIs

Pregnancy (Esp 1st trimester)

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27
Q

Aplastic anemia is….

A

Auto Immune disorder

Bone marrow fails to produce sufficient blood cells. All 3 types

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28
Q

Difference between mood & affect

A

Mood = what client tells you they are feeling

Affect = what you see the client feeling

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29
Q

Phenelzine (Nardil)
Tranylcypromine (Parnate)
Isocarboxazid (Marplan)
Selegiline (Eldepryl, Zelapar)

Are this type of medication

They may lower BS, which intervention would the nurse perform?

A

MAOIs

Check bs often

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30
Q

Ataxia

A

Impaired balance or coordination, can be due to damage to brain, nerves, or muscles.

31
Q

Which do MAOI’s cause
Hypotension Or Hypertension

A

Both

Hypotension is common

Hypertensive Crisis can happen when mixing medication: Levodopa

32
Q

Duloxetine hydrochloride

Class, Use, SE & Contradictions

A

Serotonin-norepinephrine reuptake inhibitor (SNRI)

Uses:

Major depressive disorder (MDD)
Generalized anxiety disorder (GAD)
Diabetic peripheral neuropathic pain
Fibromyalgia
Chronic musculoskeletal pain
Side Effects:

Nausea
Dry mouth
Drowsiness or insomnia
Dizziness
Fatigue
Constipation
Loss of appetite
Sweating

Serious Side Effects:

Suicidal thoughts or behavior, especially in younger patients

Serotonin Syndrome

Hypertension

Contradictions

MAOI
Liver / Renal Impairment
Uncontrolled narrow angle glaucoma

List

Desvenlafaxine (Khedezla®, Pristiq®).
Duloxetine (Cymbalta®, Drizalma®, Irenka®).
Levomilnacipran (Fetzima®).
Milnacipran (Savella®).
Venlafaxine (Effexor®).

33
Q

Safe level of Lithium carbonate

A

0.6 - 1.2

34
Q

Which is associated with Lithium Toxicity >1.6

Black tongue
Increased tearing
Constipation
Persistent gi upset

A

Persistent gi upset (mild - moderate)

Black tongue is associated with mirtazapine (Remeron)

Diarrhea is more common than Constipation

35
Q

Lithium

Class, use, SE, Contradictions, Special Precautions

A

Class:

Mood stabilizer
Uses:

Acute mania in bipolar disorder

Maintenance treatment for bipolar disorder to prevent manic and depressive episodes

Major depressive disorder when other treatments are not effective

SE

Lithium toxicity (symptoms include severe tremors, confusion, muscle twitching, and seizures)
Renal impairment (kidney damage)
Thyroid dysfunction (e.g., hypothyroidism)
Electrolyte imbalances (e.g., low sodium levels)
Cardiac issues (e.g., arrhythmias)
Severe gastrointestinal symptoms

Contraindications:

Severe renal impairment

Severe cardiovascular disease

Known hypersensitivity to lithium

Significant dehydration or electrolyte imbalances

Pregnancy (particularly in the first trimester, due to potential fetal risk; use with caution and under close supervision)

Special precautions: Blood Level monitoring 0.5 - 2 Therapeutic, >2 toxic,

36
Q

Mirtazapine Class,Use, SE, Contradictions, Other Medications in this class

A

Class:

Noradrenergic and specific serotonergic antidepressant (NaSSA)
Uses:

Major depressive disorder (MDD)
Sometimes used off-label for anxiety disorders and insomnia

Side Effects:

Common:
Drowsiness or sedation
Weight gain
Increased appetite
Dry mouth
Constipation
Dizziness

Serious SE
Suicidal thoughts or behavior, particularly in younger patients
Severe allergic reactions (e.g., rash, itching, swelling)
Agranulocytosis (severe drop in white blood cells)
Serotonin syndrome (symptoms include agitation, hallucinations, fever, sweating, and tremor)
Liver toxicity (elevated liver enzymes, jaundice)

Contradictions
Hypersensitivity to mirtazapine or any component of the formulation
Concurrent use with monoamine oxidase inhibitors (MAOIs) or within 14 days of stopping MAOIs
Severe liver impairment

Other Medications in This Class:

Trazodone (Desyrel)
Nefazodone (Serzone)
Vilazodone (Viibryd)

37
Q

Providing care for first stage of Alzheimer’s the nurses priority is.

  1. Offering nourishing finger foods
  2. Providing emotional support and individual counseling
  3. Monitoring client to prevent minor illness from turning into major problems
  4. Suggesting new activities for client and family to enjoy together
A

Providing emotional support & counseling

The other answers are appropriate for 2nd stage of Alzheimer’s

38
Q

Schizophrenic in a catatonic state. Clients arm remains outstretched after nurse obtains pulse & BP. The client is exhibiting:

  1. Suggestibility
  2. Negativity
  3. Waxy flexibility
  4. Retardation
A
  1. Waxy flexibility

Waxy flexibility (ability to remain in a awkward posistion until reposisioned) seen in Schizophrenics in a catatonic state.

Negativity = resistance to being moved

Retardation = Slowed movements

39
Q

Client had auditory hallucinations for the past 2 weeks. Today they are free from the hallucinations. What is the nursing priority

  1. Client anxiety levels throughout the day
  2. Compliance with medications over past 6 months
  3. Characteristics and tone of last hallucinations
  4. Deficit in cognitive function
A
  1. Client anxiety levels throughout the day

Increases anxiety can trigger hallucinations

40
Q

Schizophrenic reports hearing voices of dead parents. Nurse recommends

  1. Sit in silent, dark room and concentrate on the voices
  2. Listen to a personal radio and sing along with the music
  3. Call a friend and discuss the voices and feelings towards then
  4. Engage in exercise
A
  1. Listen to a personal radio and sing along with the music

Audiotry stimulation will help to focus on external sounds

41
Q

Define: myalgia

A

Pain in muscle or group of muscles

42
Q

Akathisia

A

Agitation side-effect of antipsychotic and antidepressant drugs.

43
Q

Dystonia

A

state of abnormal muscle tone resulting in muscular spasm and abnormal posture, typically due to neurological disease or a side effect of drug therapy.

44
Q

Buccolingual stereotypy

A

repetitive movements of your mouth TD

45
Q

Myoclonus

A

spasmodic jerky contraction of groups of muscles.

46
Q

Chorea

A

neurological disorder characterized by spasmodic involuntary movements of the limbs or facial muscles.

47
Q

Long-term exposure to first and second-generation neuroleptics, certain antidepressants, lithium, and some antiemetic medications.

Symptoms stiff, jerky movements of your face and body that you can’t control.

Name disease

A

Tardative dyskinesia TD

48
Q

Lithium toxicity can cause interstitial nephritis, arrhythmia, sick sinus syndrome, hypotension, T wave abnormalities, and bradycardia.

Rarely, toxicity can cause pseudotumor cerebri and seizures.

Describe Interstitial nephritis

What is Lithium’s antidote

A

Lithium has no antidote

Interstitial nephritis:

Interstitial nephritis can cause mild to severe kidney problems, including acute kidney failure. In about half of cases, people will have decreased urine output and other signs of acute kidney failure.

Symptoms of this condition may include:

Blood in the urine
Fever
Increased or decreased urine output
Mental status changes (drowsiness, confusion, coma)
Nausea, vomiting
Rash
Swelling of any area of body
Weight gain (from retaining fluid)

Treatment:

Limiting Salt & Fluid
Dialysis
Corticosteroids

49
Q

False personal beliefs a symptom of schizophrenia is

Hallucinations or Delusion

A

Delusion

50
Q

Client hears voices from the television talking to them. They now are thinking about quitting their job. Which action to take first.

  1. Obtain information about medication compliance
  2. Remind client that hearing voices is a symptom of their illness and they can cope with this.
  3. Check with employer about their work performance
  4. Arrange for client to be admitted to psych hospital for short stay.
A
  1. Med compliance

Symptoms of schizophrenia occur with nonmed compliance.

Helping recognize the symptoms is important but not the firs4 step

51
Q
A

Atypical Antipsychotic
Uses
Treatment-resistant schizophrenia: Used when other antipsychotic medications have failed.
Reduction of suicidal behavior: In patients with schizophrenia or schizoaffective disorder.

Side Effects
Common Side Effects:
Sedation
Weight gain
Hypersalivation (excessive saliva production)

52
Q

Which is characteristic of Delirium

  1. Disturbances in cognition and consciousness that fluctuate during the day.
  2. Failure to ID objects despite intact sensory function
  3. Impairment in social or occupational function over time
  4. Memory Impairment to the degree of being called amnesia
A
  1. Disturbances in cognition and consciousness that fluctuate during the day. (In addition to onset of hours to days) = classic delirium

Other options indicate dementia, not delirium

53
Q

Depressed client was pacing around the day room quickly, swinging arms, and rubbing hands together.

What term describes these behaviors

A

Psychomotor agitation

54
Q

Difference between

Echopraxia & Echolalia

A

Echopraxia = mimicking gestestures

Echolalia = mimicking words (Parroting)

55
Q

Client with schizophrenia spends most of the morning in their room but during the afternoon they stand by nurses station for conversation.
Which goal is most appropriate

  1. Participation in community meeting
  2. Volunteer to organize an evening of games with his peers
  3. Helping put a puzzle together
  4. Engaging 3 of his peers in a card game
A
  1. Helping put a puzzle together

A one-on-one basis will help a client with suspicious, fearful, and withdrawn ways

56
Q

Bipolar clients states : I’m the special messenger of the Messiah and I need to be sacrificed to save the world. Which is the first action

  1. Admin oral antipsychotic
  2. Ask family member to stay with client
  3. Institute suicide precautions
  4. Encourage client to talk about suicide plan.
A
  1. Institute suicide precautions

Safety first.

Then worry about the other things

Obvious family cannot stay with him as a fix to the problem

57
Q

Which is typical of schizotypical personality disorder

  1. Aggressive
  2. Paranoid
  3. Emotional
  4. Independence needs
A
  1. Paranoid

Social anxiety leads to paranoid thoughts.

Emotionally cold with flattened effects

58
Q

Client is banging head against the wall. Why is it incorrect to immediately call the crisis team to intervene?

A

The client isn’t attacking staff or other clients.

First, try verbal deescalate techniques

59
Q

Client tells nurse that earth will be invaded by people from Mars.
Best response

  1. That must be frightening, can you tell me how you feel about it.
  2. There are no people living on Mars
  3. What do you mean when you say they are going to invade?
  4. I know you believe that earth is going to be invaded, but I don’t believe that
A
  1. That must be frightening, can you tell me how you feel about it.

Addresses underlying fears without feeding the delusion.

Vocalizing disbelief won’t help client deal with underlying fears

60
Q

Client has arching back, extension and rotation of neck, slow involuntary contractions of arms & neck. Which med is this associated with

Benztropine
Pantoprazole
Propranolol
Haloperidol

A

Haloperidol

These symptoms are associated with Dystonia- common adverse side effect of antipsychotic medications - such as Haloperidol.

Benztropine = antiparkinsons
Pantoprazole = antiulcer

61
Q

Desvenlafaxine
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
Levomilnacipran
Milnacipran

This type of medication

A
62
Q

Client diagnosed with severe depression is given bupropion. 48 hrs later client is singing, dancing, and laughing. How should this behavior be interpreted

  1. Medication was therapeutic
  2. Client is acting like this to be discharged.
  3. Client is most likely bipolar, rather than depressed
  4. Unusual SE of medication
A
  1. Client is most likely bipolar, rather than depressed

This behavior is seen in bipolar clients when given an antidepressant.

They need a mood stabilizer (Lithium or lamotrigine)

63
Q

Which are characteristics of schizophrenia

  1. Loose associations, grandiose delusions, auditory hallucinations
  2. Periods of hyperactivity and irritability alternating with depression
  3. Delusion of jealousy and persecution, and mistrust
  4. Sadness, apathy, feeling of worthlessness, Anorexia, weight loss
A
  1. Loose associations, grandiose delusions, auditory hallucinations
    (Can’t take care of themselves, ramble from one topic to the next)

Hyperactive & alternating depression = bipolar bear

Delusions of jealousy, persecution and mistrust = paranoid disorder

64
Q

xerostomia

Seen with Tri cyclic antidepressants

A

Dry mouth

65
Q

Extrapyramidal side effects (EPS), AKA drug-induced movement disorders, are involuntary movements caused by dopamine-blocking medications, such as antipsychotics.

Akathisia…

Dystonia…

Parkinsonism….

Tardive dyskinesia….

A

Akathisia
A feeling of restlessness, like you can’t sit still, and the urge to fidget, tap your fingers, or jiggle your legs

Dystonia
Involuntary muscle contractions that can be painful

Parkinsonism
Symptoms similar to Parkinson’s disease, such as tremors, difficulty speaking or finishing thoughts, and stiff facial muscles

Tardive dyskinesia
A rare but potentially irreversible side effect that can occur during long-term therapy or after stopping the drug. Symptoms include involuntary tongue protrusion, puffing of the cheeks, and chewing or puckering of the mouth

66
Q

Malignant catatonia, Withdrawn catatonia, Akinetic catatonia, Excited catatonia, Stuporous catatonia

The most common type, where patients may appear non-responsive and stare blankly

Patients may move in an impulsive or pointless way, and may appear agitated or delirious. They may also mimic the movements of someone who’s trying to help them.

A dangerous type that can develop rapidly, and can lead to other health problems like dangerous changes in breathing, heart rate, body temperature, or blood pressure.

Patients may seem slow, with trouble moving, talking, staring, or getting “stuck” in positions.

Patients may have very limited responses or no response at all to what’s happening around them.

A

Akinetic catatonia

The most common type, where patients may appear non-responsive and stare blankly

Excited catatonia

Patients may move in an impulsive or pointless way, and may appear agitated or delirious.They may also mimic the movements of someone who’s trying to help them.

Malignant catatonia

A dangerous type that can develop rapidly, and can lead to other health problems like dangerous changes in breathing, heart rate, body temperature, or blood pressure.

Stuporous catatonia

Patients may seem slow, with trouble moving, talking, staring, or getting “stuck” in positions.

Withdrawn catatonia

Patients may have very limited responses or no response at all to what’s happening around them.

67
Q

Neoplasm

A

a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer.

68
Q

The CAGE (Cut down, Annoyed, Guilty, Eye-opener) score is a screening tool that helps identify people with alcohol problems. The score is calculated by adding together the responses to four questions, with each response worth 0 points for “no” and 1 point for “yes”:

Have you ever felt you needed to cut down on your drinking?

Have people annoyed you by criticizing your drinking?

Have you ever felt guilty about drinking?

Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover?

What score is considered a need for further assessment

A

2

69
Q

The CAGE (Cut down, Annoyed, Guilty, Eye-opener) score is a screening tool that helps identify people with alcohol problems. The score is calculated by adding together the responses to four questions, with each response worth 0 points for “no” and 1 point for “yes”:

Have you ever felt you needed to cut down on your drinking?

Have people annoyed you by criticizing your drinking?

Have you ever felt guilty about drinking?

Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover?

What score is considered a need for further assessment

A

2

70
Q

asterixis

A

Flapping hands tremor

Not actually a tremor but a negative myoclonus

71
Q

The half-life of naloxone in adults is _____

The patient should have vital signs, including pulse oximetry, monitored until obtaining a full recovery.

A

30 to 80 minutes

72
Q

The feeling of bugs crawling under the skin is termed as _______, and is associated with cocaine use.

A

formication

73
Q

Client states: My heart has stopped and my blood has turnes to black ash. The nurse interprets this statement to be evidence of which problemas

  1. Hallucinations
  2. Illusion
  3. Delusion
  4. Paranoia
A

Delusion

Delusion is a firm-fixed, false belief that is resistant to change, even when presented with facts.

Hallucinations = false sensory perception unrelated to external stimulus

Illusion is misinterpretation of a real sensory stimulus

NCLEX Psych (2 decks)

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