Proctored Review Flashcards
What are some findings that are consistent with mania and schizophrenia?
Mania: Marked increased activity and elevated mood.
Schizophrenia: Withdrawn behavior, paranoia, alteration in speech, hallucinations, delusions
A client comes into the unit with persecutory hallucinations and delusions. What is the nurse’s priority action?
Hallucinations before delusions. If a client has hallucinations that tell them to hurt a someone safety becomes a priority. Delusion intervention can happen later.
What are some expected interventions for a client that is experiencing hallucinations and delusions?
In a client with hallucinations and delusions, it is expected to use reality-based interventions, decrease external stimuli, administer an antipsychotic, and encourage the client to listen to music.
What labs are important to check for a patient that is currently taking clozapine?
Check neutrophil counts when patient is on clozapine
A nurse is conducting an AIMS test for a patient taking anti-psychotic medication. Why is the nurse conducting this test?
AIMS test checks for EPS symptoms
During the orientation phase of a patient with hallucinations, what is the nurse’s priority during this phase?
During the orientation phase, the nurse should first assess the patient’s belief and reasoning for therapy.
What is a sign of a patient with schizophrenia experiencing relapse?
If the patient stops attending social events, this could be a sign of relapse.
If a patient is undergoing TMS, what is an adverse effect that the nurse should watch out for?
Seizures are an uncommon adverse effect of TMS
If a child is taking methylphenidate IR, what are some adverse effects of this medication?
Appetite suppression. This can stunt growth, especially in children.
A dementia patient states that they can’t remember how to brush their teeth. What kind of symptoms are they showing?
Cognitive Symptoms.
A nurse finds that their patient with MDD has fallen silent during conversation. The nurse sits with the patient silently. What is the purpose of this type of therapeutic communication?
This therapeutic communication allows the client time to formulate their thoughts and expressions.
A patient with ADHD is administered lithium. What finding in the patient shows that the medication is effective?
When lithium is administered to a patient with ADHD, it is to reduce their aggression.
A nurse is assessing a patient with acute mania. Why would it be contraindicated to say that the patient is eating too much food?
A client with acute mania would be too distracted and stimulated to eat, that is why high protein finger foods is a priority intervention.
A patient with cognitive impairment states “It is 5:00 PM and I have to leave because my father is making dinner at this time.” A nurse responds, “It is 5:30 PM, and you are at the hospital. We will bring you dinner shortly.” Why is this response from the nurse not appropriate?
The nurse’s response is inappropriate because they do not validate the patient’s feelings. It is important to validate the patient’s feelings before reorienting them
At what stage of Alzheimer’s is a client unable to recognize family and friends?
Stage 4
A patient with schizophrenia is experiencing dysphoria. Would this be considered a positive or negative symptom of schizophrenia?
Positive. Dysphoria means that a patient is experiencing consistent dissatisfaction.
A nurse admits a patient with anorexia and has light skin. What finding is expected in the patient?
Lanugo, fine neonatal-like hair growth due to malnutrition
What is an indication of codependency in a patient that is suffering from alcohol abuse?
Patient states “I call my partner’s boss when she’s too drunk and can’t go to work.”
A client has manifestations of vegetative depression. What should the nurse include in the patient’s care plan?
Provide the client with decaffeinated beverages so that their sleep is not interrupted.
A nurse is caring for an elderly patient who makes a statement that indicates that they could be depressed. What is the nurse’s priority action?
Use the geriatric depression scale. This also applies to patients who are not geriatric
A patient is experiencing brief psychotic disorder, what manifestations are expected?
Disorganized speech, delusions, confusion, and hallucinations.
A client with PTSD is undergoing EMDR therapy. What is the purpose of this therapy?
EMDR therapy uses therapy to change the way that the client processes trauma
A nurse is working with a patient that has Borderline Personality Disorder. What would be the goal for the nurse during the working phase of the therapeutic relationship?
Facilitate change in the client’s behavior
A patient comes in stating that work is stressing her out too much, and she cannot control her blood pressure because of this. What should the nurse instruct the client to do?
Improve her ability to cope with stressors.
A nurse has a patient with a neurocognitive disorder who consistently wanders around at night. What is the priority intervention to keep this patient safe?
Keep the client’s mattress on the floor.
A nurse finds a patient with borderline personality disorder cutting themselves with a paper clip. After administering first aid, what is the nurse’s priority?
Identify the client’s feelings that encourage the self harm.
What is the least restrictive intervention for a patient who is pacing around and agitated?
Decrease external stimuli
What should a nurse expect in a client with MDD?
The nurse should expect difficulty sleeping, inability to concentrate, indecisiveness, lack of personal hygiene, and anhedonia
A client has just undergone ECT therapy. What information should the client include for patient?
The client will wake up 15 minutes after the procedure and can be disoriented for several hours afterwards.
A client is screaming that they’re going to die and that they’re having a heart attack. What is the patient’s panic level?
This patient is suffering from panic. If it was severe, they would not be able to focus on anything else aside from relieving their anxiety.
If a client with schizophrenia is hearing voices, what is the nurse’s priority?
Ask the patient what the voices are saying
What adverse reaction of tricyclic antidepressants should the nurse immediately try and rectify?
Urinary retention
A patient is taking alprazolam, what is an adverse effect of this medication that a nurse should watch out for?
The nurse should be wary of drowsiness. CNS depression
Depression and Anxiety share potential assessment findings: change in appetite, alteration in concentration, and sleep disturbance. What finding would you only find in anxiety disorder?
Sudden onset episodes of tachycardia, diaphoresis, nausea
What are some expected medications to prescribe for a patient who is suffering from a panic disorder?
Sertraline and Escitalopram (antidepressant medications that are also used to treat anxiety disorder), Lorazepam and Alprazolam (benzodiazepines)
A client with antisocial personality disorder uses manipulation to get what they want in the facility. What statement should the nurse make towards this client?
“Let’s review the consequences of your actions.”
A nurse sees that their patient is prescribed lithium. What can be expected in a patient that is taking lithium?
Patients on lithium are most likely to gain weight.
A nurse cares for a client who reminds them of someone they had a negative experience with. Because of this, the nurse starts to displace their negative feelings towards the client. What is this called?
Countertransference occurs when a nurse displaces negative or positive feelings about another person towards a client.
How should a nurse speak to a patient who is experiencing panic-level anxiety?
It is crucial to speak to a client that is experiencing panic-level anxiety by talking to clem firmly and authoritatively. It is important to protect the client from harmful or impulsive behavior, and speaking to them this way can help accomplish this goal.
What is a nonpharmacological stress-reduction therapy that activates the insular cortex and allows the client to focus on one thing?
Mindfulness engages the insular cortex as the person focuses on the sensations and surroundings of the present moment.
If a patient comes into the ED with injuries and the nurse suspects intimate partner violence, what is the nurse’s priority action?
Check the client’s injuries.
A nurse is caring for a client who has schizophrenia. They state that aliens came into their room last night. How should the nurse respond?
By saying, “That does not sound real.” This allows the nurse to express doubt, which will allow the patient to rethink their initial response.
A nurse is caring for a client with bipolar disorder who is experiencing mania. What is the nurse’s priority?
The nurse should determine if the client is a danger to themself.
What is it called when a group therapy session reenacts realistic situations to help process past events?
Psychodrama group
If a patient is taking tranylcypromine and they also have a prescription for sertraline, how would these medications react in the body?
Serotonin Syndrome
What should a nurse prioritize when caring for a patient that is taking valproic acid?
Monitor the client’s liver function
A client is taking buspirone, what is an adverse effect of this medication?
Xerostomia: dry mouth, nausea, headache, and insomnia
A client with bipolar disorder is taking lithium. What medication can be safely administered alongside lithium?
Valproic Acid. Both anti-seizure medications and lithium can be administered to patients with bipolar disorder.
What would a patient with histrionic disorder do?
Whispering in the provider’s ear. Tries to act provocatively and seductively.
A nurse is caring for a client with alcohol use disorder. What are some signs that the patient is going through alcohol withdrawal?
Insomnia or restlessness
A nurse is caring for a client with delirium, what item should the nurse provide to improve the patient’s cognitive function?
Wall Calendar
What findings are present in both schizophrenia and bipolar disorder? What findings are exclusive?
Speech pattern, though process, and hallucinations are both present in schizophrenia and bipolar disorder. However, bipolar disorder has an onset of findings.
A bipolar client is is having hallucinations that they are Poseidon. What is the nurse’s priority action?
Make sure that they are safe from injury that can be caused by their hallucinations.
A client is diagnosed with bipolar disorder. What are some expected interventions and what are some actions that are contraindicated?
Anticipated: Provide opportunities for rest periods throughout the day, use short and concise explanations, offer frequent, high-calorie foods
Contraindicated: apply restraints if client refuses to take scheduled medication, maintain high levels of stimulation in client’s environment, administer PRN medication for altered thought patterns.
What is the recommended patient education for someone with bipolar disorder getting discharged?
Take medication with meals, monitor blood levels, hand tremor is a sign of lithium toxicity, and diarrhea is a sign of lithium toxicity or dehydration that can lead to it.
How should a nurse respond to a patient that has insomnia?
“If you aren’t able to sleep, you can get out of bed and read a book.”
What should be the nurses first action when treating a patient that has come out of ECT treatment?
Administer oxygen because during preparation for ECT, patients take succinylcholine, which paralyzes their respiratory muscles.
What is an indication of severe alcohol withdrawal?
Hallucinations
A client has a new prescription of a benzodiazepine. What would be a contraindication found in the patient’s chart?
Benzodiazepines can increase the risk for severe hypotension.
A nurse is caring for a client with BPD and is pitting employees against each other. What should a nurse do to intervene?
Explore with the client his use of clinging and distancing behaviors. (Splitting)
A client is experiencing nausea, headache, and extreme thirst after taking disulfiram for alcohol aversion therapy. What is happening to this patient?
Mild acetaldehyde syndrome
What can be provided for a patient with dementia that can help them improve their level of orientation?
Large Calendar
A nurse is caring for a client, and they are 2 hours late on their day pass and return intoxicated. How should the nurse respond?
“We will discuss your actions once you’ve had a chance to sleep.”
A client is taking valproic acid. What should the nurse prioritize in this patient?
Liver should be consistently assessed while taking valproic acid.
A client reports that their injuries are the result of their partner hitting them. When offered information on shelters, the patient denies them and says that she can’t leave her kids. What is the appropriate response for the nurse?
What can you do to ensure your safety the next time this occurs?
A nurse restates a client’s statement that they are feeling lost at work by saying that “you must feel like you’re not getting things done?” What is this an example of?
Attempting to translate words into feelings
What are signs that a patient with antisocial personality disorder are improving?
Clients with antisocial disorder show improvement when they start to show empathy and also start to conform to rules. Signs that they are not improving include feeding their superiority complex as well as manipulating people using flattery.
A client is experiencing stimulant withdrawal. What can be expected from this ailment?
Depression is a manifestation of stimulant withdrawal.
