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Schizophrenia: Withdrawn behavior, paranoia, alteration in speech, hallucinations, delusions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
