Psychiatric Flashcards
When a nurse is using restraints for an agitated/aggressive patient, which of the following items should NOT influence the nurse’s actions during this intervention?
1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.
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Strategy: Think about each answer choice.
(1) nurse should follow the policies of the institution
(2) must get written permission from the patient for restraints; if patient has been judged incompetent, permission is obtained from the legal guardian
(3) correct—the need for restraints is based on patient’s behavioral status and condition, not the patient’s voluntary/involuntary status
(4) must first try less restrictive means to control patient before using restraints
The nurse prepares to administer an injection of haloperidol decanoate (Haldol D) to a client. Which of the following actions by the nurse is MOST appropriate?
1. Massage the injection site. 2. Give deep IM in a large muscle mass. 3. Use a 2 inch 25 gauge needle. 4. Administer the medication in divided doses.
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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) should not be done because medication is very irritating to subcutaneous tissue
(2) correct—medication is very irritating to subcutaneous tissue
(3) should use a 2 inch 21 gauge needle
(4) should administer in single dose; patient should lie in recumbent position for one-half hour after administration of IM haloperidol decanoate
The nurse’s INITIAL priority when managing a physically assaultive client is which of the following?
1. Restrict the client to the room. 2. Place the client under one-to-one supervision. 3. Restore the client's self-control and prevent further loss of control. 4. Clear the immediate area of other clients to
prevent harm.
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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) time out or room restriction might be a useful strategy before the client becomes assaultive; once client is assaultive, he/she may continue this behavior in his/her room without any redirection and support
(2) may not stop assaultive behavior
(3) correct—most important priority in the nursing management of an assaultive client is to maintain milieu safety by restoring the client’s self-control; a quick assessment of situation, psychological intervention, chemical intervention, and possibly physical control are important when managing the physically assaultive client
(4) is helpful but may not be realistic if the situation escalates quickly
A client takes perphenazine (Trilafon) by mouth for 2 days and now displays the following: head turned to the side, neck arched at an angle, and stiffness and muscle spasms in neck. The nurse expects to give which of the following as a PRN medication?
1. Promazine (Sparine). 2. Biperiden (Akineton). 3. Thiothixene (Navane). 4. Haloperidol (Haldol).
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Strategy: Think about each answer choice.
(1) antipsychotic medication, would not relieve the side effects
(2) correct—antiparkinsonian agent, used to counteract extrapyramidal side effects the client is experiencing
(3) antipsychotic medication, would not relieve the side effects
(4) antipsychotic medication, would not relieve the side effects
A client takes perphenazine (Trilafon) by mouth for 2 days and now displays the following: head turned to the side, neck arched at an angle, and stiffness and muscle spasms in neck. What is this patient exhibiting?
Extrapyramidal symtoms
A client is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse identifies which of the following comments by the client is MOST indicative of this disorder?
1. "I keep having recurring nightmares." 2. "I have a headache, and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am, and I don't know where I live."
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Strategy: Think about each answer choice.
(1) posttraumatic stress disorder (PTSD) is characterized by anxiety and stress symptoms that occur after an intense traumatic event; characteristic symptoms are hypervigilance, insomnia, and recurring nightmares
(2) somatoform disorder (or hypochondria) is concerned with physical and emotional health, accompanied by various bodily complaints for which there is no physical basis
(3) reflects the compulsive checking behavior of the anxiety associated with obsessive-compulsive disorder
(4) correct—dissociative disorders characterized by either a sudden or a gradual disruption in the integrative functions of identity, memory, or consciousness; disruption may be transient or may become a well-established pattern; development of these disorders is often associated with exposure to a traumatic event
A client diagnosed with bipolar disorder receives haloperidol (Haldol) 2 mg PO tid. The client tells the nurse, “Milk is coming out of my breasts.” Which of the following responses by the nurse is BEST?
1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge?" 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication."
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Strategy: The topic of the question is unstated.
(1) hallucinations usually not seen with patients with bipolar disorder; seen with psychotic disorders
(2) assumption that patient just wants attention
(3) correct—side effects include galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands)
(4) indicates a side effect, not effectiveness of medication
A client is scheduled for a left lower lobectomy. The physician orders diazepam (Valium) 2 mg IM for anxiety. The nurse determines the medication is appropriate if the client displays which of the following symptoms?
1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure.
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Strategy: Determine if the answer choice relates to Valium.
(1) more indicative of preoperative complications, should be reported before medications are given
(2) more indicative of preoperative complications, should be reported before medications are given
(3) correct—observation most indicative for antianxiety drugs is restlessness and increase in heart rate due to circulating catecholamines (fight or flight)
(4) hostility may be treated best by ventilating feelings
The nurse observes care given to a client experiencing severe to panic levels of anxiety. The nurse should intervene in which of the following situations?
1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.
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Strategy: “Nurse would intervene” indicates that you are looking for an inappropriate response.
(1) appropriate nursing action for this level of anxiety
(2) appropriate nursing action for this level of anxiety
(3) correct—at this level of anxiety, client is unable to process thoughts and feelings for problem solving
(4) appropriate nursing action for this level of anxiety
An extremely agitated client receives haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. It is MOST important for the nurse to take which of the following actions?
1. Monitor blood pressure every 30 minutes. 2. Remain at the client's side to provide reassurance. 3. Tell the client the name of the medication and its effects. 4. Assess for anticholinergic effects of the medication.
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Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes.
(1) correct—assessment; monitoring vital signs is of utmost importance to ensure client safety and physiological integrity; rapid neuroleptization is a pharmacological intervention used to rapidly diminish severe symptoms that accompany acute psychosis; alpha-adrenergic blockade of peripheral vascular system lowers BP and causes postural hypotension
(2) implementation; should be done but is not highest priority
(3) implementation; should be done but is not highest priority
(4) assessment; circulatory system takes priority
The nurse recognizes which of the following as a positive response to fluoxetine HCl (Prozac)?
1. The nurse notes hand tremors and leg twitching. 2. The client states that he is able to sleep for longer periods of time. 3. The client has an increased energy level and participates in unit activities. 4. The nurse observes that the client is hypervigilant and scans the environment.
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Strategy: Think about each answer choice.
(1) can be side effect of the medication
(2) not an effect of Prozac, can actually inhibit sleep; is useful with clients who experience increased sleeping and psychomotor retardation and lethargy
(3) correct—fluoxetine HC (Prozac) is an “energizing” antidepressant; as client begins to demonstrate a positive response, he has an increased energy level, is able to participate more in milieu
(4) can be side effect of medication
When administering antipsychotic medications parenterally, the nurse should take which of the following actions?
1. Monitor the client's blood pressure while the client is sitting and standing before and after each dose is given. 2. Caution the client not to drink or operate machinery that requires mental alertness for safety. 3. Have an emergency cart available in case of an adverse reaction. 4. Reassure the client that side effects are only temporary.
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Strategy: Answers are a mix of assessments and implementations. Does the assessment make sense? Yes.
(1) correct—primary concern with postural hypotension caused by medication and preventing an injury from a fall; monitoring vital signs will provide data to address this concern
(2) not relevant with this classification of medications
(3) not relevant with this classification of medications
(4) not relevant with this classification of medications
An elderly patient is admitted to the hospital for treatment of a fractured femur. The patient’s spouse tells the nurse that the patient has become very hard of hearing. The nurse might expect the patient to exhibit which of the following characteristics?
1. The patient prefers to be left alone. 2. The patient appears suspicious of strangers. 3. The patient communicates best in writing. 4. The patient's speech is difficult to understand.
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Strategy: All answers are assessments. Determine how each assessment relates to this situation.
(1) unrelated to hearing deficit
(2) correct—suspiciousness results from interference with communication
(3) writing may be difficult for patient, depends on intellectual capacity
(4) diminished hearing late in life does not cause speech difficulties
When caring for a client with a nursing diagnosis of rape trauma syndrome, acute phase, the nurse should consider which of the following the MOST important initial goal for the client?
1. Within 3 to 5 months, the client will state that the memory of the event is less vivid and distressing. 2. The client will indicate a willingness to keep a follow-up appointment with a rape crisis counselor. 3. The client will be able to describe the results of the physical examination that was completed in the emergency room. 4. The client will begin to express her reactions and feelings about the assault before leaving the emergency room.
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Strategy: Think about each answer choice.
(1) valid goal that needs to be addressed but after the initial goal has been met
(2) valid goal that needs to be addressed but after the initial goal has been met
(3) valid goal that needs to be addressed but after the initial goal has been met
(4) correct—is nurse’s initial priority to encourage client to begin dealing with what happened by verbalizing her feelings and gaining some acceptance and perspective
The nurse prepares a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is MOST important for the nurse to ask?
1. "Did you have anything to eat or drink before you came in today?" 2. "Have you had any headaches since your last treatment?" 3. "Who came with you to the hospital today?" 4. "Have you had much memory loss since you began your treatments?"
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Strategy: Determine how each answer choice relates to ECT.
(1) correct—client given general anesthesia for ECT; NPO after midnight
(2) not relevant to ECT
(3) not most important
(4) memory loss is an expected outcome
