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
The nursing staff plans to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program?
1. Monitor the client's ability to complete her activities of daily living (ADL). 2. Assess the client's levels of pain and correlate it with her response to analgesia. 3. Observe the client's behavior at regular intervals to obtain baseline information related to her screaming. 4. Ask the client why she is screaming and document it on her nursing assessment record.
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Strategy: Determine what is being assessed in each answer choice and how it relates to screaming.
(1) important because activities of daily living can contribute to the targeted behavior of screaming; assessing only the area of ADLs does not provide comprehensive data for developing a behavior management program
(2) important because activities of pain can contribute to the targeted behavior of screaming; assessing only the area of pain does not provide comprehensive data for developing a behavior management program
(3) correct—to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors
(4) client may be unable to state why she is screaming; asking “why” questions is nontherapeutic
A middle-aged female client begins outpatient therapy sessions for management of a phobic disorder. The nurse identifies which of the following interventions is MOST effective to reduce the client symptoms?
1. Antianxiety medication. 2. Group psychotherapy. 3. Systematic desensitization. 4. Biofeedback.
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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) may be used for social phobia or social anxiety disorder
(2) may benefit from cognitive-behavioral therapy
(3) correct—phobic disorders are learned responses; learned responses can be unlearned through certain techniques, such as behavior modification; systematic desensitization is a form of behavior modification; is a strategy used in conjunction with deep muscle relaxation to decrease the extreme response to anxiety-producing situations as they are gradually exposed; then exposure is increased; goal is to eradicate the phobic response by replacing it with the relaxation response
(4) one learns to control the autonomic nervous system; is usually more useful for reducing stress associated with physiologically based disorders
On a home health visit, an elderly client tells the nurse, “This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.” Which of the following nursing responses by the nurse is BEST?
1. "Have you and your neighbors formed a Neighborhood Watch?" 2. "It must be very difficult for you to live in this neighborhood." 3. "I see a lot of police cars, so you should be pretty safe." 4. "Tell me what has happened to make you feel that you are not safe."
Show/hide explanation
Strategy: Remember therapeutic communication.
(1) jumps ahead to solutions without adequately defining the problem
(2) empathetic response, but does not obtain more information from the client or encourage the client to continue
(3) false reassurance
(4) correct—assessing the basis for client’s fears and encouraging client to talk about them is the first positive step
A client begins doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should recommend a change in the client’s therapy if which of the following occurs?
1. The client refuses to speak and sits quietly in the room. 2. The client becomes excitable and develops tremors. 3. The client refuses to eat breakfast. 4. The client sleeps 18 hours a day.
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Strategy: Think about the cause of each assessment and how it relates to Sinequan.
(1) not relevant to this medication
(2) correct—doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include excitability and tremors
(3) not relevant to this medication
(4) not relevant to this medication
When caring for an elderly client with a depressed affect, which of the following nursing actions is MOST appropriate to help the client to complete activities of daily living?
1. Medicate the client before the activities begin. 2. Develop a written schedule of activities, allowing extra time. 3. Assist the client with grooming activities so it doesn't take as long. 4. Provide frequent forceful direction to keep the client focused.
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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) will not increase the client’s independence and may interfere with the client’s self-esteem
(2) correct—written schedule with built-in extra time will allow client to understand what is expected and will allow client to participate at a slower pace
(3) will not increase the client’s independence; allow extra time for care
(4) will not increase the client’s independence and may interfere with the client’s self-esteem
Which of the following strategies is MOST therapeutic as the nurse tries to analyze a bulimic client’s eating habits and the circumstances that precipitate the client’s eating problems?
1. Observe family communication patterns at a "monitored mealtime." 2. Distract the client at mealtime. 3. Assign the client a food/thought/feelings/actions journal. 4. Assign the client to write a "lifeline" in relation to eating behaviors.
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Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation.
(1) assessment, should be done after a food/thought/feelings/actions journal
(2) implementation, should be done after a food/thought/feelings/actions journal
(3) correct—implementation, nurse is trying to analyze and understand what triggers the client’s binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client’s eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a “lifeline” in relation to eating behaviors will further benefit the client
(4) implementation, should be done after a food/thought/feelings/actions journal
A client taking chlorpromazine (Thorazine) should be instructed to notify the nurse immediately if the client experiences which of the following?
1. Dry mouth and nasal stuffiness. 2. Increased sensitivity to heat. 3. Difficulty urinating. 4. Weight gain and constipation.
Show/hide explanation
Strategy: Determine the cause of each answer choice and how it relates to chlorpromazine
(1) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem
(2) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem
(3) correct—is an anticholinergic reaction that may become a severe health problem unless treated
(4) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem
An elderly female client is frantically yelling for the nurse to come into the room. The nurse enters the room as the client states, “See it? It’s the devil!” Which of the following responses by the nurse is BEST?
1. "The devil is here?" 2. "Show me where the devil appeared to you." 3. "I don't see the devil, but I understand that he is real to you." 4. "The devil is not here; your mind is playing tricks on you."
Show/hide explanation
Strategy: Remember therapeutic communication.
(1) yes/no question, attempt to reason or argue with the client will only entrench her more firmly into this distortion
(2) attempt to reason or argue with the client will only entrench her more firmly into this distortion
(3) correct—nurse should not reinforce client’s hallucinatory experiences; direct challenge to client’s belief about sensory-perceptual intake will only increase mistrust and conflict between nurse and client
(4) argumentative, attempt to reason or argue with the client will only entrench her more firmly into this distortion
While planning care for an elderly client with dementia, which of the following is a priority for the nurse?
1. Encourage dependency with activities of daily living. 2. Provide flexibility in schedules due to his confusion. 3. Limit reminiscing due to poor memory. 4. Speak slowly in a face-to-face position.
Show/hide explanation
Strategy: The topic of the question is unstated. Read the answer choices for clues.
(1) independence should be encouraged
(2) schedules need to be routine, reinforced, and repeated; flexibility leads to confusion
(3) reminiscence and life reviews help client resume progression through grief process associated with disappointing life events, and increases self-esteem
(4) correct—is most effective when communicating with an elderly client
