Untitled Quiz

Questions and Answers

What should you report if you notice increased thoughts of suicide?

Increased thoughts of suicide

Which statement is true regarding anxiety interventions?

Everyone experiences the same level of anxiety.

Anxiety can only be classified as mild or moderate.

Anxiety treatments are identical for all patients.

Interventions are based on the degree of anxiety. (correct)

Performing repetitive behaviors can help in coping with anxiety.

True

What indicates that Ms.S understands the teaching about anxiety?

Uses relaxation techniques Signup and view all the answers

Which nursing assessments should Nurse Stacy complete for Mr.Moore?

Fall Risk Assessment Signup and view all the answers

What is one question included in the CAGE questionnaire?

Have you ever felt bad or guilty about your drinking? Signup and view all the answers

Which medication is commonly prescribed for acute alcohol withdrawal?

Lorazepam (Ativan) Signup and view all the answers

What should be included in the nursing report using the SBAR format for Mr.Moore?

The situation, background, assessment, and recommendation. Signup and view all the answers

What should be available in Mr.Moore's room as part of seizure precautions?

Suction equipment Signup and view all the answers

What nursing intervention is appropriate for a client in alcohol withdrawal?

Promote a low-stimulation environment. Signup and view all the answers

What is the rate to set the IV pump for administering ranitidine (Zantac) 50 mg in 100 mL over 20 min?

300 ml/hr. Signup and view all the answers

What is the role of thiamine (vitamin B1) in alcohol withdrawal?

It prevents encephalopathy. Signup and view all the answers

Which is an example of Mr.Moore's use of denial as a maladaptive coping mechanism?

Mr.Moore talks about going out for drinks with coworkers. Signup and view all the answers

What is an appropriate response by Nurse Stacy to Mr.Moore's denial of having an alcohol problem?

So you don't think you're an alcoholic? Signup and view all the answers

What is a priority intervention for Mr.Moore when he is angry?

Tell him in a firm voice to stop his behavior. Signup and view all the answers

What is a key feature of an intensive outpatient program?

Care will be individualized to meet treatment needs. Signup and view all the answers

Which medications are appropriate to include in the discussion about decreasing alcohol cravings?

Naltrexone Signup and view all the answers

What is an adverse effect of using disulfiram (Antabuse) with alcohol?

Throbbing headache. Signup and view all the answers

What is a relapse prevention strategy for substance use disorder?

Encourage Mr.Moore to write important information in a notebook. Signup and view all the answers

Which of the following responses by Ken should Nurse Anne identify as an example of associative looseness?

Altered speech pattern of communication in which the patient shifts from one idea to another. Signup and view all the answers

Which of the following actions should Nurse Anne take when Ken is becoming increasingly anxious?

Stand off to the side of Ken, more than arms reach away. Signup and view all the answers

Which of the following manifestations should the nurse include as positive symptoms of schizophrenia?

Delusions Signup and view all the answers

Which type of delusion should Nurse Anne document when Ken believes others are trying to harm him?

Delusion of Persecution Signup and view all the answers

What should the nurse first assess in Ken related to his hallucinations?

Command Hallucinations Signup and view all the answers

Which tool should Nurse Anne use to assess the risk for suicide in Ken?

SAFE-T Signup and view all the answers

What manifestation should Nurse A identify as a sign of cocaine intoxication?

Psychosis Signup and view all the answers

Which statement should Nurse A make to increase Ken's socialization?

'Emily, visiting and talking with Ken on a regular basis will help him maintain his social interactions.' Signup and view all the answers

What should Nurse A inform Ken about paliperidone?

'You should let your provider know if you are experiencing abnormal body movements.' Signup and view all the answers

Nurse A is preparing to administer Ken's first injection of paliperidone. When should the medication reach peak effectiveness?

In about 13 days Signup and view all the answers

What should Nurse A recommend regarding group therapy for Ken?

Establish a goal for long-term commitment to attending group therapy. Signup and view all the answers

Which response should Nurse A make when communicating with Ken about his auditory hallucinations?

'Hearing voices must be frightening, but you are safe.' Signup and view all the answers

What should Nurse Anne ask Ken when discussing substance use?

'Tell me some of your reasons for using marijuana.' Signup and view all the answers

What action should Nurse A recommend to decrease Ken's paranoia at home?

Avoid whispering or talking quietly to others when in the same room as Ken. Signup and view all the answers

What is true about durable power of attorney for health care (DPAHC)?

DPAHC can be terminated by the client. Signup and view all the answers

What should Nurse A include regarding relapses of schizophrenia?

Group therapy can help prevent relapse. Signup and view all the answers

Which nursing assessment finding indicates correct nursing assessment in a client with a manic episode?

Grandiose thinking and racing/magical thinking. Signup and view all the answers

What should Nurse Ben convey about the genetic predisposition for bipolar disorders?

There is a strong genetic predisposition for bipolar disorders. Signup and view all the answers

What is Nurse Ben's appropriate response when Susan behaves seductively?

It is the expectation on this unit that there is no inappropriate physical contact. I need you to stop. Signup and view all the answers

Which expected outcomes should Nurse B anticipate from administering olanzapine?

Promote sedation, decrease agitation, prevent mania relapse. Signup and view all the answers

After reconstitution with 2.1 mL sterile water to yield 5 mg/mL, how many mL should B administer for 10 mg IM of olanzapine?

2 mL Signup and view all the answers

What action should Nurse Ben take when Susan forcefully refuses the olanzapine injection?

Explain the benefits of the injection. Signup and view all the answers

What action should Nurse Ben take when Susan interrupts the group therapy session?

Ask the AP to assist the client out of the room. Signup and view all the answers

Which lab tests must be drawn prior to starting lithium therapy?

T3, T4, TSH; BUN and Serum Creatinine. Signup and view all the answers

What instruction should Nurse Ben include in his teaching about lithium therapy?

Consume 2-3 L of fluid per day. Signup and view all the answers

What nursing actions should Ben implement to promote Susan Choi's recovery?

Use a firm, calm, matter of fact approach. Signup and view all the answers

What meal would be appropriate for a client in a manic episode?

Peanut butter jelly sandwich, chips, banana, and strawberry milkshake. Signup and view all the answers

Which finding should the nurse monitor for signs of severe lithium toxicity?

Ataxia Signup and view all the answers

Which assessment tool should Nurse Ben use to identify suicide risk factors and hospitalization need?

SAFE-T Signup and view all the answers

Which serious adverse effect must Nurse Ben report regarding lamotrigine?

Stevens-Johnsons Syndrome Signup and view all the answers

What should Nurse Ben ask when responding to Susan's despondent behavior?

'Do you have a plan for how you would end your life?' Signup and view all the answers

What client outcomes should Nurse Ben identify in preparing discharge outcomes for Susan?

Review education material about bipolar disorder and its management. Signup and view all the answers

What is the priority action for Nurse T when admitting Ms. S?

Assess respiratory status. Signup and view all the answers

Which assessment scale is appropriate for assessing anxiety in Ms. S?

Hamilton-A Signup and view all the answers

What should Nurse T do after determining Ms. S's Hamilton-A score is 26?

Obtain a prescription for lorazepam (Ativan). Signup and view all the answers

What should Nurse T include in findings when preparing to call the provider about Ms. S?

Situation, Background, Assessment, Recommendation. Signup and view all the answers

How many mL should Nurse T administer of lorazepam if available in 4 mg/mL and 2 mg is ordered?

0.5 mL Signup and view all the answers

What actions should Nurse T take to initiate therapeutic communication with Ms. S?

Engaged and active listening, including direct eye contact. Signup and view all the answers

What action should Nurse T take when communicating with Ms. S?

Restate the concerns voiced by Ms. S. Signup and view all the answers

What coping mechanisms is Ms. S exhibiting while describing her stressors?

Denial, Displacement, Rationalization. Signup and view all the answers

What action should Nurse T take first when discussing Ms. S's most stressful situation?

Continue to gather more information regarding finances. Signup and view all the answers

What thought process reflects Ms. S's self-injury behavior?

Self-Destruction. Signup and view all the answers

Study Notes

Schizophrenia

Associative looseness: An altered speech pattern characterized by shifting from one idea to another.
When dealing with anxious patients, maintain a safe distance and ensure an exit path for safety.
Positive symptoms include delusions, hallucinations (visual, auditory), motor agitation, and altered speech.
Delusion types:
- Persecution: Belief that others intend to harm the individual.
- Grandeur: Belief in one's superiority.
- Nihilistic: Belief of being dead or nonexistent.
- Somatic: Belief of having internal dysfunctions or changes.
Assess for command hallucinations due to risks for harm.
Utilize the SAFE-T tool for suicide risk assessment, focused on identifying risk and protective factors.
Cocaine intoxication can induce psychosis, anxiety, and increased sociability.
Regular visits from trusted individuals can enhance a patient’s socialization while minimizing anxiety.
Paliperidone can cause extrapyramidal effects; notify healthcare providers of abnormal body movements.
Medications take approximately 13 days to peak effectiveness.
Long-term commitment to group therapy improves social skills and belonging.
Provide reassurance regarding safety in response to auditory hallucinations.
Encourage open discussions about substance use to gain insight into patient behaviors.
Advise against whispering in the presence of paranoid patients to alleviate fears.
Durable Power of Attorney for Health Care (DPAHC) can be revoked by the patient.

Bipolar Disorder

Manic episodes show grandiose and racing thoughts during mental assessments.
Family history increases the likelihood of developing bipolar disorder.
Maintain boundaries by addressing inappropriate behaviors assertively.
Olanzapine reduces agitation and prevents mania relapse.
Prior to lithium therapy, obtain lab tests for thyroid function and kidney health.
Instruct patients to maintain fluid intake and consistent sodium levels during lithium therapy.
Use calm approaches and offer high-calorie drinks to support manic patients.
Monitor for signs of lithium toxicity, including ataxia and blurred vision, with therapeutic range being 0.4 to 1.0 mEq/L.
Use SAFE-T tool for evaluating suicide risk.
Serious side effect of lamotrigine includes Stevens-Johnson Syndrome; monitor for rashes.
Engage in direct conversations about suicidal thoughts to determine plans and risks.

Anxiety

Respiratory status is the priority in assessing patients with anxiety symptoms.
Hamilton Anxiety Rating Scale effectively measures severity of anxiety.
High scores indicate the need for medication management, such as lorazepam.
Utilize the situation-background-assessment-recommendation (SBAR) model for effective communication with providers.
Active listening and engagement are crucial in establishing therapeutic relationships.
Coping mechanisms in anxiety can include denial, displacement, rationalization, and regression.
Initial nursing actions should focus on gathering detailed information on stressful situations.
Reflective self-destructive thought patterns may be present without suicidal intent.
Educate patients on the increased risk of suicide associated with medications like escitalopram.
Anxiety treatment is individualized; recognize and address the varying levels of anxiety severity.

Alcohol Abuse Disorder

Complete CAGE questionnaire to assess alcohol-related issues during admission.
CAGE includes four Yes/No questions to determine the probability of alcohol use disorder.
A majority of 'yes' answers indicates increasing concern over potential alcohol problems.### Alcohol Abuse Disorder Overview
Lorazepam (Ativan) is commonly prescribed for acute alcohol withdrawal to manage symptoms and prevent seizures.
Alternatives like Diazepam (Valium) are also used as anxiolytics, but Paroxetine (Paxil) is ineffective for withdrawal treatment.

SBAR Communication for Acute Withdrawal

Situation: Patient found lying on the floor, disheveled with saline lock evident.
Background: 45-year-old male, history of alcohol intoxication from a motor vehicle accident (MVA), presented with gastritis and esophagitis.
Assessment: Patient is alert but confused about time, reports nausea and moderate tremors, elevated vital signs with a Clinical Institute Withdrawal Assessment (CIWA) score of 23.
Recommendation: Immediate need for antiemetics and medication for withdrawal symptoms.

Seizure Precautions

Essential to have suction equipment readily available in the room to manage potential seizure episodes.

Nursing Interventions for Withdrawal

Promote a low-stimulation environment to support rest, reduce anxiety, and facilitate recovery.

IV Medication Administration

Ranitidine (Zantac) should be administered as an IV bolus of 50 mg in 100 mL over 20 minutes, which translates to a delivery rate of 300 mL/hr.

Thiamine (Vitamin B1) Importance

Thiamine replacement therapy is crucial to prevent Wernicke-Korsakoff syndrome associated with alcohol withdrawal.

Coping Mechanisms and Denial

Mr. Moore exemplifies denial by dismissing his alcohol use disorder while discussing plans to drink with co-workers.

Therapeutic Responses

Restating Mr. Moore's denial of addiction through affirming questions can help him explore this defense mechanism further.

De-escalation Techniques

Prioritizing safety, the intervention should involve firmly instructing Mr. Moore to cease his disruptive behavior.

Intensive Outpatient Program (IOP)

IOP offers individualized care plans targeting specific treatment needs of patients battling alcohol addiction.

Medications to Reduce Cravings

Naltrexone (opioid antagonist) and Topiramate (anticonvulsant) are effective medications for reducing cravings in alcohol use disorder.

Disulfiram (Antabuse) Considerations

Adverse effects of disulfiram upon alcohol consumption include severe throbbing headaches.

Relapse Prevention Strategies

Encourage the use of notebooks for clients to document vital information as an effective relapse prevention strategy for substance use recovery.

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