Podcast
Questions and Answers
A client taking lithium exhibits severe diarrhea, blurred vision, and muscle weakness. Which of the following is the most appropriate nursing intervention?
A client taking lithium exhibits severe diarrhea, blurred vision, and muscle weakness. Which of the following is the most appropriate nursing intervention?
- Administer an anti-diarrheal medication and encourage oral fluids.
- Immediately notify the healthcare provider and prepare for possible discontinuation of the medication. (correct)
- Encourage the client to increase sodium intake to counteract the effects of lithium.
- Reduce the next scheduled dose by half and monitor for improvement.
A patient on haloperidol develops muscle rigidity and a shuffling gait. Which of the following interventions is most important for the nurse to implement?
A patient on haloperidol develops muscle rigidity and a shuffling gait. Which of the following interventions is most important for the nurse to implement?
- Hold the next dose of haloperidol and consult with the healthcare provider regarding the symptoms.
- Reassure the patient that these symptoms are temporary and will subside with continued use of the medication.
- Increase the patient's fluid intake and encourage regular exercise to alleviate muscle stiffness.
- Administer an anticholinergic medication as prescribed and monitor for improvement in motor function. (correct)
A client is prescribed alprazolam for anxiety. Which of the following instructions should the nurse emphasize to the client regarding the medication?
A client is prescribed alprazolam for anxiety. Which of the following instructions should the nurse emphasize to the client regarding the medication?
- Alprazolam should be taken only when experiencing acute episodes of anxiety.
- The medication can be stopped abruptly once anxiety symptoms subside.
- Avoid abrupt cessation of alprazolam to prevent withdrawal symptoms. (correct)
- It is safe to consume moderate amounts of alcohol while taking alprazolam.
A child is prescribed methylphenidate for ADHD. Which of the following side effects should the nurse prioritize when educating the parents?
A child is prescribed methylphenidate for ADHD. Which of the following side effects should the nurse prioritize when educating the parents?
A nurse is preparing to administer haloperidol 1.5g in 150 mL over 60 minutes, with a drop factor of 15 gtt/mL. What is the correct flow rate in drops per minute (gtt/min)?
A nurse is preparing to administer haloperidol 1.5g in 150 mL over 60 minutes, with a drop factor of 15 gtt/mL. What is the correct flow rate in drops per minute (gtt/min)?
A patient prescribed phenelzine is preparing to be discharged. Which of the following instructions should the nurse prioritize to prevent a hypertensive crisis?
A patient prescribed phenelzine is preparing to be discharged. Which of the following instructions should the nurse prioritize to prevent a hypertensive crisis?
During a mental status examination, a patient consistently misinterprets simple instructions and struggles to maintain focus. Which domain of cognitive function is MOST likely impaired?
During a mental status examination, a patient consistently misinterprets simple instructions and struggles to maintain focus. Which domain of cognitive function is MOST likely impaired?
A patient with a history of aggression is escalating, pacing, and speaking loudly. Which intervention should the nurse implement FIRST?
A patient with a history of aggression is escalating, pacing, and speaking loudly. Which intervention should the nurse implement FIRST?
A patient states, “I feel completely worthless, like I’m a burden to everyone.” Which therapeutic communication technique would be MOST effective in exploring this patient’s feelings?
A patient states, “I feel completely worthless, like I’m a burden to everyone.” Which therapeutic communication technique would be MOST effective in exploring this patient’s feelings?
A client being treated for depression has been prescribed Amitriptyline. What potential side effect of this medication should the nurse prioritize when educating this client?
A client being treated for depression has been prescribed Amitriptyline. What potential side effect of this medication should the nurse prioritize when educating this client?
A nurse restrains a patient against their will without a provider's order due to the patient being disruptive. Which tort has the nurse committed?
A nurse restrains a patient against their will without a provider's order due to the patient being disruptive. Which tort has the nurse committed?
A patient expresses intent to harm a specific individual upon discharge. Which of the following actions should the nurse undertake FIRST?
A patient expresses intent to harm a specific individual upon discharge. Which of the following actions should the nurse undertake FIRST?
While documenting an interaction where a patient is exhibiting agitated behavior, which of the following is the MOST appropriate and objective way for the nurse to record the observation?
While documenting an interaction where a patient is exhibiting agitated behavior, which of the following is the MOST appropriate and objective way for the nurse to record the observation?
Flashcards
Lithium
Lithium
Used to stabilize mood; monitor for toxicity, which presents as severe diarrhea, blurred vision, and muscle weakness.
Haloperidol
Haloperidol
An antipsychotic that may cause extrapyramidal symptoms (EPS) such as muscle rigidity, shuffling gait, and tardive dyskinesia
Anxiolytics (e.g., alprazolam)
Anxiolytics (e.g., alprazolam)
Have a risk of dependency; do not stop taking them suddenly; avoid taking with alcohol to prevent CNS depression.
Stimulants (e.g., methylphenidate)
Stimulants (e.g., methylphenidate)
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Maslow’s Hierarchy in Nursing
Maslow’s Hierarchy in Nursing
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Cognitive Function Assessment
Cognitive Function Assessment
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Mental Status Assessment
Mental Status Assessment
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Affect
Affect
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Mood
Mood
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Right to Refuse Treatment
Right to Refuse Treatment
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Duty to Warn
Duty to Warn
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Therapeutic Milieu
Therapeutic Milieu
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Seclusion & Restraints
Seclusion & Restraints
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Study Notes
- Study notes for NRS 202 Exam 1
Mental Health Assessment & Cognitive Function
- Assessing cognitive function involves memory recall, orientation, attention span, and the ability to follow instructions
- Mental status assessment includes appearance, behavior, cognition, and thought processes
- Affect is the outward expression of emotion, like facial expressions and tone
- Mood is the client's emotional state
Therapeutic Communication
- Effective communication techniques involve using open-ended questions
- Avoid judgmental or directive language
- Use reflection, active listening, and summarization
- Barriers to communication include giving false reassurance, interrupting, and minimizing feelings
Legal & Ethical Considerations
- Even involuntarily committed patients can refuse treatment unless court-ordered
- Duty to warn means confidentiality can be breached if a client threatens harm to others
- False imprisonment is the unjustified restraint of a client
- Battery is physically touching a client without consent
- Assault is threatening a client with harm
- Documentation should use objective language
Mental Health Disorders & Treatment Approaches
- Cognitive Behavioral Therapy (CBT) focuses on identifying and modifying negative thought patterns
- Psychobiological interventions include medication administration and monitoring for side effects
- Therapeutic milieu means using a structured environment to promote healing and social interaction
Crisis Management & Safety
- When handling aggression, ensure safety first, use de-escalation techniques, and avoid confrontation
- Seclusion & restraints should only be used as a last resort
- Continuous monitoring is required during seclusion or restraint
- A provider's order is needed for seclusion or restraint
- Emergency admission is required when there is imminent danger to self or others
Medication Safety & Pharmacology
- Antidepressants include SSRIs, MAOIs, and tricyclic antidepressants
- SSRIs (e.g., fluoxetine) may take 4-6 weeks for full effect
- MAOIs (e.g., phenelzine): Avoid tyramine-rich foods (aged cheese, red wine, salami) to prevent hypertensive crisis
- Tricyclic antidepressants (e.g., amitriptyline) can cause orthostatic hypotension, dry mouth, and weight gain
- Mood stabilizers require monitoring for toxicity; signs include severe diarrhea, blurred vision, and muscle weakness
- Antipsychotics like Haloperidol can cause extrapyramidal symptoms (EPS) such as muscle rigidity, shuffling gait, and tardive dyskinesia
- Anxiolytics (e.g., alprazolam) carry a risk of dependency; do not stop suddenly
- Avoid alcohol when taking anxiolytics to prevent CNS depression
- Stimulants (e.g., methylphenidate for ADHD) can cause weight loss, increased BP, and insomnia
- Sedative-hypnotics (e.g., zolpidem for insomnia) should be taken before bed and may cause daytime drowsiness
Maslow's Hierarchy in Nursing Care
- Basic physiological needs (food, water, warmth, rest) come first
- Safety needs (ensuring a client does not harm self or others) are next
- Self-esteem and self-actualization interventions come after physiological and safety needs are met
Dosage Calculation Review
- Calculations: (Ordered dose / Available dose) × Volume = Amount to give
- IV flow rate: (Total volume in mL / Time in hours) = mL/hr
- Drop factor calculation: (Volume in mL × Drop factor) / Time in minutes = gtt/min
- Example calculations:
- Ordered: 250 mg, Available: 500 mg/5 mL, Give 2.5 mL
- Ordered: Haloperidol 1g in 100 mL over 45 min, Drop factor: 10 gtt/mL, 22 gtt/min
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