HESI Case Study

E. Successful use of manipulation to get needs met F. Erratic display of discipline, moral values, and loving attention by significant others

All of the following may explain the origins of antisocial personality disorder. Socio-cultural explanations include:

A. sitting with him at eye level, B. talking with him slowly and gently D. providing him with information about what is happening in simple, accurate terms E. telling him he is safe and that the staff will not hurt him, or allow him to hurt himself or anyone else F. actively listening to and reflecting what he is saying

At this point, approaches to help control Terry's behavior and prevent further aggressiveness include:

C. Hyperthermia Ecstasy can cause an uncontrolled rise in body temperature which, although rare, can be fatal.

Given that Terry may have taken Ecstasy, you are especially alert for which potentially fatal drug reaction?

C. Dexedrine, an amphetamine Correct Dexedrine, an amphetamine, is a central nervous system stimulant that produces hypervigilance (exceptionally watchful), feelings of grandiosity (exaggerated self-importance), a desire to talk a lot, motor unrest, hallucinations (false perceptions), delusions (false beliefs), violent behavior, increased blood pressure, chills, nausea, and vomiting. Terry has exhibited aggressiveness and paranoia (delusions of persecution) and could have ingested amphetamines. E. Crack, a cocaine derivative Correct Hydrochloride cocaine, or crack (also called rock), often leads to paranoia (delusions/false beliefs of persecution) and distortion of reality, difficulty sleeping, fatigue, depression, poor judgment, inability to abstract, and perhaps aggression. Other signs/symptoms of crack use include shortness of breath, black phlegm, increased cardiac and respiratory rates, scorched facial hairs, and weight loss. Terry has exhibited aggressiveness and paranoia and may have crack in his system. F. Ecstasy (MDMA), a ketamine derivative Correct Terry has exhibited several signs/symptoms that could be associated with Ecstasy (MDMA) use: psychomotor agitation, anxiety, emotional lability (instability), self-importance, and sensory sensitivity. Hallucinations and delusions are also possible with Ecstasy use. Physical effects include increased heart rate and blood pressure. Nausea, vomiting, chills, sweating, and hyperthermia are also possible. Similar to both methamphetamine and mescaline, MDMA is classified as a Schedule 1 drug; and, for some people, may be addictive.

In addition to alcohol, what drugs can lead to the behaviors displayed by Terry?

C. A patient recovering from general anesthesia starts climbing over the side rails of his stretcher A person can be restrained without an order when there is immediate indication that he/she may harm himself or others. A patient recovering from general anesthesia (who would not be fully alert) who is climbing over side rails may harm himself. Physical restraint is indicated to insure this patient is not injured. In an emergency, a patient can be restrained or secured without an order. However, an order for the restraint/seclusion, with justification of the need for the restraint and/or seclusion, must be obtained within one hour.

In an emergency, a patient can be restrained or secured without an order. Which of the following would be considered emergencies requiring physical restraint of a patient?

A. Risk for Injury related to being restrained, thrashing about, and impaired judgment B. Risk for Deficient Fluid Volume related to inadequate intake and the dehydrating effects of alcohol, Ecstasy, and tachypnea E. Disturbed Thought Processes related to changes in brain chemistry and anxiety secondary to Ecstasy/alcohol F. Risk for Violence related to disinhibiting and irritating effects of Ecstasy/alcohol and history of assaults

In caring for Terry, you need to address which of the following as priorities?

B. help him become more calm Your first priority is to help Terry feel calmer and more in control. He will be less likely to cause self-harm if he is more calm and more in control. This will also expedite removal of restraints. Also, Terry will be in a better position to share information, respond to questions, and participate in care if he is more calm.

In providing for Terry's care, your FIRST priority is to:

A. Monitor skin turgor and temperature, mucous membranes, periorbital areas, urinary output, thirst B. Monitor blood pressure, observe for increased restlessness and dystonias D. Pad restraints and side rails, rotate release of restraints E. Avoid providing drinks with caffeine Correct F. Role model slow breathing Correct This intervention is appropriate. Modeling slow breathing should lead Terry to breathe more slowly, which would decrease insensible water loss, as well as help relax him.

In working with Terry, you use a variety of interventions. These appropriately include which of the following? Select all that apply (there are 5 correct answers).

A. Haldol (haloperidol) by intramuscular injection Haldol (haloperidol), a typical (conventional) antipsychotic drug, given intramuscularly, should successfully control Terry's agitation, paranoia, anxiety, and aggression. It is fast-acting, with an onset of 20-30 minutes, peaking in 30-45 minutes. IM Haldol (haloperidol) is ordered for and administered to Terry. D. Zyprexa (olanzapine) by intramuscular injection Zyprexa (olanzapine) is an atypical antipsychotic medication available as an injectable that would be useful with Terry. It has less anticholinergic side effects than typical antipsychotic medications, and is fast-acting. However, it is more expensive than some other antipsychotic drugs.

Medication is now indicated to control Terry's behavior. What medication might the physician order to help Terry become less violent?

C. able to steal and lie without remorse The person with an antisocial personality is not internally motivated by knowing what is right and wrong. Often, he has not been exposed to or has not taken in messages from parents or other important adults that would normally help to form a "conscience." Consequently, he does not feel guilt, remorse, regret, or anxiety. He may rationalize actions, explaining his "having" to "fix" things because other people are incompetent or jealous of his "talent." And, although he may apologize for having lied or stolen, his words are not sincere. Persons like Terry may apologize only to protect themselves or to get what they want.

Terry is definitively diagnosed as having antisocial personality disorder. The person with an antisocial personality usually is:

C. You sound concerned about Terry. This response is empathic and caring. It reflects the friend's feelings back to him and lets him know that you care about him. It also opens the door for further discussion and communication that might be helpful to the friend, and Terry. Although the Health Insurance Portability and Accountability Act (HIPAA) does limit the amount of information that can be provided to others without a patient's permission, information can be shared if the provider believes it is in the best interest of the patient. Terry's friend may have information that can help Terry, and giving the friend information about the seriousness of Terry's situation may be helpful.

Terry's friend is obviously frightened and worried about Terry, saying, "No drug should do that. What is wrong with him? Will he be alright?" What response to Terry's friend is best?

B. Nausea and vomiting may develop with alcohol withdrawal Anorexia, nausea, and vomiting are common with alcohol withdrawal. These signs/symptoms typically begin 6-12 hours after the last alcohol intake. With vomiting, prevention of aspiration is important for patient safety. D. Alcohol withdrawal symptoms can include hallucinations Alcohol withdrawal can include visual, auditory, or tactile hallucinations without disorientation (alcoholic hallucinosis, onset 12-24 hours after last alcohol intake, seldom lasting beyond 48 hours), and/or withdrawal delirium (delirium tremens) (onset 48-72 hours after last alcohol intake, with symptoms peaking at 5 days after last alcohol intake). Withdrawal delirium includes hallucinations (primarily visual), disorientation, and elevated vital signs (temperature, blood pressure, pulse). Withdrawal delirium can be life-threatening. Hallucinations can be very frightening. The nurse's approach should include kind, supportive reorientation and clarification. Submit

Terry's history reflects that he has been drinking large amounts of alcohol on a daily basis for an extended period of time. Understanding withdrawal from alcohol is necessary for safe nursing care. Which of the following statements about alcohol withdrawal are true?

A. the need to conform with behaviors expected of their new peer group Peer relationships and groups are especially important during late adolescence. It is probable that the association these teens have with Terry fills a need to belong. Belonging to a group during adolescence often means conforming to group rules, whatever they may be.

The change in behavior noted in Terry's "followers" can be attributed to

B. Opportunities such as group and activity therapies and community meetings can be used to provide feedback to Terry about his manipulative, controlling behaviors C. Terry's progress can be plotted on a behavioral chart D. Staff expectations can be explained to Terry in terms of benefits to him F. Terry can be encouraged to work out in the gym G. Terry can participate in daily sessions in which he is taught how to problem solve

What approaches can be used to help resolve Terry's problem of Defensive Coping? Select all that apply

D. You sound frightened. I won't let anyone hurt you." Acknowledging Terry's underlying feeling of fear and reassuring him that you will help him stay safe would be best. Terry's excessive bravado, false display of strength, and use of the word "experiments" reflect his vulnerable position. His cursing, threats, demands, and loud voice are attempts to overcome fear and powerlessness through the effects of the drugs.

What is your best response?

D. countertransference

When a staff member has feelings about a patient or the patient's care that emerge because of events or feelings in his/her own life, the process is referred to as:

C. Terry cannot care for himself and refuses to agree to contract for safety To commit a person, evidence indicating that the person is at risk for harming himself or others is required. Terry cannot yet care for himself (he is a danger to himself). He will not or cannot agree to contract for safety (therefore, he may be a danger to himself or others). Involuntary admission to the Chemical Dependency Unit is justified.

Which of the following criteria would allow a judge or magistrate to commit him?

C. Continuously assess for effectiveness of the least-restrictive interventions for Terry while he is restrained D. While Terry is restrained, frequently inform and remind him of the reasons for his restraint and the behavior necessary for restraints to be removed E. Assessment by a qualified staff person at least every 15 minutes while Terry is restrained

With regard to use of restraints, which of the following actions are necessary for safe and legal care of Terry?

A. Use the approach recommended by the unit's treatment plan For someone like Terry, who tries to control and manipulate people and systems to his advantage, a unified approach is best. If all team members use the same approach in responding to Terry's refusal to attend classes, he will be less likely to continue his unhealthy pattern of behavior.

You are assigned to oversee Terry's care. He refuses to attend class. Which of the following approaches would be best?

D. "As I do your exam, I will tell you exactly what I'm going to do." Letting Terry know what you are going to do is important. Telling him your approach would convey respect and acceptance of his current inability to process information quickly.

You need to complete a history and physical assessment. Which verbal approach is best?