Hesi Case Study: Psychosis

While teaching the client about the anticholinergic side effects related to benztrophine, which intervention is most important for the nurse to ensure is include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.) A. Take daily naps to decrease the tiredness caused by benztrophine. B. Expect dizziness that occurs after taking beztrophine. C. Report urinary retention or feeling that the bladder does not empty. D. Observe for sudden onset of hand tremors. E. Relay any feeling of heart palpations.

C, E

What is the most important part of this admission process? A. Ask the client if he has any valuables that need to be locked in a safe place. B. Allow the client to explain his understanding of the reason for his hospital admission. C. Introduce the client to the nursing staff and explain the role of the case manager and the staff members. D. Take away the client's cigarettes and lighter.

D

What is the most important benefit the client can receive from his attendance at the community meeting? A. Reality orientation. B. Limits set on behaviors. C. Psychosocial skills. D. Mutual goal setting.

A

Which assessment finding warrants immediate intervention by the nurse? A. Motor restlessness. B. Involuntary muscle contractions. C. Lip smacking. D. Drooling.

B

Diphenhydramine is available as 100 mg/mL. The ordered dose is 75 mg IM. How many mL should the nurse administer? (Enter numerical value only. If rounding is necessary, round to the hundredth.)

0.75

Since the client is also experiencing delusions, what action is most important for the nurse to take to address the client's delusions? A. Encourage the client to verbalize the meaning of the delusions. B. Firmly tell the client that the delusions are not real. C. Have the client to explain why they believe the delusion. D. Give the client a list of reasons the delusions are not real.

A

The client is questioning the nurse about taking another pill. Which nursing intervention best promotes effective communication? A. Explain that this pill is to help prevent the muscle spasms in neck and jaw. B. Tell the client this pill will prevent the risk for tardive dyskinesia. C. Say to the client that this pill will help the haloperidol be more effective. D. To further alleviate sudden periods of delusions.

A

The nurse understands that the purpose of the urine drug screen is to assess the client for what important information? A. Detection of substances that may have caused the client's delusions and/or hallucinations. B. Determination of the approximate time the client stopped taking his medications. C. Provision of information about the type of psychosis the client is experiencing. D. Documentation of medication noncompliance and reinforcement of the need for hospitalization.

A

Which nursing problem is best to include in the initial care plan? A. Sensory-perceptual alteration related to withdrawal into self. B. Chronic low self-esteem related to impaired cognition. C. Ineffective individual coping related to personal vulnerability. D. Knowledge deficit related to medication compliance.

A

After the content of the voices are assessed, which interventions should the nurse implement? (Select all that apply. One, some, or all options may be correct.) A. Ask the client how the voices make them feel. B. Instruct the client to utilize distractions to deal with hallucinations. C. Tell the client to instruct the voices to go away. D. Give the client statements to say to the voices. E. Encourage the client to write down what voices are saying.

A, B

Which medications should the nurse anticipate giving the client after getting orders from the healthcare provider? (Select all that apply. One, some, or all options may be correct.) A. Short-acting anxiolytic (benzodiazepines). B. Antipsychotic medication. C. Mood-stabilizing medication. D. Nonbenzodiazepine anxiolytic (antianxiety agent). E. Antidepressant.

A, B

Which assessment data are the best indicators of the potential for violence? (Select all that apply. One, some, or all options may be correct.) A. Gender and age. B. Past suicide attempts. C. History of violence. D. Multiple prescribed medications. E. Medication noncompliance.

A, B, C, E

What are the advantages for prescribing the atypical antipsychotic, olanzapine? (Select all that apply. One, some, or all options may be correct.) A. Lower incidence of extrapyramidal symptoms (EPSEs). B. Rapid onset. C. Less weight gain. D. Alpha-adrenergic blockade. E. Acute and maintenance therapy.

A, B, E

Interventions for a client experiencing hallucinations upon admission should occur in a sequence. Which interventions are most important to be include in the client's initial plan of care? (Select all that apply. One, some, or all options may be correct.) A. Acknowledge that it appears the client is hearing voices. B. Tell the client to stop listening to the voices. C. Ask the client to verbalize what the voices are saying. D. Assess the content of the hallucinations message. E. Identify distractions to keep the client focused on reality.

A, C, D

What are important reasons for this teaching? (Select all that apply. One, some, or all options may be correct.) A. To encourage the client to continue compliance with medications. B. To document the client's response to the medication education. C. To monitor for early tardive dyskinesia, which can be reversible. D. To reinforce education done throughout the hospitalization. E. To tell the client to discuss symptoms with his nurse.

A, C, D, E

The client admits that the voices he hears have been getting louder over the past couple of weeks. Which nursing intervention best promotes effective communication? A. Ask the client what helps the voices go away. B. Determine how long the client has been hearing voices. C. Document when the voices began getting louder. D. Have the client repeat what he thinks the voices are saying.

D

When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond? A. Insist that no one has followed the client there. B. State how he must be concerned and assure him he will be safe there. C. Tell the client that the police will make sure no one is out there D. Ask the client why he thinks that someone is out there.

B

When the client looks around the room and mumbles to himself, how should the nurse respond? A. Have the client express how he is feeling. B. Ask the client if they are hearing voices. C. See if the client recalls being here before. D. Tell the client to say what they are thinking.

B

Which action should the nurse implement first? A. Offer the client a glass of juice and ask him if he ate breakfast. B. Take the client's blood pressure while he is sitting and standing. C. Tell the client that his dizziness is orthostatic hypotension that will subside after he eats. D. Hold the morning dose of haloperidol, and notify the HCP.

B

Which assessment data provides evidence that the client can be involuntarily committed to the hospital, if he insists on leaving? A. Past history of suicide attempts. B. Losing 10 pounds in 2 weeks. C. Auditory hallucinations. D. Persecutory delusions.

B

Which lab results from the urinalysis can the nurse expect to be related to the client's 10-pound weight loss in the past 2 weeks? (Select all that apply. One, some, or all options may be correct.) A. Positive for red blood cells. B. Positive ketones. C. Decreased urine pH. D. Increased urine specific gravity. E. Absence of glucose.

B, D

Based on established and approved facility protocol orders, which medication is the nurse able to give to immediately relieve the muscle spasms in the client's neck and jaw? A. Lorazepam IM. B. Benztropine PO. C. Diphenhydramine IM. D. Acetaminophen PO.

C

The nurse observes the client looking to the corner of the room and mumbling to himself. Which intervention is most important for the nurse to make sure is in the client's plan of care? A. Encourage the client to share the meaning of their delusions. B. Interview the client to identify his feelings of depersonalization. C. Begin a sequence of interventions to address the client's hallucinations. D. Orient the client to their place and situation.

C

What is a goal of being in this activity group? A. Learn social behaviors and gain insight about one's personality. B. Gain information about disorders, symptoms, and medications. C. Gain self-acceptance and express feelings. D. Identify and resolve specific problems related to the treatment plan.

C

What is it most important intervention for the nurse to perform before discharging the client? A. Complete contracts to follow discharge plans. B. Provide resources for community support. C. Re-evaluate thoughts of harm to self or others. D. Identify support for the client's family.

C

What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication? A. To determine the presence of cardiac disease. B. To monitor for hepatotoxicity. C. To determine if other medical issues are present. D. To assess elevations in liver enzymes.

C

What neurotransmitter is targeted by haloperidol? A. GABA. B. Serotonin. C. Dopamine. D. Norepinephrine.

C

Which thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him? A. Hallucination B. Phobia C. Delusions D. Confabulation

C

The nurse is training a new team member. Which explanation best promotes effective communication when discussing group process and group content? A. Group content refers to the group rules. Group process is how clients react to the rules. B. Group process refers to where the group meets, while group content refers to the type of group that is meeting. C. Group content is client-led and group process is nurse-led. D. Content includes the clients' words, and group process is how the clients communicate.

D

Which nursing action is appropriate for this request? A. Direct the caseworker to talk with the pharmacist. B. Ask for the client's permission to obtain medications. C. Explain that the nurse can return the medications. D. Obtain an order from the HCP to return medications.

D

Which response from the client indicates that the haloperidol has been effective? A. Feels less anxious and nervous. B. Reports that mood is more stable. C. Initiates more social interactions. D. Experiences fewer hallucinations.

D