HESI Case Study Psychosis

How many mls should nurse give?

0.75

Meet the Patient

A client is accompanied to the emergency department (ED) by several police officers and a caseworker. The caseworker called the police to enter the client's apartment because the client refused to answer the door. The caseworker brings some medication bottles from the client's apartment and reports that 4 months ago, the client stopped taking all psychotropic medications. The client has poor eye contact, disheveled, dirty uncombed hair, and stained clothes. The client denies current suicidal ideation, although the caseworker reports a history of past suicide attempts and violence. The client has lost 10 pounds in the past 2 weeks, sleeps 12 hours daily, and doesn't leave the apartment. The nurse observes that the client sometimes looks to the corner of the room and then looks down and mumbles during the interview. The client admits to the nurse that they do not want to leave the apartment because they think someone is waiting to kill them.

The nurse understands that the purpose of the urine drug screen is to assess the client for what important information?

A urine drug screen is routinely ordered to determine the presence of any substances that may have altered a client's mental status. Blood and urine are the body fluids most often tested for drug content, although methods of analyzing saliva, hair, breath, and sweat have been developed.

Which medications should the nurse anticipate giving the client after getting orders from the healthcare provider?

A. short acting anxiolytic,. Antianxiety medications (benzodiazepines, lorazepam clonazepam, or diazepam) are most effective for anxiety-related symptoms to produce calming and sedation. When used in conjunction with an atypical antipsychotic medication, such as olanzapine, benzodiazepines, especially IM, can augment the efficacy of the antipsychotic medication, quickly alleviating acute agitation of a client. B. antipsychotic medication, Antipsychotic medications are effective for psychosis-related symptoms and manifestations of agitation associated with mental illness.

which thought process describes the client's inability to leave his apartment because he believes someone is waiting to kill him?

Delusion (a false and firm belief not shared by others) A delusion is a false belief that is firmly maintained even though it is not shared by others and is contradicted by reality.

Since the client is also experiencing delusions, what action is most important for the nurse to take to address the client's delusions?

Encourage client to verbalize meaning of delusions. The underlying theme of the delusions can be used to address the client's emotional state. Monitoring the affect of the delusions can help identify situations where the client may be inclined to harm themselves or others.

Which response from the client indicates that the haloperidol has been effective?

Experiences fewer hallucinations. The client should experience fewer hallucinations if the medication has been effective.

Which nursing action is appropriate for this request?

Obtain a order from the HCP to return medications. The HCP must write a order for the client to receive medications. Medications were changed while hospitalized and required prescriptions should accompany the client upon discharge. All other medication should be properly disposed of as prescribed.

The client is questioning the nurse about taking another pill. Which nursing intervention best promotes effective communication?

Pill is to prevent muscle spasms in neck and jaw. The addition of benztropine will reduce the likelihood of severe extrapyramidal symptoms that occur more often with prototype antipsychotic medications such as haloperidol.

pt is dizzy, which intervention should nurse implement first

Take client's BP while sitting and standing. Since the client is feeling dizzy, a blood pressure reading should be taken while he is both sitting and standing to determine if a positional change, referred to as orthostatic hypotension, is associated with a change in the blood pressure readings.

Olanzapine injection is effective in the treatment of acutely agitated psychotic clients and there is sustained efficacy when the client is switched to oral maintenance treatment.

Reality orientation Meetings that are designed to introduce clients to one another, plan activities for the day, and address client concerns and questions help ground the psychotic client in the present and reality.

purpose of CBC prior to antipsychotic medication

To determine if other medical issues are present A CBC can provide helpful information on the client's health status. It is important to determine if there are other issues that could be causing some of the symptoms, and whether the client is healthy enough to take the medication. Some antiypsychotic medications can cause neutropenia. If the client has other medical issues, considerations will need to be discussed regarding what medications should be prescribed.

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?

a. Acknowledge that it appears client is hearing voices The initial approach is to acknowledge the voices. They are real to the client and it is necessary to know what the voices are telling the client. The voices may be telling the client to harm themself or others. c. Ask client to verbalize what voices are saying Once the voices are acknowledged, the nurse needs to know what the voices are saying. They are real to the client and it is necessary to know what the voices are telling the client. The voices may be telling the client to harm themself or others. d. Assess content of hallucinations message. The voices may be telling the client to harm themself or others. Immediate interventions will need to be put in place to keep the client and others safe.

After the content of the voices are assessed, which interventions should the nurse implement?

a. Ask client how vices make them feel. It may be helpful to know how the voices make the client feel. It can provide understanding to the client's actions and reactions so they can be addressed in a therapeutic manner. b. Instruct the client to utilize distractions to deal with hallucinations.Once the hallucinations have been revealed and evaluated, it is important to disconnect the hallucinations from reality. Distractions can be a therapeutic.

What are the advantages for prescribing the atypical antipsychotic, olanzapine?

a. Lower incidence of extrapyramidal symptoms (EPSEs). Olanzapine has fewer incidences of extrapyramidal side effects (EPSEs) than other antipsychotic medications. b. Rapid onset Olanzapine has a rapid onset. f. Acute and maintenance therapy Olanzapine injection is effective in the treatment of acutely agitated psychotic clients and there is sustained efficacy when the client is switched to oral maintenance treatment.

Medication prescriptions for discharge include olanzapine 5 mg PO BID. The nurse plans to educate the client about side effects that do not go away. What are important reasons for this teaching?

a. encourages medication compliance, Education about side effects is important so that medication compliance can be enhanced. c. To monitor for early tardive dyskinesia which is reversible. It is very important to teach the client to report uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia and suggest modifications in the client's medication regimen. Tardive dyskinesia, although rare with olanzapine, can be reversed, by reducing the medication dose, if it is assessed in a timely manner. d. Reinforce education done in hospital. Educating the client about medications at discharge will reinforce the client's knowledge. e. To tell the client to discuss symptoms with his nurse It is very important to reinforce the client's medication compliance by recommending that the client discuss any uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia.

Which assessment data are the best indicators of the potential for violence?

a. gender and age Demographic variables such as gender and age are variables for predicting violence when assessing the client with psychosis. b. past suicide attempts Past suicide attempts are indicators of violence toward self. c. history of violence The best single predictor of violence is a past history of violence. e. medication noncompliance Clients with active psychotic symptoms are at increased risk for violence (symptom exacerbation), especially if they are medication noncompliant.

When the client looks around the room and mumbles to himself, how should the nurse respond?

ask client if they are hearing voices. The client is demonstrating nonverbal cues that he is experiencing auditory hallucinations, so the nurse should ask the client if he is hearing voices.

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?

b. positive ketones Ketones in the urine can suggest malnutrition, fasting, or starvation. d. increased specific urine gravity Increased urine specific gravity is associated with dehydration which could be contributing to the client's weight loss.

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?

begin a sequence of interventions to address the hallucinations. Hallucinations can be nonverbal or they can include talking to oneself, moving the lips without making sounds, rapid eye movements, and grinning or inappropriate laughter.

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?

c. Report urinary retention or feeling that the bladder does not empty. Serious side effects include urinary retention, blurred vision or eye pain, confusion and hallucinations, and uncontrollable movements of the client's eyes, lips, tongue, face, and limbs. Dry mouth and constipation are less serious anticholinergic effects. e. Relay feeling of heart palpitation. Tachycardia, palpitations, blurred vision or eye pain, confusion and hallucinations, and uncontrollable movements of the client's eyes, lips, tongue, face, and limbs are all serious anticholinergic side effects. Dry mouth, constipation, and drowsiness are less serious anticholinergic effects.

The client is encouraged to attend a medication psychoeducation group that the nurse is leading. The qualities of an effective nurse leader are the same qualities that are important in the therapeutic relationship: empathy, genuineness, creativity, and assertiveness. While leading the group, the nurse should be aware of group content and group process. The nurse is training a new team member. Which explanation best promotes effective communication when discussing group process and group content?

content includes client's words, process is how clients communicate. Group content includes what the group members say, and group process refers to how they communicate their thoughts and feelings.

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?

diphenhydramine IM. The client is experiencing a dystonic reaction, so the nurse should provide relief with diphenhydramine IM or benztropine IM.

neurotransmitter intercepted by haldol

dopamine. Traditional antipsychotics block excessive dopamine, an excitatory neurotransmitter, so that symptoms related to psychosis are reduced.

Group activities, such as drawing, exercising to music, baking, community trips, and arts & crafts are offered on the unit. In the afternoon, the client decides to join the group that has chosen drawing as their activity. What is a goal of being in this activity group?

gain self acceptance and express feelings. An activity group promotes self-acceptance, expression of feelings, and a focus on group goals rather than individual issues.

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?

have client repeat what he thinks the voices are saying. The nurse should first ask what the voices are saying in order to assess for command hallucinations.

Which assessment finding warrants immediate intervention by the nurse?

involuntary muscle contractions. Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, particularly of the face, tongue, neck, and jaw which is a serious side effect of halcinonide.

Which assessment data provides evidence that the client can be involuntarily committed to the hospital, if he insists on leaving?

losing 10 pounds in 2 weeks The criteria for commitment includes danger to self and/or others, unable to provide for own basic needs, and/or the need for immediate and adequate treatment. Excessive weight loss demonstrates the client's inability to provide for his own basic needs by not maintaining adequate nutrition.

What is it most important intervention for the nurse to perform before discharging the client?

re-evaluate thoughts to harm self or others. It is very important to reassess that the client is free of suicidal and/or homicidal ideation so that the nurse can document this in the discharge notes.

Which nursing problem is best to include in the initial care plan?

sensory-perceptual alteration related to withdrawal into self. The priority nursing problem is related to the client's hallucinations, which impact his functioning and social interaction.

how should the nurse respond when client says he believes that someone is waiting to kill him?

state how he must be concerned and assure him he will be safe there. The nurse should respond to the client's underlying feelings and not make assumptions about his delusions.

most important part of admission process

take away cigarettes and lighter Safety for the client and the unit environment is the highest priority, so the staff should keep any potentially dangerous objects away from the client.