Psychosis Practice Qs

D

Adam admits that the voices he hears have been getting louder over the past couple of weeks. which question should the nurse ask Adam next? A. "what helps the voices go away?" B. "how long have you heard voices?" C. "when do the voices get louder?" D. "what do the voices say?"

A, B

Adam becomes very agitated and angry, and he talks loudly to himself as he waits to be seen by the healthcare provider (HCP). which medications should the nurse anticipate giving Adam after securing a prescription from the healthcare provider? select all that apply: A. short-acting anxiolytic (benzodiazepines) B. antipsychotic medication C. mood-stabilizing medication D. non-benzodiazepine anxiolytic

C

Adam continues to explain that someone has followed him to the ED and is waiting outside the door to the ED. which thought process describes Adam's inability to leave his apartment because he thinks someone is wanting to kill him? A. hallucination B. phobia C. delusions D. confabulation

B

Adam insists that he needs to leave and should not be in the hospital. which assessment data provides evidence that Adam 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

A

After receiving diphenhydramine (Benadryl) and benztropine (Cogentin) IM for immediate relief, Adam receives a new prescription for benztropine (Cogentin) 2mg PO daily. why is Adam prescribed this medication? A. to reduce severity of extrapyramidal effects B. to prevent the risk for tardive dyskinesia C. to potentiate haloperidol (Haldol) so that it will be more effective D. to further alleviate dystonic reactions

D

after 5 days, the nurse assesses Adam's response to the prescribed haloperidol (Haldol). which response from the client indicates that the haloperidol (Haldol) 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

as part of the admission process, the nurse orients Adam to the program and to his room. what is the most important part of this admission process? A. ask Adam if he has any valuables that need to be locked in a safe place B. allow Adam to explain his understanding of the reason for his hospital admission C. introduce Adam to the nursing staff and explain the role of the case manager and the staff members D. take away Adam's cigarettes and lighter

A

because Adam has hallucinations and delusions, the nurse develops an initial plan of car related to psychosis. which nursing diagnosis 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

B

on the fifth hospital day, Adam reports feeling dizzy as he stands to leave the morning group activity. which action should the nurse implement first? A. offer Adam a glass of juice and ask him if he ate breakfast B. take Adam's blood pressure while he is sitting an standing C. tell Adam that his dizziness is orthostatic hypotension that will subside after D. hold morning dose of haloperidol (Haldol) and notify the healthcare provider

B

several hours after receiving his medication, Adam complains of muscle spasms in his neck and jaw. what side effect of the medication should the nurse suspect? A. akathisia B. dystonia C. tardive dyskinesia D. parkinsonism

B, C, E

the nurse completes the assessment and determines the best precautions to ensure client and staff safety on the unit. which assessment data are the best indicators of the potential for violence? select all that apply: A. gender and age B. past suicide attempts C. history of violence D. medication compliance E. medication noncompliance

A

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

A, B, E

what are the advantages for prescribing the atypical antipsychotic, olanzapine (Zyprexa)? select all that apply: A. lower incidence of extrapyramidal symptoms B. rapid onset C. less weight gain D. alpha-adrenergic blockade E. acute and maintenance therapy

C

what aspect is the most important for the nurse to perform follow-up before discharge? A. contracts to follow discharge plans B. resources to provide community support C. thoughts of harm to self or others D. significant others for support

C, D, E

what interventions are essential to a successful plan during the acute phase of illness? select all that apply: A. isolation B. daily activities C. consistency D. medications E. adequate rest

D

what is the difference between 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 the 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

A

what is the most important benefit that a patient can receive from their attendance at the community meeting? A. reality orientation B. limits set on behaviors C. psychosocial skills D. mutual goal setting

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 (Haldol)? A. GABA B. serotonin C dopamine D. norepinephrine

D, E

what nursing interventions should be included in the care plan that is initiated early after admission and reinforced until discharge? select all that apply: A. an understanding of psychosis and causes of it B. the importance of attending support groups after discharge C. depression and anxiety are common causes of psychosis D. client safety E. the purpose and side effects of psychotropic medications

B

when Adam explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond? A. "believe me. no one has followed you here." B. "you must be concerned, but you are safe here." C. "the police will make sure no one is out there." D. "why do you think that someone is out there?"

B

when Adam looks around the room and mumbles to himself, how should the nurse respond? A. "how are you feeling?" B. "are you hearing voices?" C. "have you been here before?" D. "tell me what you're thinking"

B, D

which lab values from the urinalysis can the nurse expect to be related to Adam's 10-pound weight loss in the past 2 weeks? select all that apply: A. positive for red blood cells B. positive ketones C. decreased urine pH D. increased urine specific gravity E. absence of glucose

C

which medication should the nurse give to immediately relieve the muscle spasms in the client's neck and jaw? A. lorazepam (Ativan) IM B. benztropine (Cogentin) PO C. diphenhydramine (Benadryl) IM D. acetaminophen (Tylenol) PO

C, E

which serious, anticholinergic side effects are related to the use of benztrophine (Cogentin)? select all that apply: A. feeling tired B. dizziness C. urinary retention D. hand tremors E. tachycardia

C

which term fits the nurse's observation that Adam looks to the corner of the room and mumbles to himself? A. delusions B. depersonalization C. hallucinations D. disorientation