Semester 4. Unit 1. Psychosis

The nurse is providing instructions to a client who is on isocarboxazid for depression. Which statements made by the client indicate effective learning? Select all that apply. One, some, or all responses may be correct. 1. "I will include yogurt in my diet." 2. "I will avoid soy sauce in my diet." 3. "I will avoid pepperoni in my diet." 4. "I will include cream cheese in my diet." 5. "I will avoid fermented bean curds in my diet."

Correct1 "I will include yogurt in my diet." Correct3 "I will avoid pepperoni in my diet." Correct4 "I will include cream cheese in my diet." Correct5 "I will avoid fermented bean curds in my diet." Isocarboxazid is a monoamine oxidase inhibitor (MAOI) used to treat depression. Clients on MAOIs should avoid foods containing high amounts of tyramine. Yogurt and cream cheese have low to no tyramine content. Fermented bean curds are high in tyramine and should be avoided. Pepperoni is a high-tyramine food that should be avoided. Soy sauce with low tyramine content is permissible.

Which response would the nurse make to a client who says, "Please let me go. I trust you. The Mafia is going to kill me tonight"? 1. "You're frightened. Come with me to your room, and we can talk about it." 2. "Come with me to your room. I'll lock the door and no one will get in to harm you." 3. "Nobody here wants to harm you, and you know that. I'll come with you to your room." 4. "Thank you for trusting me. Maybe you can trust me when I tell you that no one will kill you here."

Correct1 "You're frightened. Come with me to your room, and we can talk about it." The nurse would say, "You're frightened. Come with me to your room, and we can talk about it." Acknowledging that the client is frightened and offering a chance to talk acknowledges the client's feelings and provides assurance that the staff member will be present. Locking the client in a room will only increase the fear and worsen the delusion, and it is illegal. The client does not know that no one wants to cause the client harm; otherwise, the delusion would not be present. Also, saying, "you know that" is accusatory. The client is not ready to accept that no one wants to kill the client and really believes that danger is imminent. Thus saying "no one will kill you here" is ineffective.

Which intervention would the nurse use for a client taking quetiapine for acute psychosis who develops lead-pipe rigidity, trismus, and tachycardia? Select all that apply. One, some, or all responses may be correct. 1. Perianal care 2. Fall precautions 3. Use of a cooling blanket 4. Monitoring of intake and output 5. Discontinuation of the medication 6. Administration of bromocriptine as prescribed

Correct1 Perianal care Correct2 Fall precautions Correct3 Use of a cooling blanket Correct4 Monitoring of intake and output Correct5 Discontinuation of the medication Correct6 Administration of bromocriptine as prescribed The client is demonstrating symptoms of neuroleptic malignant syndrome (NMS). Perianal care would be needed for incontinence. Fall precautions would be instituted for alterations in consciousness. Cooling blankets would be used for pyrexia. Intake and output would be monitored to assess for dehydration caused by diaphoresis, fever, and reduced oral intake because of a change in consciousness. The medication would be discontinued as NMS is a potentially fatal adverse effect of antipsychotic therapy. Symptoms usually last for 5 to 10 days after discontinuation of oral medications and 13 to 30 days with depot antipsychotic medicine. Bromocriptine is a dopamine agonist used to treat NMS.

Which would be the nurse's priority when caring for a schizophrenic client exhibiting signs of impaired judgment, paranoia, and agitation? 1. Protecting other clients 2. Placing the client in seclusion 3. Giving antipsychotic medication 4. Talking to the client in a calm manner

Correct1 Protecting other clients When managing the care of a client with schizophrenia who is agitated and paranoid, the nursing priority would be to ensure the safety of the other clients. Once clients are safe, the nurse would talk to the client in a calm manner to attempt to de-escalate the situation. A client may need antipsychotic medication if other nonpharmacological methods are unsuccessful, but this is not the priority intervention. Seclusion would be used only as a last resort.

Which information would the nurse provide a client beginning treatment with haloperidol to prevent injury? 1. Monitor temperature. 2. Wear a mask when out. 3. Change positions slowly. 4. Report pacing and squirming.

Correct3 Change positions slowly. Antipsychotic medications can cause orthostatic hypotension through their mechanism of action—blocking alpha 1-adrenergic receptors in blood vessels. To prevent injury, the nurse will instruct clients to change positions slowly to help prevent light-headedness and subsequent injury from falls. Temperature would be monitored with neuroleptic malignant syndrome. Agranulocytosis can occur with certain antipsychotics and increases the risk of infection. Pacing and squirming, or akathisia, can be disturbing for clients but does not place them at risk for injury.

After reviewing the data of a client with depression, the primary health care provider decided not to prescribe bupropion. Which statements made by the client would support the decision? Select all that apply. One, some, or all responses may be correct. 1. "I have a history of epilepsy." 2. "I have not used phenelzine for 2 months." 3. "I have recently been diagnosed with glaucoma." 4. "I have a history of congestive heart failure." 5. "I have recently been diagnosed with anorexia nervosa."

Correct1 "I have a history of epilepsy." Correct4 "I have a history of congestive heart failure." Correct5 "I have recently been diagnosed with anorexia nervosa." Bupropion is contraindicated in clients with a history of seizures because this medication lowers the seizure threshold. Cardiac diseases such as congestive heart failure and eating disorders such as anorexia nervosa are contraindications for bupropion. Bupropion is contraindicated with concurrent use or 14 days' previous use of phenelzine. Duloxetine is contraindicated for clients with uncontrolled angle-closure glaucoma.