NGN Mental Health Mental Health Concepts

The following scenario applies to the next 1 times The nurse is caring for a client in the mental health unit experiencing psychosis Item 1 of 1 Nurses' NotesMedicationsMedical History 1300 - Client was banging their food tray and shouting at other clients. De-escalated the situation by escorting the client back to their room. Once back to their room, the client kept shouting 'they are after me!' at the roommate. The client stopped the shouting but resumed several minutes later. The client refused the scheduled by-mouth (PO) olanzapine, stating, 'they don't want me to take that.' Olanzapine 10 mg PO Daily Schizophrenia Vitamin D deficiency Hyperlipidemia ➢ Select two (2) actions the nurse should take Provide therapeutic touch Limit interaction with the client Place the client in seclusion Ask if the client hears any voices Crush the olanzapine in the client's food Reassign the client to a private room Submit Answer

Ask if the client hears any voices Reassign the client to a private room Explanation This client is experiencing overt paranoia, and the nurse should ask if the client hears any voices. Auditory hallucinations are the most common perceptual disturbance associated with schizophrenia and may contribute to a client's paranoia. If auditory hallucinations are evident, this allows the nurse to intervene by exploring the content of the hallucination and reorientating the client. Reassigning the client to a private room is appropriate. The client is in the mental health unit, and milieu therapy provides an organized, structured, and safe environment for all clients. The client's condition is disrupting this type of therapy, and for the safety of the other clients, the client should be reassigned to a private room close to the nursing station. Therapeutic touch is not recommended because the client experiencing paranoia may misinterpret this action. Interaction should not be limited because this would hinder the therapeutic relationship. The client's behavior also warrants increased monitoring. Seclusion is not recommended because the client is not exhibiting any violence (self-directed or towards others). Since the client has refused the medication, crushing olanzapine, and placing it in the client's food is unethical and not permitted. Additional Info A client experiencing psychosis has a detachment from reality. Psychosis is often described as the fever of schizophrenia. Key Interventions for Psychosis and Paranoia: Maintain a safe environment Assess the client for suicidal and homicidal ideations Establish a therapeutic rapport Avoid therapeutic touch and whispering in the client's presence Focus on reality-based topics and frequently reorientate the client.

The following scenario applies to the next 1 times A 22-year-old is evaluated in the emergency department for recurrent seizure activity Item 1 of 1 History And PhysicalOrders A 22-year-old female client was with friends at a restaurant and reportedly started acting odd and then had uncontrollable and uncoordinated movements. This lasted three minutes. Once this terminated, EMS was called, and this occurred again and lasted four minutes. EMS administered lorazepam. The client does not have any medical history or take any medications. On exam, she did not recall the seizure, nor did she remember how she felt leading up to the seizure. She denied any drug use. She is drowsy following the administration of lorazepam but can sustain attention and is fully oriented. Glasgow Coma Scale 14. Will admit the client for observation. CT Scan of head Electroencephalogram (EEG) Magnetic Resonance Imaging (MRI) of brain Complete blood count Complete metabolic panel Loading dose of intravenous (IV) phenytoin Urine drug screen Urine pregnancy test ➢ For each physician order, click to specify the appropriate nursing intervention OrderNursing Intervention Magnetic Resonance Imaging (MRI) of brain Ensure the client has a negative pregnancy test prior to the exam Assess if the client has claustrophobia prior to the exam Have the client nothing by mouth (NPO) eight hours prior to the exam Loading dose of intravenous (IV) phenytoin Monitor, the client's lung, sounds for pulmonary edema Establish continuous cardiac monitoring during the infusion Insert an indwelling urinary catheter to monitor intake and output Electroencephalogram (EEG) Position the client side-lying with their knees to their chest Instruct the client how to remove the adhesive after the test Assess the client for an allergy to intravenous (IV) contrast dye Submit Answer

Assess if the client has claustrophobia prior to the exam Establish continuous cardiac monitoring during the infusion Instruct the client how to remove the adhesive after the test Explanation Claustrophobia is a concern for the client scheduled to undergo an MRI because most MRIs are closed. Claustrophobia may impede an effective exam as the client may move. While some MRIs are open, a remedy to this problem may be the physician prescribing a benzodiazepine or antihistamine prior to the exam. MRIs do not require a negative pregnancy test as they are safe during all trimesters of pregnancy. MRIs do not require a client to be NPO. For a client receiving phenytoin, continuous cardiac monitoring must be established and maintained because of the risk of arrhythmias. This medication must be infused in a large-bore IV catheter because of the risk of thrombophlebitis. Mannitol, an osmotic diuretic, may adversely cause pulmonary edema, but this medication is not intended to prevent seizures. Inserting an indwelling catheter to monitor accurate output is not an appropriate intervention for this medication. Phenytoin is a medication used for preventing seizure activity. An electroencephalogram (EEG) is a non-invasive diagnostic test utilized to look at brain waves. In this test, the client has electrodes placed around their head for a set period of time. Fasting is avoided because hypoglycemia may alter the brain waves. Additionally, the nurse should clarify the administration of central nervous stimulants and depressants prior to this exam, as this will alter brain waveforms. Finally, the nurse should instruct the client to avoid the use of hair creams, gels, and conditioners prior to the exam, as this will prevent the electrodes from adhering to the skin. The adhesive gel can be removed at the end of the procedure. The client does not need to be side lying for this procedure as this is one of the two positions used for a lumbar puncture. Finally, the client does not need to be assessed for contrast dye allergy as this contrast dye is not used in this procedure. Additional Info For a client experiencing a seizure not associated with known epilepsy, several diagnostic tests will be done to rule out conditions such as substance use or tumors. It is essential that seizure precautions be maintained for any client at risk for seizures. Seizure precautions include - Having a bed with padded side rails Oxygen available at the bedside Suction at the bedside Prescribed benzodiazepines to terminate an acute seizure

The following scenario applies to the next 1 times The nurse is caring for a client diagnosed with schizophrenia with catatonia Item 1 of 1 History And Physical A 22-year-old female was admitted from the emergency department (ED) after wandering in the local park. The client was disheveled, completely mute during the assessment, and did not respond to external stimulation. The client had a fixed stare at the ceiling and a marked reduction in purposeful movements. The physical exam noted flaky skin with tenting and dry mucous membranes. Medical records reveal that this client has a history of schizophrenia. ➢ Which prescriptions should the nurse anticipate from the primary healthcare provider (PHCP) based on the history and physical? Levodopa-Carbidopa Methylprednisolone Lorazepam Intravenous fluids Venlafaxine Levothyroxine Submit Answer

Explanation Options C, D - Correct - Catatonia is a serious psychiatric syndrome that may occur with psychiatric and medical conditions. The gold standard treatment for catatonia is benzodiazepines such as lorazepam. Lorazepam is preferred because of its modulating effects on the neurotransmitter GABA. The nurse should also request a prescription for intravenous fluids because the clinical data suggests dehydration (skin tenting and dry mucous membranes) which is a likely consequence of catatonia. Options A, B, E, F - Incorrect - Dopaminergic medications (both agonists and antagonists) should be avoided. Agonists should be avoided because they would trigger psychosis, therefore, levodopa-carbidopa would be contraindicated. Antagonists may worsen catatonia and complicate treatment. Therefore, antipsychotics and levodopa-carbidopa are avoided in the treatment of catatonia. Further, steroids (methylprednisolone), serotonergic agents (venlafaxine), and thyroid hormone (levothyroxine) have no role in the treatment of catatonia. Additional Info Catatonia is a syndrome that may co-occur with bipolar disorder or schizophrenia. This condition may cause symptoms such as mutism, stupor, negativism, waxy flexibility, hypokinesia, staring, and bizarre speech patterns such as echolalia. Medical treatment includes parenteral benzodiazepines and electroconvulsive therapy (ECT) in severe cases. Depending on the degree of catatonia, nursing care aims to prevent complications of immobility such as venous thromboembolism and skin breakdown. Intravenous hydration is often used when the client does not drink.

15-20 The following scenario applies to the next 6 times 72-year-old male presents to the emergency department Item 1 of 6 Nurses' Notes 1430 - A 72-year-old white male stated he hasn't felt good lately and feels sad much of the time. He becomes tearful when telling you about the loss of his wife eight months ago. He states he feels lonely and hopeless. The client also stated that the osteoarthritis he was diagnosed with five years ago has worsened. He stated that lately, he gets tired easily but has difficulty falling and staying asleep. He reported that the only activity he has maintained is attending church services. ➢ Which four (4) assessment findings require further investigation by the nurse? Feelings of hopelessness Worsening osteoarthritis Only attending church services Feelings of loneliness Loss of his wife eight months ago Sleep disturbances Submit Answer ➢ Based on these findings, it would be essential for the nurse to make which statement? "Would you tell me more about your bedtime routine?" "Could you describe the severity and quality of your pain?" "Are you having any thoughts of harming yourself?" "Have you ever received mental health services before?" Submit Answer ➢ Complete the following sentence from the list of options The greatest concern for this client is MDD suicide insomnia evidenced by the client's feeling of hopelessness increase fatigue sleep disturbance Submit Answer 72-year-old male presents to the emergency department Item 4 of 6 OrdersAdditional Nursing Note Admit to involuntary status Provide enhanced observation Regular diet Consult psychiatry 1450 - Client endorsed suicidal ideations stating, "I am thinking about ending my life." The client verbalized no specific plan. Enhanced observation and suicide precautions were initiated based on the client's statements. Removed all sharps from the room. The client's belongings were inventoried and stored. The nurse updates the nursing note with an entry at 1450 and receives orders from the primary healthcare provider (PHCP) ➢ The nurse is developing the plan of care for this client. For each possible intervention, click to specify whether or not the intervention is appropriate Possible InterventionAppropriateNot Appropriate Restrict the client's visitors Open letters and packages before giving them to the client Provide information on how to obtain their medical record Round at frequent and regular intervals Inform the client that they may not leave the facility Submit Answer 72-year-old male presents to the emergency department Item 5 of 6 Nurses' NotesOrdersMedicationsAdditional Nursing Note 1430 - A 72-year-old white male stated he hasn't felt good lately and feels sad much of the time. He becomes tearful when telling you about the loss of his wife eight months ago. He states he feels lonely and hopeless. The client also stated that the osteoarthritis he was diagnosed with five years ago has worsened. He stated that lately, he gets tired easily but has difficulty falling and staying asleep. He reported that the only activity he has maintained is attending church services. Admit to involuntary status Provide enhanced observation Regular diet Consult psychiatry Bupropion 150 XL PO After receiving a consultation with psychiatry, the physician prescribed this client medications ➢ The nurse prepares to administer the prescribed bupropion. Which two (2) teaching points should the nurse include? This medication may cause you to gain weight. You may notice a decreased libido while on this medicine. Have a diet that has a consistent intake of salt and water. You may have more energy with the medication. You will need ongoing laboratory work while on this medicine. Take this medication in the morning to prevent sleep problems. Submit Answer ➢ Click to highlight the findings in the progress note that specify that the client is ready for discharge Progress Note The client was alert and oriented. He described his mood as good and had a cheerful affect. He denied any suicidal ideations. The client stated he still isn't sleeping well and would like a prescription for a sleep aid. The client has not attended group therapy since admission. The client stated he would be staying with friends from church. He also stated that he found an outpatient therapist. Submit Answer

Explanation The client is exhibiting depressive symptoms that are a concern for suicidality. His hopelessness, loneliness, loss of his wife four months ago, and sleep disturbances were all quite concerning. Hopelessness is a very significant risk factor of suicide because it inhibits forward-thinking by the client. Consequently, the client's loneliness from the loss of his wife is also a risk factor for suicide. This significant disruption in a support system likely stems from the client's dysphoria. Insomnia is a risk factor for suicide ideations and further characterizes the client's depression. Feelings of hopelessness Feelings of loneliness Loss of his wife eight months ago Sleep disturbances Explanation It is essential that the nurse recognize the client's cues as a concern for suicide. It is appropriate for the nurse to ask the client directly if he is having any thoughts of harming himself. The nurse should not ask leading questions such as "You are not thinking about harming yourself, are you?" This type of question discourages the client from being honest. Assessing the client's bedtime rituals, pain level, or history of obtaining mental health services does not address the core concern of the client's safety. "Are you having any thoughts of harming yourself?" Explanation Suicide is absolutely the primary concern for this client. Central to suicidality is a client feeling hopeless, and this was explicitly expressed by the client. The depressive disorder that the client is likely experiencing needs to be addressed but is not life-threatening as the thoughts of suicide. suicide feeling of hopelessness Explanation When a client is admitted involuntarily, they still retain the client bill of rights. It would be appropriate to provide information on how a client may obtain their medical record because this is a right afforded to the client. It would also be appropriate to inform the client that leaving the facility is prohibited while being admitted involuntarily. It is not appropriate to restrict visitors or open postal packages prior to giving them to the client. The client has the right to privacy, opening postal packages, and denying the client phone privileges would violate their bill of rights. Finally, rounding the client at regular intervals is discouraged. It would be appropriate to round on the client at irregular intervals to decrease predictability and enhance client surveillance. Restrict the client's visitors not Open letters and packages before giving them to the client not Provide information on how to obtain their medical record appr Round at frequent and regular intervals not Inform the client that they may not leave the facility appro Explanation Bupropion is an atypical antidepressant that modulates norepinephrine and dopamine. This medication is activating and does provide the client with increased energy, therefore, decreasing their weight. Bupropion does not cause sexual side effects like other antidepressants. Considering that this medication is activating, it would be appropriate for the nurse to advise the client to take it in the morning and not in the evening to avoid worsening the insomnia. Laboratory work is not necessary while a client is taking bupropion, nor is maintaining a diet consistent in fluid and salt. This dietary recommendation is for lithium. You may have more energy with the medication. Take this medication in the morning to prevent sleep problems. Explanation Client statements and behavior indicating he is ready for discharge are alert and oriented. This is a positive cognitive finding. His mood and affect appear positive and harmonious and, thus, is also another indicator for discharge. The client stating that he will be staying with friends from church is reassuring as he will have a support system after discharge. Finally, working with an outpatient therapist is a reassuring finding. Findings that indicate that the client is not ready for discharge include his reluctance to attend inpatient group therapy and not being able to sleep. His report of insomnia will need to be mitigated to help decrease his further risk of suicide. Additional Info Suicide is a pervasive issue, and the nurse should work diligently to recognize individuals at risk for suicide. General risk factors for suicide include - Being divorced, separated, or widowed White males over the age of 45 A psychiatric diagnosis Previous suicide attempts Substance use Chronic illness Women attempt more; men are complete more suicide Feelings of hopelessness and loneliness Progress Note The client was alert and oriented. He described his mood as good and had a cheerful affect. He denied any suicidal ideations. The client stated he would be staying with friends from church. He also stated that he found an outpatient therapist.

The following scenario applies to the next 1 times The emergency department nurse is caring for a 22-year-old with altered mental status Item 1 of 1 Admission NotesVital Signs 2330 - 22-year-old male client arrived at the emergency department (ED) with friends who were at a party and was observed snorting a white powder and started acting erratically. The client is hyper-alert, agitated, and only oriented to place on assessment. The client started shouting at staff during the assessment and struck a nurse with his fist. The primary healthcare provider (PHCP) was immediately notified of this incident. Temperature 98.0o F (37o C) Pulse 110/minute Respirations 16/minute Blood Pressure 155/96 mm Hg O2 saturation 96% on room air ➢ Complete the following sentences from the list of options Based on the client assessment, the client is likely intoxicated with (heroin cocaine an opioid) The nurse should immediately restrain the client obtain a prescription for an antihypertensive obtain a urine drug screen) based on the client's (BP substance intoxication physical violence) Submit Answer

Explanation The client is most likely intoxicated with cocaine based on the client's hyperarousal, hypertension, tachycardia, and agitation. Cocaine intoxication produces central nervous stimulation, making the client feel paranoid and act erratically. The nurse should restrain the client based on the client's physical violence. The client's physical violence seriously threatens the safety of those around him. The nurse has appropriate cause to restrain the client and then obtain an order from the PHCP within one hour of the initiation of restraints. The client is exhibiting hypertension and tachycardia; however, his physical violence is the priority to address as this creates an immediate safety concern. Additional Info Cocaine is a stimulant and produces significant blood pressure and pulse increases. Psychotic symptoms such as paranoia are also common. Withdrawal symptoms cause the client to become drowsy and crave food, especially sweet foods. Heroin and opioid intoxication would produce CNS depressive symptoms.

3-8 The following scenario applies to the next 6 times The nurse cares for a 33-year-old male in the emergency department (ED) Item 1 of 6 History And PhysicalVital Signs Client was brought to the ED by the police after he started driving erratically and had almost collided with several vehicles. After being pulled over, the client stated he was 'driving into this future.' The client was incoherent in his responses to police officers and became angry when he was arrested. He is brought to the emergency department for medical clearance. On exam, the client is hyperalert/hyper aroused and has an expansive affect. He recognizes that he is in a hospital, but when asked what year it is, he states, "we are in the future." He states the bright lights he sees sparkle and that it is showing him the future. He cannot detail any of his medical history or current medications. The client does not stay on topic during the interview and frequently switches topics. He is pacing within the exam room and insists on going outside to the roof to see 'if he can fly.' The client has impaired insight and judgment. His father arrived to provide collateral information, stating that his son has bipolar disorder and ran out of medication several days ago. He states that four days ago, he noticed a change in his son, becoming more talkative and staying longer at work to feel more productive. His father states that his last call with his son was two days ago, and he noticed that his symptoms had worsened, and he could not go to work. Oral Temperature 98o F (36.7o C) Pulse 83/minute Respirations 15/minute Blood pressure 134/79 mm Hg O2 saturation 96% on room air The nurse assesses the client and reviews the history and physical. ➢ Which client finding has the nurse most concerned? The client's expansive affect. impaired judgment. medication adherence. inability to stay on topic. Submit Answer ➢For each client finding, click to specify if it is consistent with hypomania or mania. Client FindingHypomaniaMania Talkative and able to still go to work Impairment in insight and judgment Worsening of symptoms leading to work absenteeism Visual hallucinations ➢ Drag words from the choices below to fill the blank in the following sentence The client most likely has Word choices The client is at greatest risk for Word choices Word choices self-harm. mania. hypomania. ineffective health maintenance. Submit Answer The client is transferred to the behavioral health unit and diagnosed with a manic episode. ➢ Select the anticipated provider orders from each of the following categories. Each category must have at least one option selected. CategoryPotential Orders Admission Status Involuntary Voluntary Medications Valproic Acid Haloperidol Monitoring Seizure precautions Enhanced observation Submit Answer The nurse receives orders from the physician ➢The nurse is preparing to administer a dose of valproic acid to the client. The nurse should be prepared to monitor which laboratory data while the client takes this medication? Select all that apply Complete blood count Liver function tests Arterial blood gas Urine electrolytes Valproic acid level Submit Answer The nurse reviews the physician's progress note ➢The nurse is providing discharge education regarding the prescribed valproic acid. Which statement, if made by the client, requires follow-up? I will need follow-up laboratory work while taking this medication. I may need to take a multivitamin while taking this medication. It is okay for me to skip a dose of this medication if I get nausea. I should notify my physician if I notice any yellowing of my eyes. Submit Answer

Explanation The client's impaired judgement is of significant concern because it threatens the safety of the client and others. The other findings are not significantly important because it does not present a safety issue when compared to impaired judgement. Explanation A significant difference between hypomania and mania is its impairment on an individual's life. Hypomania causes an individual to be euphoric, have an expansive affect, and have the need for little sleep. A key difference is that hypomania typically lasts four days or less and does not impair and individual's life, where mania does cause an impairment. Additionally, mania may induce perceptual disturbances such as hallucinations. This is not a feature found in hypomania. Talkative and able to still go to work hypo Impairment in insight and judgment Mania Worsening of symptoms leading to work absenteeism Mania Visual hallucinations Mania Explanation The client is demonstrating mania as evidence by his erratic driving and impairment of cognition and judgement. This client will need to be admitted because of his risk of self-harm. This self-harm is linked to his inability to make appropriate judgments. The client most likely has mania. The client is at greatest risk for self-harm. Explanation This client's inability to make sound judgments makes him at risk for harm to himself and others. Thus, this client should be involuntarily admitted as the criteria for this type of admission is if the client is a danger to themselves or others. Valproic acid (VPA) needs to be administered to the client because it is a mood stabilizer. This medication has the goal to break the client's mania. Haloperidol would be inappropriate because this is indicated for psychotic disorders such as schizophrenia. Considering the client's volatile behavior, it is appropriate for the client to receive enhanced observation to minimize and risk of self-harm. Involuntary Valproic Acid Enhanced observation Explanation Valproic acid (VPA) is a mood stabilizer and may cause blood dyscrasias such as thrombocytopenia. The client's CBC should be monitored closely. VPA is also hepatotoxic and the live function tests should be observed for any type of liver injury. Arterial blood gas and urine electrolytes are unnecessary to monitor while a client is taking VPA. Complete blood count Liver function tests Valproic acid level Explanation This statement requires follow-up because valproic acid requires good adherence to maintain a therapeutic level between 50-125 mcg/mL. Nausea is a common side effect associated with this medication and may be minimized by the client taking the medication with food. The other statements are true regarding this medication and do not require follow-up. Additional Info Mania is a feature of bipolar I disorder. Mania causes an individual to have an impairment in functioning, which poses a serious risk to themselves or others regarding safety. Other clinical features associated with mania include - Unstable mood Expansive affect Pressured speech with irregularities, including tangential and circumstantial speech Perceptual disturbances such as delusions of grandeur Hypersexuality It is okay for me to skip a dose of this medication if I get nausea.

The following scenario applies to the next 1 times The nurse cares for a 22-year-old female with an eating disorder Item 1 of 1 History And Physical A 22-year-old female was admitted voluntarily to the inpatient unit following a need to 'get help with her eating habits.' Reportedly, the client admits to eating a large amount of food and feeling 'disgusted' afterward, which triggers self-induced vomiting. She has done this multiple times and reports it has 'gotten out of control.' She says she is always worried about her appearance 'not being good enough.' She denies using any laxatives or diuretics; however, her mother reports she found two empty boxes of laxatives in her apartment. On exam, the client is alert and completely oriented. She is cooperative during the exam and has an anxious and worried affect. She has a slender appearance and a current body mass index (BMI) of 20. Scars were observed on both index fingers. She says physically, her only complaint is daily heartburn and occasional dizziness during exercise. The nurse develops a care plan for this client based on the history and physical ➢ For each nursing diagnosis, click to specify the appropriate nursing intervention Nursing DiagnosisPotential Interventions Imbalanced Nutrition have the client fast overnight provide small frequent meals allow the client to eat meals alone Disturbed Body Image recommend inpatient group therapy focus all convo on the clients weight restrict visitation with friends and fam Anxiety make decisions for the pt promote positive reframing provide the client with time to be alone Submit Answer

Explanation This client is demonstrating signs of bulimia nervosa. To address the imbalanced nutrition nursing diagnosis, the nurse should provide small, frequent meals. This decreases the interval between large meals, decreasing the likelihood of purging. The client should not eat meals alone as they risk purging. They should be supervised thirty minutes following meal consumption. Group therapy is recommended for a client with a disturbed body image. This allows the client to engage with others and develop rapport and self-esteem. Conversations should not be focused on the client's weight as this will further condition their altered perception. Visitation with friends and family should not be restricted as they will be essential in the discharge process. Promoting positive reframing is always an effective strategy for anxiety nursing diagnosis. This helps decondition this cognitive and behavioral disconnect. Decision-making should not be made for the client; allowing the client to be alone encourages rumination. This could increase anxiety. Additional Info Bulimia nervosa is an eating disorder characterized by an individual binging and purging. An individual usually consumes a large number of calories and may experience a sense of revulsion, triggering them to purge. An individual may also abuse laxatives and diuretics and engage in excessive exercise. Fluoxetine is the only approved medication indicated in the treatment of this eating disorder.

The following scenario applies to the next 1 times The nurse is caring for a client terminally ill and newly admitted and receiving hospice services Item 1 of 1 Admission Note 65-year-old female was admitted for stage IV ovarian cancer. The client decided to forego further treatment and decided on comfort measures only. The client is drowsy and reports nausea and generalized pain. She makes little eye contact and reports increasing discomfort when the head of the bed is elevated. Skin is cool and mottled. The client is experiencing urinary incontinence. ➢ For each client need, click to specify the potential nursing intervention that would be appropriate for the client's care. Each category must have at least one option selected. Client NeedPotential Nursing Intervention Nutritional Keep the client nothing by mouth (NPO) Offer high calorie small frequent meals Use moist swabs to the mouth and lips Thermoregulation Layer the client with warm blankets Apply heating pads to the extremities Turn on a fan to cool the client Comfort Restrain the client during periods of agitation Play soothing music and aromatherapy Position the client on their side for gurgling Elimination Place plastic underpads for incontinence Offer an indwelling catheter for comfort Give an enema for nausea caused by c

Nutritional Keep the client nothing by mouth (NPO) Use moist swabs to the mouth and lips Thermoregulation Layer the client with warm blankets Comfort Play soothing music and aromatherapy Position the client on their side for gurgling Elimination Offer an indwelling catheter for comfort Give an enema for nausea caused by constipation Explanation For the client receiving hospice services and comfort measures only, the nurse must collaborate with the interprofessional team to maintain client comfort. This client experiences discomfort when the head-of-the-bed is elevated and drowsy; thus, the nurse should keep the client nothing by mouth (NPO). This would prevent aspiration and would cause significant distress and discomfort. The nurse should use moist swabs to the mouth and lips to prevent chapping and maximize comfort. Layering the client with warm blankets is appropriate, considering the client's appearance is cold and mottled. The nurse should not apply heating pads to the extremities as this could cause injury considering the client's drowsiness. Another unhelpful intervention would be turning on a fan to cool the client, considering the client's mottling skin and cool temperature. Comfort measures can be achieved by playing soothing music and offering aromatherapy. This would be helpful for the client's nausea. Placing the client on their side for any gurgling would be helpful in preventing aspiration. The nurse should not restrain the client for periods of restlessness or agitation. Pharmacotherapy could be utilized, such as benzodiazepines, for this symptom. Offering a urinary catheter is an appropriate comfort measure. This would minimize discomfort as urinary incontinence would cause skin breakdown. Infection is not a concern regarding using an indwelling catheter; rather, achieving comfort is essential. Using plastic underpads would be unhelpful as this traps moisture and contributes to skin breakdown and discomfort. The client's complaints of nausea may be caused by constipation; if this is the case, an appropriate nursing intervention would be to administer an enema to alleviate constipation.

The following scenario applies to the next 1 times The nurse cares for a client in the emergency department with suspected substance intoxication Item 1 of 1 Nurses' NotesVital Signs A 31-year-old male client was brought to the emergency department (ED) by police after being found acting bizarrely at a local park. The client is hyper-alert and oriented. His speech is fast, and repeatedly states that 'someone is after him.' He has vomited twice approximately 100 mL of opaque fluid. Oral temperature 99.5 F (37.5° C) Pulse 110 bpm Respirations 22/minute BP 193/113 mm Hg Oxygen saturation 95% on room air. ➢ For each assessment finding, click to indicate if it is consistent with alcohol intoxication or amphetamine intoxication. Each row must have at least one, but may have more than one, response option selected. Assessment FindingsAlcoholAmphetamine Paranoia Vomiting Hypertension Tachycardia

Paranoia am Vomiting al am Hypertension am Tachycardia al am Explanation Amphetamine is a central nervous stimulant. During intoxication of amphetamines, a client will experience profound hypertension, tachycardia, agitation, impulsivity, a feeling of euphoria, mydriasis, vomiting, and psychotic symptoms such as hallucinations and paranoia. Amphetamine intoxication may be fatal because of significant hypertension and tachycardia, which may cause cardiovascular collapse. Alcohol is a central nervous depressant. During intoxication of alcohol, a client will experience ataxia, the slurring of speech, poor motor coordination, and impairment in memory and attention. Alcohol has a diuretic and vasodilation effect, which may cause hypotension and tachycardia. Alcohol is also highly irritating to the gastrointestinal tract, and vomiting is a clinical feature, especially with high levels of intoxication. Additional Info Amphetamine is a central nervous stimulant. During intoxication of amphetamines, a client will experience profound hypertension, tachycardia, agitation, impulsivity, a feeling of euphoria, mydriasis, vomiting, and psychotic symptoms such as hallucinations and paranoia. Amphetamine intoxication may be fatal because of significant hypertension and tachycardia, which may cause cardiovascular collapse. Alcohol is a central nervous depressant. During intoxication of alcohol, a client will experience ataxia, the slurring of speech, poor motor coordination, and impairment in memory and attention. Alcohol has a diuretic and vasodilation effect which may cause hypotension and tachycardia. Alcohol is also highly irritating to the gastrointestinal tract, and vomiting is a clinical feature, especially with high levels of intoxication.

The following scenario applies to the next 1 times The nurse is caring for a client newly admitted to the medical-surgical unit Item 1 of 1 Nurse's NotePhysician Orders 2100 -A 17-year-old female was admitted with severe dehydration. The client was at school and 'blacked out.' The client is underweight and appears malnourished. She was diagnosed with anorexia nervosa two years ago. She endorsed suicidal ideations saying, 'she is tired of her body and wants to end it all.' She reports persistent dizziness and a headache. Primary Healthcare Provider (PHCP) Prescriptions - 0.9% saline at 150 mL/hr - Psychiatry consultation - Fluoxetine 40 mg PO daily - Daily weights - Dietician consultation - Supervise mealtimes ➢ Drag one (1) prescription and one (1) nurse's note finding to complete the sentence Based on the client's clinical data, the nurse should immediately Physician's orders based on the client's Health History Findings Physician's orders administer olanzapine initiate 0.9% saline infusion weigh the client establish a therapeutic rapport Health History Findings suicidal ideations severe dehydration altered nutrition underweight appearance Submit Answer

initiate 0.9% saline infusion based on the client's severe dehydration Explanation The client is exhibiting concerning signs of severe dehydration (persistent dizziness and an episode of syncope). The nurse must prioritize physical needs and interventions, which is initiating the intravenous fluids. The intravenous fluids will positively effect severe dehydration. The nurse should then address the client's suicidal ideations by ensuring the environment is safe and then establishing a therapeutic rapport. While no approved medication is available for anorexia, olanzapine has shown some benefit as it increases weight. This medication will take several days to gain efficacy and is not the priority. Weighing the client will not correct the client's severe dehydration, which is causing her dizziness and syncope. If a client has a mental health disorder, physical needs still are a priority. Additional Info Anorexia nervosa can be a life-threatening eating disorder. This eating disorder is characterized by an intense fear of weight gain, restriction of food take that causes a significantly low weight, and a distorted self-perception. Anorexia nervosa may also feature binging and purging. The key distinguishing factor between anorexia nervosa and bulimia nervosa is the abnormally low BMI in anorexia. The primary treatment of anorexia nervosa is psychotherapy with potential augmentation with olanzapine. Subject Mental Health Lesson Mental Health Concepts Client Need Area Psychosocial Integrity Client Need Topic Mental Health Concepts Question Type Take Action Last Updated - 23, Nov 2022