Hesi case study Psychosis RN

On what aspect is it most important for the nurse to perform follow-up before discharge?

C. Thoughts of harm to self or others Rationale: Important to reassess client is free of thoughts to harm to self and/or others.

Which serious anticholinergic side effects are related to the use of benztrophine (Congentin)? (Select All that Apply).

C. Urinary retention, E. Tachycardia

Which nursing diagnosis is important to include in the initial care plan?

A. Sensory-perceptual alteration related to withdrawal into self. Rationale: Priority focuses on client's hallucination, which impact his functioning and social interaction.

Which lab value(s) from the urinalysis can the nurse expect to be related to Brian's 10-pound weight loss in the last 2 weeks? Select all that apply

B. Positive keytones. D. Increased urine specific gravity. Rationale: B. Suggests malnutrition, starvation, and fasting. D. Suggests dehydration.

Which action should the nurse implement first?

B. Take Brian's BP sitting and standing. Rationale: Since the client is feeling dizzy orthostatic vitals are recommended.

What medication should the nurse immediately give to relieve the muscle spasms of the clients neck and jaw?

C. Diphenhydramine (Benadryl) IM. Rationale: To reduce severity of extrapyramidal effects

What neurotransmitter is targeted by (haloperidol)Haldol?

C. Dopamine Rationale: Traditional antipsychotics medication block excessive dopamine.

What is the goal of being in this activity group?

C. Gain self-acceptance and expression of feelings Rationale: Promotes self-acceptance, expression of feelings, and focuses on group goals rather than individual issues.

Which term fits the nurses' observation that the client looks to the corner of the room and mumbles to himself?

C. Hallucinations Rationale: nonverbal cues of hallucinations include talking to oneself or moving the lips without making sounds, rapid eye movements, grinning or inappropriate laughter.

Diphenhydramine (Benadryl) IM is available 100mg/mL. The dosage is 75mg IM. How many mL should the nurse administer?

0.75 Rationale: 75 divided by 100

The client becomes very agitated and angry, and he talks loudly to himself as he waits to be seen by the HCP. Which medication(s) should the nurse anticipate giving the client after securing a prescription from the HCP? (Select All that Apply)

A&B. Short-acting anxiolytic (benzodiazepines) and Antipsychotic medication. Rationale: Short-acting anxiolytic (benzodiazepines) are most effective for anxiety-related symptoms to produce calming and sedation. Antipsychotic medication are effective for psychosis-related symptoms and manifestations of agitation associated with mental illness.

What are the advantages for prescribing atypical antipsychotic olanzapine (Zyprexa)?

A. Calming but not sedating, B. Rapid Onset, E. Acute and maintenance therapy. Rationale: Zyprexa is not sedating, provides rapid onset, and treatment is effective with acutely agitated through injection.

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

A. Detection of substances that may have caused Brian's delusions and/or hallucinations. Rationale: Presence of substances that may have altered the client's mental health status.

What is the most important benefit client can receive from his attendance at the community meeting?

A. Provides reality orientation Rationale: Meetings are designed to introduce clients to one another and address clients concerns and questions and help ground the client to reality.

Why is Brian started on this medication?

A. Reduce severity of extrapyramidal effects Rationale: The addition of benztrophine (Congentin) will reduce the likelihood of severe of extrapyramidal effects.

What is the purpose of a baseline CBC prior to initiation of the antipsychotic medication?

C. Monitor for agranulocytosis Rationale: is a potentially life-threatening side effect that manifests as fatigue, sore throat, and fever.

What are the important reason(s) for this teaching?

A. To encourage client continued compliance of meds C. To monitor the early tardive dyskensia D. to reinforce education done throughout hospitalization. E. To tell client to discuss symptoms with his nurse.

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

B. "Are you hearing voices?" Rationale: The client is demonstrating nonverbal cues that he is experiencing hallucinations, so the nurse should ask the client if the nurse is hearing voices.

When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond?

B. "You must be concerned, but you are safe here." Rationale: The nurse should respond to the clients underlying feelings and not make assumptions about his delusions.

What side effect of the medication should the nurse expect?

B. Dystonia Rationale: Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, of the face, tongue, neck and jaw.

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

B. Losing 10 pounds in two weeks. (basic care needs.) Rationale: The criteria for commitment includes danger to self/others, unable to provide for basic needs (excessive weight loss because he is not getting adequate nutrition), and or mentally ill and in need or immediate and adequate treatment.

Which assessment data are the best indicators of the potential for violence? (Select All that Apply).

B. Past suicide attempts, C. History of violence, and E. Medication noncompliance. Rationale: history of self harm, history of violence, and violence increased with under medication clients.

Meet the Client: Brian Jones

Brian Jones, a 36-year-old is accompanied to the emergency department (ED) by several police officers and his caseworker. The caseworker called the police to enter the client's apartment because Brian refused to answer the door. The caseworker brings some medication bottles from Brian's apartment and reports that 4 months ago Brian stopped taking all psychotropic medications. Brian has poor eye contact, his appearance is disheveled, his hair is dirty and uncombed, and there are stains on his clothes. Brian denies current suicidal ideation, although the caseworker reports a history of past suicide attempts and violence. He has lost 10 pounds in the past 2 weeks, sleeps 12 hours daily, and doesn't leave his apartment. The nurse observes that Brian sometimes looks to the corner of the room and then looks down and mumbles to himself during the interview. Brian admits to the nurse that he did not want to leave his apartment, because he thought someone was waiting to kill him.

What additional interventions are essential to a successful plan? (Select All that Apply).

C. Consistency, D. Medications Rationale: Consistency is essential. Administration of additional prescribed scheduled and PRN medications based on the observations of clients behaviors are unsafe for the client, others, and for the staff may be required.

Which thought process describes the client's inability to leave his apartment because he thought someone was waiting to kill him?

C. Delusions Rationale: A delusion is a false belief that is firmly maintained even though it is not shared others and is contradicted by reality.

Which nursing action is appropriate for this request?

D. Obtain a prescription from the health care provider to return medications.

What is the most important part of this admission process?

D. Take away Brian's cigarettes and lighter Rationale: safety for the client and the milieu.

The client admits that the voices he hears has been getting louder over the past couple of weeks. Which question should the nurse ask next?

D. "What do the voices say?" Rationale: the nurse should first ask what the voices are saying in order to assess for command hallucinations.

What nursing intervention(s) should be included in Brian's care plan initiated early after admission and reinforced until discharge? (Select All that Apply).

D. Client Safety and E. The purpose and side effects of psychotropic medications. Rationale: During early admission Briand should understand that not eating endangers his health, and Once Brian is able to process the information, he should be informed about the purpose and any side effects of the antipsychotic medications that are prescribed.

What is the difference between group content and group process?

D. Content includes the clients' words, and group process is how the clients communicate Rationale: Group content includes what the group members say. Group process involves how the group communicates their feelings and thoughts.

Which response from the client indicates that Haldol is effective?

D. Experiences fewer hallucinations Rationale: Client should experience fewer hallucinations if the medication is effective.