HESI Patient Review: Terry Johnson

Successful use of manipulation to get needs met Wanting to be accepted as a part of a group, we constantly compare our own behaviors and attitudes with those around us. When our behavior is acknowledged and even supported by our family and peers, we feel like we belong. The socio-cultural model suggests that a person with an antisocial personality has adopted manipulative (influencing another to get one's own needs met) and aggressive attitudes and behaviors similar to those in his immediate environment in an effort to "belong." Use of these behaviors resulted in rewards and thus reinforced their continued use. Erratic display of discipline, moral values, and loving attention by significant others. A socio-cultural model would support the idea that lack of or inconsistency in showing right from wrong, love, respect, approval, or acceptance could account for the behavior seen with the antisocial personality.

All of the following may explain the origins of antisocial personality disorder. Socio-cultural explanations include: Select all that apply Reduced levels of serotonin and its metabolite 5-HIAA in cerebrospinal fluid Early childhood trauma to the central nervous system Fixation at a preadolescent cognitive level Never moving beyond using projection, rationalizing and splitting as major protective mechanisms Successful use of manipulation to get needs met Erratic display of discipline, moral values, and loving attention by significant others.

C. Continuously assess for effectiveness of the least-restrictive interventions for Terry while he is restrained D. While Terry is restrained, frequently inform and remind him of the reasons for his restraint and the behavior necessary for restraints to be removed E. Assessment by a qualified staff person at least every 15 minutes while Terry is restrained

Although somewhat calmer, Terry is still agitated and continues to periodically exhibit paranoid behaviors.Physical restraints continue to be necessary because Terry will not contract for safety. He cannot safely care for himself. With regard to use of restraints, which of the following actions are necessary for safe and legal care of Terry? Select all that apply Obtain a standing PRN order for seclusion/restraints so that Terry can be immediately restrained if necessary in the future Avoid restraining Terry for any reason in the future without a written order Continuously assess for effectiveness of the least-restrictive interventions for Terry while he is restrained While Terry is restrained, frequently inform and remind him of the reasons for his restraint and the behavior necessary for restraints to be removed Assessment by a qualified staff person at least every 15 minutes while Terry is restrained

A. sitting with him at eye level, term-0 B. talking with him slowly and gently D. providing him with information about what is happening in simple, accurate terms E. telling him he is safe and that the staff will not hurt him, or allow him to hurt himself or anyone else F. actively listening to and reflecting what he is saying

At this point, approaches to help control Terry's behavior and prevent further aggressiveness include: sitting with him at eye level talking with him slowly and gently suggesting to the physician that IM Haldol (haloperidol) be ordered providing him with information about what is happening in simple, accurate terms telling him he is safe and that the staff will not hurt him, or allow him to hurt himself or anyone else actively listening to and reflecting what he is saying leaving him alone for short intervals

Terry's stat blood and urine drug screens have come back positive for MDMA and alcohol; negative for benzodiazepines, opioids, THC, and cocaine.

Blood/Urine drug Screen +Alcohol +Ecstacy (MDMA) -benzodiazepine -OPiate -THC (cannabinoids, Marijuana) -Cocaine

C. Hyperthermia Ecstasy can cause an uncontrolled rise in body temperature which, although rare, can be fatal.

Given that Terry may have taken Ecstasy, you are especially alert for which potentially fatal drug reaction? Muscle flaccidity Bradycardia Hyperthermia

C. A patient recovering from general anesthesia starts climbing over the side rails of his stretcher

In an emergency, a patient can be restrained or secured without an order. Which of the following would be considered emergencies requiring physical restraint of a patient? An alert, coherent hospitalized patient with cancer who is receiving IV chemotherapy is removing his IV catheter A patient with dementia wanders into the hospital parking lot and refuses to leave A patient recovering from general anesthesia starts climbing over the side rails of his stretcher An alert but disagreeable patient threatens to sign himself out of the hospital

A. Risk for Injury related to being restrained, thrashing about, and impaired judgment B. Risk for Deficient Fluid Volume related to inadequate intake and the dehydrating effects of alcohol, Ecstasy, and tachypnea E. Disturbed Thought Processes related to changes in brain chemistry and anxiety secondary to Ecstasy/alcohol F. Risk for Violence related to disinhibiting and irritating effects of Ecstasy/alcohol and history of assaults

In caring for Terry, you need to address which of the following as priorities? Risk for Injury related to being restrained, thrashing about, and impaired judgment Risk for Deficient Fluid Volume related to inadequate intake and the dehydrating effects of alcohol, Ecstasy, and tachypnea Constipation related to decreased food intake and immobility Self-Care Deficit: Bathing/Hygiene related to confinement and short attention span Disturbed Thought Processes related to changes in brain chemistry and anxiety secondary to Ecstasy/alcohol Risk for Violence related to disinhibiting and irritating effects of Ecstasy/alcohol and history of assaults

B. help him become more calm Your first priority is to help Terry feel calmer and more in control. He will be less likely to cause self-harm if he is more calm and more in control. This will also expedite removal of restraints. Also, Terry will be in a better position to share information, respond to questions, and participate in care if he is more calm.

In providing for Terry's care, your FIRST priority is to:

A. Monitor skin turgor and temperature, mucous membranes, periorbital areas, urinary output, thirst B. Monitor blood pressure, observe for increased restlessness and dystonias D. Pad restraints and side rails, rotate release of restraints E. Avoid providing drinks with caffeine Correct F. Role model slow breathing Correct This intervention is appropriate. Modeling slow breathing should lead Terry to breathe more slowly, which would decrease insensible water loss, as well as help relax him.

In working with Terry, you use a variety of interventions. These appropriately include which of the following? Select all that apply (there are 5 correct answers). Monitor skin turgor and temperature, mucous membranes, periorbital areas, urinary output, thirst Monitor blood pressure, observe for increased restlessness and dystonias Keep Terry busy with lots of activities Pad restraints and side rails, rotate release of restraints Avoid providing drinks with caffeine Role model slow breathing

A. Haldol (haloperidol) by intramuscular injection D. Zyprexa (olanzapine) by intramuscular injection

Medication is now indicated to control Terry's behavior. What medication might the physician order to help Terry become less violent? Ludiomil (maprotiline) by mouth Haldol (haloperidol) by intramuscular injection Lithonate (lithium) by mouth Zyprexa (olanzapine) by intramuscular injection

D. "As I do your exam, I will tell you exactly what I'm going to do." Letting Terry know what you are going to do is important. Telling him your approach would convey respect and acceptance of his current inability to process information quickly.

Terry continues to respond to structure and a firm tone of voice, but he still struggles in his restraints. You need to complete a history and physical assessment. Which verbal approach is best? "Listen while I ask you some questions and do your physical exam." "Stop struggling! You're only hurting yourself." "We're going to finish this exam whether you like it or not." "As I do your exam, I will tell you exactly what I'm going to do."

C. able to steal and lie without remorse The person with an antisocial personality is not internally motivated by knowing what is right and wrong. Often, he has not been exposed to or has not taken in messages from parents or other important adults that would normally help to form a "conscience." Consequently, he does not feel guilt, remorse, regret, or anxiety. He may rationalize actions, explaining his "having" to "fix" things because other people are incompetent or jealous of his "talent." And, although he may apologize for having lied or stolen, his words are not sincere. Persons like Terry may apologize only to protect themselves or to get what they want.

Terry is definitively diagnosed as having antisocial personality disorder. The person with an antisocial personality usually is: careful to maintain lawful behavior and respect social rules free of behavioral problems until age 20 able to steal and lie without remorse careful to plan ahead

C. Terry cannot care for himself and refuses to agree to contract for safety

Terry refuses to admit himself voluntarily to the Chemical Dependency Unit. Which of the following criteria would allow a judge or magistrate to commit him? Continued agitation and periodic paranoid behavior History of assault with related jail sentences Terry cannot care for himself and refuses to agree to contract for safety Diagnoses of Alcohol Intoxication and Drug-induced Psychotic Disorder

C. You sound concerned about Terry.

Terry's friend is obviously frightened and worried about Terry, saying, "No drug should do that. What is wrong with him? Will he be alright?" What response to Terry's friend is best? "I am sorry. Because of confidentiality laws, I am not allowed to tell you anything." "Why don't you just try not to worry." "You sound concerned about Terry." "We do not know what is wrong with Terry right now; so, we cannot predict if he will be alright."

B. Nausea and vomiting may develop with alcohol withdrawal D. Alcohol withdrawal symptoms can include hallucinations

Terry's history reflects that he has been drinking large amounts of alcohol on a daily basis for an extended period of time. Understanding withdrawal from alcohol is necessary for safe nursing care. Which of the following statements about alcohol withdrawal are true? Select all that apply Alcohol withdrawal symptoms typically include somnolence Nausea and vomiting may develop with alcohol withdrawal Although uncomfortable for patients, alcohol withdrawal poses no serious physiological threat Alcohol withdrawal symptoms can include hallucinations

A. the need to conform with behaviors expected of their new peer group Peer relationships and groups are especially important during late adolescence. It is probable that the association these teens have with Terry fills a need to belong. Belonging to a group during adolescence often means conforming to group rules, whatever they may be.

The change in behavior noted in Terry's "followers" can be attributed to the need to conform with behaviors expected of their new peer group a need to be noticed, given all the attention now focused on Terry ambivalence about Terry's power over them changed expectations of staff members

B. Opportunities such as group and activity therapies and community meetings can be used to provide feedback to Terry about his manipulative, controlling behaviors C. Terry's progress can be plotted on a behavioral chart D. Staff expectations can be explained to Terry in terms of benefits to him F. Terry can be encouraged to work out in the gym G. Terry can participate in daily sessions in which he is taught how to problem solve

What approaches can be used to help resolve Terry's problem of Defensive Coping? Select all that apply

D. You sound frightened. I won't let anyone hurt you." Acknowledging Terry's underlying feeling of fear and reassuring him that you will help him stay safe would be best. Terry's excessive bravado, false display of strength, and use of the word "experiments" reflect his vulnerable position. His cursing, threats, demands, and loud voice are attempts to overcome fear and powerlessness through the effects of the drugs.

What is your best response? "You sound drugged. I won't let you speak to me that way." "Don't curse at me! I won't take that from anybody." "You're getting aggressive again. I won't let you hurt yourself." "You sound frightened. I won't let anyone hurt you."

D. countertransference When a staff member has feelings about a patient or the patient's care that emerge because of events or feelings in his/her own life, the process is referred to as countertransference. In countertransference, the patient is really being responded to as if he were someone else. Countertransference impedes therapy by preventing the staff member from seeing the patient as he really is. Feelings of countertransference need to be recognized and personally acknowledged, and possibly discussed with a colleague. It is important that personal feelings not interfere with judgments about a patient.

When a staff member has feelings about a patient or the patient's care that emerge because of events or feelings in his/her own life, the process is referred to as: projection sublimation reaction formation countertransference

C. Dexedrine, an amphetamine Correct Dexedrine, an amphetamine, is a central nervous system stimulant that produces hypervigilance (exceptionally watchful), feelings of grandiosity (exaggerated self-importance), a desire to talk a lot, motor unrest, hallucinations (false perceptions), delusions (false beliefs), violent behavior, increased blood pressure, chills, nausea, and vomiting. Terry has exhibited aggressiveness and paranoia (delusions of persecution) and could have ingested amphetamines. E. Crack, a cocaine derivative Correct Hydrochloride cocaine, or crack (also called rock), often leads to paranoia (delusions/false beliefs of persecution) and distortion of reality, difficulty sleeping, fatigue, depression, poor judgment, inability to abstract, and perhaps aggression. Other signs/symptoms of crack use include shortness of breath, black phlegm, increased cardiac and respiratory rates, scorched facial hairs, and weight loss. Terry has exhibited aggressiveness and paranoia and may have crack in his system. F. Ecstasy (MDMA), a ketamine derivative Correct Terry has exhibited several signs/symptoms that could be associated with Ecstasy (MDMA) use: psychomotor agitation, anxiety, emotional lability (instability), self-importance, and sensory sensitivity. Hallucinations and delusions are also possible with Ecstasy use. Physical effects include increased heart rate and blood pressure. Nausea, vomiting, chills, sweating, and hyperthermia are also possible. Similar to both methamphetamine and mescaline, MDMA is classified as a Schedule 1 drug; and, for some people, may be addictive.

You are able to have a stat blood screen drawn, and Terry provides a specimen for a stat urine screen. In addition to alcohol, what drugs can lead to the behaviors displayed by Terry? Ativan (lorazepam), a benzodiazepine Heroin, an opioid Dexedrine, an amphetamine Marijuana, a cannabis derivative Crack, a cocaine derivative Ecstasy (MDMA), a ketamine derivative

A. Use the approach recommended by the unit's treatment plan. For someone like Terry, who tries to control and manipulate people and systems to his advantage, a unified approach is best. If all team members use the same approach in responding to Terry's refusal to attend classes, he will be less likely to continue his unhealthy pattern of behavior.

You are assigned to oversee Terry's care. He refuses to attend class. Which of the following approaches would be best? Use the approach recommended by the unit's treatment plan Just nod and say, "Okay." Use the approach that seems best given Terry's affect at the moment Very matter-of-factly say, "You are expected to attend. Otherwise, you need to go into locked seclusion."

You are a member of the psychiatric and chemical dependency nursing staff float pool. Today you are assigned on-call to the Emergency Department (ED). During your shift, a young male in handcuffs, accompanied by a friend, is brought in by the police. He is cursing, yelling, and physically struggling. One of the police officers says disparagingly, "Drugs .... Where do you want him?" Your patient is taken to a private back room by other staff members, and still accompanied by the police. Before joining them you ask the friend to wait, because you would like to talk with him after you meet with the new patient. The friend agrees and adds, "His name is Terry .... Terry Johnson."

You observe that your patient, Terry, looks about 19 or 20 years old. Terry is muscular and cleanly groomed, although his clothes and hair are disheveled. There are no obvious deformities, track marks, missing teeth, bruises, or limitations in mobility. Terry is breathing fast, making odd faces, and yelling profanities at anyone who goes near him. His voice tone is loud and his speech is forceful. You notice he has occasional difficulty in forming words. Though now in four-point restraints, Terry repeatedly tries to throw punches. He believes he is being brought to "a holding cell for spies where he is going to be tortured and experimented on."