mental exam 2
A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate?
"According to our agreement, no exercising is permitted until you have gained a specific amount of weight."
A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response.
"An individual is supported by peers while striving for abstinence one day at a time."
A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy?
"Being thin doesn't seem to solve your problems. You are thin now but still unhappy.
A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis?
"I am fat and ugly."
Taylor, a psychiatric registered nurse, orients Regina, a patient with anorexia nervosa, to the room where she will be assigned during her stay. After getting Regina settled, the nurse informs Regina:
"I need to go through the belongings you have brought with you."
Malika agrees to try losing weight according to the nurse practitioner's outlined plan. Additional teaching is warranted when Malika states:
"I prefer to have a gastric bypass rather than use this plan."
A client diagnosed with obsessive-compulsive personality disorder takes the nurse aside and mentions, "I've observed you interacting with that new patient. You are not approaching him properly. You should be more forceful with him." The best response for the nurse would be
"I will be continuing to follow the care plan for the patient."
When assessing a patient diagnosed with a borderline personality disorder, which statement by the patient warrants immediate attention?
"I'd really like to hurt her for hurting me."
Which statement made by the psychiatric nurse demonstrates an accurate understanding of the factors that affect an individual's personality?
"I'll need to learn more about this patient's cultural beliefs."
Which patient statement acknowledges the characteristic behavior associated with a diagnosis of pica?
"I'm ashamed of it, but I eat my hair."
Which patient statement supports the diagnosis of anorexia nervosa?
"I'm terrified of gaining weight."
A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone?
"It helps prevent relapse by reducing drug cravings."
Belinda is a 24-year-old patient with borderline personality disorder (BPD). She is admitted to the inpatient psychiatric unit following a suicide attempt. You are caring for Belinda. Which of the following statements by Belinda illustrates a primary coping style of persons with BPD?
"Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here." (splitting)
Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response.
"Make your loved one responsible for the consequences of behavior."
A teaching need is revealed when a client taking disulfiram states
"Most over-the-counter cough syrups are OK for me to use."
A teaching need is revealed when a client taking disulfiram (Antabuse) states:
"Most over-the-counter cough syrups are safe for me to use."
A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively?
"Tell me what happened the last time you drank."
A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient:
"What do you eat in a typical day?"
During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse?
"While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol."
One bed is available on the inpatient eating-disorder unit. Which patient should be admitted to this bed? The patient whose weight decreased from
150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9 C; pulse, 38 beats/min; blood pressure 60/40 mm Hg
When considering an eating disorder, what is a physical criterion for hospital admission?
A daytime heart rate of less than 50 beats per minute
Which of the following statements most accurately describes the concept of tolerance?
A person needs increasing amounts of a substance to achieve a desired effect.
Malika has been overweight all of her life. Now an adult, she has health problems related to her excessive weight. Seeking weight loss assistance at a primary care facility Malika is surprised when the nurse practitioner suggests:
A trial of SSRI antidepressant therapy
What is an appropriate long-term client-centered goal/outcome for a recovering substance abuser.
Abstain from the use of mood-altering substances
Which goal for treatment of alcoholism should the nurse address first?
Achieve physiologic stability.
Which intervention will promote independence in a patient being treated for bulimia nervosa?
Allow the patient to make limited choices about eating and exercise as weight gain progresses.
Which is true of pharmacological therapies for treatment of personality disorders?
Although there are no FDA-approved drugs specific to the treatment of personality disorders, patients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident.
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely?
Anorexia nervosa
Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa?
Assist the patient to identify triggers to binge eating.
Which of the drugs used by a polysubstance abuser is most likely to be responsible for withdrawal symptoms requiring both medical intervention and nursing support?
Barbiturates
An unconscious client is admitted to the emergency department. The admitting diagnosis is "rule out opiate overdose." Which item of assessment data would be most consistent with opiate overdose?
Blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min
Josie, a 27-year-old patient, complains that most of the staff do not like her. She says she can tell that you are a caring person. Josie is unsure of what she wants to do with her life and her "mixed-up feelings" about relationships. When you tell her that you will be on vacation next week, she becomes very angry. Two hours later, she is found using a curling iron to burn her underarms and explains that it "makes the numbness stop." Given this presentation, which personality disorder would you suspect?
Borderline
Connor is a 28-year-old student, referred by his university for a psychiatric evaluation. He reports that he has no friends at the university and people call him a loner. Recently, Connor has been giving lectures to pigeons at the university fountains. Connor is diagnosed as schizotypal, which differs from schizophrenia in that persons diagnosed as schizotypal:
Can be made aware of their delusions
The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction?
Cardiovascular
A 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital?
Client will be medically stabilized while in the hospital.
Which statement is true regarding substance addiction and medical comorbidity?
Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities.
A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action?
Consult the health care provider.
Obesity can be the end result of a binge-eating disorder. The nurse understands that the best treatment option in persons with a binge-eating disorder promotes:
Coping strategies
Which of the following are true of antisocial personality disorder (APD)? (select all that apply):
D. Persons with APD are concerned with personal pleasure and power. E. It is characterized by deceitfulness, disregard for others, and manipulation. G. Frontal lobe dysfunction is a brain change identified in APD.
Which of the following complications of substance abuse is considered life threatening?
Delirium tremens
A client who is dependent on alcohol tells the nurse, "Alcohol is no problem for me. I can quit anytime I want to." The nurse can assess this statement as indicating which defense mechanism?
Denial
A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism?
Denial
Which of the following medications is frequently used to detoxify a client in alcohol withdrawal?
Diazepam (Valium)
Personality disorders often co-occur with mood and eating disorders. A young woman is undergoing treatment at an eating disorders clinic and her nurse suspects the patient may also have a Cluster B personality disorder due to the young woman's:
Dramatic response to frustration
Which assessment findings are likely for an individual who recently injected heroin?
Drowsiness, constricted pupils, slurred speech
Which anorexia nervosa symptom is physical in nature?
Dry, yellow skin
Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction.
Empathetic, supportive
Benzodiazepines are useful for treating alcohol withdrawal because they are associated with which action?
Exerting a calming effect
Safety measures are of concern in eating-disorder treatments. Patients with anorexia nervosa are supervised closely to monitor: Select all that apply.
Foods that are eaten b. Attempts at self-induced vomiting d. Weight
A client on an inpatient unit has been diagnosed with bulimia nervosa. The client states' "I'm going to the bathroom and will be back in a few minutes." Which nursing response is most appropriate?
I will accompany you to the bathroom
Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges?
Imbalanced nutrition: less than body requirements
A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies?
Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia
A patient being admitted to the eating-disorder unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5'4". The patient says, "I won't eat until I look thin." Select the priority initial nursing diagnosis.
Imbalanced nutrition: less than body requirements related to self-starvation
Garret's wife of 8 years is divorcing him because the marriage never developed a warm or loving atmosphere. Garrett states in therapy, "I have always been a loner," and was never concerned about what others think. The nurse practitioner suggests that Garrett try a trial of bupropion (Wellbutrin) to:
Increase the pleasure of living
Which behavior would be inconsistent with defining characteristics for the nursing diagnosis of ineffective coping?
Interdependence
Which signs and symptoms are associated with opioid withdrawal?
Lacrimation, rhinorrhea, dilated pupils, and muscle aches.
As a patient admitted to the eating-disorder unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5'4" tall. Which term should be documented?
Lanugo
3. A nurse sitting with a client diagnosed with anorexia nervosa notices that the client has eaten 80% of lunch. The client asks the nurse "What do you like better, hamburgers or spaghetti?" Which is the best response by the nurse?
Let's focus on your continued improvement. You ate 80% of your lunch
Larry is from a small town and began displaying aggressive and manipulative traits while still a teenager. Now at 40 years old, Larry is serving a life sentence for the murders of his wife and her brother. John, the prison psychiatric nurse practitioner, recognizes that Larry's treatment will most likely:
Manifest as small incremental changes
Select the priority nursing intervention when caring for a patient after an overdose of amphetamines.
Monitor vital signs
Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids?
Naltrexone (ReVia)
A client has a 4 year history of using cocaine intranasally. When brought to the hospital in an unconscious state, what nursing measure should be included in the client's plan of care?
Observation for tachycardia and seizures
Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight?
Observe for adverse effects of refeeding.
A client diagnosed with an eating disorder has a nursing diagnosis of low self-esteem. Which nursing intervention would address this client's problem?
Offer independent decision-making opportunities
A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated?
One-on-one supervision
Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor?
Patient expresses satisfaction with body appearance
A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain?
Patient involvement in decision making increases sense of control and promotes adherence to the plan of care.
The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions?
Readiness to change and support system
A patient with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate?
Residential program
A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority?
Respiratory
Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa?
Rigidity, perfectionism
A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
Risk for injury
A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action?
Self-assess personal attitude, values, and beliefs about this health problem.
Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose?
Simple and safe
Cocaine exerts which of the following effects on a client?
Stimulation and anesthetic effects
Cocaine exerts which of the following effects on a client?
Stimulation and euphoria
A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information?
Substance Abuse and Mental Health Services Administration (SAMHSA)
What is the ethical obligation of the nurse who has seen a peer divert a narcotic compared with the ethical obligation when the nurse observes a peer to be under the influence of alcohol?
Supervisory staff should be informed as soon as possible in both cases.
Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization?
Systolic blood pressure 62 mm Hg
A 7-year-old child was diagnosed with pica. Which assessment finding would the nurse expect associated with this diagnosis?
The child frequently eats newspapers and magazines.
A client was in an automobile accident. Although he has the odor of alcohol on his breath, his speech is clear and he is alert and answers questions posed to him. The law enforcement officer requests that the emergency department staff draw a blood sample for blood alcohol level determination. The level is determined to be 0.30 mg%. What conclusion can be drawn?.
The client has a high tolerance to alcohol.
Which outcome indicates that the client's problem of impaired body image has improved?
The client has acknowledged that perception of being fat is incorrect
While helping an addicted individual plan for ongoing treatment, which of the following interventions is the first priority for a safe recovery?
The client strives to maintain abstinence.
The term tolerance, as it relates to substance abuse, refers to which situation?
The need to take larger amounts of a substance to achieve the same effects
A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed?
The nurse interacts with the patient in a protective fashion.
What is the current accepted professional view of the effect of culture on the development of a personality disorder?
There aren't sufficient studies to confirm the role that ethnicity and race have on the prevalence of personality disorders.
Which statement is descriptive of clients with a personality disorder?
They are resistant to behavioral change.
A 26-year-old patient who abuses heroin states to you, "I've been using more heroin lately because I've begun to need more to feel the effect I want." What effect does this statement describe?
Tolerance
When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred?
Tolerance has developed
Nursing assessment of an alcohol-dependent client 6 to 8 hours after the last drink would most likely reveal the presence of which early sign of alcohol withdrawal?
Tremors
A client with a long history of bulimia nervosa is seen in the emergency department. The client is seeing things that others do not, is restless, and has dry mucous membranes. Which is most likely the cause of this client's symptoms?
Vomiting, which may lead to dehydration and electrolyte imbalance
In the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority outcome.
Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min.
A patient with a history of alcohol use disorder has been prescribed disulfiram (Antabuse). Which physical effects support the suspicion that the patient has relapsed? Select all that apply.
a) intense nausea b) diaphoresis d) confusion e) dyspnea
Which assessment data confirm the suspicion that a patient is experiencing opioid withdrawal? Select all that apply.
a) pupils are dilated d) extreme anxiety
Which personality disorders are generally associated with behaviors described as "odd or eccentric"? Select all that apply.
a. Paranoid b. Schizoid
A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.)
a. Peripheral edema c. Constipation d. Hypotension f. Lanugo
When considering the need for monitoring, which intervention should the nurse implement for a patient with anorexia nervosa? Select all that apply.
a. Provide scheduled portion-controlled meals and snacks. c. Limit time spent in bathroom during periods when not under direct supervision. e. Observe patient during and after meals/snacks to ensure that adequate intake is achieved and maintained.
Which behaviors are examples of a primitive defense mechanism often relied upon by those diagnosed with a personality disorder? Select all that apply.
a. Regularly attempts to split the staff b. Attempts to undo feelings of anger by offering to do favors c. Regresses to rocking and humming to sooth themselves when fearful
A young woman reports that although she has no memory of the event, she believes that she was raped. This raises suspicion that she unknowingly ingested what substance?Select all that apply.
a. Rohypnol b. Gamma-hydroxybutyrate (GHB)
The nurse can assist a patient to prevent substance abuse relapse by: (select all that apply)
a. rehearsing techniques to handle anticipated stressful situations. c. assisting the patient to identify life skills needed for effective coping. e. informing the patient of physical changes to expect as the body adapts to functioning without substances.
An appropriate long-term goal/outcome for a recovering substance abuser would be that the client will
abstain from the use of mood-altering substances.
A client arrested for an assault in which he savagely beat a classmate states, "The guy deserved everything he got." The behaviors described are most consistent with the clinical picture of
antisocial personality disorder.
The priority nursing intervention for a client diagnosed with borderline personality disorder is to
assess for suicidal and self-mutilating behaviors.
An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should
assess lung sounds and extremities.
The nursing diagnosis ineffective denial is especially useful when working with substance use disorders and gambling. Which statements describe this diagnosis? Select all that apply.
b) does not perceive danger of substance use or gambling c) minimizes symptoms d) refuses healthcare attention e) unable to admit impact of disease on life pattern
A client brought to the emergency department after phenylcyclohexylpiperidine (PCP) ingestion is both verbally and physically abusive. What nursing intervention should be implemented to best assure the safety of the client and the milieu? Select all that apply.
b. Obtaining an order for seclusion and close observation e. Obtaining a prescription for a benzodiazepine
A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to: (select all that apply)
b. avoid alcohol-based skin products. c. read labels of all liquid medications. f. avoid breathing fumes of paints, stains, and stripping compounds.
A nurse who is idealized by a client is at risk for
becoming overinvolved and being protective and indulgent.
Benzodiazepines are useful for treating alcohol withdrawal because they
bind to ã-aminobutyric acid-benzodiazepine receptors
The client diagnosed with a personality disorder who is most likely to be admitted to a psychiatric unit is one who has
borderline personality disorder and is impulsive.
A new patient beginning an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Select the nurse's most therapeutic responses. Select all that apply.
c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening."
A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? (Select all that apply.)
c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips
Detoxification protocols have been developed and implemented for all of the following substances, except
cannabinoids
At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as:
codependence
What action should you take when a female staff member is demonstrating behaviors associated with a substance use disorder?
confront her about your concerns and/or report your concerns to a supervisor immediately
The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should:
consider each diagnosis primary and provide simultaneous treatment.
Characteristics the nurse will assess in the client diagnosed with antisocial personality disorder are
deceitfulness, impulsiveness, and lack of empathy.
Maxwell is a 30-year-old male who arrives at the ED stating, "I feel like I am having a stroke". During the intake assessment, the nurse discovers that Max has been working for 36 hours straight w/o eating and has consumed 8 double espresso drinks and 12 sodas. The nurse suspects:
dehydration and caffeine overdose
A client who is dependent on alcohol and drinks several six-packs of beer daily tells the nurse "Alcohol is no problem to me. I can quit anytime I want to." The nurse can assess this statement as indicating
denial.
A person who covertly supports the substance-abusing behavior of another is called a(n)
enabler.
Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will
gain 1 to 2 pounds.
Lester and Eileen have always enjoyed gambling. Lately, Eileen has discovered that their savings account is down by $50,000. Eileen insists that Lester undergo therapy for his gambling behavior. The nurse recognizes that Lester is making progress when he states:
gambling activates the reward pathways in my brain"
Characteristic behaviors the nurse will assess in the narcissistic client are
grandiose, exploitive, and rage-filled behavior.
An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect:
hallucinogen ingestion
Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the relationship between the behavior and blood alcohol level, which conclusion is most probable? The patient:
has a high tolerance to alcohol.
A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child:
has accidents of defecation at kindergarten three times a week.
A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient:
has symptoms of alcohol-withdrawal delirium.
A nurse provides health teaching for a patient diagnosed with bulimia nervosa. Priority information the nurse should provide relates to
how to recognize hypokalemia.
A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will
identify two alternative methods of coping with loneliness.
Clients demonstrating characteristics of personality disorders have various self-defeating behaviors and interpersonal problems despite having near-normal ego functioning and intact reality testing. A nursing diagnosis that addresses this sort of interpersonal dysfunction is
impaired social interaction.
A nurse caring for a client who has been diagnosed with a personality disorder should expect that the client will exhibit
inflexible and maladaptive responses to stress.
Patients with borderline personality disorder (BPD) exhibit negative effect, which includes emotional _____________, described as rapidly moving from one emotional extreme to another.
lability
Research has indicated that the antisocial personality may be characterized by
lack of remorse.
A patient diagnoses with opioid use disorder has expressed a desire to enter into a rehabilitation program. What initial nursing intervention during the early days after admission will help ensure the patient's success?
manage the patient's withdrawal symptoms well
All of the following substances are considered central nervous system stimulants, except
methadone
When providing care for a client diagnosed with borderline personality disorder, the nurse will need to consider strategies for dealing with the client's
mood shifts, impulsivity, and splitting.
Symptoms of withdrawal from opioids for which the nurse should assess include:
nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.
Terry is a young male in a chemical dependency program. Recently he has become increasingly distracted and disengaged. The nurse concludes that Terry is
not ready to change
An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient
not to skip meals or restrict food.
Donald, a 49-year-old male, is admitted for inpatient alcohol detoxification. He is cachexic, has multiple scabs on his arms and legs, and has lower extremity edema. An appropriate nursing diagnosis for Donald along with an expected outcome is:
nutrition: less than body requirements/ maintains nutrient intake for metabolic needs
A client has been using cocaine intranasally for 4 years. Two months ago she started freebasing. For the past week she has locked herself in her apartment and has used $8000 worth of cocaine. When brought to the hospital she was unconscious. Nursing measures should include
observation for hyperpyrexia and seizures.
A client brought to the emergency department at the university hospital after PCP ingestion tries to run up and down the hallway. The nursing intervention that would be most therapeutic is
obtaining an order for seclusion and close observation.
The only class of commonly abused drugs that has a specific antidote is
opiates.
Physical assessment of a patient diagnosed with bulimia often reveals
prominent parotid glands.
A nurse conducting group therapy on the eating-disorder unit schedules the sessions immediately after meals for the primary purpose of
promoting processing of anxiety associated with eating.
A newly admitted client has an axis II diagnosis of schizoid personality disorder. The nursing intervention of highest priority will be to
respect need for social isolation.
The most helpful message to transmit about relapse to the recovering alcoholic client is that lapses
result from lack of good situational support.
Mary Alice is a 37-year-old patient referred to the mental health clinic with a suspected personality disorder. She is withdrawn and suspicious and states she has always preferred to be alone. She describes herself as having "special powers" and states that she is thinking of opening a business where she gives "readings" to people about their future. She states, "I believe we can all read each other's thoughts at times." Based on this presentation, you suspect:
schizotypal personality disorder (STPD).
A hospitalized patient diagnosed with an alcohol abuse disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n):
sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium).
Splitting is a process in which the client
sees things as divided into "all good" or "all bad."
A patient asks for information about Alcoholics Anonymous. Select the nurse's best response. "Alcoholics Anonymous is a:
self-help group for which the goal is sobriety."
Playing one staff member against another is an example of
splitting.
Select the priority outcome for a patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will:
state, "I know I need long-term treatment."
A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes:
substance addiction
The term tolerance, as it relates to substance abuse, refers to
the need to take larger amounts of a substance to achieve the same effects.
The primary goal of milieu therapy for clients diagnosed with personality disorders is
to manage the effect the behavior has on the entire group.
Opioid use disorder is characterized by:
tolerance
Nursing assessment of an alcohol-dependent client 6 to 12 hours after the last drink would most likely reveal the presence of
tremors.
A syndrome that occurs after stopping the long-term use of a drug is called
withdrawal
A syndrome that occurs after stopping use of a drug is
withdrawal.
