Psych/Mental Health Nursing HESI Review

Case study (cont'd): The nurse notifies the healthcare provider about the client's behavior and the nurse's inability to obtain an electrocardiogram. Complete the following sentence by choosing from the list of options: The client is most at risk for __________ as evidenced by the client's __________. injury psychomotor agitation

injury; psychomotor agitation

Case study: Client's speech is loud, rapid, and incoherent. She says, "Police don't see my stardom. The stars twinkle at night. I like to eat ice cream and watch movies. Have you seen the show about the detective and the angel? I have angels watching over me." Drag from Word Choices to complete the sentence: The nurse recognizes the client's speech as ___________, __________, and ___________. Word choices: echolalia loose associations clang association pressured tangential circumstantial

loose associations, pressured, tangential Abnormal speech patterns may be associated with psychological conditions. Pressured speech is often loud, rapid, and incoherent. Clients may display tangentiality in their speech by adding unnecessary details and being unable to reach a point. Conversation may drift off topic and fail to return to the original concept. Similarly, loose associations display when thoughts are represented in words that have limited connections to the previous statement.

An adolescent who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy session at the mental health clinic. Today the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement? A. Advise the mother to call the police if violent behavior occurs again. B. Reinforce the need for the adolescent to attend group therapy sessions. C. Tell the mother to describe her feelings of helplessness to her child. D. Refer the mother for psychiatric evaluation for anxiety and depression.

A. Advise the mother to call police if violent behavior occurs again. The safety of the family is the primary concern. The nurse should advise the mother to call the police if the child's violent behavior occurs again.

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor? A. Blood pressure B. Urinary output C. Temperature D. Respiratory rate

A. Blood pressure

A young adult client is admitted to the emergency department because of being raped that evening by the client's date. Which computer documentation should the nurse enter in the electronic medical record as the client's primary problem? A. Client states, "My date raped me tonight." B. Client has been sexually assaulted. C. Client reported having sexual relations against the client's will. D. Client claims being force to participate in sexual intercourse.

A. Client states, "My date raped me tonight."

Case study: The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete IV antibiotic administration. What other treatment(s) might be helpful for this client? Select all that apply. A. Cognitive behavioral therapy B. Animal therapy C. Electroconvulsive therapy D. Administration of lithium E. Consciousness raising F. Phototherapy

A. Cognitive behavioral therapy B. Animal therapy Cognitive behavioral therapy and animal therapy are evidence based approaches to treat acute stress disorder.

A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days she has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated? A. Encourage verbalization of feelings B. Ensure client attend groups addressing coping skills for dealing with depression C. Allow the client to rest and sleep D. Begin planning for the client's discharge

C. Allow the client to rest and sleep

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit? A. Current vital signs B. 24-hour urinary output C. Blood sugar level D. White blood cell count

A. Current vital signs Haloperidol has high risk for neurological side effects. Symptoms of neuroleptic malignant syndrome (NMS), a life-threatening, neurological disorder caused by an adverse reaction to neuroleptic or antipsychotic drugs, include high fever, sweating, unstable blood pressure, stupor muscle rigidity, and autonomic dysfunction. It is most important to obtain the client's vital signs to assess for NMS.

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply. A. Encourage the client to discuss thoughts and feelings about wanting to die. B. Reinforce statements regarding a will to live and realistic plans for the future. C. Limit time allowed to play video games. D. Restrict visitors to family members only. E. Discuss the client's suicide plan.

A. Encourage the client to discuss thoughts and feelings about wanting to die. B. Reinforce statements regarding a will to live and realistic plans for the future. E. Discuss the client's suicide plan.

A nurse who is coleading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement? A. Escort the client from the group to reduce stimuli. B. Assist the client with relaxation techniques in the group C. Provide education about ways to cope with anxiety. D. Ask the client to describe and identify the source of the feelings.

A. Escort the client from the group to reduce stimuli.

Case study (cont'd): The nurse educates the client about lithium. Click to highlight the 4 statements that indicate the client understands the medication teaching: A. I will use a reliable birth control method while on lithium. B. I will keep the antidote at my bedside in case of toxicity. C. I will follow up monthly for kidney function and thyroid lab work. D. I will report diarrhea and vomiting to my healthcare provider. E. I may experience fine hand tremors while adjusting to this medication. F. I will take lithium on an empty stomach to ensure proper absorption. G. I understand that taking lithium daily is crucial to my treatment plan.

A. I will use a reliable birth control method while on lithium. D. I will report diarrhea and vomiting to my healthcare provider. E. I may experience fine hand tremors while adjusting to this medication. G. I understand that taking lithium daily is crucial to my treatment plan. Lithium can cause fetal anomalies like cardiovascular malformation and neonatal toxicity during pregnancy. Therefore, clients on lithium should use reliable birth control to avoid pregnancy. Lithium serum levels should be between 0.6 to 1.5 mEq/L. Clients can experience mild to moderate toxicity when the level is greater than 2 mEq/L. Symptoms of lithium toxicity include diarrhea and vomiting. Fine hand tremors are a side effect that can occur when lithium is at therapeutic levels. They should subside with time. Clients should adhere to their treatment plan by taking lithium as prescribed.

The nurse is caring for a client who has anxiety and compulsive hoarding syndrome. When developing a plan of care for the client, which outcome is most important for the nurse to include? A. Identifies ineffective coping and compulsive behavior. B. Verbalizes acceptance of self and a positive self worth. C. Delays decision making when experiencing stress. D. Establishes a schedule for sorting and purging.

A. Identifies ineffective coping and compulsive behavior. Often, individuals with hoarding disorder do not recognize how their behaviors have affected their lives and the nurse should help the client to first identify a problem exists. The nurse can then assist the client to learn techniques to cope with stress and control anxiety more effectively.

A client is receiving benztropine mesylate for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the nurse should further evaluate the client? A. Increased mouth movements B. Decreased bowel movements C. Decreasing hand tremors. D. Presence of a dry mouth.

A. Increased mouth movements Benztropine is an anti-Parkinson's agent and anticholinergic agent that is used to manage abnormal involuntary movements precipitated by antipsychotics. Increased mouth movements could indicate the persistence of symptoms related to EPS and tardive dyskinesia, which is characterized by involuntary mouth and tongue worming movements.

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately? A. Nausea and vomiting B. Depressed affect C. Short term memory loss D. Five pound (2.3 kg) weight gain

A. Nausea and vomiting

Naloxone is administered to an adult client following a suicide attempt with an overdose of hyrdrocodone bitrartrate. Within 15 minutes, the client is alert and oriented. While planning nursing care, which intervention has the highest priority at this time? A. Observe the client for further narcotic effects B. Encourage the client to increase fluid intake C. Determine the client's reason for attempting suicide D. Obtain the client's serum hydrocodone/acetaminophen level

A. Observe the client for further narcotic effects

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care? A. Spend time sitting in silence with client. B. Observe for signs of possible psychosis. C. Involve client in daily exercise program D. Ask the client to describe the feelings of depression.

A. Spend time sitting in silence with client. The client's plan of care should include spending time quietly sitting with this severely depressed client because the nurse's presence is likely to help improve the client's self-perception as a worthwhile person.

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client? A. Take the medication each morning, beginning 48 hours after your last drink of alcohol. B. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol. C. Take the medication with at least 8 oz of water and limit alcohol consumption while taking this medication. D. Take the medication at bedtime and avoid consuming any more than 1 oz of alcohol daily.

A. Take the medication each morning, beginning 48 hours after your last drink of alcohol.

During admission assessment to the mental health unit, a client reports that people at the office are antagonistic and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse? A. The nurse and the therapist will be asked to educate other team members on appropriate sharing of client information. B. The therapist is reprimanded for divulging confidential patient information without obtaining consent. C. Both the nurse and therapist are reprimanded for divulging patient information to others. D. The nurse is reprimanded for divulging confidential patient information without obtaining informed consent.

A. The nurse and therapist will be asked to educate other team members on appropriate sharing of client information.

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately? A. Vitamin B1 B. Folic Acid C. Haloperidol D. Trazodone

A. Vitamin B1

A client is experiencing high levels of stress caused by social situations that involve performance and judgment. The client receives a prescription for a short term medication. Which class of medications should the nurse expect to administer to the client? A. Norepinephrine reuptake inhibitors B. Selective serotonin reuptake inhibitors C. Benzodiazepines D. Antipsychotics

C. Benzodiazepines Social anxiety disorder is characterized by high levels of stress caused by social situations that involve performance and judgment. The nurse should expect to administer benzodiazepines, which are proven to be effective for short term treatment for anxiety.

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines that the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem? A. Ineffective community coping B. Acute confusion C. Self-care deficit D. Disturbed sensory perception

B. Acute confusion The priority problem is acute confusion because the client's behavior demonstrates disorganized speech, disorientation, and confusion.

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make? A. The voices you are hearing are not real. B. You appear to be speaking with someone. C. You need to be calm and focus on something else. D. Let's talk about the next time this happens.

B. "You appear to be speaking with someone"

Case study: The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete IV antibiotic administration. The nurse reviews the health providers (HCP) orders for clonazepam and gives the medication as ordered. What nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply. A. Have an opioid agonist at the bedside. B. Assess mental status regularly. C. Provide oral care at least twice a day. D. Screen for orthostatic hypotension. E. Assist the client to the bathroom. F. Monitor calcium levels.

B. Assess mental status regularly. C. Provide oral care at least twice a day. D. Screen for orthostatic hypotension. E. Assist the client to the bathroom. Benzodiazepines like clonazepam can cause dizziness and orthostatic hypotension, so the client should be assisted to the bathroom and have their blood pressure monitored. The medication may also cause dry mouth, so the nurse should encourage oral care. The nurse should also assess the client's mental status regularly as the treatment goal of clonazepam is to reduce anxiety.

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take? A. Invite a colleague to document during the interview. B. Close the examination room door for privacy. C. Ask the client to describe the history of the injuries. D. Request hospital security to come to the department.

B. Close the examination room door for privacy.

A client who has been abused by a spouse multiple times is admitted to the emergency department. When taking the history, which information is most important for the nurse to obtain? A. Ask if the spouse drinks alcohol or does drugs before abuse occurs B. Determine if the client has a plan to leave if their life is in danger C. Discuss the injuries that occurred from the previous abuse D. Find out the circumstances that prompted this abusive episode

B. Determine if the client has a plan to leave if their life is in danger

A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement? A. Avoid recognizing the behavior. B. Escort the client to a private area. C. Isolate the client from other clients. D. Administer a PRN sedative.

B. Escort the client to a private area.

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care? A. Concentrate on and ventilate emotions when distressed. B. Focus on small achievable tasks, not taxing problems. C. Shift attention from self to the needs and requests of others. D. Relax and reduce the amount of effort to solve the problem.

B. Focus on small achievable tasks, not taxing problems.

A client presents in the emergency department and states, "I was raped tonight." Which intervention is most important for the nurse to implement? A. Obtain a history of sexually transmitted diseases. B. Instruct the client to remove clothing carefully. C. Assess client's sexual activity for the past 30 days. D. Ask the client if the attacker can be identified.

B. Instruct the client to remove clothing carefully.

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment? A. Lethargy and depression B. Stimulation and dilated pupils C. Hallucinations and delusions D. Bradycardia and bradypnea

B. Stimulation and dilated pupils

Which individual should the nurse consider at highest risk for suicide? A. A single working mother with three preschool aged children. B. A nurse who works in an pediatric emergency department C. A retired older male whose significant other has passed away D. An adolescent male whose parents recently divorced.

C. A retired older male whose significant other has passed away.

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone. When the client walks to the nurse's station in a laterally contracted position, he reports something has made his body contort into a monster. Which action should the nurse take? A. Offer the client a prescribed physical therapy hot pack for muscle spasms. B. Medicate the client with the prescribed antipsychotic thioridazine. C. Administer the prescribed anticholinergic benztropine for dystonia. D. Direct client to occupational therapy to distract him from somatic complaints.

C. Administer the prescribed anticholinergic benztropine for dystonia.

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related? A. Episodic intervals of pruritus. B. Evidence of patches of lost hair. C. Ecchymotic blood accumulations. D. Erythema of the localized lesions.

C. Ecchymotic blood accumulations. Ecchymosis with blood accumulation in the areas of hair loss indicates traumatic injury, which occurs when the hair is pulled or used to drag or jerk the child, causing blood vessels under the scalp to break.

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because the client's spouse reported the client had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool? A. Consumption, liver enzyme, gastrointestinal issues and bleeding. B. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake. C. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye opener." D. Cancer screening results, anger, gastritis, daily alcohol intake.

C. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye opener."

On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse, "I am the son of God." Based on this statement, which intervention should the nurse include in the client's plan of care? A. Lead the client by the arm to the seclusion room B. Schedule activity therapy twice weekly C. Ensure the client's environment is safe D. Confront the client's delusion as not consistent with reality

C. Ensure the client's environment is safe.

A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? A. Progressively expose the client to larger crowds. B. Encourage deep breathing when anxiety escalates in a crowd. C. Establish trust by providing a calm, safe environment. D. Encourage substitution of positive thoughts for negative ones.

C. Establish trust by providing a calm, safe environment.

The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance place the client at highest risk for myocardial infarction? A. Benzodiazepine B. Alcohol C. Methamphetamine D. Marijuana

C. Methamphetamine

A client with a major depressive disorder is admitted to the inpatient psychiatric unit. Which intervention should the nurse use to demonstrate support of the client? A. Recommend journaling and time taken in self reflection. B. Assist the client to identify symptoms of depression. C. Schedule regular periods of time for interaction with client. D. Incorporate animated communication techniques.

C. Schedule regular periods of time for interaction with client.

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition? A. Disorganization B. Reexperience C. Somatization D. Preoccupation

C. Somatization

A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family? A. The client should plan to participate in group or individual therapy while at college. B. The client should be aware of the signs and symptoms of his illness. C. The client's serum lithium levels should be routinely evaluated. D. Despite the illness, the client should be able to live away from home.

C. The client's serum lithium levels should be routinely evaluated.

An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? A. The interactions with others. B. Level of activity C. The emotional quality of attitude D. Appetite

C. The emotional quality of attitude

Case study: ...the nurse suspects that the client has delirium and confirms with a Confusion Assessment Method screen. For each client need, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each client need may support more than one potential nursing intervention. Each category must have at least one response option selected. Client Need Rest & Sleep: Sensory stimulation: Pain control:

Client Need Rest & Sleep: Cluster care activities, especially at night Sensory stimulation: Keep window blinds open during the day and closed at night Pain control: Add non-pharmacological methods to the current pain management plan For a client with delirium, the nurse should pay careful attention to pain control, providing appropriate sensory stimulation, and encouraging rest and sleep. The nurse should add non-pharmacological methods to any pharmacological pain control technique to assure pain control. The nurse should maintain light appropriate for the time of day. This can be done by keeping window blinds open during the day and closed at night. The nurse should also cluster care activities, especially at night, to allow the client to sleep.

Case study (cont'd): The inpatient nurse reviews the chart and identifies important interventions for the client during an acute manic episode. For each goal category, choose the indicated intervention and rationale for this client: Communication Nutrition Structure of safe milieu

Communication - Listen attentively to concerns Nutrition - Offer high-calorie protein drinks and finger foods throughout the day. Structure of safe milieu - Turn off bright lights and reduce noise

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder? A. An older adult who continuously reports a headache and back pain. B. A middle aged adult who is reporting shortness of breath and is diaphoretic. C. An adolescent who becomes extremely anxious about going outside. D. A young adult who suddenly goes blind with no indication of organic pathology.

D. A young adult who suddenly goes blind with no indication of organic pathology. Conversion disorder involves unexplained, usually sudden, deficits in sensory or motor function, such as blindness or paralysis, which suggest a neurologic disorder that has no organic pathology and is associated with psychological factors.

While sitting in the day-room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrates the client's behaviors. Which is the main goal of this therapeutic technique? A. Discuss the client's feelings when he responds. B. Initiate a non-threatening conversation with the client. C. Dialog about the ineffectiveness of his interactions. D. Allow the client to identify the way he interacts.

D. Allow the client to identify the way he interacts.

Which is the best approach for the nurse to use when interviewing a client about suicidal ideations? A. Get the most difficult questions over with first. B. Ask questions in a vague, non-specific format. C. Share personal values to put the client at ease. D. Begin with questions that are less sensitive in nature.

D. Begin with questions that are less sensitive in nature.

During a family group meeting, the client's child tells the group, "I hope I didn't cause my parent to be depressed." Which response is best for the nurse to provide? A. Are you afraid that your parent's depression will lead to death? B. What do you think you did that led to your parent's depression? C. You are not alone in feeling responsible for others in your family. D. I hear you say you worry about causing your parent's distress.

D. I hear you say you worry about causing your parent's distress.

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit? A. Ineffective sexual patterns B. Compromised family coping C. Disturbed sensory perception D. Impaired environmental interpretation

D. Impaired environmental interpretation

The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information? A. Current weight B. Any history of heart disease C. Familial history of mental illness D. Medication history

D. Medication history

The nurse is performing the admission assessment for a client with schizophrenia in an acute inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia? A. Describes times of depression followed by feelings of euphoria. B. Exhibits compulsive, ritualistic behaviors. C. Admits to frequently thinking about committing suicide. D. Responds with illogical answers to questions.

D. Responds with illogical answers to questions.

During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take? A. Resolve the feelings with the client after discharge. B. Share similar experiences the nurse has had in the past. C. Identify the client's transference of feelings of annoyance. D. Terminate the session before the feelings escalate.

D. Terminate the session before the feelings escalate

The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment? A. The fire is burning my skin away right now. B. The voices are telling me to kill the next person I see. C. The snakes on the wall are going to eat me. D. The nurse at night is trying to poison me with pills.

D. The nurse at night is trying to poison me with pills.

Case study continued... 1100 Noted that the client is using fantasy, isolation, and suppression as defense mechanisms. Notified the client's healthcare provider (HCP) about the client's issues and concerns. 1200 Provided the client with education about acute stress disorder. What client statement(s) require(s) follow up teaching by the nurse? Select all that apply. A. I am at high risk for post traumatic stress disorder because I have acute stress disorder. B. I can use holistic approaches like medication to help my symptoms. C. Many people have the same response to a stressful situation as I am having right now. D. I can learn to manage my thoughts better through therapy. E. This diagnosis means that I am crazy. F. I will probably need to be on medication for the rest of my life.

E. This diagnosis means that I am crazy. F. I will probably need to be on medication for the rest of my life.

Case study (cont'd): The nurse is planning care for the client and reviews the most recent vital signs, notes, and orders. Click to indicate which interventions are indicated and contraindicated for the client at this time. Administer 5mg haloperidol and 2mg lorazepam IV. Allow the client to express frustrations with staff. Reassess the electrocardiogram for signs of shortening QT interval. Apply oxygen via nasal cannula. Monitor the client for tremors and rigidity.

Indicated: Allow the client to express frustrations with staff. Monitor the client for tremors and rigidity. Contraindicated: Reassess the electrocardiogram for signs of shortening QT interval. Apply oxygen via nasal cannula. Administer 5mg haloperidol and 2mg lorazepam IV. It is important for the nurse to develop a relationship with a client who is experiencing a bipolar manic episode. Clients should be able to verbalize thoughts or opinions, even if they are negative. By allowing clients to do so, the nurse is helping individuals feel accepted and understood, which promotes a better relationship. It is important to continue monitoring clients for tremors and rigidity. They are signs of extrapyramidal symptoms which are side effects of haloperidol.

Case study (cont'd): The nurse evaluates the client's presentation and considers the assessment findings. For each assessment finding, click to indicate whether findings from the client's assessment are generally associated with bipolar disorder (mania), schizophrenia, or both. Loose association Flat or blunt affect Motor agitation Elevated mood Labile Delusions Low appetite

Loose association: BOTH Flat or blunt affect: Schizophrenia Motor agitation: BOTH Elevated mood: Bipolar disorder (mania) Labile: BOTH Delusions: BOTH Low appetite: Bipolar disorder (mania) Schizophrenia is traditionally characterized by a flattened or blunt affect. Meanwhile, clients with bipolar disorder (mania) tend to have an elevated mood. Clients experiencing mania also display low appetite and altered eating patterns. Both clients with bipolar disorder (mania) and clients with schizophrenia share symptoms such as being labile, having delusions, using loose associations, and having motor agitation. With lability, clients can present with emotional instability and rapidly changing emotions. Delusions are beliefs that are not based on reality. They are also fixed and false. With loose associations, speech patterns shod an inability to stay on point as the client brings up unrelated ideas. Motor agitation is purposeless of unintentional restlessness, such as pacing.

Case study: The client is a 55-year-old male on this 3rd day of hospitalization following a motor vehicle accident. He sustained rib fractures and a traumatic pneumothorax in the accident. His blood alcohol level was 0.19% (Ref range: 0% to 0.05%). Client currently has a chest tube on the L side to water weal and a R subclavian central line. Complete the diagram by dragging from choices to specify which condition client is likely experiencing, 2 actions RN should take to address it, and 2 parameters RN should monitor. Potential conditions: Post-traumatic stress disorder Delirium tremens Depression Opioid overdose Actions to take: Place client on seizure precautions Restrain the client Alert the provider and security Give a dose of naloxone Give a dose of morphine Parameters to monitor: White blood cell count Mood Pupil size Sleep Respiratory rate

Potential condition: Delirium tremens Actions to take: Place client on seizure precautions; Alert the provider and security Parameters to monitor: Mood; Sleep Delirium tremens is a result of sudden alcohol withdrawal. Symptoms include tachycardia, hypertension, fever, diaphoresis, and delirium. It usually occurs after 48 to 72 hours, so many clients who had alcohol-related accidents and are hospitalized should be monitored for the condition during that time frame. DT is a medical emergency and may cause the client to behave in paranoid and violent ways, so both the provider & security should be notified. The client should also be placed on seizure precautions as seizures may occur because of DT. After the acute withdrawal stage, the client is likely to experience post-acute withdrawal syndrome (PAWS), which includes mood & sleep problems, so those should be monitored.

Case study: The client reports general malaise, fatigue, and decreased appetite. His skin is pale in color. He denies pain or discomfort. the client is withdrawn, soft spoken, and does not offer information without being prompted. The client reports a six pack of beer daily for the last eight months... Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram: specify which condition client is likely experiencing, 2 actions RN should take to address it, and 2 parameters RN should monitor. Potential conditions: Depression Abnormal grieving Delirium Alcoholism Actions to take: Orient to environment Assess for suicidal ideation Arrange for in-patient psych transfer Education on medication regime Refer to alcoholic support group Parameters to monitor: Blood pressure Sodium levels Exercise regime Monitor for medication side effects Symptom resolution

Potential conditions: Depression Action to take: Assess for suicidal ideation; Education on medication regime Parameters to monitor: Symptom resolution; Monitor for medication side effects The cardinal signs of depression include depressed mood, changes in weight, apathy, sleep disturbances, movement disturbances, lack of energy, sense of worthlessness, inability to concentrate, and thoughts of death. An individual who exhibits at least five of these signs meets the criteria for a diagnosis of depression. Anti-depressive medication should be administered and client educated on the medication, therapeutic levels, and side effects. Client should also be assessed for suicidal ideation and appropriate interventions taken, as applicable. Monitoring should include medication side effects and resolution of symptoms of depression and return to normal functioning.

Case study: 0900 Pain assessment completed. The client's pain is 2 on a 0 to 10 pain scale. The client requests sleeping medication for the night. She explains that she keeps having horrible thoughts and memories about the house collapsing and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' stations and hears talking and alarms constantly. Highlight the aspects of the assessment that require urgent attention.

She explains that she keeps having horrible thoughts and memories about the house collapsing A client exposed to a traumatic event who is having reoccurring thoughts about the event and mood problems needs immediate attention.

Case study: A 22-year-old female client is brought to the emergency department by her mother after the client became dizzy and fell. The mother says that the client has been away at college and is home for winter break. The client's mother is greatly concerned because while her daughter has always been thin and athletic, she has never seen her so skinny and emaciated. The client responds by telling her mother, "That is not true. You keep trying to force food down my throat even though it is obvious that I have so much weight to lose!" Click to indicate if the listed finding is a characteristic primarily of anorexia nervosa, bulimia nervosa, or binge eating. Significantly low body mass index (BMI) Binging without compensatory behavior Intense fear of weight gain Caloric restriction Vomiting after eating

Significantly low body mass index (BMI) - Anorexia nervosa Binging without compensatory behavior - Binge eating Intense fear of weight gain - Anorexia nervosa Caloric restriction - Anorexia nervosa Vomiting after eating - Bulimia nervosa

Case study (cont'd): The nurse engages the client in conversation about her feelings and some of her coping mechanisms. Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one but may have more than one answer selected. (For each, choose Suppression, Isolation, and/or Fantasy) 1. The client states that she sometimes forgets why she is in the hospital. 2. The client discusses moving to Hawaii instead of returning to rebuild her house. 3. The client seems unemotional when talking about needing to rebuild her house. 4. The client is frightened that the hospital will burn down.

The client is exhibiting defense mechanisms such as fantasy, isolation, and suppression. The client has distorted or unattainable desires, a separation of feelings from otherwise overhwhelming topics and a removing the distressing situations from consciousness

Case study (cont'd): After listening to the client's symptoms, the nurse realizes that she likely has _______________ r/t _________________. Options for 1: hallucinations separation anxiety acute stress disorder phobia Options for 2: traumatic stress exposure side effects of medication undiagnosed mental health disorder overstimulation

acute stress disorder; traumatic stress exposure