RN Hesi Case Study - Psychosis

When the client looks around the room and mumbles to himself, how should the nurse respond? - Have the client express how he is feeling. - Ask the client if they are hearing voices. - See if the client recalls being here before. - Tell the client to say what they are thinking.

- Ask the client if they are hearing voices.

Which thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him? A. Hallucination. B. Phobia. C. Delusions. D. Confabulation.

C. Delusions.

Which medication should the nurse give to immediately relieve the muscle spasms in the client's neck and jaw? A. Lorazepam (Ativan) IM. B. Benztropine (Cogentin) PO. C. Diphenhydramine (Benadryl) IM. D. Acetaminophen (Tylenol) PO.

C. Diphenhydramine (Benadryl) IM.

What neurotransmitter is targeted by haloperidol (Haldol)? A. GABA. B. Serotonin. C. Dopamine. D. Norepinephrine.

C. Dopamine.

What is a goal of being in this activity group? A. Learn social behaviors and gain insight about one's personality. B. Gain information about disorders, symptoms, and medications. C. Gain self-acceptance and express feelings. D. Identify and resolve specific problems related to the treatment plan.

C. Gain self-acceptance and express feelings.

Which serious, anticholinergic side effects are related to the use of benztrophine (Cogentin)? A. Feeling tired. B. Dizziness. C. Urinary retention. D. Hand tremors. E. Tachycardia.

C. Urinary retention. E. Tachycardia.

What is the most important benefit the client can receive from his attendance at the community meeting? A. Reality orientation. B. Limits set on behaviors. C. Psychosocial skills. D. Mutual goal setting.

A. Reality orientation.

What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication? A. To determine the presence of cardiac disease. B. To monitor for hepatotoxicity. C. To determine if other medical issues are present. D. To assess elevations in liver enzymes.

C. To determine if other medical issues are present.

After the content of the voices are assessed, which interventions should the nurse implement? (Select all that apply. One, some, or all options may be correct.) - Ask the client how the voices make them feel. - Instruct the client to utilize distractions to deal with hallucinations. - Tell the client to instruct the voices to go away. - Give the client statements to say to the voices. - Encourage the client to write down what voices are saying.

- Ask the client how the voices make them feel. - Instruct the client to utilize distractions to deal with hallucinations.

Which assessment finding warrants immediate intervention by the nurse? - Motor restlessness. - Involuntary muscle contractions. - Lip smacking. - Drooling.

- Involuntary muscle contractions. (Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, particularly of the face, tongue, neck, and jaw which is a serious side effect of halcinonide.)

Which nursing diagnosis is best to include in the initial care plan? A. Sensory-perceptual alteration related to withdrawal into self. B. Chronic low self-esteem related to impaired cognition. C. Ineffective individual coping related to personal vulnerability. D. Knowledge deficit related to medication compliance.

A. Sensory-perceptual alteration related to withdrawal into self.

What side effect of the medication should the nurse suspect? A. Akathisia. B. Dystonia. C. Tardive dyskinesia. D. Parkinsonism.

B. Dystonia.

Interventions for a client experiecing hallucinations upone admission should occur in a sequence. Which interventions are most important for the nurse to include in the client's initial plan of care? (Select all that apply. One, some, or all options may be correct.) - Acknowledge that it appears the client is hearing voices. - Tell the client to stop listening to the voices. - Ask the client to verbalize what the voices are saying. - Assess the content of the hallucinations message. - Identify distractions to keep the client focused on reality.

- Acknowledge that it appears the client is hearing voices. - Ask the client to verbalize what the voices are saying. - Assess the content of the hallucinations message.

The nurse observes the client looking to the corner of the room and mumbling to himself. Which intervention is most important for the nurse to include in the client's plan of care? - Encourage the client to share the meaning of their delusions. - Interview the client to identify his feelings of depersonalization. - Begin a sequence of interventions to address the client's hallucinations. - Orient the client to their place and situation.

- Begin a sequence of interventions to address the client's hallucinations. (Hallucinations can be nonverbal or they can include talking to oneself, moving the lips without making sounds, rapid eye movements, and grinning or inappropriate laughter.)

The client is questioning the nurse about taking another pill. Which nursing intervention best promotes effective communication? - Explain that this pill is to help prevent the muscle spasms in neck and jaw. - Tell the client this pill will prevent the risk for tardive dyskinesia. -Say to the client that this pill will help the haloperidol be more effective. - To further alleviate sudden periods of delusions.

- Explain that this pill is to help prevent the muscle spasms in neck and jaw. (The addition of benztropine will reduce the likelihood of severe extrapyramidal symptoms that occur more often with prototype antipsychotic medications such as haloperidol.)

The client admits that the voices he hears have been getting louder over the past couple of weeks. Which nursing intervention best promotes effective communication? - Ask the client what helps the voices go away. - Determine how long the client has been hearing voices. - Document when the voices began getting louder. - Have the client repeat what he thinks the voices are saying.

- Have the client repeat what he thinks the voices are saying.

What is it most important intervention for the nurse to perform before discharging the client? - Complete contracts to follow discharge plans. - Provide resources for community support. - Re-evaluate thoughts of harm to self or others. - Identify support for the client's family.

- Re-evaluate thoughts of harm to self or others. (It is very important to reassess that the client is free of suicidal and/or homicidal ideation so that the nurse can document this in the discharge notes.)

While teaching the client about the anticholinergic side effects related to benztrophine, which intervention is most important for the nurse to include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.) - Take daily naps to decrease the tiredness caused by benztrophine. - Expect dizziness that occurs after taking beztrophine. - Report urinary retention or feeling that the bladder does not empty. - Observe for sudden onset of hand tremors. - Relay any feeling of heart palpations.

- Report urinary retention or feeling that the bladder does not empty. - Relay any feeling of heart palpations. (Tachycardia, palpitations, blurred vision or eye pain, confusion and hallucinations, and uncontrollable movements of the client's eyes, lips, tongue, face, and limbs are all serious anticholinergic side effects. Dry mouth, constipation, and drowsiness are less serious anticholinergic effects.)

Which action should the nurse implement first? - Offer the client a glass of juice and ask him if he ate breakfast. - Take the client's blood pressure while he is sitting and standing. - Tell the client that his dizziness is orthostatic hypotension that will subside after he eats. - Hold the morning dose of haloperidol, and notify the healthcare provider.

- Take the client's blood pressure while he is sitting and standing. (Since the client is feeling dizzy, a blood pressure reading should be taken while he is both sitting and standing to determine if a positional change, referred to as orthostatic hypotension, is associated with a change in the blood pressure readings.)

Diphenhydramine (Benadryl) is available as 100 mg/mL. The prescribed dose is 75 mg IM. How many mL should the nurse administer? (Enter numerical value only. If rounding is necessary, round to the hundredth.)

0.75

The nurse understands that the purpose of the urine drug screen is to assess Adam for what important information? A. Detection of substances that may have caused Adam's delusions and/or hallucinations. B. Determination of the approximate time Adam stopped taking his medications. C. Provision of information about the type of psychosis Adam is experiencing. D. Documentation of medication noncompliance and reinforcement of the need for hospitalization.

A. Detection of substances that may have caused Adam's delusions and/or hallucinations.

Which assessment data are the best indicators of the potential for violence? A. Gender and age. B. Past suicide attempts. C. History of violence. D. Medication compliance. E. Medication noncompliance.

A. Gender and Age B. Past suicide attempts. C. History of violence. E. Medication noncompliance.

What are the advantages for prescribing the atypical antipsychotic, olanzapine (Zyprexa)? A. Lower incidence of extrapyramidal symptoms (EPSEs). B. Rapid onset. C. Less weight gain. D. Alpha-adrenergic blockade. E. Acute and maintenance therapy.

A. Lower incidence of extrapyramidal symptoms (EPSEs). B. Rapid onset. E. Acute and maintenance therapy.

Which medications should the nurse anticipate giving the client after securing a prescription from the healthcare provider? (Select all that apply. One, some, or all options may be correct.) A. Short-acting anxiolytic (benzodiazepines). B. Antipsychotic medication. C. Mood-stabilizing medication. D. Nonbenzodiazepine anxiolytic (antianxiety agent). E. Antidepressant.

A. Short-acting anxiolytic (benzodiazepines). B. Antipsychotic medication.

What are important reasons for this teaching? A. To encourage the client to continue compliance with medications. B. To document the client's response to the medication education. C. To monitor for early tardive dyskinesia, which can be reversible. D. To reinforce education done throughout the hospitalization. E. To tell the client to discuss symptoms with his nurse.

A. To encourage client to continue compliance with medications. C. To monitor for early tardive dyskinesia, which can be reversible. D. To reinforce education done throughout the hospitalization. E. To tell the client to discuss symptoms with his nurse.

Which assessment data provides evidence that the client can be involuntarily committed to the hospital, if he insists on leaving? A. Past history of suicide attempts. B. Losing 10 pounds in 2 weeks. C. Auditory hallucinations. D. Persecutory delusions.

B. Losing 10 pounds in 2 weeks.

Which lab values from the urinalysis can the nurse expect to be related to Adam's 10-pound weight loss in the past 2 weeks? A. Positive for red blood cells. B. Positive ketones. C. Decreased urine pH. D. Increased urine specific gravity. E. Absence of glucose.

B. Positive ketones. D. Increased urine specific gravity.

The nurse is training a new team member. Which explanation best promotes effective communication when discussing group process and group content? A. Group content refers to the group rules. Group process is how clients react to the rules. B. Group process refers to where the group meets, while group content refers to the type of group that is meeting. C. Group content is client-led and group process is nurse-led. D. Content includes the clients' words, and group process is how the clients communicate.

D. Content includes the clients' words, and group process is how the clients communicate.

Which response from the client indicates that the haloperidol (Haldol) has been effective? A. Feels less anxious and nervous. B. Reports that mood is more stable. C. Initiates more social interactions. D. Experiences fewer hallucinations.

D. Experiences fewer hallucinations.

Which nursing action is appropriate for this request? A. Direct the caseworker to talk with the pharmacist. B. Ask for the client's permission to obtain medications. C. Explain that the nurse can return the medications. D. Obtain a prescription from the HCP to return medications.

D. Obtain a prescription from the HCP to return medications. (The HCP must write a prescription for the client to receive medications. Medications were changed while hospitalized and required prescriptions should accompany the client upon discharge. All other medication should be properly disposed of as prescribed.)

What is the most important part of this admission process? A. Ask the client if he has any valuables that need to be locked in a safe place. B. Allow the client to explain his understanding of the reason for his hospital admission. C. Introduce the client to the nursing staff and explain the role of the case manager and the staff members. D. Take away the client's cigarettes and lighter.

D. Take away the client's cigarettes and lighter.

Since the client is also experiencing delusions, what action is most important for the nurse to take to address the client's delusions? - Encourage the client to verbalize the meaning of the delusions. - Firmly tell the client that the delusions are not real. - Have the client to explain why they believe the delusion. - Give the client a list of reasons the delusions are not real.

Encourage the client to verbalize the meaning of the delusions.

When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond? - Insist that no one has followed the client there. - State how he must be concerned and assure him he will be safe there. - Tell the client that the police will make sure no one is out there. - Ask the client why he thinks that someone is out there.

State how he must be concerned and assure him he will be safe there.