THE PRACTICE OF MENTAL HEALTH/ PSYCHIATRIC NURSING
A child in the first grade is murdered, and counseling is planned for the other children in the child's school. Which should the nurse identify first to understand a child's response to crisis? 1. Developmental level of the child 2. Quality of the child's peer relationships 3. Child's perception of the crisis situation 4. Child's communication patterns with family members
1. Developmental level of the child Developmental level is essential to understanding a child's response to a crisis situation; the variety of coping abilities usually increases as the child progresses through the stages of growth and development.
The statement that best describes the practice of psychiatric nursing is: 1. Helps people with present or potential mental health problems 2. Ensures clients' legal and ethical rights by acting as a client advocate 3. Focuses interpersonal skills on people with physical or emotional problems 4. Acts in a therapeutic way with people who are diagnosed as having a mental disorder
1. Helps people with present or potential mental health problems An important aspect of the role of the psychiatric nurse is primary, secondary, and tertiary interventions to promote emotional equilibrium.
A 30 year old who has been in a gay relationship for the past 3 years comes to the emergency department in a near panic state. He tells the nurse that his lover of many years has just terminated their relationship. What should the nurse do to help the client cope with this loss? 1. Identify his support system 2. Explore his psychotic thoughts 3. Reinforce his current self-image 4. Suggest he explore his sexual orientation
1. Identify his support system A client in crisis needs to rely on available support systems for assistance; therefore it is vital for the nurse to identify the client's support system.
A Latino American client with schizophrenia is admitted to an emergency department crisis unit in an aggravated and disheveled state after failing to take prescribed medication for the last 5 days. When developing a plan of care that incorporates the client's cultural background, the nurse gives priority to: 1. Inclusion of the family in the client's plan of care 2. The client's need to control personal and social space 3. The meaning and attention the client places on the future 4. Socioeconomic considerations regarding hospitalization
1. Inclusion of the family in the client's plan of care In the Latino American culture, usually there is a strong family bond, and the support of the family is essential during problematic times.
A female client, whose long-term live-in lover has just terminated their relationship, comes to the emergency service in severe crisis. After being seen by the nurse, the client agrees to call the local mental health clinic for short-term counseling. Which client behavior helps the nurse evaluate whether the nursing intervention was effective? The client: 1. Is seeking out assistance for help with coping 2. Has returned to her pre crisis level of functioning 3. Has learned new methods of coping with her loss 4. Is demonstrating diminished symptoms of anxiety
1. Is seeking out assistance for help with coping Going for counseling demonstrates the client's recognition that assistance is needed.
The nurse understands that the most potentially dangerous side effect of tricyclic antidepressants is: 1. Mydriasis 2. Dry mouth 3. Constipation 4. Urinary retention
1. Mydriasis Mydriatic action can precipitate an acute attack of glaucoma, which may result in blindness.
The nurse teaches clients that they should follow their diet restrictions while taking a monoamine oxidase inhibitor. What will develop if they do not follow these restrictions? 1. Occipital headaches 2. Generalized urticaria 3. Severe muscle spasms 4. Sudden drop in blood pressure
1. Occipital headaches Occipital headaches are the beginning of a hypertensive crisis that results form excessive tyramine.
In psychiatric nursing, the most important tool the nurse brings to a helping relationship is: 1. Oneself and a desire to help 2. Knowledge of psychopathology 3. Advanced communication skills 4. Years of experience in psychiatric nursing and milieu management
1. Oneself and a desire to help The nurse brings to a therapeutic relationship the understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship.
The nurse understands that neuroleptics are the drugs of choice to relive symptoms of: 1. Psychosis 2. Depression 3. Excessive activity 4. Narcotic withdrawal
1. Psychosis The neuroleptics modify the behavior of psychotic clients so they can cope more effectively with the environment and benefit from therapy.
Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? Select all that apply. 1. Rigidity 2. Tremors 3. Mydriasis 4. Photophobia 5. Bradykinesia
1. Rigidity 2. Temors 5. Bradykinesia Because of the effect of antipsychotics on the postsynaptic dopamine receptors in the brain, antipsychotic medications may cause this response.
The physician prescribes olanzapine (Zyprexa) for a client with bipolar disorder, manic episode. What cautionary advice should the nurse give the client? 1. Sit up slowly 2. Report double vision 3. Expect increased salivation 4. Take the medication on an empty stomach
1. Sit up slowly Zyprexa, a thienobenxodiazepine, can cause orthostatic hypotension.
When assisting clients to cope with a crisis, the professional care provider should follow the principles of intervention. Place the following interventions in order of priority when caring for a person experiencing a crisis. 1. Stabilize the victim 2. Intervene immediately 3. Encourage self-reliance 4. Utilize available resources 5. Facilitate understanding of the event
2,1,5,4,3
A nurse leads an assertiveness trainmen program for a group of clients. Which statement demonstrates that the treatment has been effective? 1. "I know I should put the needs of others before mine." 2. "I don't like to be called 'Dearie,' so I told him not to do it anymore." 3. "I won't stand for it. I told my boss he's a jerk and to get off my back." 4. "I find it easier to agree up front and then just do enough so that no one notices."
2. "I don't like to be called 'Dearie,' so I told him not to do it anymore." This is an assertive statement; it clearly states what the problem is and sets limits on undesired behavior without being demeaning.
For the last 5 days, a client has been receiving tranylcypromine (Parnate) 10 mg po twice a day for treatment of a major depressive episode. This morning, the client refuses the medication, stating, "It doesn't help, what what's the use of taking it?" What response by the nurse best demonstrates an understanding of the action of this monoamine oxidase inhibitor (MAOI)? 1. "It takes 6 to 8 weeks for this medication to have an effect." 2. "Sometimes it takes 2 to 4 weeks to see an improvement." 3. "You should have felt a response by now. I'll notify your physician." 4. "I'll talk to the physician about increasing the dosage, and that will help."
2. "Sometimes it takes 2 to 4 weeks to see an improvement." It usually takes 2 to 4 weeks to attain a therapeutic blood level of this monoamine oxidase inhibitor (MAOI).
A depressed client has been prescribed a tricycle antidepressant. The nurse teaches the client to expect to notice a significant change in the depression within: 1. 4 to 6 days 2. 2 to 4 weeks 3. 5 to 6 weeks 4. 12 to 16 hours
2. 2 to 4 weeks It takes this long for the drug to reach therapeutic blood levels.
Which approach should the nurse use during crisis intervention? 1. Passive and reflective 2. Active and goal-directed 3. Future-oriented and passive 4. Interpretative and analytical
2. Active and goal-directed During crisis intervention the nurse should be goal-directed and active in assessing the current situation and handling the interview with authority.
A week after the admission of a client with the diagnosis of paranoid schizophrenia, the client stands up in the lounge and throws a chair across the room and starts yelling at the other clients. Several of the other clients have frightened expressions, one starts to cry, and another beings to pace. After removing the agitated client from the room, what should the nurse do next? 1. Refocus the clients' negative comments to more positive ones 2. Arrange a unit meeting to discuss what just happened 3. Continue the unit's activities as if nothing has happened 4. Have a private talk with the clients who cried and started to pace
2. Arrange a unit meeting to discuss what just happened This provides an opportunity for the other clients to voice and share feelings and to identify and separate real from imaginary fears; an open expression of feelings allows the nurse to deal with client's fears and provide reassurance.
A 35 year-old is admitted for an amputation of the left leg. Before surgery the nurse observes that the client is diaphoretic, voiding frequently, having difficulty understanding what is being said, and complaining of palpitations. What should the nurse do first after making these assessments? 1. Have a stat ECG done on the client 2. Ask the client to talk about feelings 3. Obtain a urine specimens for culture and sensitivity 4. Ask the physician for a stat order for an IM tranquilizer
2. Ask the client to talk about feelings The symptoms presented are indicative of a severe anxiety reaction related to a crisis; the client has a need to vent feelings.
A client with diabetes, who has been taking insulin, is psychotic and now is to receive haloperidol (Haldol). The nurse should be concerned with this drug combination because it may: 1. Depress respirations 2. Decrease control of the diabetes 3. Intensify the action of both drugs 4. Increase the danger of extrapyramidal side effects
2. Decrease control of diabetes Haldol alters the effectiveness of exogenous insulin, and the combination of Haldol and insulin must be used with caution.
Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. The nurse must identify the signs and symptoms of this syndrome. Select all that apply. 1. Jaundice 2. Diaphoresis 3. Hyperrigidity 4. Hyperthermia 5. Photosensitivity
2. Diaphoresis 3. Hyperrigidity 4. Hyperthermia This occurs with neuroleptic malignant syndrome as a result of dopamine blockade in the hypothalamus.
A nurse working on a unit in a psychiatric hospital is responsible for performing a variety of functions. Which are the ones that a registered nurse is legally permitted to perform? Select all that apply. 1. Psychotherapy 2. Health promotion 3. Case management 4. Prescribing medication 5. Treating human responses
2. Health promotion 3. Case management 5. Treating human responses
During a staff development program, the nurse educator emphasizes that nurse caring for middle-aged adults who are experiencing midlife crisis should understand that this crisis is most often a result of the: 1. Many role changes adults experience at this time 2. Individual's perception of his or her life situation 3. Anticipation of negative changes associated with old age 4. Lack of support of family members who are busy with their own lives
2. Individual's perception of his or her life situation Th most significant factor in either precipitation or avoiding crisis is not the events but how the individual perceives them.
After 2 weeks of neuroleptic drug therapy, the nurse notices that the client has become jaundiced. The nurse continues to give the neuroleptic until the psychiatrist can be consulted. In situations such as this: 1. Jaundice is a benign side effect and has little significance 2. Jaundice is sufficient reason to discontinue the neuroleptic 3. The blood level of neuroleptics must be maintained once established 4. The psychiatrist's orders for the neuroleptic should be reduced by the nurse
2. Jaundice is sufficient reason to discontinue the neuroleptic Liver damage is a well-documented toxic side effect of neuroleptics. By continuing to administer the drug, the nurse failed to use professional knowledge in the performance of responsibilities as outlined in the Nurse Practice Act.
The nurse identifies that the main goal in planning care for a client in crisis is to: 1. Schedule follow-up counseling for the client 2. Restore the client's psychologic equilibrium 3. Have the client gain insight into the problems 4. Refer the client for occupational and physiotherapy
2. Restore the client's psychologic equilibrium Crisis intervention is short-term therapy with the major goal of restoring clients to their pre crisis state.
The nurse is caring for a client who abruptly withdrew from barbiturate use. The nurse should expect the client to experience: 1. Ataxia 2. Seizures 3. Diarrhea 4. Urticaria
2. Seizures This is a serious side effect the may happen with abrupt withdrawal from barbiturates.
A client is to be discharged from a psychiatric unit with orders for haloperidol (Haldol) therapy. As part of the teaching plan concerning this medication, the nurse should teach the client to avoid: 1. Driving at night 2. Staying in the sun 3. Ingesting aged cheeses 4. Taking medications containing aspirin
2. Staying in the sun Haldol causes photosensitivity. Severe sunburn can occur on exposure to the sun.
One of the initial goals of anger management is to have clients: 1. Express remorse over aggressive actions 2. Take responsibility for their hostile behaviors 3. Develop alternative methods to release feelings 4. Teach others how to avoid triggering their anger
2. Take responsibility for their hostile behaviors Before progress can be made in treating anger, clients need to take responsibility for their behavior. As long as they blame others, they will not be motivated to change.
A male nurse reminds a client that it is time for group therapy. The clients responds by yelling at the nurse, "You are always telling me what to do, just like my father." This clients response is an example of: 1. Regression 2. Transference 3. Reaction formation 4. Counter transference
2. Transference With transference a client assigns to someone the feelings and attitudes originally associated with an important significant other.
During a group meeting a male client tells everyone of his impending discharge from the hospital. It is most appropriate of the nurse leading the group to respond: 1. "You ought to be happy that you're leaving." 2. "Maybe you're not ready to be discharged yet." 3. "Maybe others in the group have similar feelings that they would share." 4. "How many in the group feel that this member is ready to be discharged?"
3. "Maybe others in the group have similar feelings that they would share." This permits the client to see that personal feelings are not unique but are shared by others.
A newly licensed primary nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. When talking with the nurse manager, the primary nurse expresses disgust that the woman returns to the same situation. The best response by the nurse manager is: 1. "She must not have the financial resources to leave her husband." 2. "The woman is free to choose her own life and there is nothing staff can do." 3. "Most woman attempt to leave about six times before they are able to do so." 4. "The woman should be told how foolish she is to remain in her current situation."
3. "Most women attempt to leave about six times before they are able to do so." Nurses who work with clients who are victims of partner abuse need to be supportive and patient. It takes time and several attempts for most victims to be able to leave abusive relationships.
When a psychiatric nurse uses the family systems theory in practice, which statement by the nurse is most typical of this theory? 1. "Describe for me in your own words what caused this situation." 2. "You need to abide by the unit rules and attend the community meetings." 3. "Whenever someone permanently leaves the home, the boundaries are upset." 4. "You're doing better; let's talk to the doctor about lowering your medication dosage
3. "Whenever someone permanently leaves the home, the boundaries are upset." Boundaries relate to family systems theory.
For most nurses the most difficult part of the nurse-client relationship is: 1. Remaining therapeutic and professional 2. Being able to understand and accept the client's behavior 3. Developing an awareness of self and the professional role in the relationship 4. Accepting responsibility in identifying and evaluating the real needs of the client
3. Developing an awareness of self and the professional role in the relationship The nurse's major tool in psychiatric nursing is the therapeutic use of self. Psychiatric nurses must learn to identify their own feelings and understand who they affect the situation.
A client is receiving lithium carbonate. While this medication is being administered, is it important that the nurse: 1. Restricts the client's daily sodium intake 2. Test the client's urine specific gravity weekly 3. Monitor the client's drug blood level regularly 4. Withhold the client's other medications for 1 week
3. Monitor the client's drug blood level regularly Lithium carbonate alters sodium transport in nerve and muscle cells and causes a shift toward intraneuronal metabolism of catecholamines. Since the range between therapeutic and toxic levels is very small, the client's serum lithium level should be monitored closely.
During a staff development program, when discussing the reaction of middle-aged women to their children leaving home, the nurse educator reminds the group that recent studies have demonstrated that today's women most commonly experience a feeling of: 1. Anxiety 2. Depression 3. Satisfaction 4. Hopelessness
3. Satisfaction Studies demonstrate that as more women enter the work force, the experience fewer negative responses to the "empty nest" created by children leaving home.
The nurse monitors a client with chronic undifferentiated schizophrenia for the side effects of an antipsychotic drug. For which potentially irreversible extrapyramidal side effects should the nurse monitor the client? 1. Torticollis 2. Oculogyric crisis 3. Tardive dyskinesia 4. Pseudoparkinsonism
3. Tardive Dyskinesia The occurs as a late of persistent extrapyramidal complication of long-termantipsychotic therapy. It can take many forms (e.g. torsion spasm, opisthotonos, oculogyric crisis, drooping of the head, protrusion of the tongue).
A client with depression is to receive fluoxetine (Prozac). A precaution that the nurse must remember when initiating treatment with this drug is that: 1. It must be given with milk and cracked to avoid hyperacidity and discomfort 2. Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis 3. The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks 4. Blood levels will need to be obtained weekly for 3 months to check for appropriate levels
3. The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. This drug does not produce an immediate effect; nursing measures must be continued to decrease the risk for suicide.
The nurse is aware that a co-worker's mother died 16 months ago. The co-worker cries every time someone mentions the word "mother" or if the mother's name is mentioned. Which should the nurse understand in this situation? 1. Everyone cries when their mother dies 2. This behavior is an expected response 3. This person should seek help with grieving 4. The co-worker was extremely attached to the mother
3. This person should seek help with grieving Crying a release, but the individual should have developed effective coping mechanisms by this time.
A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. The client's spouse wants to know which of the prescribed medications will be most helpful to that the psychosis. The nurse should tell the client that the drug most helpful to reduce psychotic symptoms is: 1. Citalopram (Celexa) 2. Benztropine mesylate (Cogentin) 3. Ziprasidone hydrochloride (Geodon) 4. Acetaminophen with hydrocodone (Lortab)
3. Ziprasidone hydrochloride (Geodon) Ziprasidone hydrochloride (Geodon) is a neuroleptic, which will reduce psychosis by affecting the action of both dopamine and serotonin.
A 45-year-old physician is admitted to the psychiatric unit of a community hospital. The client is restless, loud, aggressive, and resistive during the admission procedure and states, "I will take my own blood pressure." What is the most therapeutic response by the nurse? 1. "Right now, doctor, you are just another client." 2. "If you would rather, doctor, I'm sure you will do it OK." 3. "If you do not cooperate, I will get the attendants to hold you down." 4. "I am sorry, but I cannot allow that. I must take your blood pressure."
4. "I am sorry, but I cannot allow that. I must take your blood pressure." This simply states facts without getting involved in role conflict.
The father of a 16-year-old boy who has just been diagnosed with Hodgkin's disease tells the nurse he does not want his son to know the diagnosis. What response by the nurse is best in this situation? 1. "It is best is he knows the diagnosis." 2. The cure rate for Hodgkin's disease is high." 3. "Would you like someone with Hodgkin's to talk to you?" 4. "Let's talk about why you don't want him to know."
4. "Let's talk about why you don't want him to know." This statement does not prejudge the father; if encourages communication.
As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because, "I have nothing to talk about." What is the best response by the nurse? 1. "Maybe tomorrow you will feel more like talking." 2. "Could you start off by talking about your family?" 3. "A person like you has a great deal to offer the group." 4. "You feel you will not be accepted unless you have something to say?"
4. "You feel you will not be accepted unless you have something to say?" This reflective statement allows the client to either validate or correct the nurse.
A client on the psychiatric unit asks the nurse about psychiatric advance directives (PAD). The nurse explains that these advanced directives: 1. Make the appointment of a surrogate decision maker unnecessary 2. Permit the client to dictate what treatment will be given during the future hospitalizations 3. Eliminate the need for involuntary admissions when the client is a threat to self or others 4. Allow the client, while having the capacity, to consent or refuse potential psychiatric treatments in the event of a future incapacitating mental health crisis
4. Allow the client, while having the capacity, to consent or refuse potential psychiatric treatments in the event of a future incapacitating mental health crisis The purpose of a PAD is to allow psychiatric clients the opportunity to provide input into future treatment decisions.
Drugs such as trihexyphenidyl (Artane), biperiden (Akineton), or denztropine (Cogentin) are often prescribed in conjunction with: 1. Barbiturates 2. Antidepressants 3. Antianxiety agents/ anxiolytics 4. Antipsychotic agents/ neuroleptics
4. Antipsychotic agents/ neuroleptics These drugs are used to control the extrapyramidal (parkinson-like) symptoms that often develop as a side effect of neuroleptic therapy.
The psychiatric nurse teaches clients in a medication education group that photosensitization is a side effect associated with the use of: 1. Sertraline (Zoloft) 2. Lithium carbonate (Lithane) 3. Methylphenidate hydrochloride (Ritalin) 4. Chlorpromazine hydrochloride (Thorazine)
4. Chlorpromazine hydrochloride (Thorazine) Clients taking chlorpromazine should be told to stay out of the sun. Photosensitivity makes the skin more susceptible to burning.
The nurse understands that the outcome that is unrelated to a client in a crisis state is: 1. Decompensating to a lower level of functioning 2. Learning and using more constructive coping skills 3. Adapting and returning to prior level of functioning 4. Continuing a high level of anxiety for more than 3 months
4. Continuing a high level of anxiety for more than 3 months This is not an expected outcome of a crisis because by definition a crisis is resolved in 6 weeks.
The nurse understands that the theory that anxiety has a biologic basis, and therefore anti anxiety agents are effective, is continent on the concept that: 1. Degernation of myelin will increase anxiety 2. An excess of dopamine is found in anxious clients 3. Decreased amounts of norepinephrine and serotonin cause anxiety 4. Drugs with an inhibitory effect that activate GABA receptors can calm anxiety
4. Drugs with an inhibitory effect that activate GABA receptors can calm anxiety GABA, a neurotransmitter, promotes a balance between dopamine and glutamate; it is effective in reducing anxiety.
A client is scheduled for a 6-week electroconvulsive therapy treatment program. What intervention by the nurse is important to maintain safety of the client during the 6-week treatment program? 1. Tyramine-free meals 2. Avoidance of exposure to the sun 3. Maintenance of a steady sodium intake 4. Elimination of benzodiazepines for nighttime sedation
4. Elimination of benzodiazepines for nighttime sedation The use of these drugs can raise the seizure threshold, which is counterproductive.
What is the most important information the nurse should teach to prevent relapse in a client with a psychiatric illness? 1. Develop a close support system 2. Create a stess-free environment 3. Refrain from activities that cause anxiety 4. Follow the prescribed medication regimen
4. Follow the prescribed medication regimen This is important because side effects and denial of illness may cause clients to stop taking their medications; this is a common cause of relapse.
The physician orders imipramine (Tofranil), 75 mg three times per day, for a client. What nursing action is appropriate when administering this drug to a client? 1. Avoid administration of barbiturates or steroids with this drug 2. Warn the client not to eat cheese, fermenting products, and chicken liver 3. Observe the client for increased tolerance so that the therapeutic dosage is maintained 4. Have the client checked for intraocular pressure and provide instructions to be alert for symptoms of glaucoma
4. Have the client checked for intraocular pressure and provide instructions to be alert for symptoms of glaucoma The development of glaucoma is one of the side effects of imipramine (Tofranil), and the client should be taught the symptoms.
A client in the the hyperactive phase of a mood disorder, bipolar type, is receiving lithium carbonate. The nurse identifies that the client's lithium blood level is 1.8 mEq/L. It is most important for the nurse to: 1. Continue the usual dose of lithium and note any adverse reaction 2. Discontinue the drug until the lithium serum level drops to 0.5 mEq/L 3. Ask the physician to increase the dose of lithium because the blood lithium level is too low 4. Hold the drug and notify the physician immediately because the blood lithium level may be toxic
4. Hold the drug and notify the physician immediately because the blood lithium level may be toxic The lithium level should be maintained between 0.5 and 1.5 mEq/L.
The psychiatrist orders "Restraints PRN" for a client who has a history of violent behavior. Then nurse should: 1. Utilize the restraint order if the client begins to act-out 2. Ask the psychiatrist to clarify the type of restraint order 3. Ensure that the entire staff is aware of the restraint order 4. Recognize that PRN orders for restraints are unacceptable
4. Recognize that PRN orders for restraints are unacceptable New orders must be written each time a client requires restraints. When a client is acting-out, the nurse may use restraints or a seclusion room and then obtain the necessary order.
A male client with schizophrenia is receiving benztropine mesylate (Cogentin) in conjunction with an antipsychotic. When at the clinic, the client tells the nurse that occasionally he forgets to take the Cogentin. The nurse should teach him that if this should happen again, he should: 1. Notify the physician immediately 2. Use 2 pills at the next regularly scheduled dose 3. Skip the dose, but take the next regularly scheduled dose 2 hours early 4. Take the pill as soon as possible, up to 2 hours before the next dose
4. Take the pill as soon as possible, up to 2 hours before the next dose This is the advised intervention when a dose is missed; interruption of the medication may precipitate signs of withdrawal such as anxiety and tachycardia.
Which is the most important assessment data for the nurse to gather from the client in crisis? 1. The client's work habits 2. Any significant physical health data 3. A history of any emotional problems in the family 4. The specific circumstances surrounding the client's perceived crisis situation.
4. The specific circumstances surrounding the client's perceived crisis situation This assessment assists the nurse to determine what the situation means to the client
The nurse understands that a common manageable side effect of neuroleptics is: 1. Jaundice 2. Melanocytosis 3. Drooping eyelids 4. Unintentional tremors
4. Unintentional tremors Unintentional tremors are one of the extrapyramidal side effects of the neuroleptics an dare considered common and manageable.
The nurse encourages the client to join self-help group after being discharged from a mental health facility. The purpose of having people work in a group is to provide: 1. Support 2. Confrontation 3. Psychotherapy 4. Self-awareness
1. Support Self-help group members share similar experiences and an provide valuable understanding and support to each other.
A 30-year-old woman is brought to the local community hospital by a family member because the woman "has been acting strange." When the nurse assess the client, which statements meet involuntary hospitalization criteria? Select all that apply. 1. "I cry all the time I am so depressed." 2. "I would like to end it all with sleeping pills." 3. "The voices say it is okay for me to kill all prostitutes." 4. "My boss is always picking on me and it makes me angry."
2. "I would like to end it all with sleeping pills." This statement indicates a suicide threat; it is a direct expression of intent but without action. 3. "The voices say it is okay for me to kill all prostitutes." The threat to harm others must be heeded; the client must be protected from harming herself as well as harming others
After examining a client who continues to exhibit negative symptoms (flat affect, isolation, poverty of speech, and lack of motivation) of schizophrenia, the physician writes an order to change the client's drug therapy from haloperidol (Haldol) to risperidone (Risperdal). This dosage ordered is 1 mg twice per day for 3 days. What is the most important safety measure for the nurse to take? 1. Monitor the client for mood changes and suicidal tendencies, especially during early therapy 2. Determine if the morning dosage of Haldol has been given and then start the initial dose of Risperdal at bedtime 3. Assess for the side effects of sedation, restlessness, and muscle spasm after the drug has been administered 4. Review the medication sheet to determine the time of the last dose of Haldol before administering the correct dosage of Risperdal at 2 PM
2. Determine if the morning dosage of Haldol has been given and then start the initial dose of Risperdal at bedtime It is important that the nurse discontinue previous antipsychotic medications before starting risperidone to minimize the period of overlap and therefore avoid a drug interaction.
A monoamine oxidase inhibitor (MAOI) is prescribed. What should the nurse teach the client to avoid? 1. Prolonged exposure to the sun 2. Ingesting wines and aged cheeses 3. Engaging in active physical exercise 4. Over-the-counter NSAID medication
2. Ingesting wines and aged cheeses The monoamine oxidase inhibitors can cause a hypertensive crisis if food or beverages that are high in tyramine are ingested.
An acting-out, older client has been receiving fluphenazine (Prolixin) for several months. After identifying that the client sits rigidly in a chair, the nurse assesses the client closely for other evidence of adverse side effects of the drug, including: 1. Inability to concentrate, excess salivation 2. Uncoordinated movements, tremors 3. Reluctance of converse, nonverbal clues indicating fear 4. Minimal use of nonverbal expressions, rambling speech
2. Uncoordinated movements, tremors Acute dystonic reactions, parkinsonian syndrome, dyskinesia, and akathisia are observable side effects of fluphenazine (Prolixin) therapy.
A male nurse is caring for a client. The client states, "You know, I've never had a male nurse before." The nurse's best reply should be: 1. "Does it bother you to have a male nurse?" 2. "There aren't many of us; we're a minority." 3. "How do you feel about having a male nurse?" 4. "You sound upset. I will get a female nurse to care for you."
3. "How do you feel about having a male nurse?" This statement encourages the client to express and explore feelings; also, it is open and nonjudgmental.
What medication should the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines? 1. Lithium 2. Methadone 3. Romazicon 4. Chlorpromazine
3. Romazicon Flumazenil (Romazicon) is the drug of choice in the management of overdose when a benzodiazepine is the only agent ingested by a client not at risk for seizure activity. This medication competitively inhibits activity at benzodiazepine recognition sites on GABA/ benzodiazepine receptor complexes.
A client with schizophrenia, who has type II (negative) symptoms, is prescribed risperidone (Risperdal). The nurse should evaluate the medication has minimized the type II symptoms when the client: 1. Is less agitated 2. Has fewer delusions 3. Shows interest in unit activities 4. Reports that the hallucinations have stopped
3. Shows interest in unit activities Apathy is a common type II (negative) symptom; flat affect and lack of socialization also are common.
An extremely anxious client enters a crisis center and asks for help. Which response by the nurse best reflects the nurse's role in crisis intervention? 1. "Tell me what you have done to help yourself." 2. "Can you tell me about what is bothering you?" 3. "I understand in the past you have had problems." 4. "I will be here for you to help you figure things out."
4. "I will be here for you to help you figure things out." Clients in crisis need assistance with coping; the nurse must be involved with problem solving.
A nurse is evaluating the medication regimens of a group of clients to determine whether the therapeutic level has been achieved. For which medication should the nurse review the client's serum blood level? 1. Sertraline (Zoloft) 2. Lorazepam (Ativan) 3. Olanzapine (Zyprexa) 4. Valproic acid (Depakene)
4. Valproic acid (Depakene) Valproic acid (Depakene) must reach a therapeutic level to be effective, and the serum level must be monitored for therapeutic and toxic levels of the drug.
A psychotic client is receiving olanzapine (Zyprexa). When administering this drug, it is important that the nurse understand that this medication: 1. Can be given only intramuscularly 2. Requires a special tyramine-free diet 3. Should be taken on an empty stomach 4. Will dissolve instantly after placement in the clients mouth
4. Will dissolve instantly after placement in the client's mouth Olanzapine (Zyprexa, Zydis) is an oral disintegrating tablet, which will instantly dissolve on contact of moisture.
A 52-year-old male client with a diagnosis of schizophrenia is about to be discharged to a halfway house. This is his fifth admission in less than 1 year. He improves while in the hospital, but after discharge he forgets to take his medication, is unable to function, and must be rehospitalized. A medication that can be administered IM by the nurse to this client on an out-patient basis every 2 to 3 weeks is: 1. Haldol 2. Valium 3. Lithium carbonate 4. Prolixin decanote
Prolixin decanote This medication can be given IM every 2 to 3 weeks for clients who are unreliable in taking oral mediations; it allows them to live in the community while keeping the symptoms under control.