Case Study - Psychosis

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.

B. Past suicide attempts. C. History of violence. E. Medication noncompliance.

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.

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

B. Take Adam's blood pressure while he is sitting and standing.

What additional interventions are essential to a successful plan during the acute phase of the illness? A. Isolation. B. Daily activities. C. Consistency. D. Medications. E. Adequate rest.

C. Consistency. D. Medications. E. Adequate rest.

Which thought process describes Adam'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. A delusion is a false belief that is firmly maintained even though it is not shared by others and is contradicted by reality.

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 term fits the nurse's observation that Adam looks to the corner of the room and mumbles to himself? A. Delusions. B. Depersonalization. C. Hallucinations. D. Disorientation.

C. Hallucinations. These can be nonverbal or they can include talking to oneself, moving the lips without making sounds, rapid eye movements, and grinning or inappropriate laughter.

On what aspect is it most important for the nurse to perform follow-up before discharge? A. Contracts to follow discharge plans. B. Resources to provide community support. C. Thoughts of harm to self or others. D. Significant others for support.

C. Thoughts of harm to self or others.

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.

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 difference between 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.

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

D. Take away Adam's cigarettes and lighter.

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.

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.

What is the most important benefit Adam 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.

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.

Which medications should the nurse anticipate giving Adam after securing a prescription from the healthcare provider? 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 Adam to continue compliance with medications. B. To document Adam'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 Adam to discuss symptoms with his nurse.

A. To encourage Adam 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 Adam to discuss symptoms with his nurse.

Why is Adam prescribed this medication? A. To reduce severity of extrapyramidal effects. B. To prevent the risk for tardive dyskinesia. C. To potentiate haloperidol (Haldol) so that it will be more effective. D. To further alleviate dystonic reactions.

A. To reduce severity of extrapyramidal effects.

Which assessment data provides evidence that Adam 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.

When Adam looks around the room and mumbles to himself, how should the nurse respond? A. "How are you feeling?" B. "Are you hearing voices?" C. "Have you been here before?" D. "Tell me what you're thinking."

B. "Are you hearing voices?" The client is demonstrating nonverbal cues that he is experiencing auditory hallucinations, so the nurse should ask the client if he is hearing voices.

When Adam explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond? A. "Believe me. No one has followed you here." B. "You must be concerned, but you are safe here." C. "The police will make sure no one is out there." D. "Why do you think that someone is out there?"

B. "You must be concerned, but you are safe here." The nurse should respond to the client's underlying feelings and not make assumptions about his delusions.

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

B. Dystonia.

Adam admits that the voices he hears have been getting louder over the past couple of weeks. Which question should the nurse ask Adam next? A. "What helps the voices go away?" B. "How long have you heard voices?" C. "When do the voices get louder?" D. "What do the voices say?"

D. "What do the voices say?" The nurse should first ask what the voices are saying in order to assess for command hallucinations.

What nursing interventions should be included in the care plan that is initiated early after admission and reinforced until discharge? A. An understanding of psychosis and the causes of it. B. The importance of attending support groups after discharge. C. Depression and anxiety are common causes of psychosis. D. Client safety. E. The purpose and side effects of psychotropic medications.

D. Client safety. E. The purpose and side effects of psychotropic medications.