HESI Patient Review: Terry Johnson

Medication is now indicated to control Terry's behavior. What medication might the physician order to help Terry become less violent? Select all that apply (there are 2 correct answers). A. Haldol (haloperidol) by intramuscular injection B. Lithonate (lithium) by mouth C. Ludiomil (maprotiline) by mouth D. Zyprexa (olanzapine) by intramuscular injection

A. Haldol (haloperidol) by intramuscular injection Haldol (haloperidol), a typical (conventional) antipsychotic drug, given intramuscularly, should successfully control Terry's agitation, paranoia, anxiety, and aggression. It is fast-acting, with an onset of 20-30 minutes, peaking in 30-45 minutes. IM Haldol (haloperidol) is ordered for and administered to Terry. D. Zyprexa (olanzapine) by intramuscular injection Zyprexa (olanzapine) is an atypical antipsychotic medication available as an injectable that would be useful with Terry. It has less anticholinergic side effects than typical antipsychotic medications, and is fast-acting. However, it is more expensive than some other antipsychotic drugs.

In working with Terry, you use a variety of interventions. These appropriately include which of the following? Select all that apply (there are 5 correct answers). A. Monitor skin turgor and temperature, mucous membranes, periorbital areas, urinary output, thirst B. Monitor blood pressure, observe for increased restlessness and dystonias C. Keep Terry busy with lots of activities D. Pad restraints and side rails, rotate release of restraints E. Avoid providing drinks with caffeine F. Role model slow breathing

A. Monitor skin turgor and temperature, mucous membranes, periorbital areas, urinary output, thirst Given Terry's Risk for Deficient Fluid Volume, these interventions are appropriate. Assessing Terry for signs of dehydration, such as poor skin turgor, dry oral mucosa, "sunken" eye sockets, thirst, and a decrease in urine output, are indicated. B. Monitor blood pressure, observe for increased restlessness and dystonias Adverse reactions to Haldol (haloperidol) include hypotension, and central nervous system symptoms such as akathisia (restlessness, inability to sit down) and dystonia (prolonged muscle contractions with rhythmic jerking). Monitoring for these is appropriate. D. Pad restraints and side rails, rotate release of restraints Given Terry's Risk for Injury related to the use of restraints, these interventions are appropriate. When restraints are in use, padding is imperative to help decrease risk for abrasions around Terry's wrists and ankles. Padding of side rails is also indicated. Restraints should be released on a rotating basis (every two hours if Terry is not violent) for short periods. Circulation should be monitored to avoid ischemia of hands and feet. E. Avoid providing drinks with caffeine To help maintain Terry's hydration status, drinks containing caffeine such as coffee, tea, and colas should be avoided. These would increase fluid loss through the kidneys. Also, caffeine is a stimulant and should not be used with an agitated patient. F. Role model slow breathing This intervention is appropriate. Modeling slow breathing should lead Terry to breathe more slowly, which would decrease insensible water loss, as well as help relax him.

In caring for Terry, you need to address which of the following as priorities? A. Risk for Injury related to being restrained, thrashing about, and impaired judgment B. Risk for Deficient Fluid Volume related to inadequate intake and the dehydrating effects of alcohol, Ecstasy, and tachypnea C. Constipation related to decreased food intake and immobility D. Self-Care Deficit: Bathing/Hygiene related to confinement and short attention span E. Disturbed Thought Processes related to changes in brain chemistry and anxiety secondary to Ecstasy/alcohol F. Risk for Violence related to disinhibiting and irritating effects of Ecstasy/alcohol and history of assaults

A. Risk for Injury related to being restrained, thrashing about, and impaired judgment Terry's Risk for Injury is an immediate concern. Terry is prone to abrasions and impaired circulation from his restraints. In addition, broken bones and blood vessels can occur as Terry resists the restraints. Nursing and medical interventions to prevent/avoid injury are indicated. B. Risk for Deficient Fluid Volume related to inadequate intake and the dehydrating effects of alcohol, Ecstasy, and tachypnea Terry is at risk for becoming dehydrated. He should be offered water or juice every hour during his calmer moments. During this time, he should be watched carefully for his ability to swallow. If Terry refuses to drink, or if he has difficulty swallowing, IV hydration may be necessary. Given Terry's fear of experimentation, Terry would probably require sedation if IV fluids were needed. E. Disturbed Thought Processes related to changes in brain chemistry and anxiety secondary to Ecstasy/alcohol Terry's apparent delusions validate Disturbed Thought Processes as a current problem for him. F. Risk for Violence related to disinhibiting and irritating effects of Ecstasy/alcohol and history of assaults Terry's potential for violence takes high priority. He has demonstrated aggressive behavior, been unable to contract for safety, remains under the influence of drugs, and has a history of aggravated assaults. Preventing Terry from becoming violent and causing injury to himself or others is a major goal of care.

You are assigned to oversee Terry's care. He refuses to attend class. Which of the following approaches would be best? A. Use the approach recommended by the unit's treatment plan B. Just nod and say, "Okay." C. Use the approach that seems best given Terry's affect at the moment D. Very matter-of-factly say, "You are expected to attend. Otherwise, you need to go into locked seclusion."

A. Use the approach recommended by the unit's treatment plan For someone like Terry, who tries to control and manipulate people and systems to his advantage, a unified approach is best. If all team members use the same approach in responding to Terry's refusal to attend classes, he will be less likely to continue his unhealthy pattern of behavior.

The change in behavior noted in Terry's "followers" can be attributed to: A. the need to conform with behaviors expected of their new peer group B. a need to be noticed, given all the attention now focused on Terry C. ambivalence about Terry's power over them D. changed expectations of staff members

A. the need to conform with behaviors expected of their new peer group Peer relationships and groups are especially important during late adolescence. It is probable that the association these teens have with Terry fills a need to belong. Belonging to a group during adolescence often means conforming to group rules, whatever they may be.

At this point, approaches to help control Terry's behavior and prevent further aggressiveness include: A. sitting with him at eye level B. talking with him slowly and gently C. suggesting to the physician that IM Haldol (haloperidol) be ordered D. providing him with information about what is happening in simple, accurate terms E. telling him he is safe and that the staff will not hurt him, or allow him to hurt himself or anyone else F. actively listening to and reflecting what he is saying G. leaving him alone for short intervals

At this point, approaches to help control Terry's behavior and prevent further aggressiveness include: A. sitting with him at eye level Terry will feel less threatened if interaction with him occurs at eye level. Standing above Terry while communicating with him would emphasize his powerlessness and restrained condition, and would probably contribute to further aggressiveness. B. talking with him slowly and gently It is important to avoid approaches that could escalate Terry's anger and aggressiveness. Talking loudly could be perceived as confrontive and might precipitate a power struggle. Generally, a gentle, slow approach helps to diffuse anger. It is important, however, that Terry not perceive you as weak and unable to control his anger and aggression. Therefore, ongoing assessment of Terry's response to you is indicated. D. providing him with information about what is happening in simple, accurate terms It is important to speak clearly and in simple terms to Terry, without being condescending. Because of his anger and the possible ingestion of mood and mind-altering drugs, Terry's interpretation of information and the situation may be inaccurate. Clear, simple explanations are most likely to be accurately interpreted. E. telling him he is safe and that the staff will not hurt him, or allow him to hurt himself or anyone else Both patient and staff safety are major concerns in the Emergency Department. Conveying this information to Terry should help to decrease his sense of vulnerability and increase his ability to control himself. F. actively listening to and reflecting what he is saying Anger is an emotional response to frustration or threats, real or imagined. Underlying feelings can include feeling discounted, ignored, and out of control of the situation. Active listening would convey to Terry that he is being heard, and is worthwhile and respected. These attitudes should help him regain self-control.

Terry's history reflects that he has been drinking large amounts of alcohol on a daily basis for an extended period of time. Understanding withdrawal from alcohol is necessary for safe nursing care. Which of the following statements about alcohol withdrawal are true? Select all that apply (there are 2 correct answers). A. Alcohol withdrawal symptoms typically include somnolence B. Nausea and vomiting may develop with alcohol withdrawal C. Although uncomfortable for patients, alcohol withdrawal poses no serious physiological threat D. Alcohol withdrawal symptoms can include hallucinations

B. Nausea and vomiting may develop with alcohol withdrawal Anorexia, nausea, and vomiting are common with alcohol withdrawal. These signs/symptoms typically begin 6-12 hours after the last alcohol intake. With vomiting, prevention of aspiration is important for patient safety. D. Alcohol withdrawal symptoms can include hallucinations Alcohol withdrawal can include visual, auditory, or tactile hallucinations without disorientation (alcoholic hallucinosis, onset 12-24 hours after last alcohol intake, seldom lasting beyond 48 hours), and/or withdrawal delirium (delirium tremens) (onset 48-72 hours after last alcohol intake, with symptoms peaking at 5 days after last alcohol intake). Withdrawal delirium includes hallucinations (primarily visual), disorientation, and elevated vital signs (temperature, blood pressure, pulse). Withdrawal delirium can be life-threatening. Hallucinations can be very frightening. The nurse's approach should include kind, supportive reorientation and clarification.

What approaches can be used to help resolve Terry's problem of Defensive Coping? Select all that apply (there are 5 correct answers). A. Staff should be assertive and firm with Terry B. Opportunities such as group and activity therapies and community meetings can be used to provide feedback to Terry about his manipulative, controlling behaviors C. Terry's progress can be plotted on a behavioral chart D. Staff expectations can be explained to Terry in terms of benefits to him E. Terry can be allowed to develop his own schedule of activities, rewards, and consequences F. Terry can be encouraged to work out in the gym G. Terry can participate in daily sessions in which he is taught how to problem solve

B. Opportunities such as group and activity therapies and community meetings can be used to provide feedback to Terry about his manipulative, controlling behaviors Confronting Terry in a group setting would be better than confronting him in an individual session. With staff support and the strength afforded by a group, Terry's peers may be able to express their feelings and reactions about being intimidated by him. With a competent group leader, Terry is less likely to get control of a group situation, even if he does "play to an audience." C. Terry's progress can be plotted on a behavioral chart Using a graph to monitor Terry's behaviors would allow for an objective view of his progress. Ideally, the items on the graph should be stated in positive terms, such as "Talked about his frustrations without using aggression" and "Completed care of his room by himself with minimal reminders." A positive focus should raise the attention of staff to Terry's good qualities and de-emphasize his disruptive ones. Not only will this positive focus reward Terry with more caring, understanding responses from staff, it should also decrease staff tension and fear by allowing Terry to be viewed as a whole person, not just an aggressive/manipulative one. D. Staff expectations can be explained to Terry in terms of benefits to him It is improbable that Terry can be changed into a warm, empathic, compliant person in a short time and against his will. He has many narcissistic qualities and an engrained sense of entitlement to getting what he wants. However, you can expose Terry to new ways of getting his needs met without causing so much trouble for himself. For example, the more he follows the treatment program, the more time he has off the unit. Terry is more likely to comply with responsibilities when the rewards are relevant and understandable to him. F. Terry can be encouraged to work out in the gym Terry's aggressive tendencies can be vented in the form of physical activity. Aggression can be sublimated into acceptable activities such as basketball, volleyball, or body building. G. Terry can participate in daily sessions in which he is taught how to problem solve Terry needs to learn how to problem solve to determine non-aggressive ways of getting what he wants. Issues such as feeling powerful and important, thrill seeking and taking risks, immediate gratification, and the release of frustration/tension need to be addressed in individual therapy sessions.

In providing for Terry's care, your FIRST priority is to: A. determine what drugs he has taken B. help him become more calm C. draw a blood sample for drug screening D. make sure he is processed for insurance and ability to pay

B. help him become more calm Your first priority is to help Terry feel calmer and more in control. He will be less likely to cause self-harm if he is more calm and more in control. This will also expedite removal of restraints. Also, Terry will be in a better position to share information, respond to questions, and participate in care if he is more calm.

In an emergency, a patient can be restrained or secured without an order. Which of the following would be considered emergencies requiring physical restraint of a patient? A. An alert, coherent hospitalized patient with cancer who is receiving IV chemotherapy is removing his IV catheter B. A patient with dementia wanders into the hospital parking lot and refuses to leave C. A patient recovering from general anesthesia starts climbing over the side rails of his stretcher D. An alert but disagreeable patient threatens to sign himself out of the hospital

C. A patient recovering from general anesthesia starts climbing over the side rails of his stretcher A person can be restrained without an order when there is immediate indication that he/she may harm himself or others. A patient recovering from general anesthesia (who would not be fully alert) who is climbing over side rails may harm himself. Physical restraint is indicated to insure this patient is not injured. In an emergency, a patient can be restrained or secured without an order. However, an order for the restraint/seclusion, with justification of the need for the restraint and/or seclusion, must be obtained within one hour.

With regard to use of restraints, which of the following actions are necessary for safe and legal care of Terry? Select all that apply (there are 3 correct answers). A. Obtain a standing PRN order for seclusion/restraints so that Terry can be immediately restrained if necessary in the future B. Avoid restraining Terry for any reason in the future without a written order C. Continuously assess for effectiveness of the least-restrictive interventions for Terry while he is restrained D. While Terry is restrained, frequently inform and remind him of the reasons for his restraint and the behavior necessary for restraints to be removed E. Assessment by a qualified staff person at least every 15 minutes while Terry is restrained

C. Continuously assess for effectiveness of the least-restrictive interventions for Terry while he is restrained Designated, trained care providers must continuously assess a person who is restrained or in seclusion to determine if alternative, less-restrictive methods can be used to manage the patient's behavior. D. While Terry is restrained, frequently inform and remind him of the reasons for his restraint and the behavior necessary for restraints to be removed Informing and reminding Terry of the reasons for restraint and conditions required for restraint removal are important. This would allow Terry some autonomy and control with regard to readiness for removal of the restraint. E. Assessment by a qualified staff person at least every 15 minutes while Terry is restrained Assessment by a qualified staff person should be done at least every 15 minutes when a patient is restrained and/or in seclusion. Terry is in four-point restraints and very aggressive. Terry should be monitored continuously to assure his safety, health, and well-being.

You need to complete a history and physical assessment. Which verbal approach is best? A. "Listen while I ask you some questions and do your physical exam." B. "Stop struggling! You're only hurting yourself." C. "We're going to finish this exam whether you like it or not." D. "As I do your exam, I will tell you exactly what I'm going to do."

D. "As I do your exam, I will tell you exactly what I'm going to do." Letting Terry know what you are going to do is important. Telling him your approach would convey respect and acceptance of his current inability to process information quickly.

In addition to alcohol, what drugs can lead to the behaviors displayed by Terry? Select all that apply (there are 3 correct answers). A. Ativan (lorazepam), a benzodiazepine B. Heroin, an opioid C. Dexedrine, an amphetamine D. Marijuana, a cannabis derivative E. Crack, a cocaine derivative F. Ecstasy (MDMA), a ketamine derivative

C. Dexedrine, an amphetamine Dexedrine, an amphetamine, is a central nervous system stimulant that produces hypervigilance (exceptionally watchful), feelings of grandiosity (exaggerated self-importance), a desire to talk a lot, motor unrest, hallucinations (false perceptions), delusions (false beliefs), violent behavior, increased blood pressure, chills, nausea, and vomiting. Terry has exhibited aggressiveness and paranoia (delusions of persecution) and could have ingested amphetamines. E. Crack, a cocaine derivative Hydrochloride cocaine, or crack (also called rock), often leads to paranoia (delusions/false beliefs of persecution) and distortion of reality, difficulty sleeping, fatigue, depression, poor judgment, inability to abstract, and perhaps aggression. Other signs/symptoms of crack use include shortness of breath, black phlegm, increased cardiac and respiratory rates, scorched facial hairs, and weight loss. Terry has exhibited aggressiveness and paranoia and may have crack in his system. F. Ecstasy (MDMA), a ketamine derivative Terry has exhibited several signs/symptoms that could be associated with Ecstasy (MDMA) use: psychomotor agitation, anxiety, emotional lability (instability), self-importance, and sensory sensitivity. Hallucinations and delusions are also possible with Ecstasy use. Physical effects include increased heart rate and blood pressure. Nausea, vomiting, chills, sweating, and hyperthermia are also possible. Similar to both methamphetamine and mescaline, MDMA is classified as a Schedule 1 drug; and, for some people, may be addictive.

Given that Terry may have taken Ecstasy, you are especially alert for which potentially fatal drug reaction? A. Muscle flaccidity B. Bradycardia C. Hyperthermia

C. Hyperthermia Ecstasy can cause an uncontrolled rise in body temperature which, although rare, can be fatal.

Which of the following criteria would allow a judge or magistrate to commit him? A. Continued agitation and periodic paranoid behavior B. History of assault with related jail sentences C. Terry cannot care for himself and refuses to agree to contract for safety D. Diagnoses of Alcohol Intoxication and Drug-induced Psychotic Disorder

C. Terry cannot care for himself and refuses to agree to contract for safety To commit a person, evidence indicating that the person is at risk for harming himself or others is required. Terry cannot yet care for himself (he is a danger to himself). He will not or cannot agree to contract for safety (therefore, he may be a danger to himself or others). Involuntary admission to the Chemical Dependency Unit is justified.

Terry is definitively diagnosed as having antisocial personality disorder. The person with an antisocial personality usually is: A. careful to maintain lawful behavior and respect social rules B. free of behavioral problems until age 20 C. able to steal and lie without remorse D. careful to plan ahead

C. able to steal and lie without remorse The person with an antisocial personality is not internally motivated by knowing what is right and wrong. Often, he has not been exposed to or has not taken in messages from parents or other important adults that would normally help to form a "conscience." Consequently, he does not feel guilt, remorse, regret, or anxiety. He may rationalize actions, explaining his "having" to "fix" things because other people are incompetent or jealous of his "talent." And, although he may apologize for having lied or stolen, his words are not sincere. Persons like Terry may apologize only to protect themselves or to get what they want.

Terry, who had been calm and immobile for a short time, is again struggling, fighting, and cursing. He yells to you, "You b----! Let me out of here! You're not going to do any experiments on me! Don't think you're going to get away with this, you f-----!" What is your best response? A. "You sound drugged. I won't let you speak to me that way." B. "Don't curse at me! I won't take that from anybody." C. "You're getting aggressive again. I won't let you hurt yourself." D. "You sound frightened. I won't let anyone hurt you."

D. You sound frightened. I won't let anyone hurt you." Acknowledging Terry's underlying feeling of fear and reassuring him that you will help him stay safe would be best. Terry's excessive bravado, false display of strength, and use of the word "experiments" reflect his vulnerable position. His cursing, threats, demands, and loud voice are attempts to overcome fear and powerlessness through the effects of the drugs.

When a staff member has feelings about a patient or the patient's care that emerge because of events or feelings in his/her own life, the process is referred to as: A. projection B. sublimation C. reaction formation D. countertransference

D. countertransference When a staff member has feelings about a patient or the patient's care that emerge because of events or feelings in his/her own life, the process is referred to as countertransference. In countertransference, the patient is really being responded to as if he were someone else. Countertransference impedes therapy by preventing the staff member from seeing the patient as he really is. Feelings of countertransference need to be recognized and personally acknowledged, and possibly discussed with a colleague. It is important that personal feelings not interfere with judgments about a patient.

All of the following may explain the origins of antisocial personality disorder. Socio-cultural explanations include: Select all that apply (there are 2 correct answers). A. Reduced levels of serotonin and its metabolite 5-HIAA in cerebrospinal fluid B. Early childhood trauma to the central nervous system C. Fixation at a preadolescent cognitive level D. Never moving beyond using projection, rationalizing and splitting as major protective mechanisms E. Successful use of manipulation to get needs met F. Erratic display of discipline, moral values, and loving attention by significant others.

E. Successful use of manipulation to get needs met Wanting to be accepted as a part of a group, we constantly compare our own behaviors and attitudes with those around us. When our behavior is acknowledged and even supported by our family and peers, we feel like we belong. The socio-cultural model suggests that a person with an antisocial personality has adopted manipulative (influencing another to get one's own needs met) and aggressive attitudes and behaviors similar to those in his immediate environment in an effort to "belong." Use of these behaviors resulted in rewards and thus reinforced their continued use. F. Erratic display of discipline, moral values, and loving attention by significant others. A socio-cultural model would support the idea that lack of or inconsistency in showing right from wrong, love, respect, approval, or acceptance could account for the behavior seen with the antisocial personality.

Terry's friend is obviously frightened and worried about Terry, saying, "No drug should do that. What is wrong with him? Will he be alright?" What response to Terry's friend is best? A. "I am sorry. Because of confidentiality laws, I am not allowed to tell you anything." B. "Why don't you just try not to worry." C. "You sound concerned about Terry." D. "We do not know what is wrong with Terry right now; so, we cannot predict if he will be alright.

Terry's friend is obviously frightened and worried about Terry, saying, "No drug should do that. What is wrong with him? Will he be alright?" What response to Terry's friend is best? C. You sound concerned about Terry. This response is empathic and caring. It reflects the friend's feelings back to him and lets him know that you care about him. It also opens the door for further discussion and communication that might be helpful to the friend, and Terry. Although the Health Insurance Portability and Accountability Act (HIPAA) does limit the amount of information that can be provided to others without a patient's permission, information can be shared if the provider believes it is in the best interest of the patient. Terry's friend may have information that can help Terry, and giving the friend information about the seriousness of Terry's situation may be helpful.