mental health IRSC nurse 2

One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, "I am not going to take medicine every day." Which response by the nurse would be most appropriate?

"I hear you say that you do not like taking medication daily." Correct Explanation: By saying, "I hear you say that you do not like taking medication daily," the nurse accepts the client's statement so that the client feels heard and understood. The nurse demonstrates openness toward hearing unacceptable attitudes to foster further sharing among the clients.

A new nurse is co-leading a family education group for those who have relatives with paranoid schizophrenia. Which statement by the new nurse indicates the need for further teaching about symptom management

"The more we push the clients to spend time with friends, the more their voices decrease." Correct Explanation: Pushing a suspicious client into social situations is likely to increase anxiety, which increases, not decreases, the hallucinations. The statement about spending some time alone if the client is overwhelmed indicates awareness and understanding of how to intervene when the client is exposed to stress. The statement about lack of motivation indicates awareness and understanding of avolition. The statement about reminding the client that the family does not hear the voices indicates awareness and understanding of the client's hallucinations

MAOIs have a low incidence of sedation and anticholinergic effects, they must be used with extreme caution for several reasons: most common side effects of MAOIs include daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and sexual dysfunction

A life-threatening side effect, hypertensive crisis, may occur if the client ingests foods containing tyramine (an amino acid) while taking MAOIs. Because of the risk for potentially fatal drug interactions, MAOIs cannot be given in combination with other MAOIs, tricyclic antidepressants, meperidine (Demerol), CNS depressants, many antihypertensives, or general anesthetics. MAOIs are potentially lethal in overdose and pose a potential risk in clients with depression who may be considering suicide.

The nurse is caring for a client with bipolar disorder who was recently admitted to an inpatient unit and is experiencing a manic episode. What is a priority nursing intervention for this client?

Closely monitor the client's eating and sleeping habits. Explanation: Distraction and disorganization may prevent clients from eating or sleeping. Monitoring for needed intervention can prevent exhaustion and malnutrition. Liquid medications are indicated only if the client cannot or will not swallow tablets. Manic clients tend to disrupt group therapy, so this treatment usually is not for them. Family visits should not be tied to compliance with treatment. The client is unlikely to be able to concentrate and complete a journal at this time

Which of the following phases of psychological reaction to rape is characterized by fear and flashbacks?

Heightened anxiety phase Correct Explanation: During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.

Which of the following nursing actions displays linguistic competence?

Learning pertinent words and phrases in the client's language Explanation: Linguistic competence is best displayed by learning pertinent words or phrases in the client's language. Speaking loudly and repeating English words do not solve the communication barrier or show an effective response to a linguistic need. Asking the client's family to translate is discouraged because it is often unreliable and leads to confusion for the client and the nurse.

Sigmund Freud: The Father of Psychoanalysis

Psychoanalytic theory supports the notion that all human behavior is caused and can be explained (deterministic theory)

After being treated for minor cuts, a client appears confused and has trouble focusing on what the nurse is saying. The client reports nausea and dizziness, has tachycardia, and is hyperventilating during the nursing assessment. The nurse would interpret the level of anxiety as which of the following?

Severe Explanation: Clients with severe anxiety are unable to solve problems and may have a poor grasp of the happenings in their environment. The client's described somatic symptoms are usually present. Mild anxiety is less uncomfortable, and some individuals experiencing mild anxiety may even find their performance enhanced. Some difficulty with problem solving and decision making is usually present with mild anxiety. When experiencing panic, individuals typically experience markedly disturbed behavior and may lose touch with reality

Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which conditions?

achycardia, weight loss, and mood swings Explanation: Stimulants produce mood swings, anorexia and weight loss, and tachycardia. Hyperpyrexia, slow pulse, weight gain, hypotension, listlessness, increased appetite, slowing of sensorium, and arrhythmias indicate CNS depression.

anticholinergic side effects:

dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, and blurred near vision; commonly seen as side effects of medication

Antidepressants

four groups: 1.Tricyclic and the related cyclic antidepressants 2.Selective serotonin reuptake inhibitors (SSRIs) 3.MAO inhibitors (MAOIs) 4.Other antidepressants such as desvenlafaxine (Pristiq), venlafaxine (Effexor), bupropion (Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone).

ego,

is the balancing or mediating force between the id and the superego. The ego represents mature and adaptive behavior that allows a person to function successfully in the world.

superego

is the part of a person's nature that reflects moral and ethical concepts, values, and parental and social expectations; therefore, it is in direct opposition to the id.

unconscious

is the realm of thoughts and feelings that motivate a person even though he or she is totally unaware of them. This realm includes most defense mechanisms (see discussion to follow) and some instinctual drives or motivations. According to Freud's theories, the person represses into the unconscious the memory of traumatic events that are too painful to remember.

Which nursing intervention is the highest priority when a client is placed in restraints?

monitoring the client every 15 minutes Explanation: Safety of the client and staff is the utmost priority. Therefore, the client must be monitored closely and frequently, such as every 15 minutes, to ensure that the client is safe and free from injury. Assisting with nutrition and elimination, performing range-of-motion exercises on each limb, and changing the client's position every 2 hours are important after the safety of the client and staff is ensured by close, frequent monitoring.

A client refuses his evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to:

remove all other clients from the day room. Explanation: The nurse's first priority is to consider the safety of the clients in the therapeutic setting. Checking for an as-needed drug order and calling the physician are appropriate responses after ensuring the safety of other individuals. Because the client poses a danger to himself and others, restraints may be used; however, less restrictive interventions should be attempted first

The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's:

self-awareness and understanding. Explanation: The nurse must be aware of herself and understand personal feelings before she can understand and help others. Although wanting to help others, accepting others, and being knowledgeable of psychiatric nursing are desirable traits, self-awareness and understanding are the basis of a therapeutic nurse-client relationship.

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a:

somatic delusion. Explanation: Somatic delusions focus on bodily functions or systems and commonly include delusions about foul odor emissions, insect infestations, internal parasites, and misshapen parts. Delusions of persecution are morbid beliefs that one is being mistreated and harassed by unidentified enemies. Delusions of grandeur are gross exaggerations of one's importance, wealth, power, or talents. Jealous delusions are delusions that one's spouse or lover is unfaithful.

id

the part of one's nature that reflects basic or innate desires such as pleasure-seeking behavior, aggression, and sexual impulses. The id seeks instant gratification, causes impulsive unthinking behavior, and has no regard for rules or social convention.

Preconscious

thoughts and emotions are not currently in the person's awareness, but he or she can recall them with some effort—for example, an adult remembering what he or she did, thought, or felt as a child

A painter who recently fractured his tibia worries about his finances because he can't work. To treat his anxiety, his physician orders buspirone, 5 mg by mouth three times per day. Which drugs interact with buspirone?

Monoamine oxidase (MAO) inhibitors Explanation: Buspirone interacts only with MAO inhibitors, producing a hypertensive reaction. Administration of beta-adrenergic blockers, antineoplastic drugs, or antiparkinsonian drugs wouldn't cause an interaction, so they can be administered simultaneously with buspirone

A client seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. He also has aches and pains. A nursing diagnosis for this client might include

Situational low self-esteem. Explanation: All symptoms define a disturbance in self-esteem. There isn't enough information to determine delayed growth and development. The client's complaints don't involve his ability to perform in his roles. Posttrauma syndrome occurs after experiencing a traumatic event and doesn't coincide with the data obtained from this client.

The nurse is caring for a client with severe depression. In which conditions would the nurse anticipate the use of electroconvulsive therapy (ECT)? Select all that apply.

The client cannot tolerate monoamine oxidase inhibitors (MAOIs) • The client has not responded to conventional therapy. • The client is having acute suicidal thoughts. Explanation: ECT is used to treat acute depressive illnesses in an attempt to rapidly reverse a life-threatening situation, such as disturbing delusions, agitation, and attempted suicide or when conventional therapies have been unsuccessful. It is also used when the client cannot tolerate antidepressants, since other medication regimens for depression can take weeks to become fully effective. ECT is usually not indicated for situational depression caused by intense stress. Clients with dementia are not given ECT because ECT may further exacerbate cognitive impairment. The decision to use ECT is not based on where the client lives.

A client has been receiving chlorpromazine, an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism?

Tremors, shuffling gait, and masklike face Explanation: Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and "pill rolling." Akathisia may occur several weeks after starting antipsychotic therapy, consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis characterized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered a medical emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing.

During hospitalization, a client with bulimia stops purging but becomes fearful that she will gain weight. She tells the nurse, "I cannot gain weight. I am fat enough as it is. I will be really disgusting if I get fatter." When responding to this client, which response by the nurse would be most therapeutic?

Use nonjudgmental and realistic comments. Explanation: Using nonjudgmental, realistic comments corrects the client's misperception without challenging or disagreeing with her verbalization of her thoughts and feelings.

What should the nurse teach a client with generalized anxiety disorder to help the client cope with anxiety?

cognitive and behavioral strategies Explanation: A client with generalized anxiety disorder needs to learn cognitive and behavioral strategies to cope with anxiety appropriately. In doing so, the client's anxiety decreases and becomes more manageable. The client may need assertiveness training, reframing, and relaxation exercises to adaptively deal with anxiety.

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions. Explanation: The nurse's first priority is to keep a suicidal client safe and alive. Although establishing a rapport and promoting trust are important in psychiatric nursing, neither is the highest priority. Using restraints is inappropriate and could be interpreted as punishment of the client or a convenience for the nurse. Trying to communicate in writing is also inappropriate because there is no indication that the client can't hear. (

A client diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client?

matter-of-fact Correct Explanation: For this client, the nurse needs to use a calm, matter-of-fact approach to create a nonthreatening and secure environment because the client is experiencing problems with suspiciousness and trust. Use of "I" statements and responses would be therapeutic to reduce the client's suspiciousness and increase his trust in the staff and the environment. An authoritarian approach is nontherapeutic and inappropriate because the client may perceive this approach as an attack, subsequently responding with anger and threatening behavior. A parental or controlling approach may be perceived as authoritarian, and the client may become defensive and angry.