Psych Exam 1

Do's and Don'ts with psych patients:

DO -establish trust and rapport with the client -be self-aware -maintain boundaries -ask open ended questions, explore, validate, clarify, listen, offer self DON'T -bargain, reassure the patient, plead with the patient -ask close ended questions, such as yes/no questions -ask why

A nurse in a psychiatric unit is caring for several patients. Which of the following clients should the nurse recommend for group therapy?: 1. a client who has been taking Amitriptyline for 3 months for depression 2. a client exhibiting psychotic behavior 3. a client admitted 12 hours ago for acute mania 4. a client who is experiencing alcohol intoxication

a client who has been taking Amitriptyline for 3 months for depression

A nurse is planning care for a group of clients. The nurse should identify which of the following clients as having a contraindication for restraints?: 1. a client who has a personality disorder and tries to manipulate the staff to gain privileges 2. a client who is recovering from a heroin overdose 3. a client who has an eating disorder and refuses to come to the dining room for meals 4. a client who has obsessive compulsive disorder and insists on mopping the floor in the day room

a client who is recovering from a heroin overdose

A client with schizophrenia begins to talk about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: 1. a neologism 2. concrete thinking 3. thought insertion 4. an idea of reference

a neologism

hallucination =

a sensory experience with no existing external stimulation

Your client is crying and upset because her dog died. What is the most therapeutic response?: 1. "I know how you feel - my dog died too." 2. "Would you like to talk about this?" 3. "Don't worry, you can get a new dog?" 4. "Are you feeling depressed?"

"Would you like to talk about this?"

DSM-5

-"Diagnostic and Statistical Manual" (5th edition) -"Bible" of psychiatry -classifies mental disorders -20 diagnostic categories which are evidence-based 1. depressive disorders 2. anxiety disorders 3. personality disorders 4. etc.

prevalence of schizophrenia =

-1% worldwide -no differences related to race, social status, culture, or environment -usual age of onset: late teens to early 20's -men and women equally

assertive community treatment =

-ACT teams: mobile treatments unit -responds to client in community -these clients have repeated hospitalizations -many have schizophrenia -goal: to prevent hospitalization

HIPAA

-Health Insurance Portability and Accountability Act -right to privacy -NOT HIPPA!!! -you may not disclose information about the client without their consent -only exception if client is suicidal/homicidal, we need to tell others about this

therapeutic Milieu =

-Milieu: word of French origin (mi = middle; lieu = place) -refers to surroundings and physical environment -comfortable secure environment

Communication tactics to avoid:

-NEVER argue with client -NEVER put words in client's mouth -NEVER criticize other staff members/clients -NEVER moralize to client -don't say "You should..." -don't say "Why don't you..." -don't say "You need to..."

QSEN =

-Quality and Safety Education for Nurses -overall goal is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work

psychosis =

-disorganization of the personality, deterioration in social functioning, and loss of contact with, or distortion of, reality -there may be evidence of hallucinations and delusional thinking -psychosis can occur with or without the presence of organic impairment

atypical antipsychotics =

-target positive AND negative symptoms -fewer side effects -better tolerated -e.g: Zyprexa (Olanzapine) -also comes in LAI- long acting injectables, such as Risperdal Consta, Invega Sustenna -disadvantages: 1. Metabolic Syndrome 2. weight gain 3. dyslipidemia 4. altered glucose metabolism 5. hypertension 6. more expensive than traditionals

traditional antipsychotics =

-target the positive symptoms only (hallucinations, delusions, disordered thinking, paranoia) -e.g.: Haldol (Haldoperidol), Haldol-D (depot form) -becoming used less frequently -less expensive -more EPS (extrapyramidal symptoms) 1. akathisia 2. acute dystonia 3. pseudo parkinsonism 4. tardive dyskinesia (TD) -target the POSITIVE symptoms only

schizoaffective disorder =

-type of psychotic disorder -can have major depression, manic, or mixed mood episode with symptoms of schizophrenia

Hildegard Peplau

-wrote "Interpersonal Relations in Nursing" -established the foundation for Psychiatric Nursing -nurse-client relationship stages: 1. orientation 2. working 3. termination -psychiatric skills of nursing needed: 1. observation 2. interpretation 3. listening 4. self-awareness

After putting your patient in restraints and/or seclusion, you only have _________ to get an order.

1 hour

The nurse understands that an atypical antipsychotic like Zyprexa requires what period of time to reach a steady state?: 1. 2 weeks 2. 4 or more weeks 3. 1 week 4. 2 days

1 week

Alterations in speech include:

1. associative looseness -positive symptom -loosely-associated, haphazard, illogical, confused speech that can sometimes be decoded -e.g. "I need a Band-aid. Do you have AIDS?" 2. disorganized speech -characteristic of a thought disorder such as schizophrenia 3. neologisms -newly coined words having meaning only for the client 4. echolalia -pathological repeating of another's words 5. clang association -meaningless rhyming of words 6. word salad -mixture of words meaningless to the listener -e.g. blue, bear, ball, board

Alterations in behavior include:

1. bizarre -behavior takes the form of stilted demeanor, eccentric dress, grooming, and rituals 2. agitated -behavior difficulty with impulse control -because of cognitive deterioration, clients lack social sensitivity and may act out impulsively 3. stupor -remaining motionless and unresponsive

Confidentiality for each client includes:

1. client has a right to know who else will be given the information shared with the nurse -ex: the information may be shared with others on the health care team 2. you as a nurse must be aware of this right and must not violate it -ex: if phone rings at nurse's station and someone is asking for that client, what would you do? (say "I can neither confirm nor deny")

When verifying data, include:

1. family 2. police 3. friends 4. neighbors 5. lab data

Having a first degree relative with schizophrenia increases the risk to ___________. If one twin has it, ___________________.

10% 50% chance the other twin (identical) and 15% chance (fraternal) the other twin has it

How should the nurse interpret Bob's belief that he is a famous movie star, and a limousine driver will arrive to get him later in the day?: 1. psychotic thinking 2. delusional thoughts 3. flight of ideas 4. confabulation

delusional thoughts

What is the most accurate assessment if the client believes that the healthcare providers are FBI agents and there are cameras in his apartment to monitor his moves?: 1. hallucinations 2. delusions 3. confabulation 4. thought broadcasting

delusions

Which behavior is characteristic of a thought disorder?: 1. blunted affect 2. irritability 3. disorganized speech 4. preoccupation with guilty feelings

disorganized speech

Which nursing problem has priority?: 1. ineffective community coping 2. disturbed thought processes 3. sensory-perceptual disturbance 4. ineffective denial

disturbed thought processes

empathy vs. sympathy

empathy: -power of understanding and entering into another person's life -"putting yourself in someone else's shoes" sympathy: -overinvolvement and sharing of your own feelings after hearing about another person's similar experience -changes the focus of communication from the client to you as a nurse -not something you want to do as a nurse -we need to be empathetic, not sympathetic

The nurse asks Mr. Tyler what he would like to be called. He replies, "You've seen me on TV. My name is Bob!" The nurse assesses that Bob's behavior is guarded and suspicious. Based on this, what is the most important nursing intervention?: 1. establish rapport and trust 2. assess for hallucinations 3. maintain adequate social space 4. plan to give a PRN antipsychotic

establish rapport and trust

dopamine hypothesis =

excess dopamine = psychotic features

What will be the most important group activity to promote wellness in the community?: 1. explore symptom management 2. review education about medications 3. practice social skills 4. identify community coping resources

explore symptom management

Which side effects are characteristics of atypical antipsychotics?: 1. increased tardive dyskinesia 2. less incidence of weight gain 3. fewer extrapyramidal effects 4. more extrapyramidal effects

fewer extrapyramidal effects

Schizophrenia most likely occurs as a result of a combination of factors, including:

genetic and nongenetic (viral infection, birth injuries, nutritional)

A nurse should NEVER:

go into the client's room by him/herself

Your client comes to the nurse's station complaining that he is hungry, because he has not eaten all day. He is scheduled for surgery later in the morning. What is your priority intervention?: 1. give him sips of juice 2. call surgery to cancel 3. inform client to remain NPO 4. call dietary/order breakfast

inform client to remain NPO

In planning a delusional patient's care, what is the most important short-term client outcome?: 1. interact without expressing delusional thoughts 2. create a support network within the community 3. identify at least one symptom management technique 4. identify actions to take to prevent relapse

interact without expressing delusional thoughts

A client is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?: 1. place the client in seclusion if visual hallucinations are present 2. limit the number of questions asking during assessments 3. use frequent touch to provide client support 4. directly tell the client that delusions are not real

limit the number of questions asking during assessments

1:1 =

may be indicated for client who is escalating and getting upset - offer 1:1 to encourage discussion of feelings

Bob is admitted for 96 hrs. The nurse reviews the routine admission lab and medication prescriptions and notes that the client will resume the Prolixin. The Cogentin has not been prescribed. Which nursing action is best?: 1. obtain a prescription to begin the Cogentin 2. monitor Bob for medication side effects 3. ask Bob if he had any side effects from the Prolixin 4. do not give Prolixin, and document the reason

obtain a prescription to begin the Cogentin

somatic delusion =

occurs when an individual has an unsubstantiated belief that he is experiencing a physical defect, disorder, or disease

Positive vs. negative symptoms of schizophrenia:

positive: -behaviors which may be added as client becomes more ill -ex: 1. delusions 2. hallucinations negative: -behaviors that may be taken away from client as illness takes hold -ex: 1. apathy 2. anhedonia 3. affective blunting 4. inappropriate affect 5. bizarre affect

Why wouldn't someone be adherent to their medication?

side effects, cost, etc.

_____________ provides meaningful moments of reflection.

silence

The nurse further assesses Bob's mental status to determine if he still has thoughts about FBI agents spying on him and hiding cameras in his apartment. The long-term goal is that Bob will not experience delusional thoughts by discharge. Which intervention by the nurse will best assess if this goal has been met?: 1. observe Bob for signs of talking to himself 2. talk to Bob for at least 20 minutes 3. ask Bob to describe how he feels 4. ask Bob to explain how the medication helps him

talk to Bob for at least 20 minutes

The unlicensed assistive personnel (UAP) asks you what is the difference between a therapeutic relationship and a social relationship. What is your best response?: 1. therapeutic relationship allows for you to have coffee with your clients 2. social relationship allows for you to have coffee with your clients 3. you should never have coffee with your clients 4. therapeutic relationship is focused on the client; social is focused on friends

therapeutic relationship is focused on the client; social is focused on friends

ideas of reference =

when a client believes that conversations of others always concern him and that others are ridiculing him

Maslow's Therory

-Abraham Maslow: Hierarchy of Needs -eeds based on 6 stages, beginning with physiological survival needs and ending with self-transcendent needs

Factors that enhance growth include:

-genuineness -self-awareness -empathy -respect

What side effects would the nurse most likely observe with Prolixin, a traditional antipsychotic?: 1. high extrapyramidal effects, low anticholinergic effects 2. low extrapyramidal effects, high anticholinergic effects 3. risk for agranulocytosis, fever, and elevated blood pressure 4. blood dyscrasias such as thrombocytopenia

high extrapyramidal effects, low anticholinergic effects

Your client asks you about cognitive behavioral therapy (CBT). Which items should you include? Select all that apply: 1. CBT helps with distorted thoughts 2. CBT is rarely used 3. CBT helps with the way you view problems 4. CBT is not a structure treatment 5. you are given homework

CBT helps with distorted thoughts CBT helps with the way you view problems you are given homework

A nurse is reviewing the medical record of a client who has a prescription for Clozapine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to Clozapine?: 1. asthma 2. fasting blood glucose 120mg/dL 3. WBC cound 3,300/mm3 4. hypertension

WBC cound 3,300/mm3

Which of the following clients represent a crisis and needs intervening first?: 1. client complains of severe headache 2. client starts to punch a staff member 3. client complains of upset stomach 4. client who lunges at the dietician

client starts to punch a staff member

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?: 1. visual hallucination 2. gustatory hallucination 3. command hallucination 4. tactile hallucination

command hallucination

echolalia =

constant repeating of what another person is saying

delusional disorder =

having a false fixed belief about a person or situation that is believed to be real, but that is not what the client is displaying

In what case would a patient who signed in voluntarily become involuntary?

if they become a threat

Communication skills help us:

understand the client

Which group will be most therapeutic for Bob (delusional patient)?: 1. structured medication group 2. unstructured group about personal issues 3. psychoeducational group about self esteem 4. supportive therapy group

structured medication group

hallucinations =

-positive symptom of schizophrenia -sensory perceptions for which there is no external stimulus -types: 1. auditory a) hallucinations are the most common among schizophrenics b) indicators that client may be hallucinating include darting eyes, tilted head, and mumbling to self c) may also be visual, olfactory, gustatory, or tactile d) always important to assess what the client is hearing (if they believe they hear someone talking to them, we need to ask them what the voice is telling them) 2. command (voices telling them what to do)

Nursing attitudes:

-attending -refers to the intensity of presence -body posture/language -eye contact

akathisia =

-extrapyramidal symptom of antipsychotic drugs -restlessness -patient can be "hyper", agitated, pacing the halls -sometimes this is misinterpreted as part of the psychosis, when really it is a side effect of the med

acute care psychiatric treatment =

-hospitalization to stabilize crisis 1. suicide 2. harming others 3. detox -length of stay has decreased -inpatient setting provides intensive treatment -admission criteria: 1. clear risk of client danger 2. danger to self or others 3. failure of outpatient treatment 4. detox from heavy alcohol/drug use -goals of inpatient hospitalization: 1. client to remain SAFE 2. crisis stabilization 3. medication management 4. discharge to outpatient as soon as feasible -client has the right to be treated in the least restrictive environment, which means that a person cannot be restricted to an institution when he can be successfully treated in the community (they cannot be restrained or locked in a room unless all other "less restrictive" interventions are tried first) -least to most restrictive treatment: 1. therapy 2. support group 3. psychiatrist appointment 4. inpatient 5. long-term institutionalized

associative looseness =

-ideas that do not connect to each other and are expressed in garbled and illogical speech -a typical disturbance for the client who has schizophrenia

somatic delusions =

person believes that his/her body is undergoing unusual or unnatural changes

Know the importance of documentation.

-if it wasn't documented, it wasn't done -client behaviors, not diagnoses -helps validate the need for hospitalization -appropriate documentation: 1. very detailed (what you tried before you try something else, etc.) 2. clear 3. explains what you did 4. etc.

discharge planning =

-important part of nursing -discharge teaching: nurses help clients learn coping skills -medication education: teach patients to continue to make meds regularly -begins on day of admission -work with case management

How can someone ensure safe communication?

-let client set the pace -client should NOT be positioned between nurse and door -avoid a desk barrier

Crisis management includes:

-medical 1. chest pain -behavioral 1. yelling 2. kicking 3. punching 4. pacing -e.g. detox (clients at risk for death) -may need to call code for 911

What is mental illness?

-medical conditions that affect a person's thinking, feeling, mood, ability to relate to others, and daily functioning -includes flawed biological, psychological, social, and cultural processes -in some cultures, is perceived as a failure -nurses adjust their practices to meet the clients cultural beliefs and practices -clients may or may not feel ashamed of their mental illness

MSE =

-mental status examination -evaluates cognitive process -critical component of assessment -includes: 1. age 2. sex 3. marital status 4. religion 5. race 6. ethnicity 7. job 8. living arrangements 9. grooming/hygiene 10. dress 11. pupils 12. facial expression 13. height/weight 14. nutirion 15. body piercings/tattoos 16. behavior a) excessive body movements b) abnormal movements c) eye contact 17. speech a) slow/rapid/normal rate b) loud/soft/normal volume c) stuttering d) rapid 18. mood a) sad/liable/euphoric b) flat/bland/animated/angry/withdrawn affect 19. thought a) disorganized/coherent/flight of ideas b) delusions/obsessions/suicidal ideation 20. perceptual disturbances (auditory/visual hallucinations) 21. cognition (orientation/LOC/attention/insight/judgment)

Other side effects of antipsychotics include:

1. neuroleptic malignant syndrome (NMS) -rare; <1% of cases -serious and potentially fatal -decreased level of consciousness -increased muscle tone -fever, hypertension, tachycardia, tachypnea, diaphoresis, drooling 2. sedation 3. anticholinergic side effects -dry mouth -constipation 4. orthostatic hypotension 5. lowered seizure threshold 6. agranulocytosis

How does a code in pysch work?

1. one person will talk to the patient ("I notice that you were acting out..."; "You refused to take your PRN medication...") -talk slow and repeat yourself 2. not everyone will come in the room, but will hang out in the general vicinity -ensure all workers are there for PATIENT's safety 3. all other patients will go to their rooms so the situation doesn't get worse 4. this can lasts for hours -ex: if patient won't take their medication, explain that the only option you have now is for it to be inserted rectally -patient will either change their mind and take their medication or will get even more worked up (which is when all the other staff members waiting outside the door come in) 5. last resort is to use the restraints and take them to the quiet room or vice versa -once you get to the restraints, there is no turning back (don't let the patient convince you otherwise) a) can't leave restraints or seclusion until calm (no leaving to go to the bathroom, eat, etc.) - bring them a urinal b) if patient is acting calm and taken out but hell breaks loose again, put them right back in seclusion -after putting restraints on patient, go get an order for the restraints (only have 1 hour)

Types of therapy:

1. psychotherapy -client concerns that can be addressed are: a) relationship problems b) family concerns c) depression d) losses e) medications 2. individual therapy -supportive therapy is found to be most helpful -skills training to enhance social functioning -cognitive rehabilitation to improve information processing skills, and cognitive content therapy to change abnormal thoughts or responses to hallucinations 3. group therapy -may be used to develop interpersonal skills, resolve community problems, and teach use of community supports -med groups can help clients deal with side effects, alert staff to potential adverse or toxic effects, and increase compliance 4. family therapy -reduces relapse rate when a psycho educational approach is used -expands social networks, problem solving capacity, and lowers emotional over involvement of families

Types of relationships:

1. therapeutic relationship -nurse maximizes his/her communication skills, understanding of human behaviors, and personal strengths to enhance client's growth -clients engage in the relationship when the clinician's interactions address their concerns, respect the client as partner in decision making, and use straightforward language -focuses on client problems and needs 2. nurse-client relationship -facilitates communication -assists with problem solving -helps client to examine behaviors -promotes self-care 3. social -friendship -intamacy -emotional commitment

catatonia =

1. withdrawn phase -the essential feature of catatonia is abnormal motor behavior -onset is usually abrupt and prognosis is favorable -in the withdrawn phase, the client may demonstrate posturing, waxy flexibility -(arm raised and remains immobile) stereotyped behaviors, extreme negativism -nursing interventions: a) when a client is extremely withdrawn, physical needs take priority b) client may need assistance with hygiene, dressing, and grooming c) explain care in simple, explicit terms 2. excited phase -during the excited phase, the person talks or shouts continually -verbalizations may be incoherent -staff communication should be clear and direct -the major concern is safety of clients and others -nursing interventions: a) client may exhibit gross hyperactivity (running, striking out) b) exhaustion and collapse, as well as safety, are the primary concerns c) client may be destructive or aggressive in response to hallucinations or delusions d) IM administration of antipsychotic medication e) provision of nutrition, fluids, and rest

The nurse asks Bob if he has any allergies to medications. He reports an allergy to Haldol. The nurse asks him to describe the type of reaction he experienced. Bob states, "My neck got real stiff, and I couldn't move it." What type of reaction should the nurse suspect?: 1. akathisia 2. dystonia 3. parkinsonism 4. synergistic

dystonia

AMA =

-against medical advice -just because the client has the right to "request" to leave AMA, does not mean they will be able to leave -involuntary clients do not have the right to leave - insurance will NOT pay for stay

What is the role of a psychiatric nurse?

-nurse maintains therapeutic milieu -communication is key -maintaining safety on units is major responsibility (e.g. client rounds, safety rounds, visitors) -making rounds and making sure all consult rooms and kitchen is locked during evening/night

An interdisciplinary team:

-all disciples meet on a regular basis to discuss plan of care for client -client has a problem list, with goals, interventions, and outcomes -consists of: 1. nurse (in charge of communication between the team) 2. social worker 3. counselor 4. psychologist 5. psychiatrist 6. pharmacist 7. dietician 8. psychiatric technician 9. recreation therapy 10. etc.

case management =

-allows effective monitoring of client progress -alternatives to hospitalization include partial hospitalization, halfway houses, and day treatment programs -self-help community groups may also help

control delusions =

-person believes others are trying to control them -often believed to be by forcing thoughts into the brain

Haldol (Haloperidol) =

-an antipsychotic drug that decreases excitement in the brain -used to: 1. treat psychotic disorders like schizophrenia 2. control motor (movement) and verbal (for example, Tourette's syndrome) tics 3. treat severe behavior problems in children

Risperidone (Risperdal) =

-an atypical antipsychotic -can help you think clearly and take part in everyday life -can treat: 1. schizophrenia 2. bipolar disorder 3. irritability caused by autism

obsessive-compulsive disorder (OCD) =

-a client shoes a pattern of being preoccupies with orderliness as a way to manage anxiety -characterized by recurrent obsessive thoughts and uncontrollable compulsive behaviors -obsessive thoughts can include: 1. contamination 2. order 3. feelings -compulsive behaviors may include: 1. counting 2. hand hygiene 3. repeating actions 4. checking

What are some conditions that are contraindications to using restraints?

-recovering from a drug overdose -having severe suicidal tendencies -having dementia -not being able to tolerate decreased stimulation -method of discipline -method of punishment

home care =

-requires homebound status -psychiatric diagnosis -skills of psych RN -treatment plan supervision by MD

What are the stages of the nurse-client relationship and what do they include?

1. orientation -trust is established -nurse establishes parameters of the relationship -termination begins in this orientation phase 2. working -maintain the relationship -gather further data -promote client's problem solving skills -facilitate change and overcome resistance 3. termination -termination is discussed during the first interview -the final phase of the relationship -feelings: both client and nurse (client may withdraw; regress) -summarize the goals/objectives

A psychosocial nursing assessment includes:

1. personal/social background 2. strengths/weaknesses 3. coping strategies 4. cultural/spiritual beliefs

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints?: 1. the provider must renew a restraint prescription every 8 hours 2. the client must understand the need for restraints 3. the restraints should promote the client's safety and prevent injuries 4. the nurse has already considered alternatives to restraints

the nurse has already considered alternatives to restraints

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?": 1. "You need to tell the voices to leave you alone." 2. "You need to understand that there are no voices." 3. "What are the voices telling you to do?" 4. "Why do you think you are hearing the voices?"

"What are the voices telling you to do?"

touch =

-communication skill -tricky -depends on client/history background

Which intervention used for clients diagnosed with thought disorders is a milieu therapy approach?: 1. assist family members to deal with major upheavals in their lives caused by interactions with the client 2. one on one interactions to discuss feelings 3. role play to enhance motor and interpersonal skills 4. emphasize the rules and expectations of social interactions mediated by peer pressure

ANSWER: emphasize the rules and expectations of social interactions mediated by peer pressure RATIONALE: -when the nurse emphasizes the rules and expectations of social interactions mediated by peer pressure, the nurse is using a milieu therapy approach -milieu therapy emphasizes group and social interaction -rules and expectations are mediated by peer pressure for normalization of adaptation

A nurse is caring for a young adult client who has acute schizophrenia disorder and tells the nurse, "Yester noon the sun moon went over the rover to see the lawnmower." Which of the following manifestations is the client exhibiting?: 1. delusional disorder 2. associative looseness 3. hallucination 4. anhedonia

associative looseness

Patients have the right to refuse medications unless:

they become a danger

Schizophrenia brain structure abnormalities include:

-enlarged lateral cerebral ventricles -reduced frontal lobe volumes -increased size of fissures -other theories: 1. prenatal stressors (viral infection, malnutrition, exposure to toxins) 2. psychological trauma to mom during pregnancy 3. environmental stressors (chronic poverty, high crime)

tardive dyskinesia (TD) =

-extrapyramidal symptom of antipsychotic drugs -persistent EPS/appears after prolonged treatment -involuntary tonic muscular contractions -"guppy-like"mouth movement, tongue protrusions -involve the tongue, fingers, toes, neck, trunk or pelvis -drugs should be discontinued -no cure for TD -assessment is performed using AIMS (Abnormal Involuntary Movement Scale)

pseudo parkinsonism =

-extrapyramidal symptom of antipsychotic drugs -pseudo = false -client looks like they have Parkinson's disease 1. tremor 2. impaired gait 3. stiff muscles 4. flat affect

apathy =

-negative symptom of schizophrenia -flat affect -lack of motivation

A client with schizophrenia is disturbed and violent. After several doses of haloperidol (Haldol), he is calm. Two hours later the nurse sees the client's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?: 1. an acute dystonic reaction 2. tardive dyskinesia 3. waxy flexibility 4. akathisia

an acute dystonic reaction

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?: 1. act to the client as if the hallucination is real 2. instruct the client to argue with the voices that are a part of the hallucination 3. ask the client direct questions about the hallucination 4. tell the client that the hallucination is not a part of reality

ask the client direct questions about the hallucination

What is the first step the nurse should use to teach about effective symptom management?: 1. talk about specific support systems 2. review current ways to manage symptoms 3. identify problem symptoms 4. discuss other ways to manage symptoms After implementing the first step, which step is next?: 1. identify current ways to manage symptoms 2. talk about specific support systems 3. discuss other ways to manage symptoms 4. develop a new symptom management plan

identify problem symptoms discuss other ways to manage symptoms

What is the most common cause of relapse in the client with schizophrenia?: 1. symptom management 2. medications 3. lack of community support 4. health practices

medications

The nurse understands that schizophrenia can be differentiated from psychosis by which assessment?: 1. disorganized speech 2. disorganized behavior 3. auditory hallucinations 4. negative symptoms

negative symptoms

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating, "The flakalas are here. The flakalas are here." The nurse correctly recognizes the client's use of the word flakala as an example of which of the following alterations in speech?: 1. echolalia 2. clang association 3. neologism 4. word salad

neologism

A client storms out of her room, visibly upset, and suddenly starts to cry. What should you do?: 1. tell her to stop acting so immaturely 2. call the hospital operator to call a code 3. ask her why she is crying suddenly 4. offer a 1:1 in a private area

offer a 1:1 in a private area

persecution delusions =

person believes that others are trying to hurt him/her

erotomanic delusions =

person believes that someone desires a romantic relationship with him/her

What are the tasks of the working phase? Select all that apply: 1. promote problem solving 2. establish trust 3. gather further data 4. promote resistance 5. facilitate change

promote problem solving gather further data facilitate change

A client with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms?: 1. neuroleptic malignant syndrome 2. hepatocellular effects 3. pseudoparkinsonism 4. akathisia

pseudoparkinsonism

The family of a client with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend?: 1. psychoeducational 2. psychoanalytic 3. transactional 4. family

psychoeducational

The client comes to the nurse's desk, shouting. He points his finger at you saying "I hate this place!" What should the nurse do?: 1. tell him to calm down and go back to his room 2. instruct the secretary to buzz the client out before he hurts anyone 3. restrain client immediately 4. remain calm and note "It sounds like you are upset."

remain calm and note "It sounds like you are upset."

The nurse can best communicate to the client that he or she is interested in listening by: 1. restating the feeling or thought the client has expressed 2. making a judgment about the client's problem 3. asking a direct question, such as "Did you feel angry?" 4. saying "I understand what you are saying"

restating the feeling or thought the client has expressed

Which of the following are client rights in the inpatient psychiatric unit? Select all that apply: 1. right to vote 2. right to informed consent 3. right to punch the nurse 4. right to leave the AMA 5. right to have visitors

right to vote right to informed consent right to have visitors

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?: 1. self-destructive behavior despite alternative interventions 2. coercion to take prescribed medications 3. discipline for throwing objects at staff 4. punishment for verbally abusing other clients

self-destructive behavior despite alternative interventions

After 3 weeks of hospitalization, Bob continues to be delusional and to talk to himself. The nurse often finds him sitting alone in the dining area. He declines some of the group activities and sits for several hours without initiating any activity. Persistent nursing interventions are required to get Bob to perform routine tasks. Which nursing problem should be included on the treatment plan?: 1. impaired adjustment 2. social isolation 3. anxiety 4. confusion

social isolation

How should the nurse explain schizophrenia symptom triggers to a client?: 1. symptom triggers are stressors that lead to increased difficulty handling anger 2. symptom triggers can be related to health, the environment, or attitudes 3. symptom triggers are behaviors that lead to medication noncompliance 4. symptom triggers are stressors caused by hospitalization

symptom triggers can be related to health, the environment, or attitudes

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with Chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?: 1. tardive dyskinesia 2. parkinsonism 3. dystonia 4. akathisia

tardive dyskinesia

What is mental health?

the ability to recognize reality and cope with the demands of daily life such as: 1. successful performance of mental functions 2. able to engage in productive activities 3. enjoy fulfilling relationships 4. cope with adversity 5. psychological syndrome marked by distress or disability 6. all mental disorders with definable diagnoses

It's important to perform a mental status exam (MSE) on all your clients. Which best demonstrates part of the MSE?: 1. assessing client's thought processes 2. assessing client's family 3. administering prescribed medications 4. ordering client's lunch

assessing client's thought processes

assessment strategies =

assessment: 1. assess -establishes rapport -understands problem -assess risk factors -current level of functioning 2. diagnosis -based on 3 factors: a) problem b) cause c) supporting data 3. outcomes 4. planning 5. evaluation -ongoing -evaluate client outcomes -often neglected problem-solving approach facilitates safety/quality care for clients

erotomania =

behavior in which the client believes another individual desires him/her romantically

grandeur =

behavior in which the client believes he/she is extremely important or powerful

A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through the satellites." The nurse should document that the client is experiencing which of the following types of delusions?: 1. persecution 2. control 3. erotomanic 4. somatic

control

One week later Bob has achieved the long-term goal to be free of delusions, and he has attended the wellness group to promote wellness in the community. Bob's community caseworker has been contracted about the discharge plans and need for transportation to Bob's apartment. What is the greatest benefit of a caseworker for this client?: 1. coordinate services for Bob 2. make sure Bob takes his medications 3. empower Bob to be independent 4. provides guidance for disability income

coordinate services for Bob

A client's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?: 1. detachment and overconfidence 2. darting eyes, tilted head, mumbling to self 3. euphoric mood, hyperactivity, distractibility 4. food tapping and writing the same phrase

darting eyes, tilted head, mumbling to self

Bob is unable to report his current med regimen, so the nurse contacts his case worker. Additional info from the caseworker indicates that Bob has been sleeping only 3-4 hrs each night for the past few nights. Bob has demonstrated less energy and states that he feels "really bad and pretty down". The case worker reports that Bob was taking Prolixin 5mg in the morning and 10mg at bedtime, along with Cogentin 2mg BID because he cannot afford the newer antipsychotics. Why is Prolixin prescribed?: 1. disorganized thoughts 2. difficulty sleeping at night 3. feelings of depression 4. stabilize client's mood

disorganized thoughts

A nurse is caring for a client who has schizophrenia and is taking Haloperidol. The nurse should monitor for which of the following adverse effects of Haloperidol?: 1. extrapyramidal symptoms 2. fever 3. intractable hiccups 4. excessive salivation

extrapyramidal symptoms

anhedonia =

failure to experience pleasure in activities that were previously enjoyed

clang association =

the use of words that rhyme

Voluntary patients can leave whenever they want as long as:

they are not suicidal or homicidal

A client asks the nurse leader why individuals develop schizophrenia. Which understanding is the most accurate?: 1. there is an imbalance of brain neurotransmitters, dopamine, and serotonin 2. there is a marked increase in brain volume, which causes abnormal functioning 3. schizophrenia develops when at least one parent or distance relative has schizophrenia 4. this brain disorder has many predisposing factors and a biological basis

this brain disorder has many predisposing factors and a biological basis

What is the purpose of therapeutic communication?

to promote growth and change for your client

What do we put major emphasis on during the first few encounters with the client?

to provide an atmosphere in which trust and understanding, or rapport, can be nurtured

fall precautions =

be aware of clients on multiple meds/ECT - may be at risk for falls

Because Bob was violent with his father prior to admission, another long-term goal is that the client will not verbalize the desire to harm self or others. Which statement will assist the nurse to assess if this goal has been met?: 1. "Do you have a history of violence?" 2. "Tell me about your relationship with your father." 3. "How do you feel about your father now?" 4. "Do you think about hurting anyone now?"

"Do you think about hurting anyone now?"

During reassessment of the client, the nurse notices that Bob sometimes pauses and mumbles something quietly to himself. He tilts his head to one side and then returns his attention to the nurse. What is the best response by the nurse?: 1. "What are you thinking right now?" 2. "Tell me how you're feeling?" 3. "Have you been hearing any voices?" 4. "I notice that you talk to yourself."

"Have you been hearing any voices?"

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response: 1. "Nothing you are saying is clear." 2. "Your thoughts are very disconnected." 3. "Try to organize your thoughts and then tell me again." 4. "I am having difficulty understanding what you are saying."

"I am having difficulty understanding what you are saying."

In addition to Bob's thoughts that the FBI had cameras in his apartment and his moves were broadcast on TV, reassessment by the nurse indicates that he remains suspicious and guarded with orientation only to day and place. Bob believes that he is a famous movie star and explains to the nurse that a limousine driver will be there to get him later in the day. How should the nurse respond?: 1. "Everything is confidential, so I doubt this will happen." 2. "I know that this is probably unlikely. What do you think?" 3. "What if the limousine does not get here?" 4. "It sounds like you are anxious to leave here."

"It sounds like you are anxious to leave here."

A client asks, "Why do we need to know about symptom triggers for schizophrenia?" Which explanation is best?: 1. "Knowing symptom triggers and how to manage them can help prevent relapse." 2. "Identifying symptom triggers can prevent the risk of violence and promote safety." 3. "It promotes communication with your case worker." 4. "It allows you to increase your medications immediately."

"Knowing symptom triggers and how to manage them can help prevent relapse."

Which hallucination necessitates the nurse to implement safety measures? The patient says: 1. "I hear angels playing harps." 2. "The voices say everyone is trying to kill me." 3. "My dead father tells me I am a good person." 4. "The voices talk only at night when I'm trying to sleep."

"The voices say everyone is trying to kill me."

A client in the wellness group states that he was taking his medications every day and started hearing voices more and had to be hospitalized. What is the nurse's best response?: 1. "This can happen even if you are taking medications every day." 2. "Maybe you forgot to take some of your medication." 3. "How long have you been taking your medications?" 4. "Compliance with medications will prevent relapse."

"This can happen even if you are taking medications every day."

A nurse sits with a client with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the best response: 1. "Why are you laughing?" 2. "Please share the joke with me." 3. "I don't think I said anything funny." 4. "You're laughing. Tell me what's happening."

"You're laughing. Tell me what's happening."

cognitive behavioral therapy (CBT) =

-Aaron Beck's method is basis for CBT -active, time-limited, structured -often called CBT -homework will be assigned -some people have schema (unique assumptions about themselves) -helps with cognitive distortions (distorted thoughts) -how people feel and behave is determined by the way they think about their world (helps with the way you view probelms)

Zyprexa (Olanzapine) =

-an atypical antipsyhotic -affects chemicals in the brain -can treat: 1. schizophrenia 2. bipolar disorder

Cogentin (Benztropine) =

-anti-tremor medication -anticholinergic -reduces the effects of certain chemicals in the body that may be unbalanced as a result of disease, drug therapy, or other causes -can treat: 1. symptoms of Parkinson's disease 2. involuntary movements due to the side effects of certain psychiatric drugs

Other medications for schizophrenia include:

-antidepressants may be ordered for depression -antimanic agents may be helpful for suppressing episodic violence and may help alleviate co-morbid depression -benzodiazepines may be ordered during acute phase to reduce agitation

Which medication with potentially life-threatening side effects should the nurse expect the healthcare provider to prescribe for clients who do not respond to the use of other antipsychotics?: 1. Clozaril 2. Haldol 3. Prolixin 4. Trilafon

Clozaril

Voluntary vs. involuntary admission to the psychiatric unit:

voluntary: -inpatient treatment is reserved for patients who are acutely ill -person enters treatment facility, participates in the treatment planning process, and follows through with the treatment -the person maintains all civil rights and is free to leave at any time even if it against medical advice -client/guardian initiated -has right to demand release -unless a minor involuntary: -confined hospitalization of a person without the person's consent but with a court order (first step of involuntary commitment: admit for 96 hours) -involuntary patients are often high acuity patients, meaning they are at risk for self harm, elopement, or other risky behaviors -nursing implication is to monitor very closely -person must be: 1. mentally disordered 2. dangerous to self or others 3. unable to provide for basic needs ("gravely disabled") -patients who are involuntarily committed have the right to receive treatment, but they also may have the right to refuse it -today, laws about commitment and refusal of medication may vary from state to state -commitment procedures vary among states -most have provisions for an emergency short term hospitalization of 48-92 hours authorized by a certified mental health provider -at the end of that period, the individual either to voluntary treatment or extended commitment procedures are begun -the judge must order the commitment

suicide precautions =

-be aware of clients trying to harm self with objects such as pencils, tableware, etc. -clients that are suicidal may need to be placed on a 1:1 (meaning that there needs to be one staff member assigned to watch client at all times)

restraint/seclusion =

-behavior has to be harmful to self/others -less restrictive means don't work -need MD order/time limited -need to renew every 24 hours; less for children -can place client in an emergency before getting MD order -behaviors must be documented -must never be used as punishment -least restrictive rule applies

Pay attention to the important factors of communication, such as:

-body language -verbals -non-verbals -facial expressions -tones

paranoia =

-characterized by intense and strongly defended irrational suspicion -projection is the most common defense mechanism used by paranoid clients -these clients feel frightened, lonely, and helpless -nursing interventions: 1. usually minimal 2. nutrition may be problematic if client is suspicious that food has been tampered with 3. provide food in unopened containers

milieu therapy =

-clients with schizophrenia improve more in a structured hospital unit rather than in an open environment -provides safety, useful activities, resources for resolving conflicts, and opportunities for learning social and vocational skills

Care management:

-coordination of care -case managers communicate with insurance companies -collaborate with interdisciplinary team -case managers also work in community setting -establish longer term relationships with clients to coordinate care -e.g. medication assistance, housing issues -case manager may have to arrange for temporary housing

boundaries =

-crucial -client's needs should be separate from nurse's -can be at risk for blurring -what would you do if a client asked you out on a date?

evidence-based practice =

-current best evidence about care -use evidence (research) to guide care/treatment

Nursing diagnoses of schizophrenia include:

-disturbed thought processes -disturbed sensory perception -impaired verbal communication -ineffective coping -imbalanced nutrition: less than body requirements -risk for self-directed violence -risk for other directed violence -activity intolerance -constipation, incontinence, impaired physical mobility, self-care -deficit, compromised family coping chronic low self esteem, risk for loneliness, social isolation, etc.

culturally relevant care =

-each culture has different patterns of nonverbal communication -ex: 1. eye contact 2. personal space 3. touch

acute dystonia =

-extrapyramidal symptom of antipsychotic drugs -muscle cramping of head and neck -acute dystonic reaction is when the client's head is twisted to one side; or they may complain to you that their tongue is thick -nursing intervention: 1. give Cogentin 2. give Artane 3. give Benadryl (usually given IM not PO)

bizarre affect =

-negative symptom of schizophrenia -grimacing, giggling, etc.

inappropriate affect =

-negative symptom of schizophrenia -incongruent response

anhedonia =

-negative symptom of schizophrenia -lack of pleasure -inability to experience pleasure -poor social functioning -poverty of thought -poverty of speech

affective blunting =

-negative symptom of schizophrenia -minimal emotional response

partial hospitalization =

-not 24 hour -transition from acute to partial prior to discharge -outpatient therapy can minimize future hospitalizations

active listening =

-observe, listen, understand -provide feedback: 1. restate 2. paraphrase 3. clarify (helps nurse examine the meaning of the word) 4. reflect a) allows the client to validate the nurse's understanding of what has been communicated b) shows that the nurse is interested in listening to the client

What types of patients have medical comorbidities that impede health?

-poor nutrition -diabetes -alcohol consumption -cigarettes

delusions =

-positive symptom of schizophrenia -fixed false beliefs -themes: 1. grandiosity 2. persecution 3. jealousy 4. control -ideas of reference: 1. giving personal significance to trivial events 2. perceiving events as relating to you when they are not 3. e.g. when Maria saw staff talking, she believed they were plotting against her

Interventions for maintenance of schizophrenia:

-psycho education about the disease, medication, side effect management, cognitive and social skills enhancement, identifying signs of relapse, attention to self-care deficits -psychosocial rehab-helps patient readjust to community living by promoting necessary skills, such as social skills training and basic job skills -minimize stress! -helping client reduce vulnerability to relapse will include providing information about: 1. maintaining a regular sleep pattern 2. reducing alcohol, drug, and caffeine intake 3. keeping in touch with supportive family and friends 4. staying active 5. having a daily/weekly schedule 6. taking meds regularly

Client rights include:

-right to privacy, confidentiality, respect -right to informed consent -involved in treatment team -to refuse treatment -to have visitors -to request to leave against medical advice (AMA) -to legal counsel -to vote -to communicate privately by phone -to lodge a complaint -to participate in religious worship

Nursing interventions of schizophrenia include:

-short, frequent interactions that are not demanding of the client -plan simple one on one activities -maintain consistency and honesty -slowly encourage client to interact with others in nonthreatening environment -enhance self esteem without giving false reassurance or flattery -interact with client in a calm demeanor -use good eye contact -speak clearly and simply -don't invade their private "bubble" -explain any meds/treatments BEFORE acting -assume a matter of fact approach -treat client as an adult -monitor client's eating patterns -assist with hygiene/grooming, only IF client unable to do so -be wary of touching client, they may be paranoid -be mindful that clients respond well to structure and routine -let your client choose between two things- e.g.: would you like to put on the red dress or the blue one? -be professional 1. watch your boundaries and don't be overly friendly 2. allow client as much independence and autonomy as possible -avoid reinforcing suspicious/paranoid thoughts- try to use distraction instead -intervene when the client becomes increasingly anxious/escalating -do not focus attention on client's hallucinations or delusions -re-orient client to reality -re-direct to a structured activity -do ask if client is hearing voices, and if so, what are the voices telling him -do tell client that you do not share his perception- e.g.: "I do not hear the voices you say you hear", BUT 1. validate that you believe the voices are real 2. avoid arguing with client 3. respond to client's feelings - "You appear frightened." -observe early cues of agitation -intervene BEFORE client acts out -provide a safe quiet environment -decrease stimuli -encourage client to verbalize/ventilate feelings -offer PRN meds -set limits on unacceptable behavior- isolate client if they become highly agitated -call for back up - call hospital operator to call a code for all personnel to come help - housekeeping, maintenance come to help -"Show of Force" -least restrictive environment is mantra for psych mental health

behavioral crisis =

-staff trained in CPI (crisis prevention intervention) -special teams who respond to code "helping hands"

comorbidity =

-substance abuse occurs in 40-50% -incarceration, violence, suicide, and HIV infection -nicotine dependence is as high as 80-90% -depression occurs in 10% of cases

Self-assessment guidelines:

-the intensity of client's emotions can evoke intense, uncomfortable, and frightening emotions in staff -guidelines: 1. important to assess if client had a medical workup 2. make sure that there are no real physical symptoms, such as chest pain. 3. important to check out any patient complaints, real or imagined- e.g., lice 4. assess if client is dependent on alcohol/ drugs 5. ask if client is taking medications and is he/she adhering to med regimen as prescribed 6. assess support for client (family, significant others) 7. assess client's global functioning

Tarasoff Case (1974) =

-therapist has duty to warn a client's potential victim of potential harm -"duty to warn" -a university student who was in counseling at University of California had "fatal attraction" to a girl, named Tatiana Tarasoff, whom he had kissed once, but she rejected him -the psychologist notified police verbally and in writing that the young man might pose a danger to Tarasoff -police questioned the student, found him to be rational, as he promised to stay away from Tatiana - he killed her 2 months later -this case created much controversy and confusion in the psych community over breach or client confidentiality and its impact on the therapeutic relationship in psych care

A client states to the nurse "I see headless people walking down the hall at night." Which nursing response is appropriate?: 1. "What makes you think there are headless people here?" 2. "Now let's think about this. A headless person would not be able to walk down the hall." 3. "It must be frightening. I realize this is real to you, but there are no headless people here." 4. "I don't see those people you are talking about."

ANSWER: "It must be frightening. I realize this is real to you, but there are no headless people here." RATIONALE: -empathizing with the client about the altered perception encourages trust and promotes further client communication about hallucinations -the nurse must follow this by presenting the reality of the situation -clients must be assisted to accept that the perception is unreal to maintain reality orientation

A voluntary client on a psychiatric inpatient unit asks the nurse to get her the forms for discharge against medical advice so she can leave immediately. The best response for the nurse to make would be: 1. "I can't give you those forms without your physician's knowledge." 2. "I'll get the forms for you and bring them to your room." 3. "Your lawyer must get the forms for you from your doctor." 4. "Please tell me how you came to the decision to leave treatment."

ANSWER: "Please tell me how you came to the decision to leave treatment." RATIONALE: -a client who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states -however, as a client advocate, the nurse is responsible for weighting factors related to the client's wishes and best interests -by asking for information, the nurse may be able to help the client reconsider the decision -option a is not a true statement -option b: facilitating discharge without consent is not in the client's best interests before exploring the reason for the request

The client has a long history of schizophrenia, which has been controlled by haloperidol (Haldol). During an admission assessment resulting from an exacerbation of the disease, the nurse notes continuous restlessness and fidgeting. Which medication would the nurse expect the physician to prescribe for this client?: 1. Haloperidol (Haldol) 2. Fluphenazine decanoate (Prolixin Decanoate) 3. Clozapine (Clozaril) 4. Benztropine mesylate (Cogentin)

ANSWER: Benztropine mesylate (Cogentin) RATIONALE: -D-Cogentin is an anticholinergic medication used for the treatment of extrapyramidal symptoms such as akathisia -the nurse would expect the physician to prescribe this drug for the client's symptoms of restlessness and fidgeting

Which aspect of care is the hospital psychiatric nurse most likely to provide for a client?: 1. hygiene assistance 2. assertiveness training 3. diversional activity 4. assistance with job hunting

ANSWER: assertiveness training RATIONALE: -assertiveness training relies on the counseling and psychoeducational skills of the nurse -the other tasks are usually performed by the lowest cost staff member who can effectively perform the task

The nurse receives three telephone calls regarding a newly admitted client. The psychiatrist wishes to see the client for an assessment interview, the medical doctor wants to perform a physical examination, and the client's lawyer wishes to set up an appointment to see the client. The nurse schedules the three activities for the client. This exemplifies the role of the nurse know as: 1. advocate 2. milieu manager 3. case manager 4. provider of care

ANSWER: case manager RATIONALE: -nurses on psychiatric units routinely coordinate client services as described in this scenario -option a: the role of advocate would require the nurse to speak out on the client's behalf -option b: the role of milieu manager refers to maintaining a therapeutic environment -option d: provider of care refers to giving direct care to the client

The assessment data item more relevant for the community psychiatric health nurse than the hospital based psychiatric nurse for planning client interventions is: 1. history of mental illness in the family 2. culturally related psychotropic dosing 3. financial status of the client 4. physical state of the client

ANSWER: financial status of the client RATIONALE: the financial status of the client determines the viability of certain interventions in the community but is of little or no concern when determining a program of in-hospital treatment

The nurse caring for a 72 year old client admitted for treatment of depression notes that the physician's order to begin therapy with an antidepressant calls for a dose greater than the usual adult dose. The nurse should: 1. consult a drug reference 2. implement the order 3. give the usual adult dose 4. hold the medication and consult the physician

ANSWER: hold the medication and consult the physician RATIONALE: -the dose of antidepressants for elderly clients is often less than the usual adult dose -the nurse should withhold the medication and consult the physician who wrote the order -the nurse's duty is to intervene and protect the client -option a is unnecessary because the nurse already knows the doses is excessive -option b is negligent -option c: a nurse without prescriptive privileges cannot change the dose

A Vietnamese immigrant is a student at the local community nursing program. The nursing instructor is concerned because the student has poor eye contact and has difficulty asking the direct questions necessary for client assessment. The nursing instructor arranges for the student to be assessed by the nurse practitioner in the college health service. This action reflects: 1. appropriate secondary prevention by the instructor 2. insufficient understanding of the student's culture 3. a violation of the student's civil rights 4. prejudice and discrimination

ANSWER: insufficient understanding of the student's culture RATIONALE: in the student's culture making eye contact can be perceived as disrespectful

Outcomes established with the mentally ill client in the community compared with those planned for a hospitalized client will: 1. involve a longer time frame 2. require more psychoeducation 3. have greater focus on symptom absence 4. be more concerned with medication management

ANSWER: involve a longer time frame RATIONALE: community care is concerned with long term outcomes, whereas hospital care is concerned with short term outcomes

Which speech process should the nurse document on the daily mental status exam record?: 1. loose associations 2. tangential 3. monotone 4. poverty of speech

ANSWER: poverty of speech RATIONALE: -loose associations = patient's responses do not relate to the interviewer's questions or one paragraph, sentence, or phrase is not logically connected to those that occur before or after -tangential = train of thought wanders; lack of focus; never returning to the initial topic of conversation (to go off on a tangent) -poverty of speech = lack of additional, unprompted content seen in normal speech

The psychiatric home care nurse makes visits to a Hispanic client being treated for depression. The client greets the nurse with a smile and eagerly offers to make coffee. The nurse initiates a handshake, politely refuses the coffee so as not to make work for the client, and suggests they talk about how the client is doing. During the session the nurse notes the client seems less spontaneous in affect and becomes more withdrawn. In analyzing the situation the nurse should correctly conclude that: 1. the client is experiencing rapid cycling 2. the client may feel rejected by the nurse 3. the nurse has broached a taboo topic 4. social touch is inappropriate for Hispanic clients

ANSWER: the client may feel rejected by the nurse RATIONALE: in the Hispanic culture, good etiquette requires accepting offers of food and spending some time in small talk before getting down to business

The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted?: 1. the client who is experiencing tremors and has a need for medication adjustment 2. the client who is experiencing anxiety and a sad mood after separation from spouse 3. the client who is a single parent and hears voices telling her to smother her infant son 4. the client who argued with her boyfriend and inflicted a superficial cut on her arm

ANSWER: the client who is a single parent and hears voices telling her to smother her infant son RATIONALE: -admission to the hospital would be justified by the risk of client danger to self or others -the other clients have issues that can be handled without hospitalization

When the nurse asks Bob to share one goal for the day in community meeting, he states "I am going to take a shower and..." He pauses for several seconds and begins talking again. Which thought process does this exemplify?: 1. concrete thinking 2. flight of ideas 3. word salad 4. thought blocking

ANSWER: thought blocking RATIONALE: -concrete thinking = focused on the physical world (facts in the here in now, physical objects, literal definitions, etc.) -flight of ideas = person rapidly shifts between conversation topics -word salad = confused or unintelligible mixture of random words and phrases -thought blocking = person stops speaking suddenly and without explanation in the middle of a sentence

Two psychotic clients in the inpatient unit get into fights when they are in the same room. During a team meeting, one nurse suggests the safety of the two clients is of paramount importance and that their treatment plans should call for both to placed in seclusion to keep them from injuring each other. The suggestion is significant because it: 1. violates the civil rights of the two clients 2. reinforces the autonomy of the two clients 3. reveals that the nurse values the principle of justice 4. represents the intentional tort of battery

ANSWER: violates the civil rights of the two clients RATIONALE: -clients have a right to treatment in the least restrictive setting -less restrictive measures should be tried first -unnecessary seclusion may result in a charge of false imprisonment -option b: seclusion removes the client's autonomy -option c: the principle by which the nurse is motivated is beneficence, not justice -option d: the tort represented is false imprisonment

adherence vs. compliance =

adherence is better -you know why you're taking the meds -you want to take the meds -you want to get better -etc. compliance -you don't know why you're taking the meds -you do it just cause "the doctor told me to" -etc.

Which strategy is best for clients who hear voices?: 1. avoid certain situations 2. smoke more cigarettes 3. decrease caffeine intake 4. take more medication

avoid certain situations

sexual acting out precautions =

be aware of clients suggestively asking other clients to meet up in another room later

elopement precautions =

be aware of clients trying to "elope" - which means run away

Why is the Tarasoff case so important in mental health. Select the priority answer: 1. it teaches about inappropriate relationships 2. it teaches about professional boundaries 3. it teaches about gun control 4. it teaches about the duty to warn

it teaches about the duty to warn

The student nurse (SN) you are training asks you what is the difference between voluntary and involuntary. What is your best response?: 1. go look it up - it will be a good way to learn 2. we rarely get involuntary, so don't worry about it 3. voluntary patients want to be there; involuntary don't 4. voluntary patients sign themselves in; involuntary patients are committed

voluntary patients sign themselves in; involuntary patients are committed

depersonalization =

-person might feel that parts of his/her body belong to someone else or are different in some way -experienced as a loss of personal identity

If a client who has voluntarily chosen to be hospitalized should want to leave the hospital, which assessment would be most important in deciding to release the client against medical advice (AMA)?: 1. mental status of client 2. reason client wants to leave 3. response to medications 4. potential danger to self or others

potential danger to self or others

A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?: 1. "Clients should be given medications even if they refuse them." 2. "The laws regarding restraints are different for clients who are admitted involuntarily." 3. "Clients who are admitted involuntarily can be hospitalized for as long as the provider deems necessary." 4. "Clients who are involuntarily admitted have the right to informed consent."

"Clients who are involuntarily admitted have the right to informed consent."

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates understanding of a relapse prevention plan?: 1. "I can remember when my hallucinations first began." 2. "I know which of my hallucinations trigger a relapse." 3. "I record the number of hallucinations I have each day." 4. "I will read as much information as I can about schizophrenia."

"I know which of my hallucinations trigger a relapse."

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?: 1. "I will begin 48 hours before the client's discharge." 2. "I will begin once the client's discharge order is written." 3. "I will begin upon the client's admission to the facility." 4. "I will begin once the client's insurance company approves discharge coverage."

"I will begin upon the client's admission to the facility."

A nurse is providing teaching to a client who has schizophrenia and is receiving Chlorpromazine. Which of the following client statements indicates an understanding of the teaching?: 1. "I will contact my provider if have difficulty urinating." 2. "I am less likely to get an infection while taking this medication." 3. "Weight loss is a sign that my medication dose is too high." 4. "I need to take this medication with an antacid due to stomach upset."

"I will contact my provider if have difficulty urinating."

A nurse is reading the medical record for a client who has schizophrenia which indicates that the client exhibits depersonalization. Which of the following statements by the client confirms that she is experiencing depersonalization?: 1. "I have broken off all of my past relationships because my family and friends are trying to kill me." 2. "I hear voices telling me that I have been bad." 3. "My hands and feet are much smaller than they used to be." 4. "Everything in this room has changed and I don't recognize it anymore."

"My hands and feet are much smaller than they used to be."

A nurse is providing teaching for a client who has schizophrenia and a new prescription for Fluphenazine. Which of the following information should the nurse provide?: 1. "This medication might turn your urine orange." 2. "Sleepiness should subside within a week." 3. "Stop the medication if hypotension occurs." 4. "A low-grade fever is expected with first doses."

"Sleepiness should subside within a week."

A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?: 1. "You are mistaken. Nobody is lying about you or trying to poison you." 2. "You seem to be having very frightening thoughts." 3. "Why do you think you are being lied about and poisoned?" 4. "Who is lying about you and trying to poison you?"

"You seem to be having very frightening thoughts."

post-traumatic stress disorder (PTSD) =

-associated with a terrifying event, such as: 1. military combat 2. assault 3. kidnapping 4. torture 5. rape 6. natural disasters -client with PTSD can relive the trauma through recurrent thoughts and memories of the event -nightmares, flashbacks, and hallucinations may be experienced -nursing interventions: 1. provide a nonthreatening enviornment 2. encourage the client to discuss the traumatic event 3. reinforce appropriate coping strategies

flat affect =

-described as affect devoid of emotional tone -having no emotional expression is an indication of flat affect -even with a flat affect, the client continues to experience feelings; however, these emotions are not presented in facial expressions

schizophrenia =

-devastating brain disorder -characterized by a group of psychotic behaviors that affect thought, behavior, emotion, and perception of reality (the brain chemistry, structure, and activity are different in a person with schizophrenia) -the brain affected by schizophrenia lacks the ability to make many of the connections that we count on -because it is a thought disorder, people have difficulty with attention, memory, planning, and organizing -speech disturbances include neologism, which is making up words that are meaningful only to the client -other disturbances include: 1. echolalia 2. clang association 3. word salad -recent study by Washington University (2014) researchers found that it isn't a single disease, but a group of 8 genetically distinct disorders, each with their own set of symptoms -affects: 1. thinking/language 2. emotions 3. social behavior 4. ability to perceive reality accurately

persecutory delusion =

-individual believes he or she is being malevolently treated in some way -frequent themes include being: 1. conspired against 2. cheated 3. spied on 4. followed 5. poisoned or drugged 6. maliciously maligned 7. harassed 8. obstructed in the pursuit of long term goals

bipolar disorder =

-mood disorder -characterized by moods that alternate between episodes of depression and episodes of mania or hypomania -manic episodes are periods of: 1. elevated mood 2. irritability 3. grandiosity 4. talkativeness 5. accelerated speech 6. racing and fragmented thoughts 7. excessive indulgence in pleasurable activities

Findings that occur in tardice dyskinesia (TD) include:

-twisting tongue movement -tics -suddenly involuntary jerking movements of the extremities

Psychotherapy groups provide clients with the opportunity to:

1. enhance their personal relationships 2. increase self-awareness 3. try new behaviors in a safe social setting

A nurse is assessing a client who has schizophrenia which has been treated with Fluphenaine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?: 1. shuffling gait 2. constant tapping of feet when sitting 3. sudden onset of high fever 4. twisting tongue movements

twisting tongue movements

The nurse is educating the family members of a client diagnosed with schizophrenia about the effects of psychotherapy. Which statement should be included in the teaching plan?: 1. "Psychotherapy is a short term intervention that is usually successful." 2. "Much patience is required during psychotherapy because clients often relapse." 3. "Major changes in client symptoms can be attributed to immediate psychotherapy." 4. "Independent functioning can be gained by immediate psychotherapy."

ANSWER: "Much patience is required during psychotherapy because clients often relapse." RATIONALE: -the psychotherapist requires much patience when treating clients with schizophrenia -depending on the severity of the illness, psychotherapeutic treatment may continue for many years before clients regain some extent of independent functioning

Which client has the best chance of a positive prognosis?: 1. a client diagnosed with schizophrenia taking antipsychotic medications consistently 2. a client diagnosed with schizophrenia participating in psychosocial therapies 3. a client diagnosed with schizophrenia complying with antipsychotic medications and participating in psychosocial therapies 4. a client whose family provides psychosocial support

ANSWER: a client diagnosed with schizophrenia complying with antipsychotic medications and participating in psychosocial therapies RATIONALE: -research shows that antipsychotic medications are more effective at all levels when combined with psychosocial therapies

Which intervention used for clients diagnosed with thought disorders is a behavioral therapy approach?: 1. offer opportunities for learning about psychotropic medications 2. attach consequences to adaptive and maladaptive behaviors 3. establish trust within a relationship 4. encourage discussions of feelings related to delusions

ANSWER: attach consequences to adaptive and maladaptive behaviors RATIONALE: -when the nurse attaches consequences to adaptive or maladaptive behaviors, the nurse is using a behavioral therapy approach -behavior therapy can be a powerful treatment tool for helping clients change undesirable behaviors

After 3 weeks of hospitalization, Bob continues to be delusional and to talk to himself. The nurse often finds him sitting alone in the dining area. He declines some of the group activities and sits for several hours without initiating any activity. Persistent nursing interventions are required to get Bob to perform routine tasks. Which nursing assessment accurately describes Bob's lack of energy?: 1. apathy 2. anhedonia 3. avolition 4. affective

ANSWER: avolition RATIONALE: -apathy = lack of interest, enthusiasm, or concern -anhedonia = inability to experience pleasure from activities usually found enjoyable -avolition = severe lack of initiative to accomplish purposeful tasks -affective = lack of the full range of emotional expression that others have

A homeless client being seen in the mental health clinic complains of an infestation of insects on the skin. Which intervention would the nurse implement first?: 1. check the client for body lice 2. present reality regarding somatic delusions 3. explain the origin of persecutory delusions 4. refer for inpatient hospitalization because of substance induced psychosis

ANSWER: check the client for body lice RATIONALE: -before assuming that the client is experiencing a somatic delusion, the nurse first must rule out a physical cause for the client's symptoms, such as body lice -a somatic delusion occurs when an individual has an unsubstantiated belief that he is experiencing a physical defect, disorder, or disease

The nurse is performing an admission assessment on a client diagnosed with paranoid schizophrenia. To receive the most accurate assessment information, which should the nurse consider: 1. this client will be able to make a significant contribution to history data collection 2. much data will need to be gained by reviewing old records and talking with family and significant others 3. assessment of this client will be simple because of the commonly occurring nature of the disease process of schizophrenia 4. the nurse will refer to the client's global assessment of functioning score to determine client problems and nursing interventions

ANSWER: much data will need to be gained by reviewing old records and talking with family and significant others RATIONALE: -background assessment information must be gathered from numerous sources, including family members and old records -a client in an acute episode would be unable to provide accurate and insightful assessment information because of deficits in communication and thought

A client newly admitted to an inpatient psych unit is scanning the environment continuously. Which nursing intervention is most appropriate to address this client's behavior?: 1. offer self to build a therapeutic relationship with the client 2. assist the client to formulate a plan of action for discharge 3. involve the family in discussions about dealing with the client's behaviors 4. reinforce the need for medication compliance on discharge

ANSWER: offer self to build a therapeutic relationship with the client RATIONALE: -the client is exhibiting signs of paranoia -clients with this symptom have trouble trusting others -the nurse should use the therapeutic technique of offering self to assist in building a trusting therapeutic relationship with this client

The nurse documents that a client diagnosed with schizophrenia is expressing a flat affect. What is an example of this symptom?: 1. the client laughs when told of the death of the client's mother 2. the client sits alone and does not interact with others 3. the client exhibits no emotional expression 4. the client experiences no emotional feelings

ANSWER: the client exhibits no emotional expression RATIONALE: -flat affect is described as affect devoid of emotional tone -having no emotional expression is an indication of flat affect -even with a flat affect, the client continues to experience feelings; however, these emotions are not presented in facial expressions

Which outcome should the nurse expect from a client with a nursing diagnosis of social isolation? 1. the client will recognize distortions of reality by day 4 2. the client will use appropriate verbal communication when interacting with others by day 3 3. the client will actively participate in unit activities by discharge 4. the client will rate anxiety as 5/10 by discharge

ANSWER: the client will actively participate in unit activities by discharge RATIONALE: -actively participating in unit activities by discharge is an outcome for the nursing diagnosis of social isolation -participation in unit activities indicates interaction with others on the unit, which leads to decreased social isolation

A client on an inpatient psych unit refuses to take medications because "The pill has a special code written on it that will make it poisonous." What kind of delusion is this client experiencing?: 1. an erotomanic delusion 2. a grandiose delusion 3. a persecutory delusion 4. a somatic delusion

ANSWER: a persecutory delusion RATIONALE: -a persecutory delusion in which the individual believes he or she is being malevolently treated in some way -frequent themes include being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long term goals

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?: 1. administer Diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record 2. reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient 3. give Trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time 4. administer atropine sulfate 2 mg subcut from the PRN medication administration record

administer Diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?: 1. affective flattening 2. bizzare bavhior 3. illogicality 4. somatic delusions

affective flattening

flight of ideas =

an alteration in speech in which a client's speech moves rapidly from one thought to the next and the client verbalizes one unrelated idea after another

A nurse is caring for a group of clients in an acute mental health facility. Which of the following clients has the legal right to refuse treatment?: 1. a 16-year-old client whose parents have requested treatment 2. an adult client who has delusions and refuses treatment for religious reasons 3. an older adult client who was voluntarily admitted 4. a client who is competent but was involuntary admitted

an older adult client who was voluntarily admitted

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms?: (Select all that apply) 1. delusions 2. hallucinations 3. anhedonia 4. poor judgment 5. blunt affect

anhedonia blunt affect

Bob's healthcare provider decides to discontinue Prolixin and begins a new antipsychotic, Zyprexa. Which data is most important to obtain before Bob begins the Zyprexa, which is an atypical antipsychotic?: 1. baseline weight 2. orthostatic blood pressure 3. complete blood count 4. screening for tardive dyskinesia

baseline weight

Which finding depicts negative symptoms of schizophrenia?: 1. difficulty sitting still 2. rapid and disorganized speech 3. flat affect and social inattentiveness 4. delusional statements

flat affect and social inattentiveness

A nurse is preparing to administer the monthly injection of Haloperidol Decanoate to a client who has schizophrenia. Which of the following actions should the nurse plan to take?: 1. have the client lie down for 30 mins after the medication is injected 2. monitor the client for bradycardia following the injection 3. assess the client for a sudden relapse of manifestations 4. administer the medication using a tuberculin syringe

have the client lie down for 30 mins after the medication is injected

A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling, "You all are making fun of me." Which of the following behaviors is this client displaying?: 1. grandeur 2. flight of ideas 3. erotomania 4. ideas of reference

ideas of reference

A nurse is assessing a client who has schizophrenia. Which of the following behaviors should the nurse anticipate?: 1. periods of elation with unusual talkativeness 2. preoccupies with folding clothes 3. invents words that have no meaning 4. recurrent thoughts of past trauma

invents words that have no meaning

The nurse understands that a client with schizophrenia will experience which benefit from Prolixin if it is administered intramuscularly?: 1. prevent more extrapyramidal side effects 2. maintain long-term mediation compliance 3. minimize side effects from Cogentin 4. prevent risk of cardiac or renal disease

maintain long-term mediation compliance

Bob agrees to participate in a group that is scheduled to last for 3 weeks. He remains attention and responds to questions when asked. During the first group he shares, "The meds cause too many side effects. I have been taking them for a long time." Which nursing problem should the nurse document for the group progress note?: 1. ineffective denial 2. knowledge deficit 3. ineffective coping 4. risk for adherence

risk for adherence

A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?: 1. the sense of self among individual family members 2. the future goals of the family 3. the roles of family members 4. the family's religious practices

the family's religious practices

neologism =

the use of a fictitious word that has meaning only to the client

word salad =

the use of real words spoken in a sequence so that the words have no logical meaning with one another

Which client behavior validates the need for involuntary hospitalization?: 1. beliefs about FBI surveillance 2. diagnosis of schizophrenia 3. violence towards father 4. guarded and suspicious

violence towards father

A nurse is reviewing the medical record of a client who has schizophrenia and is receiving Olanzapine. Which of the following findings should the nurse identify as an adverse effect of Olanzapine?: 1. weight gain of 3 lb in 2 weeks 2. delusions of grandeur 3. heart rate 60/min 4. oral candidiasis

weight gain of 3 lb in 2 weeks