HESI CASE STUDY ADRIAN
Which response to Ad is indicated? "Ad, everything is ready. You need to have the treatment." "Ad, you have signed the consent form, and you need to have the treatment." "It sounds like you have made a firm decision and changed your mind." "It sounds like someone has influenced you to change your mind."
"It sounds like you have made a firm decision and changed your mind." This response is a good response. It acknowledges Ad's right to change his mind while reflecting what he has verbally and nonverbally said to you. After discussion with Ad, his family and treatment team accept his decision to not have treatments, at least for now.
Ad has continued to have difficulty being open and direct in his grief. Which of Ad's statements indicates the best hope for his progress after discharge? "I think I know what I need to do once I leave here." "I'm going to try to cry and get angry more openly." "It's hard; but, I'm going to work on sharing my feelings a little bit at a time with my new therapist." "Nobody knows how difficult it is. My feelings are inside me and I can't show them to anyone."
"It's hard; but, I'm going to work on sharing my feelings a little bit at a time with my new therapist." This statement sounds positive and realistic. In it, Ad acknowledges that although progress may be slow, he is committed.
Ad grumbles to you about "all the blood they're taking." What explanation would be best? "The doctor has ordered tests to see what's causing your depression." "The doctor has ordered thyroid and other tests to see if your feelings have a physical basis." "The doctor wants to find out if you have any physical problems." "T3, T4, and TSH all help measure the amount of hormones released from your thyroid gland."
"The doctor has ordered thyroid and other tests to see if your feelings have a physical basis." This response gives simple, specific, and accurate information. Ad is entitled to know as much as he is ready and willing to learn, without having to feel overwhelmed with too much information or patronized with too little.
Before answering Ad, you consider several possible responses. Which of the following responses would help? Select all that apply 1. "It's a burden to feel responsible for people leaving you." 2. "You deserve to be punished?" 3. "It's all right to feel so guilty." 4. "You're feeling all alone and as if you have nothing?"
1,2,3
To minimize risk for patient injury during an ECT treatment, which of the following are implemented? Select all that apply 1. Use of a bite block 2. Administration of an IV muscle relaxant 3. Four-point restraints 4. Pulse oximetry monitoring 5. Blood pressure monitoring 6. Electrocardiogram (ECG) monitoring
1,2,4,5,6
As you meet with Ad and try to develop a relationship, what factors will you assess to monitor his depression? Select all that apply 1.Ad's food and fluid intake 2. Ad's pulse, respirations, and blood pressure 3. Ad's bladder and bowel elimination patterns 4. Ad's activity level
1. The depressed patient may not feel he deserves to eat or drink and/or may not have the energy to do so. Preferred foods, if any, tend to be sweet and high in fat. Fluids may not be consumed voluntarily and need to be offered to avoid dehydration. Increase in food and fluid intake may suggest that depression is lifting. Therefore, it is appropriate to assess Ad's food and fluid intake as you monitor his depression. It is also appropriate to determine Ad's baseline weight and to continue monitoring his weight through the course of his depression. Weight loss is often consistent with the anorexia that accompanies depression. Weight gain often reflects an increase in appetite and a lifting of depression. 3. All body processes slow with depression, secondary to a metabolic decrease. Constipation is common, a result of decreased activity level and peristalsis. Lack of adequate fluid intake can result in scant, concentrated urine. Therefore, it is appropriate to assess Ad's bladder and bowel elimination patterns when monitoring his depression. 4. The depressed person feels tired, unworthy, and has little energy or interest. The person typically does not initiate much activity on his own as he remains severely depressed. An increase in activity level would suggest that depression was lifting. Therefore, it is appropriate to assess Ad's activity level when monitoring his depression. Also, the depressed patient often has difficulty sleeping and reports feeling fatigued. With depression, sleep is usually restless, and early morning awakening is common. Increased ability to sleep and reports of feeling refreshed after sleep would suggest that depression was lifting. Therefore, it is appropriate to assess Ad's sleep and rest patterns as you monitor his depression.
How often should you have visual contact with someone on suicide precautions?
15 minute irregular intervals
Electroconvulsive therapy (ECT) is a possibility for Ad. ECT is discussed with Ad and his family. Which of the following are true about ECT? Select all that apply 1. To achieve relief from depression, 1-3 treatments are needed 2. Preparation for ECT treatments require that the patient be NPO 3. Written consent is required for treatments 4. The patient is asleep during ECT treatments 5. Memory impairment is common with ECT treatments Usually
2,3,4,5
Many variables place Ad in a high-risk category for suicide. Which of the following factors increase Ad's risk for suicide? Select all that apply 1.His African-American heritage 2, His single lifestyle 3. The fact that Ad is male 4. The fact that Ad is unemployed 5. His state of depression 6. The fact that Ad is 18 years old 7. His history of losses
2. Being single places Ad in a slightly higher risk category for suicide than if he was married. 3. Males are three times more likely to complete suicide than females. Ad's male gender increases his risk for suicide. 4. Employment increases opportunity for self-esteem, social contacts, and meaningful contributions to society. Unemployment typically contributes to diminished self-esteem which can lead to feelings of hopelessness. This can increase risk of suicide. 5. ad's depression and associated hopelessness increase his risk for suicide. 6. As a late adolescent, Ad is at increased risk for suicide. Suicide is the third leading cause of death in adolescents and the age group of 18-24 years. 7. Ad's history of losses makes him vulnerable to hopelessness, and subsequently at risk for suicide.
Ad has been placed on suicide precautions. Suicide precautions involve: Select all that apply 1.having visual contact with Ad once an hour 2. assessing Ad's suicidal risk and lethality once a day 3. removing belts, glass objects, coat hangers, razors, and other sharp items from Ad's environment 4. checking to be sure that Ad swallows his medication 5. monitoring meal trays for missing utensils 6. searching gifts and other items brought by visitors
3, 4, 5, 6
You need to determine administration times for Ad's Prozac (fluoxetine). Which administration schedule is best? 6 PM and 10 PM 8 AM and 12 noon 10 AM and 6 PM 12 noon and 8 PM
8am and 12 noon: Insomnia, restlessness, and nightmares commonly occur with Prozac (fluoxetine). These occur less frequently when Prozac is administered during morning hours.
Activity Intolerance is another nursing diagnosis that applies to Ad. What is the best way to help Ad become active and motivated? Remind Ad ten minutes before each activity he is expected to participate in Walk with Ad to the bathroom, kitchen, and milieu when he indicates he wants to go to these areas Allow Ad to stay in his room except for your individual sessions with him, when you meet in the interview room Assist Ad in preparing a structured activity schedule so that he knows what is expected
Assist Ad in preparing a structured activity schedule so that he knows what is expected Assisting Ad in preparing a structured activity schedule would allow him to anticipate activities and plan for his day. Meals, medication times, therapy sessions, time to sit in the milieu, visiting hours, and rest periods are some of the items to be included on Ad's activity schedule.
Which of the following goals is most appropriate with regard to the nursing diagnosis Dysfunctional Grieving? By the time of discharge, Ad will no longer be grieving By the time of discharge, Ad will begin to grieve in a direct and open manner At the end of three weeks, Ad will have experienced almost all of the grieving process
By the time of discharge, Ad will begin to grieve in a direct and open manner Ad needs assistance in learning how to express his feelings and thoughts honestly and directly. It would be realistic to expect that Ad could grieve in a direct and open manner by discharge. Ad will need to identify his losses and share feelings about his brother's death. Acute symptoms of grieving are common for 4-8 weeks. Active symptoms of grieving may be present from 3-6 months. The complete work of mourning takes 1-2 years.
What approach would be best in getting Ad to follow his expected routine? Kind but firm Passive but friendly Matter-of-fact
Kind but firm A kind but firm approach uses words, voice tone, body stance, and gestures to communicate expectations. It would be the best approach to use to get Ad to follow his expected routine.
Which of the following would be best in encouraging interaction between Ad and his peers? Reflect to Ad that he seems to be enjoying the music and suggest that he join the music group Continue observing Ad to be sure he is enjoying the music Reflect to Ad that you notice him tapping his foot
Reflect to Ad that he seems to be enjoying the music and suggest that he join the music group Reflecting to Ad that he seems to be enjoying the music and suggesting that he join the music group would allow him opportunity for validation of his feelings as well as provide opportunity for interpersonal interaction.
Considering Ad's continued difficulty in sharing his thoughts and feelings about loss, how can you best help him deal with the loss of your relationship? Wait for him to raise the issue, once he knows he will be discharged Listen for his allusions to loss and words which symbolize loss of your relationship Say to him, "If our relationship has meant anything, you should be able to tell me what the loss of our working together means to you." Say to him, "You'll be leaving in a few days. How are you feeling about ending our relationship?"
Say to him, "You'll be leaving in a few days. How are you feeling about ending our relationship?" Initiating the topic of ending your relationship would give Ad permission to talk about his thoughts and feelings in a time frame that would encourage closure. Important areas to explore with Ad would include what he has learned from the work you've done together, how he feels about it, and what regrets he may have. It would also be important for him to determine if there is anything he wants to tell you in the time that is left.
As Ad begins to talk more with you, you make a no-suicide contract with him. The goal of the contract is to prevent Ad from harming himself or committing suicide. The elements of the contract include: Select all that apply a promise to contact you or another staff member if he is tempted to act on destructive impulses giving personal items to friends and family surrendering of items such as sharps or pills willingness to manage several days medication on his own participation of family and friends in the contract
a promise to contact you or another staff member if he is tempted to act on destructive impulses - A promise to speak with a member of the health care team before acting on a suicidal impulse is an important component of a no-suicide contract. However, it should not preclude processes of constant observation or hospitalization when suicidal risks are high. surrendering of items such as sharps or pills - Surrendering of potentially lethal items is a necessary component of a no-suicide contract. participation of family and friends in the contract - A no-suicide contract should include involvement of family members. Involvement of family members and friends increases a client's sense of obligation to avoid acts of self-destruction.
How many treatments of ECT are needed to relieve depression?
at least 6
Ad was 11 years old when his parents were divorced. He is now 18 years old. According to Erikson, the developmental task for Ad at age 11 was: a. Identity vs. Role Diffusion b. Intimacy vs. Isolation c. Industry vs. Inferiority
c. Between the ages of 6 and 12 years old, Ad was learning how to use his knowledge and skills to master his environment through persistence and relationships with peers. This is the task of Industry vs. Inferiority. Ad currently is attempting to solidify his self-concept, including self-image, values, and beliefs. This is the task of Identity vs. Role Diffusion (ages 12-20).
As you work with Ad, you realize that his descriptions of loss in his life remind you of losses in your own. This process is called: denial countertransference splitting undoing
counter-transference
You determine that the following nursing diagnoses apply to Ad. Which takes highest priority? a. Risk for Constipation related to immobility and decreased food and fluid intake b. Imbalanced Nutrition: Less than Body Requirements related to fatigue and lack of interest in eating c. Disturbed Sleep Pattern related to inadequate coping with losses and altered circadian rhythms d. Risk for Self-Harm related to previous suicide attempt and unresolved grief
d. Since admission, Ad has neither confirmed nor denied whether or not he is still suicidal. His safety is a priority concern. Risk for Self-Harm is the nursing diagnosis that takes highest priority at this time.
Suicide risk and degree of lethality should be assessed how often?
every 8 hours
After about 15 minutes of being with Ad, he stops responding and stares into space with no affect. What is the best way to proceed?
tell ad you will stay with him for a few more minutes and then return in another hour
The staff members' reaction to Ad's isolated, introspective behavior is known as: dissociation withdrawal rationalization suppression
withdrawal Reacting to an isolated patient with similar behavior is called withdrawal. This a nontherapeutic response that needs to be changed.
