N129 HESI REMEDIATION on Psychosis

After receiving diphenhydramine and benztropine IM for immediate relief, the client receives a new prescription for benztropine 2 mg PO daily. The client is questioning the nurse about taking another pill. Which nursing intervention best promotes effective communication?

Explain that this pill is to help prevent the muscle spasms in neck and jaw. The addition of benztropine will reduce the likelihood of severe extrapyramidal symptoms that occur more often with prototype antipsychotic medications such as haloperidol.

What is the most important part of this admission process?

Take away the client's cigarettes and lighter. Safety for the client and the unit environment is the highest priority, so the staff should keep any potentially dangerous objects away from the client.

When the client looks around the room and mumbles to himself, how should the nurse respond?

Ask the client if they are hearing voices. The client is demonstrating nonverbal cues that he is experiencing auditory hallucinations, so the nurse should ask the client if he is hearing voices.

The nurse observes the client looking to the corner of the room and mumbling to himself. Which intervention is most important for the nurse to include in the client's plan of care?

Begin a sequence of interventions to address the client's hallucinations. Hallucinations can be nonverbal or they can include talking to oneself, moving the lips without making sounds, rapid eye movements, and grinning or inappropriate laughter.

CASE OUTCOME

Case OutcomeIn addition to giving the client a copy of the discharge summary upon his release from the hospital, the nurse writes the following note in his chart:"Client is discharged ambulatory and accompanied by caseworker. Client receives all personal belongings, including valuables. He denies suicidal/homicidal ideation and reports that the last time he heard voices was several days ago. Affect is pleasant and mood is without feelings of depression. Speech is clear and organized without maladaptive patterns or evidence of disorganized thoughts. The client acknowledges plans to take olanzapine as prescribed and to follow up at the medication clinic in 2 weeks. Education about the purpose and potential side effects is provided, and the client is encouraged to talk with the HCP or nurse if he has questions or concerns about the medications."

The client is encouraged to attend a medication psychoeducation group that the nurse is leading. The qualities of an effective nurse leader are the same qualities that are important in the therapeutic relationship: empathy, genuineness, creativity, and assertiveness. While leading the group, the nurse should be aware of group content and group process. The nurse is training a new team member. Which explanation best promotes effective communication when discussing group process and group content?

Content includes the clients' words, and group process is how the clients communicate. Group content includes what the group members say, and group process refers to how they communicate their thoughts and feelings.

Meet the Client A client is accompanied to the emergency department (ED) by several police officers and a caseworker. The caseworker called the police to enter the client's apartment because the client refused to answer the door. The caseworker brings some medication bottles from the client's apartment and reports that 4 months ago, the client stopped taking all psychotropic medications. The client has poor eye contact, disheveled, dirty uncombed hair, and stained clothes. The client denies current suicidal ideation, although the caseworker reports a history of past suicide attempts and violence. The client has lost 10 pounds in the past 2 weeks, sleeps 12 hours daily, and doesn't leave the apartment. The nurse observes that the client sometimes looks to the corner of the room and then looks down and mumbles during the interview. The client admits to the nurse that they do not want to leave the apartment because they think someone is waiting to kill them. The client continues to explain that someone has followed him to the emergency department (ED) and is waiting outside the of the ED door. Which thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him?

Delusions. A delusion is a false belief that is firmly maintained even though it is not shared by others and is contradicted by reality.

Routine Admission Prescriptions Following the admission assessment, the nurse calls the HCP for admission prescriptions and laboratory work. The admitting diagnosis is Unspecified Psychotic Disorder. The nurse completes requisitions for a complete blood count with differential, thyroid function studies, chemistry profile, urinalysis, and urine drug screen. Medications include haloperidol 2 mg BID. The nurse understands that the purpose of the urine drug screen is to assess the client for what important information?

Detection of substances that may have caused the client's delusions and/or hallucinations. A urine drug screen is routinely ordered to determine the presence of any substances that may have altered a client's mental status. Blood and urine are the body fluids most often tested for drug content, although methods of analyzing saliva, hair, breath, and sweat have been developed.

The nurse knows that dizziness is a common side effect of some psychotropic medications. The HCP notes that the client continues to have significant side effects from haloperidol and is concerned about the client becoming noncompliant as a response to repeated problems with the typical antipsychotic. The HCP prescribes olanzapine 10 mg daily. What are the advantages for prescribing the atypical antipsychotic, olanzapine? (Select all that apply. One, some, or all options may be correct.)

Lower incidence of extrapyramidal symptoms (EPSEs). Olanzapine has fewer incidences of extrapyramidal side effects (EPSEs) than other antipsychotic medications. Rapid onset. Olanzapine has a rapid onset. Acute and maintenance therapy. Olanzapine injection is effective in the treatment of acutely agitated psychotic clients and there is sustained efficacy when the client is switched to oral maintenance treatment.

Diphenhydramine is available as 100 mg/mL. The prescribed dose is 75 mg IM. How many mL should the nurse administer? (Enter numerical value only. If rounding is necessary, round to the hundredth.) Submit

0.75

Three basic interventions are helpful when a client is in the acute phase of hallucinations and delusions. These interventions include the following: Do not make direct eye contact; instead, take a side-by-side position. Speak in simple terms and speak in a slightly louder voice than usual. Call the client by his or her name. The nurse understands that the rationale for these interventions is to give sensory validation to override the abnormal sensory processes that are occurring in the brain. Direct eye contact may make a paranoid client feel more paranoid. Use non-threatening body language and tone of voice. Interventions for a client experiecing hallucinations upone admission should occur in a sequence. Which interventions are most important for the nurse to include in the client's initial plan of care? (Select all that apply. One, some, or all options may be correct.)

Acknowledge that it appears the client is hearing voices. The initial approach is to acknowledge the voices. They are real to the client and it is necessary to know what the voice Ask the client to verbalize what the voices are saying. Once the voices are acknowledged, the nurse needs to know what the voices are saying. They are real to the client and it is necessary to know what the voices are telling the client. The voices may be telling the client to harm themself or others. Assess the content of the hallucinations message. The voices may be telling the client to harm themself or others. Immediate interventions will need to be put in place to keep the client and others safe.

After the content of the voices are assessed, which interventions should the nurse implement? (Select all that apply. One, some, or all options may be correct.)

Ask the client how the voices make them feel. It may be helpful to know how the voices make the client feel. It can provide understanding to the client's actions and reactions so they can be addressed in a therapeutic manner. Instruct the client to utilize distractions to deal with hallucinations. Once the hallucinations have been revealed and evaluated, it is important to disconnect the hallucinations from reality. Distractions can be a therapeutic.

Which medication should the nurse give to immediately relieve the muscle spasms in the client's neck and jaw?

Diphenhydramine IM. The client is experiencing a dystonic reaction, so the nurse should provide relief with diphenhydramine IM or benztropine IM. (benadryl)

Antipsychotic Medications: Initiation Haloperidol 2 mg twice a day (BID) is prescribed for the client's psychosis. Haloperidol is the prototype traditional antipsychotic. It is a potent medication that causes numerous extrapyramidal symptoms but few anticholinergic side effects. It is prescribed for clients who experience symptoms of psychosis or manifestations of agitation related to mental illness.Psychosis is thought to be caused by the over activity of a neurotransmitter. The nurse understands that traditional antipsychotic medications, such as haloperidol, will be effective in decreasing the symptoms of psychosis by blocking a variety of receptors in the brain. What neurotransmitter is targeted by haloperidol?

Dopamine. Traditional antipsychotics block excessive dopamine, an excitatory neurotransmitter, so that symptoms related to psychosis are reduced.

Since the client is also experiencing delusions, what action is most important for the nurse to take to address the client's delusions?

Encourage the client to verbalize the meaning of the delusions. The underlying theme of the delusions can be used to address the client's emotional state. Monitoring the affect of the delusions can help identify situations where the client may be inclined to harm themselves or others.

Antipsychotic Medication: Continued UseAfter 5 days, the nurse assesses the client's response to the prescribed haloperidol. Which response from the client indicates that the haloperidol has been effective?

Experiences fewer hallucinations. The client should experience fewer hallucinations if the medication has been effective.

Group activities, such as drawing, exercising to music, baking, community trips, and arts & crafts are offered on the unit. In the afternoon, the client decides to join the group that has chosen drawing as their activity. What is a goal of being in this activity group?

Gain self-acceptance and express feelings. An activity group promotes self-acceptance, expression of feelings, and a focus on group goals rather than individual issues.

Safety Precautions The nurse completes the assessment and determines the best precautions to ensure client and staff safety on the unit. Which assessment data are the best indicators of the potential for violence? (Select all that apply. One, some, or all options may be correct.)

Gender and age. Demographic variables such as gender and age are variables for predicting violence when assessing the client with psychosis. Past suicide attempts. Past suicide attempts are indicators of violence toward self. History of violence. The best single predictor of violence is a past history of violence.

The client admits that the voices he hears have been getting louder over the past couple of weeks. Which nursing intervention best promotes effective communication?

Have the client repeat what he thinks the voices are saying. The nurse should first ask what the voices are saying in order to assess for command hallucinations.

Several hours after receiving his medication, the client complains of muscle spasms in his neck and jaw. Which assessment finding warrants immediate intervention by the nurse?

Involuntary muscle contractions. Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, particularly of the face, tongue, neck, and jaw which is a serious side effect of halcinonide.

Admission to the UnitThe HCP admits the client to the mental health unit because his mental status impairs his ability to meet his basic needs and remain safe in the community. The mental health technician escorts the client to the unit, where the nurse completes the assessment and orients the client to the unit and his room.The nurse explains the unit rules and informs the client of his rights. The client immediately insists that he needs to leave and should not be in the hospital. Which assessment data provides evidence that the client can be involuntarily committed to the hospital, if he insists on leaving?

Losing 10 pounds in 2 weeks. The criteria for commitment includes danger to self and/or others, unable to provide for own basic needs, and/or the need for immediate and adequate treatment. Excessive weight loss demonstrates the client's inability

As the client is leaving the unit, the caseworker remembers that some of the client's medication bottles were brought to the hospital and the caseworker wants to return them to the client. Which nursing action is appropriate for this request?

Obtain a prescription from the HCP to return medications. The HCP must write a prescription for the client to receive medications. Medications were changed while hospitalized and required prescriptions should accompany the client upon discharge. All other medication should be properly disposed of as prescribed.

Which lab values from the urinalysis can the nurse expect to be related to the client's 10-pound weight loss in the past 2 weeks? (Select all that apply. One, some, or all options may be correct.)

Positive ketones. Ketones in the urine can suggest malnutrition, fasting, or starvation. Increased urine specific gravity. Increased urine specific gravity is associated with dehydration which could be contributing to the client's weight loss.

On the day of discharge, the client's caseworker arrives at the hospital to take him to his apartment. The nurse prepares to give the client a copy of his discharge paperwork. What is it most important intervention for the nurse to perform before discharging the client?

Re-evaluate thoughts of harm to self or others. It is very important to reassess that the client is free of suicidal and/or homicidal ideation so that the nurse can document this in the discharge notes.

Treatment Modalities for PsychosisOn the seventh day of hospitalization, the nurse asks the client to attend the community meeting to be held the following morning. The structure of the meeting is to introduce clients, plan activities for the day, address clients' concerns, and clarify any questions about the program. All clients are strongly encouraged to attend the community meetings. What is the most important benefit the client can receive from his attendance at the community meeting?

Reality orientation. Meetings that are designed to introduce clients to one another, plan activities for the day, and address client concerns and questions help ground the psychotic client in the present and reality.

The nurse explains the anticholinergic side effects associated with the client's medications. While teaching the client about the anticholinergic side effects related to benztrophine, which intervention is most important for the nurse to include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.)

Report urinary retention or feeling that the bladder does not empty. Serious side effects include urinary retention, blurred vision or eye pain, confusion and hallucinations, and uncontrollable movements of the client's eyes, lips, tongue, face, and limbs. Dry mouth and constipation are less serious anticholinergic effects. Relay any feeling of heart palpations. Tachycardia, palpitations, blurred vision or eye pain, confusion and hallucinations, and uncontrollable movements of the client's eyes, lips, tongue, face, and limbs are all serious anticholinergic side effects. Dry mouth, constipation, and drowsiness are less serious anticholinergic effects.

Nursing Process Care Plan Because the client has hallucinations and delusions, the nurse develops an initial plan of care related to psychosis. Which nursing diagnosis is best to include in the initial care plan?

Sensory-perceptual alteration related to withdrawal into self. The priority nursing diagnosis is related to the client's hallucinations, which impact his functioning and social interaction.

Prescribed MedicationsThe client becomes very agitated and angry, and he talks loudly to himself as he waits to be seen by the healthcare provider (HCP). Which medications should the nurse anticipate giving the client after securing a prescription from the healthcare provider? (Select all that apply. One, some, or all options may be correct.)

Short-acting anxiolytic (benzodiazepines). Antianxiety medications (benzodiazepines, lorazepam clonazepam, or diazepam) are most effective for anxiety-related symptoms to produce calming and sedation. When used in conjunction with an atypical antipsychotic medication, such as olanzapine, benzodiazepines, especially IM, can augment the efficacy of the antipsychotic medication, quickly alleviating acute agitation of a client. Antipsychotic medication. Antipsychotic medications are effective for psychosis-related symptoms and manifestations of agitation associated with mental illness.

When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond?

State how he must be concerned and assure him he will be safe there. The nurse should respond to the client's underlying feelings and not make assumptions about his delusions.

On the fifth hospital day, the client reports feeling dizzy as he stands to leave the morning group activity. Which action should the nurse implement first?

Take the client's blood pressure while he is sitting and standing. Since the client is feeling dizzy, a blood pressure reading should be taken while he is both sitting and standing to determine if a positional change, referred to as orthostatic hypotension, is associated with a change in the blood pressure readings.

What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication?

To determine if other medical issues are present. A CBC can provide helpful information on the client's health status. It is important to determine if there are other issues that could be causing some of the symptoms, and whether the client is healthy enough to take the medication. Some antypsychotic medications can cause neutropenia. If the client has other medical issues, considerations will need to be discussed regarding what medications should be prescribed.

Discharge Planning After 9 days of hospitalization, the client demonstrates fewer hallucinations, and his thoughts are not influenced by delusions. The client explains that several months before admission, he and his HCP decided that he could stop taking his psychotropic medications. He states that he does not know what happened and stated that he thought that he was handling everything just fine. The client's discharge is planned within several days.Medication prescriptions for discharge include olanzapine 5 mg PO daily BID. The nurse plans to educate the client about side effects that do not go away. What are important reasons for this teaching? (Select all that apply. One, some, or all options may be correct.)

To encourage the client to continue compliance with medications. Education about side effects is important so that medication compliance can be enhanced.