Real Life RN Mental Health 3.0
7. Alcohol Abuse Disorder Nurse Stacy is preparing to administer an intermittent IV bolus of ranitidine (Zantac) 50 mg in 0.9% sodium chloride 100 mL over 20 min. Stacy should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
300 ml/hr
14. Schizophrenia Nurse A is teaching Emily about ways to decrease K paranoia at home. Which of the following actions should Nurse A recommend?
avoid whispering or talking quietly to others when in the same room as Ken. Ensuring that K is able to overhear conversations decreases the possible belief that others are talking about him.
12. Bipolar Disorder Nurse Ben is planning care for Susan and is reviewing manifestations of lithium toxicity. The nurse should monitor for which of the following findings?
Ataxia The nurse should monitor for ataxia, blurred vision, and oliguria which are signs of severe lithium tocxicity -lithium should be between 2.0 and 2.5 mQg/L
15. Bipolar Disorder Nurse Ben responds to Susans despondent behavior. Which of the following is an appropriate response by Ben?
"Do you have a plan for how you would end your life?"When the client shares suicidal thoughts, the nurse shoudl ask if there is a specific plan and then determine the lethality of the method and whether or not the client has access to the desired method.
8. Schizophrenia Nurse A is teaching K and E about actions that can decrease K's anxiety and increase this socialization. Which of the following statement should A make?
"Emily, visiting and talking with ken on a regular basis will help him maintain his social interactions." Regular but brief visits to the pt about topics that do not cause anxiety is recommended. Gradually increasing the length and number of interactions to let the pt get more comfortable.
6. Bipolar Disorder Nurse B is attempting to admin the olanzapine (Zyprexa) IM to Susan Choi, but she forcefully refuses it. Which of the following actions should Ben take?
Explain the benefits of the injection. The pt has the right to refuse the treatment. Her Adminssion to the mental health facility was voluntary.
9. Schizophrenia Nurse A is teaching K and E about the adverse effects of paliperidone. Whichc of the following statements should A include?
"You should let your provider know if you experiencing abnormal body movements" Paliperidone can cause Extrapyramidal Effects such as unusual body movements, tremors, or muscle contractions. The pt should notify the provider immediately if they experience these adverse effects.
11. Anxiety Nurse T is providing medication teaching regarding escitalopram (Lexapro). Which statements should T include in the teaching?
"You should report increased thoughts of suicide" pts especially Children and young adults who start with escitalopram are at increased risk for suicidal ideation.
13. Schizophrenia Nurse A is talking with ken about substance use and the results of this drug screen. Which of the following statements should Nurse Anne say when discussing this topic with K?
"tell me some of your reasons for using marijuana" Uses the trerapeutic communication of broad opening and open ended questions. Encouraging the pt to openly discuss the topic so that the nurse can gain info and insight into the situation.
5. Anxiety Nurse T is calculating the dose of lorazepam. Available 4mg/mL, ordered was 2mg. How many mL should the nurse admin?
0.5 mL
15. Bipolar Disorder Nurse Ben is planning discharge outcomes for Susan. Identify client outcomes for Susan in the following areas..:
1. review education material about bipolar disorder and its management 2. Maintain consistent patterns in sleep, meals, and activities. 3. Identify strategies for enhancing communication and problem-solving skills. 4. recognize support systems at home (family and friends) 5. carry names and contact information for local bipolar support groups, such as the national alliance for the mentally ill 6. attend the follow-up appointment.
5. Bipolar Disorder Olanzapoine 10 mg IM for pt SC, for acute mania. After reconstitution with 2.1 mL sterile water to yield 5 mg/mL. How many mL should B admin?
2 mL
12. Schizophrenia Nurse A confirms that K is not experiencing command hallucications. Which of the following responses should Nurse A make when further communicatin with K about his auditory hallucinations?
:Hearing voices must be frightening, but you are safe" Pt is not experiencing command hallucinations, the nurse should reassure the pt he is safe ans show empathy fo.r his feelings. Providing reassurance can decrease K's anxiety which decreases the risk for self and other directed harm
1. Schizophrenia Nurse Anne noticed that Ken is exhibiting an altered speech pattern. Which of the following respnses by Ken should Nurse Anne identify as an example of associative looseness?
A. Altered speech pattern of communication in which the pt shifts from one idea to another.
2. Bipolar Disorder Nurse Ben continues to collect information related to Susan Choi's episode of manic behaviour. Which of the following responses to the question asked by the clien's mother is appropriate?
According to the literature ther is strong genetic predisposition for bipolar disorders. The risk of developoing bipolar disorder increaes when a person has a relative with this disorder compare to those who don't.
7. Bipolar Disorder Nurse B is leading a group therapy session and Susan Choi interrupts the session. Which of the following actions should Ben take to manage Susan's disruptive behaviour?
Ask the AP to assist the client out of the room. Pt experiencing manic disorder can't benefit from group therapy at the moment. Helpful one the pt is no longer in an acute state.
1. Anxiety Nurse T is admitting Ms. S. Which of the following is the priority action for T to take?
Assess respiratory status Using the airway,breathing, circulation (ABC) approach to the pt is asess respiratory status of a pt experiencing SOB and tachypnea.
1. Alcohol Abuse Disorder Nurse Stacy is completing the admission process for Mr. Moore. Which of the following nursing assessments should Stacy complete?
CAGE Questionaire Fall Risk Assessment Braden Scale: Numeric Pain Scale
5. Schizophrenia Nurse Anne is continuing to assess Ken. Which of the following manifestations should Anne Assess for first?
Command Hallucinations Auditory Hallucinations is the risk for self or other directed harm due to cmmand hallucinations. The nurse should continue assessing the pt to determine exactly what the voices are commanding.
9. Bipolar Disorder Nurse B is preparing to instruct Susan Choi and her family regarding Lithium therapy. Which of the following instructions should Ben include in his teaching?
Consume 2-3 L of fluid per day. Maintain Consisten Na Intake (Lithium decreases Na reabsorption causing hyponatremia, Prevent toxicity). Take the med with meals (Prevent GI upset).
9. Anxiety Nurse T is discussing Ms. S is most stressful situation. Which actions should T take first?
Continue to gather more into regaring finances. First action in the nursing process is to collect data from the pt.
15. Schizophrenia Nurse A is providing info to K and E about a durable power of attorney for health care (DPAHC). Which of the following info should Nurse A include in the teaching?
DPAHC can be terminated by the client. Inform the pt the designation of a trusted indvidual to make healthcare related decisions on his behalf ih he is unable to doso. The pt retains the right to terminate the DPAHC relationship.
4. Schizophrenia Nurse Anne identifies that Ken is experiencing a delusion. Which of the following types of delusions should she document in the pts medical record?
Delusion of Persecution: The pts false belief that others are trying to harm or persecute them in some way. The pt does not want to take the medication becuase he thinks the pharmacyst is trying to poison him. Delusion of Grandeur: False belief in one's own superiority, greatness, or intelligence. People experiencing delusions of grandeur do not just have high self-esteem; instead, they believe in their own greatness and importance even in the face of overwhelming evidence to the contrary. Nihilistic Delusion: Negative belief of the world or one being dead, decomposed or annihilated, having lost one's own internal organs or even not existing entirely as a human being. Somatic Delusion: The pt is convinced their organs are damaged or malfunctioning, or that they are suffering from some type of hidden malady, or that their physical appearance has somehow been altered or distorted.
3. Schizophrenia Nurse Anne is teaching Ken and sister about positive and negarive symptoms of schizophrenia. Which of the following manifestations should the nurse include as positve symptoms?
Delusions Motor agitation Hallucinations Manifestations of altered mental functioning. Delusions, Hallucications (visual, auditory, gustatory, olfatory), altered speech (eholalia, clang association, associatice looseness), Motor agication. Negative schizophrenic Sx=decreased physical and mental functioning such as Flat Affect, Anhedonia, Alogia, Apathy, and Avolition.
8. Anxiety Nurse T is listening to Ms. S while she describes the stressors that contribute to her anxiety. Which coping mechanisms is Ms. S. exhibiting?
Denial: conscious effort of not thinking about an unpleasant event or occurence that causes stress. Displacement: when there is a tranfer of feelings about an individual or circumstance to another person or object that is uninvolved in the situation. Rationalization: The belief in or acting upon an idea that that is unrealistic in order to satisfy the response of the communicationr and the listener. Splitting is the inability to blend both the positive and negative qualities of self. Regression involves the acting out behaviors of an individual at an earlier stage in life.
15. Alcohol Abuse Disorder Nurse Stacy identifies substance use disorder relapse prevention strategies that will be discussed during Mr. Moore's outpatient treatment program. Nurse Stacy reviews substance use disorder relapse prevention strategies with Nurse Kathy. Which of the following is a relapse prevention strategy?
Encourage Mr. Moore to write important info in a notebook. Relapse prevention strategies focus on cognitive and behavioral changes. Alcoholics may experience cognitive changes, which may affect their ability to remember and use relapse prevention strategies effectively.
6. Anxiety Nurse T is initiating therapeutic communication with Ms. S. Which video demosntrate an appropriate interaction between the nurse and the pt?
Engaged and active listening, including direct eye contact, are key of effective communication and will assisst in building a rapport with the client.
11. Schizophrenia Nurse A is discussing group therapy with K and E. Which of the following recommendations should Nurse A make?
Establilsh a goal for long term commitment to attending group therapy. Group therapy has the greatest effectiveness when it is attended on a long term basis. This commitment to group therapy can provide the pt a sense of belonging, improved social skills, and increased ability to manage schizophrenia.
16. Schizophrenia Nurse A is teaching K and E about relapses of Schizophrenia. Which of the following info should the nurse include?
Group therapy can help prevent relapselearning . Learning New coping skills can help prevent relapse. Substance use can cause a relapse. Notify trusted people if there is a desire for social withdrawal. Notify the provider right away if any indications of relapse occur so that treatment is not delayed. Aware the pt of early warning signs of relapse: Decreased sleep, Social withrawal, and Thought Disturbances.
2. Anxiety Nurse T assess Ms. S. Which assessment scales is appropriate?
Hamilton-A Assessment scale to assess anxiety. Anxiety Symptoms: SOB, Chest pain, headaches, restlessness, and trembling.
5. Alcohol Abuse Disorder Nurse Stacy implements seizure precautions for Mr. Moore. Which of the following should Stacy include in the plan of care?
Have suction equipment available in Mr. Moore's room. Suction equipment is needed as part of seizure precautions.
2. Alcohol Abuse Disorder Nurse Stacy plans to complete the CAGE questionnaire as part of the Nursing Assessment. Which of the following questions is included in this questionnaire?
Have you ever felt bad or guilty about your drinking? Thre are 4 questions in the CAGE questionnaire: 1. Have you ever felt you needed to Cut down on your drinking? Yes or No 2. Have people Annoyed you by criticizing your drinking? Yes or No 3. Have you ever felt Guilty about drinking? Yes No 4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover? Yes No A yes Answer to 2 or more of these questions indicates >>Then the probability of you having an alcohol problem is about 50%, 3 75%, 4 100%.
12. Alcohol Abuse Disorder Nurse Steve and Social Worker Eva discuss the objective of an intensive outpatient program with Mr. Moore.QuestionNurse Steve reviews the objective of an intensive outpatient program with Mr. Moore. Which of the following is an appropriate statement by Steve?
In an intensive outpatient program, care will be individualized to meet your treatment needs. Intensive outpatient programs are responsive to the specific needs of the client.
12. Anxiety Nurse T is explaining Ms. S diagnosis. Which statements should T include in the teaching?
Interventions are based on the degree of anxiety you are experiencing. You can experience four levels of anxiety. It is common to perform repetitive behaviors in order to cope with anxiety. Anxiety Tx is individualized to the degree of anxiety (Mild, Moderate, Severe, and Panic).
3. Bipolar Disorder Susan Choi behaves seductively towards Nurse B. Which of the following responses by Ben is appropriate?
It is the expectation on this unit that there is no inappropriate physical contact. I need you to stop. The nurse provides info about unit expectations and gives cleas instructions for th pt to stop the inappropriate behaviour.
3. Alcohol Abuse Disorder Nurese S is caring for Mr. Moore,who is in acute alcohol withdrawal. She should anticipate the provider will prescribe which of the following medications?
Lorazepam (Ativan) Benzodiazepine commonly used to treat acute alcohol withdrawal. Sedative, It can treat seizure disorders, such as epilepsy. It can also be used before surgery and medical procedures to relieve anxiety. -Lithium (Lithobid): Bipolar disorder, Antidepressant, Oral med, reduces the risk for suicide in these disorders -Diazepam (Valium): Anxiolytic and sedative, It can treat anxiety, muscle spasms, and seizures. -Paroxetine (Paxil)-- antidepressant and is not used to tx acute alcohol withdrawal
9. Alcohol Abuse Disorder Mr. Moore had interactions with hospital personnel earlier in the day. Which of the following videos is an example of Mr. Moore's use of denial as a maladaptive coping mechanism? (Review each of the videos. After making your selection, click on the submit button.)
Mr. Moore talks to Social Worker Eva about going out for drinks at the end of the day with other construction workers. option D. The client uses denial when he refuses to admit he has an alcohol use disorder while talking with the social worker.
13. Alcohol Abuse Disorder Discharge planning includes teaching Mr. Moore about medications prescribed to decrease his alcohol craving. Which of the following medications are appropriate to include in this discussion? (Select all that apply.)
Naltrexone opioid antagonist Tipiramate anticonvulsant
3. Anxiety Nurse T completes the Hamilton-A assessment of Ms. S and determines her score to be 26. Which appropriate action for the nurse to take?
Obtain a prescription forlorazepam (Ativan).
11. Bipolar Disorder Nurse Ben is preparing to instruct Susan Choi and her family regarding lithium therapy. Which of the following instructions should Ben include in his teaching?
Peanut butter jelly sandwhich, chips, bannana and strawberry milkshake in a plast cup with straw. a client who is experiencing a manic episode is hyperactive and typically unable to sit for meals. This meal is appropriate for a client experiencing a manic episode because it offers "Finger foods" which the client can eat while moving around, the non-caffeinated beverage is appropriate. The meal also offers high-protein, high calorie foods with no utensils.
4. Bipolar Disorder Nurse B is preparing to administer olanzapine to Susan Choi who is in the early phase of acute mania. Which of the following are expected outcomes of the medication?
Promote Sedation Decrease Agitation Prevent Mania Relapse Side Effects: Premenstrual Syndrome Symptoms and weight gain.
6. Alcohol Abuse Disorder Nurse Stacy is planning care for Mr. Moore. Which of the following nursing interventions is appropriate for a client in alcohol withdrawal?
Promote a low-stimulation environment. A low-stimulation environment promotes rest and energy conservation, and is calming for the client
7. Schizophrenia Nurse A is teaching E & K abut the effects of cocaine use. Which of the following findings should Nurse A indentify as a manifestation of cocaine intoxication?
Psychosis Cocaine is an stimulant. Other intoxication manifestations include fellings of exhilaration, anxiety, panic, and anger. An increased desire for socialization, hypertansion, tachycardia, decrease appetite, and dialated pupils.
7. Anxiety Nurse T is communicating with Ms. S. Which is an appropriate action for T to take?
Restate the concerns voiced by Ms. S. This allows for exploring and clarifying the pt's statements
4. Anxiety Nurse T preparing to call the provider. List the findings.
S (Situation) = Ms. Simpson is a 22-year-old African-American female admitted to the inpatient mental health unit for anxiety. She is restless and fidgety, has poor concentration, and has been experiencing chest pain and shortness of breath.B (Background) = She has a history of generalized anxiety disorder and has previously taken paroxetine 20 mg PO daily, but has not been taking it for approximately 2 weeks.A (Assessment)= Her vital signs from report at 0745 were: heart rate 115, blood pressure 148/76, respirations 32, oxygen saturation 96% on room air, and temperature 37.0 C (98.6 F). Her score on the Hamilton A scale is 26, and she has been unable to focus on answering questions due to her severe level of anxiety. She continues to pace, wring her hands, and rock when sitting.R (Recommendation) = I am calling to request a prescription for lorazepam.
13. Bipolar Disorder Ben reviews Susans assessment data. Which of the following assessment tools should he use to identify suicide risk factors and the need for hospitalization?
SAFE-T
10. Anxiety Nurse T has discovered Ms. S self-injury. Which thought processes is most likely a reflection of Ms. S behavior?
Self-Destruction Self-destructive thought without suicide intent.
4. Alcohol Abuse Disorder Using the SBAR format, Nurse S calls Dr. E and reports her assessment findings. What should the nurse include in her report?
Situation: At 0200, discovered client lying at foot of bed, disheveled, saline lock dangling from arm. Client awake and responsive. Background: 45 year-old-white male who had MVA yesterday at approximately 1400. Admitted by ambulance in acute alcohol intoxication with abrasions and accompanied by police. History of gastritis and esophagitis. Transferred to medical-surgical unit. No change in status prior to this time. Assessment: Alert to person and place, but not time. States he has nausea with dry heaves. Moderate tremor of upper extremities. Appears moderately anxious and restless. No auditory or visual disturbances. States: "I feel the bugs all over me." Reports mild headache. Vital signs: BP 160/94; T 37.9; P 106, and R 24, which are elevated from midnight findings. CIWA score of 23. Recommendation: Needs antiemetic and medication for agitation and withdrawal.
10. Alcohol Abuse Disorder Nurse Stacy offers a therapeutic response to Mr. Moore, who is using the defense mechanism of denial QuestionMr. Moore states he does not have a problem with alcohol. Which of the following is a therapeutic response to this statement by Nurse Stacy?
So you don't think you're an alcoholic? This is an appropriate use of the therapeutic technique of restating.
2. Schizophrenia Murse Anne observes that Ken is becoming increasingly anxious. Which of the following actions should Nurse Anne take?
Stand off to the side of Ken, more than arms reach away...... To avoid increasing the pt's anxiety. Pts who are exhibiting anxious behaviors are at risk ofr violence. The nurse should have a direct path to the door in case the client becomes violent & the nurse needs to leave the room immediately.
14. Bipolar Disorder Nurse Ben is reviewing the adverse effects of lamotrigine (Lamictal). Which of the following is a serious adverse effect of this medication?
Stevens-Johnsons Syndrome Immediately report rashes.
8. Bipolar Disorder The admission orders indicate Susan Choi is to have several la tests drawn and to start therapy with lithium. Which of the following lab test must be drawn prior to starting lithium therapy?
T3, T4, TSH (Hypothyrodism Side Effect) BUN and Serum Creatinine (Kidney Damage) HCG (not indicated in Pregnancy)
11. Alcohol Abuse Disorder Nurse Steve intervenes with a potentially violent Mr. Moore to de-escalate the situationNurse Steve is caring for Mr. Moore, who is angry and is raising his voice. Which of the following is Steve¶s priority intervention at this time?
Tell him in a firm voice to stop his behavior
6. Schizophrenia Nurse Anne is continuing to assess Ken. Which of the following tools should Anne use?
The Suicide Assessment Five Step Evaluation and Triage (SAFE-T). Tool comprise of 5 steps that ssess a pt's risk for suicide. Identifies both risk and protective factors related to suicide risk. The pt may be at an increased risk for suicide due to psychosis or depression.
10. Schizophrenia Nurse A is preparing to administer K's 1st injection of paliperidone. Which of the following statements should she make?
The medication will reach peak effectiveness in about 13 days. The onset of paliperidone is unknown, but it peaks in about 13 days of admin. It lasts approx. 1 month.
10. Bipolar Disorder Nurse B and the nursing staff conduct a care planning conference to discuss nursing actions to promote Susan Choi's recovery. Whcih of the following nursing actions should Ben implement?
USe a firm, calm, matter of fact approach. Offer frequent, high calorie drinks. Decrease noise, lights, and interactions. Use distraction to redirect the client's energy.
8. Alcohol Abuse Disorder Nurse Stacy is preparing to review the importance of thiamine (vitamin B1) replacement therapy with Mr. Moore. Which of the following statements should be included in this discussion?
This medication works on the nervous system to prevent encephalopathy. A deficiency of thiamine can result in Wernicke-Korsakoff syndrome.
1. Bipolar Disorder Nurse Ben performs Susan Choi's (pt with manic episode) initial Mental status assessment. Which of the following categories indicates correct nursing assessment findings?
Thought Content: Grandiose thinking and Racing/Magical thinking
14. Alcohol Abuse Disorder The nurse reviews disulfiram (Antabuse). Adverse effect if Mr. Moore uses alcohol with it.
Throbbing headache
13. Anxiety Nurse T is teaching Ms. S about anxiety. Which indicate Ms. S understands the teaching?
Uses relaxation techniques Using relaxation technique is an indicator of positive self control, monitoring of anxiety levels and environmental distractions, and the ability to maintain restful sleep.