Mental health exam 2
A client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me." The term "volmers" Can't be assessed as what?
A neologism
A teenage client is being discharged from the psychiatric unit with a prescription for risperidone. The nurse is providing medication teaching to the clients mother should provide which response when asked about the risk her child faces for extrapyramidal Side effects (EPSs)?
Risperidone is a newer antipsychotic medication and has a lower risk of EPSs then older antipsychotics
When a client diagnosed with schizophrenia was discharged six months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot" What are common side effects the nurse should validate with the client?
Sedation and muscle stiffness
A client is receiving risperidone reports severe muscle stiffness at 10:30. By 12 o'clock the client has difficulty swallowing and is drooling by 1600 vital signs are 102.8°F pulse 110 respirations 26 150/90. The client is diaphoretic. What is the nurses best analysis and action?
Neuroleptic malignant syndrome; notify healthcare provider stat.
A client has a four year history of using cocaine intranasally. When brought to the hospital in an unconscious state what nursing measures should be included in the patient's plan of care?
Observation for tachycardia and seizures
A client diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the client continues to have apathy, poverty of thoughts, and social isolation. The nurse would expect a change to which medication?
Olanzapine
A client diagnosed with schizophrenia has been stable for a year; However, the family now reports the client is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The client says my computer is sending out infected radiation beams. The nurse can correctly assess this information as an indication of what?
Relapse
The laboratory report for a client taking clozapine shows a white blood cell count of 3000mm^3. What is the nurses best action?
Report the results to the healthcare provider immediately
A 20 year old was sexually molested at age 10, but he can no longer remember the incident. Which ego defense mechanism is used?
Repression
A client diagnosed with schizophrenia was hospitalized after arguing with coworkers and threatening to harm them. The client is aloof, suspicious, and says "two staff members I saw talking or plotting to kill me." Based on data gathered at this point, which nursing diagnosis is relate?
Risk for other directed violence Disturb thought processes
For a client experiencing panic, which nursing intervention should be implemented first?: 1. teach relaxation techniques 2. administer a PRN medication 3. prepare to implement physical controls 4. provide calm, brief, directive communication
provide calm, brief, directive communication
A client performs ritualistic handwashing. Which action should the nurse implement to help the client develop more effective coping?
Encourage the client to participate in social activities
A nurse leads psychoeducational Group about first generation antipsychotic medication with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications?
Gynecomastia
An adult in the emergency department states everything I see appears to be waving. I am outside my body looking at myself. I think I am losing my mind. When vital signs are slightly elevated what should the nurse suspect
Hallucinogen ingestion
A professional football player is seen in the emergency department after losing consciousness from an illegal block. Prior to discharge the nurse assist the client to schedule an out client computer tomography (CT)scan for the next day. Which strategy should the nurse use to ensure the client remembers the appointment?
Log the appointment day time and location into the players cell phone calendar feature
A client diagnosed with schizophrenia anxiously says, I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror. While listening, the nurse should engage in what behavior?
Maintain a normal social interaction distance from the client
A client with an abdominal mass is scheduled for a biopsy the client has difficulty understanding the nurses comments and asks what do you mean what are they going to do. Assessment findings include tremulous voice respirations 28 and pulse 110. What is the client level of anxiety?
Moderate
Selective intention is first noted when experiencing which level of anxiety?
Moderate
What is the priority nursing intervention when caring for a client after an overdose of amphetamines?
Monitor vital signs
What statement made by a client taking disulfiram reveals a need for further teaching?
Most over-the-counter cough syrups are safe for me to use
Which symptoms of withdrawal from opioids should the nurse assess for?
Nausea, vomiting, diaphoresis, anxiety, and hyperreflexia
A nurse prepares to administer a second generation antipsychotic medication to a client diagnosed with schizophrenia. Additional monitoring for adverse effect will be most important if the client has which co-morbid health problems?
Parkinson's disease Hyper lipidemia Diabetes
Working to help the client view an occurrence in a more positive light is referred to by which term?
cognitive restructuring
A client tells a nurse my best friend is a perfect person. She is kind considerate good looking and successful with every task. I could have been like her if I had the opportunity luck and money she had. This client is demonstrating?
Rationalization
A person who recently gave up smoking and now talks constantly about how smoking fouls the air, causes cancer and burns money when they could be better spent to feed the poor is demonstrating which ego defense mechanism?
Reaction formation
The most common causes of schizophrenia is an initial episode followed by what course of events?
Recurrent acute exacerbations and deterioration
A symptom commonly associated with panic attacks?
Fear of impending doom
The nurse administers a medication that potentiates the action of a-aminobutyric acid (gaba). Which affect would be expected?
Reduced anxiety
A nurse asked the client diagnosed with schizophrenia, "what is meant by the old saying you can't judge a book by looking at the cover?" Which response by the client indicates concrete thinking?
"The table of contents tells what a book is about"
Which side effect of antipsychotic medication is generally nonreversible?
tardive dyskinesia
Which hallucination expressed by a client necessitatesthe nurse to implement safety measures?
" The voices say everyone is trying to kill me"
which hallucination expressed by a client necessitates The nurse to implement safety measures?
" The voices say everyone is trying to kill me"
A newly admitted client diagnosed with schizophrenia says, the voices are bothering me. They yell and tell me I am bad. I have got to get away from them. So I asked the nurse is most helpful reply
" i'll stay with you. Focus on what we are talking about, not the voices"
A client diagnosed with schizophrenia anxiously Tulsa nurse, "the voice is telling me to do things." What is the nurses priority assessment question?
" what is the voice telling you to do?"
A nurse sits with a client diagnosed with schizophrenia the client starts to laugh uncontrollably, although the nurse has not said anything funny. What is the nurses most therapeutic response?
" you're laughing. Tell me what's happening"
Currently what is understood to be the causation of schizophrenia?
A combination of inherited and non-genetic factors
A client diagnosed with schizophrenia begins to talk about "Macnabs" hiding in the warehouse at work. The clients use of "macnabs" Should be documented using what term?
A neologism
An obsession is defined as what?
A recurrent, persistent thought or impulse
An acutely violent client diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the client head rotated to one side and a stiffly fixed position the lower jaw thrust forward and drooling which intervention by the nurses indicated?
Administer benztropine 2 mg IM from the prn medication administration records
An acutely violent client diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the clients head rotator to one side and a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?
Administer diphenhydramine 50mg IM from the PRN medication administration record
A client diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the client is calm. Two hours later the nurse is the clients how to rotate to one side and a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?
An acute dystonic reaction
Which of the following would be assessed as a negative symptoms for schizophrenia?
Anhedonia
A woman is 5'7" 160 pounds and wears a size 8 shoe. She says my feet are huge and I've asked three orthopedist to surgically reduce my feet. This person tries to buy shoes to make her feet look smaller and in social settings conceals both feet under a table or chair which health problem is likely?
Body dysmorphic disorder
What can be said about the comormobility of anxiety disorders?
Depression may occur prior to onset of anxiety
Which assessment questions would be most appropriate for the nurse to ask a quiet with possible obsessive compulsive disorder?
Are there others in your family who must do things in a certain way to feel comfortable? Is it difficult to keep certain thoughts out of your awareness? Do you do certain things over and over again?
A healthcare provider considers which antipsychotic medication to prescribe for a client diagnosed with schizophrenia who has auditory hallucinations and poor social function. The client is also over white and hypertensive. Which drug should the nurse advocate?
Aripiprazole
A healthcare provider considers which antipsychotic medication to prescribe for a client diagnosed with schizophrenia who has auditory hallucinations and poor social function. The client is also overweight and hypertensive. Which drug should the nurse advocate?
Aripiprazole
A client who has been prescribed clozapine Six weeks ago reports flu like symptoms including a fever and a very sore throat the nurse should initiate which nursing intervention?
Arrange for the client to have blood drawn for a white blood cell count
A client has acute anxiety related to an automobile accident two hours ago. The nurse should teach the client about medication from which group?
BenzodiazepineS
A nurse assesses a client with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?
Do you find it difficult to control your worrying
A person has minor physical injuries after an auto accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic
C. Severe
A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a salute. The client remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?
Catalonia
A nurse plans health teaching for a client diagnosed with generalized anxiety disorder who begins a new prescription of lorazepam. What information should be included?
Caution and use of machinery The importance of caffeine restriction Avoidance of alcohol and other sedatives
A client is experiencing moderate anxiety. The nurse encourage the client to talk about feelings and concerns. What is the rationale for this intervention?
Concerns stated aloud become less overwhelming and help problem-solving begin
A client is thin, tense, jittery, and has dilated pupils. The client says, "My heart is pounding in my chest. I need help." The client allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The client refuses further examination. Abuse of which substance is most likely? a. phencyclidine (PCP) b. Heroin c. Barbiturates d. Amphetamines
D. Amphetamines
A client diagnosed with schizophrenia says, "my coworkers are out to get me. I also saw two doctors plotting to kill me." How does this client perceive the environment?
Dangerous
A clients care plan includes monitoring for auditory hallucinations. Which assessment finding suggests the client may be having a hallucination?
Darting eyes, tilted head, mumbling to self
The nurse is developing a plan for psycho educational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for the group members?
Demonstrate improved social skills
A client undergoing diagnostic test says, " Nothing is wrong with me except a stubborn chest cold". The spouse reports the client smokes cops daily lost 15 pounds and is easily fatigued. Which defense mechanism is the client using?
Denial
A man continues to speak of his wife as though she were still alive, three years after her death. This behavior suggests the use of which ego defense mechanism?
Denial
A client diagnosed with schizophrenia says, contagious bacteria are everywhere. When they get in your body, you'll be locked up with other infected people. Which problem is evident?
Paranoia
A client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia. The clients activities of daily living are severely compromised. What will be inappropriate outcome for this client?
Perform self-care activities with coaching by the end of day 3
A client diagnosed with schizophrenia exhibit a little spontaneous movement and demonstrate Catalonia. Which client needs are of priority important?
Physiological
A client preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate?
Presenting information again in a calm manner using simple language
A nurse would anticipate that treatment for a client with memory difficulties might include medication designed to do what?
Prevent destruction of acetylcholine
A client has reached the maintenance phase of schizophrenia. What is the appropriate clinical planning focus for this client?
Social, vocational, and self-care skills
Cocaine exerts which of the following affects on a client?
Stimulation in euphoria
A client has smoked two packs of cigarettes daily for many years. When the client tries to reduce smoking, anxiety, Craven, poor concentration, and headache occur. This scenario should be described using which term?
Substance addiction
A client diagnosed with schizophrenia has received fluphenazine deconoate twice a month for three years. The client nurse notes that the client grimaces and constantly smacks both lips. The clients neck and shoulders twist in a slow snake like motion. Which problem with the nurse suspect?
Tardive dyskinesia
The purpose for the abnormal involuntary movement scale (AIMS) assessment on a persistently mentally ill client who has been diagnosed with schizophrenia is early detection of?
Tardive dyskinesia
Which nursing intervention is designed to help a schizophrenic client minimize the occurrence of a relapse?
Teach the client and family about behaviors associated with relapse
A person who has been unable to leave home for more than a week because of severe anxiety says I know it doesn't make sense, but I just can't bring myself to leave my apartment alone which nursing intervention is appropriate?
Teach the person to use positive self talk techniques
A client experiencing panic suddenly began running and shouting, " I'm going to explode" what is the nurses best action
Tell the client "stop running and take a deep breath. I will help you"
A client says, Facebook has a new tracking capacity. If I use the Internet, homeland security will detain me as a terrorist. What is the nurses best initial action?
Tell the client, you are in a safe place where you will be helped
Generally which statement regarding ego defense mechanisms is true?
They often involve some degree of self-deception.
Nursing assessment of an alcoholic dependent client 6 to 8 hours after the last drink would most likely reveal the presence of which early sign of alcohol withdrawal?
Tremors
Which questions asked by the nurse in a non-judge mental Manor would be most helpful when obtaining information about a client use of complementary and herbal remedies?
What herbal medicines have you used to relieve your symptoms? What over-the-counter medicines vitamins and nutritional supplements do you use? What difference in your symptoms do you notice when you take herbal supplements? Have you experienced problems from using herbal and prescription drugs at the same time?
Which of the following symptoms would alert a healthcare provider to a possible diagnosis of schizophrenia in a 22-year-old male client?
Withdraw from college because of failing grades
A newly hospitalized client experiencing psychosis says, "red chair out of town board." Which term should the nurse use to document this finding?
Word salad
An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident?
a. Rationalization Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings.
What is an appropriate long-term client centered goal/outcome for a recovering substance abuser?
abstain from the use of mood-altering substances.
A client diagnosed with disorganized Schizophrenia would have greatest difficulty with the nursing intervention?
giving multistep directions.
Delusionary thinking is a characteristic of which form of anxiety?
panic level anxiety
