Mental Health: Psychosis Case Study

The client continues to state 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? a. Hallucination. b. Phobia. c. Delusions. d. Confabulation.

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

What is it most important intervention for the nurse to perform before discharging the client? a. Complete contracts to follow discharge plans. b. Provide resources for community support. c. Re-evaluate thoughts of harm to self or others. d. Identify support for the client's family.

c. 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.

What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication? a. To determine the presence of cardiac disease. b. To monitor for hepatotoxicity. c. To determine if other medical issues are present. d. To assess elevations in liver enzymes.

c. 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.

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

0.75 75 mg / 100 mg = 0.75 mL

Interventions for a client experiencing hallucinations upon admission should occur in a sequence. Which interventions are most important to be include in the client's initial plan of care? (Select all that apply. One, some, or all options may be correct.) a. Acknowledge that it appears the client is hearing voices. b. Tell the client to stop listening to the voices. c. Ask the client to verbalize what the voices are saying. d. Assess the content of the hallucinations message. e. Identify distractions to keep the client focused on reality.

a. 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 voices are telling the client. The voices may be telling the client to harm themself or others. c. 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. d. 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.) a. Ask the client how the voices make them feel. b. Instruct the client to utilize distractions to deal with hallucinations. c. Tell the client to instruct the voices to go away. d. Give the client statements to say to the voices. e. Encourage the client to write down what voices are saying.

a. 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. b. 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.

The nurse completes requisitions for a complete blood count (CBC) with differential, thyroid function studies, chemistry profile (CHEM), urinalysis (UA), and urine drug screen. Medications include haloperidol 2 mg by mouth (PO) two times a day (BID.) The nurse understands that the purpose of the urine drug screen is to assess the client for what important information? a. Detection of substances that may have caused the client's delusions and/or hallucinations. b. Determination of the approximate time the client stopped taking his medications. c. Provision of information about the type of psychosis the client is experiencing. d. Documentation of medication noncompliance and reinforcement of the need for hospitalization.

a. 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.

Since the client is also experiencing delusions, what action is most important for the nurse to take to address the client's delusions? a. Encourage the client to verbalize the meaning of the delusions. b. Firmly tell the client that the delusions are not real. c. Have the client to explain why they believe the delusion. d. Give the client a list of reasons the delusions are not real.

a. 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.

The client is questioning the nurse about taking another pill. Which nursing intervention best promotes effective communication? a. Explain that this pill is to help prevent the muscle spasms in neck and jaw. b. Tell the client this pill will prevent the risk for tardive dyskinesia. c. Say to the client that this pill will help the haloperidol be more effective. d. To further alleviate sudden periods of delusions.

a. 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.

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.) a. Gender and age. b. Past suicide attempts. c. History of violence. d. Multiple prescribed medications. e. Medication noncompliance.

a. Gender and age. Demographic variables such as gender and age are variables for predicting violence when assessing the client with psychosis. b. Past suicide attempts. Past suicide attempts are indicators of violence toward self. c. History of violence. The best single predictor of violence is a past history of violence. e. Medication noncompliance Clients with active psychotic symptoms are at increased risk for violence (symptom exacerbation), especially if they are medication noncompliant.

What are the advantages for prescribing the atypical antipsychotic, olanzapine? (Select all that apply. One, some, or all options may be correct.) a. Lower incidence of extrapyramidal symptoms (EPSEs). b. Rapid onset. c. Less weight gain. d. Alpha-adrenergic blockade. e. Acute and maintenance therapy.

a. Lower incidence of extrapyramidal symptoms (EPSEs). Olanzapine has fewer incidences of extrapyramidal side effects (EPSEs) than other antipsychotic medications. b. Rapid onset. Olanzapine has a rapid onset. e. 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.

What is the most important benefit the client can receive from his attendance at the community meeting? a. Reality orientation. b. Limits set on behaviors. c. Psychosocial skills. d. Mutual goal setting.

a. 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.

Because the client has hallucinations and delusions, the nurse works with the RN team leader to develop an initial plan of care related to psychosis. Which nursing problem is best to include in the initial care plan? a. Sensory-perceptual alteration related to withdrawal into self. b. Chronic low self-esteem related to impaired cognition. c. Ineffective individual coping related to personal vulnerability. d. Knowledge deficit related to medication compliance.

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

The 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 getting orders from the healthcare provider? (Select all that apply. One, some, or all options may be correct.) a. Short-acting anxiolytic (benzodiazepines). b. Antipsychotic medication. c. Mood-stabilizing medication. d. Nonbenzodiazepine anxiolytic (antianxiety agent). e. Antidepressant.

a. 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. b. Antipsychotic Medication Antipsychotic medications are effective for psychosis-related symptoms and manifestations of agitation associated with mental illness.

What are important reasons for this teaching? (Select all that apply. One, some, or all options may be correct.) a. To encourage the client to continue compliance with medications. b. To document the client's response to the medication education. c. To monitor for early tardive dyskinesia, which can be reversible. d. To reinforce education done throughout the hospitalization. e. To tell the client to discuss symptoms with his nurse.

a. To encourage the client to continue compliance with medications. Education about side effects is important so that medication compliance can be enhanced. c. To monitor for early tardive dyskinesia, which can be reversible. It is very important to teach the client to report uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia and suggest modifications in the client's medication regimen. Tardive dyskinesia, although rare with olanzapine, can be reversed, by reducing the medication dose, if it is assessed in a timely manner. d. To reinforce education done throughout the hospitalization. Educating the client about medications at discharge will reinforce the client's knowledge. e. To tell the cliet to discuss symptoms with his nurse. It is very important to reinforce the client's medication compliance by recommending that the client discuss any uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia.

When the client looks around the room and mumbles to himself, how should the nurse respond? a. Have the client express how he is feeling. b. Ask the client if they are hearing voices. c. See if the client recalls being here before. d. Tell the client to say what they are thinking.

b. 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.

Which assessment finding warrants immediate intervention by the nurse? a. Motor restlessness. b. Involuntary muscle contractions. c. Lip smacking. d. Drooling.

b. 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.

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? a. Past history of suicide attempts. b. Losing 10 pounds in 2 weeks. c. Auditory hallucinations. d. Persecutory delusions.

b. 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 to provide for his own basic needs by not maintaining adequate nutrition.

Which lab results 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.) a. Positive for red blood cells. b. Positive ketones. c. Decreased urine pH. d. Increased urine specific gravity. e. Absence of glucose.

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

When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond? a. Insist that no one has followed the client there. b. State how he must be concerned and assure him he will be safe there. c. Tell the client that the police will make sure no one is out there. d. Ask the client why he thinks that someone is out there.

b. 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.

Which action should the nurse implement first? a. Offer the client a glass of juice and ask him if he ate breakfast. b. Take the client's blood pressure while he is sitting and standing. c. Tell the client that his dizziness is orthostatic hypotension that will subside after he eats. d. Hold the morning dose of haloperidol, and notify the HCP.

b. 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.

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 make sure is in the client's plan of care? a. Encourage the client to share the meaning of their delusions. b. Interview the client to identify his feelings of depersonalization. c. Begin a sequence of interventions to address the client's hallucinations. d. Orient the client to their plance and situation.

c. 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.

Based on established and approved facility protocol orders, which medication is the nurse able to give to immediately relieve the muscle spasms in the client's neck and jaw? a. Lorazepam IM. b. Benztropine PO. c. Diphenhydramine IM. d. Acetaminophen PO.

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

What neurotransmitter is targeted by haloperidol? a. GABA. b. Serotonin. c. Dopamine. d. Norepinephrine.

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

What is a goal of being in this activity group? a. Learn social behaviors and gain insight about one's personality. b. Gain information about disorders, symptoms, and medications. c. Gain self-acceptance and express feelings. d. Identify and resolve specific problems related to the treatment plan.

c. 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.

While teaching the client about the anticholinergic side effects related to benztrophine, which intervention is most important for the nurse to ensure is include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.) a. Take daily naps to decrease the tiredness caused by benztrophine. b. Expect dizziness that occurs after taking beztrophine. c. Report urinary retention or feeling that the bladder does not empty. d. Observe for sudden onset of hand tremors. e. Relay any feeling of heart palpations.

c. 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. e. 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.

The nurse is training a new team member. Which explanation best promotes effective communication when discussing group process and group content? a. Group content refers to the group rules. Group process is how clients react to the rules. b. Group process refers to where the group meets, while group content refers to the type of group that is meeting. c. Group content is client-led and group process is nurse-led. d. Content includes the clients' words, and group process is how the clients communicate.

d. 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.

Which response from the client indicates that the haloperidol has been effective? a. Feels less anxious and nervous. b. Reports that mood is more stable. c. Initiates more social interactions. d. Experiences fewer hallucinations.

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

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? a. Ask the client what helps the voices go away. b. Determine how long the client has been hearing voices. c. Document when the voices began getting louder. d. Have the client repeat what he thinks the voices are saying.

d. 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.

Which nursing action is appropriate for this request? a. Direct the caseworker to talk with the pharmacist. b. Ask for the client's permission to obtain medications. c. Explain that the nurse can return the medications. d. Obtain a order from the HCP to return medications.

d. Obtain a order from the HCP to return medications. The HCP must write a order 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.

What is the most important part of this admission process? a. Ask the client if he has any valuables that need to be locked in a safe place. b. Allow the client to explain his understanding of the reason for his hospital admission. c. Introduce the client to the nursing staff and explain the role of the case manager and the staff members. d. Take away the client's cigarettes and lighter.

d. 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.