Midterm - Jersey College

"Tell me more about the incident that causes you to feel like the rape just occurred."

A female victim of sexual assault is being seen in the crisis center. The client states that she feels "as though the rape just happened yesterday", even though it has been a few months since the incident. Which is the most appropriate nursing response?

crackers and tossed salad

A hospitalized client is started on phenalzine for the tx of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? SATA -figs -yogurt -crackers -aged cheese -tossed salad -oatmeal raisin cookies

healthy

A person in crisis is assumed to be mentally ________________.

ideas of reference

A psychiatric-mental health client informs the nurse that a tornado that hit a neighboring town was the client's fault because the client dislikes a neighbor. This disturbance of thought content is known as what?

impassive

A(n) _________ face is frozen into an emotionless deadpan expression similar to a mask.

Heights

Acrophobia is a fear of ?

Open spaces

Agoraphobia is a fear of ?

Thought phase

All participants are asked to discuss their initial thoughts about the incident. What phase of critical incident stress debriefing is this?

Electrical Storms

Astraphobia is a fear of ?

MAOIs

Avoid tryamine with which class of antidepressants?

denial and blame, emotional abuse, control through isolation, control through intimidation, control through economic abuse, control through power

Characteristics of violent partner (6)?

SAD PERSONS Scale 0-5 may be safe to discharge 6-8 probably requires psychiatric consultation >8 probably requires hospital admission, voluntary or involuntary (need 2 psychiatrists)

Commonly used in emergency departments and helps staff to quickly evaluate the urgency of referral to mental health sources or protective care?

rage, violence, loss of emotional control

Damage to the frontal lobe results in ?

short term memory loss, decreased motivation

Damage to the hippocampus results in ?

problems with circulation and respirations

Damage to the medulla results in ?

OCD, decreased ability to experience pleasure

Damage to the thalamus results in ?

overt - obvious and direct statements covert - indirect statements

Difference between overt and covert statements?

get up slowly when changing positions avoid sunlight 2nd generation/atypical anti-psychotic

Discharge instructions for a patient taking risperidone?

benzodiazipines

Discontinuation of this class of drug, such as lorazepam, places the client at risk for withdrawal symptoms?

the death of a loved one

Example of a situational crisis? -witnessing a murder -the death of a loved one -a fire that destroyed the client's home -a recent rape episode experienced by the client

seizures

Excessive amounts of bupropion (Wellbutrin) can cause ________?

narrative is a descriptive statement of patient status written in chronological order throughout a shift. problem-oriented charting - SOAPIE

Explain the difference between narrative and problem-oriented charting?

use of alcohol and other drugs and experiencing role reversal in childhood

Factors that are related to revictimization include?

thorazine

First psychotropic drug was called ?

Talking

Glossophobia is a fear of ?

H - home environment E - education and employment A - activities D - drugs, alcohol, tobacco use S - sexuality S - suicide risk/symptoms of depression S - savagery (acts of violence in environment)

HEADSSS - What do the letters stand for?

Blood

Hematophobia is a fear of ?

incongruent

How should the nurse describe the mood and affect of a client who has a mask-like facial expression but states, "I'm really happy"?

Water

Hydrophobia is a fear of ?

Being alone

Monophobia is a fear of ?

identifying anxiety producing situations

Most appropriate maintenance goal for maintaining client safety at home upon discharge for a client with chronic anxiety?

Germs or dirt

Mysophobia is a fear of ?

bipolar disorder and depression

Name the two affective disorders ?

Darkness

Nyctophobia is a fear of ?

Fact phase

Participants are assisted in discussing the facts of the incident from their perspectives. What phase of critical incident stress debriefing is this?

Symptom phase

Participants describe cognitive, physical, emotional, or behavioral experiences at the time of the incident and ongoing. What phase of critical incident stress debriefing is this?

Reaction phase

Participants engage in freewheeling discussion about the worst, most painful parts of the incident. What phase of critical incident stress debriefing is this?

Fire

Pyrophobia is a fear of ?

constipation

Side effect of oxazepam:

cant see, cant pee, cant spit, cant shit

Side effects of antidepressants? (fun rhyme)

-hyeprtension -anxiety -isomnia -anorexia -disorientation, changes in LOC -agitation -fever -delusions

Symptoms of alcohol withdrawal delirium (10)?

hyperreflexia, hyperthermia, diarrhea

Symptoms of serotonin syndrome (3)?

Reentry phase

The debriefing process thus far is reviewed, and any new topics are discussed. Team members provide encouragement and resources for additional help, and summarize the experience.

information regarding shelters

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions?

Teaching phae

The feelings of the participants are affirmed. Guidance is provided regarding future symptoms and stress management techniques. What phase of critical incident stress debriefing is this?

anosignosia

The inability to recognize you are mentally ill because you are mentally ill is called ?

-putting the client down -calling the client names -making the client feel guilty

The nurse is concerned that a client may be experiencing emotional abuse. The nurse observes an interaction between the client and a family member. Which assessment findings related to the actions of the family member toward the client led the nurse to make this clinical determination? Select all that apply. -making all the decisions -calling the client names -limiting contact with others -putting the client down -making the client feel guilty

A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?

GI dysfunction CNS dysfunction Sleeplessness and/or drowsiness during day SSRI

The nurse is performing a follow up teaching session with a client discharged one month ago. The client is taking fluoxetine (Prozac). Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of this medication?

-dental decay -loss of tooth enamel -electrolyte imbalances

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? -dental decay -moist, oily skin -loss of tooth enamel -electrolyte imbalances -body weight well below ideal range

2-3 weeks TCA - trycyclic antidepressant

The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication?

tardive dyskinesia

The nurse notes that the client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication?

Introductory phase

The purpose and overview of the debriefing process is presented. Confidentiality is assured, team members are identified, and questions are answered. What phase of critical incident stress debriefing is this?

< 0.4 to 1 mEq/L

Therapeutic level of lithium?

Flight of ideas

This type of speech is characterized by an excessive amount and rate of speech composed of fragmented or unrelated ideas?

Loose association

This type of speech is characterized by jumping from one idea to another with little or no evident relation between the thoughts?

Tension, batter, honeymoon

Three phases of the cycle of violence ?

relaxation, reframing, sleep, exercise (aerobic), lower/eliminate caffeine intake,

What are 5 stress reduction techniques?

(1) bruises involving no breaks in skin integrity, (2) burns, usually due to immersion in hot water, contact with cigarettes, tying with a rope, or the application of a hot iron, (3) lacerations, abrasions, welts, and scars noted on the lips, eyes, face, and external genitalia, (4) missing or loosened teeth, and (5) skeletal injuries such as fractured bones, epiphyseal separation, or stiff, swollen, enlarged joints.

What are the 5 most common indicators of physical abuse of a child?

physical, psychological, financial/exploitation, neglect, sexual

What are the five kinds of elder abuse?

physical, emotional, sexual, neglect

What are the four types of abuse?

used in problem-oriented charting s - subjective data o - objective data a - assessment p - plan i - interventions e - evaluation

What is SOAPIE ?

stress that causes emotional and physical problems

What is distress?

good stress

What is eustress?

ASD resolves within one month

What is the difference between ASD and PTSD?

To return to at least the pre-crisis level of functioning.

What is the goal of crisis intervention?

antidepressants

What is the most common type of drug prescribed in the US?

It is a standardized, reliable depression tool.

What is the most significant benefit of using Beck's Depression Inventory to the practice of evidence-based nursing practice?

circumstantial thinking

When a client gives excessive and unnecessary details and then gives the answer it is known as?

SSRI, SNRI, MAOI

Which classes of antidepressants should not be stopped abruptly (3)?

-monitor vital signs -provide a safe environment -address hallucinations therapeutically -provide reality orientation as appropriate

Which interventions are most appropriate for caring for a client in alcohol withdrawal? SATA -monitor vital signs -provide a safe environment -address hallucinations therapeutically -provide stimulation in the environment -provide reality orientation as appropriate -maintain NPO status

Aaron Beck

Who pioneered the type of therapy we now know as Cognitive Behavioral Therapy?

SNRI

With which class of antidepressants should liver enzymes be checked?

Strangers

Xenophobia is a fear of ?

Animals

Zoophobia is a fear of ?

Conversion

__________ disorder is part of a group of illnesses called Somatoform disorders, in which there is no physical or laboratory evidence to support the physical manifestations that the client presents.

Data collection

_______________ refers to the objective data that nurses observe and the subjective data that clients report

dissociation

a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment (can't remember) - immature defense mechanism

sublimation

an unconscious process of substituting constructive and socially acceptable activity for strong impulses that are not acceptable in their original form. i.e., boxing, butcher, etc - healthy defense mechanism ?

ideas of reference

beliefs that external events have personal significance?

undoing

compensates for an act or communication (gifts after beatings) - intermediate defense mechanism ?

altruism

emotional conflicts and stressors are addressed by meeting the needs of others - healthy defense mechanism ?

rationalization

justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener - intermediate defense mechanism ?

somatization

occurs when anxiety is repressed to an unconscious level but is revealed on a physical level in the form of physical symptoms that have no organic cause (making excuses) - intermediate defense mechanism ?

devaluation

occurs when emotional conflicts or stressors are handled by attributing negative qualities to self or others. the individual appears good by contrast (that award didn't mean anything anyway) - immature defense mechanism

thought broadcasting

the belief that others can hear or know what the client is thinking?

magical thinking

the belief that thinking about something will make it happen?

suppression

the denial of a disturbing situation or feeling ("I can't worry about paying my rent because I have a test tomorrow.") - healthy defense mechanism ?

repression

the exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness - intermediate defense mechanism ?

displacement

transfer of emotions associated with a particular person, object, or situation to another person, object or situation that is nonthreatening - intermediate defense mechanism ?

reaction formation/overcompensation

unacceptable feelings or behaviors that are kept out of awareness by developing the opposite behavior or emotion ("I don't like kids so I think I'll go be a boy scout leader.") - intermediate defense mechanism ?

obsession

unwanted repetitive thoughts?

use an indirect light source and turn off the tv

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially.

frequent hand washing with hot, soapy water. TCA used to treat OCD

A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?

conversion disorder

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult?

avoid alcohol while taking this medication

A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place the highest priority on teaching the client which point that directly relates to client safety?

Avoidant

A client is unwilling to go to his church because his ex gf goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains housebound. The home care nurse develops a plan of care that address which personality disorder?

toxic

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. The nurse plans the care based on which representation of this level?

Body identity integrity disorder

A client who feels alienated from a part of the body and is desiring amputation is identified as having _______________________. Clients with this disorder often want to have limbs removed.

rapid heartbeat or anxiety

A client who has been taking busprione for 1 month returns to the clinic for a follow up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred?

white blood cell count

A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication?

at the same time each evening

A client's medication sheet contains a prescription for Sertraline (Zoloft). To ensure safe administration of the med, how should the nurse administer the drug?

4-6 weeks

A crisis is self-limiting and is usually resolved within what time frame?