Module 9 Exam 4 Foundations Chapter 34 & 35
Withdrawal Problems
A 60-year-old man was admitted for cholecystokinin that resulted in a cholecystectomy. On his third day of hospitalization, he begins to sweat profusely, tremble, and has a blood pressure of 160/100. Based on these findings, what focused assessment should the nurse complete?
Positive Behavior
A patient believes himself to be the president of the United States and that terrorists are trying to kidnap him. The nurse records these observations as which type of behavior?
Somatic Symptom Disorder
A patient complains of a recurrent, multiple physical ailments for which there is no organic cause. How should the nurse assess this?
Obssesive-Compulsive Disorder (OCD)
A patient is frequently late for appointments because he goes back to his room numerous times to assure himself that none of his belongings have been stolen. What does this behavior represent?
"It may take several weeks for this drug to take effect."
A patient who has been prescribed a serotonin norepinephrine reuptake inhibitor (SNRI) one week ago reports that she has not noticed any difference in her depression level since beginning this drug. What is your best response?
"Did you know that St. John's Wort can raise your blood pressure dramatically?"
A patient who is taking a monoamine oxidase inhibitor (MAOI) asks the nurse about the addition of St. John's Wort to help with his depression. What would be the best response of the nurse?
"You need to start psychotherapy to get the effect you need."
A patient who started taking the antidepressant fluoxetine (Prozac) stated he has not felt any relief from his depression and it has been 7 days. What is the best response?
Schizophrenia
A profound, disabling mental illness is characterized by bizarre, non reality thinking. What is this illness?
Suicidal thoughts
A young adult patient taking an SSRI for the past 2 weeks comes in for an evaluation and follow-up appointment. Which potential side effect should you check for in this patient?
Delirium
A young man with malaria spikes a temperature of 105 F (40.5 C) and begins to hallucinate. How should the nurse assess this?
1. To increase self-esteem 2. To promote positive interaction 3. To enhance reality orientation 4. To stimulate communication
Adjunctive therapies are used for which reasons? (Select all that apply)
1. Extremely high blood pressure 2. Dilated pupils 3. Restlessness 4. Confusion
Too much serotonin can lead to the adverse effect known as serotonin syndrome. Which of the following symptoms are associated with serotonin syndrome? (Select all that apply)
Arrange for transportation to and from the appointment
What should the nurse preparing a patient for a scheduled appointment for electroconvulsive therapy (ECT) remind the patient to do?
"I am required to report any intent to hurt yourself or others."
The patient is concerned about confidentiality and asks the nurse not to tell anyone what is said. What is the best response by the nurse?
Hallucination
The patient talks with this dead brother and arranges furnitures so that his brother will have a place to sit. How should the nurse document this behavior?
1. Drug or alcohol abuse 2. Personality changes 3. Talking about suicide 4. Difficulty concentrating at work / school
What are considered warning signs of suicide? (Select all that apply)
Anorexia Nervosa
What disorder is a severe form of self-starvation that can lead to death?
1. General Anxiety Disorder 2. Obsessive-Compulsive Disorder (OCD) 3. Post Traumatic Stress Disorder (PTSD)
What disorders would a selective serotonin uptake inhibitor (SSRI) be prescribed for? (Select all that apply)
Good
What is the prognosis for a schizophrenic patient who is exhibiting positive behaviors?
Prodromal
What is the term used for the beginning stage of schizophrenia, characterized by a lack of energy and complaints of multiple physical problems?
10 treatments over several weeks
What is the typical schedule for electroconvulsive therapy (ECT)?
Receive treatment for substance abuse
What must a patient in the late stages of dependence do in order to recover?
Use night lights and remove extra furniture from the room
What should the nurse do to decrease the patient's disorientation at night during the detoxification period?
Report observations to a supervisor
What should the nurse do when suspecting a coworker of abusing drugs while at work?
Panic Attack
When a patient demonstrates accelerated heart rate, trembling, choking and chest pain along with acute, intense and overwhelming anxiety. The nurse should recognized that the patient is most likely experiencing what condition?
"Can you think of any time your behavior created an unpleasant situation in your life?"
When a patient denies any problems related to addiction, what is the nurse's most therapeutic response?
Narcan (naloxone)
When a patient is admitted with an overdose of an opioid narcotic, the nurse should anticipate an order for which drug to reverse the effects of the narcotic?
Coach in deep breathing
When a patient is experiencing a panic attack, how should the nurse best assist the patient?
Probating
When the a patient with psychosis is thought to be in danger to self or others, by what method should the patient be admitted to the hospital?
Flumazenil (Romazicon)
Which drug would you anticipate will be given to a patient who experienced an overdose of a benzodiazepine?
The nurse will be allowed to work as a nurse under supervision
Which statement describes the impaired nurse who is in a peer assistance program?
1. Increased energy 2. Catatonia 3. Poor judgement
Which symptoms would you expect a patient who is experiencing mania? (Select all that apply)
1. Muscle Rigidity 2. Elevated temperature 3. Increased WBC
You are caring for a patient with schizophrenia who is taking antipsychotic drugs for the control of hallucinations and delusions. Which symptoms experienced by the patient would alert you to that the development of neuroleptic malignant syndrome? (Select all that apply)
Increased drowsiness, weakness and nausea
You are taking the history of a patient who is suspected of having lithium toxicity. What symptoms would you expect the patient to report?
Posttraumatic Stress Disorder (PTSD)
A 14-year-old survivor of a school shooting screams and dives under a table when firecrackers go off. What does this behavior represents?
Have her drug blood level checked every month
A home health nurse has a patient taking lithium. What should be included in the teaching plan?
1. Patient reports they did not receive their medication 2. Rapid changes in mood and performance 3. Frequently absent from the unit
A nurse suspects a coworker is abusing drugs. Which of the following symptoms, noticed in the coworker, would contribute to the suspicions? (Select all that apply)
Sundowning Syndrome
A patient admitted for delirium demonstrates increased disorientation and agitation only during the evening and night time. What is the term applied to this type of delirium?
Suicidal ideation
A patient admitted to the hospital after a motorcycle crash that has left him paralyzed from the waist down tells the nurse he has feelings of helplessness and hopelessness. What other feelings may the patient have that should be recognized?
Cerebral Disease
Dementia is an organic mental disease secondary to what problem?
Keep the patient safe from aspiration and seizure
During the detoxification period, what does the nurse aim to achieve when designing interventions?
1. Amount of drug uses 2. Time of last use 3. Usual pattern of use 4. Specific drug
During the initial intake assessment of a drug user, the nurse should attempt to obtain which subjective data? (Select all that apply)
Bipolar Disorder
For the past 3 weeks, the nurse has observed a patient interacting with staff and other patients, helping decorate the dining room for a party, and leading the singing in the activity room. Today, the nurse recognizes these behaviors as evidence of which psychiatric disorder?
Thorazine is used for chronic mental illness
The family members of a patient admitted for hallucinations and delusions tells you that the patient is currently taking chlorpromazine (Thorazine) for the treatment of schizophrenia. Which statement about this drug is true?
Call the healthcare provider to report these symptoms
The family of a patient who has been taking the antipsychotic fluphenazine (Prolixin) for the last 2 years. The patient's family reports the patient has suddenly begun smacking her lips, and involuntarily sticking out her tongue. What would be the best first action?
Agoraphobia
The home health nurse assesses a patient who creates elaborate excuses for not leaving home. Further questioning reveals the patient had not left home for 6 months. How should this be documented?
Domino game with 3 other patients
The nurse alters the care plan for a patient with depression to include what type of activity?
"We visited Yellowstone Park last summer."
The nurse asks a patient with schizophrenia if he had any visitors on Sunday. Which response indicates loose association?
6 hours
The nurse assesses an alcoholic patient carefully for signs of withdrawal. How soon after cessation of alcohol intake do withdrawal symptoms usually appear?
The patient fixedly begins to watch his feet
The nurse cautions a patient to watch his step. What response indicates concrete thinking?
"All my difficulties are related to my drinking."
The nurse concludes that a significant goal of the care plan for an alcoholic patient has been met when the patient makes which statement?
Anxiety traits
The nurse is assessing a female patient who has become rapidly and exceedingly anxious because her fingernail polish is chipped. What type of anxiety should the nurse conclude that the patient is exhibiting?
Talks excitedly about going home
The nurse is caring for a patient with a diagnosis of Catatonic Schizophrenia. What behavior is consistent with this diagnosis?
The patient has insight that there is an emotional problem
The nurse is discussing the difference between a patient with a neurosis and one with a psychosis. What is true of the patient experiencing a neurosis?
Having a nonjudgemental attitude
The nurse is performing an initial assessment on an alcoholic patient. Which of the following actions by the nurse would best ensure honest answers?
Transsexualism
The nurse is told that a patient believes he was born into the wrong body. What is the correct terminology for the desire to have the body of the opposite sex?
1. Excessive use of the substance 2. Uncontrollable consumption 3. Psychological disturbances
The nurse should assess a patient for which criteria of addiction? (Select all that apply)
