final exam

A patient reports, "I am overwhelmed by stress." Which question by the nurse would be most important to use in the initial assessment of the patient?

a. "Tell me about your family history. Do you have any relatives who have problems with stress?"

b. "Tell me about your exercise. How much activity do you typically get in a day?"

c. "Tell me about the kinds of things you do to reduce or cope with your stress."

d. "Stress can interfere with sleep. How much did you sleep last night?"

c. "Tell me about the kinds of things you do to reduce or cope with your stress."

To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms:

d. provide relief from health anxiety.

 Lithium therapeutic range

0.6 -1.2

Lithium Toxicity

1.5  (hold medication)

treat lithium over 2.0

IV fluid treatment required

Lithium medical emergency

2.5 can lead to seizures or coma

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care?

a. Insulting, aggressive behavior

b. Pressured speech and grandiosity

c. Hyperactivity; not eating and sleeping

d. Poor concentration and decision making

c. Hyperactivity; not eating and sleeping

Rationale: Safety and physiological needs have the highest priority

A person was online continuously for over 24 hours, posting rhymes on official government web-sites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident?

a. Increased muscle tension and anxiety

b. Vegetative signs and poor grooming

c. Poor judgment and hyperactivity

d. Cognitive deficits and paranoia

c. Poor judgment and hyperactivity

 When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority?

a. Allow the patient to act out his or her feelings.

b. Set limits on the patient's behavior as necessary.

c. Provide verbal instructions to the patient to remain calm.

d. Restrain the patient to reduce hyperactivity and aggression

b. Set limits on the patient's behavior as necessary.

The patient is hearing voices what would be the priority assessment questions

"What do you hear?" 

"Are the voices telling you to do something?" 

"Do you believe what you hear is real?" 

"Are you feeling unsafe or worried?"

Which of the following are positive symptoms of schizophrenia? Choose all that apply.

1. Restricted affect

2. Hallucinations

3. Disorganized speech

4. Avolition

5. Delusions

1. Hallucinations

2. Disorganized speech

   5. Delusions

Which of the following are negative symptoms of schizophrenia? Choose all that apply.

1. Inability to empathize

2. Restricted affect

3. Delusions

4. Avolition (a lack of motivation or an inability to initiate and persist in goal-directed activities)

1. Inability to empathize

2. Restricted affect

   4. Avolition (a lack of motivation or an inability to initiate and persist in goal-directed activities)

If a patient becomes​ violent, your first action should be​ to:

A.

call for additional resources.

B.

restrain the patient.

C.

try to calm the patient.

D.

retreat from the​ scene, if possible.

D.

retreat from the​ scene, if possible.

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will update the plan of care as a client's manifestations of depression change."

Mild Anxiety

• everyday feeling of problem solving

• grasp more info effectively

• symptoms: discomfort, restlessness, irritability

• relieving strategies: nail biting, foot/finger tapping, fidgeting, lip chewing

Moderate anxiety

• concentration difficulties

• tiredness

• pacing

• increase pulse, respiration, perspirations (sweat),

• Mild somatic symptoms: gastric discomfort, headache/ backache, urinary urgency or hesitation, insomnia, voice change in pitch/ voice tremors

Severe Anxiety

• sense of impending doom

• dazed/confused, withdrawal, loud/rapid speech, tachycardia/pounding heart, hyperventilation, difficulty in concentrating

• increased somatic symptoms: headache, dizziness, nausea, insomnia

• learning and problem solving is not possible

panic anxiety

• dysfunction in speech

• extreme fright/horror

• severe hyperactivity/flight (sympathetic system)

• possible immobility

• dilated pupils

• severe shakiness

• severe withdrawal

• difficulty sleeping

• delusion/hallucination (psychosis)

Which statement about dissociative disorders is true?

a. Dissociative symptoms are under the person's conscious control.

b. Dissociative symptoms are not under the person's conscious control.

c. Dissociative symptoms are usually a cry for attention.

d. Dissociative symptoms are always negative.

b. Dissociative symptoms are not under the person's conscious control.

Rationale: Dissociation is involuntary and results in failure of normal control over a person's mental processes and normal integration of conscious awareness. Dissociative symptoms are not a cry for attention and are not always negative.

Which of the following is TRUE of dissociative disorders?

Select one:

a. Dissociative fugue involves an actual loss of information from memory and typically results from a physiological cause.

b. In dissociative amnesia, people have a constant fear of illness and a preoccupation with their health.

c. In dissociative identity disorder, an individual displays characteristics of two or more distinct personalities.

d. In multiple personality disorder, an individual experiences a significant, selective memory loss

c. In dissociative identity disorder, an individual displays characteristics of two or more distinct personalities.

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurses immediate attention?

a. Its good to be home. I missed my family and friends.

b. I saw my best friend get killed by a roadside bomb. It should have been me instead.

c. Sometimes I think I hear bombs exploding, but its just the noise of traffic in my hometown.

d. I want to continue my education but Im not sure how I will fit in with other college students.

b. I saw my best friend get killed by a roadside bomb. It should have been me instead.

Characteristics of OCPD

pervasive pattern of perfectionism, inflexibility and orderliness. They become so preoccupied with unimportant details that they are often unable to complete simple tasks in a timely fashion. They appear stiff, serious, and formal, with constricted affect. They are often successful professionally but have poor interpersonal skills. 

• They find it hard to express their feelings. 

• They have difficulty forming and maintaining close relationships with others.

• They're hardworking, but their obsession with perfection can make them inefficient. 

• They often feel righteous, indignant, and angry.

• They often face social isolation. 

• They can experience anxiety that occurs with depression.

Medications for alcohol maintaining absence from alcohol

Disulfiram: if alcohol is consumed the patient experiences Nausea/Vomiting, flushing, palpitations, headache, blurred vision, weakness, chest pain, thirst, sweating, headache

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority?

A. orient the client frequently to time, place, and person

B. offer fluids and nourishing diet as tolerated 

C. implement seizure precautions

D. encourage participation in group in group therapy sessions

C. implement seizure precautions

A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicate an understanding of the teaching? SELECT ALL THAT APPLY

a. "we need to understand that she is responsible for her disorder."

b. "eliminating any codependent behavior will promote her recovery."

c. "she should participate in an Al-Anon group to help her recover."

d. "the primary goal of her treatment is abstinence from substance use."

e. "she needs to discuss her feelings about substance use to help her recover."

b. "eliminating any codependent behavior will promote her recovery."

d. "the primary goal of her treatment is abstinence from substance use."

e. "she needs to discuss her feelings about substance use to help her recover."

A young adult tells the nurse, "I have a new prescription for medical marijuana. I use it several times a day for my frequent muscle spasms." What information should the nurse provide first to this patient?

a. Guidance that the prescription should not be shared with peers

b. Directions to weigh self once a week and maintain a log of the results

c. Instructions about safety issues associated with driving or operating machinery

d. Information about the potential for amotivational syndrome and memory problems

c. Instructions about safety issues associated with driving or operating machinery

Rationale: All of the options are correct, but safety is the nurse's first concern. Marijuana is a psychoactive substance. Effects include euphoria, sedation, perceptual distortions, and hallucinations; therefore driving or operating machinery may be hazardous.

Adverse effects of alprazolam (xanax)

CNS: Drowsiness, sedation, light-headedness, dizziness, syncope, depression, headache, confusion, insomnia, nervousness, fatigue, clumsiness, unsteadiness, rigidity, tremor, restlessness, paradoxical excitement, hallucinations. CV: Tachycardia, hypotension, ECG changes.

Special Senses: Blurred vision. Respiratory: Dyspnea.

A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make?

A. "Of course people care. Your family comes to visit every day."

B. "Why do you feel that way?"

C. "Tell me who you think doesn't care about you."

D. "I care about you, and I am concerned that you feel so sad."

D. "I care about you, and I am concerned that you feel so sad."

A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively?

d. "Tell me what happened the last time you drank."

Rationale: The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

Which goal for treatment of alcohol use disorder should the nurse address first?

a. Learn about addiction and recovery.

b. Develop alternate coping strategies.

c. Develop a peer support system.

d. Achieve physiological stability.

d. Achieve physiological stability.

Rationale:

The individual must have completed withdrawal and achieved physiological stability before he or she is able to address any of the other treatment goals.

Intoxication:

When people are in the process of using a substance to excess

Addiction

unable to consistently abstain from the substance or activity. They are also unwilling or unable to recognize the extent to which the addictions are creating serious problems in functioning, interpersonal relationships, and emotional responses

Tolerance:

a person no longer responds to the drug in the way that the person initially responded. It takes a higher dose of the drug to achieve the same level of response achieved initially

A nurse enters a client's room, and observes that the client is agitated and pacing rapidly. The pt looks at the nurse and says, "back off. Leave me alone" What statement should the nurse make?

a. "I demand that you calm down now. Your behavior is unacceptable."

b. "I will close the door to provide privacy, and you can tell me what is bothering you."

c. "I will give you space if you calm down. Tell me what is causing you to feel so tense."

d. "I will leave you alone for a few minutes while you try to control yourself."

c. "I will give you space if you calm down. Tell me what is causing you to feel so tense."

The nurse should stay at a safe distance and remain calm while stressing the importance of maintaining control. The nurse should use verbal de-escalation techniques while determining the client's needs and respecting the client's personal space.

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the day room. While following the patient into the day room, the nurse should:

make sure there is adequate physical space between the nurse and patient.

Dissociative fugue:

wanders far from home for days at a time may be triggered by physical/psychological trauma and completely forgets identity, pastlike nad association do not recall fugue period and reclusive quiet and not not attract attention

Dissociative amnesia

one or more episodes of memory loss of important personal information

Dissociative Identity Disorder:

presence of 2 or more distinct personalities within one individual

Personalities emerge during stress and takes full control of the person’s behavior

A nurse is caring for a client who screams, "I can read your minds!" The nurse should identify this finding as a manifestation of which of the following personality disorders?

Schizotypal personality disorder

Paranoid personality disorder

Antisocial personality disorder

Avoidant personality disorder

Schizotypal personality disorder

Rationale: The nurse should identify that schizotypal personality disorder is often characterized by a belief that one has magical powers.

A nurse in a mental health unit is caring for a client who has a new diagnosis of borderline personality disorder. The client states "I will just see my regular doctor at my annual checkup after I am discharged." Which of the following responses should the nurse make?

"You have made such great progress here. I can see why you feel so well."

"Since you have such a good relationship with your family practice provider, you do not need to see a mental health provider."

"You should follow up with your regular doctor in the next few months so they can manage your new diagnosis."

"It is recommended that you receive follow-up care from a mental health provider after you are discharged.

"It is recommended that you receive follow-up care from a mental health provider after you are discharged.

Rationale: The nurse should identify that clients who have personality disorders will need to be followed by mental health specialists for a period of time after hospitalization.

Which disorder has self harm behavior as part of the symptoms, because the goal is to become a patient.

Factitious disorder: pretends to be ill to get emotional needs met and attain the status of the ‘’ patient”

Artificially, deliberately and dramatically fabricate symptoms or self- inflected injury with the goal of assuming a sick role

A nurse is talking with the parent of a child who has a history of trauma and was just diagnosed with dissociative identity disorder. The parent states, "I don't think this is right, my daughter is just doing this for attention." Which of the following responses is the most therapeutic response?

-"Why would your daughter do something like this for attention?" 

- "Our physician is very capable of making an accurate diagnosis. I would trust their judgment." 

- "Dissociation is a symptom that can be overlooked in children. Trauma can increase dissociation." 

- "You're right; dissociative identity disorder is commonly overdiagnosed in children."

- "Dissociation is a symptom that can be overlooked in children. Trauma can increase dissociation."

Rationale: Dissociative identity disorder is characterized by the development of alternate personalities (alters) that have distinct personalities and behaviors. Childhood trauma is a significant risk factor for the development of this disorder

For dissociative disorder, What is the first action of the nurse towards the patient 

• Provide undemanding, simple routine 

• Ensure patient safety by providing safe protected environment and frequent observation 

  • Confirm identity  of patient and orientation to time and place

A nurse is caring for a client who has somatic symptom disorder. The client says to the nurse, "If I can't get the medical help I need, I might as well just end it all. "Which of the following actions should the nurse take?

Determine if the client has a suicide plan

A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely?

a. PCP

b. Heroin

c. Barbiturates

d. Amphetamines

d. Amphetamines

The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.

A patient has blindness related to conversion (functional neurological) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient?

a.suppressing accurate feelings regarding the problem.

b.relieving anxiety through the physical symptom.

c.meeting needs through hospitalization.

d.refusing to disclose genuine fears.

b.relieving anxiety through the physical symptom.

Rationale: Psychoanalytic theory suggests conversion reduces anxiety through the production of a physical symptom that is symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously).

Aphasia:

is the loss of language ability. Initially, the person has difficulty finding the correct word, then is reduced to a few words, and finally is reduced to babbling or mutism.

Apraxia

is the loss of purposeful movement in the absence of motor or sensory impairment. This results in the inability to perform familiar and purposeful tasks. For example, in apraxia of dressing, the person is unable to put clothes on properly (e.g., putting arms in trousers).

Anhedonia

means the absence of happiness or the inability to feel pleasure in aspects of life that once made a person happy

Agnoisa

is the loss of sensory ability to recognize objects. For example, a person may lose the ability to recognize familiar sounds (auditory agnosia), such as a ringing telephone. This loss may extend to an inability to recognize a familiar object (visual or tactile agnosia), such as a magazine, pencil, or toothbrush.

Subjective data

refers to all information that you gather from a patient and from people who may accompany the patient.

Objective data

refers to all things that nurses observe or are verified through tests

Historical data

This refers to past information about the patient, including their medical history, previous illnesses, and family history.

Secondary data

This involves information gathered from sources other than the patient directly, such as patient charts, family members, or other healthcare professionals.

Which sign, according to the DSM-5, supports a patient's diagnosis of gambling disorder?

The patient lies to family members about the extent of their gambling behaviors.Lying about gambling behaviors is one of 9 diagnostic criteria from the DSM-5 for gambling disorder

A nurse is assessing a client in an emergency department who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication?

Be direct and honest when speaking with the client.

A nurse is assessing a client who has a history of alcohol use disorder and is experiencing alcohol withdrawal. Which of the following findings should the nurse identify as a manifestation of severe alcohol withdrawal?

a. Decreased appetite

b. Slurred speech

c. Insomnia

d. Hallucinations

d. Hallucinations

Other symptoms 

-fine tremors of both hands 

- vomiting 

- restlessness

Substance abuse is often present in people diagnosed with bipolar disorder. Laura, a 28-year-old with a diagnosis of bipolar disorder, drinks alcohol instead of taking her prescribed medications. The nurse caring for this patient recognizes that:

a. Anxiety may be present.

b. Alcohol ingestion is a form of self-medication.

c. The patient is lacking a sufficient number of neurotransmitters.

d. The patient is using alcohol because she is depressed.

b. Alcohol ingestion is a form of self-medication.

What is the major reason for the hospitalization of a depressed client?

A. Inability to go to work

B. Suicidal ideation

C. Psychomotor agitation

D. Loss of appetite

B. Suicidal ideation

Rationale: Suicidal thoughts are a major reason for hospitalization for clients with major depression. It is imperative to intervene with such clients to keep them safe from self-harm. The other options describe symptoms of major depression but aren't by themselves the major reason for hospitalization.

Characteristic of anorexia

• intense fear of gaining weight or becoming fat

• Generally underweight

• Poor body image

• Amenorrhea (lack of menstrual cycle)

• Due to low body weigh

Characteristics of bullemia

• Eating large amounts of food in a relatively short period of time

• Binging

• Feelings of loss of control

• Followed by inappropriate weight compensatory behavior

  • Purging

  • Laxative use

  • Dieting

  • Excessive exercise

• Distorted image

• Appear to have normal body weight.

Interventions for anorexia nervosa 

• Establish trust

• Encourage patient to identify thoughts/feelings associated w/eating

• Promote healthy coping skills/adequate nutrition

• Monitor for hiding food

• Establish goals w/patient and team for weight gain (Behavior modification goal: gain 2lbs a week)

• Encourage patient to talk about body image/promote realistic image

a nurse is caring for a client who has binge-eating disorder. which of the following client statements should the nurse expect?

• after I binge, I feel so disgusted with myself

• I feel so defeated and want to hide after i have binged

A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to:

• How to recognize hypokalemia

What is pica?

Eating nonfood items well past toddlerhood

Not part of other illness

A nurse is assessing a client diagnosed with anorexia nervosa. Which characteristic is most likely a factor towards the diagnosis? 

rigidity, perfectionism

Gender dysphoria

a feeling of distress that can occur when a person's gender identity (their internal sense of being male, female, or non-binary) differs from their sex assigned at birth.

Which patient statement suggests a concern over one's ability to perform sexually?

a. "My partner and I aren't as close as we once were."

b. "I'm not as desirable as I once was."

c. "My personal life has changed a lot."

d. "I'm not the partner I used to be."

d. "I'm not the partner I used to be."

Which of the following statements about paraphilias is true?

Though they are by definition unusual, paraphilias are not necessarily unhealthy or problematic.

A nurse is assessing a 4 year old child for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess?

A. Impulsive behavior

B. Repetitive counting

C. Destructiveness

D. Somatic problems

B. Repetitive counting

What assessment question should the nurse ask when attempting to determine a teenager's mental health resilience? Select all that apply

A. How did you cope when your father deployed with the Army for a year in Iraq

B. Who did you go to for advice while your father was away for a year in Iraq

C. How do you feel about talking to a mental health counselor

D. Where do you see yourself in 10 years

E. Do you like the school you go to

A. How did you cope when your father deployed with the Army for a year in Iraq

B. Who did you go to for advice while your father was away for a year in Iraq

D. Where do you see yourself in 10 years

When discussing therapy options, the nurse should provide information about interpersonal therapy to which patient? Select all that apply.

a. The teenager who is the focus of bullying at school

b. The older woman who has just lost her life partner to cancer

c. The young adult who has begun demonstrating hoarding tendencies

d. The adolescent demonstrating aggressive verbal and physical tendencies

e. The middle-aged adult who recently discovered her partner has been unfaithful

a. The teenager who is the focus of bullying at school

b. The older woman who has just lost her life partner to cancer

e. The middle-aged adult who recently discovered her partner has been unfaithful

What is the reason we include family when it comes to a patient with schizophrenia

so that they can contribute to that person's recovery and the family's own needs for information, support and treatment can be addressed

Which activity is most appropriate for a child with ADHD?

A. Reading an adventure novel.

B. Playing monopoly

C. Playing tennis.

D. Playing checkers

C. Playing tennis.

The nurse asks an 87-year-old client, "How are you doing?" The client replies, "I have good days and bad days." What is the nurse's most appropriate response?

"Tell me more about that."

Transference:

 refers to unconscious feelings that the patient has toward a healthcare worker that were originally felt in childhood for a significant other

Counter transference

refers to unconscious feelings that the healthcare worker has toward the patient. For instance, if the patient reminds you of someone you do not like, you may unconsciously react as if the patient were that individual.

A patient has a long history of bipolar disorder with frequent episodes of mania secondary to stopping prescribed medications. The patient says, "I will use my whole check next month to buy lottery tickets. Winning will solve my money problems." Select the nurse's best action.

a. Educate the patient about the low odds of winning the lottery.

b. Present reality by saying to the patient, "That is not good use of your money."

c. Confer with the treatment team about appointing a legal guardian for the patient.

d. Tell the patient, "If you buy lottery tickets, your money will run out before the end of the month."

c. Confer with the treatment team about appointing a legal guardian for the patient.

Eating disorder medication

Fluoxetine (Prozac) (SSRI) is FDA-approved – reduces binge-purge behavior 

SSRIs also help with underlying depression and impulse control

which of the following statements indicates a correct understanding of ADHD medication  methylphenidate.

• The medication should be given 4 to 6 hours before bedtime to diminish insomnia.

• Should avoid caffeine 

• Take 45 minutes before meal

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "This patient is like one of my grandparents ... so helpless." Which response is the nurse demonstrating?
a. Transference
b. Countertransference
c. Catastrophic reaction
d. Defensive coping reaction

b. Countertransference

A nurse begins a therapeutic relationship with a client diagnosed with schizophrenia. The client has severe paranoia. Which comment by the nurse is most appropriate?

"Let's begin by talking about the goals you have for yourself."

"I understand that you have problems with fear and suspiciousness of others."

"As you get to know me better, I hope you will feel comfortable talking to me."

"I am part of your treatment team. Our goal is to help stabilize your symptoms."

"As you get to know me better, I hope you will feel comfortable talking to me."

Rationale: The nurse's statement that he or she hopes the client will become comfortable talking with him or her as the client is most appropriate.

A client diagnosed with schizophrenia is laughing and talking while sitting alone. Which is the best response by the nurse?
A. "Can you share your joke with me?"
B. To sit with the client quietly until the client is ready to talk.
C. "Tell me what's happening."
D. "You look lonely here. Let's join the others in the day room."

C. "Tell me what's happening."

The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning their head as if listening to another person. Which statement by the nurse is most appropriate?
A. "Are you hearing something?"
B. "It's a beautiful day, isn't it?"
C. "Would you like to go to your room to talk?"
D. "Would you like to take some of your PRN medication?"

A. "Are you hearing something?"

The nurse enters the room of a client with schizophrenia the day after the client has been admitted to an inpatient setting and says, "I would like to spend some time talking with you." The client stares straight ahead and remains silent. Which would be the best response by the nurse?
A. "I can see you want to be alone. I'll come back another time."
B. "You don't need to talk right now. I'll just sit here for a few minutes."
C. "I've got some other things I can do now. I hope you'll feel like talking later."
D. "You would feel better if you would tell me what you're thinking."

B. "You don't need to talk right now. I'll just sit here for a few minutes."

Which of the following statements describes active listening?

engaging in paraphrasing and questioning while the speaker is speaking

What medication would you give for a patient who is agitated and has hallucinations

First Gen Antipsychotic

chlorpromazine HCl (Thorazine) = 1st gen antipsychotic 

A patient expresses they are agitated but the patient says not having hallucinations.

Fluphenazine (1st gen antipsychotic) + agitation/restless + no hallucinations = add benzo 

Which assessment finding would be likely for a patient experiencing a hallucination? The patient:

a. looks at shadows on a wall and says, I see scary faces.

b. states, I feel bugs crawling on my legs and biting me.

c. reports telepathic messages from the television.

d. speaks in rhymes

b. states, I feel bugs crawling on my legs and biting me.

Rationale: A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination.

Education to a patient newly prescribed with naltrexone

• Treats alcohol use disorder and opioid use disorder 

• It can have withdrawal symptoms if opioids are in the system 

• If they stop naltrexone and then use opioids, they are at high risk of overdose due to reduced tolerance.

• liver function tests (LFTs) may be needed

• Naltrexone reduces cravings, but doesn’t make drinking dangerous or cause a reaction like disulfiram does

Basic concepts of AA

• 12 steps

• step 1: We admitted we were powerless over alcohol that our lives had become unmanageable.

• step 2: Came to believe that a power grater than ourselves could restore us to sanity.

• step 3: made a decision to turn our will and our lives over to the care of God as we understood him.

• step 4: made a searching and fearless moral inventory of ourselves.

• step 5: admitted to god, to ourselves, and to another human being the exact nature of our wrongs.

• step 6: were entirely ready to have god remove all these defects of character.

• step 7: humbly asked him to remove our shortcomings.

• step 8: made a list of all persons we had harmed, and became willing to make amends to them all.

• step 9: made direct amends to such people wherever possible, except when to do so would injure them or others.

• step 10: continued to take personal inventory and when we were wrong promptly admitted it.

• step 11: sought through prayer and meditation to improve our conscious contact with god as we understood him, praying only for knowledge of his will for us and the power to carry that out.

• step 12: having had spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

What is a basic principle of Alcoholics Anonymous (AA) that a nurse should understand when caring for a client who has been hospitalized for alcohol withdrawal?

A. Spouses should attend Al-Anon meetings

B. A commitment to permanent abstinence must be made

C. Amends must be made to each person who has been harmed

D. People have the power to overcome alcoholism if they truly want to stop drinking

B. A commitment to permanent abstinence must be made

Patient education regarding chlordiazepoxide (benzo) (alcohol withdraw)

• helps manage symptoms of alcohol withdrawal such as anxiety, agitation, tremors, and risk of seizures.

•  typically used short-term during detox to keep you safe and more comfortable

• This medication can make you drowsy or dizzy

• not a long-term solution, and stopping suddenly can be dangerous, tapering may be necessary.

Which of the following is true of active listening?

a. It illustrates that people are selective listeners.

b. It is useful when resolving conflict.

c. It doesn't require much emotional or physical effort.

d. It involves listening for pleasure.

b. It is useful when resolving conflict.

Best way to assess patient who just got sexually assaulted

Ensure the patient is safe, examination, assessment

What is a basic principle of Alcoholics Anonymous (AA) that a nurse should understand when caring for a client who has been hospitalized for alcohol withdrawal?

A. Spouses should attend Al-Anon meetings

B. A commitment to permanent abstinence must be made

C. Amends must be made to each person who has been harmed

D. People have the power to overcome alcoholism if they truly want to stop drinking

B. A commitment to permanent abstinence must be made

Which of the following is true of active listening?

a. It illustrates that people are selective listeners.

b. It is useful when resolving conflict.

c. It doesn't require much emotional or physical effort.

d. It involves listening for pleasure.

b. It is useful when resolving conflict.

Lucas is a nurse on a medical floor caring for Kelly, a 48 year old patient with newly diagnosis type 2 diabetes. He realizes that depression is a complicating factor in a patient's adjustment to her new diagnosis. What problem has the most potential to arise?

Treatment nonadherence

Which statement demonstrates an expression of anxiety rather than fear?

1

"I can't stand spiders."

2

"You'd never get me on a roller coaster."

3

"I really dislike knowing that we have a 50-point test tomorrow."

4

"I can't imagine why anyone would want to parachute out of an airplane."

3 (Anxiety is an emotion without a specific object that is provoked by the unknown or by new experiences. Being worried about a test is a common expression of anxiety. An intense dislike for spiders, roller coasters, and parachuting are fears because they are focused.)

Characteristics of anorexia vs bulimia

Bulimia:

• normal weight

• tooth erosion, dental caries

• excessive food intake w/ purging, excessive excessing

• parotid swelling due to increase amylase levels

• electrolyte imbalance

Anorexia:

2 types:

restricting type: not engaging in recurrent episodes of binge-eating purging behavior

binge-eating/purging type: individual has engaged in recurrent episodes of binge-eating or purging behavior

• under weight BMI

• amenorrhea (lack of menstrual cycle)

• yellow skin= hypercarotenemia

• lanugo (baby hair)

• cold extremities

• low thyroxine levels

• hypokalemia

• anemic pancytopenia

• decreased bone density= low calcium intake

exhibitionistic disorder

Disorder in which sexual gratification is attained by exposing the genitals to unsuspecting strangers