HESI Case Studies–Psychiatric/Mental Health-Schizophrenia (Bob Tyler) – Flashcards
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1. Based on this assessment. what is the most important nursing intervention?
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Establish rapport and trust
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2. What is the most accurate assessment if the client believes that the healthcare providers are FBI agents and that there are cameras in his apartment to monitor his moves?
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Delusions
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3. Which behavior is characteristic of a thought disorder?
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Disorganized speech
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4. The nurse understands that schizophrenia can be differentiated from psychosis by which assessment?
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Negative symptoms
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5. Which finding depicts negative symptoms of schizophrenia?
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Flat affect and social inattentiveness
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6. Which nursing problem has priority?
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Disturbed thought process
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7. What is the reason that Prolixin is prescribed for this client?
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Disorganized thoughts
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8. The nurse understands that a client with schizophrenia will experience which benefit from fluphenazine (Prolixin) if it is administered intramuscularly?
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Maintain long-term medication compliance
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9. Which client behavior validates the need for involuntary hospitalization?
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Violence towards father
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10. If a client who has voluntarily chosen to be hospitalized should want to leave the hospital, which assessment would be most important in deciding to release the client against medical advice (AMA)?
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Potential danger to self or others
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11. The benztropine (Cogentin) has not been prescribed. Which nursing action is best?
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Obtain a prescritption to begin the Cogentin
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12. Which side effects would the nurse most likely observe with fluphenazine (Prolixin), a traditional antipsychotic?
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High extrapyramidal effects, low anticholinergic effects
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13. "My neck got real stiff, and I couldn't move it." What type of reaction should the nurse suspect?
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Dystonia
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14. How should the nurse respond?
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It sounds like you are anxious to leave here
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15. How should the nurse interpret Bob's belief that he is a famous movie star and that a limousine driver will arrive to get him later in the day?
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Delusional thoughts
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16. In planning this client's care, what is the most important short-term client outcome?
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Interact without expressing delusional thoughts
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17. What is the best response by the nurse?
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Have you been hearing any voices?
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18. Which group will be most therapeutic for Bob?
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Structured medication group
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19. Based on Bob's statement, which nursing problem should the nurse document for the group progress note/
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Risk for adherence
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20. Which understanding is most accurate?
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This brain disorder has many predisposing factors and a biological basis
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21. How should the nurse explain symptom triggers to the clients?
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Symptom triggers can be related to health, the environment, or attitudes
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22. Which explanation is best?
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Knowing symptom triggers and how to manage them can prevent relapse
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23. Which nursing assessment accurately describes Bob's lack of energy?
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Avolition
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24. Which nursing problem should be included on the treatment plan?
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Social isolation
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25. Which data is most important to obtain before Bob begins the Zypreza, which is an atypical antipyshotic?
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Baseline weight
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26. Which side effect(s) are characteristics of atypical antipsychotics? (Select all)
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-Fewer extrapyramidal effects -Dry mouth
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27. The nurse understands that an atypical antipsychotic like olanzapine (Zyprexa) requires what period of time to reach a steady state?
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1 week
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28. Which medication with potentially life-threatening side effects should the nurse expect the healthcare provider to prescribe for clients who do not respond to the use of other antipyschotics?
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Clozapine (Clozaril)
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29. Which speech process should the nurse document on the daily mental status exam record?
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Poverty of speech
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30. Which thought process does this exemplify?
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Thought blocking
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31. Which intervention by the nurse will best assess if this goal has been met?
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Talk to Bob for at least 20 minutes
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32. Which statement will assist the nurse to assess if this goal has been met?
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Do you think about hurting anyone now?
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33. What will be the most important group activity to promote wellness in the community?
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Explore symptom management
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34. What is the first step the nurse should use to teach about effective symptom management?
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Identify problem symptoms
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35. After implementing the first step, what step is taken next?
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Identify current ways to manage symptoms
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36. Which strategy is best for clients who hear voices?
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Avoid certain situations
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37. What is the most common cause of relapse in the client with schizophrenia?
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Medications
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38. What is the nurse's best response?
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This can happen even if you are taking medications every day
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39. What is the greatest benefit of a case worker for this client?
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Coordinate services for Bob
