HESI Case Studies–Psychiatric/Mental Health-Psychosis (Brian Jones) – Flashcards
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Delusions
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1. Which thought process describes the client's inability to leave his apartment because he thought someone was waiting to kill him?
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"You must be concerned, but you are safe here,"
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2. When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond?
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Hallucinations
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3. Which term fits the nurse's observation that the client looks to the corner of the room and mumbles to himself?
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"Are you hearing voices?"
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4. When the client looks around the room and mumbles to himself, how should the nurse respond?
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"What do the voices say?"
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5. The client admits that the voices he hears have been getting louder over the past couple of weeks. Which question should the nurse ask next?
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-Short-acting anxiolytic (benzodiazepines) -Antipsychotic medication
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6. Which medication(s) should the nurse anticipate giving the client after securing a prescription from the healthcare provider? (Select all)
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Losing 10 pounds in 2 weeks
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7. Which assessment data provides evidence that Brian can be involuntarily committed to the hospital, if he insists on leaving?
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Take away Brian's cigarettes and lighter
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8. What is the most important part of this admission process?
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-Past suicide attempts -History of violence -Medication noncompliance
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9. Which assessment data are the best indicators of the potential for violence? (Select all)
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Detection of substances that may have caused Brian's delusions and/or hallucinations
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10. The nurse understands that the purpose of the urine drug screen is to assess Brian for what important information?
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-Positive ketones -Increased urine specific gravity
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11. Which lab value(s) from the urinalysis can the nurse expect to be related to Brian's 10 pound weight loss in the past 2 weeks? (Select all)
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To monitor for agranulocytosis
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12. What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication?
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Sensory-perceptual alteration related to withdrawal into self
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13. Which nursing diagnosis is best to include in the initial care plan?
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-Consistency -Medications
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14. What additional interventions are essential to a successful plan? (Select all)
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-Client safety -The purpose and side effects of psychotropic medications
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15. What nursing intervention(s) should be included in Brian's care plan initiated early after admission and reinforced until discharge? (Select all)
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Dopamine
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16. What neurotransmitter is targeted by haloperidol (Haldol)?
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Dystonia
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17. Several hours after receiving his medication, Brian complains of muscle spasms in his neck and jaw. What side effect of the medication should the nurse suspect?
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Diphenhydramine (Benadryl) IM
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18. Which medication should the nurse give to immediately relieve the muscle spasms in the client's neck and jaw?
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0.75
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19. Diphenhydramine (Benadryl) is available as 100mg/mL. The prescribed dose is 75mg IM. How many mL should the nurse administer?
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To reduce severity of extrapyramidal effects
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20. Why is Brian started on this medication?
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Experiences fewer hallucinations
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21. Which response from the client indicates that the haloperidal (Haldol) has been effective?
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-Urinary retention -Tachycardia
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22. Which serious, anticholinergic side effects are related to the use of benztrophine (Cogentin)? (Select all)
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Take Brian's blood pressure while he is sitting and standing
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23. Which action should the nurse implement first?
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-Calming but not sedating -Rapid onset -Acute and maintenance therapy
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24. What are the advantages for prescribing the atypical antipsychotic, olanzapine (Zyprexa)? (Select all)
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Reality orientation
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25. What is the most important benefit Brian can receive from his attendance at the community meeting?
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Gain self-acceptance and express feelings
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26. What is a goal of being in this activity group?
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Content includes the clients' word, and group process is how clients communicate
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27. What is the difference between group content and group process?
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-To encourage Brian to continue compliance with medications -To monitor for early tardive dyskinesia, which can be reversible -To reinforce education done throughout the hospitalization -To tell Brian to discuss symptoms withhis nurse
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28. What are important reason(s) for this teaching? (Select all)
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Thoughts of harm to self or others
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29. On what aspect is it most important for the nurse to perform follow-up before discharge?
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Obtain a prescription from the HCP to return medications
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30. Which nursing action is appropriate for this request?
