Elsevier- Case Study- Psychosis

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The client continues to explain that someone has followed him to the ER and is waiting outside the door to the emergency room?
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Delusion
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When the client explains that someone has been following him and is waiting outside the door of the emergency room, how should the nurse respond?
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you must be concerned, but you are safe here.
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Which definition describes the nurses observation that the client looks to the corner of the room and mumbles to himself?
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Hallucinations nonverbal cues include talking to oneself or moving the lips without making sounds rapid eye movements and grinning or inappropriate laughter.
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When the client looks around the room and mumbles to himself, how should the nurse respond?
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“are you hearing voices?” the client is demonstrating nonverbal cues that he is experiencing auditory hallucinations, so the nurse should ask the client if he is hearing voices.
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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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“what do the voices say?” the nurse should first ask what the voices are saying in order to assess for command hallucinations.
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The client becomes very agitated and angry and he talks loudly to himself as he waits to be seen by the health care provider which medication should the nurse anticiate giving the client after securing a prescription from the health care provider?
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Short acting Anxiolytic (Banzodiazepines) antipsychotic medication antipsychotic medications are effective for psychosis-related symptoms and manifestations or agitation associated with mental illness
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Which assessment data provides evidence that brian can be involuntarily committed to the hospital if he insists on leaving
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Losing 10 pounds in 2 weeks the criteria for commitment includes danger to self and or others unable to provide for own basic needs, and or mentally ill and in need of treatment.
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What is the most important part of this admission process
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take away Brian’s cigarettes and lighter safety for the client and milieu is the highest priority so the staff should keep any potentially dangerous objects away from the client.
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Which assessment data are the best indicators of the potential for violence
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Past suicide attempts history of violence Medication non compliance
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The nurse understands that hte purpose of the urine drug screen is to assess brian for what important information?
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Detection of substances that may have caused brian’s delusions and or hallucinations. a urine drug screen is routinely ordered to determine the presence of any substances that may have altered the clients mental status.
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Which lab values from the urinalysis can the nurse expect to be related to brians 10 lb weight loss in the past 2 weeks
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Positive ketones Increased urine specific gravity ketones in the urine can suggest malnutrition, fasting, or starvation increased urine specific gravity is associated with dehydration which could be contributing to Brian’s weight loss
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What is the purpose of a baseline complete blood count CBC prior to initiation of the antipsychotic medication?
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To monitor for agranulocytosis a baseline CBC is indicated to allow for monitoring of the development of agranulocytosis, a potentially life threatening side effect, as evidenced by fatigue, sore throat, and fever.
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Which nursing diagnosis is best to include in the initial care plan?
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sensory-perceptual alteration related to withdrawal into self the priority nursing diagnosis is related to the clients hallucinations which impact his functioning and social interactions.
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What additional intervention is essential to a successful plan
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Consistency Medications consistency in Brian’s management is essential because it increases the staffs shared time with him and lays a foundation for trust which is essential in the management of delusions and hallucinations
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Which teaching should be included in Brian’s education plan initiated early after admission and reinforced until discharge?
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Client safety The purpose and side effects of psychotropic medications before being discharged brian should understand the purpose and side effects of any psychotropic medications prescribed
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What neurotransmitter is targeted by haloperidol (Haldol)
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Dopamine traditional antipsychotics block excessive dopamine an excitatory neurotransmitter, so that symptoms related to psychosis are reduced.
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What side effect of the medication should the nurse suspect (he was complaining of muscle spasms in his neck and jaw)
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Dystonia dystonia is a neurological movement disorder characterized by involuntary muscle contractions, particularly in the face, tongue, neck and jaw
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Which medication should the nurse give to immediately relieve the muscle spasms in the clients neck and jaw
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Diphenhydramine (Benadryl) IM. the client is experiencing a dystonic reaction, so the nurse should provide relief with Benadryl 50 mg IM or Cogentin 2 mg IM
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Diphenhydramine (Benadryl) is available 100 mg/ml the presciribed dose is 75 mg IM how many ml sholud the nurse administer
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0.75
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After his Benadryl he receives a new prescription for benztropine (Cogentin) 2 mg PO daily why is Brian starting this medication
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reduces severity of extrapyramidal effects the addition of Cogentin will reduce th likelihood of severe extrapyramidal symptoms that occur more often with prototype antipsychotic medications such as Haldol.
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Which response from the client indicates the Haldol has been effective
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experiences fewer hallucinations Brian should experience fewer hallucinations if the medication has been effective
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Which anticholinergic side effect is related to the use of haloperidol (Haldol)?
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Urinary retention Tachycardia urinary retention, blurred vision, dry mouth, constipation, and tachy
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On the 5th hospital day, brian reports feeling dizzy as he stands to leave the morning group activity which action should the nurse take
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Take Brian’s blood pressure sitting and standing since he is feeling dizzy, a blood pressure reading should be taken both sitting and standing to determine is a positional change is associated with a change in the blood pressure reading
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What are the advantages for prescribing the atypical antipsychotic olanzapine (Zyprexa)? SATA
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Calming but not sedating Rapid onset Acute and maintenance therapy
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What action mechanism of Haldol causes this side effect
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Alpha adrenergic blockade blockade of alpha-adrenergic receptors in the heart can cause orthostatic hypotension and dizziness.
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What is the most important benefit brian can receive from his attendance at the community meeting
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Provide Reality orientation meetings that are designed to introduce clients to one another, plan activities for the day, and address client concerns and questions help ground the psychotic client in the present and reality
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What is a goal of being in this activity group?
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Gain self-acceptance and express feelings an activity group promotes self acceptance, expression of feeling, and a focus on group goals, rather than individual issues.
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What is the difference between group content and group process
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Content includes the clients words, and group process is how clients communicate group content includes what the group members say, and group processes refers to how they communicate their thoughts and feelings
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What is the most important reason for this teaching?
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To encourage Brian to continue compliance with medications Monitor for early tardive dyskinesia which can be reversible To reinforce education done through out hospitalization To tell Brian to discuss symptoms with his nurse it is very important to teach the client to report uncontrollable movements of the the face and extremities so the nurse can asses for tardive dyskinesia an suggest medication modification. it can be reversed if assessed in a timely manner
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What aspent is the most important for the nurse to provide follow up on before discharge
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Thoughts of harm to self or other it is very important to reassess that the client is free of suicidal an or homicidal ideation so that the nurse can document this in the discharge notes.
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Which nursing action is appropriate for retuning medications after hospitalization
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obtain a prescription from the health care provider to return medications the health care provider must write a prescription for the client to receive medications. sometimes the client is not allowed to receive any medications that were brought to the hospital, especially if they are different from the discharge medications.

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