HESI Case Studies–Psychiatric/Mental Health-Schizophrenia (Bob Tyler) – Flashcards

Unlock all answers in this set

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