Psychosis Case Study – Flashcards
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Delusion (false belief that is firmly maintained even though it is not shared by others and is contradicted by reality.)
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Client continues to explain that someone has followed him to the ED and is waiting outside. Which thought process describes the client's inability to leave his apartment because he thought someone was wanting to kill him?
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morbid fear associated with extreme anxiety.
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Phobia is:
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perceptual distortion that involves any of the senses
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Hallucinations is:
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involves filling memory gaps with situations or events that cannot be remembered.
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Confabulation is:
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You must be concerned, but you are safe here. (respond to feelings, and not make assumptions about his delusions)
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When the client explains someone is waiting outside the ED, how should the nurse respond?
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Hallucinations
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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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feeling of unreality and alienations from oneself, characterized by difficulty distinguishing self from others.
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Depersonalization is:
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confusion about the correct person, place and/or situation
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disorientation is:
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Are you hearing voices?
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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. (the nurse should first ask what the voices are saying in order to assess for command hallucinations)
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The client admits that the voices are getting louder over the last couple of weeks. Which question should the nurse ask next?
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Short acting anxiolytic (benzo) (pams are most effective for anxiety related symptoms to produce a calming and sedation.) AND a antipsychotic medication (effective for psychosis related symptoms)
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The client becomes very agitated and angry. Which meds should the nurse anticipate from HCP?
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losing 10 pounds in 2 weeks. (danger to self and others as well as unable to provide for own basic needs)
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Patient is admitted to unit and inability to meet basic needs. Which assessment data provides evidence that he can be involuntarily committed to hospital if he insists on leaving?
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Take away cigarettes and lighter. (safety)
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Orientations to program and room. What is the most important part of this process.
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Past suicide attempts; history of violence; and medication noncompliance.
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the nurse completes assessment. What are the best indicators of the potential for violence? SATA
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Detect any other substance and/or drugs that could have caused hallucinations and or delusions.
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The nurse understands that the purpose for the UA is to?
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Positive Ketones and Increased urine specific gravity.
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Which lab value from UA is related to brains 10lbs weight loss in 2 weeks. SATA
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To monitor for agranulocytosis (seen in patients taking clozapine (clozaril); and is potentially life-threatening side effect that manifests as fatigue, sore throat, and fever.
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What is the purpose of a baseline CBC prior to initiation of antipsychotic meds?
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Sensory-perceptual alteration related to withdrawal into self (this diagnosis is r/t hallucinations, which impact his functioning and social interaction)
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Which nursing diagnosis is best to include in the initial care plan?
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consistency and medications
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Which addition interventions are essential to a successful plan?
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Client safety; the purpose and side effects of psychotropic medications
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Which interventions should be started on admission and continued through care:
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Dopamine (traditional antipsychotics block excessive dopamine, and excitatory neurotransmitter)
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What neurotransmitter is targeted by Haldol?
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Dystonia (is neurological movement disorder characterized by involuntary muscle contractions, i.e. face, tongue, neck and jaw)
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Patient c/o of muscle spasms in his neck and jaw several hours after meds. Which side effect of the medication is suspected?
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Benadryl IM OR benztropine (Cogentin) IM NOT PO
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What medication should the nurse give to immediately relieve the muscle spasms?
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To reduce severity of extrapyramidal effects.
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After receiving Benadryl and Cogentin for spams via IM; patient receives a new rx for Cogentin 2mg PO daily. Why is this medication started?
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Experiences fewer hallucinations
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Which response from client indicated that Haldol is working?
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Urinary retention, Tachycardia
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What are anticholinergic side effects r/t Cogentin? SATA
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Take BP while sitting and standing.
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He feels dizzy when he stands to leave. Which action should the nurse implement first?
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Calming but not sedating; rapid onset; acute maintenance therapy
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What are the advantages for rx atypical antipsychotic zyprexa? SATA
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Reality orientation. (Meetings are designed to introduce clients to one another, plan activities, and address concerns.)
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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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He chose arts and crafts as an activity. What is a goal of being in this activity group?
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Contents includes the clients' words, and group process is how clients communicate.
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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; and to tell brian to discuss symptoms with the nurse
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Discharge meds incluued zyprexa 5m PO BID. What are important reasons for theaching regarding side effects that may not go away. SATA
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Thoughts of harm to self or others.
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Which aspect is most important for the nurse to follow up on before discharge?
