Mental Health Nursing Exam 1 - Jersey College Questions and Answer

Mental Health Nursing Exam 1 - Jersey College Questions and Answer at the same time each evening A client's medication sheet contains a prescription for Sertraline (Zoloft). To ensure safe administration of the med, how should the nurse administer the drug? crackers and tossed salad A hospitalized client is started on phenalzine for the tx of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? SATA -figs -yogurt -crackers -aged cheese -tossed salad -oatmeal raisin cookies white blood cell count A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? avoid alcohol while taking this medication A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place the highest priority on teaching the client which point that directly relates to client safety? constipation Side effect of oxazepam: get up slowly when changing positions avoid sunlight 2nd generation/atypical anti-psychotic Discharge instructions for a patient taking risperidone? 2-3 weeks TCA - trycyclic antidepressant The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication? tardive dyskinesia The nurse notes that the client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? GI dysfunction CNS dysfunction Sleeplessness and/or drowsiness during day SSRI The nurse is performing a follow up teaching session with a client discharged one month ago. The client is taking fluoxetine (Prozac). Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of this medication? rapid heartbeat or anxiety A client who has been taking busprione for 1 month returns to the clinic for a follow up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? toxic A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. The nurse plans the care based on which representation of this level? 0.4 to 1 mEq/L Therapeutic level of lithium? frequent hand washing with hot, soapy water. TCA used to treat OCD A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? seizures Excessive amounts of bupropion (Wellbutrin) can cause ________? the death of a loved one Example of a situational crisis? -witnessing a murder -the death of a loved one -a fire that destroyed the client's home -a recent rape episode experienced by the client A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client. The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? overt - obvious and direct statements covert - indirect statements Difference between overt and covert statements? SAD PERSONS Scale 0-5 may be safe to discharge 6-8 probably requires psychiatric consultation 8 probably requires hospital admission, voluntary or involuntary (need 2 psychiatrists) Commonly used in emergency departments and helps staff to quickly evaluate the urgency of referral to mental health sources or protective care? information regarding shelters The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? "Tell me more about the incident that causes you to feel like the rape just occurred." A female victim of sexual assault is being seen in the crisis center. The client states that she feels "as though the rape just happened yesterday", even though it has been a few months since the incident. Which is the most appropriate nursing response? -monitor vital signs -provide a safe environment -address hallucinations therapeutically -provide reality orientation as appropriate Which interventions are most appropriate for caring for a client in alcohol withdrawal? SATA -monitor vital signs -provide a safe environment -address hallucinations therapeutically -provide stimulation in the environment -provide reality orientation as appropriate -maintain NPO status -dental decay -loss of tooth enamel -electrolyte imbalances The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? -dental decay -moist, oily skin -loss of tooth enamel -electrolyte imbalances -body weight well below ideal range -hyeprtension -anxiety -isomnia -anorexia -disorientation, changes in LOC -agitation -fever -delusions Symptoms of alcohol withdrawal delirium (10)? use an indirect light source and turn off the tv A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially. identifying anxiety producing situations Most appropriate maintenance goal for maintaining client safety at home upon discharge for a client with chronic anxiety? Avoidant A client is unwilling to go to his church because his ex gf goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains housebound. The home care nurse develops a plan of care that address which personality disorder? conversion disorder A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult? Heights Acrophobia is a fear of ? Open spaces Agoraphobia is a fear of ? Electrical Storms Astraphobia is a fear of ? Talking Glossophobia is a fear of ? Blood Hematophobia is a fear of ? Water Hydrophobia is a fear of ? Being alone Monophobia is a fear of ? Germs or dirt Mysophobia is a fear of ? Darkness Nyctophobia is a fear of ? Fire Pyrophobia is a fear of ? Strangers Xenophobia is a fear of ? Animals Zoophobia is a fear of ? To return to at least the pre-crisis level of functioning. What is the goal of crisis intervention? 4-6 weeks A crisis is self-limiting and is usually resolved within what time frame? healthy A person in crisis is assumed to be mentally ________________. Introductory phase The purpose and overview of the debriefing process is presented. Confidentiality is assured, team members are identified, and questions are answered. What phase of critical incident stress debriefing is this? Fact phase Participants are assisted in discussing the facts of the incident from their perspectives. What phase of critical incident stress debriefing is this? Thought phase All participants are asked to discuss their initial thoughts about the incident. What phase of critical incident stress debriefing is this? Reaction phase Participants engage in freewheeling discussion about the worst, most painful parts of the incident. What phase of critical incident stress debriefing is this? Symptom phase Participants describe cognitive, physical, emotional, or behavioral experiences at the time of the incident and ongoing. What phase of critical incident stress debriefing is this? Teaching phae The feelings of the participants are affirmed. Guidance is provided regarding future symptoms and stress management techniques. What phase of critical incident stress debriefing is this? Reentry phase The debriefing process thus far is reviewed, and any new topics are discussed. Team members provide encouragement and resources for additional help, and summarize the experience. physical, emotional, sexual, neglect What are the four types of abuse? short term memory loss, decreased motivation Damage to the hippocampus results in ? OCD, decreased ability to experience pleasure Damage to the thalamus results in ? problems with circulation and respirations Damage to the medulla results in ? rage, violence, loss of emotional control Damage to the frontal lobe results in ? hyperreflexia, hyperthermia, diarrhea Symptoms of serotonin syndrome (3)? denial and blame, emotional abuse, control through isolation, control through intimidation, control through economic abuse, control through power Characteristics of violent partner (6)? Tension, batter, honeymoon Three phases of the cycle of violence ? physical, psychological, financial/exploitation, neglect, sexual What are the five kinds of elder abuse? Aaron Beck Who pioneered the type of therapy we now know as Cognitive Behavioral Therapy? narrative is a descriptive statement of patient status written in chronological order throughout a shift. problem-oriented charting - SOAPIE Explain the difference between narrative and problem-oriented charting? used in problem-oriented charting s - subjective data o - objective data a - assessment p - plan i - interventions e - evaluation What is SOAPIE ? relaxation, reframing, sleep, exercise (aerobic), lower/eliminate caffeine intake, What are 5 stress reduction techniques? H - home environment E - education and employment A - activities D - drugs, alcohol, tobacco use S - sexuality S - suicide risk/symptoms of depression S - savagery (acts of violence in environment) HEADSSS - What do the letters stand for? antidepressants What is the most common type of drug prescribed in the US? MAOIs Avoid tryamine with which class of antidepressants? SSRI, SNRI, MAOI Which classes of antidepressants should not be stopped abruptly (3)? SNRI With which class of antidepressants should liver enzymes be checked? cant see, cant pee, cant spit, cant shit Side effects of antidepressants? (fun rhyme) good stress What is eustress? stress that causes emotional and physical problems What is distress? ASD resolves within one month What is the difference between ASD and PTSD? altruism emotional conflicts and stressors are addressed by meeting the needs of others - healthy defense mechanism ? sublimation an unconscious process of substituting constructive and socially acceptable activity for strong impulses that are not acceptable in their original form. i.e., boxing, butcher, etc - healthy defense mechanism ? suppression the denial of a disturbing situation or feeling ("I can't worry about paying my rent because I have a test tomorrow.") - healthy defense mechanism ? repression the exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness - intermediate defense mechanism ? displacement transfer of emotions associated with a particular person, object, or situation to another person, object or situation that is nonthreatening - intermediate defense mechanism ? reaction formation/overcompensation unacceptable feelings or behaviors that are kept out of awareness by developing the opposite behavior or emotion ("I don't like kids so I think I'll go be a boy scout leader.") - intermediate defense mechanism ? somatization occurs when anxiety is repressed to an unconscious level but is revealed on a physical level in the form of physical symptoms that have no organic cause (making excuses) - intermediate defense mechanism ? undoing compensates for an act or communication (gifts after beatings) - intermediate defense mechanism ? rationalization justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener - intermediate defense mechanism ? dissociation a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment (can't remember) - immature defense mechanism devaluation occurs when emotional conflicts or stressors are handled by attributing negative qualities to self or others. the individual appears good by contrast (that award didn't mean anything anyway) - immature defense mechanism anosignosia The inability to recognize you are mentally ill because you are mentally ill is called ? bipolar disorder and depression Name the two affective disorders ? thorazine First psychotropic drug was called ? -putting the client down -calling the client names -making the client feel guilty The nurse is concerned that a client may be experiencing emotional abuse. The nurse observes an interaction between the client and a family member. Which assessment findings related to the actions of the family member toward the client led the nurse to make this clinical determination? Select all that apply. -making all the decisions -calling the client names -limiting contact with others -putting the client down -making the client feel guilty use of alcohol and other drugs and experiencing role reversal in childhood Factors that are related to revictimization include? (1) bruises involving no breaks in skin integrity, (2) burns, usually due to immersion in hot water, contact with cigarettes, tying with a rope, or the application of a hot iron, (3) lacerations, abrasions, welts, and scars noted on the lips, eyes, face, and external genitalia, (4) missing or loosened teeth, and (5) skeletal injuries such as fractured bones, epiphyseal separation, or stiff, swollen, enlarged joints. What are the 5 most common indicators of physical abuse of a child? ideas of reference beliefs that external events have personal significance? magical thinking the belief that thinking about something will make it happen? thought broadcasting the belief that others can hear or know what the client is thinking? obsession unwanted repetitive thoughts? ideas of reference A psychiatric-mental health client informs the nurse that a tornado that hit a neighboring town was the client's fault because the client dislikes a neighbor. This disturbance of thought content is known as what?