A nurse is caring for a client admitted to the acute mental health unit with phencyclidine (PCP)
intoxication. What should be the nurse's primary focus during the acute intoxication period?
Suggested Mental Health Learning Activity: Substance & Non-Substance Abuse: General Review
and Stimulant Abuse
Maintain a safe environment to prevent falls; implement seizure precautions as needed
Provide close observation for withdrawal manifestations, possibly one-on-one supervision
physical restraint should be last resort
Orient the client to time, place and person
Maintain adequate nutrition and fluid balance
Create low stimulation environment
Administer medications as prescribed to treat the effects of intoxication or to prevent or
manage withdrawal. This can include substitution therapy.
Monitor for covert substance use during the detoxification period
A nurse is caring for a client experiencing opioid withdrawal. What manifestations should the nurse
anticipate?
Suggested Mental Health Learning Activity: Substance and Abuse and Addictive Disorders
Abstinence syndrome begins with sweating and rhinorrhea progressing to
piloerection(gooseflesh), tremors, and irritability, followed by severe weakness, diarrhea,
fever, insomnia, pupil dilation, nausea and vomiting, pain and in the muscles and bones and
muscle spasms
Withdrawal is very unpleasant but not life threatening
What is nursing care for the client with acute mania related to bipolar disorder?
Suggested Mental Health Learning Activity: Personality Disorders
Focus on safety and maintaining physical health
Provide a safe environment during the acute phase
Assess the client regularly for suicidal thoughts, intentions, and escalating behavior
Decrease stimulation without isolating the client if possible. In certain cases seclusion may
be the only way to safely decrease stimulation for the client.
Implement frequent rest periods
Provide outlets for physical activities. Do not involve client in activities that last a long
time or involve a high level of concentration and/or detailed instructions.
Protect client from poor judgement and impulsive behavior
Provide portable high calorie foods
Avoid power struggles
What is electroconvulsive therapy (ECT) used to treat? How does a nurse prepare a client for ECT
and what are some common side effects of ECT?
Suggested Mental Health Learning Activity: Brain Stimulation
This study source was downloaded by 100000881663784 from CourseHero.com on 09-10-2024 18:14:37 GMT -05:00
https://www.coursehero.com/file/27285277/capstonerem13docx/
intoxication. What should be the nurse's primary focus during the acute intoxication period?
Suggested Mental Health Learning Activity: Substance & Non-Substance Abuse: General Review
and Stimulant Abuse
Maintain a safe environment to prevent falls; implement seizure precautions as needed
Provide close observation for withdrawal manifestations, possibly one-on-one supervision
physical restraint should be last resort
Orient the client to time, place and person
Maintain adequate nutrition and fluid balance
Create low stimulation environment
Administer medications as prescribed to treat the effects of intoxication or to prevent or
manage withdrawal. This can include substitution therapy.
Monitor for covert substance use during the detoxification period
A nurse is caring for a client experiencing opioid withdrawal. What manifestations should the nurse
anticipate?
Suggested Mental Health Learning Activity: Substance and Abuse and Addictive Disorders
Abstinence syndrome begins with sweating and rhinorrhea progressing to
piloerection(gooseflesh), tremors, and irritability, followed by severe weakness, diarrhea,
fever, insomnia, pupil dilation, nausea and vomiting, pain and in the muscles and bones and
muscle spasms
Withdrawal is very unpleasant but not life threatening
What is nursing care for the client with acute mania related to bipolar disorder?
Suggested Mental Health Learning Activity: Personality Disorders
Focus on safety and maintaining physical health
Provide a safe environment during the acute phase
Assess the client regularly for suicidal thoughts, intentions, and escalating behavior
Decrease stimulation without isolating the client if possible. In certain cases seclusion may
be the only way to safely decrease stimulation for the client.
Implement frequent rest periods
Provide outlets for physical activities. Do not involve client in activities that last a long
time or involve a high level of concentration and/or detailed instructions.
Protect client from poor judgement and impulsive behavior
Provide portable high calorie foods
Avoid power struggles
What is electroconvulsive therapy (ECT) used to treat? How does a nurse prepare a client for ECT
and what are some common side effects of ECT?
Suggested Mental Health Learning Activity: Brain Stimulation
This study source was downloaded by 100000881663784 from CourseHero.com on 09-10-2024 18:14:37 GMT -05:00
https://www.coursehero.com/file/27285277/capstonerem13docx/
