The patient tells the nurse "I just want to kill myself!" what would be a priority intervention for the nurse
after a patient makes a statement like this? - (correct Answer) - safety should always be at the core of the
nurses intervention process. the first priority for the vare of a suicidal client is "protection" from harm.
suicidal idaeation and suicidal threats.
What type of patient would benefit/respond quicker from benzodiazepine pharmaceutical therapy? -
(correct Answer) - a patient suffering from anxiety
severe anxiety
panic attacks
panic disorder
What is a benzodiazepine? - (correct Answer) - oldest anxilytic, fast acting, main side effects is
drowsiness, potential for dependcy, withdrawal symptoms if stopped abruptly.
acts by increasing GABA activity, which results in decreased anxiety.
what pain medications can be given with MAOIs? - (correct Answer) - acetaminophen
NSAIDS nonsteroidal anti-inflammatory drugs
avoid drugs with epinephrine or stimulants.
What are MAOIs? - (correct Answer) - tricyclic Antidepressant,
used primarily to treat depression
What nursing actions are important when providing care to a patient with a mood disorder? - (correct
Answer) - conducting a risk assessment
assess the patient for thoughts of suicide
Definition of delusion? - (correct Answer) - Fixed false beliefs that are maintained despite overwhelming
evidence to the contrary,
false belief that is resistant to reasoning or change.
Example of a Delusion? - (correct Answer) - Believing church members or class members are a cult,
The belief that one's thoughts, feelings, or actions are being controlled by outside forces.
The false belief that another person, often someone of higher status, is in love with them.
An individual might believe they have special powers, are a famous historical figure, or are destined to
,save the world.
What is flight of ideas? - (correct Answer) - Jump from word to word. (This room is big, I liked the movie
BIG when they were on the piano, Elvis could play the piano). Rapid changes from one thought to
another related thought.
what is disorganized ideas? - (correct Answer) - disordered thining, speech, and behavior. emotions flat
or inappropiate, primitive, uninhibited behaviors.
a pattern of thought that is fragmented, incoherent, and lacks clear structure or logical connections.
what is an example of disorganized ideas? - (correct Answer) - A person might start talking about their
job, then suddenly shift to discussing a completely unrelated topic like the weather, without any logical
connection.
What is an hallucination? - (correct Answer) - a perception of something not present with on of the 5
senses. Hallucinations can occur in various mental health conditions, including schizophrenia, bipolar
disorder, severe depression, and some neurological conditions like Parkinson's disease.
what are some examples of a hallucination? - (correct Answer) - Hearing voices, sounds, or noises that
are not actually present.
Seeing objects, people, lights, or patterns that do not exist in reality.
Feeling sensations on the skin that are not real, such as bugs crawling on or under the skin.
Smelling odors that aren't actually present, such as a burning smell or perfume.
what is the definition of extrapyramidal symptoms? - (correct Answer) - abnormal involuntary movement
disorders that develop because of drug induced imbalance between two major neurotransmitters,
dopamine and acetylcholine.
examples of extrapyramidal symptoms - (correct Answer) - Dystonia: Sustained muscle contractions
causing abnormal postures, such as twisted neck or protruding tongue.
Akathisia: Restlessness and an inability to sit still, often leading to pacing or constant movement.
Parkinsonism: Symptoms similar to Parkinson's disease, including tremors, rigidity, and bradykinesia
(slowness of movement).
Tardive Dyskinesia: Involuntary, repetitive movements, often involving the face and tongue, such as
grimacing or lip-smacking
How can a nurse apply ethical principle of autonomy to patient care? - (correct Answer) - respecting a
patient's right to make their own decisions regarding their health and treatment.
, informed consent
supporting patient decisions regarding their care.
protect the patients privacy
advocate for the patients wishes and needs.
include and encourage patient to be active in their care and decision making process.
what is the definition of false imprisonment? - (correct Answer) - detaining a competent person against
his or her will.
what would constitute a person being involuntarily admitted to a inpatient psych? - (correct Answer) -
Risk of Harm to Self: If the individual is expressing suicidal thoughts or has attempted self-harm, they
may be admitted for their own protection.
Risk of Harm to Others: If the person poses a threat to others, such as making threats or engaging in
violent behavior, they may be admitted to prevent harm to others.
Grave Disability: If the individual is unable to care for themselves due to a mental health condition, such
as severe depression or psychosis, and cannot meet their basic needs (e.g., eating, hygiene, shelter),
they may be admitted for care.
Lack of Insight: In cases where the person lacks awareness of their illness and refuses treatment, they
may be admitted involuntarily to ensure they receive the necessary care
When is it okay to violate confidentiality of a patient? - (correct Answer) - Risk of Harm to Self or Others:
If a patient poses a serious threat to themselves or others, healthcare providers may need to disclose
information to prevent harm.
Child or Elder Abuse: Healthcare providers are mandated reporters and must report any suspicions of
child or elder abuse to the appropriate authorities.
Public Health Concerns: In cases of communicable diseases or public health emergencies, information
may be shared to protect the public.
Legal Requirements: If a court order or legal requirement mandates disclosure, healthcare providers
must comply.
Informed Consent: When obtaining informed consent for treatment, relevant information may need to
be shared with other healthcare providers involved in the patient's care.
Statement - (correct Answer) - when you are a nurse documenting observation, the best way to
document is with specifics and direct quotes from the patient, do not want it to be vague. subjective and
objective data.
what is the most common nursing diagnosis with children who have autism? - (correct Answer) -
Impaired Social Interaction. This diagnosis is related to deficits in communication and social skills, which