HESI RN MENTAL HEALTH

HESI RN MENTAL HEALTH Middle age female with no previous mental illness and the family states that she is having paranoid thoughts, pt states: "I want to find out why people are stalking me". Therapeutic response: "it sounds like this experience is frightening for you" Pt is mad at mom for turning him in and wants mom to bring belongings and does not want to talk to her. What action does the nurse need to take before the visit? Discuss methods of clear communication Duty to warn question: Pt tells the nurse that he wants to kill his boss, nurse tells healthcare provider, healthcare provider tells his boss. What disciplinary action is needed? None. The action was appropriate Defense mechanism question: for projection "I am here because the police said I did something wrong" pt with stress admits to taking care of the ex-husband 's parents. Which defense mechanism is this? Regression therapeutic Milieu: Pt had a recent suicide attempt after his wife offered divorce, lost his job, and his best friend moved away. What is the best nursing intervention to support therapeutic Milieu ? Encourage activities that will allow him to take control over his environment Interview noting taking question arrange the setting and decrease any stimuli Prep from D/C from the psychic unit, what should the nurse include ? Explore that pt's feelings regarding the discharge People in a group home and they are wiping feces on the wall. What is the nurse's highest priority? Infection control Pt refuses to take medications and in defiance sits in the middle of the hallway floor. Best nursing action? To move other clients to another room Nurse and client trade roles: nurse demonstrates bad behavior of the client. Why is this important? Role play assists the client to recognize their own behavior Pt states, "I don't know, I just can't think". What is the best activity by the nurse? Set daily goals Adolescent interrupts group to talk about pets during group therapy. Best nursing action? Redirect him with a handout Crisis intervention: male client feeling stressed, increased anger over the last month. What is an appropriate nursing action? Ask to identify problems that have occurred during the last month Pt discharged after diening suicide thoughts to the healthcare provider. Pt mutters as walking towards the door, " Now I can kill myself". What is the best nursing action? Notify the HCP and stop the patient from leaving Long term care client who is anxious and agitated. What is the best nursing action? decrease stimuli by lowering the TV volume Elderly pt anxious about procedure. What is the best nursing action? Encourage the pt to express their feelings about the procedure Agoraphobia question: Highest priority question: To establish trust by providing a calm, safe environment Agoraphobia question: client afraid to leave house due to fear of open places. What is the nursing diagnosis? Anxiety related to real or perceived fear OCD: a client that continues to wash hands for 2 hours. What is the priority nursing intervention? To set limits OCD: a client that keeps cleaning windows. What should you do? Give a list of activities A pt with PTSD after rape who displays a detached effect. Best action from nurse? To ask if they are thinking about harming themselves PTSD: what should you include in the plan of care? to provide a quiet room away from a recreational area conversion disorder: Pt with new onset of blindness, what would suggest a conversion reaction? No organic correlation to symptoms Borderline personality disorder: Splitting question Client's view people as all good or all bad Bulimia pt who has eroded tooth enamel, complains of severe chest and abdominal pain. Mentions heartburn for two weeks. What should the nurse address first? Chest and abdominal pain Pt with eating disorder. What should be included in the plan of care? To weigh in everyday Teenager with self inducing vomiting. Nursing priority? Assess frequency of binging and purging behaviors Depression: Pt with major depressive disorder is not motivated and has insomnia. Best nursing action? Design a teaching plan with structured activities The male client admitted after attempted suicide due to a recent divorce. What is the source of the current depression? A sense of loss Client with history of major depressive disorder is exhibiting increased energy, to assess for suicide what would you ask? Do you still feel sad? Client very depressed and slow to respond to questions and when asked how to explain how he feels, he looks down at the table. What is the best nursing intervention? Return at a later time to talk A depressed client has only had four hours of sleep. Would you wake the client for vital signs ? NO ! Let them sleep. A depressed client sleeps all day. What would be the best nursing action? Encourage the client to get out of bed Postpartum depression: Parent of a 8 month old states that the child is not growing normally, that something is wrong with him and not right. What is the priority action? To ask if the parent wants to harm the infant A client has just given birth and is now displaying sadness, poor concentration, sleep disturbance, and tiredness. What is the priority nursing action? Suicide assessment Grief/loss/depression: Husband died and the spouse is not sleeping. Best action? Assess for depression related to grief Bipolar: Wife states that patient is spending large sums of money, not sleeping, has weight loss. Pt has a bipolar diagnosis. What would be an appropriate nursing diagnosis? Risk for violence related to impulsivity Bipolar patient tells the nurse that he needs to make some business deals. What should the nurse include in his plan of care? Delay business decisions until the mania subsides Bipolar patient who superficially cuts himself. How should you communicate? Be non-judgmental Client visits clinic and asks nurse for more lithium and Elavil to help sleep. A serum creatinine was obtained. What is the reason for the lab test? Lithium is excreted by the kidneys and creatinine is related to kidney function Schizophrenia- client isolates himself to his room, vaguely answers questions, and peeks down hallway occasionally. Which problem can the nurse anticipate? Delusions of persecution Schizophrenic patient using echolalia and is becoming more annoying. What is the best nursing intervention? Escort them to their room Schizophrenic patient refuses to eat because the food is poisoned. What is the best intrevention? Get food that is in an unopened container Substance abuse- Client with tremors, auditory hallucinations, confused, and dehydrated. What is the priority? To assess vital signs Chronic drinker with alcohol withdrawal risk. What is the best action? Seizure precautions Patient admitted with chronic alcohol abuse. What should be included in the plan of care? IV assess Patient with history of alcohol abuse, admitted for detox, and getting Ativan. What else should be administered? Vitamin B1 (Thiamine) Which statement made by a spouse of an alcoholic indicates codependency? A statement that basically makes excuses for their behavior- couldn't remember exact answer, so general idea (example:wife is making excuses) Client admitted for aspiration of material related to a suicide attempt. Highest priority? Risk for ineffective breathing 18 year old admitted with suspected drug overdose. What is the most important information to obtain from family/friends? What drug was ingested Patient with schizophrenia in a hospital with drug and alcohol abuse, is admitted for hepatitis. The nurse should consult the HCP prior to giving which medication? Acetaminophen (Tylenol) The client falls downstairs with signs and symptoms of early narcotic withdrawal. What other signs and symptoms would the nurse suspect? Agitation, sweating, and abdominal cramps Amphetamines Puts a person at high risk for myocardial infarction Intimate partner violence: which findings of the injury should the nurse include in documentation? Photographs Rape and sexual assault: A client who was raped. What is an appropriate nursing diagnosis? Decreased self-esteem due to blaming themselves for the rape Attention deficit disorder: A child has impulsiveness, hyperactivity, inappropriate attention span. What is the best nursing intervention? Administer the prescribed medications Antidepressant medication side effects (example drug: Cymbalta) Anticholinergic effects: dry mouth, blurred vision, constipation Patient is taking chlorpromazine for schizophrenia, starts to exhibit signs of tardive dyskinesia. What is the best action? Administer Benztropine (Cogentin) A patient is being administered Xanax (Alprazolam) and reports dizziness, lightheadedness, low blood pressure. What is the highest priority? Monitor vital signs Patient is prescribed buspar. Patient is concerned how long it will take for the medication to work? Normally takes 2 to 3 weeks to start working For trazodone or lidisoril: if the patient develops priapism what do you ask them about? Ask about other erectile dysfunction medications Patient is getting Depakote for mania, how do you know if this medication is working? Decrease hyperexcitable behaviors Schizophrenic patient on Haldol times two weeks. What should the nurse obtain during the initial visit? Vital signs Patient on Haldol develops tremors. Best nursing action? Call the HCP to decrease the dose Schizophrenic patient on Risperdal, exhibiting negative symptoms. Best nursing action? Give Benztropine (Cogentin) for dystonia Patient with schizophrenia getting Geodon, spouse concerned as to why this medication would be administered? Will help the patient think more clearly Patient taking Clozaril and Benztropine, and Clozaril is discontinued. What should the next nurse's action be? Call the HCP to get the Benztropine discontinued Teaching for the client about the initial of Antabuse. What info to include Should remain alcohol free 12 hours prior to the first dose Alzheimer's medications: What type of medication is Namenda (Memantine) NMDA Antagonis