Assess
A patient signs in as a voluntary commitment for treatment. He maintains he does not have a problem. “I’m only here because my boss threatened to fire me if I didn’t come in.” Best Response?
"What happened that your boss threatened to fire you?” (TELL ME MORE)
Difficulty sleeping
Insomnia; disturbed sleep pattern
The client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention?
Assigning the client to a room at the end of the hall to prevent disturbing other clients
Lithium Toxicity Symptoms
MOST Common: thirst and dry mouth, nausea and vomiting, abdominal pain, and fatigue.
LATE Signs of toxicity include severe diarrhea, persistent nausea and vomiting, muscle weakness, tremors, blurred vision, slurred speech, and seizures.
Hans Seyle theorized if a person does not adapt to the stress i eventually the person will experience:
Exhaustion
An example of a person who may have a factitious disorder is demonstrated as?
Sally tells her mother she doesn't feel well so her mother will take care of her.
Overeating, compulsive
Risk for imbalanced nutrition: More than body requirements
Drug-induced parkinsonism; Akathisia; Dystonia; Tardive dyskinesia (TD)
Extrapyramidal symptoms (EPS)
Therapeutic Lithium
serum levels between 0.5 and 1.2 mEq/L
(1.0 to 1.5 in acute mania).
Patient with a brain tumor asks the nurse if she should have surgery. Most therapeutic response?
"Tell me what you know about the surgery."
TELL ME MORE.
What major symptoms of PTSD separate it from anxiety disorder?
Vivid flashbacks
Nightmares
Projection of blame, rationalization of failures, denial of personal responsibility
Defensive coping
Bipolar/Depression
Promote honest/therapeutic communication; Provide consistency in care; Encourage healthy nutrition; Encourage appropriate activity; Provide clear, firm limits; Ensure patient safety
Known to cause serious blood dyscrasias and requires regular monitoring of blood counts.
Clozapine (Clozaril)
Neuroleptic malignant syndrome (NMS)
Potentially fatal reaction to treatment with some antipsychotic (sometimes referred to as neuroleptic) medications. Symptoms include muscle rigidity, hyperpyrexia, fluctuations in blood pressure, and altered level of consciousness.
History of alcohol abuse with agitation, tremors, and hallucinations
Alcohol (ETOH) withdrawal
Vomiting, excessive, self-induced
Risk for deficient fluid volume
Patient and client family are educated on side effects
The best approach to promote compliance with mood stabilizers
Anxiety
buspirone, alprazolam, lorazepam
Gorman & Anwar (2018) p. 362
Standards of Nursing Practice for LPNs/LVNs Appendix D
Helpful reference for Scope of Practice Paper!!
Commonly Used SSRI Agents
citalopram (Celexa), fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), escitalopram (Lexapro), and venlafaxine (Effexor)
Detoxification, withdrawal from substances
Risk for injury
Survivors of homicide
Spiritual assessment; Therapeutic communication; Depression screening; Support Groups
Commonly Used SSRI Agents
citalopram (Celexa), fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), escitalopram (Lexapro), and venlafaxine (Effexor)
MCC PN 2021
WHO WILL PASS THE NCLEX?