Severe Mental Illness
Risk for self harm or harm to others
An expected finding with cocaine use
Dilated pupils and increased BP
A key nursing approach when caring for a client with antisocial personality disorder
Set firm, consistent limits
A crisis finding that must be reported to the provider immediately
Suicidal ideation with a plan
This phase of the nurse-client relationship focuses on trust building
Orientation phase
This is the priority intervnetion during an acute manic episode
Provide a low stimulation environment.
A medication commonly used for opioid maintenance therapy
Methadone or buprenorphine
A plan of care strategy for antisocial personality disorder
Use matter of fact communication and enforce consequences
A risk factor that increases the likelihood of delirium
Infection or polypharmacy
A client demonstrates understanding of thougth stopping by doing this
Saying "stop" when negative thoughts begin
A priority finding that indicates a possible relapse of mania
Decreased need for sleep
A teaching point indicating understanding of nicotine withdrawal
Cravings peak within the first few days
A goal when contributing to the plan of care for a child with ADHD
Improve attention span and impulse control
A priority finding to report for a client experiencing delirium
Acute change in level of consciousness
The best way to assess abstract thinking
Ask the client to interpret a proverb
This outcome best indicates improvment in a client with PTSD
Decreased frequency of flashbacks or nightmares
A priority finding for a client taking valproic acid
Elevated liver enzymes
This defense mechanism involves blaming others for one's own behavior
Projection
A priority nursing action for delirium
Provide frequent reorientation
The priority when assisting with hygeine care for a cognitively impaired client
Provide step-by-by step instructions
The priority intervention for a a hospitalized client with bipolar disorder
Ensure adequate nutrition and hydration
A medication that may be prescribed for delirium-related agitation
Low-dose antipsychotic such as holoperidol
A maladaptive defense mechanism often seen in anxiety disorders
Denial
A priority when assisting with the plan of care for delirium
Treat the underlying cause
A key intervention for a client with somatic symptom disorder
Focus on feelings rather than physical complaints
A reportable lab finding for a client taking lithium
Serum lithium leval above therapeutic range
A client malnourished due to alcohol use disorder needs this vitamin supplementation
Thiamine (B1)
A finding indicating improvement in a client with anorexia nervosa
Weight gain and normalized eating behaviors
An expected finding indicating improvment in delirium
Improved attention and orientation
Teaching for a client taking selegiline includes avoiding this
Tyramine-rich foods
An expected lab finding in a client with anorexia nervosa
Electrolyte imbalances such as hypokalemia
An adverse effect of phenelzine that requires immediate intervention
Hypertensive crisis
A key issue when caring for preschool-age children with mental health concerns
Difficulty with emotional regulation
A nursing action that helps prevent injury and delirium
Use a calm environment and avoid restraints when possible.
Foods to avoid when taking phenelzine include this category
Aged chesses and cured meats