Disorders & Manifestations
This eating disorder is characterized by severe restriction of intake, lanugo, amennorhea, and dangerously low body weight.
What is Anorexia Nervosa?
Follow up question: What is lanugo and why would that occur?
The nurse’s first action when a client begins showing signs of agitation.
What is ensure safety / reduce stimuli?
The primary purpose of the orientation phase in group therapy.
What is establishing rules, expectations, and informed consent?
Including expectations of confidentiality.
This medication reduces craving and relapse in alcohol use disorder.
What is naltrexone?
A parent of a child with ADHD should be reminded to administer stimulant medications at this time of day.
What is: in the morning?
Exception: clonidine for ADHD
This disorder is characterized by swollen parotid glands, enamel erosion, hypokalemia, hyponatremia, and Russell’s sign are hallmark findings of this condition.
What is bulimia nervosa?
Follow up question 1: What are the parotid glands and where are they located?
Follow up question 2: Why would parotid glands swell and why enamel erosion?
Follow up question 3: What is Russell's sign?
Vomiting/laxative use- you are flushing out electrolytes rich in potassium/sodium.
This severe form of withdrawal may include hallucinations, fever, and hypertension and requires immediate intervention.
What is delirium tremens?
Appropriate therapeutic response when a group member uses aggressive language.
What is setting firm limits calmly?
Effectiveness of naltrexone is demonstrated by this client report.
What is reduced craving for alcohol?
High-calorie finger foods are recommended for clients experiencing this mood episode.
What is mania?
Flat affect, apathy, avolition, and alogia are examples of these symptoms in schizophrenia.
What are examples of negative symptoms with schizophrenia?
Follow up question: What are examples of positive symptoms of schizophrenia? euphoria, delusions, echolalia, paranoia, hallucinations, agitation
The highest priority when caring for a client with borderline personality disorder.
What is risk for self-harm?
Teaching technique where the nurse demonstrates desired behavior, such as assertiveness.
What is behavioral modeling?
A serious adverse effect of chlorpromazine requiring immediate reporting.
What is neuroleptic malignant syndrome or agranulocytosis?
Follow up Question 1: What are s/s of NMS?
Follow up Question 2: What would be a priority finding with agranulocytosis?
This finding indicates delirium rather than dementia.
What is acute onset and fluctuating LOC?
*LOC changes can manifest as agitation, stupor.
Fear of abandonment, splitting, and impulsive self-harm behaviors are common in this personality disorder.
What is borderline personality disorder?
Before applying mechanical restraints, the nurse must ensure these two conditions have been met.
What is:
1.less restrictive measures have been attempted
2. client poses immediate danger to self and/or others
This therapeutic strategy involves restating or reflecting the client’s message.
What is clarifying communication?
Restlessness and an inability to sit still describe this extrapyramidal symptom.
The therapy most effective for OCD.
What is systemic desentization e.g. exposure and response prevention (ERP) aka exposure therapy / cognitive behavioral therapy (CBT)?
Suspiciousness, hypervigilance, and misinterpreting others’ motives are hallmark traits of this personality disorder.
What is paranoid personality disorder?
*Project blame onto others.
A client in restraints must be monitored for these three key complications.
What are: circulation impairment, respiratory issues, and psychological distress?
Follow up question: what findings would indicate the above issues?
The focus of the working phase of the nurse–client relationship.
What is promoting behavior change and problem-solving?
*Evaluating progress toward established goals, implement measures to help the client meet goals.
Appropriate intervention for akathisia.
What is administering beta-blockers (propranolol), antiparkinsonian agent (benztropine), or benzodiazepines (lorazepam)?
Follow up question 1: Why beta blockers?
Follow up question 2: Why benzodiazepines?
Follow up question 3: Why antiparkinsonian agent?
A predisposing factor for delirium common in hospitalized older adults.
What is infection (UTI/pneumonia)?
*Febrile illness, hepatic failure (build up of acetone), hypoxia, head trauma, stroke
Attention seeking behavior, self-centeredness, excessive emotionality.
What is histrionic personality disorder?
PRAISE ME: Provocative behavior, Relationships seen as more intimate than they are, Attention-seeking, Influenced easily, Speech (vague/impressive), Emotional lability/shallowness, Make-up/appearance focus, and Exaggerated emotions, all centered on being the dramatic, theatrical "life of the party" who needs the spotlight.
Document client condition every 15 min, maintain continous observation of the client, prevent aspiration.
Priority interventions for mechanical restraints.
*Also consider the importance of removing 1 restraint at a time until the client regains control, debrief any situations with client and staff. The provider must see the patient within 1 hour of initiating restraints.
This therapeutic communication technique involves restating the clients message to show understanding and encourage further expression.
What is reflection?
*Review validation therapy, feedback, reminiscence therapy.
*Choose open-ended options with clear boundaries.
A client with alcohol withdrawal becomes increasingly disoriented, reports seeing insects on the wall, and has a BP of 184/102. What is the nurse’s priority action?
What is administer a benzodiazepine immediately to prevent seizures / delirium tremens?
Remember- preventing seizures is a priority for alcohol withdrawal! Review CIWA to see assessments done for alcohol withdraw patients.
Must be signed by the patient after the provider explains the risks, benefits, and alternatives of the procedure.
What is informed consent?
*The client must be compentent, voluntary, and fully informed before signing.