Therapeutic Communication
During the initial phase of group therapy, this should be discussed so members understand expectations and feel safe participating.
What are group rules, confidentiality, goals, and expectations?
The initial/orientation phase focuses on introductions, purpose, boundaries, expectations, and establishing trust.
Tachycardia, hypertension, dilated pupils, agitation, and increased energy are expected with use of this substance.
What is cocaine?
Cocaine is a CNS stimulant and commonly causes hyperalertness, insomnia, decreased appetite, and cardiovascular stimulation.
Attention-seeking behavior, rapidly shifting emotions, and dramatic or seductive behavior are associated with this personality disorder.
What is histrionic personality disorder?
A client taking valproic acid develops abdominal pain, nausea, and jaundice. This finding should be reported because of this serious adverse effect.
What is hepatotoxicity?
Also monitor for pancreatitis and thrombocytopenia.
Previous suicide attempt, access to firearms, hopelessness, and a specific plan are examples of these.
What are suicide risk factors?
Focusing attention on breathing and allowing thoughts to pass without judgment describes this relaxation technique.
What is meditation or mindfulness?
A malnourished client with alcohol use disorder should receive this vitamin before glucose.
Thiamine
A client says, “Nobody understands what I’m going through.” This response demonstrates therapeutic communication.
What is “Tell me more about what you’re experiencing”?
Use open-ended statements, reflection, clarification, and silence rather than advice or false reassurance.
Muscle aches, yawning, rhinorrhea, diarrhea, abdominal cramping, and dilated pupils are characteristic of withdrawal from this substance.
What are opioids?
Opioid withdrawal is extremely uncomfortable but is generally not life-threatening.
Unstable relationships, impulsivity, intense fear of abandonment, and splitting are common findings with this disorder.
What is borderline personality disorder?
A client taking an antipsychotic develops muscle rigidity, tremors, and a shuffling gait. This medication may be prescribed.
What is benztropine?
Benztropine is used for antipsychotic-induced parkinsonism and acute dystonia.
When a client says, “Everyone would be better off without me,” the nurse should do this next.
What is ask directly about suicidal thoughts, plan, means, and intent?
Asking directly about suicide does not increase suicide risk.
Memory loss, confusion, impaired judgment, and decreased ability to perform ADLs can indicate a change in this.
What is mental status or cognitive function?
Sudden confusion, decreased level of consciousness, or new disorientation represents this.
A change in neurological/mental status that should be reported
A sudden decrease in consciousness or new neurological deficit requires immediate assessment and notification of the provider/rapid response as indicated
The nurse-client relationship progresses through these three major phases.
Response: What are orientation, working, and termination?
This medication may be administered to decrease manifestations of opioid withdrawal.
What is clonidine?
Clonidine decreases autonomic manifestations such as hypertension, sweating, and tachycardia. Buprenorphine may also be used.
This behavior creates the greatest immediate risk in a client with borderline personality disorder.
What is self-harm or suicidal behavior?
Safety takes priority over manipulation, relationship difficulties, or emotional lability.
A client taking an MAOI should avoid aged cheese, cured meats, and red wine because these foods contain this substance.
What is tyramine?
Tyramine with an MAOI can cause a hypertensive crisis.
What does hypertensive crisis look like?
A client experiencing psychosis says voices are commanding them to kill themselves. This represents the greatest risk.
What are command hallucinations directing self-harm?
When assisting a cognitively impaired client with hygiene, the nurse should use this approach.
What is give one simple direction at a time and encourage as much independence as possible?
While a client is in seclusion or restraints, the nurse must frequently assess these.
Circulation, respiratory status, hydration, nutrition, elimination, mental status, and continued need for restraint
Restraints and seclusion should be discontinued as soon as the client can maintain safety
A client has just lost their home in a fire and is crying. This is the nurse’s priority response.
What is remain with the client and address immediate safety and basic needs?
During a crisis, focus first on safety, food, shelter, support, and stabilization rather than long-term problem solving.
This long-acting opioid medication can be used for maintenance therapy in opioid use disorder.
What is methadone?
Methadone prevents withdrawal and reduces cravings. Buprenorphine is another maintenance option.
For a child with ADHD, this environmental intervention helps improve attention and task completion.
What is providing structure, clear expectations, and limited distractions?
Give brief directions, break tasks into smaller steps, and reinforce positive behaviors.
Clients taking lithium should maintain a consistent intake of this electrolyte.
What is sodium?
A sudden decrease in sodium can increase lithium levels and lead to toxicity. Maintain consistent fluid intake as well.
A client becomes increasingly aggressive, is pacing, and is clenching their fists. The nurse should first use this approach.
What is calm verbal de-escalation while maintaining personal space and an exit route?
Use the least restrictive intervention first whenever possible.
A client scheduled for ECT should expect this common temporary adverse effect after treatment.
What is short-term memory loss and confusion?
ECT is performed under general anesthesia with a muscle relaxant. The client is NPO beforehand.
Four clients are on a mental health unit:
A. A client with borderline personality disorder who is angry because a visitor left
B. A client withdrawing from opioids who has diarrhea and muscle aches
C. A client withdrawing from alcohol who is confused and reports seeing bugs crawling on the wall
D. A client with somatic symptom disorder requesting another assessment for abdominal discomfort
Who is Client C?
Why?
Confusion and visual hallucinations during alcohol withdrawal may indicate delirium tremens, which can progress to seizures, severe autonomic instability, and death.
NCLEX Rule: Uncomfortable does not always mean unstable.
Alcohol withdrawal = potentially life-threatening. Opioid withdrawal = usually miserable but not fatal.
A nurse asks a client, “What do people mean when they say, ‘Don’t cry over spilled milk’?” This assesses this type of thinking.
What is abstract thinking?
Interpretation of proverbs assesses abstraction. A very literal response may indicate concrete thinking.
A client experiencing alcohol withdrawal is agitated and tremulous. This is the nurse’s priority concern.
What is preventing seizures and injury?
Alcohol withdrawal can progress to seizures and delirium tremens. Benzodiazepines are commonly used.
For a client with somatic symptom disorder, the nurse should focus less on physical complaints and more on this.
What are feelings, coping skills, and functional activities?
The nurse should acknowledge symptoms without reinforcing repeated focus on physical complaints.
A client taking lithium develops severe diarrhea, coarse tremors, confusion, and unsteady gait. The nurse should suspect this.
What is lithium toxicity?
A restrained client develops cyanotic fingers and a weak radial pulse. The nurse should do this immediately.
What is release or loosen the restraint and assess circulation?
Neurovascular compromise requires immediate intervention.
Match the therapy with the condition:
Dementia — Social Phobia — Borderline Personality Disorder
What are:
Ethical nursing decisions commonly consider autonomy, beneficence, nonmaleficence, justice, and this principle involving truthfulness.
Veracity