Psych Medications
A patient taking lorazepam (Ativan) becomes very drowsy and unsteady when walking.
What is the priority nursing intervention?
What is implement fall precautions and assist with ambulation?
A patient with major depression says,
“Everyone would be better off without me.”
What is the priority nursing question?
What is “Are you thinking about harming yourself?”?
A patient says, “The voices are telling me to hurt someone.”
What is the nurse’s priority assessment?
What is assess for command hallucinations and safety risk?
Care of the Patient with Psychi…
A patient experiencing panic is hyperventilating and says, “I’m dying!”
What is the nurse’s first action?
What is stay with the patient?
A patient shows lack of empathy, manipulation, and criminal behavior.
What personality disorder is most likely?
What is antisocial personality disorder?
A patient taking fluoxetine (Prozac) reports nausea, agitation, sweating, and muscle rigidity after starting St. John’s Wort.
What condition should the nurse suspect?
What is serotonin syndrome?
A manic patient is pacing constantly and refusing meals.
What nursing intervention is most appropriate?
What is offer high-calorie finger foods?
A patient states, “The TV is sending secret messages to me.”
What symptom is this?
What is delusion?
A patient repeatedly checks the door locks 20 times before sleeping.
What disorder does this suggest?
What is Obsessive-Compulsive Disorder (OCD)?
A patient with unstable relationships and fear of abandonment.
What disorder is this?
What is borderline personality disorder?
A patient taking phenelzine (MAOI) eats aged cheese and develops a severe headache and hypertension.
What complication is occurring?
What is hypertensive crisis?
A patient starting antidepressants reports increased energy but still feels depressed.
Why is this period considered high risk?
What is increased suicide risk because energy returns before mood improves?
A patient says they hear voices insulting them.
What type of hallucination is most common in schizophrenia?
What is auditory hallucinations?
A PTSD patient hears fireworks and suddenly believes they are back in combat.
What symptom is occurring?
What is flashback?
A patient refuses social interaction and shows emotional detachment.
What personality disorder is likely?
What is schizoid personality disorder?
A patient taking lithium for bipolar disorder develops vomiting, tremors, and confusion.
What is the nurse’s priority action?
What is hold the medication and obtain a lithium level?
A bipolar patient has decreased need for sleep, impulsive spending, and grandiosity.
What phase of bipolar disorder is occurring?
What is mania?
A patient says, “The voices are real!”
What is the most therapeutic nurse response?
What is “I understand the voices feel real to you, but I do not hear them.”?
A patient with severe anxiety cannot focus on instructions.
Why?
What is panic level anxiety prevents learning?
A patient is obsessed with perfectionism, rigid rules, and control.
What disorder is this?
What is obsessive-compulsive personality disorder (OCPD)?
A patient taking haloperidol suddenly develops neck spasms and torticollis shortly after medication administration.
What medication should the nurse anticipate administering?
What is diphenhydramine or benztropine?
A patient taking lithium states they started a low sodium diet and intense exercise program.
Why is this concerning?
What is increased risk of lithium toxicity due to sodium depletion?
A patient receiving antipsychotics develops lip smacking and tongue movements after long-term therapy.
What condition is this?
What is tardive dyskinesia?
A patient with PTSD avoids crowded places and loud noises.
What PTSD symptom category is this?
What is avoidance behavior?
A nurse caring for a personality disorder patient should prioritize what key strategy?
What is set clear and consistent boundaries?