Assessment & Nursing Intervention
A patient in the unit has begun pacing and talking to herself. She is becoming louder and is cursing at no one in particular. Which of the following responses from the nurse would be inappropriate?
A. Tell the patient in a firm tone of voice that her behavior is disrupting the milieu and she needs to go to her room.
B. Offer PRN medication for breakthrough psychotic symptoms.
C. Clear the hallways of the unit of unattended computers and chairs.
D. Notify the attending psychiatrist and obtain an order for emergency medication.
A. Tell the patient in a firm tone of voice that her behavior is disrupting the milieu and she needs to go to her room.
Rationale: This answer is the most confrontational and risks further escalating the patient to violence.
A client has recently been diagnosed with generalized anxiety disorder. What statements indicates teaching has been successful?
A. “I will take my Wellbutrin only on days where I anticipate there will be a lot on my plate.”
B. “It’s okay to drink just one beer while taking my anti-anxiety meds. Just to loosen me up and get me in the mood.”
C. “I’ll take a few puffs of my rescue inhaler when I feel an anxiety attack coming on to help with the difficulty breathing.”
D. “When I’m feel overwhelmed, I’ll try to distance myself from the issue and give my mind some time to process everything.”
D. “When I’m feel overwhelmed, I’ll try to distance myself from the issue and give my mind some time to process everything.”
Rationale: This answer illustrates a successful usage of a positive coping skills.
Answer A is incorrect because Wellbutrin should not be taken as needed and should be taken regularly.
Answer B is incorrect because best practice is to avoid alcohol while taking most anti-anxiety / antidepressant meds.
Answer C is incorrect because shortness of breath related to a panic attack is not true a physiological response, and a rescue inhaler will not actually make breathing easier. The medication in the inhaler may actually worsen anxiety symptoms.
You are interviewing a client who has a hx of schizophrenia. In between your questions, you observe him staring straight at the wall with a fixed stare and there is a delay of about 30 seconds to 1 minute from when you ask your question to his answer. His answers to your questions are simple "yes" and "no", even when you ask him to elaborate.
What do these findings suggest?
A. The client is uncomfortable speaking with you and may prefer a clinician of the opposite gender.
B. The client may have Autism Spectrum d/o and may be avoiding eye contact.
C. The client is being very thoughtful with his responses.
D. The client may be experiencing auditory hallucinations and is internally stimulated.
D. The client may be experiencing auditory hallucinations and is internally stimulated.
Rationale: The delay in response and the inability to focus on the interviewer or their questions strongly suggests that the patient is experiencing hallucinations. There is no indication that this is a cultural issue or that the patient has an autism spectrum d/o.
A patient who has recently been prescribed haloperidol 5mg Daily reports feeling stiff shortly after his dose. You observe that his neck is tense and he keeps looking sideways. Which best describes this reaction?
A. Akathisia
B. Tardive Dyskinesia
C. Dystonia
D. Pseudo-parkinsons
C. Dystonia
Rationale: Dystonia is the symptom most likely to occur immediately following the administration of an antipsychotic. It is also characterized by involuntary muscle contractures, which the patient is demonstrating with his neck being tense.
Akathisia and pseudoparkinsons typically manifest later in therapy, several days to weeks after. Akathisia is a sense of restlessness which presents as a constant need to pace or tap one's foot. Pseudoparkinsons is involuntary movements such as resting tremors, problems with balance and a delay in movement.
Tardive dyskinesia typically manifests after years of being on medication therapy. Similar to pseudoparkinsons, it also involves involuntary movements though more like "tics" such as tongue wagging, facial grimaces, excessive blinking.
A 25M client presenting at a wellness clinic reports poor sleep & decreased appetite for the past week, difficulty concentrating, and recent development of anhedonia. He denies psychiatric sx including SI, HI, AH, VH, but states "I'm so tired of this, I can't keep living like this".
What is the nurse's most appropriate intervention?
A. Refer the client to speak with the psychiatrist for a focused assessment
B. Request an RX from the psychiatry team for PRN sleeping medicine
C. Place the client on a 5150 hold for DTS / GD
D. Call family to do an at-home safety screening
A. Refer the client to speak with the psychiatrist for a focused assessment
Rationale: The best answer would be to have the psychiatrist do a more thorough evaluation of the patient. This could determine if the patient is actually experiencing SI with a direct plan, or if the feelings of hopelessness are situational and can be addressed with medication and support.
Which is the priority nursing diagnosis for an eating disorder patient diagnosed with anorexia nervosa?
A. Disturbed Body Image
B. Imbalanced Nutrition: Less Than Body Requirements
C. Ineffective Coping
D. Decreased Cardiac Output
D. Decreased Cardiac Output
Rationale: The interventions can either be considered "physiological" or "psychological". Physiological concerns will almost always take priority over psychological concerns, therefore we can eliminate choices A & C.
While both answers B & D are important and relevant to a patient with anorexia, answer D is more immediate due to Decreased Cardiac Output directly relating to dizziness, hypotension, and the possibility of falling. For answer B, we would usually have several hours or even longer to replete electrolytes (and if they're so critically low that they could develop an arrhythmia spontaneously, they probably need to be getting the electrolytes via IV).
You are interviewing a client with schizophrenia at the mental health clinic. You ask him what he did before his appointment and he responds with “I woke up around 10 and had eggs and waffles for breakfast. The eggs came from chickens, they weren’t those duck eggs, and I’m pretty sure the waffles were Eggo brand. Oh, Eggo makes the frozen pancakes too, those are pretty good. I like eating mine with maple syrup, the authentic stuff from Canada. That’s what Canada is famous for, you know?”
Which best describes this speech pattern?
A. Loose associations
B. Echolalia
C. Tangential
D. Word Salad
C. Tangential
Rationale: This pattern of speech describes tangential speech, which is characterized by shifting topic to topic, or "tangents". You can usually follow the patient's line of thinking if you listen to the conversation and how the topics shift.
Loose associations would be completely irrelevant responses such as "I ate breakfast. The baby is in the cradle. Mom wore her purple jacket today. "
Echolalia is repetition of words or phrases, and sometimes the person repeats what you have said to them.
Word salad is completely disorganized speech with no meaningful understanding.
A patient is being prescribed Zyprexa 10mg daily in the morning as he is being discharged. Which statement by the patient's family member indicates the need for further teaching?
A. He's so sluggish and tired when he gets it in the morning, so we've been giving him the medicine at night.
B. He's been doing really well at home so we've been slowly cutting down on the dose.
C. If he does well on this medication, hopefully we can transition to a long acting version.
D. I've been encouraging him to drink plenty of fluids and move around a lot during the day.
B. He's been doing really well at home so we've been slowly cutting down on the dose.
Rationale: Medication dosages should not be adjusted without explicit direction from the provider. Going down on the prescribed dosage can even increase the risk of relapse or symptoms reappearing.
While answer A may also be correct, it is not uncommon for patients to be prescribed Zyprexa QHS or BID, and the patient is still being dosed safely at 10mg / day.
You are working with an adolescent client on a behavioral unit. Which statement by the adolescent requires your immediate attention?
A. “I should reach out to my friends on social media when I’m feeling down.”
B. “My mom won’t let me get a dog, but a dog would give me a reason to get out of the house.”
C. “I’ve been smoking a lot more cigarettes at home, but I’ve been cutting myself less.”
D. “The other patient and I cried together when we talked about her dog who passed away.”
C. “I’ve been smoking a lot more cigarettes at home, but I’ve been cutting myself less.”
Rationale: Answer C is the most alarming because it's replacing a negative coping skills with another one (replacing cutting with smoking / substance use). The other answers all do not explicitly mention the patient utilizing any coping skills that are harmful.
A veteran with PTSD is being evaluated by you. Which statement by the patient requires your immediate attention?
A. “Things are about to get a lot harder, next month will be the anniversary of my sergeant's death”
B. I’ve had to take the PRN anxiety medication the doctor prescribed 3 times a day instead of 2 times like he ordered.”
C. “I keep thinking about my squad mates who were killed, especially when I’m drinking.”
D. “I feel so tired when I wake up, even though I’m sleeping 8 hours a night.
C. “I keep thinking about my squad mates who were killed, especially when I’m drinking.”
Rationale: Answer C is the most alarming because it highlights a heightened risk for suicide in this client. Becoming acutely depressed, especially when a client is in an uninhibited state, is a risk factor for suicide.
Although Answer B sounds concerning as well most PRN anxiety medications are dosed at the lowest effective dose. This would be an indicator that the patient may be under-medicated and may be a signal to have the patient discuss with the treatment team about dosage adjustments.
You are discussing the treatment plan with a patient diagnosed with panic disorder. Which of the following statements indicates a positive client response?
A. "I went out to the movies with my friends last week."
B. "Today I decided I can stop taking my medication."
C. "I'm hyperventilating only when I'm having a panic attack."
D. "I've been working on my diet and eating three healthy meals a day."
A. "I went out to the movies with my friends last week."
Rationale: Answer A reflects an achievement that the patient made which is a positive outcome of their treatment plan.
Answer B is not recommended as stopping medication suddenly can lead to dangerous or unpleasant side effects and should be done under direction of a provider.
Answer C does not indicate a positive outcome, and Answer D is not relevant for panic disorder.
You are taking care of a patient diagnosed with schizophrenia who was recently a missing person prior to his admission. He was found by police officers wandering around, confused, and he had not been eating or taking his medication. As you are reviewing orders for your patient you notice the doctor just put in an order for Clozaril 400mg QHS, first dose to be given tonight. Which is the most appropriate nursing action?
A. Request the doctor to order Milk of Magnesia PRN for constipation.
B. Notify the doctor to hold the medication.
C. Review the patient's most recent CBC.
D. Measure the patient’s weight and document it in the chart.
B. Notify the doctor to hold the medication.
Rationale: While all of these interventions should be implemented, the key indicator that tells us to hold the medication is knowing the patient has not been on this medication for a while AND that he is ordered to get 400mg tonight. Clozaril 400mg is a high dose, and for a medication as "dangerous" as Clozaril, it must be re-titrated back up slowly.
Checking the CBC for neutropenia is absolutely appropriate, but the priority is to hold the medication and to re-titrate safely.