Foundations for Mental Health Nursing
Restating (allows the nurse to repeat the main idea expressed)
Name a physiological condition that can result in delirium.
Infection, surgery, prolonged hospitalization, hypoxia, fever, medications
A nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. Which medications should the nurse anticipate the provider to prescribe?
Benzodiazepines
A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which type of hallucination would be a priority for the nurse to address?
Command hallucination (These pose a potential safety risk to the client and others because they may instruct the client to harm themselves or others.)
A nurse is caring for a client who has borderline personality disorder. Which defense mechanism is commonly used by clients who has this disorder and has the potential to create division amongst the healthcare team?
A nurse is caring for a client who experiences severe anxiety when going to work. The nurse should identify that which area of the autonomic nervous system is stimulated when the client goes to work?
Sympathetic nervous system (fight or flight response). In times of stress, this part of the nervous system is stimulated.
A nurse has admitted a client who has schizophrenia. He notices these symptoms: flat affect, bizarre behavior, illogicality, paranoid delusions. Which finding is a negative symptom?
Flat affect (Negative symptoms are the absence of things that are normally present.)
A nurse is caring for a client who has developed tardive dyskinesia from anti-psychotic medication use. What adverse symptoms would be expected?
Uncontrollable movements around the mouth (e.g. lip smacking), involuntary movements of the arms, legs, and trunk.
A nurse is caring for a client who is screaming at staff members and other clients. What is an appropriate, therapeutic communication technique that should be used by the nurse?
Set limits. Can also use physical activity (walking) to de-escalate anger. ("Stop screaming, and walk with me outside.")
*NOTE: Asking "What was going through your mind when you started screaming?" (is not appropriate because the client is not ready to discuss this issue).
A nurse is caring for an adult client who has injuries resulting from partner violence. The client does not wish to report the violence to Metro. What is your highest priority action as a nurse?
Assist the client to develop a safety plan (e.g. location of safe houses and shelters).
A client is exhibiting ____________ when she treats her nurse in a negative way because she reminds her of her abusive mother.
Transference (patient views member of health care team as having characteristics of another significant person in their personal life).
A nurse is caring for a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." What manic characteristic is the client exhibiting?
Grandiosity (belief that he has special abilities or great powers)
A nurse is caring for a client who has been taking fluoxetine for a few days and asks about herbal treatments. The nurse should tell the client what herbal treatment is used for depression? She should also educate the patient to not take it while still on fluoxetine because it can lead to what?
St. John's Wort; Serotonin Syndrome
Name 2 symptoms of Serotonin Syndrome.
S - Sweaty & hot + fever
R - Rigid muscles + restlessness & agitation
I - Increased HR
Others: hallucinations, tremors, disorientation, seizures, labile BP, n/v/d
Name 2 expected manifestations of conduct disorder.
Bullying, SI, law-and/or rule-breaking behavior, low self-esteem, irritability, temper outbursts
A client asks a nurse to give him advice about whether or not to start antidepressants. Rather than giving advice to the client who has difficulty making decisions, the nurse helps the client explore all alternatives and arrive at a choice. Which ethical principle is the nurse displaying?
Autonomy (client's right to make their own decisions)
A nurse is caring for a client who frequently breaks their arms and other bones on purpose. The nurse understands that the client likely has which diagnosis?
Factitious disorder (conscious falsifying of an illness or intentionally causing self-injury)
A nurse is reinforcing teaching with an adolescent client who is to start atomoxetine for ADHD. The nurse should instruct the client to monitor for which adverse effects? (Name 2)
Hepatoxicity - Dark urine, yellowing skin (jaundice), flu-like manifestations (fever, malaise, decreased appetite), nausea/vomiting, abdominal pain
A client started on haloperidol for a week and has developed some adverse symptoms. The nurse suspects neuroleptic malignant syndrome. Name 2 symptoms that the patient may be exhibiting.
F = fever
E = encephalopathy (confusion)
V = vitals unstable (BP fluctuations)
E = elevated CK
R = rigidity
Other symptoms: dysrhythmias, sweating, drooling...
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which lab finding does the nurse expect to be altered and reflects malnutrition over an extended period of time?
Albumin (low)
A nurse is educating a client about automatic refills of prescribed medications. This nursing intervention is an example of which level of prevention?
Tertiary prevention (directed toward reducing residual effects associated with a mental health crisis that has already occurred). Goal is to prevent any further complications or long-term effects.
A nurse is caring for a client who screams, "I can read your minds!" The nurse should identify this as a manifestation of which personality disorder?
Schizotypal personality disorder (often characterized by the belief that one has magical powers).
Name one medication that is prescribed for binge-eating disorder and 2 adverse effects from the medication.
Orlistat (prevents absorption of some of the fat in food intake, so should take with each meal, during or within 1 hour after the meal)
Hepatotoxicity (dark-colored urine, light-colored stools, jaundice, anorexia, vomiting, fatigue)
2 - 3 days; Severe disorientation, psychotic effects (hallucinations), severe HTN, cardiac dysrhythmias
A nurse is reviewing lab results for a client and notes a serum lithium level of 1.6 mEq/L. Name 3 manifestations the nurse should expect the client to report.
Early lithium toxicity symptoms:
Mental confusion, sedation, poor coordination, coarse tremors, ongoing GI distress (n/v/d).