Delirium
What is the pathophysiology of delirium?
What is the priority nursing interventions for dementia?
What is safety?
What medication is the first line treatment for a patient with PTSD
What is an SSRI? Selective Serotonin Reuptake Inhibitors (Sertraline, paroxetine, fluoxetine)
Reduces anxiety, depression and intrusive thoughts
What are the major complications of a patient with an eating disorder?
What is cardiac dysrhythmias(low potassium), esophageal tears(bulimia), Dehydration, refeeding syndrome
What findings is associated with FASD?
What is smooth philtrum, thin upper lip, growth restriction, microcephaly and developmental delay?
Think everything is small!!!
What are 3 common cause of delirium?
What is Medical condition, infection, meds, substance abuse, electrolyte imbalance and hypoxia?
What medications would you not give to a patient with dementia?
What is Anticholinergics and Benzodiazepines?
Anticholinergics(worsen confusion)
Benzodiazepines(increase fall risk and worsen cognition)
What kind of therapy would a patient with PTSD receive?
What is CBT(cognitive behavioral therapy), exposure therapy, trauma force therapy, EMDR(eye movement desensitization and reprocessing)
What medication do you give for a patient to decrease binge-purge cycle?
What is Fluoxetine?
A nurse is caring for a client admitted for alcohol withdrawal. Which prescription should the nurse question if administered before thiamine?
A. IV fluids
B. Folic acid
C. Glucose-containing IV solution
D. Multivitamin infusion
What is C?
Why C is correct Thiamine should be given before glucose in alcohol withdrawal to prevent Wernicke encephalopathy. Giving glucose first can worsen neurologic injury.
What is the priority nursing interventions for delirium?
Identify and treat the cause (infection, hypoxia and med)
What kind of communications strategies would you use for a patient with dementia?
What is short simple questions, one-step instructions and validation therapy?
A nurse is assessing a veteran who experienced combat trauma. Which cluster of symptoms is most characteristic of PTSD?
A) Depression, anhedonia, and social withdrawal
B) Re-experiencing the event, avoidance behaviors, and hyperarousal
C) Flashbacks, memory loss, and confusion
D) Panic attacks, agoraphobia, and compulsive behaviors
What is B?
Why B is correct: PTSD has three core symptoms: re-experiencing the event, avoiding reminders of the event (coupled with generalized emotional numbing), and a persistent state of hyperarousal.
What electrolyte imbalance is priority to monitor?
What is Hypokalemia?
A pregnant client reports cocaine use during pregnancy. Which newborn finding should the nurse anticipate?
A. Macrosomia
B. Increased head circumference
C. Low birth weight
D. Hyperglycemia
What is C?
Why is C correct Maternal cocaine use is associated with low birth weight, prematurity, shorter length, and small head circumference.
A nurse is assessing a 78-year-old hospitalized patient. Which finding is most characteristic of delirium?
A) Gradual onset of memory loss over several months
B) Inability to focus attention with fluctuating symptoms throughout the day
C) Persistent auditory hallucinations with organized delusions
D) Consistent disorientation to person, place, and time
What is B?
Why B is correct: The cardinal symptoms of delirium are an inability to direct, focus, sustain, and shift attention; an abrupt onset with clinical features that fluctuate with periods of lucidity; and disorganized thinking.
A nurse is assessing a patient recently diagnosed with Alzheimer's disease. Which nursing action is most important during the psychosocial assessment?
A) Assess for suicide risk and ask about suicidal thoughts
B) Immediately notify the family of all cognitive deficits
C) Encourage the patient to make all healthcare decisions independently
D) Reassure the patient that memory loss will not progress
What is A?
Why A is correct: Patients who recently received a diagnosis of dementia should be assessed for suicide risk. Establishing a therapeutic relationship and asking if they currently have or have had thoughts of suicide is an important part of nursing assessment. If considering suicide, determine if there is a plan and if the patient has means to commit suicide, including firearms. Older men with dementia are most at risk for suicide because they are often depressed and anxious.
What do you want your patient to report when having PTSD?
What is suicidal ideation, severe flashback, self-harm behaviors, inability to sleep for days, and worsening panic or aggression?
A nurse is evaluating a patient with anorexia nervosa for possible hospitalization. Which finding would warrant immediate admission?
A) BMI of 17
B) Weight at 80% of ideal body weight
C) Daytime heart rate of 48 beats per minute
D) Body fat percentage of 15%
What is C?
Why C is correct: A daytime heart rate of less than 50 beats per minute is a criterion for hospitalization in patients with anorexia nervosa, along with other criteria including systolic blood pressure less than 90, temperature less than 96°F, and arrhythmias.
Which client is at greatest risk for developing a substance use disorder?
A. A client with strong family support and no psychiatric history
B. A client with a family history of untreated depression
C. A client with unstable coping skills and healthy peer relationships
D. A client with occasional stress related to work
What is D?
Why is D correct major risk factors include family history, mental health disorders, peer pressure, loneliness, and lack of support systems.
What priority assessments would you as a nurse need for a patient experiencing delirium?
What is O2 stat, vital signs, labs, and meds?
What interventions help promote structure and routine
What is same caregivers if possible, reduce stimuli, label drawers and room and have family pictures up?
A nurse is educating a patient with PTSD about treatment options. Which psychotherapy approach uses repeated reimagining of traumatic events to reduce their emotional power?
A) Stress inoculation training
B) Eye movement desensitization and reprocessing (EMDR)
C) Exposure therapy
D) Cognitive behavioral therapy (CBT)
What is C
Why C is correct: Exposure therapy is a very effective trauma-focused therapy technique in which patients repeatedly reimagine traumatic events as a way to make those events lose their power.
What is the difference between Anorexia and Bulimia?
What is Anorexia is a severe restriction of intake(low body weight, bradycardia, hypotension, distorted body image)
Bulimia is binge eating and compensatory behavior(vomiting, laxative abuse and excessive exercising) normal or slightly increased weight, Russells signs: calluses on knuckles, parotid gland enlargement and tooth erosion
A nurse is planning care for a client in acute detoxification. Which intervention is the priority?
A. Teaching relapse prevention skills
B. Encouraging group therapy attendance
C. Providing a safe environment
D. Discussing long-term outpatient treatment
What is C?
Why is C correct safety is the first priority during detoxification because withdrawal can lead to injury, seizures, or medical instability.