Foundations
This is the nurse's most important goal in the pre-orientation phase.
What is preparing self and reviewing the client record?
This anxiety disorder involves sudden episodes of intense fear with physical symptoms like palpitations and shortness of breath.
What is panic disorder?
These are symptoms of schizophrenia that include hallucinations, delusions, and disorganized speech.
What are positive symptoms?
This screening tool asks about C-cut down, A-annoyed, G-guilty, and E-eye-opener.
What is the CAGE questionnaire?
In an older adult, sudden confusion that comes on quickly is more likely this condition than dementia.
What is delirium?
A client says, "I don't want to talk about it." The nurse replies, "You seem upset. Would you like to sit quietly for a minute?" This is an example of this therapeutic communication skill.
What is offering self/acknowledging feelings/silence?
A client with PTSD repeatedly relives a traumatic event through flashbacks and nightmares. This symptom category is called this.
What are re-experiencing symptoms?
A client hears voices telling them to harm themselves. This type of hallucination is called this.
What is an auditory command hallucination?
A client with pinpoint pupils, respiratory depression, and decreased level of consciousness likely overdosed on this substance.
What is an opioid?
This is the priority nursing action when a client becomes increasingly agitated and starts pacing, clenching fists, and shouting.
What is de-escalation and safety assessment?
This defense mechanism involves unconsciously refusing to accept a painful reality.
A client says, "I'm not worth anything anymore. Everyone would be better off without me." What is the nurse's priority concern?
What is risk for suicide?
Which statement is best: "That must be scary for you," or "Those voices aren't real, just ignore them"?
What is "That must be scary for you"?
This medication is used to reverse opioid overdose.
What is naloxone (Narcan)?
A school-age child suddenly says, “I want to die.” What is the nurse’s priority action?
What is perform immediate suicide risk assessment and ensure safety?
This legal concept means a client must be told the risks, benefits, and alternatives before agreeing to treatment.
What is informed consent?
This mood disorder is marked by depressed mood plus increased energy, decreased need for sleep, grandiosity, and impulsive behavior.
What is bipolar disorder, manic episode?
A client on haloperidol develops muscle rigidity, high fever, and autonomic instability. This is the term for this emergency.
What is neuroleptic malignant syndrome?
A client in alcohol withdrawal is most at risk for this severe complication if untreated.
What are seizures?
This developmental group is most likely to struggle with abstract reasoning and needs concrete, simple instructions.
What is children?
This phase of the therapeutic relationship focuses on evaluating outcomes and saying goodbye.
What is the termination phase?
A client taking an SSRI develops agitation, hyperreflexia, fever, and diarrhea. This life threatening condition is called this.
What is serotonin syndrome?
This antipsychotic side effect causes involuntary lip smacking and tongue movements after long-term use.
What is tardive dyskinesia?
A client who is heavily intoxicated with alcohol should be monitored for this major nursing priority.
What is respiratory depression/airway safety/risk for aspiration?
This finding is more consistent with dementia than delirium.
What is slow, gradual cognitive decline?