Somatoform Disorders
Definition
Subjective Characterized by the presence of one or more physical symptoms accompanied by abnormal thoughts, feelings, and behavioral reactions that cannot be defined by an underlying medical condition or disease.
Somatoform disorder
Highest Priority
Often undergo unnecessary surgeries, invasive diagnostic procedures, and drug trials, all of which can be life-threatening.
Somatoform Disorder
Secondary Gains
Somatization may be used for secondary gains such as attention and decreased responsibilities.
Hypochondriasis or Illness Anxiety Disorder
Definition
Preoccupied with having or eventually developing a serious illness.
May or may not present with somatic symptoms, and if they do, the symptoms are usually mild.
High level of anxiety and alarm about their health lasting at least 6 month.
May either excessively check for problems or avoid medical care.
Hypochondriasis
Signs and Symptoms
The most common symptoms are pain, gastric or intestinal distress, palpitations, dizziness, shortness of breath, sexual dysfunction, neurological symptoms, and fatigue.
Hypochondriasis
Nursing Interventions
Nurses role is to assess for any objective data and to explain the health complaints. Show concern, but avoid fostering dependency.
Conversion Disorder
Definition
Common Signs and Symptoms
Medical disorder (objective) that cannot be explained.
This disorder presents with one or more symptoms of impaired motor or sensory function. Findings are incompatible with or an exaggeration of recognized neurological conditions and are not better explained by another mental or medical disorder.
Most common are blindness, deafness, paralysis, inability to talk. Symptoms are beyond conscious control and are related directly to conflict .
Conversion Disorder
Nursing Interventions
Encourage independence in ADL’s in a matter of fact manner.
Dissociative Disorders
Definition
A disturbance in the normally well-integrated continuum of consciousness, memory, identity, and perception.
Dissociation is an unconscious defense mechanism to protect the individual against overwhelming anxiety related to past trauma, and ranges from minor to severe in presentation.
Patients with dissociative disorders have intact reality testing, meaning they are not delusional or hallucinating.
Dissociative Fugue
The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited.
The distracters are more consistent with paranoid schizophrenia, generalized anxiety disorder, or bipolar disorder. Head injury, posttraumatic stress disorder, or a neurological disorder should also be considered.
Dissociative Amnesia
Related to a traumatic incident, and may be accompanied by a fugue where the patient flees from their normal life to another location and starts a new life. Gradually over time, memories of the original life may be triggered. Patients can become confused and embarrassed when the amnesia subsides and memory returns.
Dissociative Identity Disorder
The most severe of the dissociative disorders. Disruption of identity by two or more distinct personality states. Involves discontinuity in the sense of self, accompanied by alterations in affect, behavior, memory, and functioning. Patients lose time, meaning they do not have memory of periods of time ranging from minutes to weeks.
The patient is often unaware of the other personalities. Each alternate personality has its own pattern of personality, perception, and memories.
Body Dysmorphic Disorder
Definition
A highly distressing and impairing disorder that ranges along the continuum from distressing to delusional severity.
They have preoccupation with an imagined defective body part; obsessional thinking, compulsive behaviors.
Individuals with BDD are frequently concerned with the face, skin, genitalia, thighs, hips, and hair.
Body Dysmorphic Disorder
Care Plan
Body Dysmorphic Disorder
Highest priority
There is a high risk of completed suicide.
Personality Disorders
Definition
A personality disorder is a type of mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving. A person with a personality disorder has trouble perceiving and relating to situations and people. This causes significant problems and limitations in relationships, social activities, work and school.
Borderline Personality Disorder
Definition
Characteristics
A mental disorder characterized by unstable moods, behavior, and relationships.
Characteristics include emotional liability.
Instability in moods, interpersonal relationships, and high rates of self-injury.
Instability of affect.
Emotional instability
Poor Impulse control
Chronic Depression
Demonstrates a self-defeating cycle of behavior.
Borderline Nursing Interventions
Set limits, be consistent and assess your reactions toward patient.
Identify the needs and feelings preceding impulsive acts.
Teach or refer patient to appropriate place to learn needed coping skills.
Dialectical Behavior Therapy (DBT).
Histrionic Personality Disorder
Definition
Attention-Driven
Manipulating others through their dramatic, charming, flamboyant and sexual/seductive behaviors.
Meant to remain the center of attention.
Histrionic Disorder
Nursing Interventions
PsychoTherapy: Discussing the motivations and fears associated with their thoughts and behaviors.
Antisocial Personality Disorder
Description/Characteristics
Narcissistic
Deceit, manipulation, revenge and harm to other with an absence of remorse for hurting others.
They do not adhere to traditional values, morals, ethics, boundaries, and standards of society.
Obsessive Compulsive Disorder
Description
Difficulty expressing warm tender emotion, perfectionism, stubbornness, control issues, devotion to work.
Overly conscientious, inflexible, detail oriented (won’t focus on anything else), exclude leisure time, miserable, hoarding, rituals.
Avoidant Personality Disorder
Description
Social withdrawal, extreme sensitivity to rejection, feels inadequate, hypersensitive to reactions of others, dislikes criticism, social isolation, lack of support system.
Dependent personality disorder
Description
This individual relies on others in every aspect of their life.
Has difficulty or unable to complete tasks or make decision on their own without excessive reassurance.
Anorexia
Signs and Symptoms
Concerns
May have lanugo, mottled, cool skin on the extremities, low blood pressure, pulse and temp, all consistent with malnourished and dehydrated state.
They often have overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food and wear loose fitting clothes.
Can be life threatening due to fluid and electrolyte imbalances , suicide, cardiomyopathy, and malnutrition.
Anorexia Nursing Interventions
Milieu Therapy
Milieu therapy, close supervision of the patient’s eating, prevention of exercise, and purging.
Monitoring at meal time and after to prevent purging and throwing away food. May need parenteral nutrition.
Adhere to a selected menu
Observe during and after meals.
Monitor, especially during bathroom trips.
Re-feeding Syndrome
Description/Manifestations
Re-feeding resulting in rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse.
All-or-Nothing Thinking
Description
Reasoning is absolute and extreme, in mutually exclusive terms of black or white, excellent or aweful.
“If I have one Popsicle, I must eat five.”
“If I allow myself to gain weight, I’ll blow up like a balloon.”
Bulimia Nervosa
Important Facts
Hypokalemia is often associated with a patient with bulimia due to vomiting.
Bulimia can cause Metabolic Alkalosis.
Secretly consumes high calorie food then feels guilty.
May vomit, use diuretics, enemas, amphetamines.
Bulimia Nursing Interventions
The nurse should help the patient identify his/her triggers
Assess for sign of impulsive eating
Explore the need for dietary and health teaching.
NEUROCOGNITIVE DISORDERS
Those disorders that affect the structural or functional areas of the brain and cause disturbances in normal cognition such as memory, abstract thinking, or judgment.
Affect the brain’s ability to function intellectually, emotionally, socially, and occupationally.
Dementia
Difficulties
Nurse’s Role
The person’s children need to make difficult decisions for their parent. This can cause stress and guilt for the children.
Nurses role is to teach the family about dementia.
Dementia
Family Teaching
Patients are known for wandering.
Patient can be a fall risk.
Lock doors at night.
Place sensors on all outside doors.
Types of Dementia
- Alzheimer’s disease: irreversible form of senile dementia due to nerve cell deterioration,
- Vascular dementia: abrupt onset, rapid change in function, vascular lesions, decreased blood supply to the brain.
- Pick’s disease: degenerative brain disease, affects frontal and temporal lobes, similar to Alzheimer’s onset 60 years.
- Creutzfeldt Jakob disease: CNS disorder that develops around age 40-60yrs. Altered vision, loss of coordination, rapid progression, encephalopathy caused by is caused by an infectious particle.
- Parkinson: slow progressive neurological condition, tremors, rigidity, bradykinesia, postural instability.
s• Huntington’s disease: genetic , involves cerebral atrophy. Onset late 30-40’s.
Dementia can Cause
- Aphasia (echolalia, palilalia): language disturbance in understanding and expressing spoken word.
- Apraxia: inability to perform motor activities, despite intact motor function.
- Agnosia: failure to recognize or identify familiar objects despite intact sensory function.
- Amnesia: loss of memory as a result of degeneration.
Dementia Clinical Course/Onset
- Mild: forgetfulness, that exceeds normal occasional forgetfulness, difficulty finding words, frequently loses objects.
- Moderate: confusion is apparent, progressive memory loss, can no longer perform tasks. Still recognizes familiar people.
- Severe: personality and emotional changes, delusional, wandering, forget names of family and children, angry outbursts, require assistance with ADLs.
Memory Care
Reminiscing. Very common for older adults to reminisce about their pasts. Talking about the good old days can help them reduce feelings of loneliness and isolation.
Agnosia
Agnosia: failure to recognize or identify familiar objects despite intact sensory function.
Seen in patients with dementia.
Delirium
Describe
Sudden onset, reduced awareness and responsiveness to the environment, disorientation and incoherency and severe memory disturbances.
Delirium is a syndrome that is always secondary to another condition such as a general medical condition. Typically resolved if underlying issue is taken care of.
Delirium Nursing Interventions
Speak calmly in a clear low voice, allow adequate time for response, use orienting verbal cues, supportive touch. Keep environmental noise to a minimum. Monitor sleep and void pattern. Monitor intake, discourage daytime napping, encourage some exercise.
Dementia Differentiation from Delirium
Dementia has a gradual onset with progressive deterioration, short and long term memory impaired eventually destroyed.
Delirium has a sudden onset and can be resolved once underlying problem is fixed.
Agnosia
A client with agnosia does not recognize objects or understand what they’re used for, so the nurse should give the client concrete directions.
Visual and Tactile Hallucinations
Wandering, pulling out intravenous lines and Foley catheters, and falling out of bed are common dangers that require nursing intervention.
Hallucinations are false sensory stimuli. Visual hallucinations are common in delirium. For example, delirious individuals may become terrified when they “see” giant spiders crawling over the bedclothes or “feel” bugs crawling on their bodies.
Visual and Tactile Hallucinations
Priority Nursing DX
Risk of Injury
Self Care Defecit
The physical safety of the patient is of highest priority. Patients experiencing hallucinations may experience fluctuating levels of consciousness disturbed orientation and visual and tactile hallucinations.
Visual and Auditory Illusions
Definition and Nursing Intervention
Sensory misperceptions. For example, a person may mistake folds in the bedclothes for white rats or the cord of a window blind for a snake. The stimulus is a real object in the environment; however, it is misinterpreted and often becomes the object of the patient’s projected fear.
Eye glasses and hearing aides can help clarify sensory perceptions.
Medications for Behavioral Symptoms and Combativeness in Alzheimer’s Patients
Cholinesterase inhibitors
Antidepressants
Antipsychotics
Mood stabilizers
Caregiver Fatigue
Nursing Interventions
Respite care
Support groups
Assistance from agencies
Support to maintain personal life.
Abuse
Refers to the habitual use of a substance that falls outside of medical necessity or social acceptance and is used for the single purpose of altering one’s mood, emotion, or state of consciousness.
Addiction
Is a chronic, relapsing brain disease characterized by compulsive drug-seeking behavior motivated by cravings, despite harmful consequences, and by long-lasting changes in the brain.
Substance Dependence
A pattern of repeated use which usually results in tolerance, withdrawal, and compulsive drug taking behavior. Substances are taken in larger amounts and over longer periods than was intended. There is an effort to cut down or quit, most attempts are unsuccessful. Daily activities revolve around use of the drugs “next fix”. Substance tolerance is the need for increased amounts of the substance to achieve the high.
Dysfunctional Behaviors Related to Substance Abuse
- Preoccupation with obtaining the substance, manipulation, anger, violence , abuse, avoidance of relationships.
- Family unit may become distant or dysfunctional, the drug seeker may feel a false sense of importance and require special attention, denial (they blame everything but the substance for their issues).
Rationalization and projection to justify the use and unacceptable behavior. Depression, low self-esteem.
Co-dependency Issues
Description
Examples
- Behaviors that exist in a significant other that enables the addict to abuse w/o experiencing consequences.
- Examples: paying the addicts bills, bailing the addict out of jail, helping the addict call in sick to work.
- It’s important to address codependency issues to maximize the recovery for the addict.
Alcohol Abuse
Manifestations
Assessment
Slurred speech, uncoordinated movements, unsteady gait, restlessness, belligerence, confusion, sneaking drinks, drinking in the morning, experiencing blackouts, binge drinking, arguments about drinking, missing work, increased alcohol tolerance, intoxication.
Part of the assessment should include type of alcohol, how much, how long, and when was it last consumed.
Alcohol Abuse Signs and Symptoms
Depression, hostility, suspiciousness, irritability, isolation, decreased inhibitions, decrease self esteem, denial that a problem exists.
Complications of Alcohol Abuse
- Vitamin deficits: vitamin B deficiency can cause peripheral neuropathy, thiamine deficiency can cause korsakoff’s syndrome.
- Alcohol induced persisting amnesic disorder, causing severe memory problems.
- Wernicke’s encephalopathy, causing confusion, ataxia, and abnormal eye movements.
- Hepatitis, cirrhosis, esophagitis, gastritis, pancreatitis, anemia, immune system
dysfunction, brain damage, peripheral neuropathy, cardiac disorders.
Alcohol Dependence
United States Statistics
The United States has one of the highest levels of substance abuse and addiction in the world. Drug overdose is the leading cause of accidental death in the United States.
Alcohol Withdrawal
Signs and Symptoms
Anorexia (nausea/vomiting) anxiety, easily startled, hyper-alertness, hypertension, insomnia, irritability, jerky movements, hallucinations, illusions, delusions, vivid nightmares, reports of shaking inside,
SEIZURES (7-48 hrs), tachycardia and tremors.
Alcohol Withdrawal Delirium
Manifestations of alcohol withdrawal delirium: 48-72 after cessation and lasts 2-3 days. agitation, anorexia, anxiety, delirium, diaphoresis, disorientation w/ fluctuating levels of consciousness, fever, hallucinations, insomnia, tachycardia and hypertension.
Alcohol Withdrawal Delirium Medications
- Chlordiazepoxide (Librium) is a common medication given for alcohol withdrawal.
You can also give BENZOs such as lorazepam or chloriazepoxide to decrease symptoms.
CNS Stimulant Withdrawal
Depression, paranoia, lethargy, anxiety, insomnia, nausea, vomiting, sweating and chills— all signs of the body struggling to regain its normal chemical balance.
CNS Overdose
Overdose can cause cardiovascular and respiratory depression, coma, shock, seizure, and death.
Nursing interventions: if the client is awake, vomiting is induced and activated charcoal is administered.
Observe for depression and suicidal ideation.
Flumazenil (romazicon) IV may be used for a benzodiazepine OD (ativan, lorazepam).
Phencyclidine Piperidine PCP or angel dust Overdose
What should you administer
Possible hypertensive crisis or cardiovascular accident, respiratory arrest, hyperthermia, seizure.
Nursing Interventions are administer diazepam (benzodiazepine) or Haloperidol may be used for severe behavioral disturbance.
Opioid Use Signs and Symptoms
Constricted pupils, decreased respirations, drowsiness, euphoria, hypotension, impairment of memory, judgement, and attention, psychomotor retardation, slurred speech.
Opioid Overdose
Opioids include prescribed medications such as oxycodone and morphine, and the illegal substances such as heroin.
Respiratory depression, CNS depression, shock, coma, seizures, death – Overdose is treated with antagonist naloxone (Narcan).
Bradycardia
Bradypnia
Hypothermia
Pinpoint pupils
Opioid Withdrawal Medications
- Withdrawal may be treated with methadone detox or tapering dosage of other opioids.
- Catapres (clonidine) a-adrenergic blocker assists in the severity of the sympathetic.
nervous system generated withdrawal discomfort. - Specific symptom management can include kaopectate for diarrhea and tylenol for
muscle aches.
Heroin Overdose
Yawning, insomnia, irritability, runny nose (rhinorrhea), panic, diaphoresis, cramps, nausea, vomiting, muscle aches (“bone pain”), chills, fever, lacrimation, diarrhea.
Narcan
Early symptoms of narcotic withdrawal are flulike in nature.
Seizures are more commonly seen in alcohol withdrawal syndrome.
Common symptom are muscle aches, abdominal cramps, and gooseflesh. Patient will feel terrible.
Narcan Nursing Interventions
Monitor the patient closely, monitor VS every 15 minutes, especially respirations.
Muscle aches, abdominal cramps and gooseflesh are side effects of narcotic withdrawal.
Cocaine Abuse & Alcohol
To decrease the feeling of drunkenness.
To intensify the cocaine high.
To ease the unwanted symptoms of coming down from cocaine.
There is a consistent and significant association between alcohol or drug use and injury. Intracranial hematomas, subdural hematomas, and other conditions can remain unnoticed if the symptoms of acute alcohol intoxication and withdrawal are not distinguished from the symptoms of a brain injury.
Domestic Violence
A woman or man who is a victim of domestic violence often does not seek help or speak about the abuse. Identifying the problem by a health care worker is the first step in helping this patient get help.
Emotional Abuse
Examples of emotional abuse include having an adult demean a child’s worth or frequently criticize or belittle the child. Demeaning a person’s worth, frequent criticism. A nurse is a mandated reporter of real or suspected abuse in children, elderly and mentally disabled.
Child Abuse
Nurse’s legal responsibility. MUST REPORT Child Abuse in Florida. Each state has specific regulations for reporting child abuse that must be observed. The reporter does not need to be absolutely sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts.
Potential Nursing Diagnosis:
The difference between Anger and Aggression is
Intent:
Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others.
Rape
Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told.
Written information acknowledges this fact and provides a solution.
Anger
Feeling of annoyance that may be displaced on another person or object – anger is used to avoid anxiety and gives a feeling of power in situations.
Aggression
Can be harmful and destructive when not controlled.
Violence
Is a physical force that is threatening to the safety of self or others. Combative, aggressive behavior.
Antipsychotic medications can be given to reduce aggression.
Violence Assessment
- History of violence or self harm, poor impulse control, low tolerance for frustration.
- Defiant and argumentative, raising of voice, making verbal threats, pacing and agitation.
- Muscle rigidity, flushed, glaring at others.
Violence Nursing Interventions
- Use a calm approach , and a clear tone of voice.
- Maintain a large personal space, use non-aggressive posture.
- Listen actively , acknowledge the clients anger, learn their needs.
- Provide the client with clear options that deal with the clients behavior.
- Discuss the use of restraints or seclusion if they cant control their anger.
- Assist the client in problem solving.
Restraints
1.Restraints and seclusion should never be punishment and are a last resort.
- Restraints are used when behavior is physically harmful to self or others.
- Restraints can be requested by the client.
- The nurse must document the behavior leading up to the use of restraints.
- In an emergency a qualified nurse may place a client in restraints then call for an order.
- Within 1 hour of restraints being placed a psychiatrist must make a face to face assessment and must continuously reevaluate.
- While in restraints the client must be protected from all sources of harm.
- While in restraints the client must be closely supervised , physical/ comfort needs need assessed q 15 min- q30 min (foods, fluids, ambulation).
Seclusion
A process in which a client is placed alone in a specially designed room for protection and close supervision.
Chemical Restraints
Medications given for the purpose of sedation to inhibit undesired behavior.
ADHD Medications
Central nervous system stimulants, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD.
Autism
- Presents by early childhood; boys more than girls.
- Little eye contact, few facial expressions, limited gestures to communicate, limited capacity to relate to peers or parents, lack of spontaneous enjoyment, apparent absence of mood and affect.
Child fails to display affections toward others.
- Goals: reduced behavioral symptoms, promote learning and development.
•Special education: language therapy; medications to target symptoms.
Sexual Assault
Nursing Interventions
Provide referral information verbally and in writing.
- A nurse is teaching a group of students about the risk factors and complications of anorexia nervosa, which of the following complications should be stressed as the most serious?a. Increased risk of mortality 2. The Nurse is conducting a presentation for family members on personality disorders. What would be included in this presentation (select all that apply) a. Personality traits can be challenging to change b. Personality traits are formed early in life c. Stress has an impact on daily behaviors and attributes 3. A newly admitted client diagnosed with somatization disorder asked for his pain medication that is ordered on as needed basis. What is the nurses best action to this request?a. Administer the medication as prescribed 4. What behavior by the client diagnose with bulimia nervosa indicates progress in treatment?a. Verbalizing feelings 5. A child diagnosed with autism spectrum disorder makes no eye contact, does not respond to verbal directions from the staff members, and constantly twists, spins and head bangs. Which of the following would be the best nursing action?a. Ensuring the child does not receive an injury from body movements6. The parent of a child with attention deficit hyperactivity disorder (ADHD) tells the nurse that the child does not follow directions well. What strategy would be best for the nurse to recommend?a. Try having the child repeat the instructions before starting the task 7. A client is prescribed lorazepam 0.5 mg PO four times a day (QID) and 1 mg PT every 8 hours PRN. The maximum daily does of lorazepam shouldnot exceed 4 mg daily. This client would be able to receive __ PRN doses as the maximum number of PRN lorazepam doses (round as a wholenumber. Do not use trailing zero, type the number only, do not include the label) a. 28. The nurse is working with a client who is preoccupied with perfection, cannot discard anything, and has trouble relaxing. Which of the following personality disorders is being described within this example?a. Obsessive Compulsive 9. A nurse working on a inpatient psychiatric unit observes a client diagnosed with obsessive compulsive disorder (OCD) rearranging the magazines in the dayroom. The nurse understands this action is primarily meant to do with of the following?a. Temporarily reduce the anxiety the client is feeling 10. A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client asks for assistance with a shower, which comment by the urse is the most appropriate?a. “I will be glad to assist, ill be right back with your supplies.”11. A 4-year old child states to the nurse “if I can make a big enough wish, my dad wont be dead anymore.” What is the conclusion made by the nurse?a. The child is voicing thoughts that are normal for children this age 12. While caring for a teenage client with attention deficit hyperactivity disorder who is at high risk for self-harm due to poor judgment, high risk-taking behaviors and impulsivity. Which of the following is the priority nursing intervention?a. Have a staff member assigned for one-on-one observation at all times 13. The nurse is caring for a client diagnosed with somatic symptom disorder. The client continues to focus on his severe back pain. Which of the following is the most therapeutic nursing intervention?a. Allow the client to discuss physical concerns and then redirect to coping skills for stress 14. A child is diagnose as being on the autistic spectrum. Which clinical manifestations should the nurse expect? (Select all that apply)a. Inability to maintain eye contact b. Inability to express themselves c. Repetitive body movements15. What factor is precipitating symptom of depression and suicidal intent in the elderly?a. Bereavement overload 16. A client with past experiences of eating disorder symptoms uses the ego defense mechanism of sublimation in dealing with this disorder. How is this expressed?a. The client speaks at high schools about her disorder 17. A client has blindness related to conversion disorder. To assist the client with eating, which of the following interventions should the nurse implement?a. Expect the client to feed himself after explaining the arrangement of the food on the tray 18. Which assessment data should the school nurse recognize as sign of physical neglect?a. The child is often absent from school, wears dirty clothes, and seems withdrawn and tired 19. A child diagnosed on the autism spectrum may experience repetitive behaviors. Which of the following are examples of repetitive behavior which could be observed.a. Flapping their hands b. Spinning in circles 20. A client diagnosed with dissociative disorder suddenly begins to speak with a child’s vocabulary and voice. What interpretations should the nurse make of this behavior?a. A state of depersonalization 21. A nurse is preparing to administer buspirone 7.5mg PO every 12 hr to a client. The amount available is buspirone 15 mg/tablet. How many tablet(s)should the nurse administer per dose? (Record answer to the tenth, or one decimal place. Use leading zero if it applies. Do not use a trailing zero. Type the number only. Do not include the label.)a. 0.522. An elderly client was neglected by family in the home setting. The abuse was reported. What factor would have the client to remain home?a. Competent adults can decide to remain in the setting 23. A client is diagnosed with antisocial personality disorder. She has a violent verbal, physically threatening outburst in the dayroom of the unit when the nurse explains she cannot smoke in the hospital. What is the priority action the nurse should take?a. Remove all other clients from the dayroom to ensure safety 24. The client is ordered venlafaxine 225mg PO daily. Available on the unit is venlafaxine 75mg tablets. How many tablets will the nurse administer forthe daily dose? (Record answer to the tenth, or one decimal place. Use leading zero if it applies. Do not use a trailing zero. Type the number only. Do not include the label.)
a. 325. A terminal client expresses concern that his spouse seems distant and continues the activities always carried out with him, now without him. This situation is an example of what type of grief?a. Anticipatory grief 26. The nurse is caring for the client who is prescribed haloperidol 4mg orally on admission. An oral suspension of haloperidol 2mg/mL is received from the pharmacy. What amount of mL of the suspension should the nurse administer to the client? (Record answer to the tenth, or one decimal place. Use leading zero if it applies. Do not use a trailing zero. Type the number only. Do not include the label.)a. 227. The nurse is caring for a client with attention deficit hyperactivity disorder. The child has been prescribed methylphenidate. Which of the following symptoms are side effects the nurse will monitor for? (Select all that apply?a. Insomnia b. Decreased appetite c. Headache 28. A nurse is preparing to administer haloperidol 75 mg IM per week. Available is haloperidol decanoate 100 mg/mL for injection. How many mL should the nurse administer per dose? (Record answer to the tenth, or one decimal place. Use leading zero if it applies. Do not use a trailing zero. Type the number only. Do not include the label.)a. 0.7529. The nurse is caring for a client who has just been injured by her male partner. The client states that for the first time he has been physical abusive, but her apologized and has since sent her flowers. What is the intervention by the nurse? a. Teach the client the cycle of battering 30. What behavior best describes physical aggression a. Stomping away from the nurse’s station, going to the day room, and grabbing a pool cue from a client standing at the pool table. 31. A client has been prescribed buspirone for a new diagnosis of generalized anxiety disorder (GAD). Which statement by the client indicates an understanding of the medication?a. “I should begin to feel better in a few days”32. The provider ordered lorazepam 2 mg IM stat. Available is lorazepam injection 5mg/mL. How many mL will the nurse administer? (Record answer to the tenth, or one decimal place. Use leading zero if it applies. Do not use a trailing zero. Type the number only. Do not include the label.)a. 0.433. A client is diagnosed with terminal cancer. Which situation should the nurse asses as reflecting Kubler-Ross’s grief stage of anger?a. The client is devoted catholic but refuses to attend church and states that his faith has failed him34. A 7-year old male client has sever bruising on his arms and injury to his abdomen. The nurse should consider child abuse if the parents act in what manner?a. The parent delayed seeking treatment 35. Which of the following statements best describes a goal of group therapy?a. The members can hear from others who have experienced similar experiences 36. A 79-year-old client admits that his daughter hits him while helping him dress each morning. What is the appropriate nursing action?a. The nurse is required to make sure the proper authority is informed 37. A client states she is hearing voices that tell her to cut herself. She already has several superficial marks on her wrists from scratching herself with the plastic eating utensils. She will not contract for safety. What is the priority nursing intervention?a. Place on one-to-one, constant observation to ensure she does not harm self 38. A client recently lost his wife to Covid-19. Which statement by the client may alert the nurse the client may be negatively coping with the death?a. “Avoiding contact with others is easier to deal with.”39. A client is diagnosed with obsessive-compulsive disorder. Which action by the nurse would increase the client’s anxiety?a. Changing the schedule throughout the day 40. A community health nurse is planning a training for post-traumatic stress disorder. Which of the following clients would be considered the most vulnerable to post-traumatic stress disorder?a. A 20-year-old college student with diabetes mellitus who experienced date rape 41. A child Is admitted to the inpatient psychiatric unit with a diagnosis of conduct disorder. The nurse would expect to find which of the following syndrome?a. A history of cruelty towards people and animals 42. A client with antisocial personality disorder states to the nurse, “a novice like you can’t possible help me.” What is the best response by the nurse?a. “What needs do you thing I can’t meet?”43. A child diagnose with oppositional defiant disorder is spiteful, vindictive and argumentative and has a history of aggression towards others. Which of the following would be apriority nursing concern?a. Ineffective coping in dealing with negative behaviors 44. A client diagnosed with borderline personality disorder is angry that the night shift staff would not let her during coffee at 3 a.m. she discusses this in a community meeting and develops a following of clients who demand access to the cafeteria at all hours. How can the nursing staff manage this situation to prevent “splitting”?a. Staff discuss the situation and agree upon consistency 45. Which of the following statements by the nurse, who cares for children psychiatric disorders, is a concern?a. “I know exactly how the child feel since I went through the same thing”46. The family of a 17-year-old client diagnose with anorexia nervosa is encouraged to attend family therapy sessions. The parents state, “we don’t have the eating disorder, why should we attend?” what is the best response by the nurse?a. “Gaining insight about her illness and what contributes to it will be beneficial”47. A 16-year-old is admitted to the adolescent unit with a diagnosis of conduct disorder. This condition is often manifested by what behavior a. Physical aggression in violation of others 48. The nurse has determined systematic desensitization is the therapy being used to treat the client with acrophobia. How is this demonstrated?a. Gradual exposure to higher areas 49. A nurse is developing a care plan for a client with post-traumatic stress disorder. Which of the following should be completed first?a. Encourage the client to verbalize thoughts and feelings about the trauma 50. The nurse is assessing the client in a fugue state. What assessment findings would the nurse recognize as most significant to experiencing a fugue state?a. History of childhood trauma - What is the priority nursing intervention when providing care to the client who was brought to the emergency department after sexual assault?a. Ensure safety of the client in a private room 52. A female client expresses to the nurse that she feels like she didn’t do enough o prevent the loss of her father. Which of the following intervention should the nurse use to address the clients’ feelings?a. Review the circumstances of the loss and the reality that it could not be prevented 53. A child drowned while swimming in a local lake 2 years ago. Which behavior best indicates the child’s parents are mourning in an effective way?a. They throw flowers on the lake at each anniversary date of the accident. 54. A client is diagnosed with agoraphobia. Which question indicates the nurse understands the etiology related to this disorder?a. Can you share the places that cause you fear?55. A client is prescribed diazepam as needed (PRN) for panic disorder. Which of the following facts would cause the nurse to question the order?a. The client had a sever addiction problem in the past 56. A client has an order for triazolam 0.625 mg PO at bedtime for insomnia. On hand is triazolam 0.25 mg tablets. How many tablets will the nurse administer with each dose? (Record answer to the tenth, or one decimal place. Use leading zero if it applies. Do not use a trailing zero. Type the number only. Do not include the label.)a. 2.557. A nurse is caring for a client experiencing panic level anxiety The nurse understands which of the following nursing actions should be considered a priority?a. Stay with the client and reduce the stimuli in the room 58. A client weighs 190 lb. what is the clients wight in kg? (Round answer to the nearest tenth, or one decimal place)a. 86.459. A 28-year-old male client has poor relationships and is suspicious of others. According to Erikson’s theory of psychological adjustment, at what stage were tasks unmet?a. Trust vs. mistrust 60. The nurse observes a client diagnosed with anorexia nervosa doing repeated, vigorous sit-ups in her room. What is the most therapeutic interventionby the nurse?a. Interrupt the routine and offer to walk with her 61. A client states “I was diagnosed with panic attacks. I have heard of dissociative disorders. What is the difference?” what is the nurses best response a. In dissociative disorders, the person experiences an involuntary escape from reality characterized by a disconnection between thoughts, identity, consciousness, and/or memory.”62. A client is admitted with a diagnosis of dependent personality disorder. Which question by the nurse indicates an understanding of the essential features of the disorder?a. “Are you afraid of being alone?”63. What are the effective intervention to facilitate autonomy for a client diagnosed with an eating disorder?a. Have the client give input when establishing the expected outcomes 64. Which statement by an elderly client might suggest financial abuse is occurring?a. “After I gave my son access to my bank account, I noticed he has a brand-new car”65. A nurse is caring for a client with factitious disorder imposed on another, which of the following statement by the client would the nurse expect?a. “I made my daughter sick because no one was paying us any attention”66. Which of the following is a therapeutic approach to setting limits with clients diagnosed with antisocial personality disorder?a. Clarify the rules for all and make expectations clear67. A school-age child is talking with her grandmother, who is dying. What should the nurse say to the child?a. “Even though she may not answer you, she can hear you”68. A 7-year-old male without any other diagnosed problem engages in jaw clenching, rocking back and forth, and unable to engage in physical contact. The nurse recognizes these symptoms of which of the following conditions?a. Autism spectrum disorder 69. The nurse is caring for a 12-year-old client diagnosed with oppositional defiant disorder. The client’s mother asks what type of medication is usually prescribed for this diagnosis. Which of the following is the most appropriate response by the nurse?a. “Though medications may be used to treat symptoms, the focus will be on behavioral therapy”70. Which statement by the nurse in the emergency department indicates a firm knowledge base regarding intimate partner violence?a. “Power and control are the central dynamics of abuse”71. A child diagnose with oppositional defiant disorder begins to yell at staff members when asked to leave group therapy because of inappropriate behaviors. Which nursing intervention would be most appropriate?a. Accompany the child to a quiet area to decrease external stimuli 72. A nurse is working with a client with a histrionic personality disorder. Which of the following nursing interventions must be implemented throughout the inpatient stay?a. Setting appropriate limits on maladaptive behaviors 73. What is the difference between post-traumatic stress disorder (PTSD) and Acute stress disorder?a. in ASD the symptoms start and end with in 1 month74. When planning the care of a 6-year-old child diagnosed with oppositional defiant disorder, the nurse should include which method of therapy?a. Cognitive therapy 75. A female adolescent client says to the nurse, “Hey, you stupid blonde, what are you looking at?” Which of the following responses would be inappropriate for the nurse make?a. “Don’t you ever talk to me like that again”