sign of anorexia
amenorrhea
signs of bulimia
tooth erasion
Russell's sign= callused knuckles from self induced vomitting
what lab value do you expect with alcohol cardiomyopathy
high CPK
which PD- pt needs external input to make everyday decisions
dependent
a client that demonstrates a dedication to his job that excludes time for leisure activitites
OCD
adheres to a rigid set of rules
OCD
a client who has trouble starting new relationships unless he feels accepted
avoidant personality disorder
healthy adolescnet behavior
realistic self concept
healthy preschool behavior
displays an egocentric apprach to problem solving
toddler healthy behavior
requires literal explanations
who displays mistrust of others
an infant
what should you teach parents about autism spectrum disorder
language delay
does an autistic kid have fear of abandonment
nope- a kid with separation anxiety does
does an autistic kid have hostile behavior
no- a kid with oppositional defiant disorder does
what demonstrates active listening
attention to body language (identifying verbal and nonverbal communication)
a pt is getting a new Rx of haldol- what symptom should you tell them to report
shuffling gait
(dry mouth and blurred vision are common- also teach the client to stay out of sun)
the nurse is caring for a client who has anorexia- which criteria requires hospitalization
weight loss of over 30% in 6 months
hypothermia- less than 96.8
K less than 3
HR less than 40
how often should you offer the client food in seclusion
every hour
also document behavior every 15-30 min
a nurse is planning DC teaching to a family member of a pt newly diangosed with depression= what should the nurse teach about relapse
early identification of changes such as decreased social involvement is important
is this true= medication compliance will prevent further need for inpatient hospitalization
not always
intoxication of _____
HR 104
BP 152/94
dilated pupils
cocaine
intoxication of _____
constricted pupils
low BP
heroin
would a high BP and HR be common if intoxicated with inhalants
nope- these are depressants
SE of imipramine (4)
mild tachycardia (not brady)
urinary retention
increased appetite and wt gain
tinnitus
signs of PTSD
distressing dreams
difficulty concentrating
exaggerated startle response
(not delusions and compulsions)
purpose of attending support group
provide assurance that others have a similar problem
sign of delerium
sudden onset- rapid inappropriate speeach
do clients with delerium have slow speech
no- rapid
do clients with delerium have a flat affect
no-appropriate
do they have normal moods?
no- mood swings
can ECT increase risk of parkisnons
no
how often does ECT happen
2-3 times a week for 6 to 12 treatments so 4-6 weeks
should you move a pt with depression to a private room
no- they are risk of self harm and isolated
better to move the bipolor patient
what lab should you do if patient is getting risperidone
glucose- can cause diabetes
defense mechanism of conversion
uncosciously converting anxiety into physical symptoms
transferring feeling about illness to another less threatening situations
displacement
client demonstrates opposite action of what she is really feelings
reaction formation
priority goal for a client with borderline personality disorder
client will refrain from self mutiliation
in the presence of low ____ levels renal excretion of lithium is reduced and client is at risk for toxicity
NA
so less than 135 is bad
what is tranylcypromine
MAOI
is bologna okay to eat with MAOI
no- processed meet
can a client with MD make informed health desicions and give consent
yes
who can not give consent
kids less than 18
intoxicated- blood alcohol level of .08
client with a dose of morphine
what should you do to help encourage a silent group member to participate in group
divide the group into pairs to discuss a topic, then summarize the discussion to the group
wht should you do if people try to monopolize the discussion
encourage the group that everyone should have a chance to participate
ask the group to share observations of other group members (dont do this for the silent patient)
what should you do if a patient exhibits demoralizing or negative behavior
focus on the group member and emphasize their helpfullness
___ increases the likelyhood of family violence
substance use
"my son has a few drinks each night to unwind" is a sign
clinical findings of mild anxeity
restless, irritable, nail biting, fidgeting
moderate anxiety
tensions, palpitation, increase heart rate, sweating
severe anxiety
trouble sleeping
light headed
nausea
tremors
sense of impending doom
panic
hyperactive
severe tremors
uncoordinated impulsive behavior
sign that valporic acid is working
less pressured speech (remember for bipolar)
less insmonia
less gradiose
a client was admitted as involuntary for substance abuse and is refusing the lorazepam- what do you do
dont give it- they still have the right to refuse treatment
when the client maintains eye contact and leans forward
shows he trusts the nurse
child with conduct disorder is behaving in a destructive manner- throwing things and kicking people- what is highest priority intervention
1. encourage kid to express feelings
2. promote attendance at an assertive training group
3. try relaxing breathing
4. use a therapeutic holding technique
4- hold- need to maintain safety
to establish a trusting nurse relationship th enurse should first
inform the client that her admission will be confidential (express confidentiality in the initial phase or relationships)
what should you do in working phase
introduce clients to others in the day room
assist the client to make behavioral changes
determine coping strategies the client has used in the past
what indicates a risk for complicated grief (cmplicated when it affects daily functioning)
when a client has trouble carrying on normal activities after a loss "I feel so empty without my wife, its hard to get up every morning"
dementia patient- useful to help orient them to reality
place a large calendar on the wall
the tx plan is for a pt with schizo to gain autonomy from his parents. Prior to DC the nurse should plan to
schedule a family conference
not stress to the client that he needs to be more independent
in group a bipolar patient begins bragging and dominating the situation- what should the nurse do
tell the client to calm down or he will dismiss him from the group
example of situational crisis
lost a grandparent in a motor vehicle crash
an unexpected even
adventitious crisis
town hit by tornado
external disaster
maturational crisis
son leaves for college or fear of upcoming retirement
natural life event
a nurse is developing a plan of care for a patient who exhibits anger, aggression, and violent behavior, what is the priority nursing intervention
create a large personal space- this helps provide safety
not use therapeutic communiciton (this only prevent escalation of agression and is a part of ongoing therapy)
prupose of AA
to use peer support to maintain abstinence
client in group gets angry and yells "listening to you people is making me worse. how do you respond
you sound angry and frustrated. tell us more about how you are feeling
what drug should you give for alcohol withdwaral
chlordiazepocide (librium)- benzo
does the code of ethics esure the right to tx and individualized care
yes
the duty to protect third parties requires a nurse to testify about a client
no- only if she is given info regarding potential harm
a nurse is caring for a client with a hx of agression, the client is playing cards and throws them at other patients- what should you do
ask the client how he is feeling (therapeutic cmcn)
not take the cards away (this will increase aggression)
explaining unit rules will not help either
SE of lithium that causes them to stop takin it
hand tremors- prevents them from doing ADLs
if you overhear another nurse talking bad about a client what should you do
do not confont that person directly
report it to charge nurse
anorexic client who needs to increase oral intake- what interventions should the nurse take
restrict caffiene - diuretic
should you increase or decrease fiber
increase to prevent constipation
should you offer rewards for the amt of weight gained
no- for the amt of calories taken in though can reward
should you increase daily intake to 2500 cals
initial intake should not go below 1200 but 2500 may be too overwhelming (want small frequent meals)
a nurse in a 24 hr mental health facility is planning DC for a client with a long history of alcohol use disorder- what postdischarge activity should the nurse plan to inlcude
attending a relapse prevention group several times each week
like AA 12 steps
is buprenorphine for alcohol
no- opioids- heroin
is methadone for alcohol
no- heroin
a client is experiencing alcohol withdrawal delerium- which roommate is most appropriate for this patient
one with depression- will allow client to rest
pt with acl withdrawal needs uninterrupted rest
why would a hypervigilant roommate not be good
this pt will not let the pt with alcohol withdrawal get the most rest he needs
example of the displacement defese mechanism
the client critizises the nurse each med administration time (really mad about meds but taking it out on nurse)
what defense mechanism is (the client reports a HA each day when group therpay is scheduled)
conversion
what defense mech (client always talks about healthy eating habbits)
reaction formation
defense mech (the pt complains about the taste of the food)
rationilization
good statement that shows that suicide risk has decreased
"it is easier to talk about my feelings now"
"im relieved now that my finanical affairs are in order"
more at risk when afairs are in order
"thank you for taking such good care of me"
more at risk- people show an appreciation for loved ones when contemplating suicide
who is at great risk for injury when doin gADLS
stage 6 alzheimers disease
maintenanc ephase of schizo
calm and able to preform self care
how can you help with OCD behaviors
assist the lcient to set limits of behaviors
should the client with OCD monitor the number of times he has obsessive thoughts
no- this can be ven more time consuming
how should you assess spirituality
discuss spiritual issues in a conversational manner not in a formal manner (this should be done by a pastor)
a client is taking an SSRI like paroxetine- what should you tell the client to report to you if they notive
FEVER- Serotnonin syndrome
not sex dysfunciton- this is normal
priority assessment finding for a client taking valporic acid
pt has not slept in 24 hours
not fine hand tremors (this is normal effect)
highest priority intervention for a pt with OCD
help client id sources of anxiety
not teach client focused relaxation techniques (good but not better that identifying sources of anxiety)
could also use + reinforcement for nonritual behavior but not best
admitting a pt experiencing alcohol withdrawal, is nauseas, shaking, and irritable- priority interventin
date and time of last drink (worst withdrawal 24-48 hrs after last drink)
when client is unable to openly acknowledge nd express grief
disenfranchised grief
exxaggerated grief
distorted grief
what do you expect with masochism
fantasized being humiliated and bound
recurrent, sex urges of being beaten, bound, and humiliated
exhibitionism
exposing genitals to strangers
fetishism
sex fantasies about non living objects
frotteurism
urges to touch and rub against non consenting individuals
exaple of enmeshed boundaries
children taking care of their younger siblings
what do you say if a pt becomes verbally abuseive
i am leaving now but returning in a few minutes to see if you are calmer
which label worries us with clozapine
WBC of 2500
intervention for patient with delerium
permit the client daily rituals to decrease anxiety
dont keep lighting dim (want to be able to see invironment)
dont give too man decisions because may get frustrated
teach about light therapy for SAD
wear sunglasses when go outside- bc light therapy can cause eye strain and sensitivity to light
(dont need to increase fluids bc will not cause dehydration)
should you get a no suicide contract from a pt who recently attempted suicide and is angry over being admitted
no- should wait til pt is no longer angry and you can develop rapport first
so what should you do with this patient (just attempted suicide and is angry about admission)
administer adntidepressant
1 to 1 observation
a client says about ECT "I will be able to stop taking my antidepressants after the tx"
nope= sorry need maintenacne
planning teaching about relapse prevention to a client who just began an outpatient substance use disorder tx program- what should you teach at the beginning
simple rules and objectives or program (pt still may have cog impairment RT detix)
teach about resperidone
1. may cause high blood sugar
2. mestrual irregularities may occur while on this med
3. you make experience dizziness while taking this med
(no increase in hair or excess sexual desire)
how do you use simple restitution as a behavior managment technique for a child with conduct disorder
make the child pick up books after he threw them all over the room
"Im not going to my family reunion because no one asked me to help plan it"
sign of uselessness is a sign of depression
refer families to a grief counselor following suicide
tertiary
work with nurse to determine students at risk for suicide
primary (preventing suicide)
establish a telephone hotline for individuals experiencing a suicide crisis
secondary
review suicide precautions with nursing staff
secondary (involves treating a client during suicide crisis)
an impotant consideration in promoting client adherence to treatment regiment
providing care to a clients physical health needs
teach about buspar
dont take with grapefruit bc will intensify effects
takes 3-4 weeks to work
will not cause withdrawal
early stage of grief= denial
"i think my labs got mixed up with someone elses"
highest priority intervention for a kid with ADHD
remove unesarry stuff from childs surroundings cb greatest risk if injury to impulsive behabior
not use + reinforcement when the pt gets a task done
behavior that indicates that the client shoul dhave restraints removed
listens to nurses directions
sign of recovery for someone who was sexually assulted
client expresses interest in intimate relationships
signs of depression
flat affect
anhedonia
feeling hopeless
which lab value of a pt on lithium should make you hold med and call dr
BUN of 45- lithium is hard on kidneys
BUN normal is 6-20
primary prevention
promoting self esteem
administering meds to minimize long term efects of violence
secondary
what shoul dyou do if one pt is talking too much in group
ask the clients to discuss their feelings about the monopolizing behavior
important teaching need for a pt on olonazpine
do not drive after initial doses- will make you drowsy and dizzy
order the phases of the nurse client relationship
1. pre-orientation= identify safety risks
2. orientation phase= set parameters
3. workin gphase= promote problem solving skills
4. summarize goals
secondary dementia caused by thiamine def.
korsakoff's syndrome- be sure to help client with ambulation
first action when you witness one client with dementia slap another
call team members for help
do not try to go by self
priority action by nurse to client just admitted with bipolar
provide frequent high calorie snacks
voluntary admission- doing initial assessment and pt says "I've lost control of everything in my life"
are you having thoughts of killing yourself