Clinical findings of mild anxiety can include
restlessness, irritability, nail biting, and fidgeting.
Clinical findings of moderate anxiety
Clinical findings of moderate anxiety can include tension, palpitation, increased heart rate, and diaphoresis
client receiving tranylcypromine what foods hould be avoided?
Foods containing tyramine can interact with tranylcypromine, an MAOI, which can lead to hypertensive crisis. CHICKEN IS GOOD THIS IS THE MAOI
Imipramine, a tricyclic antidepressant, has what general effects?
anticholinergic
Clients who have heroin intoxication typically have what pupils and what blood pressure?
... constricted pupils, and a decreased blood pressure.
halperidol side efefct?
Clinical findings of pseudoparkinsonism such as shuffling gait may occur 5 hr to 30 days after beginning treatment. The client should notify the provider who might prescribe an antiparkinsonism agent.
what it is an indication that there is a risk for complicated grief.
When a client has difficulty carrying on normal activities following a loss, it is an indication that there is a risk for complicated grief.
*LYNN*
review notes on nurse client relationship
sdf
The greatest risk to this child and others is harm; therefore, the nurse's priority intervention is to use a therapeutic holding technique to de-escalate the behavior and prevent injury.
Use of active listening involves identifying verbal and nonverbal communication of the client, which includes attention to body language.
A nurse is developing a plan of care for a client who exhibits anger, aggression, and violent behavior on the unit. The priority nursing intervention is to
The greatest risk is injury to the client, staff, and others; therefore, creating a large, personal space between the nurse and the client to ensure safety for the nurse and the client is the priority intervention.
do PTSD have delusions?
NO...they will have ILLUSIONS OF HALLUCINATIONS!
do PTDS have difficulty concentrating
YES
A child who has oppositional defiant disorder is more likely to demonstrate hostile behavior.
A child who has oppositional defiant disorder is more likely to demonstrate hostile behavior.
A child who has Tourette's disorder is more likely to demonstrate motor and verbal tics.
A child who has Tourette's disorder is more likely to demonstrate motor and verbal tics.
The nurse should offer food to the client in seclusion every hour.
A nurse is admitting a client to an inpatient unit who is in the acute stages of schizophrenia. The nurse observes the following findings: restlessness, pacing with clenched fists, eyes darting to one side, and muttering. Which of the following interventions should the nurse initiate?
This intervention decreases environmental stimuli, which should reduce the client's agitation. It also allows the nurse to develop a therapeutic relationship with the client and make the client feel safe.
The client's youngest son leaves for college.
The client experiences a maturational crisis during a natural life event.
Communication, which is privileged, protects professional staff from divulging communication between clients and professional staff, not between nurses.
A nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following should the nurse include in the teaching?
A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent?
A client who has just received morphine, an opioid analgesic, is functionally incompetent due to the effect on the CNS.
conversion defense mech
The client demonstrates conversion if she unconsciously converted her anxiety into physical symptoms.
supression defense mech
The client is suppressing her feelings about dealing with having a chronic illness when she consciously denies her current health status.
displacement defense?
The client demonstrates displacement if she transferred her feelings about her illness to another less threatening situation.
reaction formation defense mechanism
The client demonstrates reaction formation if she demonstrated the opposite behavior of what she is really feeling.
Criteria for hospitalization is a heart rate less than
40/min
A nurse is performing an assessment on a 78-year-old client who has injuries consistent with suspected abuse. Which of the following statements indicates the greatest potential risk factor for abuse?
Substance use increases the likelihood of family violence. The use of alcohol by this client's adult son places this client at greatest risk for abuse.
Chlordiazepoxide
The nurse should administer chlordiazepoxide for acute alcohol withdrawal to prevent withdrawal symptoms. AKA librium
naltrexone
The nurse should administer naltrexone after alcohol detoxification to assist the client to maintain abstinence. AKA REVIA
disulfiram
The nurse should administer disulfiram after alcohol detoxification to assist the client to maintain abstinence. AKA antabuse
A nurse is caring for a client in a mental health facility who has recently started a new prescription for valproic acid. For which of the following should the nurse monitor to determine effectiveness of the medication?
The nurse should monitor for decreased episodes of pressured speech, insomnia, grandiose thoughts and hyperactivity for a client who has mania and is taking valproic acid.
A nurse is conducting a group therapy session for clients who have bipolar disorder. One of the clients begins bragging and dominating the conversation. Which of the following actions should the nurse take?
Tell the client to calm down or he will be dismissed from the session.
It is important for the nurse to provide clear expectations and set limits for the client; therefore, this is an appropriate action for the nurse to take.
Alcoholics Anonymous promotes taking ___ for recovery
Alcoholics Anonymous promotes taking responsibility for recovery rather than the addiction.
cognitive reframing
A technique that replaces negative thoughts with positive self-statements is the correct use of cognitive reframing and will reduce the client's anxiety.
Anhedonia
Anhedonia is correct. The nurse should document the inability to experience pleasure as a clinical manifestation of major depressive disorde
A nurse is planning care for a newly admitted client who has bipolar disorder. Which of the following is the priority action by the nurse?
Provide frequent high-calorie snacks.
The priority action the nurse should take when using Maslow's Hierarchy of Needs is to meet the client's need for adequate nutrition; therefore, providing high-calorie snacks is the priority action.v
review what serotonin syndrome is
df
A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions is the highest priority
Remove unnecessary equipment from the child's surroundings.
The greatest risk to the child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm; therefore, the priority intervention is to remove unnecessary equipment from the child's surroundings.
A nurse is planning care for an older adult client who is experiencing delirium. Which of the following interventions will meet the needs of this client?
Permit the client daily rituals to decrease anxiety.
Allowing clients who have delirium to practice daily rituals will decrease frustration and anxiety.
look up
what dysthymic disorder is
review delirium
patients
A nurse is admitting a client who has a history of alcohol use and a new diagnosis of Korsakoff's syndrome. Which of the following should the nurse include in the client's plan of care?
Provide assistance with ambulation
A client who has Korsakoff's syndrome has a secondary dementia caused by a thiamine deficiency, often caused by long-term alcohol use. Safety precautions are necessary to protect the client from injury.
remember care plan patient
K IS NON REVERSIBLE
weirnickes is reversible
A nurse is caring for a client who has paranoid schizophrenia, has been physically violent toward others and received several as needed doses of haloperidol IM. The nurse is preparing to administer benztropine to treat which of the following adverse effects of haloperidol?
Stiff and stooped posture is a manifestation of pseudoparkinsonism, which is an extrapyramidal side effect of haloperidol that can be treated with benztropine.
t3 and t4 level norma
mbnm
bowel sounds for pancreatitis
?The nurse should expect the client who has acute pancreatitis to have decreased, and possibly absent, bowel sounds due to the risk for paralytic ileus.
bn
Clients receiving end-of-life care prefer that discussions of spirituality occur in ordinary conversation.
A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions is the highest priority?
nstruct the client to avoid driving during initial therapy.
The greatest risk to this client is injury resulting from drowsiness or dizziness; therefore, the nurse's priority intervention is to instruct the client to avoid activities that require mental alertness during initial medication therapy.
teachings for risperdol?
"This medication may cause an elevated blood sugar."
"Menstrual irregularities may occur while taking this medication."
"You may experience dizziness while taking this medication."
masochism
s and m
early finding of depression in older adults?
feelings of uselessness
"I'm not going to the reunion because no one asked me to help plan it."
busprione (buspar)
antianxiety...DIFFERENT from buproprion which is the wellbutrin,zyban for depression.
the former increases with grapefruit
when should a no suicide contract be signed?
Obtain a no-suicide contract is incorrect. The nurse should obtain a no-suicide contract when the client is no longer angry and when the nurse has developed a rapport with the client. The no-suicide contract is beneficial by assisting the client to explore alternative solutions for his problems, but does not negate the necessity for other suicide precautions.
looks up the satges of grief realted to dying
sdf
light therapy causes what sensitivity?
Wear sunglasses when outdoors.
Light therapy, or phototherapy, can cause eye strain and sensitivity to light.
what kind of qustions for the older adult interview?
The nurse should use yes-or-no and simple response questions if the older adult client becomes anxious or fatigued during the interview.
alcohol withdrawal means you need
uninterrupted rest
simple restituition?
The nurse recommends instructing the child to return the environment to its original state when using simple restitution as a behavioral management technique.
