A college student is extremely upset after failing two examinations. The student said, “No one understands how this will hurt my chances of getting into medical school.” The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? (Select all that apply.) Shame Panic attack Humiliation
Self-imposed isolation
Recent stressful life event.
Which nursing interventions will be implemented for a patient who is actively suicidal? (Select all that apply.) Maintain arm’s length, one-on-one direct observation at all times. Check all items brought by visitors and remove risk items. Use plastic eating utensils; count utensils upon collection. Remove the patient’s eyeglasses to prevent self-injury. Interact with the patient every 15 minutes.
A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? (Select all that apply.) 82-year-old white male 17-year-old white female 22-year-old Hispanic male 19-year-old Native American male 39-year-old African American male.
Which individual in the emergency department should be considered at highest risk for completing suicide? An adolescent Asian American girl with superior athletic and academic skills who has asthma A 38-year-old single, African American female church member with fibrocystic breast disease A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate.
After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? “Genetics are associated with suicide risk. Monitoring and support are important.” “Apathy underlies suicide. Instilling motivation is the key to health maintenance.” “Your child is unlikely to act out suicide when identifying with a suicide victim.” “Fraternal twins are at higher risk for suicide than identical twins.”.
A patient previously hospitalized for 2 weeks committed suicide the day after discharge. Which initial nursing measure will be most important regarding this event? Request the information technology manager to verify the patient’s medical record
is secure in the hospital information system. Hold a meeting for staff to provide support, express feelings, and identify
overlooked clues or faulty judgments. Consult the hospital’s legal department regarding potential consequences of the
event. Document a report of a sentinel event in the patient’s medical record.
Which statement by a depressed patient will alert the nurse to the patient’s need for immediate, active intervention? “I am mixed up, but I know I need help.” “I have no one to turn to for help or support.” “It is worse when you are a person of color.” “I tried to get attention before I cut myself last time.”.
The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is hopelessness. sadness. elation. anger.
When assessing a patient’s plan for suicide, what aspect has priority? Patient’s financial and educational status Patient’s insight into suicidal motivation Availability of means and lethality of method Quality and availability of patient’s social support.
A nurse counsels a patient with recent suicidal ideation. Which is the nurse’s most therapeutic comment? “Let’s make a list of all your problems and think of solutions for each one.” “I’m happy you’re taking control of your problems and trying to find solutions.” “When you have bad feelings, try to focus on positive experiences from your life.” “Let’s consider which problems are very important and which are less important.”.
A depressed patient says, “Nothing matters anymore.” What is the most appropriate response by the nurse? “Are you having thoughts of suicide?” “I am not sure I understand what you are trying to say.” “Try to stay hopeful. Things have a way of working out.” “Tell me more about what interested you before you became depressed.”.
A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, “My business is bankrupt, and I was served with divorce papers.” Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? “I wish I were dead.” “Life is not worth living.” “I have a plan that will fix everything.” “My family will be better off without me.”.
Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? As depression lifts, physical energy becomes available to carry out suicide. Patients who previously had suicidal thoughts need to discuss their feelings. For most patients, antidepressant medication results in increased suicidal thinking. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.
.
Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? Participating in reminiscence therapy Psychological postmortem assessment Attending a self-help group for survivors Contracting for at least two sessions of group therapy.
A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, “I am considering committing suicide.” “I’m glad you shared this. Please do not worry. We will handle it together.” “I think you should admit yourself to the hospital to keep you safe.” “Bringing up these feelings is a very positive action on your part.” “We need to talk about the good things you have to live for.”.
A tearful, anxious patient at the outpatient clinic reports, “I should be dead.” The initial task of the nurse conducting the assessment interview is to assess lethality of suicide plan. encourage expression of anger. establish trust with the patient. determine risk factors for suicide.
A nurse and patient construct a no-suicide contract. Select the preferable wording. “I will not try to harm myself during the next 24 hours.” “I will not make a suicide attempt while I am hospitalized.” “For the next 24 hours, I will not in any way attempt to harm or kill myself.” “I will not kill myself until I call my primary nurse or a member of the staff.”.
It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. Supervise the patient 24 hours a day. Begin discharge planning for the patient. Refer the patient to art and music therapists. Consider discontinuation of suicide precautions.
Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. “Why do you want to kill yourself?” “Do you have access to medications?” “Have you been taking drugs and alcohol?” “Did something happen with your parents?”.
A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, “We should have seen this coming. We did not do enough.” The parents’ reaction reflects guilt. denial. shame. rescue feelings.
A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will verbalize a will to live by the end of the second hospital day. describe two new coping mechanisms by the end of the third hospital day. accurately delineate personal strengths by the end of first week of hospitalization. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.
A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? Powerlessness Social isolation Risk for suicide Compromised family coping.
A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to current stress level. mood disturbance. suicide potential. level of anxiety.
A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? Calling parents Excessive crying Giving away sweaters Staying alone in dorm room.
Which change in the brain’s biochemical function is most associated with suicidal behavior? Dopamine excess Serotonin deficiency Acetylcholine excess γ-aminobutyric acid deficiency.
Which measure would be considered a form of primary prevention for suicide? Psychiatric hospitalization of a suicidal patient Referral of a formerly suicidal patient to a support group Suicide precautions for 24 hours for newly admitted patients Helping school children learn to manage stress and be resilient.
Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? Turning on the oven and letting gas escape into the apartment during the night. Cutting the wrists in the bathroom while the spouse reads in the next room. Overdosing on aspirin with codeine while the spouse is out with friends. Jumping from a railroad bridge located in a deserted area late at night.
An adult outpatient diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this patient’s history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? Amitriptyline Fluoxetine Desipramine Tranylcypromine sulfate.
For which patients diagnosed with personality disorders would a family history of similar problems be most likely? (Select all that apply.) Obsessive-compulsive Antisocial Borderline Schizotypal Narcissistic.
A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? (Select all that apply.) Reclusive behavior Callous attitude Perfectionism Aggression Clinginess Anxiety.
A patient says, “The other nurses won’t give me my medication early, but you know what it’s like to be in pain and don’t let your patients suffer. Could you get me my pill now? I won’t tell anyone.” Which response by the nurse would be most therapeutic? “I’m not comfortable doing that,” and then ignore subsequent requests for early
medication. “I understand that you have pain, but giving medicine too soon would not be safe.” “I’ll have to check with your doctor about that; I will get back to you after I do.” “It would be unsafe to give the medicine early; none of us will do that.”.
A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will adhere willingly to unit norms. report decreased incidence of self-mutilative thoughts. demonstrate fewer attempts at splitting or manipulating staff. demonstrate ability to introduce self to a stranger in a social situation.
Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are affable, generous. perfectionist, inflexible. suspicious, holds grudges. dramatic speech, impulsive.
A new psychiatric technician says, “Schizophrenia ... schizotypal! What’s the difference?” The nurse’s response should include which information? A patient diagnosed with schizophrenia is not usually overtly psychotic. In schizotypal personality disorder, the patient remains psychotic much longer. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.
A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is nonadherence. impaired social interaction. disturbed personal identity. diversional activity deficit.
Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient’s needs and maintain a therapeutic milieu? Ability to achieve true intimacy Flexibility and adaptability to stress Ability to provoke interpersonal conflict Inability to develop trusting relationships.
A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, “You used to care about me. I thought you were wonderful. Now I can see I was wrong. You’re evil.” This outburst can be assessed as denial. splitting. defensive. reaction formation.
A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should maintain a stern and authoritarian affect. provide care in a matter-of-fact manner. encourage the patient to express anger. be very rigid and challenging.
A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to an inherited disorder that manifests itself as an incapacity to tolerate stress. use of projective identification and splitting to bring anxiety to manageable levels. a constitutional inability to regulate affect, predisposing to psychic disorganization. fear of abandonment associated with progress toward autonomy and independence.
What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? Respect the patient’s need for periods of social isolation. Prevent the patient from violating the nurse’s rights. Teach the patient how to select clothing for outings. Engage the patient in community activities.
Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? Narcissistic Histrionic Avoidant Paranoid.
The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include arrogant, grandiose, and a sense of self-importance. attention seeking, melodramatic, and flirtatious. impulsive, restless, socially aggressive behavior. socially anxious, rambling stories, peculiar ideas.
For which behavior would limit setting be most essential? The patient who clings to the nurse and asks for advice about inconsequential matters. is flirtatious and provocative with staff members of the opposite sex. is hypervigilant and refuses to attend unit activities. urges a suspicious patient to hit anyone who stares.
When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include preoccupation with minute details; perfectionist. charm, drama, seductiveness; seeking admiration. difficulty being alone; indecisive, submissiveness. grandiosity, self-importance, and a sense of entitlement.
Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? “I think you are the best nurse on the unit.” “I’m never going to get high on drugs again.” “I felt empty and wanted to hurt myself, so I called you.” “I hate my mother. I called her today, and she wasn’t home.”.
A patient diagnosed with borderline personality disorder was hospitalized several times after multiple episodes of head banging and carving on both wrists. The patient remains impulsive. Which nursing diagnosis is the initial focus of this patient’s care? Self-mutilation Impaired skin integrity Risk for injury Powerlessness.
A patient says, “I get in trouble sometimes because I make quick decisions and act on them.” Select the nurse’s most therapeutic response. “Let’s consider the advantages of being able to stop and think before acting.” “It sounds as though you’ve developed some insight into your situation.” “I bet you have some interesting stories to share about overreacting.” “It’s good that you’re showing readiness for behavioral change.”.
The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by adherence to a strict moral code. manipulative, controlling strategies. acting without thought on urges or desires. postponing gratification to an appropriate time.
What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? Supporting behavioral change Maintaining consistent limits Monitoring suicide attempts Using aversive therapy.
One month ago, a patient diagnosed with borderline personality disorder and a history of self- mutilation began dialectical behavior therapy. Today the patient phones to say, “I feel empty and want to hurt myself.” The nurse should arrange for emergency inpatient hospitalization. send the patient to the crisis intervention unit for 8 to 12 hours. assist the patient to choose coping strategies for triggering situations. advise the patient to take an antianxiety medication to decrease the anxiety level.
.
When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? It provides an outlet for feelings of anger and frustration. It respects the patient’s wishes, so assertiveness will develop. External controls are necessary due to failure of internal control. Anxiety is reduced when staff assumes responsibility for the patient’s behavior.
What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? Risk for other-directed violence Risk for self-directed violence Impaired social interaction Ineffective denial.
A person’s spouse filed charges after repeatedly being battered. The person sarcastically says, “I’m sorry for what I did. I need psychiatric help.” Which statement by this person supports an antisocial personality disorder? “I have a quick temper, but I can usually keep it under control.” “I’ve done some stupid things in my life, but I’ve learned a lesson.” “I’m feeling terrible about the way my behavior has hurt my family.” “I hit because I am tired of being nagged. My spouse deserves the beating.”.
A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? Benzodiazepine Mood stabilizing medication Monoamine oxidase inhibitor (MAOI) Cholinesterase inhibitor.
A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? Flattering the nurse Lying to other patients Verbal abuse of another patient Detached superficiality during counseling.
Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, “Another nurse said you don’t do your job right.” Collectively, these interactions can be assessed as seductive. detached. manipulative. guilt-producing.
What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will identify when feeling angry. use manipulation only to get legitimate needs met. acknowledge manipulative behavior when it is called to his or her attention. accept fulfillment of his or her requests within an hour rather than immediately.
As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, “Just leave it on the table. I’ll take it when I finish combing my hair.” What is the nurse’s best response? Reinforce this assertive action by the patient. Leave the medication on the table as
requested. Respond to the patient, “I’m worried that you might not take it. I’ll come back
later.” Say to the patient, “I must watch you take the medication. Please take it now.” Ask the patient, “Why don’t you want to take your medication now?”
.
Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? Refer requests and questions related to care to the case manager. Encourage the patient to discuss feelings of fear and inferiority. Provide negative reinforcement for acting-out behavior. Ignore, rather than confront, inappropriate behavior.
A health care provider recently convicted of Medicare fraud says to a nurse, “Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I deserve the money.” These statements show shame. suspiciousness. superficial remorse. lack of guilt feelings.
Which nursing diagnoses are most applicable for a patient diagnosed with severe late stage Alzheimer’s disease? (Select all that apply.) Acute confusion Anticipatory grieving Urinary incontinence Disturbed sleep pattern Risk for caregiver role strain.
Which assessment findings would the nurse expect in a patient experiencing delirium? (Select all that apply.) Impaired level of consciousness Disorientation to place, time Wandering attention Apathy Agnosia.
A patient diagnosed with moderate stage Alzheimer’s disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient’s plan of care. (Select all that apply.) Provide clothing with elastic and hook-and-loop closures. Label clothing with the patient’s name and name of the item. Administer antianxiety medication before bathing and dressing. Provide necessary items and direct the patient to proceed independently. If the patient resist dressing, use distraction and try again after a short interval.
A nurse gives anticipatory guidance to the family of a patient diagnosed with mild early stage Alzheimer’s disease. Which problem common to that stage should the nurse address? Violent outbursts Emotional disinhibition Communication deficits Inability to feed or bathe self.
An elderly person presents with symptoms of delirium. The family reports, “Everything was fine until yesterday.” What is the most important assessment information for the nurse to gather? A list of all medications the person currently takes Whether the person has experienced any recent losses Whether the person has ingested aged or fermented foods The person’s recent personality characteristics and changes.
An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse’s best response. "The health care provider is the best person to answer your question.” “The confusion will probably get better as we treat the infection.” “Unfortunately, delirium is a progressively disabling disorder.” “I will be glad to contact the chaplain to talk with you.”.
A hospitalized patient diagnosed with delirium misinterprets reality. A patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will remain safe in the environment. participate actively in self-care. communicate verbally. acknowledge reality.
An older adult is prescribed digoxin and hydrochlorothiazide daily as well as lorazepam as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient’s change in mental status? Drug actions and interactions Benzodiazepine withdrawal Hypotensive episodes Renal failure.
What is the priority need for a patient diagnosed with severe, late-stage dementia? Promotion of self-care activities Meaningful verbal communication Preventing the patient from wandering Maintenance of nutrition and hydration.
A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? Wear large name tags. Focus interaction on familiar topics. Frequently repeat the reorientation strategies.. Place large clocks and calendars strategically.
A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse’s best reply? “Your family member will never again be able to identify you.” “I think that is a question the health care provider should answer.” “One never knows. Consciousness fluctuates in persons with dementia.” “It is disappointing when someone you love no longer recognizes you.”.
An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient’s family? Label the bathroom door. Take the older adult to the bathroom hourly. Place the older adult in disposable adult briefs. Limit the intake of oral fluids to 1000 mL/day.
Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on returning to premorbid levels of function. identifying stressors negatively affecting self. demonstrating motor responses to noxious stimuli. exerting control over responses to perceptual distortions.
A nurse counsels the family of a patient diagnosed with Alzheimer’s disease who lives at home and wanders at night. Which action is most important for the nurse to recommend for enhancing safety? Apply a medical alert bracelet to the patient. Place locks at the tops of doors. Discourage daytime napping. Obtain a bed with side rails.
During morning care, a nurse asks a patient diagnosed with dementia, “How was your night?” The patient replies, “It was lovely. I went out to dinner and a movie with my friend.” Which term applies to the patient’s response? Sundown syndrome Confabulation Perseveration Delirium.
A patient diagnosed with Alzheimer’s disease calls the fire department saying, “My smoke detectors are going off.” Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? Hyperorality Aphasia Apraxia Agnosia.
An older adult patient in the intensive care unit is experiencing visual illusions. Which intervention will be most helpful? Use the patient’s glasses. Place personally meaningful objects in view. Position large clocks and calendars on the wall. Assure that the room is brightly lit but very quiet at all times.
Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, “Move along, you’re blocking the road.” The other patient turns, shakes a fist, and shouts, “You’re trying to steal my car.” What is the nurse’s best action? Administer one dose of an antipsychotic medication to both patients. Reinforce reality. Say to the patients, “Walk along in the hall. This is not a traffic intersection.” Separate and distract the patients. Take one to the day room and the other to an activities area. Step between the two patients and say, “Please quiet down. We do not allow violence here.”.
A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? Assist the patient to perform simple tasks by giving step-by-step directions. Reduce frustration by performing activities of daily living for the patient. Stimulate intellectual function by discussing new topics with the patient. Read one story from the newspaper to the patient every day.
A patient diagnosed as mild stage Alzheimer’s disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? Self-care deficit Impaired memory Caregiver role strain Adult failure to thrive.
Consider these phenomena: accumulation of β-amyloid outside the neurons, neurofibrillary tangles, and neuronal degeneration in the hippocampus. Which health problem corresponds to these events? Huntington’s disease Alzheimer’s disease Parkinson’s disease Vascular dementia.
An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer’s disease is evident? Sundowning Early Middle Late.
An older adult was stopped by police for driving through a red light. When asked for a driver’s license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? Aphasia Apraxia Agnosia Anhedonia.
Which medication prescribed to patients diagnosed with Alzheimer’s disease antagonizes N- methyl-D-aspartate (NMDA) channels rather than cholinesterase? Donepezil Rivastigmine Memantine Galantamine.
Consider these cerebral pathophysiologies: Lewy body development, frontotemporal degeneration, and accumulation of protein β-amyloid. Which diagnosis applies? Cyclothymia Dementia Delirium Amnesia.
Which assessment finding would be likely for a patient experiencing a hallucination? The patient
a. looks at shadows on a wall and says, “I see scary faces.”
b. states, “I feel bugs crawling on my legs and biting me.”
c. reports telepathic messages from the television.
d. speaks in rhymes. Looks at shadows on a wall and says, “I see scary faces.” states, “I feel bugs crawling on my legs and biting me.” reports telepathic messages from the television. speaks in rhymes.
A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? Provide a well-lit room without glare or shadows. Limit noise and stimulation. Maintain soft lighting day and night. Keep a radio on low volume continuously. Light the room brightly day and night. Awaken the patient hourly to assess mental
status. Keep the patient by the nurse’s desk while awake. Provide rest periods in a room
with a television on.
What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? Distraction using sensory stimulation Careful observation and supervision Avoidance of physical contact Activation of the bed alarm.
What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations.
A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, “Someone get these bugs off me.” What is the nurse’s best response? “No bugs are on your legs. You are having hallucinations.” “I will have someone stay here and brush off the bugs for you.” “Try to relax. The crawling sensation will go away sooner if you can relax.” “I don’t see any bugs, but I can tell you are frightened. I will stay with you.”.
A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, “Bugs are crawling on my legs. Get them off!” Which problem is the patient experiencing? Aphasia Dystonia Tactile hallucinations Mnemonic disturbance.
An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of delirium. dementia. amnestic syndrome. Alzheimer’s disease.
A new patient beginning an alcohol rehabilitation program says, “I’m just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening.” Which responses by the nurse will be most therapeutic? (Select all that apply.) “I see,” and use interested silence. “I think you are drinking more than you report.” “Social drinkers have one or two drinks, once or twice a week.” “You describe drinking steadily throughout the day and evening.” “Your comments show denial of the seriousness of your problem.”.
After discovering discrepancies and missing controlled substances, the nursing supervisor determines that a valued, experienced staff nurse is responsible. Which actions should the nursing supervisor take? (Select all that apply.) Refer the nurse to a peer assistance program. Confront the nurse in the presence of a witness. Immediately terminate the nurse’s employment. Relieve the nurse of responsibilities for patient care. Require the nurse to undergo immediate drug testing.
The nurse can assist a patient to prevent substance abuse relapse by (Select all that apply) rehearsing techniques to handle anticipated stressful situations. advising the patient to accept residential treatment if relapse occurs. assisting the patient to identify life skills needed for effective coping. advising isolating self from significant others until sobriety is established. informing the patient of physical changes to expect as the body adapts to functioning without substances.
A patient undergoing alcohol rehabilitation decides to begin disulfiram therapy. Patient teaching should include the need to (Select all that apply) avoid aged cheeses. avoid alcohol-based skin products. read labels of all liquid medications. wear sunscreen and avoid bright sunlight. maintain an adequate dietary intake of sodium. avoid breathing fumes of paints, stains, and stripping compounds.
A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse’s best first action? Perform a thorough assessment of the patient. Verify that security services are immediately available. Self-assess personal attitude, values, and beliefs about this health problem. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.
Select the priority outcome for a patient completing the fourth alcohol detoxification program in the past year. Prior to discharge, the patient will state, “I know I need long-term treatment.” use denial and rationalization in healthy ways. identify constructive outlets for expression of anger. develop a trusting relationship with one staff member.
A patient is thin, tense, jittery, and has dilated pupils. The patient says, “My heart is pounding in my chest. I need help.” The patient allows vital signs to be taken but then becomes suspicious and says, “You could be trying to kill me.” The patient refuses further examination. Abuse of which substance is most likely? PCP Heroin Barbiturates Amphetamines.
A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? Substance Abuse and Mental Health Services Administration (SAMHSA) Institute of Medicine (IOM)–National Research Council National Council of State Boards of Nursing (NCSBN) American Society of Addictions Medicine.
An adult in the emergency department states, “Everything I see appears to be waving. I am outside my body looking at myself. I think I’m losing my mind.” Vital signs are slightly elevated. The nurse should suspect a schizophrenic episode. hallucinogen ingestion. opium intoxication. cocaine overdose.
Which assessment findings are likely for an individual who recently injected heroin? Anxiety, restlessness, paranoid delusions Muscle aching, dilated pupils, tachycardia Heightened sexuality, insomnia, euphoria Drowsiness, constricted pupils, slurred speech.
A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes cross-tolerance. substance abuse. substance addiction. substance intoxication.
Symptoms of withdrawal from opioids for which the nurse should assess include dilated pupils, tachycardia, elevated blood pressure, and elation. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. mood lability, incoordination, fever, and drowsiness. excessive eating, constipation, and headache.
Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. Monitor vital signs. Observe for depression. Awaken the patient every 15 minutes. Use warmers to maintain body temperature.
A patient diagnosed with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? 1-week detoxification program Long-term outpatient therapy 12-step self-help program Residential program.
Which goal for treatment of alcohol use disorder should the nurse address first? Learn about addiction and recovery. Develop alternate coping strategies. Develop a peer support system. Achieve physiological stability.
Family members of an individual undergoing a residential alcohol rehabilitation program ask, “How can we help?” Select the nurse’s best response. “Alcoholism is a lifelong disease. Relapses are expected.” “Use search and destroy tactics to keep the home alcohol free.” “It’s important that you visit your family member on a regular basis.” “Make your loved one responsible for the consequences of behavior.”.
In the emergency department, a patient’s vital signs are BP 66/40 mm Hg; pulse 140 beats/minute; respirations 8 breaths/minute and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to opioid intoxication. Select the priority outcome. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute. he patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. Within 6 hours, the patient’s breath sounds will be clear bilaterally and throughout lung fields.
At a meeting for family members of alcoholics, a spouse says, “I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work.” The nurse assesses these comments as codependence. assertiveness. role reversal. homeostasis.
When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? Tolerance has developed. Antagonistic effects are evident. Metabolism of the alcohol is now delayed. Pharmacokinetics of the alcohol have changed.
Which features should be present in a therapeutic milieu for a patient experiencing a hallucinogen overdose? Simple and safe Active and bright Stimulating and colorful Confrontational and challenging.
Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. Empathetic, supportive Skeptical, guarded Cool, distant Confrontational.
The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should provide long-term care for the patient in a residential facility. withdraw the patient from cannabis, then treat the schizophrenia. consider each diagnosis primary and provide simultaneous treatment. first treat the schizophrenia, then establish goals for substance abuse treatment.
During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, “After this treatment program, I think everything will be all right.” Which remark by the nurse will be most helpful to the spouse? “While sobriety solves some problems, new ones may emerge as one adjusts to
living without drugs and alcohol.” “It will be important for you to structure life to avoid as much stress as you can
and provide social protection.” “Addiction is a lifelong disease of self-destruction. You will need to observe your
spouse’s behavior carefully.” “It is good that you are supportive of your spouse’s sobriety and want to help
maintain it.”
.
Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? Bromocriptine Methadone Disulfiram Naltrexone.
A patient admitted to an alcohol rehabilitation program tells the nurse, “I’m actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening.” The patient is using which defense mechanism? Denial Projection Introjection Rationalization.
Police bring a patient to the emergency department after an automobile accident. The patient demonstrates poor coordination and slurred speech but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and blood alcohol level, which conclusion is most probable? The patient rarely drinks alcohol. has a high tolerance to alcohol. has been treated with disulfiram (Antabuse). has ingested both alcohol and sedative drugs recently.
A patient asks for information about AA. Select the nurse’s best response. “AA is a form of group therapy led by a psychiatrist.” self-help group for which the goal is sobriety.” group that learns about drinking from a group leader.” network that advocates strong punishment for drunk drivers.”.
A patient diagnosed with alcohol use disorder says, “Drinking helps me cope with being a single parent.” Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? “Sooner or later, alcohol will kill you. Then what will happen to your children?” “I hear a lot of defensiveness in your voice. Do you really believe this?” “If you were coping so well, why were you hospitalized again?” “Tell me what happened the last time you drank.”.
A hospitalized patient diagnosed with alcohol use disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? Check the patient every 15 minutes
One-on-one supervision Keep the room dimly lit Force fluids.
|
