A 25-year-old patient complains that most of the staff do not like her she states except you you are the only one who cares about me at a group therapy session you inform this patient and your group that you will be on vacation for the next 2 sessions the patient storms out of the group yelling I believe you were the one who cared during rounds you find this patient scratching her wrists with a paper clip given this presentation which personality disorder would you suspect

Borderline

what is the nurses priority focused assessment for side effects in a child taking methylphenidate for ADHD

sleep disturbances and weight loss

A new patient at the sleep disorders clinic tells the nurse I have not slept well in a year so I never feel good I do not expect things will ever improve or be any different interventions the nurse should consider include SATA

providing instruction in relaxation techniques

health teaching regarding factors that influence sleep

counseling the patient to address cognitive distortions

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts back off and then goes to the dayroom while following the patient into the dayroom the nurse should

make sure there is adequate physical space between the nurse and patient

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

The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive which topic should the coordinator emphasize

perfect and teamwork

the diathesis-stress model of theory states which of the following

a biological of genetic predisposition to mental illness but their environment determines whether or not they will actually become mentally ill

A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated the medical record shows these blood pressure and pulse reading at the times listed

0200 118/78mmHg and 72 beats/min

0400 126/80 mmHg and 76 beats/min

0600 128/82mmHg and 72 beats/min

0800 132/88 mmHg and 80 beats/min

1000 148/94 mmHg and 96 beats/min

what is the nurses priority action

begin the detox protocol

A survivor spousal abuse was treated in the emergency department for a broken wrist the patient said ive considered leaving but I made a vow and I must keep it no matter what happens which outcome should be met before discharge

name two community resources for help

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 Alzheimers disease is evident

middle

A 35 year old patient diagnosed with depression began treatment with an SSRI medication one week ago this patient complains of continued difficulty sleeping the nurse includes which of the following in educating this patient SATA

sleeping problems are a common symptom of depression

therapeutic response to SSRI may take several weeks

the nurse can assist a patient to prevent substance abuse relapse by SATA

informing the pt of physical changes to expect as the body adapts to functioning without substances

rehearsing techniques to handle anticipated stressful situations

assisting the patients to identify life skills needed for effective coping

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030 by 1200 the patient has difficulty swallowing and is drooling by 1600 vital signs are 102.8F pulse 110 respirations 26 150/90 the patient is diaphoretic select the nurses best analysis and action

neuroleptic malignant syndrome notify healthcare provider stat

which personality disorders are generally associated behaviors that are considered odd or eccentric SATA

schizoid

schizotypal

paranoid

during the morning a nurse asks a patient diagnosed with dementia how was your night the patient replies it was lovely I went out for dinner and a movie with my friend which term applies to the patients response

Confabulation

which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence

strong negative feelings intervene with assessment and judgement

which assessment finding would cause the nurse to consider a child to be most at risk for development of mental illness the child

has been raised by a parent with recurring major depressive disorder

A patient with a history of alcohol use disorder has been prescribed disulfiram (Antabuse) as an adjunct therapy to maintain sobriety which physical effects support patient has relapsed SATA

intense nausea

diaphoresis

confusion

dyspnea

the treatment team discusses the discharge plan for a patient with schizophrenia the primary nurse comments his symptoms have vastly improved the hallucinations have responded to the medication hes calmer and no longer paranoid only one thing troubles me i dont think hes going to follow through the treatment plan he still doesnt think theres anything wrong with him this scenario describes which symptoms

anosgnosia

sleep deprivation is considered a safety issue that results in loss of life and property psychomotor impairments of sleep deprivation are similar to symptoms caused by

alcohol consumption

a patient with a history of command hallucinations approaches the nurse yelling obscenities which nursing action is most likely to be effective in de-escalation for this scenario SATA

speaking in a firm but calm voice

offering to provide the patient with medication help

stating the expectation that the patient will stay in control

A 15-year-old ran away from home six times and was arrested for shoplifting the parents told the court we can't manage our teenager the adolescent is physically abusive to the mother and defiant with the father what diagnosis is supported by this adolescent's behavior

Conduct disorder

what are the primary distinguishing factors between the behavior of persons diagnosed with ODD(oppositional defiant disorder) and those with conduct disorder (CD) the person diagnosed with SATA

ODD tests limits and disobeys authority figure

CD often violates the rights of others

A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written immediately after safely secluding the patient which action is the nurses priority

notify the healthcare provider to obtain a seclusion order

select the best therapeutic approach for a nurse working with a patient beginning treatment for alcohol addiction

empathetic and supportive

what safety-related responsibility does the nurse have in any situation of suspected abuse

report the suspected abuse to the proper authorities

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting which intervention should the nurse use to prevent further escalation of the spouses anger

let the spouse know that you will periodically provide an update and progress report on the patient

when preparing to interview a patient diagnosed with a narcissistic personality disorder a nurse can anticipate the assessment findings will include

grandiosity self importance and a sense of entitlement

which of these is an example of protective factor

supportive family and friends

which finding constitutes a negative symptom associated with schizophrenia

poverty of thought

a new patient at the sleep disorders clinic tells the nurse I have not slept well in a year so I never feel good I do not expect things will improve or be any different interventions the nurse should include SATA

health teaching regarding factors that influence sleep

counseling the patient to address cognitive distortion

providing instruction in relaxation techniques

which intervention should a nurse use when helping a patient who is expressing anger in an inappropriate manner SATA

provide options regarding acceptable ways to communicating anger

approach the patient in a calm respectful manner

assist patient and identifying triggers related to angry feelings

which assessment findings mark the prodromal stage of schizophrenia

withdrawal misinterpreting poor concentration and preoccupation with religion

a patient has a history of impulsive acting out anger by striking others select the most appropriate intervention for avoiding similar incidents

help the patient identify incidents that trigger impulsive anger

shortly after the parents announced that they were divorcing a 15-year-old because of truant from school and assaulted a friend the adolescent told the school nurse id rather stay in my room and listen to music its easier than thinking about what is happening in my family which diagnosis is most applicable

defensive coping related to adjustment to changes in family relationships

which assessment finding supports the diagnosis of oppositional defiant disorder

negative hostile and spiteful towards parents blames others for misbehavior

A patient has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy today the patient shouts they're all plotting to destroy me isn't that true select the nurses most therapeutic response

feeling that people want to destroy you must be frightening

a community health nurse visits a family with four children the father behaves angrily finds fault with the oldest child and ask twice why are you such a stupid kid the wife says I have difficulty disciplining the children its so frustrating which comments by the nurse will facilitate an interview with these parents SATA

caring for small children must be difficult

tell me how you discipline your children

how do you stop your baby from crying

see who is severely abusive relationship and fears for her life is admitted to a psychiatric unit impatient unit a staff nurse asked why doesn't she just leave him which is the nursing supervisor's most appropriate response

are paralyzed into an action by a combination of physical threats and a sense of powerfulness

one month ago a patient diagnosed with borderline personality disorder and history of self mutilation began dialectical behavior therapy today the patients phone to say i feel empty and want to hurt myself the nurse should

assisted patient to choose coping strategies for triggering situations

which assessment findings are likely for an individual who recently injected heroin

drowsiness constricted pupils slurred speech

a child/adolescent psychiatric and mental health clinic nurse specialist counsels the parent of a preschool-age child who has fetal alcohol syndrome when I asked how to manage a child excitability the nurse advises the parent to

begin and end each play activity with less action

a patient diagnosed with borderline personality disorder has a history of self mutilation and suicide attempts the patient reviews feelings of depression and anger with life which type of medication would the nurse expect to be prescribed

mood stabilizing medication

a nurse assesses a 3 year old diagnosed with an autism spectrum disorder which finding is most associated with the child disorder alzheimers disease calls the fire department saying my smoke detectors are going

continuously rocks in place for 30 minutes

a patient diagnosed with alzheimers disease calls the fire department saying my smoke detectors are going off firefighters investigate and discover the patient misinterpreted the telephone ringing which problem is this patients experiencing

agnosia

for the past 18 months an eight year old child has exhibited involuntary purposeless rapid recurrent movements of the arms and face as well as spontaneous unintelligible vocalizations when receiving verbal cues that child could decrease and sometimes extinguish erratic movements for several minutes the diagnosis is

Tourette disorder

a patient asked for information about AA select the nurses best response

self-help group for which the goal is sobriety

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 page change in mental status

drug actions and interactions

an elderly patient is admitted with delirium secondary to a urinary tract infection the family asks whether the patient will ever recover select the nurses best repsonse

the confusion will likely get better as we treat the infection

a nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school establishing rapport with this adolescent is a priority because episodes of violence at school establishing rapport with this adolescent is a priority because SATA

a therapeutic alliance is the first step in the nurses therapeutic use of self

acceptance and trust convey feelings of security for the adolescent