HESI Case Studies–Psychiatric/Mental Health-Psychosis (Brian Jones)

1. Which thought process describes the client’s inability to leave his apartment because he thought someone was waiting to kill him?
Delusions
2. When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond?
“You must be concerned, but you are safe here,”
3. Which term fits the nurse’s observation that the client looks to the corner of the room and mumbles to himself?
Hallucinations
4. When the client looks around the room and mumbles to himself, how should the nurse respond?
“Are you hearing voices?”
5. The client admits that the voices he hears have been getting louder over the past couple of weeks. Which question should the nurse ask next?
“What do the voices say?”

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6. Which medication(s) should the nurse anticipate giving the client after securing a prescription from the healthcare provider? (Select all)
-Short-acting anxiolytic (benzodiazepines)
-Antipsychotic medication
7. Which assessment data provides evidence that Brian can be involuntarily committed to the hospital, if he insists on leaving?
Losing 10 pounds in 2 weeks
8. What is the most important part of this admission process?
Take away Brian’s cigarettes and lighter
9. Which assessment data are the best indicators of the potential for violence? (Select all)
-Past suicide attempts
-History of violence
-Medication noncompliance
10. The nurse understands that the purpose of the urine drug screen is to assess Brian for what important information?
Detection of substances that may have caused Brian’s delusions and/or hallucinations
11. Which lab value(s) from the urinalysis can the nurse expect to be related to Brian’s 10 pound weight loss in the past 2 weeks? (Select all)
-Positive ketones
-Increased urine specific gravity
12. What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication?
To monitor for agranulocytosis
13. Which nursing diagnosis is best to include in the initial care plan?
Sensory-perceptual alteration related to withdrawal into self
14. What additional interventions are essential to a successful plan? (Select all)
-Consistency
-Medications
15. What nursing intervention(s) should be included in Brian’s care plan initiated early after admission and reinforced until discharge? (Select all)
-Client safety
-The purpose and side effects of psychotropic medications
16. What neurotransmitter is targeted by haloperidol (Haldol)?
Dopamine
17. Several hours after receiving his medication, Brian complains of muscle spasms in his neck and jaw. What side effect of the medication should the nurse suspect?
Dystonia
18. Which medication should the nurse give to immediately relieve the muscle spasms in the client’s neck and jaw?
Diphenhydramine (Benadryl) IM
19. Diphenhydramine (Benadryl) is available as 100mg/mL. The prescribed dose is 75mg IM. How many mL should the nurse administer?
0.75
20. Why is Brian started on this medication?
To reduce severity of extrapyramidal effects
21. Which response from the client indicates that the haloperidal (Haldol) has been effective?
Experiences fewer hallucinations
22. Which serious, anticholinergic side effects are related to the use of benztrophine (Cogentin)? (Select all)
-Urinary retention
-Tachycardia
23. Which action should the nurse implement first?
Take Brian’s blood pressure while he is sitting and standing
24. What are the advantages for prescribing the atypical antipsychotic, olanzapine (Zyprexa)? (Select all)
-Calming but not sedating
-Rapid onset
-Acute and maintenance therapy
25. What is the most important benefit Brian can receive from his attendance at the community meeting?
Reality orientation
26. What is a goal of being in this activity group?
Gain self-acceptance and express feelings
27. What is the difference between group content and group process?
Content includes the clients’ word, and group process is how clients communicate
28. What are important reason(s) for this teaching? (Select all)
-To encourage Brian to continue compliance with medications
-To monitor for early tardive dyskinesia, which can be reversible
-To reinforce education done throughout the hospitalization
-To tell Brian to discuss symptoms withhis nurse
29. On what aspect is it most important for the nurse to perform follow-up before discharge?
Thoughts of harm to self or others
30. Which nursing action is appropriate for this request?
Obtain a prescription from the HCP to return medications
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