Psychosis Case Study
Client continues to explain that someone has followed him to the ED and is waiting outside. Which thought process describes the client’s inability to leave his apartment because he thought someone was wanting to kill him?
Delusion (false belief that is firmly maintained even though it is not shared by others and is contradicted by reality.)
morbid fear associated with extreme anxiety.
perceptual distortion that involves any of the senses
involves filling memory gaps with situations or events that cannot be remembered.
When the client explains someone is waiting outside the ED, how should the nurse respond?
You must be concerned, but you are safe here. (respond to feelings, and not make assumptions about his delusions)
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Which term fits the nurse’s observation that the client looks to the corner of the room and mumbles to himself?
feeling of unreality and alienations from oneself, characterized by difficulty distinguishing self from others.
confusion about the correct person, place and/or situation
When the client looks around the room and mumbles to himself, how should the nurse respond?
Are you hearing voices?
The client admits that the voices are getting louder over the last couple of weeks. Which question should the nurse ask next?
What do the voices say. (the nurse should first ask what the voices are saying in order to assess for command hallucinations)
The client becomes very agitated and angry. Which meds should the nurse anticipate from HCP?
Short acting anxiolytic (benzo) (pams are most effective for anxiety related symptoms to produce a calming and sedation.) AND a antipsychotic medication (effective for psychosis related symptoms)
Patient is admitted to unit and inability to meet basic needs. Which assessment data provides evidence that he can be involuntarily committed to hospital if he insists on leaving?
losing 10 pounds in 2 weeks. (danger to self and others as well as unable to provide for own basic needs)
Orientations to program and room. What is the most important part of this process.
Take away cigarettes and lighter. (safety)
the nurse completes assessment. What are the best indicators of the potential for violence? SATA
Past suicide attempts; history of violence; and medication noncompliance.
The nurse understands that the purpose for the UA is to?
Detect any other substance and/or drugs that could have caused hallucinations and or delusions.
Which lab value from UA is related to brains 10lbs weight loss in 2 weeks. SATA
Positive Ketones and Increased urine specific gravity.
What is the purpose of a baseline CBC prior to initiation of antipsychotic meds?
To monitor for agranulocytosis (seen in patients taking clozapine (clozaril); and is potentially life-threatening side effect that manifests as fatigue, sore throat, and fever.
Which nursing diagnosis is best to include in the initial care plan?
Sensory-perceptual alteration related to withdrawal into self (this diagnosis is r/t hallucinations, which impact his functioning and social interaction)
Which addition interventions are essential to a successful plan?
consistency and medications
Which interventions should be started on admission and continued through care:
Client safety; the purpose and side effects of psychotropic medications
What neurotransmitter is targeted by Haldol?
Dopamine (traditional antipsychotics block excessive dopamine, and excitatory neurotransmitter)
Patient c/o of muscle spasms in his neck and jaw several hours after meds. Which side effect of the medication is suspected?
Dystonia (is neurological movement disorder characterized by involuntary muscle contractions, i.e. face, tongue, neck and jaw)
What medication should the nurse give to immediately relieve the muscle spasms?
Benadryl IM OR benztropine (Cogentin) IM NOT PO
After receiving Benadryl and Cogentin for spams via IM; patient receives a new rx for Cogentin 2mg PO daily. Why is this medication started?
To reduce severity of extrapyramidal effects.
Which response from client indicated that Haldol is working?
Experiences fewer hallucinations
What are anticholinergic side effects r/t Cogentin? SATA
Urinary retention, Tachycardia
He feels dizzy when he stands to leave. Which action should the nurse implement first?
Take BP while sitting and standing.
What are the advantages for rx atypical antipsychotic zyprexa? SATA
Calming but not sedating; rapid onset; acute maintenance therapy
What is the most important benefit Brian can receive from his attendance at the community meeting?
Reality orientation. (Meetings are designed to introduce clients to one another, plan activities, and address concerns.)
He chose arts and crafts as an activity. What is a goal of being in this activity group?
Gain self-acceptance and express feelings.
What is the difference between group content and group process?
Contents includes the clients’ words, and group process is how clients communicate.
Discharge meds incluued zyprexa 5m PO BID. What are important reasons for theaching regarding side effects that may not go away. SATA
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; and to tell brian to discuss symptoms with the nurse
Which aspect is most important for the nurse to follow up on before discharge?
Thoughts of harm to self or others.