Case Study Psychosis PDF

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Elsevier case study Psychosis - correct answers and rationales...

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Incorrect Question 1 of 31

Which thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him? Hallucination. A hallucination is a perceptual distortion that involves any of the senses (sight, hearing, smell, taste, touch).

Phobia. A phobia is morbid fear associated with extreme anxiety.

Delusions. A delusion is a false belief that is firmly maintained even though it is not shared by others and is contradicted by reality. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 88, 485.

Confabulation. Confabulation involves filling in memory gaps with situations or events that cannot be remembered.

Question 2 of 31

When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond? Insist that no one has followed the client there. The client is delusional, and he will continue to firmly believe that someone is following him. The nurse should not attempt to logically explain the delusion.

State how he must be concerned and assure him he will be safe there. The nurse should respond to the client's underlying feelings and not make assumptions about his delusions. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 78, 88.

Tell the client that the police will make sure no one is out there. If the client perceives that the nurse is going along with the delusion, he will become increasingly delusional, particularly if he senses that the nurse is trying to gain his cooperation.

Ask the client why he thinks that someone is out there. Questioning the client's story before responding to the emotional component or assessing for other symptoms of a thought disorder may reinforce the delusion.

Question 3 of 31

The nurse observes the client looking to the corner of the room and mumbling to himself. Which intervention ismostimportant for the nurse to make sure is in the client’s plan of care? Encourage the client to share the meaning of their delusions. The patient appears to be having hallucinations. A delusion is a false belief that is firmly maintained even though it is not shared by others and is contradicted by reality.

Interview the client to identify his feelings of depersonalization. The patient appears to be having hallucinations. Depersonalization is a feeling of unreality and alienation from oneself, characterized by difficulty distinguishing self from others.

Begin a sequence of interventions to address the client's hallucinations.

Hallucinations can be nonverbal or they can include talking to oneself, moving the lips without making sounds, rapid eye movements, and grinning or inappropriate laughter. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 88, 487.

Orient the client to their plance and situation. The patient appears to be having hallucinations. Disorientation is confusion about the correct person, place, time and/or situation.

Question 4 of 31

When the client looks around the room and mumbles to himself, how should the nurse respond? Have the client express how he is feeling. This question does not respond to the client's nonverbal cues that he may be hearing voices.

Ask the client if they are hearing voices. The client is demonstrating nonverbal cues that he is experiencing auditory hallucinations, so the nurse should ask the client if he is hearing voices. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 262.

See if the client recalls being here before. This question is part of the admission process and does not acknowledge the client's nonverbal behavior.

Tell the client to say what they are thinking. The client is experiencing delusions and is often unable to organize his thought processes coherently.

Question 5 of 31

The client admits that the voices he hears have been getting louder over the past couple of

weeks. Which nursing interventionbestpromotes effective communication? Ask the client what helps the voices go away. This question is not very useful at this point in the client's assessment. It would be best used at a later stage of therapy, when helping the client identify ways to cope with the voices or strategies that have worked well in the past.

Determine how long the client has been hearing voices. This question is not that helpful at this point. It can eventually be used to help the client draw conclusions about stressful events that precipitated the voices in prior situations.

Document when the voices began getting louder. This question is not useful in the initial assessment. Later, during the treatment phase, it can help the client to identify symptom triggers and ways to cope.

Have the client repeat what he thinks the voices are saying. The nurse should first ask what the voices are saying in order to assess for command hallucinations. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 217, 264.

Question 6 of 31

Which medications should the nurse anticipate giving the client after getting orders from the healthcare provider?(Select all that apply. One, some, or all options may be correct.) Select all that apply

Short-acting anxiolytic (benzodiazepines). Antianxiety medications (benzodiazepines, lorazepam clonazepam, or diazepam) are most effective for anxiety-related symptoms to produce calming and sedation. When used in conjunction with an atypical antipsychotic medication, such as olanzapine, benzodiazepines, especially IM, can augment the efficacy of the antipsychotic medication, quickly alleviating acute agitation of a client. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8 thedition). St. Louis, Missouri. Elsevier. Pg. 287.

Antipsychotic medication.

Antipsychotic medications are effective for psychosis-related symptoms and manifestations of agitation associated with mental illness. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8 thedition). St. Louis, Missouri. Elsevier. Pg. 287.

Mood-stabilizing medication. Mood-stabilizing medications are effective for eliminating the symptoms of mania and for stabilizing mood to prevent cycling between depression and mania.

Nonbenzodiazepine anxiolytic (antianxiety agent). Antianxiety medications are most effective for anxiety-related symptoms to produce calming and sedation. Benzodiazepines, used in conjunction with an antipsychotic medication, are particularly useful in treating the client with agitated psychosis who is being admitted to an inpatient unit.

Antidepressant. Antidepressants are effective for treating mood disorders. They also provide a secondary benefit for treating co-occurring depressive and anxiety disorders.

Question 7 of 31

Which assessment data provides evidence that the client can be involuntarily committed to the hospital, if he insists on leaving? Past history of suicide attempts. Past history of suicide attempts is not criteria for commitment.

Losing 10 pounds in 2 weeks. The criteria for commitment includes danger to self and/or others, unable to provide for own basic needs, and/or the need for immediate and adequate treatment. Excessive weight loss demonstrates the client's inability to provide for his own basic needs by not maintaining adequate nutrition. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 24.

Auditory hallucinations. Auditory hallucinations are not criteria for commitment, unless the client was hearing voices telling him to harm himself or others.

Persecutory delusions. Delusions are not a criteria for commitment, unless the delusions interfere with another aspect of the client's behavior. For example, if the client is unable to eat because of a delusion that food is poisoned, that would be a criteria for commitment. The client is not demonstrating this behavior.

Question 8 of 31

What is themostimportant part of this admission process? Ask the client if he has any valuables that need to be locked in a safe place. Valuables should be documented and locked in a safe place, but this is not the most important part of this admission process.

Allow the client to explain his understanding of the reason for his hospital admission. This is part of the admission process, but it is not the most important thing to do at this time.

Introduce the client to the nursing staff and explain the role of the case manager and the staff members. Introducing the client to the staff is important, but it is not the most important thing to do at this time.

Take away the client's cigarettes and lighter. Safety for the client and the unit environment is the highest priority, so the staff should keep any potentially dangerous objects away from the client. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 94, 224.

Question 9 of 31

Which assessment data are thebestindicators of the potential for violence?(Select all that apply. One, some, or all options may be correct.) Select all that apply

Gender and age.

Demographic variables such as gender and age are variables for predicting violence when assessing the client with psychosis. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8 thedition). St. Louis, Missouri. Elsevier. Pg. 507.

Past suicide attempts. Past suicide attempts are indicators of violence toward self. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 322.

History of violence. The best single predictor of violence is a past history of violence. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8 thedition). St. Louis, Missouri. Elsevier. Pg. 507.

Multiple prescribed medications. Clients with active psychotic symptoms are at increased risk for violence, especially if they are medication noncompliant. The client may need multiple medications to control symptoms.

Medication noncompliance. Clients with active psychotic symptoms are at increased risk for violence (symptom exacerbation), especially if they are medication noncompliant. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 89.

Question 10 of 31

The nurse understands that the purpose of the urine drug screen is to assess the client for what important information? Detection of substances that may have caused the client's delusions and/or hallucinations.

A urine drug screen is routinely ordered to determine the presence of any substances that may have altered a client's mental status. Blood and urine are the body fluids most often tested for drug content, although methods of analyzing saliva, hair, breath, and sweat have been developed. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8 thedition). St. Louis, Missouri. Elsevier. Pg. 115.

Determination of the approximate time the client stopped taking his medications. The urine drug screen cannot provide information about when the client stopped taking his medications. The length of time that drugs can be found in blood and urine varies according to dosage and metabolites.

Provision of information about the type of psychosis the client is experiencing. The urine drug screen does not reveal information about the client's psychosis.

Documentation of medication noncompliance and reinforcement of the need for hospitalization. The urine drug screen cannot provide information about noncompliance. The length of time that drugs can be found in blood and urine varies according to dosage and metabolites.

Question 11 of 31

Which lab results from the urinalysis can the nurse expect to be related to the client's 10pound weight loss in the past 2 weeks?(Select all that apply. One, some, or all options may be correct.) Select all that apply

Positive for red blood cells. Red blood cells in the urine are not associated with weight loss.

Positive ketones. Ketones in the urine can suggest malnutrition, fasting, or starvation. Crawford, L. (2020). Fundamentals of Nursing. (2nd edition). St. Louis, Missouri. Elsevier. Pg. 748.

Decreased urine pH.

Decreased urine pH is associated with urinary tract infection, renal failure, or alkalosis, but it is not associated with weight loss.

Increased urine specific gravity. Increased urine specific gravity is associated with dehydration which could be contributing to the client’s weight loss. Crawford, . (2020). Fundamentals of Nursing. (2nd edition). St. Louis, Missouri. Elsevier. Pg. 748.

Absence of glucose. The absence of glucose in the urine is a normal finding and is not indicative of weight loss or malnutrition.

Question 12 of 31

What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication? To determine the presence of cardiac disease. A CBC is not used to determine the presence of cardiac disease. A baseline EKG and cardiac monitoring is initiated for clients with suspected cardiac disease.

To monitor for hepatotoxicity. Potential hepatotoxicity is measured by liver function tests, not by a CBC. Hepatotoxicity is most often seen in older clients and in clients on multiple medications.

To determine if other medical issues are present. A CBC can provide helpful information on the client's health status. It is important to determine if there are other issues that could be causing some of the symptoms, and whether the client is healthy enough to take the medication. Some antypsychotic medications can cause neutropenia. If the client has other medical issues, considerations will need to be discussed regarding what medications should be prescribed. Skidmore-Roth, L. (2021). Mosby’s 2021 Nursing Drug Reference. (34thedition). St. Louis, Missouri. Elsevier. Pg. 1043, 1044. Pagana, K., Pagana, T., Pagana T.N. (2019). Mosby's Diagnostic and Laboratory Test Reference.(14th edition). St Louis, Missouri. Elsevier. Pg. 269.

To assess elevations in liver enzymes. Liver enzymes are measured by liver function tests, not by a CBC.

Question 13 of 31

Which nursing problem isbestto include in the initial care plan? Sensory-perceptual alteration related to withdrawal into self. The priority nursing problem is related to the client's hallucinations, which impact his functioning and social interaction. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8 thedition). St. Louis, Missouri. Elsevier. Pg. 432.

Chronic low self-esteem related to impaired cognition. Chronic low self-esteem is not the priority nursing problem. Interventions related to self-esteem should be implemented when the client's thoughts are more organized.

Ineffective individual coping related to personal vulnerability. Ineffective coping involves a realistic appraisal of stressors, which the client will not be able to achieve until his thoughts are more organized.

Knowledge deficit related to medication compliance. The client's cognitive functioning should be clearer before effective teaching can occur about this client's medications.

Question 14 of 31

Interventions for a client experiencing hallucinations upon admission should occur in a sequence. Which interventions aremostimportant to be include in the client's initial plan of care?(Select all that apply. One, some, or all options may be correct.) Select all that apply

Acknowledge that it appears the client is hearing voices.

The initial approach is to acknowledge the voices. They are real to the client and it is necessary to know what the voices are telling the client. The voices may be telling the client to harm themself or others. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 88.

Tell the client to stop listening to the voices. The voices may be telling the client to harm themself or others.

Ask the client to verbalize what the voices are saying. Once the voices are acknowledged, the nurse needs to know what the voices are saying. They are real to the client and it is necessary to know what the voices are telling the client. The voices may be telling the client to harm themself or others. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 88.

Assess the content of the hallucinations message. The voices may be telling the client to harm themself or others. Immediate interventions will need to be put in place to keep the client and others safe. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 88.

Identify distractions to keep the client focused on reality. The voices should not be ignored. They may be telling the client to do something that is harmful to self or others.

Question 15 of 31

After the content of the voices are assessed, which interventions should the nurse implement?(Select all that apply. One, some, or all options may be correct.) Select all that apply

Ask the client how the voices make them feel.

It may be helpful to know how the voices make the client feel. It can provide understanding to the client's actions and reactions so they can be addressed in a therapeutic manner. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 88.

Instruct the client to utilize distractions to deal with hallucinations. Once the hallucinations have been revealed and evaluated, it is important to disconnect the hallucinations from reality. Distractions can be a therapeutic. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 88.

Tell the client to instruct the voices to go away. Telling the voices to go away encourages the client to communicate with the voices and may intensive aggressive behavior.

Give the client statements to say to the voices. Communicating with the voices should not be encouraged. It reinforces their presence.

Encourage the client to write down what voices are saying. Communicating with the voices should not be encouraged. It reinforces their presence.

Question 16 of 31

Since the client is also experiencing delusions, what action ismostimportant for the nurse to take to address the client's delusions? Encourage the client to verbalize the meaning of the delusions. The underlying theme of the delusions can be used to address the client's emotional state. Monitoring the affect of the delusions can help identify situations where the client may be inclined to harm themselves or others. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8 thedition). St. Louis, Missouri. Elsevier. Pg. 88.

Firmly tell the client that the delusions are not real. Arguing with the client may escalate their aggressive behavior.

Have the client to explain why they believe the delusion.

This approach is putting the client in a position to defend the delusions. The meaning of the delusions a...