CHEAP BUY ! ! !
NCLEX E-Book with FREE Saunders and KAPLAN ($4)
Situation: J., a 32 year old man with a 5 year history of multiple psychiatric admissions, is brought to the emergency department by the police. He was found wondering the streets, disheveled, shoeless, and confused. Based on h is previous medical records and current behavior, he is diagnosed as having chronic undifferentiated schizophrenia.
13. J. is escorted to the psychiatric unit by an aide. The nurse observes him sitting in the hall looking frightened. He is curled ap in a corner of the bench with his arms over his head and covering his face. How should the nurse approach the patient?
a) walk over to the bench, sit beside him quietly, and place an arm around his shoulders; then say, "I'm the nurse," and wait for a response
b) allow him to remain alone on the bench, where he can observe the unit for a half hour or so until he is more comfortable
c) greet him warmly saying, "Hi, I'm the nurse. This is a very nice unit. I think you'll like it here. Let me show you around"
d) sit about 3 or 4 feet from him on the bench and say, "Hello, J. I'm a nurse on this unit. You appear frightened"; then wait for a response
14. J. responds to the nurse by curling up on the bench even tighter. His arms still cover his head, and his hands are clasped tightly over his ears. the nurse should:
a) show acceptance of J.'s behavior by remaining with him and reassuring him, gently stroking his arms and shoulders
b) tell J. that she will leave him for a while and will return later when he feels more relaxed
c) say gently, "J., I'll just sit here quietly with you for a while," then remain seated nearby
d) say "J., most people feel uncomfortable in hospitals. You shouldn't be afraid, I'm here to help you
15. Later that evening, the nurse finds J. crouched in the corner of his room, with a curtain covering him. His roommate is sitting on the bed laughing and saying, "This guy is really a nut. He should be in a padded cell." How should the nurse respond to the roommate?
a) say "I'm sure J.'s behavior is frightening to you. I understand that you are trying to cover up how you really feel by laughing."
b) say "I'd appreciate it if you'd step outside for a while. I'd like to talk with you after I help J"
c) say nothing and attend to J
d) say, in a neutral tone, "I think your laughing is making J. feel worse. How would you feel if you were J.?"
16. What is the least threatening approach to J. while he sits huddled under the curtain?
a) sit next to him on the floor without speaking, and wait for him to acknowledge the nurse
b) gently remove the curtain and say, "J., this is the nurse. What happened?"
c) approach J. slowly and say, "J., this is the nurse. You appear to be very frightened. Can you tell me what you are experiencing?"
d) call for assistance and do not approach J. until at least two other staff members are present
17. Which is the priority nursing diagnostic category based on J.'s current behavior?
a) anxiety
b) impaired verbal communication
c) altered thought processes
d) dressing and grooming self-care deficit
18. Because J. has previously responded well to treatment with haloperidol (Haldod), the physician orders haloperidol 10 mg orally twice a day. Which adverse effects is most common with this medication?
a) extrapyramidal symptoms
b) hypotension
c) drowsiness
d) tardive dyskinesia
19. During the next several days, J. is observed laughing, yelling, and talking to himself. His behavior is characteristic of:
a) delusion
b) looseness of association
c) illusion
d) hallucination
20. J. tells the nurse, "The earth is doomed, you know. The ozone layer is being destroyed by hair spray. You should get away before you die." J. appears frightened as he says this. The most helpful response is to:
a) says, "J., I think you are overreacting. I know there is some concern about the earth's ozone later, but there is no immediate danger to anyone
b) say, "I've heard about the destruction of the ozone layer and its effect on the earth. Why don't you tell me more about it?"
c) ignore J.'s statement and redirect his attention to some activity or the unit
d) say, "J., are you saying you feel as though something bad will happen to you?"
21. After a half hour, J. continues to ramble about the ozone layer and being doomed to die. He paces in an increasingly agitated manner, and he begins to speak more loudly. At this time, the nurse should:
a) check to see whether the physician ordered haloperidol on an as-needed basis
b) allow J. to continue pacing but observe him closely
c) try to involve J. in a current events discussion group that is about to start
d) tell J. to go to his room for a while
22. The treatment team reviews J.'s behavior and decides to continue increasing his haloperidol dosage for the next few weeks. The nurse must closely observe the patient fro:
a) signs of haloperidol toxicity
b) evidence of the therapeutic window effect
c) increased incidence of orthostatic hypotension
d) indications of tardive dyskinesia
23. After several months, J. improves, and the physician decides to change the medication to haloperidol decanoate (haldol decanoate). Why is this change made?
a) haloperidol decanoate is more effective
b) haloperidol decanoate has fewer side effects
c) a change in medication produces a better response
d) haloperidol decanoate can be given monthly instead of daily
ANSWERS AND RATIONALE
13) d
- Rationale: In approaching J. for the first time, the nurse should keep in mind that schizophrenic patients fear closeness. Moving too close to the patient at first may be seen as invasion of his personal space, which could frighten him and cause him to strike out at the nurse. To avoid overwhelming J., the nurse should limit her introduction to who she is and acknowledge that the patient appears frightened. Touch can have unpredictable meanings to a frightened psychiatric patient, so it is best to avoid it, especially with someone new. Because J. is obviously in distress, the nurse should gently intervene rather than leave him alone or ignore his distress with false reassurance about how nice the unit is.
14) c
- Rationale: The nurse should attempt to establish trust by demonstrating acceptance of J.'s behavior and offering to remain with him. This lets J. know that he does not have to talk to get her attention. Touching or stroking the patient ignores the indications that he is trying to distance himself as a protective measure and would be viewed as intrusive and threatening. Because the patient's behavior results from his resistance to closeness, leaving him alone would reinforce this conduct and would add to his anxiety. Attempts to offer verbal reassurance are likely to be ineffective for a withdrawn and frightened patient such as J.
15) b
- Rationale: Because the nurse's first priority is to attend to J., the most appropriate action is to ask the roommate to step outside. The nurse should recognize the roommate's behavior as a probable sign of increased anxiety and should ask the roommate to leave without engaging him in a prolonged discussion. However, she should confront the roommate as soon as possible to discuss his reaction to J.'s behavior and to explore more appropriate responses. Any attempt to interpret the roommate's behavior at this time could escalate his anxiety about the situation and cause additional outbursts that could further increase J.'s anxiety.
16) c
- Rationale: J.'s behavior indicates that he is experiencing severe anxiety and panic. The nurse can avoid startling him by approaching him slowly while talking to him, yet maintaining a safe distance of 3' to 4' (about 1 to 1.5 m). Although sitting at the same level as the patient can facilitate communication, failing to maintain a safe distance may place the nurse at considerable risk should the patient suddenly become violent. The nurse should encourage J. to discuss his present experience by reflecting her observations of his behavior. She should not attempt to remove the curtain, which is being used to protect against intrusion. As j.'s anxiety decreases, he can be asked to remove it himself. Additional staff members should be called if the patient does not tolerate the nurse's approach and becomes agitated; however, initially, their presence would probably frighten him more.
17) a
- Rationale: The priority nursing diagnostic category is Anxiety, severe to panic-level, as evidenced by J.'s extreme withdrawal and attempt to protect himself from the environment. The nurse must act immediately to reduce his anxiety and to protect the patient and others from possible injury. Impaired verbal communication, as evidenced by noncommunicativeness. Altered thought processes, as evidenced by an inability to understand the situation, and Dressing and grooming self-care deficit, as evidenced by a disheveled appearance, are all appropriate nursing diagnostic categories but are not the priority in this situation.
18) c
- Rationale: Extrapyramidal effects, including dystonia, akathisia, pseudoparkinsonism, and tremors, are the most common adverse reactions associated with haloperidol (Haldol), a high-potency antipsychotic drug. Haloperidol rarely causes tardive dyskinesia, a severe, irreversible extrapyramidal reaction. Hypotension and drowsiness are common side effects of low-potency antipsychotic agents, such as chlorpromazine and thioridazine.
19) d
- Rationale: Auditory hallucination, hearing voices when there are no external stimuli, is common in schizophrenic patients. The nurse can indirectly determine that J. is hallucinating by observing such behaviors as laughing, yelling, and talking to himself. Delusions, false beliefs or ideas that arise without external stimuli, also are common in patients with schizophrenia. For example, a delusional patient may believe that he is being controlled by the television in his room. Schizophrenic patients may exhibit looseness of association, a pattern of thinking and communicating in which ideas are not clearly linked to one another. For example, the patient may make statements that are disconnected and unclear to the listener. A less severe perceptual disturbance is illusion, wherein in the patient misinterprets actual external stimuli. For example, the patient may see a red exit sign and think that the wall is on fire. Illusions are not commonly associated with schizophrenia.
20) d
- Rationale: J.'s statement combines truth (the ozone layer is being destroyed), some exaggeration that may be delusional (the earth is doomed), and some projection of his own fears (the nurse should get away). By choosing to respond to the underlying message about J.'s fear of being destroyed, the nurse attempts to help him identify and express his feelings in a more direct and appropriate manner. Reflecting doubt about delusional statements can help the patient see that the nurse does not share his belief. However, such reflection should not be stated judgmentally ("You are Overacting"). Pursuing a discussion about the ozone layer or ignoring his comments completely are nontherapeutic approaches because they do not acknowledge his fear.
21) a
- Rationale: Because interpersonal interventions have failed to decrease J.'s anxiety level, medication is needed. If an as-needed order is unavailable, the nurse should ask the physician to write one. If the nurse does not intervene and allows J. to continue pacing, his anxiety and agitation may escalate, which may be dangerous to the patient and others. Involving J. in a discussion group would probably increase his anxiety level and cause him act out aggressively. Telling J. to go to his room after he receives his medication would be helpful; the combination of an antipsychotic agent and reduced stimuli will help to decrease his agitation.
22) b
- Rationale: The therapeutic window effect is the point at which an increase in dosage decreases a drug's therapeutic effect. Therefore, the nurse must closely observe the patient as the haloperidol dosage is increased. The toxic level of haloperidol has not been clearly established. Orthostatic hypotension is not common with this drug; tardive dyskinesia are rare. A patient receiving haloperidol is typically observed for therapeutic effects rather than intolerable side effects.
23) d
- Rationale: Haloperidol decanoate (Haldol Decanoate), given by depot injection, has a 4 week duration of action, which makes it appropriate for patients who require long-term drug therapy. Haloperidol decanoate is not more effective; nor is it useful for treating patients with acute psychotic episodes because a therapeutic level is not achieved for up to 3 months. Although this form of haloperidol rarely causes sedation or postural hypotension, it often produces extrapyramidal symptoms. Switching antipsychotic agents does not achieve a better response; high-potency antipsychotic drugs are equivalent in clinical effectiveness.
Related Topics:
- Online Nursing Practice Test about Psychotic Disorders (24-32)
- Go back to Online Nursing Practice Test about Psychotic Disorders (1-12) to start the test from the beginning.
Posts
