Exam 1

Question 1

When can you apply restraints?

Answer 1

As a last resort if patient is a danger to others/self

Question 2

How often do you check/reevaluate restraints

Answer 2

Q2h, check for circulation and comfort every 15 minutes

Question 3

Do you have to have a doctors orders to apply restraints?

Answer 3

Yes, must have a rationale and interventions used prior to application. If an emergency apply restraints and obtain a written order ASAP.

Question 4

What should a nurse consider before using restraints?

Answer 4

Verbally intervening, reducing stimulation/triggers, actively listening, providing diversion, offering PRN meds

Question 5

What does the mental status examination include?

Answer 5

Appearance, behavior, cognition, speech, mood, harm self/others, perceptual disturbance, disordered thoughts

Question 6

Appearance

Answer 6

Grooming and dress, level of hygiene, pupil dilation or constriction, facial expression, height, weight, nutritional status, relationship between appearance and age, clothes, hygiene, tattoos/scars

Question 7

Behavior

Answer 7

Excessive or reduced body movements, peculiar body movements (scanning the environment, odd or repetitive gestures, LOC), abnormal movements (tardive dyskinesia, or tremors), level of eye contact (keep in mind cultural differences), anxious, guarded, sit still, anger

Question 8

Tardive dyskinesia

Answer 8

Caused by long-term use of neuroleptic drugs. It causes repetitive involuntary stiff, jerky movements of your face and body that you can’t control

Question 9

Cognition

Answer 9

Orientation (person, place, time), LOC (alert, confused, clouded, stuporous, unconscious, comatose), memory, fund of knowledge, insight, judgment

Question 10

Immediate memory

Answer 10

Give the person a thing to remember then in a few minutes ask them to repeat those things

Question 11

Recent memory

Answer 11

Remembering things that brought them to the hospital, knowing birthday and name, the nurse needs to ask questions that the nurse can validate

Question 12

Remote memory

Answer 12

In dementia this is the last to go, patient seen to go back to their childhood

Question 13

Ideas of harming self or others

Answer 13

Suicidal or homicidal history and current thoughts, presence of a plan, means to carry out the plan, opportunity to carry out a plan

Question 14

Speech

Answer 14

Rate (slow, rapid, normal), volume (loud, soft, normal), disturbances (articulation problems, stuttering, slurring, mumbling)

Question 15

Mood

Answer 15

Subjective data, ask the patient, Sad, labile, euphoric

Question 16

Affect

Answer 16

Objective; what do we see

Flat, bland, animated, angry, withdrawn, appropriate to context

Question 17

Perceptual disturbance types

Answer 17

Illusions, hallucinations, auditory, visual, tactile, olfactory, gustatory, command hallucinations

Question 18

Illusions

Answer 18

Something is there but it’s being misperceived. It’s an environmental stimuli

Question 19

Hallucinations

Answer 19

Are not really happening and not caused by the environment

Question 20

Auditory

Answer 20

Hearing things

Question 21

Visual

Answer 21

See things that are not there

Question 22

Tactile and olfactory

Answer 22

Feeling things that are not there and smelling things that are not there

Question 23

Gustatory

Answer 23

Taste random things

Question 24

Command hallucinations

Answer 24

Voices in a patient’s head that tells them to do something such as hurt a specific person or hurt themselves because the voices told them to

Question 25

Disordered thoughts

Answer 25

``` Thought process is how they are thinking and idea it makes sense (disorganized, coherent, flight of ideas neologisms, thought blocking, circumstantiality) Thought content is what the person is thinking about(delusions, obsessions) Word salad (random words in a sentence and the sentence does not connect or make sentences) ```

Question 26

What do you rule out before assuming psychiatric

Answer 26

Physical medical diagnoses

Question 27

Assessment data

Answer 27

``` Physical, psychosocial and mental status Presenting problem History of illness Family history Medical history Social history ```

Question 28

Psychosis

Answer 28

Symptoms in which make it difficult for a person to distinguish what is real and not real

Question 29

What kind of personality is schizophrenia?

Answer 29

A deteriorating personality

Question 30

Blueler’s four A’s of schizophrenia

Answer 30

Affective disturbance Autism Associative looseness Ambivalence (mixed emotions)

Question 31

Schizophreniform

Answer 31

Same as schizophrenia except that duration of signs is less than 6 months and social functioning may not be impaired

Question 32

Schizoaffective disorder

Answer 32

Signs meet criteria or schizophrenia but the person also has a depressed, manic, or mixed episode as well

Question 33

What are the neurotransmitters involved with schizophrenia

Answer 33

Dopamine, glutamate, serotonin, and GABA

Question 34

Dopamine

Answer 34

High levels of overactive dopamine glands associated with schizophrenia. Involved in fine muscle movement and in integration of emotions and thoughts, involved in decision making

Question 35

Glutamate

Answer 35

Excitatory neurotransmitter that is elevated. Plays a role in learning and memory

Question 36

Serotonin

Answer 36

A brain catecholamine that plays an important role in mood, sleep, sexuality, appetite and metabolism. Elevated levels cause altered perception, attention, mood, aggression, sexual drive, appetite, sleep, and mood behavior

Question 37

GABA

Answer 37

Inhibitory Neurotransmitter than had reduced levels in schizophrenia. Plays a role in aggression, excitation, and anxiety. Has a role in pain perception and also may impair cognition and psychomotor functioning.

Question 38

Positive signs

Answer 38

What the patient experiences. Hallucinations, delusions, associative looseness, circumstantiality (conversation is derailed by unnecessary and tedious details), agitation, bizarre behavior

Question 39

Negative signs

Answer 39

Physical manifestations of patient Uncommunicative, withdrawn, expresses feelings of rejection or aloneness, talks about self as bad or no good, feels guilty because of bad thoughts, anergia (lack of energy), anhedonia (people lost interest and pleasure that were usual happy events for them), loss of motivation, blunted affect, abolition (don’t have any goals), unable to initiate tasks