HESI NSG 212

Question 1

Antipsychotic Med
SX: dry mouth, blurred vision, nasal stuffiness, & ^wt.
Adverse SX: tardive dyskinesia
—>Protrusion of the tongue, puffing out of the cheeks, chewing, or puckering of the mouth. If occur REPORT to HCP immediately

Answer 1

Antipsychotic medication

Adverse SX: tardive dyskinesia.

Question 2

An emergency department nurse is preparing to care for a client demonstrating symptoms associated with rape-trauma syndrome. Which goal is the most appropriate for the client at this time?

Answer 2

The client will begin the healthy grieving process.

Question 3

Rape-Trauma Syndrome
–>beginning stages of the grieving process. Pt. use defense mech. to help control anxiety, and some defense mechanisms (ex: denial) have been described to be helpful to the individual, especially in the immediate post-traumatic period.

Answer 3

Rape-Trauma Syndrome
Phases

Priority CARE PLAN/ GOAL for new admission:
**The client will begin the healthy grieving process.

Question 4

-Short-Term GOALS: the beginning stages of dealing with the rape trauma.
—>Pt. will initially be expected to keep aptmt. , participate in care, start to explore feelings, and begin to heal the physical wounds that were inflicted at the time of the rape.
-Long Term GOAL: The resolution of feelings of anxiety and fear.

Answer 4

Victim of Rape
Goals

Question 5

Diazepam (benzodiazepine)
SX: sedative/hypnotic effects, anticonvulsant, skeletal muscle relaxant properties.
—>Common= Dizziness, drowsiness, and Lethargy
RN INTERVENT.: institute safety measures before leaving the pt.s room to ensure that the client does not injure self.

Answer 5

Diazepam (Benzodiazepine)

**After Admin: put safety precautions in place and Reduce Risk for self-injury

Question 6

Lithium (Mood Stabilizer)
Teach: @ start bi/tri blood draws, after stable for 6-12 mnths= blood draws q3mth
RISK: Hyponatremia r/t ^urine output or diarrhea= Lithium toxicity

Answer 6

Lithium

Question 7

Tacrine
(Acetylcholinesterase inhibitor)
TX: Alzheimer’s disease
SX: Flulike sx w/out fever & GI sx
REPORT HCP ADVERSE: N/V, diarrhea, rash, jaundice, or changes in the color of the stool occur R/T potential HEPATITIS
TEACH: W/out regard to food; if GI upset may take w/ food

Answer 7

Tacrine
(Acetylcholinesterase inhibitor)

*TX: AD
*REPORT changes in color of stool

Question 8

Imipramine hydrochloride
(tricyclic antidepressant)

Admin: PM r/t sedation sx

Answer 8

Imipramine hydrochloride
(tricyclic antidepressant)

*Admin PM r/t sedation sx

Question 9

An 8-year-old is admitted to the hospital after being sexually abused by an adult family member. The child is withdrawn and appears frightened. Which describes the BEST plan for the INITIAL nursing encounter to convey concern and support?

Answer 9

Introduce yourself and tell the child that you would like to sit with the child for a little while.

*Move slowly and convey willingness to spend time

Question 10

Types of Crisis

Answer 10

1. ADVENTATIOUS crises are unpredictable tragedies that occur without warning.
   Ex: tornado, robbing, crime
2. SITUATIONAL crisis occurs when a specific external event disturbs an individual’s psychological equilibrium.
   Ex: divorce, death of loved one
3. MATURATIONAL crisis involves the normal life transition that creates changes w/ individuals and how they perceive themselves, their role, and their status.
   Ex: puberty, mid-life crisis

Question 11

Post Traumatic Stress Syndrome
*Priority assist

Answer 11

Assist the client in recognizing the association between his or her feelings and behaviors and the trauma experience.

Question 12

HYPERTENSIVE CRISIS
(MAOI med RISK)
-Potentially fatal problem that occurs when the norepinephrine lvls are excessively HIGH
*–>SX: severe occipital headache, stiff or sore neck, Palpitations, ^ or dec. HR, N/V, HTN, & ^^ temp.
May Lead To=stroke, cardiac dysrhythmias (irregular Heart beat), & MI

Answer 12

HYPERTENSIVE CRISIS
(MAOI med RISK)

*Extreme HIGH lvls of Norepinephrine

*AVOID intake of foods ^^ in TRAMINE

Question 13

Tranylcypromine
(Monoamine Oxidase Inhibitor/ MAOI)
-TEACH: Foods high in TYRAMINE can cause HTN and Chest Pain
–>AVOID FOOD: aged cheese, yeast, chocolate, sherry, beer and red wine, smoked meats, ripe bananas, smoked fish, soy sauce, ripe avocado, yogurt, and yeast extract.

Answer 13

Tranylcypromine
(monoamine oxidase inhibitor/ MAOI)

*AVOID foods high in TRAMINE r/t Risk of HTN and Chest Pain

Question 14

Donepezil hydrochloride
(Cholinergic Agent)
TX: Mild-Moderate dementia/ AD
ACTION: ^^ cholinergic functions by ^^ concentration of acetylcholine.=slows the progression of Alzheimer’s disease

Answer 14

Donepezil Hydrochloride
(Cholinergic Agent)

*TX: Mild-Moderate Dementia of AD type

Question 15

Clozapine
(Antipsychotic)
ASSESS: WBC Count
ADVERSE: *agranulocytosis and Mild Leukopenia
*->SX: sore throat, malaise, and fever

Answer 15

Clozapin
(Antipsychotic)
*RISK Agranulocytosis and Mild Leukopenia

Question 16

Depression
SX: withdrawn, difficulty concentrating, loss of interest or pleasure, low energy and fatigue, feelings of worthlessness and poor self-esteem.
PLAN OF CARE: provide stimulation in a structured environment.

Answer 16

Depression

*PLAN of CARE: provide a structured daily program of activities and encourage the client to participate.

Question 17

A client who unsuccessfully attempted suicide by inhaling carbon monoxide has been treated in the emergency room and is being admitted for observation. The nurse would arrange for which service to be initiated first?

Answer 17

Psychiatric consult

Question 18

Agoraphobia
—> ^anxiety about being in places or situations from which escape is difficult
–perceived by the client as embarrassing.
—>Fears=being outside the home alone; being in a crowd or standing in a line; or traveling on a bus, bridge, train, or car.

Answer 18

Agoraphobia
* FEAR of open spaces & being trapped in a situation from which there may not be an escape
Leads to fear of leaving their “safe space”; commonly their home

Question 19

PTSD: SX Manifestations
1. Reexperience of trauma (1st primary sx)
EX: Replaying event over and over in head; or inject itself in nonrelated streams of thought (aka Thought Intrusion); Troubled sleep or Flashbacks
2. Avoidance of trauma-reminding phenomena
3. Hyperarousal.
EX: On edge or Hypervigilant (scan environment for threats; overreact to stimuli; exaggerated startle reflex)
** Hypervigilance, overreaction, and lack of sleep= pt. tired and irritable.

Answer 19

PTSD
Clinical Manifestations

** Hypervigilance, overreaction, and lack of sleep= pt. Tired and irritable.

^Risk of additional Mental Disorders=Sub. Abuse, Anxiety, or/& Depression

Question 20

Supportive psychotherapy
FOCUS:
1. Assisting the client to carry on while experiencing a mental illness.
2. Listening, offering supportive techniques such as stress management, and encouraging healthy interpersonal relationships.

Answer 20

Supportive Psychotherapy Interventions

*AVOID Suggesting actions to change or confront the existing problems

Question 21

In the termination stage of a grief support group, the nurse would evaluate the group experience by inviting the clients to engage in which activity?
A. Saying goodbye to the other clients
B. Handling conflict and decision making
C. The handling of loss and grieving in the future
D. How to help themselves and others after the group ends

Answer 21

A. Saying goodbye to the other clients

Rationale: The nurse addresses evaluation by exploring clients’ thoughts and feelings about the group experience and separating from the group.

Question 22

Tourette’s disorder
-Motor and verbal tics that cause marked distress and impairment in social and occupational fxn
—>Motor Tics= Common 1st sx is a single tic, such as eye blinking; tongue protrusion, touching, squatting, hopping, skipping, retracing steps, and twirling when walking.
—>Vocal Tics=barks, grunts, yelps, clicks, snorts, sniffs, and coughs.
*Coprolalia=uncontrollable uttering of obscenities, is a more rare Vocal Tic

Answer 22

Tourette’s Disorder
Clinical Manifestations

Question 23

Assessing pt.’s Perception of an Event EX:
–How does this situation affect your life?
–Describe how you are feeling right now?
–How do you see this event as affecting your future?

Answer 23

Assessing a Pt.’s PERCEPTION of Traumatic Event

*Goal of Assessment: to Clearly define the problem and identify a more effective solution

Question 24

Tricyclic Antidepressants (TCAs)
-Takes 4 weeks for therapeutic effect
ADVERSE: Cardiac fxn
ASSESS: ECG baseline to look for pre-existing abnormalities before admin of med

Answer 24

Tricyclic Antidepressants (TCAs)

*^ Risk for Cardiac pt.’s can be fatal= get baseline ECG