Psychiatric Nursing - APPROACH / OUTCOME Flashcards
(16 cards)
A client is experiencing a SEVERE PANIC ATTACK. Which nursing INTERVENTION would meet this client’s immediate need?
STAY with the client and offer REASSURANCE OF SAFETY.
A nurse has been caring for a client diagnosed with post-traumatic stress disorder (PTSD). What SHORT-TERM, REALISTIC, correctly written OUTCOME should be included in this client’s PLAN OF CARE?
The client will NOT require ZOLPIDEM (AMBIEN) to obtain ADEQUATE SLEEP by discharge.
Help reduce or eliminate PANIC ATTACKS
Administration of ANTI-DEPRESSANTS.
When a client experiences a PANIC ATTACK, which OUTCOME takes priority?
The client will remain SAFE all throughout the attack.
A client with a history of generalized anxiety disorder (GAD) enters the emergency department complaining of RESTLESSNESS, IRRITABILITY, and EXHAUSTION. Vital signs are BP 140/90 mm Hg, HR 96, and RR 20. Based on this assessed information, which assumption would be correct?
Further physical examination is needed to determine the ETIOLOGY of the client’s problem.
A client diagnosed with generalized anxiety disorder complains of feeling out of control and states, “I just can’t do this anymore.” Which nursing action takes priority at this time?
Ask the client, “Are you thinking about harming yourself?”
A client diagnosed with PARANOID PERSONALITY DISORDER becomes VIOLENT on a unit. Which NURSING INTERVENTION is most appropriate?
Use CLEAR, CALM statements and a CONFIDENT physical stance.
A client diagnosed with BORDERLINE PERSONALITY DISORDER brings up a CONFLICT with the staff in a community meeting and develops a following of clients who UNREASONABLY DEMAND modification of unit rules. How can the nursing staff best handle this situation?
Maintain CONSISTENCY of care by OPEN COMMUNICATION to avoid staff manipulation.
Which nursing approach should be used to maintain a THERAPEUTIC RELATIONSHIP with a client diagnosed with BORDERLINE PERSONALITY DISORDER?
Being FIRM, CONSISTENT, and EMPATHIC, while addressing specific client behaviors.
When planning care for clients diagnosed with PERSONALITY DISORDERS, what should be the anticipated treatment OUTCOME?
REDUCE INFLEXIBILITY of traits that interfere with functioning and relationships
Nurse Lynnette notices that a female client with OBSESSIVE-COMPULSIVE DISORDER washes her hands for long periods each day. How should the nurse respond to this compulsive behavior?
DESIGNATE TIMES during which the client can focus on the behavior.
After seeking help at an outpatient mental health clinic, Ruby who was RAPED while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby?
Exploring the MEANING of the traumatic event with the client.
A client with obsessive-compulsive disorder (OCD) states making a concerted effort to REDUCE THE FREQUENCY and DURATION OF RITUALS. What intervention should the nurse include to assist in these efforts?
Teach the client nonpharmacologic RELAXATION TECHNIQUES.
The nurse is teaching a client with posttraumatic stress disorder (PTSD). Which action should the nurse advise the client to do at the FIRST SIGN OF ANXIETY?
Instruct the client to perform ABDOMINAL BREATHING.
A client with posttraumatic stress disorder (PTSD) reports having repetitive negative thoughts and emotions.
Which action should the nurse suggest to ALLEVIATE NEGATIVE THOUGHTS AND FEELINGS?
Advise client to EXERCISE.
A nurse is planning care for a client who has BODY DYSMORPHIC DISORDER. Which of the following actions should the nurse plan to take FIRST?
Assess the client’s RISK for SELF-HARM.
