Psychosocial Integrity Flashcards

A patient diagnosed with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate?

Answer: Encouraging the patient to discuss the hallucinations

Encouraging a patient with schizophrenia to discuss their auditory hallucinations in a non-judgmental way is the most appropriate intervention. This approach validates the patient's experience, helps the nurse understand the nature and impact of the hallucinations, and builds trust. It allows for assessment and appropriate intervention without ignoring or reinforcing the delusion.

A patient with depression has been prescribed fluoxetine (Prozac). The nurse should monitor the patient for which potential adverse effect?

Answer: Suicidal ideation

Fluoxetine (Prozac), an SSRI antidepressant, carries a black box warning for an increased risk of suicidal thoughts and behaviors, especially in children, adolescents, and young adults, particularly at the beginning of treatment or with dose changes. While the medication can improve mood, it may initially increase energy before mood fully lifts, potentially giving patients the impetus to act on suicidal ideation. Therefore, close monitoring is crucial.

Which nursing action is most important when caring for a patient with bipolar disorder during a manic episode?

Answer: Ensuring a quiet, low-stimulation environment

During a manic episode, a patient with bipolar disorder experiences elevated energy, racing thoughts, and is easily overstimulated. Ensuring a quiet, low-stimulation environment helps to reduce agitation, promote rest, and prevent the escalation of manic symptoms. This intervention is crucial for the patient's safety and to help them regain control.

A patient with borderline personality disorder (BPD) exhibits splitting behavior. The nurse understands this behavior involves:

Answer: Switching between extremes of idealization and devaluation

Splitting is a defense mechanism commonly seen in borderline personality disorder (BPD). It involves the inability to integrate positive and negative qualities of oneself or others into a cohesive whole. As a result, individuals with BPD perceive people or situations in extreme, all-good or all-bad terms, rapidly shifting between idealization and devaluation.

When communicating with a patient diagnosed with antisocial personality disorder, the nurse should:

Answer: Set firm boundaries and consequences for inappropriate behavior

Patients with antisocial personality disorder often exhibit manipulative and deceitful behaviors, disregarding rules and the rights of others. Setting firm, consistent boundaries and clearly defined consequences is essential to establish limits, promote accountability, and prevent manipulation. This approach fosters a safe and structured therapeutic environment for both the patient and others.

Which statement by a patient with generalized anxiety disorder (GAD) indicates a need for further education?

Answer: "I drink a glass of wine every night to help me relax before bed."

Drinking alcohol to relax before bed indicates a need for further education for a patient with generalized anxiety disorder (GAD). While alcohol may provide temporary relief, it is a central nervous system depressant that can worsen anxiety in the long run, disrupt sleep patterns, and lead to dependence. This coping mechanism is maladaptive and counterproductive for managing anxiety effectively.

Which behavior by a patient diagnosed with anorexia nervosa should the nurse prioritize as needing immediate intervention?

Answer: Experiencing bradycardia and hypotension

Experiencing bradycardia (slow heart rate) and hypotension (low blood pressure) in a patient with anorexia nervosa indicates severe cardiovascular compromise due to malnutrition and electrolyte imbalances. These are critical physiological signs that put the patient at high risk for cardiac arrest and require immediate medical intervention to stabilize their condition. This is a life-threatening emergency.

A patient with schizophrenia is prescribed risperidone (Risperdal). The nurse should monitor the patient for which potential adverse effect?

Answer: Orthostatic hypotension

Risperidone (Risperdal) is an atypical antipsychotic that can cause orthostatic hypotension, a sudden drop in blood pressure upon standing. This adverse effect is due to its alpha-adrenergic blocking properties and can lead to dizziness, lightheadedness, and an increased risk of falls. Therefore, monitoring blood pressure and advising patients to change positions slowly are important nursing actions.

A patient with post-traumatic stress disorder (PTSD) is experiencing a flashback. The nurse's priority intervention is to:

Answer: Ensure a safe environment and reassure the patient

During a flashback, a patient with PTSD is intensely re-experiencing the traumatic event as if it's happening in the present, leading to extreme fear and disorientation. The nurse's immediate priority is to ensure the patient's physical safety and provide a calm, reassuring presence. This helps to reorient them to reality and create a sense of security, reducing distress.

A patient with alcohol use disorder is admitted for detoxification. The nurse understands that the priority during detoxification is to:

Answer: Monitor for signs of delirium tremens (DTs) and manage symptoms

During alcohol detoxification, the absolute priority is to monitor for and manage signs of delirium tremens (DTs). DTs are the most severe and life-threatening manifestation of alcohol withdrawal, characterized by severe agitation, hallucinations, seizures, and autonomic instability. Prompt recognition and intervention are crucial to prevent serious complications and ensure patient safety.

When assessing a patient with dementia, the nurse observes repetitive pacing and agitation. The most appropriate nursing intervention is to:

Answer: Redirect the patient's attention to a calming activity

Repetitive pacing and agitation in a patient with dementia often stem from confusion, unmet needs, or overstimulation. The most appropriate nursing intervention is to redirect the patient's attention to a calming activity. This helps to de-escalate the agitation, provide a sense of purpose, and reduce distress without resorting to more restrictive measures like sedatives or restraints.