Real Life RN Mental Health 3.0
- Schizophrenia
- Altered speech pattern of communication in which the pt shifts from one idea to
- Schizophrenia
- Schizophrenia
Nurse Anne noticed that Ken is exhibiting an altered speech pattern. Which of the following respnses by Ken should Nurse Anne identify as an example of associative looseness? - ANSWER
another.
Murse Anne observes that Ken is becoming increasingly anxious. Which of the following actions should Nurse Anne take? - ANSWER Stand off to the side of Ken, more than arms reach away...... To avoid increasing the pt's anxiety.Pts who are exhibiting anxious behaviors are at risk ofr violence. The nurse should have a direct path to the door in case the client becomes violent & the nurse needs to leave the room immediately.
Nurse Anne is teaching Ken and sister about positive and negarive symptoms of schizophrenia. Which of the following manifestations should the nurse include as positve symptoms? - ANSWER Delusions Motor agitation 1 / 3
Hallucinations Manifestations of altered mental functioning. Delusions, Hallucications (visual, auditory, gustatory, olfatory), altered speech (eholalia, clang association, associatice looseness), Motor agication.Negative schizophrenic Sx=decreased physical and mental functioning such as Flat Affect, Anhedonia, Alogia, Apathy, and Avolition.
- Schizophrenia
Nurse Anne identifies that Ken is experiencing a delusion. Which of the following types of delusions should she document in the pts medical record? - ANSWER Delusion of
Persecution:
The pts false belief that others are trying to harm or persecute them in some way.The pt does not want to take the medication becuase he thinks the pharmacyst is trying to poison him.
Delusion of Grandeur: False belief in one's own superiority, greatness, or
intelligence. People experiencing delusions of grandeur do not just have high self- esteem; instead, they believe in their own greatness and importance even in the face of overwhelming evidence to the contrary.Nihilistic Delusion: Negative belief of the world or one being dead, decomposed or annihilated, having lost one's own internal organs or even not existing entirely as a human being.
Somatic Delusion: The pt is convinced their organs are damaged or
malfunctioning, or that they are suffering from some type of hidden malady, or that their physical appearance has somehow been altered or distorted. 2 / 3
- Schizophrenia
- Schizophrenia
- Schizophrenia
- / 3
Nurse Anne is continuing to assess Ken. Which of the following manifestations should Anne Assess for first? - ANSWER Command Hallucinations Auditory Hallucinations is the risk for self or other directed harm due to cmmand hallucinations. The nurse should continue assessing the pt to determine exactly what the voices are commanding.
Nurse Anne is continuing to assess Ken. Which of the following tools should Anne use? - ANSWER The Suicide Assessment Five Step Evaluation and Triage (SAFE-T).Tool comprise of 5 steps that ssess a pt's risk for suicide. Identifies both risk and protective factors related to suicide risk. The pt may be at an increased risk for suicide due to psychosis or depression.
Nurse A is teaching E & K abut the effects of cocaine use. Which of the following findings should Nurse A indentify as a manifestation of cocaine intoxication? - ANSWER Psychosis Cocaine is an stimulant. Other intoxication manifestations include fellings of exhilaration, anxiety, panic, and anger. An increased desire for socialization, hypertansion, tachycardia, decrease appetite, and dialated pupils.