RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)

SITUATION I

 

Question 1:

Hallucination/delusion

Agitation

Insomnia

 

Question 2:

Passive social withdrawal

Avolition

Anergia

Poor hygiene

Poverty of speech

Anhedonia

 

SITUATION II

 

Question1:

It takes 2-3 weeks to reduce depression

 

Question 2:

History of child abuse and maltreatment. Her father suffered from alcoholism and the neighborhood that she grew up is a low income community.

 

Question 3:

Now, she is active in their church and is a member of their choir. She goes to college and is involve in their after-school activities (Music club). She is also a volunteer in shield of Athena

 

SITUATION III

 

Question 1:

No the patient has neuroleptic malignan syndrome

 

Question 2:

1. Take the patient's vital signs

2. Notify the physician  

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If neuroleptic malignant syndrome is suspected, high potential drugs that are said to induce NMS should be withdrawn from the regimen. It should be stopped or else, the disease might progress and may cause fatalities.

Hyperthermia is common so provide ventilation, render tepid sponge bath and administer anti-pyretics as ordered.

If infection is suspected, start antibiotic treatment as ordered.

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Be ready with prophylactic intubation especially if patients have:

Excessive salivation

Acidosis

Severe rigidity

Swallowing dysfunction

Hypoxemia

Monitor laboratories and refer any significant findings and unusualities to the physician.

Monitor cardiac functions

Monitor pulmonary functions

Monitor renal functions

 

SITUATION IV

 

Question 1:

1. Orient to reality - call him by his name

2. Consistently use the client's name in interaction. (6) Provide the client with structured activities.

 

SITUATION V

 

Question 1:

1. Reinforce the patient that he is not in danger. Reassure

2. Use a calm voice when approaching the patient.

3. Acknowledge the presence of hallucinations.

4.Use simple commands.

 

SITUATION VI

 

Question 1:

1. Sore throat

2. Fever

3. Flu-like symptoms

 

Assess white blood cells

 

SITUATION VII

 

Question 1:

1. Signs and symptoms of drug toxicity

2. Monitor lithium blood levels

3. Changes in mood should occur in 7-21 days

 

Question 2:

7-21 days

 

SITUATION VIII

 

Question 1:

Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.

 

SITUATION IX

 

Question 1:

Your behavior won't be tolerated. Go to your room immediately

The nurse should set limits on patient behaviour to ensure a comfortable environment for all patients. The nurse should accept hostile or quarrelsome patient outbursts within limits without becoming personally offended, as in option A. Option B is incorrect because it implies that the patient's actions reflect feelings toward the staff instead of the patient's own misery. Judgemental remarks, such as option D, may decrease the patient's self-esteem.

 

SITUATION X

 

Question 1:

Rotate the nurses who are assigned to the patient

 

SITUATION XI

 

Question 1:

Age cheese is high in tyramine which could lead to hypertensive crisis.

 

Question 2:

1. Increased risk of suicide

The patient has more energy to carry out the attempt when she starts to feel better

 

SITUATION XII

 

Question 1:

Supervise area and observe for 1 hour after meal. Serve the patient menu choices.

A) Contact the patients health care provider (HCP)
RATIONALE: In general, patients seek, voluntary admission. Voluntary patients have the right to demand and obtain release. The nurse needs ot be familiar with the state and facility policies and procedures. The best nursing action is to contact the HCP, who has the authority to discuss discharge with the patient. While arranging for safe transportation is appropriate it is premature in this situation and should be done only with the patients' permission. While it is appropriate to discuss why the patient feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the patient to agree to staying "a few more days" has little value and will not likely be successful. Many states require that the patient submit a written release notice to the facility staff members, who reevaluate the patient's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat to the patient.

 

SITUATION XIII

 

Question 1:

Allowing the patient to be the first to open the cart and take a tray presents the patient with the reality that the nurses are not touching the food and tray, thereby dispelling the delusion.

 

SITUATION XIV

 

Question 1:

"Focus on the feelings generated by the hallucinations and present reality."

he most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

 

SITUATION XV

 

Question 1:

Avoid laughing or whispering in front of the client.
Rationale: 
Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.

 

SITUATION XVI

 

Question 1:

"I understand that the voices are very real to you, but I do not hear them."
This reply acknowledges the client's reality but offers the nurse's perception that he or she is not experiencing the same thing.

 

SITUATION XVII

 

Question 1:

1. Share your observation about the patient appearing anxious

2. Walk with the patient