Complete an ATI Focused Review
- Manifestation Findings of a Patient with Serotonin Syndrome: Serotonin syndrome can begin 2 to 72 hrs. after the start of treatment and can be lethal. Manifestations can include mental confusion, difficulty concentrating, abdominal pain, diarrhea, agitation, fever, anxiety, hallucinations, hyperreflexia, incoordination, diaphoresis, and tremors. Nursing interventions and actions should include to start symptomatic treatment which also involves medications to create serotonin receptor blockade and muscle rigidity, cooling blankets, anticonvulsants, and artificial ventilation. The nurse should monitor the client for any of the above manifestations and if any occur the nurse should withhold the medication and notify the provider.
- Priority Action When Caring for a Client who is Experiencing a Manic Episode: Priority actions when caring for a client who is experiencing a manic episode is focused towards maintaining the safety and physical health of the client. This involves providing a safe environment for the client during the acute manic phase and regularly assessing the client for suicidal thoughts, intentions, and escalating behavior. The nurse should also decrease stimulation without isolating the client if possible while taking into consideration of all noises, music, television, and other clients that could escalate the client’s current behavior. Other priority actions consist of following agency protocols for providing client protection for example, restraints, seclusion, and one-to-one observation if the client presents a threat of self-injury or injury to others. Lastly, the nurse should protect the client from poor judgement and impulsive behavior such as giving away money or sexual indiscretions.
- Termination Phase of the Nurse-Client Relationship: In the termination phase of the nurse-client relationship the nurse provides an opportunity for the client to discuss thoughts and feelings about the termination phase and loss. In addition to summarizing the goals and achievements made with the client and reflecting back upon the memories of work made in sessions. Lastly, the nurse should discuss ways to incorporate and continue the new healthy behaviors into the client’s lifestyle, make plans for the future, and maintain limits in the final termination stage.
- Suicide/Safety Precautions for Client: Suicide precautions include milieu therapy within the facility in addition to initiating one-on-one constant supervision around the clock and always having the client in sight and close. Safety precautions include documenting the client's location, mood, quoted statements, and behavior every 15 min or per facility protocol. The nurse should also ensure to remove all glass, metal silverware, electrical cords, vases, belts, shoelaces, metal nail files, tweezers, matches, razors, perfume, shampoo, and plastic bags from the client's room and vicinity. The client should only be allowed to use plastic eating utensils and always check the environment for possible hazards for example, windows that are open or overhead pipes that are easily accessible. Additionally, during observation periods the client’s hands should always be checked, especially if they are hidden from sight. The client should also not be assigned to a private room if possible and the door should be kept open at all times. Other safety precautions include ensuring the client swallows all of their medication and identifying whether or not the client's current medications can be lethal with overdose. If so, the nurse should collaborate with the provider to have less dangerous meds substituted if possible.
- Forensic nursing is one of the many diverse behavioral health services. Define forensic nursing and what the specialty entails.
- Forensic nursing is a combination of biophysical education and forensic science. The registered nurses use scientific investigation, collection of evidence, analysis, prevention, and treatment of trauma and/or death of perpetrators and victims of violence, abuse, and traumatic accidents. A forensic nurse is a Registered or Advanced Practice nurse who has received specific education and training. Forensic nurses provide specialized care for patients who are experiencing acute and long-term health consequences associated with victimization or violence, and/or have unmet needs relative to having been victimized or accused of victimization. In addition, forensic nurses provide consultation and testimony for civil and criminal proceedings relative to nursing practice, care given, and opinions rendered regarding findings. Forensic nursing care is not separate and distinct from other forms of medical care, but rather integrated into the overall care needs of individual patients.
- Explain the difference between voluntary and involuntary commitment to a mental health facility. Discuss the legal rights of a client who is involuntarily committed to an inpatient mental health facility.
- During voluntary commitment to a mental health facility the patient or patient’s relative chooses admission to obtain treatment. A voluntarily admitted client has the right to apply for releases at any time. Additionally, a voluntarily admitted patient is considered competent and so they have the right to refuse medication and treatment. However, involuntary commitment consists of a patient entering the metal health facility against their will for an indefinite period of time. Admission is based on the patient’s need for psychiatric treatment, the risk of harm to their self or others or the inability to provide self-care. Involuntary commitment is limited to 60 days at which time a psychiatric and legal review of the admission is required. Patients involuntary committed are still considered competent and still have the right to refuse treatment.
- A nurse is admitting a client that is confused, what are some priority actions for the nurse to consider during the admission process?
- Some priority actions for the nurse to consider during the admission process and during a client’s episode of confusion would be to focus attention on providing safety and comfort and to reduce anxiety. The nurse should also provide a calm presence and environment to assist the client in feeling secure. Additional nursing actions should focus on priority patient care issues such as safety, privacy, reduction of stimuli, frequent monitoring of confusion status, and reality orientation when planning the care of the confused patient.
- A nurse is caring for a client that has been admitted for suicidal ideations. Discuss nursing and collaborative care of this client.
- Implement milieu therapy within the facility. Initiate one-on-one constant supervision around the clock with documentation of the client’s behavior every 15 minutes. Search the client’s belongings with the client present and remove any potentially harmful items from the client’s room and vicinity. Allow the client to only use plastic utensils. Ensure that the client’s hands are always visible. Do not assign the client to a private room and keep the door open to the client’s room at all times. Ensure that the client swallows all medications. Restrict visitors from bringing possibly harmful items to the client.
- A nurse is caring for a client who is experiencing a panic-level anxiety attack. What actions should the nurse take?
- For the patient that is experiencing a panic-level anxiety attack and is not able to process what is occurring in the environment, the nurse should remain with the pt. while providing a quiet environment that meets the physical and safety needs of the client. This intervention will minimize the risk to the client and help prevent intensification of the current level of anxiety the pt. is experiencing. Additionally, the nurse should use medications and restraints, but only after all other less restrictive interventions and methods have been tried and failed to decrease anxiety to safer levels. Medications and/or restraints may be necessary to prevent harm to the client and other patients and providers. The nurse should also encourage gross motor activities such as walking and exercise as it provides the client with an outlet for pent-up tension, promotes endorphin release, and improves mental well-being. Lastly, the nurse should use limit-setting to minimize the risk to the client and providers by presenting clear, simple communication that facilitates understanding. Directing the client to acknowledge reality and focus on what is present in the environment will assist with reducing the patient’s anxiety level.
- A client is extremely angry and the nurse is worried about imminent violence towards others on the unit. Identify three (3) steps the nurse can take to handle aggressive or escalating behavior.
- One step the nurse can take to handle aggressive or escalating behavior is by responding quickly and remaining calm and in control. Another step the nurse can take is to encourage the client to express their feelings verbally using therapeutic communication techniques for example reflection, silence, and active listening. The nurse should allow the client as much personal space as possible while maintaining eye contact and communicating with an honest, sincere, and nonaggressive stance. Lastly, the nurse should avoid accusatory or threatening statements and offer choices to the client while clearly describing options.
- A nurse is caring for a client with schizophrenia that is experiencing hallucinations. What priority assessment should be made regarding the client's hallucinations?
- Patient’s experiencing hallucinations may also have disturbed thoughts and may become disinterested in others and their surroundings. They may also find it difficult to maintain interpersonal skills and form relationships. Disturbances in behavior and social functioning can cause any of the following problems: Withdrawal, Decreased motivation, Poor self-care, and Poor interpersonal relationships. An assessment of a patient’s needs is essential and must consider that the patient’s physical needs are being met which includes nutritional needs, sleep, and self-care needs. The priority assessment that should be made regarding the client’s hallucinations is to maintain safety. A risk assessment should be performed as patients may become a risk to themselves or to others and should be monitored for withdrawn behavior and assessed for disturbances in thought processes.
- Define the stages of grief.
- Although many theories of grief are present, they all tend to identify the same underlying feelings for which the grieving client is experiencing. Many people experience denial as their first emotion and even might believe that a diagnosis is mistaken and instead hold onto a different reality, possibly refusing to even acknowledge what is actually happening. A patient might even feel denial right after a death or feel "numb" or refuse to accept that their loved one is gone. When an individual no longer can hold onto their denial, they will often feel angry or frustrated, and may take out their anger on those around them. They may also have conversations that surround questions or ideas of “This isn’t fair!” or “Why me?”. The third stage, bargaining, is really about avoidance. An individual may try to avoid the cause of grief, such as being around family or around the place the death occurred. Depression is the fourth stage and the stage that is mostly associated with grief. However, it may be an emotion that’s not felt right away, it can be felt in spurts or in combination with anger or other stages. In this stage the patient may withdrawal or refuse company, have trouble eating or tend to overeat, or experience other symptoms of depression. In the last stage, acceptance, the individual might not necessarily feel less sad, but they will say, "It's going to be okay. I can't fight this, but I can get through it." Calm may accompany this stage, as well as a more stable emotional state.
- Identify three (3) methods a nurse can use to determine a client's cognition level during an assessment.
- Assessment of mental status gives a general impression of how the patient is functioning. Most of the mental status examination can be completed during nurse-patient interactions. For example, language and memory can be assessed when asking the patient for details of their illness and significant past events. The nurse should also take into consider the patient's age, cultural background, and level of education when evaluating mental status. Some components of the mental status examination include general appearance and behavior. This also includes level of consciousness (ex. awake, asleep, comatose), motor activity, body posture, dress and hygiene, facial expression, and speech pattern. A patient who has deficits in self-care as evidenced by poor grooming is more likely to have other cognitive deficits. The last method a nurse can use to determine a client’s cognition level is by assessing their orientation to time, person, place, and situation. A nurse should also note the presence of factors affecting a client’s intellectual capacity, such as cognitive impairment, hallucinations, delusions, and dementia. In addition to noting any agitation, anger, depression, or euphoria, and the appropriateness of these states. Use suitable questions to reveal the patient's feelings.
- Compare and contrast the onset and outcome between delirium and dementia.
- Onset of Delirium: Occurs rapidly over a short period of time (hours or days)
- Onset of Dementia: Occurs gradually with deterioration of function over months or years
- Outcome of Delirium: Reversible if diagnosis and treatment are prompt
- Outcome of Dementia: Irreversible and progressive
- Discuss the positive and negative symptoms of schizophrenia. How should a nurse manage a client who is experiencing delusions or hallucinations?
- Positive symptoms of schizophrenia are the most easily identified and treated and include hallucinations, delusions, disorganized speech, and bizarre behaviors. Negative symptoms are more difficult to treat and indicate a further progression of the disease process. These include a flat/blunted affect, alogia (poverty of speech), avolition (lack of motivation), anhedonia (lack of pleasure/joy) or anergia (lack of energy). When a client is experiencing hallucination or delusions, the nurse should promote therapeutic communications to help decrease client anxiety, decrease defensive patterns, and encourage participation in the milieu. The nurse should ask the client about the delusion/hallucinations but not feed into it or agree with the client’s perceptions. Also, monitor for symptom triggers (ex. Loud noises), and situations that seem to trigger the delusion/hallucination.
- The nurse is caring for a client experiencing mild anxiety. Identify three (3) expected findings.
- Increased motivation
- Identify two (2) medications that are used to treat alcohol withdrawal.
- Benzodiazepines (ex. Diazepam, Lorazepam)
- A nurse is caring for a client with stage 2--moderate Alzheimer’s (middle-stage), and knows the caregiver understands this stage when they tell you that ___________.
- The second stage in the Alzheimer’s Disease spectrum, is a state of cognitive function in which individuals have problems with memory, language, or another essential cognitive function that are severe enough to be noticeable to others and show up on tests. However, these manifestations may not be severe enough to interfere with activities of daily living. In addition the casual observer of an individual with a mild cognitive impairment (MCI) may seem fairly normal. However, the person with a MCI is often aware of these significant changes in memory, and family members may observe changes in the individual's abilities.
- Discuss the rationale for administering benztropine (Cogentin) to a client who is taking chlorpromazine (Thorazine) for treatment of schizophrenia?
- Conventional antipsychotics such as chlorpromazine can cause extrapyramidal symptoms (EPS) within hours of the first dose or during the 1-2 months of treatment. Anticholinergic medications such as benztropine are then given to treat the EPS. Signs and symptoms of early extrapyramidal symptoms are acute dystonia, Parkinsonism, and akathisia. Tardive dyskinesia refers to late EPS and signs and symptoms include the twisting/wormlike movement of the tongue and face, lip smacking, uncontrollable moving limbs and trunk, and hip jerks or twisting of the pelvis. There is no known treatment for Tardive dyskinesia and discontinuing the antipsychotic medication may not stop the symptoms.
- Amoxapine (Asendin): Amoxapine (Asendin) is a TCA or tricyclic antidepressant used to treat major depressive disorder. The most common side effects are sedation, dry mouth, and constipation. Extrapyramidal side effects also occur, movement disorders that include akathisia, tardive dyskinesia, acute dystonia, and pseudoparkinsonian symptoms. Tardive dyskinesia is characterized by abnormal rhythmic movements such as tongue protrusion and limb jerks. Acute dystonia is characterized by muscle rigidity, drooling, decreased movements, and shuffling gait. Akathisia involves motor restlessness and inability to sit still or lit down. The nurse should notify the doctor about the client’s behavior and suggest changing medication to prevent extrapyramidal symptoms from occurring.
- Biofeedback: Biofeedback involves teaching the body to respond differently to stress and it is most likely involved with physical responses to pain and stress that are controlled by the mind. This technique can be used as a primary treatment modality or as adjunct therapy for management of chronic pain, stress, anxiety, urinary incontinence, asthma, and headache. During biofeedback sessions, electrodes or finger sensors are used to monitor physiological responses to stress, pain, and other triggers. The client learns to recognize triggers and practices techniques to modify responses, including relaxation techniques.
- Shaken Baby Syndrome: Shaken baby syndrome refers to injuring an infant by abusive head trauma through repeated acceleration and deceleration (coup/contrecoup injury) causing retinal hemorrhages and/or subdural hematomas in infants. Bruises on the arms or chest may occur where the infant was held during an episode or occurrence of abuse. Multiple long bone fracture in various stages of healing are another finding suspicious for child abuse. Additionally, a nurse has a legal and ethical duty to report suspicion of child abuse or neglect.
- Vagus Nerve Stimulation: Vagus nerve stimulation was initially used to treat seizure disorders but is also used to treat depression and enhance the action of antidepressants. Stimulation of vagus nerve increases the level of neurotransmitters and improves mood. Implantation of the device for stimulation of the vagus nerve is a surgical procedure with side effects related to the location of the device lead near the laryngeal and pharyngeal branches of the left vagus nerve. They may include hoarseness and voice changes.
- Anorexia Nervosa: The nurse should understand the characteristics, psychological factors, and assessment findings of anorexia nervosa as well as the associated nursing interventions. Manifestations include low weight, lanugo, amenorrhea, muscle weakening, hypokalemia, decreased bone density, constipation, and cold extremities. Nursing interventions for a patient diagnosed with anorexia nervosa include weighing the client daily for the first week and then three times per week following that, and measuring the client’s vital signs twice daily stable. After the client’s vital signs are stabilized, the client's vital signs can be measured once daily. The nurse should avoid conversations with the client that have a food theme during mealtimes, in addition to staying with the client during meals, and for one hour after meals. Lastly, the client should be provided with small meals frequently and should be given liquid supplements as prescribed.
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