Tiêu đề KEY - R12 NP5.docx ✅

RECALLS 12 NURSING PRACTICE 5 Situation: Nurse Helen is aware that, although each individual is unique, they also share common characteristics. She is tasked with personality disorders. Given the case of Vanya, a client with borderline personality disorder, Nurse Helen takes on her role as a psychiatric nurse. 1. Nurse Helen was about to administer an oral medication to Vanya diagnosed with a borderline personality disorder. However, Vanya responds to this by saying "Just leave it on the table. I will take it when I finish combing my hair." The best response from Nurse Helen would be to _____________. A. Reinforce this assertive action by Mariel. Leave the medication on the table as requested. B. Respond to Manel, "I'm worried that you might not take it. I will come back later." C. Say to Mariel, “I must watch you take the medication. Please take it now.” D. Ask Mariel, "Why don’t you want to take your medication now?" Answer: C. Rationale: Using nonjudgmental language and a matter-of-fact tone avoids giving the client verbal cues to become defensive. Regardless of the clinical setting, the nurse must provide structure and limit setting in the therapeutic relationship. Be consistent with the client. Set and maintain limits regarding behavior, responsibilities, rules, and so forth. Source: Videbeck, S. (2020). Psychiatric-Mental Health Nursing. 8th edition p. 782 2. Along with her long-standing history of self-mutilation and suicide attempts, Vanya reveals feelings of depression and anger with life. Treatment was initiated by the psychiatrist with the use of a medication. Which type of medication should Nurse Helen expect to be prescribed? A. Escitalopram (Lexapro) B. Phenelzine (Nardil) C. Alprazolam (Xanax) D. Haloperidol (Haldol) Answer: A Rationale: Researchers believe that levels of neurotransmitters, especially norepinephrine and serotonin, are decreased in depression. The goal is to increase the efficacy of available neurotransmitters and the absorption by postsynaptic receptors. To do so, antidepressants establish a blockade for the reuptake of norepinephrine and serotonin into their specific nerve terminals. This permits them to linger longer in synapses and to be more available to postsynaptic receptors. Antidepressants also increase the sensitivity of the postsynaptic receptor sites. SSRIs, the newest category of antidepressants are effective for most clients. Their action is specific to serotonin reuptake inhibition; these drugs produce few sedating, anticholinergic, and cardiovascular side effects, which makes them safer for use in children and older adults. Because of their low side effects and relative safety, people using SSRIs are more apt to be compliant with the treatment regimen than clients using more troublesome medications. Option B is a MAOI while option C is anxiolytic, and option D is an antipsychotic. Source: Videbeck, S. (2020). Psychiatric-Mental Health Nursing. 8th edition p. 666 3. During the weekend, Vanya’s boyfriend, Xylo, visited her beyond visiting hours. When the security guard prohibited him from entering the hospital, he threatened the staff, ripped art off the walls, and thrown objects. With protocols in place, the security guard used force to stop Xylo. Soon, he was detained in the police community precinct. The most appropriate nursing diagnosis for Xylo would be ______________. A. Disturbed sensory perception-auditory B. Risk for other-directed violence C. Ineffective denial D. Ineffective coping Answer: B Rationale: For clients exhibiting aggressive behavior and agitated behavior, there is a high risk for other-directed violence. These behaviors are displayed by an individual indicating his or her potential to cause physical, emotional, and/or sexual harm to others. There is no defining cues stated that would indicate disturbed sensory perception-auditory, ineffective denial or ineffective coping. Source: Videbeck, S. (2020). Psychiatric-Mental Health Nursing. 8th edition p. 418