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
4. Vanya used manipulation to get her needs met. The staff decides to apply limit-setting interventions. What is the correct rationale for this action? A. It provides an outlet for feelings of anger and frustration. B. It respects the patient's wishes so assertiveness will develop. C. External controls are necessary while internal controls are developed. D. Anxiety is reduced when staff members assume responsibility for the patient's behavior. Answer: C Rationale: The nurse must provide structure in the therapeutic relationship, identify acceptable and expected behaviors, and be consistent in those expectations. He or she must minimize attempts by these clients to manipulate and control the relationship. Limit setting is an effective technique that involves three steps: 1. Stating the behavioral limit (describing the unacceptable behavior) 2. Identifying the consequences if the limit is exceeded 3. Identifying the expected or desired behavior For clients who feel out of control, the nurse must establish external controls empathetically and non- judgmentally. These external controls provide long-term comfort to clients, though their initial response may be aggression. All staff must consistently set and enforce limits for those limits to be effective. Limits must be established by others when the client is unable to use internal controls effectively. Source: Videbeck, S. (2020). Psychiatric-Mental Health Nursing. 8th edition p. 710, 765 5. Given the behavior of Vanya or Xylo, limit setting be most essential if either of them ___________________________. A. Clings to the nurse and asks for advice about inconsequential matters. B. Flirts with and is provocative with staff members of the opposite sex. C. Displays hypervigilant behavior and refuses to attend unit activities. D. Urges a suspicious patient to hit anyone who stares. Answer: B Rationale: Erratic patterns of thinking and behaving often alienate them from others. This may be true for both professional and personal relationships. Clients can easily misinterpret the nurse’s genuine interest and caring as a personal friendship, and the nurse may feel flattered by a client’s compliments. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client’s nor the nurse’s boundaries are violated. Source: Videbeck, S. (2020). Psychiatric-Mental Health Nursing. 8th edition p. 783 Situation: Greta, 54-years old and a known hypertensive (controlled), was seen in her ophthalmologist's office for a routine eye examination. Her last examination was five (5) years ago. Reports of significant visual field loss was determined to be caused by wide-angle glaucoma. Nurse Jenny was tasked to assist the patient in her care. 6. Laser trabeculoplasty as a form of treatment was suggested to Greta. Which of the following nursing measures should receive priority in the client's plan of care after eye surgery? A. Prevent increase in intraocular pressure (IOP) and signs of infection B. Instruct on the importance of follow-up C. Instruct on how to perform the Valsalva maneuver D. Management of pain through patient-controlled analgesia (PCA) Answer: A Rationale: The primary focus of treatment is to keep the IOP low enough to prevent the patient from developing optic nerve damage. After eye surgery, include the following information in the teaching plan for the patient and caregiver: ● Proper hygiene and eye care techniques to ensure that dressings and/or surgical wound is not contaminated during eye care ● Signs and symptoms of infection (e.g., increased or purulent drainage, increased redness, any decrease in visual acuity) and when and how to report these to allow for early recognition and treatment of possible infection ● Importance of following restrictions on head positioning, bending, coughing, and Valsalva maneuver to optimize visual outcomes and prevent increased IOP ● How to instill eye medications using aseptic technique and adherence with prescribed eye medication routine to prevent infection