HESI Case Study Psychosis

Post Result Begin Again 100% Correct Let's review your results from 1/25/2022 at 5:41 pm PST Correct Incorrect Question 1 of 31 Which thought process describes the client's inability to leave his apartment because he thinks someone is waiting to kill him? Hallucination. A hallucination is a perceptual distortion that involves any of the senses (sight, hearing, smell, taste, touch). Phobia. A phobia is morbid fear associated with extreme anxiety. Delusions. A delusion is a false belief that is firmly maintained even though it is not shared by others and is contradicted by reality. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 88, 485. Confabulation. Confabulation involves filling in memory gaps with situations or events that cannot be remembered. Question 2 of 31 When the client explains that someone has been following him and is waiting outside the door of the ED, how should the nurse respond? Insist that no one has followed the client there. The client is delusional, and he will continue to firmly believe that someone is following him. The nurse should not attempt to logically explain the delusion. State how he must be concerned and assure him he will be safe there. The nurse should respond to the client's underlying feelings and not make assumptions about his delusions. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 78, 88. Tell the client that the police will make sure no one is out there. If the client perceives that the nurse is going along with the delusion, he will become increasingly delusional, particularly if he senses that the nurse is trying to gain his cooperation. Ask the client why he thinks that someone is out there. Questioning the client's story before responding to the emotional component or assessing for other symptoms of a thought disorder may reinforce the delusion. Question 3 of 31 The nurse observes the client looking to the corner of the room and mumbling to himself. Which intervention ismostimportant for the nurse to make sure is in the client’s plan of care? Encourage the client to share the meaning of their delusions. The patient appears to be having hallucinations. A delusion is a false belief that is firmly maintained even though it is not shared by others and is contradicted by reality. Interview the client to identify his feelings of depersonalization. The patient appears to be having hallucinations. Depersonalization is a feeling of unreality and alienation from oneself, characterized by difficulty distinguishing self from others. Begin a sequence of interventions to address the client's hallucinations. Hallucinations can be nonverbal or they can include talking to oneself, moving the lips without making sounds, rapid eye movements, and grinning or inappropriate laughter. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 88, 487. Orient the client to their plance and situation. The patient appears to be having hallucinations. Disorientation is confusion about the correct person, place, time and/or situation. Question 4 of 31 When the client looks around the room and mumbles to himself, how should the nurse respond? Have the client express how he is feeling. This question does not respond to the client's nonverbal cues that he may be hearing voices. Ask the client if they are hearing voices. The client is demonstrating nonverbal cues that he is experiencing auditory hallucinations, so the nurse should ask the client if he is hearing voices. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 262. See if the client recalls being here before. This question is part of the admission process and does not acknowledge the client's nonverbal behavior. Tell the client to say what they are thinking. The client is experiencing delusions and is often unable to organize his thought processes coherently. Question 5 of 31 The client admits that the voices he hears have been getting louder over the past couple of weeks. Which nursing interventionbestpromotes effective communication? Ask the client what helps the voices go away. This question is not very useful at this point in the client's assessment. It would be best used at a later stage of therapy, when helping the client identify ways to cope with the voices or strategies that have worked well in the past. Determine how long the client has been hearing voices. This question is not that helpful at this point. It can eventually be used to help the client draw conclusions about stressful events that precipitated the voices in prior situations. Document when the voices began getting louder. This question is not useful in the initial assessment. Later, during the treatment phase, it can help the client to identify symptom triggers and ways to cope. Have the client repeat what he thinks the voices are saying. The nurse should first ask what the voices are saying in order to assess for command hallucinations. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 217, 264. Question 6 of 31 Which medications should the nurse anticipate giving the client after getting orders from the healthcare provider?(Select all that apply. One, some, or all options may be correct.) Select all that apply Short-acting anxiolytic (benzodiazepines). Antianxiety medications (benzodiazepines, lorazepam clonazepam, or diazepam) are most effective for anxiety-related symptoms to produce calming and sedation. When used in conjunction with an atypical antipsychotic medication, such as olanzapine, benzodiazepines, especially IM, can augment the efficacy of the antipsychotic medication, quickly alleviating acute agitation of a client. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 287. Antipsychotic medication. Antipsychotic medications are effective for psychosis-related symptoms and manifestations of agitation associated with mental illness. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 287. Mood-stabilizing medication. Mood-stabilizing medications are effective for eliminating the symptoms of mania and for stabilizing mood to prevent cycling between depression and mania. Nonbenzodiazepine anxiolytic (antianxiety agent). Antianxiety medications are most effective for anxiety-related symptoms to produce calming and sedation. Benzodiazepines, used in conjunction with an antipsychotic medication, are particularly useful in treating the client with agitated psychosis who is being admitted to an inpatient unit. Antidepressant. Antidepressants are effective for treating mood disorders. They also provide a secondary benefit for treating co-occurring depressive and anxiety disorders. Question 7 of 31 Which assessment data provides evidence that the client can be involuntarily committed to the hospital, if he insists on leaving? Past history of suicide attempts. Past history of suicide attempts is not criteria for commitment. Losing 10 pounds in 2 weeks. The criteria for commitment includes danger to self and/or others, unable to provide for own basic needs, and/or the need for immediate and adequate treatment. Excessive weight loss demonstrates the client's inability to provide for his own basic needs by not maintaining adequate nutrition. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 24. Auditory hallucinations. Auditory hallucinations are not criteria for commitment, unless the client was hearing voices telling him to harm himself or others. Persecutory delusions. Delusions are not a criteria for commitment, unless the delusions interfere with another aspect of the client's behavior. For example, if the client is unable to eat because of a delusion that food is poisoned, that would be a criteria for commitment. The client is not demonstrating this behavior. Question 8 of 31 What is themostimportant part of this admission process? Ask the client if he has any valuables that need to be locked in a safe place. Valuables should be documented and locked in a safe place, but this is not the most important part of this admission process. Allow the client to explain his understanding of the reason for his hospital admission. This is part of the admission process, but it is not the most important thing to do at this time. Introduce the client to the nursing staff and explain the role of the case manager and the staff members. Introducing the client to the staff is important, but it is not the most important thing to do at this time. Take away the client's cigarettes and lighter. Safety for the client and the unit environment is the highest priority, so the staff should keep any potentially dangerous objects away from the client. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 94, 224. Question 9 of 31 Which assessment data are thebestindicators of the potential for violence?(Select all that apply. One, some, or all options may be correct.) Select all that apply Gender and age. Demographic variables such as gender and age are variables for predicting violence when assessing the client with psychosis. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 507. Past suicide attempts. Past suicide attempts are indicators of violence toward self. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 322. History of violence. The best single predictor of violence is a past history of violence. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 507. Multiple prescribed medications. Clients with active psychotic symptoms are at increased risk for violence, especially if they are medication noncompliant. The client may need multiple medications to control symptoms. Medication noncompliance. Clients with active psychotic symptoms are at increased risk for violence (symptom exacerbation), especially if they are medication noncompliant. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 89. Question 10 of 31 The nurse understands that the purpose of the urine drug screen is to assess the client for what important information? Detection of substances that may have caused the client's delusions and/or hallucinations. A urine drug screen is routinely ordered to determine the presence of any substances that may have altered a client's mental status. Blood and urine are the body fluids most often tested for drug content, although methods of analyzing saliva, hair, breath, and sweat have been developed. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 115. Determination of the approximate time the client stopped taking his medications. The urine drug screen cannot provide information about when the client stopped taking his medications. The length of time that drugs can be found in blood and urine varies according to dosage and metabolites. Provision of information about the type of psychosis the client is experiencing. The urine drug screen does not reveal information about the client's psychosis. Documentation of medication noncompliance and reinforcement of the need for hospitalization. The urine drug screen cannot provide information about noncompliance. The length of time that drugs can be found in blood and urine varies according to dosage and metabolites. Question 11 of 31 Which lab results from the urinalysis can the nurse expect to be related to the client's 10pound weight loss in the past 2 weeks?(Select all that apply. One, some, or all options may be correct.) Select all that apply Positive for red blood cells. Red blood cells in the urine are not associated with weight loss. Positive ketones. Ketones in the urine can suggest malnutrition, fasting, or starvation. Crawford, L. (2020). Fundamentals of Nursing. (2nd edition). St. Louis, Missouri. Elsevier. Pg. 748. Decreased urine pH. Decreased urine pH is associated with urinary tract infection, renal failure, or alkalosis, but it is not associated with weight loss. Increased urine specific gravity. Increased urine specific gravity is associated with dehydration which could be contributing to the client’s weight loss. Crawford, . (2020). Fundamentals of Nursing. (2nd edition). St. Louis, Missouri. Elsevier. Pg. 748. Absence of glucose. The absence of glucose in the urine is a normal finding and is not indicative of weight loss or malnutrition. Question 12 of 31 What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication? To determine the presence of cardiac disease. A CBC is not used to determine the presence of cardiac disease. A baseline EKG and cardiac monitoring is initiated for clients with suspected cardiac disease. To monitor for hepatotoxicity. Potential hepatotoxicity is measured by liver function tests, not by a CBC. Hepatotoxicity is most often seen in older clients and in clients on multiple medications. To determine if other medical issues are present. A CBC can provide helpful information on the client's health status. It is important to determine if there are other issues that could be causing some of the symptoms, and whether the client is healthy enough to take the medication. Some antypsychotic medications can cause neutropenia. If the client has other medical issues, considerations will need to be discussed regarding what medications should be prescribed. Skidmore-Roth, L. (2021). Mosby’s 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 1043, 1044. Pagana, K., Pagana, T., Pagana T.N. (2019). Mosby's Diagnostic and Laboratory Test Reference.(14th edition). St Louis, Missouri. Elsevier. Pg. 269. To assess elevations in liver enzymes. Liver enzymes are measured by liver function tests, not by a CBC. Question 13 of 31 Which nursing problem isbestto include in the initial care plan? Sensory-perceptual alteration related to withdrawal into self. The priority nursing problem is related to the client's hallucinations, which impact his functioning and social interaction. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 432. Chronic low self-esteem related to impaired cognition. Chronic low self-esteem is not the priority nursing problem. Interventions related to self-esteem should be implemented when the client's thoughts are more organized. Ineffective individual coping related to personal vulnerability. Ineffective coping involves a realistic appraisal of stressors, which the client will not be able to achieve until his thoughts are more organized. Knowledge deficit related to medication compliance. The client's cognitive functioning should be clearer before effective teaching can occur about this client's medications. Question 14 of 31 Interventions for a client experiencing hallucinations upon admission should occur in a sequence. Which interventions aremostimportant to be include in the client's initial plan of care?(Select all that apply. One, some, or all options may be correct.) Select all that apply Acknowledge that it appears the client is hearing voices. The initial approach is to acknowledge the voices. They are real to the client and it is necessary to know what the voices are telling the client. The voices may be telling the client to harm themself or others. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 88. Tell the client to stop listening to the voices. The voices may be telling the client to harm themself or others. Ask the client to verbalize what the voices are saying. Once the voices are acknowledged, the nurse needs to know what the voices are saying. They are real to the client and it is necessary to know what the voices are telling the client. The voices may be telling the client to harm themself or others. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 88. Assess the content of the hallucinations message. The voices may be telling the client to harm themself or others. Immediate interventions will need to be put in place to keep the client and others safe. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 88. Identify distractions to keep the client focused on reality. The voices should not be ignored. They may be telling the client to do something that is harmful to self or others. Question 15 of 31 After the content of the voices are assessed, which interventions should the nurse implement?(Select all that apply. One, some, or all options may be correct.) Select all that apply Ask the client how the voices make them feel. It may be helpful to know how the voices make the client feel. It can provide understanding to the client's actions and reactions so they can be addressed in a therapeutic manner. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 88. Instruct the client to utilize distractions to deal with hallucinations. Once the hallucinations have been revealed and evaluated, it is important to disconnect the hallucinations from reality. Distractions can be a therapeutic. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 88. Tell the client to instruct the voices to go away. Telling the voices to go away encourages the client to communicate with the voices and may intensive aggressive behavior. Give the client statements to say to the voices. Communicating with the voices should not be encouraged. It reinforces their presence. Encourage the client to write down what voices are saying. Communicating with the voices should not be encouraged. It reinforces their presence. Question 16 of 31 Since the client is also experiencing delusions, what action ismostimportant for the nurse to take to address the client's delusions? Encourage the client to verbalize the meaning of the delusions. The underlying theme of the delusions can be used to address the client's emotional state. Monitoring the affect of the delusions can help identify situations where the client may be inclined to harm themselves or others. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 88. Firmly tell the client that the delusions are not real. Arguing with the client may escalate their aggressive behavior. Have the client to explain why they believe the delusion. This approach is putting the client in a position to defend the delusions. The meaning of the delusions are important but asking the client to justify them is not therapeutic and may cause the patient to escalate. Give the client a list of reasons the delusions are not real. Knowing how the delusions make the client feel is important. This activity puts the client in a position to defend the delusions and reinforces that they are real. Question 17 of 31 What neurotransmitter is targeted by haloperidol? GABA. Traditional antipsychotic medications do not affect GABA, which has a calming effect. Serotonin. Traditional antipsychotic medications do not affect serotonin, which is inhibitory. Dopamine. Traditional antipsychotics block excessive dopamine, an excitatory neurotransmitter, so that symptoms related to psychosis are reduced. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 137. Norepinephrine. Traditional antipsychotic medications do not affect norepinephrine, which can be either inhibitory or excitatory. Question 18 of 31 Which assessment finding warrants immediate intervention by the nurse? Motor restlessness. Akathisia is an abnormal condition that is often manifested by motor restlessness, such as the inability to sit still or feeling the need to pace. Not a side effect of halcinonide. Involuntary muscle contractions. Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, particularly of the face, tongue, neck, and jaw which is a serious side effect of halcinonide. Skidmore-Roth, L. (2021). Mosby’s 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 625. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 144. Lip smacking. Tardive dyskinesia is a neurological movement disorder characterized by involuntary muscle contractions. Symptoms may include sticking out the tongue, puckering of the mouth or lips, lip smacking, puffing of the cheeks, and chewing movements. Tardive dyskinesia may be a side effect of certain antipsychotic medications, but only after a period of long-term use. Drooling. A side effect is most likely a dry mouth, not drooling. Question 19 of 31 Based on established and approved facility protocol orders, which medication is the nurse able to give to immediately relieve the muscle spasms in the client's neck and jaw? Lorazepam IM. Lorazepam is an antianxiety medication that will not relieve the dystonic reaction. Benztropine PO. The client is experiencing a dystonic reaction. Another route of administration will provide more immediate relief. Diphenhydramine IM. The client is experiencing a dystonic reaction, so the nurse should provide relief with diphenhydramine IM or benztropine IM. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 287. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 144. Acetaminophen PO. Acetaminophen is an analgesic medication that will not relieve the dystonic reaction. Question 20 of 31 Diphenhydramine is available as 100 mg/mL. The ordered dose is 75 mg IM. How many mL should the nurse administer? (Enter numerical value only. If rounding is necessary, round to the hundredth.) D/H x Q = X 75 mg divided by 100 mg x 1mL = 0.75 mL Morris, D. (2017). Calculate with Confidence. (7thedition). St. Louis, Missouri. Elsevier. Pg. 250. Question 21 of 31 The client is questioning the nurse about taking another pill. Which nursing interventionbestpromotes effective communication? Explain that this pill is to help prevent the muscle spasms in neck and jaw. The addition of benztropine will reduce the likelihood of severe extrapyramidal symptoms that occur more often with prototype antipsychotic medications such as haloperidol. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 144. Tell the client this pill will prevent the risk for tardive dyskinesia. Anticholinergic medications such as benztropine will not prevent tardive dyskinesia. Say to the client that this pill will help the haloperidol be more effective. Benztropine does not potentiate the effects of haloperidol, but it does produce anticholinergic effects. Because of the adverse effects of anticholinergic medications, the HCP may wait until the appearance of extrapyramidal symptoms before prescribing them. To further alleviate sudden periods of delusions. Intramuscular administration of benztropine provides immediate relief from the dystonic reaction the client is currently experiencing. The oral administration of benztropine is used to alleviate future dystonic reactions. It is not used to treat the delusion. Question 22 of 31 Which response from the client indicates that the haloperidol has been effective? Feels less anxious and nervous. Anxiety and nervousness is not the symptoms targeted by haloperidol therapy. Reports that mood is more stable. Mood stabilization is not a symptom targeted by haloperidol therapy. Initiates more social interactions. Avoidance of social interaction is not a symptom targeted by haloperidol therapy. Experiences fewer hallucinations. The client should experience fewer hallucinations if the medication has been effective. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 210. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 115. Question 23 of 31 While teaching the client about the anticholinergic side effects related to benztrophine, which intervention ismostimportant for the nurse to ensure is include in the client’s plan of care?(Select all that apply. One, some, or all options may be correct.) Select all that apply Take daily naps to decrease the tiredness caused by benztrophine. Drowsiness is a common side effect, but it is not an anticholinergic effect. Taking naps will not decrease the side effect. Expect dizziness that occurs after taking beztrophine. Eventhough dizziness should be reported, it is not an anticholinergic effect. Report urinary retention or feeling that the bladder does not empty. Serious side effects include urinary retention, blurred vision or eye pain, confusion and hallucinations, and uncontrollable movements of the client’s eyes, lips, tongue, face, and limbs. Dry mouth and constipation are less serious anticholinergic effects. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 213. Skidmore-Roth, L. (2021). Mosby’s 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 152. Observe for sudden onset of hand tremors. The reason for hand tremors needs to be reported but are not an anticholinergic effect, but they can be an extrapyramidal side effect. Relay any feeling of heart palpations. Tachycardia, palpitations, blurred vision or eye pain, confusion and hallucinations, and uncontrollable movements of the client's eyes, lips, tongue, face, and limbs are all serious anticholinergic side effects. Dry mouth, constipation, and drowsiness are less serious anticholinergic effects. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 213. Skidmore-Roth, L. (2021). Mosby’s 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 152. Question 24 of 31 Which action should the nurse implementfirst? Offer the client a glass of juice and ask him if he ate breakfast. Orthostatic hypotension is a common side effect of psychotropic medications that is not related to eating. When assessing the client, the nurse can also inquire about eating if the dizziness is not related to orthostatic hypotension. Take the client's blood pressure while he is sitting and standing. Since the client is feeling dizzy, a blood pressure reading should be taken while he is both sitting and standing to determine if a positional change, referred to as orthostatic hypotension, is associated with a change in the blood pressure readings. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 205, 210. Tell the client that his dizziness is orthostatic hypotension that will subside after he eats. Orthostatic hypotension is not related to eating. It is an expected occurrence for clients who are receiving psychotrophic medications. The nurse should educate the client about rising slowly and cautiously. Also, this type of reassurance should not be given to the client because it ignores the potential for injury related to the client's symptoms, and does not lead to further investigation of the problem. Hold the morning dose of haloperidol, and notify the HCP. More information is needed about the client's symptoms before holding a medication is considered. Question 25 of 31 What are the advantages for prescribing the atypical antipsychotic, olanzapine?(Select all that apply. One, some, or all options may be correct.) Select all that apply Lower incidence of extrapyramidal symptoms (EPSEs). Olanzapine has fewer incidences of extrapyramidal side effects (EPSEs) than other antipsychotic medications. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 148. Rapid onset. Olanzapine has a rapid onset. Skidmore-Roth, L. (2021). Mosby’s 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 942. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 148. Less weight gain. Olanzapine can cause significant weight gain in some clients. Alpha-adrenergic blockade. Blockage of alpha-adrenergic receptors is not a mechanism of action of olanzapine. Acute and maintenance therapy. Olanzapine injection is effective in the treatment of acutely agitated psychotic clients and there is sustained efficacy when the client is switched to oral maintenance treatment. Skidmore-Roth, L. (2021). Mosby’s 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 942. Question 26 of 31 What is the most important benefit the client can receive from his attendance at the community meeting? Reality orientation. Meetings that are designed to introduce clients to one another, plan activities for the day, and address client concerns and questions help ground the psychotic client in the present and reality. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 15, 240. Limits set on behaviors. Providing structure within the milieu is one way of setting limits on unacceptable behaviors through the use of contracts, tokens, and attendance at individual meetings, but there is a greater benefit of attending the a community meeting. Psychosocial skills. The staff in the community meeting can model psychosocial skills, but the greater benefit is gounding him to reality. Mutual goal setting. Goal setting through the planning of activities can occur in the community meeting; however, the greater benefit is grounding to reality. Question 27 of 31 What is a goal of being in this activity group? Learn social behaviors and gain insight about one's personality. A psychotherapy group, not an activity group, helps clients gain insight into their behaviors through group processes, and helps them change target behaviors. Gain information about disorders, symptoms, and medications. A psychoeducation group, not an activity group, provides information related to specific mental illnesses. Gain self-acceptance and express feelings. An activity group promotes self-acceptance, expression of feelings, and a focus on group goals rather than individual issues. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 282, 313. Identify and resolve specific problems related to the treatment plan. A problem-solving group, not an activity group, helps the client identify and work to resolve problems related to the client's treatment plan. Question 28 of 31 The nurse is training a new team member. Which explanation best promotes effective communication when discussing group process and group content? Group content refers to the group rules. Group process is how clients react to the rules. Group content has nothing to do with group rules. Group rules are referred to as the norms of the group, both formal and informal. Group process refers to where the group meets, while group content refers to the type of group that is meeting. Group process does not refer to where the group meets and group content is not the group type. Group content is client-led and group process is nurse-led. The clients bring issues and questions to the group, but the nurse plans and facilitates the content. Content includes the clients' words, and group process is how the clients communicate. Group content includes what the group members say, and group process refers to how they communicate their thoughts and feelings. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 611. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 102. Question 29 of 31 What are important reasons for this teaching?(Select all that apply. One, some, or all options may be correct.) Select all that apply To encourage the client to continue compliance with medications. Education about side effects is important so that medication compliance can be enhanced. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 132. To document the client's response to the medication education. It is important to document the client's response to the medication education, but this it is not the reason for the teaching. To monitor for early tardive dyskinesia, which can be reversible. It is very important to teach the client to report uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia and suggest modifications in the client's medication regimen. Tardive dyskinesia, although rare with olanzapine, can be reversed, by reducing the medication dose, if it is assessed in a timely manner. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 211. To reinforce education done throughout the hospitalization. Educating the client about medications at discharge will reinforce the client's knowledge. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 132. To tell the cliet to discuss symptoms with his nurse. It is very important to reinforce the client’s medication compliance by recommending that the client discuss any uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia. Halter, M. (2018). Varcarolis’ Foundations of Psychiatric Mental Health Nursing. (8thedition). St. Louis, Missouri. Elsevier. Pg. 132. Question 30 of 31 What is itmostimportant intervention for the nurse to perform before discharging the client? Complete contracts to follow discharge plans. Although it is not necessary to obtain a contract from the client stating that he will follow discharge plans, it would be a useful agreement to ensure compliance. However, this is not the most important aspect of discharge preparation. Provide resources for community support. Resources for community support after hospitalization are generally provided, but this is not the most important aspect of discharge preparation. Re-evaluate thoughts of harm to self or others. It is very important to reassess that the client is free of suicidal and/or homicidal ideation so that the nurse can document this in the discharge notes. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 75, 227. Identify support for the client's family. Identifying significant others who can provide support as needed is part of the discharge process, but it is not the most important aspect of discharge preparation. Question 31 of 31 Which nursing action is appropriate for this request? Direct the caseworker to talk with the pharmacist. Even if the caseworker talks to the pharmacist, Adam's medications cannot be released from the pharmacy to the caseworker. Ask for the client's permission to obtain medications. The client doesn't have the authority to decide whether or not to take medications with him. Explain that the nurse can return the medications. The nurse does not have the authority to return the client's medications. Obtain a order from the HCP to return medications. The HCP must write a order for the client to receive medications. Medications were changed while hospitalized and required prescriptions should accompany the client upon discharge. All other medication should be properly disposed of as prescribed. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8thedition). St. Louis, Missouri. Elsevier. Pg. 76. Previous Section