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Hello Class of 2007, Welcome to our blog community. This is our area to share information, resources, ask and answer questions. You will have fellow students, past students, and many other assets available to you through this site. Everyone is encouraged to discuss and problem solve here. Check back frequently as we post sample questions and links to relevant sites. We are on the same journey, let's discover it together.
Hello Class of 2007, Welcome to our blog community. This is our area to share information, resources, ask and answer questions. You will have fellow students, past students, and many other assets available to you through this site. Everyone is encouraged to discuss and problem solve here. Check back frequently as we post sample questions and links to relevant sites. We are on the same journey, let's discover it together.
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11. Describe priority assessment questions for the client who describes auditory hallucinations in the form of voices telling him to “do things.” (Text 396)
- Command Hallucinations : voices telling the person to do things, like harming self or others. If present, ask the client :
- Do you plan to follow the command?
- Do you believe the voices are real?
- Do you recognize the voices ?
12. Describe the severe antipsychotic medication side effect of neuroleptic malignant syndrome and priority nursing actions. (p 409 Table 20-9)
Neuroleptic Malignant Syndrome (NMS)
- Can occur in the first week of traditional antipsychotic therapy but often occurs later
- rapidly progresses over 2-3 days after initial manifestation
- rare, potentially fatal marked by :
- Severe extrapyramidal - severe muscle rigidity, oculogyric crisis, dysphasia, flexor-extensor posturing, cogwheeling
- Hyperpyrexia : elevated temp. (over 103° F or 39°C )
- Autonomic dysfunction : HTN, tachycardia, diaphoresis, incontinence
Risk Factors :
- concomittant use of psychotropics
- older age
- female gender (3:2)
- presence of mood disorder (40%)
- rapid dose titration
Priority Nursing Measures:
- Stop neuroleptic
- Transfer immediately to medical unit
- Bromocriptine (Parlodel) can relieve muscle rigidity and reduce fever
For mild NMS
- Dantrolene (Dantrium) may reduce muscle spasms
- for more severe cases of NMS through IV administration
- Cool body to reduce fever
- Maintain hydration with oral and IV fluids
- Correct electrolyte imbalance
- Arrhythmias should be treated
- Small doses of heparin may decrease possibility of pulmonary emboli
- Early detection increases client's chance of survival
13. Compare and contrast the expected levels of functioning (as expressed in GAF, Global Assessment of functioning) for clients with paranoid ideation, disorganized schizophrenia, catatonic schizophrenia, and undifferentiated schizophrenia. (p413 and GAF scale)
- The paranoid ideation, disorganized schizophrenia , catatonic schizophrenia, and undifferentiated schizo. All fall under the expected level of 21-30 that is : Behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (stays in bed all day, no job, home or friends).
- However, there are different between the subtypes of schizophrenia on how they fall under the GAF scale of 21-30.
- Paranoid ideation - fall under the GAF scale of 21-30 because a client with this has a dominant behavior that is considerably influenced by delusions or hallucination.
-Disorganized schizo. is under this level because of its dominant characteristic of serious impairment in communication.
- Catatonic schizo. fall under this level because of its dominant characteristics of serious impairment in communication and inability to function in almost all areas.
- Undifferentiated schizo. fall under this level due to its dominant behavior that is considerably influenced by delusions or hallucinations.
14. Discuss the various forms of hallucinations. (p394 Table 20-2)
Hallucinations - false sensory perception for which no external stimulus exists :
- it is different from illusions in that illusions are misperceptions or misinterpretations of a real experience. For example, a man sees his coat hanging on a coat rack and believes it to be a bear about to attack him. He does see something real but misinterprets what it is.
1. Auditory - hearing voices or sounds that do not exist in the environment
- these are projections of own inner thoughts
- most common in schizophrenia
- i.e. Anna hears the voice of her dead mother call her a whore.
2. Visual - Seeing a person, object or animal that does not exist.
- i.e. Charles who is experiencing alcohol withdrawal delirium, sees hungry rats coming toward him.
3. Olfactory - Smelling odors that are not present in the environment.
- i.e. Theresa smells her insides rotting.
4. Gustatory - Tasting sensations that have no stimulus in reality
- i.e. Sam will not eat his food because he tastes the poison the FBI is putting in his food.
5. Tactile - feeling strange sensations where no external objects stimulate such feelings.
-i.e. Jack suffers from paranoid schizophrenia. He feels electrical impulses controlling his mind.
15. Describe priority nursing interventions for clients with delirium. …with dementia.
- Client safety with respect to self-injury is the priority nursing interventions for clients with delirium and dementia.
16. Compare and contrast the four stages of Alzheimer’s disease.
- Stage 1 (forgetfulness) - short term memory losses, loses things
- Stage 2 (confusion) - progressive memory loss, withdrawn from social activities, shows decline in normal ADL's.
- Stage 3 (ambulatory dementia)- shows total loss of ADL's, loss of verbal communication and reasoning.
- Stage 4 (end stage) - does not recognize self and family.
17. Describe nursing diagnoses for a client who is homeless and severely mentally ill with substance abuse problems.
- Risk for injury related to confusion, as evidenced by wandering.
- Functional urinary continence related to disturbed cognition, as evidenced by inability to find the toilet.
- Self-care deficit related to impaired functioning, as evidenced by ability to put on and take off clothing.
- Anticipatory grieving R/T loss and deterioration of family member.
- Altered thought process
- Risk for violence
- Powerlessness
- Altered family process
- Social isolation
- Ineffective individual coping
- Self-esteem disturbance
- Risk for infection
- Altered growth and development
- Anxiety and fear
- Impaired communication
18. Describe alternative treatments for clients with chronic pain.
- Alternative medicine uses homeopathy, naturopathic preparations and spiritual healing.
- Homeopathy uses small doses of specially prepared plant extracts and minerals to stimulate the body's defense mechanisms and healing processes to treat illness.
- Naturopathy emphasizes health restoration using nutrition, herbal medicine, light therapy and therapeutic counseling.
- Spiritual healing uses prayer as an alternative therapy.
19. Discuss the stages associated with grief and appropriate nursing interventions.
Stages of grief : Kubler-Ross
1) First stage : Denial - client deny their diagnosis, feeling that there must be a mistake, and often shop for different doctors. Denial is a mechanism used by most clients, and it is usually a temporary defense. Denial may return as the client continues through the different stages (i.e. "No, not me! It cannot be true.")
2) Second stage : Anger - Clients become angry at the world, including loved ones who are closest to them. Loved ones often have a difficult time with these intense emotions and also need support through this period (i.e. "why me.")
3) Third stage : Bargaining - Most bargaining is made with their God, requesting more time. Once their request have been fulfilled, then another request may be stated. (i.e. "let me live just until")
4) Fourth stage : Depression - This is when the client can no longer deny his/her illness and physical symptoms begin to appear. Depression is a preparatory period in order to prepare the client for the separation from loved ones. (i.e. "what is the use")
5) Fifth stage : Acceptance - if the client has had enough time and help in working through the previous stages, the client will reach a period when he/she is neither angry not sad about dying. (i.e. "I am ready to die.""I am at peace.")
20. Describe characteristics of anticipatory grieving. (p 608 Box 30-2)
- Feeling of emptiness
- A sense of being numb and fatigued
- A feeling of unreality and disbelief
- Period of weeping and raging
- A desire to run away from the situation
- A need to oversee every detail of the client's care to protect her or him from suffering and death
- Fear of the future and of the unknown
- Anger at the client or the medical professionals or both
- Pronounced clinging to or dependency on the client or other family members
- Fear of going crazy
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