NURSING 3210: EXIT HESI NOTES WELL EXPLAINED LATEST UPDATE 2023/2024
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Course
NURSING 3210 (NURSING3210)
Institution
Chamberlain College Of Nursing
• Thought Disorders
o When evaluating client behaviors, consider the medications the client is receiving. Exhibited behaviors may be manifestations of schizophrenia or a drug reaction.
o There are five types of schizophrenia specified in the DSM-IV-TR, which a diagnostic manual is prepared by t...
NURSING 3210: EXIT HESI NOTES WELL EXPLAINED
LATEST UPDATE 2023/2024
• Thought Disorders
o When evaluating client behaviors, consider the medications the client is receiving.
Exhibited behaviors may be manifestations of schizophrenia or a drug reaction.
o There are five types of schizophrenia specified in the DSM-IV-TR, which a diagnostic
manual is prepared by the American Psychiatric Association that provides diagnostic
criteria for all psychiatric disorders.
o Use Bleuler’s four A’s to help remember the important characteristics of schizophrenia:
▪ Autism (preoccupied with self)
▪ Affect (flat)
▪ Associations (loose)
▪ Ambivalence (difficulty making decisions)
o Client is Delusional
▪ Encourage recognition of distorted reality
▪ Divert focus from delusional thought to reality; do not permit rumination on false
ideas.
▪ Do not agree with or support delusions.
▪ Avoid arguing about the delusion. Be very matter-of-fact.
▪ Avoid physically touching client, especially if delusions are persecutional.
▪ Administer antipsychotic drugs
▪ Monitor and treat side effects of psychotropic drugs
▪ Administer antiparkinsonian drugs
NURSING 3210: EXIT HESI NOTES WELL EXPLAINED
LATEST UPDATE 2023/2024
, NURSING 3210: EXIT HESI NOTES WELL EXPLAINED
LATEST UPDATE 2023/2024
o Client is Hallucinating
▪ Protect client from injury that might result from responding to commands of the
voices; pay attention to the content.
▪ Avoid denying or arguing with client about the hallucination.
▪ Discuss your observations with client (e.g., “You appear to be listening to
something.”)
▪ Make frequent but brief remarks to interrupt the hallucinations.
▪ Administer antipsychotic drugs
▪ Monitor and treat side effects of psychotropic drugs
▪ Administer anticholinergic drugs
o Side effects of Antipsychotics
▪ Blood Dyscrasias
• Agranulocytosis: occurs in first weeks of treatment
o Sore throat, fever, chills
o Protect from infections
o Provide comfort measures: gargle for sore throat, use
logenzes and analgesics
• Thrombocytopenia: decreased platelets
o Bruises easily, petechial
o Teach client safety measures (r/f bleeding)
▪ Extrapyramidal Effects
• Parkinsonism: occurs within 1-4 weeks after initiation of treatment
o Rigidity, shuffling gait, pill-rolling hand movements, tremors,
dyskinesia, masklike face
• Akathisia: occurs within 1-6 weeks after initiation of treatment
o Restlessness, agitation, and pacing; sudden difficulty sitting still
(can be confused with tardive dyskinesia)
• Dystonia: occurs within 1-2 days after initiation of treatment
NURSING 3210: EXIT HESI NOTES WELL EXPLAINED
LATEST UPDATE 2023/2024
, NURSING 3210: EXIT HESI NOTES WELL EXPLAINED
LATEST UPDATE 2023/2024
o Limb and neck spasms; uncoordinated, jerky movements; difficulty
speaking and swallowing; rigidity and muscle spasms
• Tardive dyskinesia: develops late in treatment
o Involuntary tongue and lip movements; blinking, choreiform
movements of limbs and trunk
▪ Photosensitivity
• Teach to stay out of sun, wear protective clothing/sunglasses
▪ Neuroleptic Malignant Syndrome
• Life-threatening emergency: high fever, tachycardia, stupor, increased
respirations, severe muscle rigidity
▪ Anticholinergic Effects
• Dry mouth, blurred vision, tachycardia, nasal congestion, constipation,
urinary retention, orthostatic hypotension
o Observe for increased motor activity and/or erratic response to staff and other clients. The
client
may be experiencing an increase in command hallucinations. When this occurs, there is an
increased potential for aggressive behavior.
o Do not argue with a client about the delusions. Logic does not work; it only increases the
client’s anxiety. Be matter-of-fact and divert delusional thought to reality. Trust is the
basis for all interactions with these clients. Be supportive and nonjudgmental. Stress
increases anxiety and the need for delusions and hallucinations. Do not agree that you
hear voices (you should be the client’s contact with reality), but acknowledge your
observation of the client; for example, “You look like you’re listening to something.”
• Substance Abuse
o What medications can the nurse expect to administer to chemically dependent clients? In
treating alcohol withdrawal, Librium or Ativan are commonly used. Antabuse is often
used as a deterrent to drinking alcohol. Client teaching should include the effects of
consuming any alcohol while on
NURSING 3210: EXIT HESI NOTES WELL EXPLAINED
LATEST UPDATE 2023/2024
, NURSING 3210: EXIT HESI NOTES WELL EXPLAINED
LATEST UPDATE 2023/2024
Antabuse. Encourage client to read all labels of over-the-counter medications and food
products that may contain small amounts of alcohol.
o Alcohol Deterrents
▪ Disulfiram (Antabuse)
• Treatment of alcoholism; aversion therapy
• Interferes with breakdown of alcohol causing an accumulation of
acetaldehyde (a byproduct of alcohol in the body)
• Severe side effects occur if alcohol is consumed:
o Nausea and vomiting
o Hypotension, headaches
o Rapid pulse and respirations
o Flushed face and bloodshot eyes
o Confusion
o Chest pain
o Weakness, dizziness
o Teach client what to expect if alcohol is consumed while taking the
drug.
• Be aware that some alcoholic clients use the side effects as a means of
“punishing” themselves or as a form of masochism, and if a client
repeatedly consumes alcohol while taking the drug, the health care
provider should be notified.
• Persons with serious heart disease, diabetes, epilepsy, liver impairment, or
mental illness should not take Antabuse.
• Use in motivated clients who have shown the ability to stay sober.
o What type of therapy is used with chemically dependent clients? Group therapy is
effective, as are support groups such as Alcoholics Anonymous and Narcotics
Anonymous.
o Harm reduction is a community health strategy designed to reduce the harm of substance
NURSING 3210: EXIT HESI NOTES WELL EXPLAINED
LATEST UPDATE 2023/2024
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