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HESI Fundamentals of Nursing : Study Guide & Practice Questions & Labvalue
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HESI Fundamentals of Nursing : Study Guide & Practice Questions & Labvalue
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HESI Fundamentals of Nursing : Study Guide & PracticeQuestions & Labvalue
the purpose of therapeutic interaction - ANSWER: to allow the client to autonomy to
make choices when appropriate. keep statements value-free, advice free, and
reassurance-free
what action should the nurse take in a psychiatric situation when the client describes
a physical problem? - ANSWER: assess. example: if a client has schizophrenia
complains of chest pain take their blood pressure
basic communication principles - ANSWER: establish trust, nonjudgemental
attitude,active listening, offer self, accept client's feelings, validate client's
statements, matter of fact approach
nausea is a common complaint after ECT - ANSWER: vomiting by an unconscious can
lead to aspiration. maintain a paten airway
common physiological responses to anxiety - ANSWER: increased heart rate, and
blood pressure, rapid shallow respirations, dry mouth, tight feeling in throat,
tremors, muscle twitching, anorexia, urinary frequency, palmar sweating
nurse-client anxiety - ANSWER: anxiety is contagious, nurse needs to asses on
anxiety level and remain calm. it helps gain control, decrease anxiety, and increase
feelings of security
desensitization - ANSWER: is the nursing intervention for phobia disorders. --assess
client to recognize the factors associated with feared stimuli.
-teach and practice with client alternative coping strategies
-expose client to feared stimuli
-provide positive reinforcement
the nurse should place an anxious client where there are reduced environmental
stimuli - ANSWER: quiet area of the unit away from the nurse's station
the best time for interaction with a client is at the completion of the performed
ritual - ANSWER: the client's anxiety is lowest at this time and its an optimal time for
learning
compulsive acts are used in response to anxiety, which may or may not be related to
the obsession. its the nurse's responsibility help alleviate anxiety - ANSWER: its the
nurse's responsibility help alleviate anxiety, interfering will increase the anxiety
as long as the client's acts are free of violence: nurse should.... - ANSWER: -actively
listen to the clients obsessive themes
-acknowledge the effects that ritualistic acts have on the client
,-demonstrate empathy
-avoid being judgmental
ford clients with PTSD, the nurse should.... - ANSWER: -actively listen to client's
stories of experiences surrounding the traumatic event
-assess suicide risk
-assist client to develop objectivity about the event and problem solve regarding
possible means of controlling anxiety related to the event
-encourage group therapy with other clients who have experienced the same
traumatic event
be aware of your own feelings when dealing with this somatoform clients. -
ANSWER: the pain is real to the person experiencing it
theses disorders cannot be explained medically, it results from internal conflict. the
nurse should... - ANSWER: -acknowledge the symptom or complaint
-reaffirm that diagnostic test results reveal no organic pathology
-determine the secondary gains acquired by the client
avoid giving clients with dissociative disorders too much information about past
events at one time - ANSWER: the various types of amnestic that accompany
dissociative disorders provide protection from pain and too much to soon can cause
decompensation
personality disorders are long standing behavioral traits that are maladaptive
responses to anxiety and that cause difficulty in relating to and working with other
individuals - ANSWER: persons with personality disorders are usually comfortable
with their disorders and believe that they are right and the world is wrong and have
little motivation
people with anorexia gain pleasure from providing others with food and watching
them eat - ANSWER: these behaviors reinforce their perception of self-control. don
not allow these clients to plan or prepare food for unit-based activities
individuals with Bulimia often use syrup of ipecac to induce vomiting. if ipecac is not
vomited and is absorbed, cardiotoxicity may occur and cause conduction
disturbances, cardiac dysrhythmias, fatal myocarditis, and circulatory failure -
ANSWER: because heart failure is not usually seen in this age group, it is often
overlooked. assess for edema and listen to breath sounds
physical assessment and nutritional support are a priority, the physiological
implication are great. nursing interventions should increase self-esteem and develop
a positive body image. - ANSWER: family therapy is most effective because issues of
control are common in these (eating disorders.) therapy is usually long term
the most important s/s of depression are a depressed mood with a loss of interest in
the pleasures in life - ANSWER: the client has a sustained loss
, s/s of depression - ANSWER: -significant change in appetite
-insomnia
-fatigue or lack of energy
-feelings of hopelessness
-loss of ability to concentrate
-preoccupation with death or suicide
depressed clients have difficulty hearing and accepting compliments because of their
lowered self-concept - ANSWER: comment on signs of improvement by noting
behavior
the nurse knows depressed clients are improving when they - ANSWER: begin to take
an interest in their appearance or begin to perform self-care activities
the nurse should suspect an imminent suicide attempt if a depressed client becomes
"better" - ANSWER: be aware a happy affect may signify the the client feels relieved
that a plan has been made and is prepared for the suicide attempt
when dealing with a depressed client the nurse should assist with personal hygiene
tasks and encourage the client to initiate grooming activities even when they dont
feel like doing so - ANSWER: this helps to promote self-esteem and a sense of control
nursing intervention for depressed client - ANSWER: sit quietly with the client,
offering your support with your presence
side effects of antianxiety drugs - ANSWER: sedation, drowsiness
s/e of antidepressants drugs - ANSWER: anticholinergic effects, postural hypotension
s/e MAO inhibitors - ANSWER: hypertensive crisis
lithium requires renal function assessment and monitoring - ANSWER:
phenothiazines cause EPS (tardic dyskinesia can be permanent)
phenothiazines cause photosensitivity so client must wear protective clothing and
sunglasses - ANSWER: MAO inhibitors require dietary restrictions to prevent
hypertensive crisis
atypical antipsychotics drugs are also indication for mania - ANSWER: monitor serum
lithium levels carefully. 0.-1.5 is therapeutic level, blood should be drawn every 12
hours after last dose
manic clients can be very caustic toward authority figures - ANSWER: avoid arguing
or becoming defensive
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