- Nurse Tara is admitting Ms Simpson. Which of the following is the priority action for Tara to take?
A) Evaluate the need for medication.
B) Check blood pressure.
C) Assess respiratory status.
D) Encourage taking deep breaths. - The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to the client is to assess the respiratory status of a client who is experiencing shortness of breath and tachypnea.
Nurse tara is preparing to call the provider. List the findings that the nurse includes when giving a report using the SBAR format.
S (Situation) = Ms. Simpson is a 22-year-old African-American female admitted to the inpatient mental health unit for anxiety. She is restless and fidgety, has poor concentration, and has been experiencing chest pain and shortness of breath.
B (Background) = She has a history of generalized anxiety disorder and has previously taken paroxetine 20 mg PO daily, but has not been taking it for approximately 2 weeks.
A (Assessment) = Her vital signs from report at 0745 were: heart rate 115, blood pressure 148/76, respirations 32, oxygen saturation 96% on room air, and temperature 37.0 C (98.6 F). Her score on the Hamilton A scale is 26, and she has been unable to focus on answering questions due to her severe level of anxiety. She continues to pace, wring her hands, and rock when sitting.
R (Recommendation) = I am calling to request a prescription for lorazepam. - Nurse Tara is calculating the dose of lorazepam. Available in 4mg/mL. How many mL should the nurse admin?
Answer: 0.5 - Nurse Tara is providing medication teaching. regarding escitalopram (Lexapro). Which of the following statements should Tara include in the teaching?
You should report increased thoughts of suicide. Clients, especially children and young adults, who start therapy with escitalopram are at increased risk for suicidal ideation. The nurse should report changes in behavior to the provider. - Nurse Tara is is initiating therapeutic communication with Ms. Simpson. Which of the following video clips demonstrates an appropriate interaction between the nurse and the client?
Answer: Video 3 - Nurse Tara is communicating with Ms. Simpson. Which of the following is an appropriate action for Tara to take?
Answer: Restate Ms S’s concern. Restating the client’s concerns allows for exploration and clarification of the client’s statements. - Nurse Tara is listening to Ms. Simpson while she describes the stressors that contribute to her anxiety. Which coping mechanisms is Ms. Simpson exhibiting?
Answer: Denial, Displacement, Rationalizing - Nurse Tara is discussing Ms. Simpson’s most stressful situation. Which actions should Tara take first?
Answer: Continue to gather more information regarding finances. - Nurse Tara has discovered Ms. Simpson self-injury. Which thought processes is most likely a reflection of Ms. Simpson behavior?
Answer: Alleviation of psychological pain. - Nurse Tara is explaining Ms. Simpson diagnosis. Which statements should T include in the teaching?
Answer:
“interventions are based on the degree of anxiety you are experiencing.”
“you can experience four levels of anxiety.”
“it is common to perform repetitive behaviors in order to cope with anxiety.”
Treatment of anxiety is individualized to degree of anxiety the client is experiencing. The four levels of anxiety include mild, moderate, severe, and panic. Manic and depressive episodes are key features in bipolar disorder. It is common to perform repetitive behaviors in order to cope with anxiety, such as continual hand washing. Grandiose thoughts are common in clients experiencing delusions and also occur in a manic phase of bipolar disorder. - Nurse Tara is teaching Ms. Simpson about anxiety. Which indicate Ms. Simpson understands the teaching?
Answer: Uses relaxation techniques. - Nurse Tara completes the Hamilton-A assessment of Ms. Simpson and determines her score to be 26. Which appropriate action for the nurse to take?
Answer: Lorazepam.
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