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Psychosis Meet the Patient: Brian Jones Brian Jones is a 36-year-old male who is accompanied to the emergency department by several police officers and his caseworker. The caseworker called the police to enter the patient's apartment because Brian refused to answer the door. The caseworker brings some medication bottles from his apartment and reports that four months ago Brian stopped taking all psychotropic medications. He has poor eye contact, his appearance is disheveled, his hair is dirty and uncombed, and there are stains on his clothes. Brian denies current suicidal ideation, although the caseworker reports a history of past suicide attempts and violence. He has lost 10 pounds in the past two weeks, sleeps 12 hours daily, and doesn't leave his apartment. The nurse observes that Brian sometimes looks to the corner of the room and then looks down and mumbles to himself during the interview. He admits to the nurse that he did not want to leave his apartment, because he thought someone was waiting to kill him. Assessment The patient continues to explain that someone has followed him to the ER and is waiting outside the door to the emergency room. 1. Which thought process describes the patient's inability to leave his apartment because he thought someone was waiting to kill him? A) Hallucination. B) Phobia. C) Delusions. D) Confabulation. Nursing Intervention 2. When the patient explains that someone has been following him and is waiting outside the door of the emergency room, how should the nurse respond? A) "Believe me. No one has followed you here." B) "You must be concerned, but you are safe here." C) "The police will make sure no one is out there." 3. Which definition describes the nurse's observation that the patient looks to the corner of the room and mumbles to himself? A) Delusions. B) Depersonalization. C) Hallucinations. D) Disorientation. 4. When the patient looks around the room and mumbles to himself, how should the nurse respond? A) "How are you feeling?" B) "Are you hearing voices?" C) "Have you been here before?" The patient admits that the voices he hears have been getting louder over the past couple of weeks. 5. Which question should the nurse ask next? A) "What helps the voices go away?" B) "How long have you heard voices?" C) "When do they get louder?" D) "What do the voices say?" Prescribed Medications The patient becomes very agitated and angry, and he talks loudly to himself as he waits to be seen by the healthcare provider. 6. Which medication should the nurse anticipate giving the patient after securing a prescription from the healthcare provider? A) Short-acting anxiolytic (antianxiety agent). B) Antipsychotic medication. C) Mood-stabilizing medication. D) Nonbenzodiazepine anxiolytic (antianxiety agent). Admission to the Unit The healthcare provider admits the patient to the mental health unit because the patient's mental status impairs his ability to meet his basic needs and remain safe in the community. The mental health technician escorts the patient to the unit where the nurse can complete the assessment and orient the patient to the unit and his room. The nurse explains the unit rules and informs Brian of his rights. Brian begins to insist that he needs to leave and should not be in the hospital. 7. Which assessment data provides evidence that Brian can be involuntarily committed to the hospital, if he insists on leaving? A) Past history of suicide attempts. B) Unable to meet basic needs. C) Auditory hallucinations. D) Persecutory delusions. As part of the admission process, the nurse orients the patient to the program and his room. 8. What is the most important part of this admission process? A) Ask Brian if he has any valuables that need to be locked in a safe place. B) Allow Brian to explain his understanding of the reason for his hospital admission. C) Introduce Brian to the nursing staff and explain the role of the case-manager and staff. D) Take away Brian's cigarettes and lighter. Safety Precautions The nurse completes the assessment and determines the best precautions to ensure patient and staff safety on the unit. 9. Which assessment data are the best indicators of the potential for violence? A) Gender and age. B) Past suicide attempts. C) History of violence. D) Medication compliance. Routine Admission Prescriptions: Following the admission assessment, the nurse calls the healthcare provider for admission prescriptions and laboratory work. The admitting diagnosis is, "Psychosis, Not Otherwise Specified." The nurse completes requisitions for a complete blood count with differential, thyroid function studies, chemistry profile, urinalysis, and urine drug screen. Medications include haloperidol 2 mg BID. 10. The nurse understands that the purpose of the urine drug screen is to assess Brian for what important information? A) Detection of substances that may have caused Brian's delusions and/or hallucinations. B) Determine the approximate time Brian stopped taking his medications. C) Provide information about the type of psychosis Brian is experiencing. D) Document medication noncompliance and reinforce need for hospitalization. 11. Which lab value from the urinalysis can the nurse expect to be related to Brian's 10-pound weight loss in the past two weeks? A) Positive for red blood cells. B) Positive ketones. C) Decreased urine pH. D) Increased urine specific gravity. 12. What is the purpose of a baseline complete blood count (CBC) prior to initiation of the antipsychotic medication? A) Determine the presence of cardiac disease. B) Monitor for hepatotoxicity. C) Monitor for agranulocytosis. D) Assess elevations in liver enzymes. Nursing Process Care Plan Because Brian has hallucinations and delusions, the nurse develops an initial plan of care related to psychosis. 13. Which nursing diagnosis is best to include in the initial care plan? A) Sensory-perceptual alteration related to withdrawal into self. B) Chronic low self-esteem related to impaired cognition. C) Ineffective individual coping related to personal vulnerability. D) Knowledge deficit related to medication compliance. Three basic interventions are helpful when a patient is in the acute phase of hallucinations and delusions. These interventions include making eye contact, speaking in simple terms and in a slightly louder voice than usual, and calling the patient by name. The nurse understands that the rationale for these interventions is to give sensory validation to override the abnormal sensory processes that are occurring in the brain. 14. What additional intervention is essential to a successful plan? A) Isolations. B) Daily activities. C) Consistency. D) Adequate rest. 15. What teaching should be included in Brian's education plan initiated early after admission and reinforced until discharge? A) An understanding of psychosis and the causes of it. B) The importance of attending support groups after discharge. C) Depression and anxiety are common causes of psychosis. D) The purpose and side effects of psychotropic medications. Antipsychotic Medications: Initiation Haloperidol (Haldol) 2 mg twice a day (BID) is prescribed for Brian's psychosis. Haldol is the prototype traditional antipsychotic. It is a potent medication that causes numerous extrapyramidal symptoms but few anticholinergic side effects. It is prescribed for patients who experience symptoms of psychosis or manifestations of agitation related to mental illness. Psychosis is thought to be caused by the overactivity of a neurotransmitter. The nurse understands that traditional antipsychotic medications, such as Haldol, will be effective in decreasing the symptoms of psychosis by blocking a variety of receptors in the brain. 16. What neurotransmitter is targeted by haloperidol (Haldol)? A) GABA. B) Serotonin. C) Dopamine. D) Norepinephrine. Several hours after receiving his medication, Brian complains of muscle spasms in his neck and jaw. 17. What side effect of the medication should the nurse suspect? A) Akathisia. B) Dystonia. C) Tardive dyskinesia. D) Parkinsonism. 18. Which medication should the nurse give to immediately relieve the muscle spasms in the patient's neck and jaw? A) Lorazepam (Ativan) IM. B) Benztropine (Cogentin) PO. C) Diphenhydramine (Benadryl) IM. D) Acetaminophen (Tylenol) PO. After receiving benztropine (Cogentin) 2 mg IM for immediate relief, Brian receives a new prescription for benztropine (Cogentin) 2 mg PO daily. 19. Why is Brian started on this medication? A) Reduce severity of extrapyramidal effects. B) Prevent the risk for tardive dyskinesia. C) Potentiate Haldol so it will be more effective. D) Further control the dystonic reaction. Antipsychotic Medication: Continued Use After five days, the nurse assesses Brian's response to the prescribed haloperidol (Haldol). 20. Which response from the patient indicates the Haldol has been effective? A) Feels less anxious and nervous. B) Reports mood is more stable. C) Initiates more social interactions. D) Experiences fewer hallucinations. The nurse explains the anticholinergic side effects associated with his medications. 21. Which anticholinergic side effect is related to the use of haloperidol (Haldol)? A) Feeling tired. B) Dizziness. C) Urinary retention. D) Hand tremors. On the fifth hospital day, Brian reports feeling dizzy as he stands to leave the morning group activity. 22. Which action should the nurse implement first? A) Offer Brian a glass of juice and ask him if he ate breakfast. B) Take Brian's blood pressure sitting and standing. C) Tell Brian that his dizziness is defined as orthstatic hypotension, should be expected, and will subside after he eats. D) Hold the morning dose of Haldol, and notify the healthcare provider. The nurse knows that dizziness is a common side effect of some psychotropic medications. 23. What action mechanism of Haldol causes this side effect? A) Histamine blockade. B) Muscarinic blockade. C) Excess dopamine. D) Alpha-adrenergic blockade. Treatment Modalities for Psychosis On the seventh day of hospitalization, the nurse asks Brian to attend the community meeting to be held the following morning. The structure of the meeting is to introduce patients, plan activities for the day, address patients' concerns, and clarify any questions about the program. All patients are strongly encouraged to attend the community meetings. 24. What is the most important benefit Brian can receive from his attendance at the community meeting? A) Provide reality orientation. B) Set limits on behaviors. C) Teach psychosocial skills. D) Promote mutual goal setting. Group activities are offered on the unit, such as drawing, exercising to music, baking, community trips, and arts and crafts. In the afternoon, Brian decides to join the group that has chosen drawing as their activity. 25. What is a goal of being in this activity group? A) Learn social behaviors and gain insight about one's personality. B) Provide information about the patient's disorders, symptoms, and medications. C) Promotes self-acceptance and expression of feelings. D) Identify and resolve specific problems related to the patient's treatment plan. Brian is encouraged to attend a medication psycho-education group that the nurse is leading. The qualities of an effective nurse leader are the same qualities that are important in the therapeutic relationship: empathy, genuineness, creativity, and the ability to be assertive. While leading the group, the nurse should be aware of group content and group process. 26. What is the difference between group content and group process? A) Group content refers to the group rules, and group process is how patients react to the rules. B) Content refers to the type of group, and process is where the group meets. C) The patients decide the group content, and group process is facilitated by the nurse. D) Content includes the patients' words, and group process is how patients communicate. Discharge Planning After nine days of hospitalization, Brian demonstrates fewer hallucinations, and his thoughts are not influenced by delusions. Brian explains that several months before admission, he and his healthcare provider decided that he could stop taking his psychotropic medications. He states, "I don't know what happened. I thought that I was handling everything just fine." Discharge is planned within several days for Brian. Medication prescriptions for discharge include Haldol 2 mg PO BID and Cogentin 1 mg PO daily. The nurse plans to educate Brian about side effects that do not go away. 27. What is the most important reason for this teaching? A) Encourage Brian to continue compliance with medications. B) Documentation of Brian's response to the medication education. C) Monitor for early tardive dyskinesia, which can be reversible. D) Reinforce education done throughout the hospitalization. On the day of discharge, Brian's caseworker arrives at the hospital to take him to his apartment. The nurse prepares to give Brian a copy of his discharge paperwork. 28. What aspect is most important for the nurse to provide follow-up on before discharge? A) Contracts to follow discharge plans. B) Resources to provide community support. C) Thoughts of harm to self or others. D) Significant others for support. As Brian is leaving the unit, the caseworker remembers that some of his medication bottles were brought to the hospital. The caseworker wants to return them to Brian. 29. Which nursing action is appropriate for this request? A) Direct the caseworker to talk with the pharmacist. B) Ask for the patient's permission to obtain medications. C) Explain that the nurse can return the medications. D) Obtain a prescription from the healthcare provider to return medications. Case Outcome In addition to giving Brian a copy of the discharge summary upon release from the hospital, the nurse writes the following note in his chart: "Patient was discharged ambulatory and accompanied by caseworker. Patient received all personal belongings, including valuables. He denied suicidal/homicidal ideation and reported that the last time he heard voices was several days ago. Affect was pleasant, and mood was without feelings of depression. Speech is clear and organized without maladaptive patterns or evidence of disorganized thoughts. The patient acknowledged plans to take Haldol and Cogentin as prescribed and follow-up at the medication clinic in two weeks. Education about the purpose and potential side effects was provided, and the patient was encouraged to talk with the healthcare provider or nurse if he had questions or concerns about the medications."



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C L I N I C A L I N V E S T I G A T I O NBland Embolization in Patients with Unresectable HepatocellularCarcinoma Using Precise, Tightly Size-Calibrated,Anti-Inflammatory Microparticles: First Clinical Experienceand One-Year Follow-UpGuido Bonomo • Vittorio Pedicini • Lorenzo Monfardini •Paolo Della Vigna • Dario Poretti • Gianluigi Orgera •Franco OrsiReceived: 30 April 2009 / Acce

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