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Provide direct nursing care.
Participate with the team in performing nursing intervention.
Therapeutic use of self.
Early recognition of the client’s needs.
Initiates nursing action with co workers.
Plans nursing care with the patient.
Speaks in behalf of the patient.
Works together with the team.
defend the patients right
refer patient for other services she needs
work with significant others
intercedes in behalf of the patient.
patients perception on the reason of her hospitalization
identification of more effective ways of coping
exploration of inadequate coping skills
establishment of regular meeting of schedules
how are you feeling right now?
do you have anyone to take you home?
what do you think will help you right now?
How does your problem affect your life?
encourage client to express feelings and concerns
helps client to learn a dance or song to enable her to participate in activities
help the client prepare in group activities
assist the client in setting limits on her behavior
Distinguishes between things in the mind and things in the reality.
Moral arm of the personality that strives for perfection than pleasure.
Reservoir of instincts and drives
Control the physical needs instincts.
tell the friends to visit the child
encourage patient to help child learn lessons missed
call the priest to intervene
tell the child’s girlfriend to visit the child.
Hypertension, hyperthermia, flushed and dry skin.
Hypotension, hypothermia, flushed and dry skin.
Hypertension, hyperthermia, diaphoresis
Hypertension, hypothermia, diaphoresis
self centered disturbance
impaired social interaction
sensory perceptual alteration
altered thought process
disregard rights of others
loss of cognitive functioning
fails to conform to social norms
not capable of experiencing guild or remorse for their behavior
ideas of reference
flight of ideas
At what time was your last drink taken?
Why didn’t you tell us you’re a drinker?
Do you drink beer or hard liquor?
How long have you been drinking?
I understand that God’s voice is real to you, But I don’t hear anything. I will stay with you.
The voice is part of your illness, it will stop if you take medication
The voice is all in your imagination, think of something else and itll go away
Don’t think of anything right now, just go and relax.
my thoughts of hurting myself are scary to me
I’d like to go to sleep and not wake up
I’ve thought about taking pills and alcohol till I pass out
I’d like to be free from all these worries
Complains of dry mouth
State he feels restless in his body
Stops pacing and sits with the nurse
Exhibits increase activity and speech
borderline personality disorder
Hold a job.
Relate to his peers.
Perform activities of daily living.
Behave in an outwardly normal
How he sleeps at night.
If he is thinking about hurting himself.
About recent stresses.
How he feels about himself.
.6 to 1.2 meq/L
6 to 12 meq/L
.6 to .12 cc/ml
.6 to .12 cc3/L
Recognize that this is a sign of toxicity and withhold the next medication.
Notify the physician.
Check V/S to validate patient’s concerns.
Recognize that this is a normal side effects of lithium and still continue the drug.
Increase Intra Ocular Pressure
Increase Intra Cranial Pressure
The client to be decompensating and in need of being readmitted to the hospital.
The client to need an adjustment or increase in his dose of antidepressant.
The depression to be improving and the suicidal ideation to be lessening.
The presence of suicidal ideation to warrant a telephone call to the client's physician
Zoloft causes erectile dysfunction in men.
Zoloft causes postural hypotension
Zoloft increases appetite and weight gain
It may take 3-4 weeks before client will start feeling better.
A laboratory error.
An anticipated therapeutic blood level of the drug.
An atypical client response to the drug.
A toxic level.
Increased heart rate, dilated pupils, and fever.
Tremulousness, impaired coordination, increased blood pressure, and ruddy complexion.
Decreased respirations, constricted pupils, and pallor.
Eye irritation, tinnitus, and irritation of nasal and oral mucosa.
Gives the medication as ordered.
Questions the physician about the order.
Questions the dosage ordered.
Asks the physician to order benztropine (Cogentin) for the side effects.
"I need to have my blood checked once every several months while I’m taking this drug."
"I need to sit on the side of the bed for a while when I wake up in the morning."
"The sleepiness I feel will decrease as my body adjusts to clozapine."
"I need to call my doctor whenever I notice that I have a fever or sore throat."
Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect.
Tell the client to stop taking the medication and to call the physician.
Encourage the client to double the dose of his medication.
Ask the client if he has resumed smoking cigarettes.
An elevated blood glucose level.
Urine sample for protein.
Creatinine clearance test.
"I need to call my doctor in 2 weeks for a checkup."
"I need to keep my appointment here at the hospital this week for a blood test."
"I can drink alcohol with this medication."
"I can take over-the-counter sleeping medication if I have trouble sleeping."
Abnormal thought form.
Hallucinations and delusions.
Asocial behaviour and anergia.
A. Increasingly agitated behaviour.
B. Markedly increased food intake.
C. Sudden increase in blood pressure.
D. Anorexia with nausea and vomiting.
Grand mal seizure.
"I need to restrict eating any food that contain salt."
"If I forget a dose, I can double the dose the next time I take it."
"I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness."
"I should increase my fluid”