Adult Nursing I - Exam #2

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Ataxia

Inability to coordinate muscle activity during voluntary movements, resulting in shaky/tremor-like movements - lack of muscle coordination

Aphasia

loss of speech due to injury or illness

Apraxia

inability to perform purposeful movements or to use objects appropriately even when there is no impairment of motor functions

intimate space

0 to 1.5 feet from person, touching

personal space

The face-to-face distance people require to feel comfortable when talking with others

social space

4 to 12 feet - distances kept with strangers or acquaintances

public space

12 feet and beyond - speaking with someone in public

sympathy

sharing the feelings of others (especially feelings of sorrow or anguish)

empathy

understanding and entering into another persons feelings

transference

(psychoanalysis) the process whereby emotions are passed on or displaced from one person to another

countertransference

the psychoanalyst's displacement of emotion onto the patient or more generally the psychoanalyst's emotional involvement in the therapeutic interaction

confabulation

The act of filling in memory gaps by making up false memories

compounded rape reaction

Additional symptoms that go along with being raped such as depression, suicide, substance abuse, psychotic behavior

silent rape reaction

person is silent and tells no one about assualt

expressed rape reaction

expresses emotions such as crying, trembling, anger towards the rape

controlled rape reaction

emotions toward rape are controlled, client appears calm, feelings are masked, hidden

What type of emergency is suicide?

psychiatric emergency

Nursing priorities for suicide

watch the patient, 1 on 1 observation, maintain patient safety and safety of others

Psych nursing priorities

SAFETY first, then ABCs

Who is more likely to commit suicide?

older, middle aged men and teenagers. Men are more successful than women.

Who is more likely to be depressed?

single, divorced people. The very rich, the very poor

When does a person with severe alcoholism show signs of withdrawal?

within 4-12 hours after last drink. For example - person admitted to hospital at midnight would start to show signs around 4am

Blood alcohol level for intoxication?

100 mg/dL

How do you assess someone with alcohol withdrawal for tremors?

touch there arm - take their radial pulse to feel for fine tremors

Bipolar - mania considerations

provide high calorie finger foods throughout the day - mania leads to feeling of not being hungry and unable to sleep

MAOI considerations

Hypertensive crisis: avoid foods high in tyramine - aged cheese, pepperoni, wine, beer, liver, chocolate

Rittalin and Adderal considerations

medications are stimulants and appetite suppressors - children on these medications experience weight loss. Take medication early in the AM after a large breakfast (if taken before breakfast, child wont eat)

purpose of mini-mental exam

used to help distinguish between depression and dementia in the elderly

signs of child abuse

unexplained injuries, neglected appearance, child may be withdrawn or act out, child may flinch when sudden movements are made

signs of childhood incest in an adult

withdrawn, insomnia, unable to maintain healthy relationships with opposite sex, may be promiscuous, low self-esteem, lack of trust

what is transgenderism?

person identifies with the opposite sex, wants to become opposite sex

what is transvestic fetish?

enjoy dressing as the opposite sex - wearing lingerie, women's underwear, bras

When do we develop human sexuality?

from birth to 12 years old

frotteurism

Compulsion to achieve sexual arousal by touching or rubbing against a nonconsenting person in public situations

vaginismus

painful spasm of the vagina from contraction of its surrounding muscles - prevents penetration of penis into the vagina - common symptom in person who has experienced sexual abuse

dyspareunia

painful intercourse

sadism

sexual pleasure through inflicting pain on others

masochism

sexual pleasure through receiving pain

Histrionic personality disorder

personality disorder - need to be center of attention, overly dramatic

Narcissistic personality disorder

characterized by a grandiose sense of self-importance, grandiose sense of power. Ex - Gaston from Beauty and the Beast. Kirk Branigan from Futurama

schizoid personality disorder

person is withdrawn, aloof, lacks emotional response

schizotypal personality disorder

personality disorder involving a pervasive pattern of interpersonal deficits featuring acute discomfort with, and reduced capacity for, close relationships, as well as cognitive or perceptual distortions and eccentricities of behavior.

paraphila

use of nonhuman objects to achieve sexual arousal, sex with on-consenting adults, inflicting suffering or humiliation

Therapeutic nurse-client relationship

occurs when each individual views the other as being a unique human being, both have needs met by the relationship

phases of the therapeutic nurse-client relationship

pre-interaction phase, orientation (trusting) working phase, termination phase

Pre-interaction phase

obtain information about the patient from chart, others. Examine own fears about working with the client

Orientation (introductory) phase

creating an environment of trust and support, identify client's strengths and weaknesses, build rapport

Working phase

use problem solving model to work toward achieving goals, evaluate progress toward goal achievement, maintain trust and rapport - transference and countertransference occur during this phase

Termination phase

conclusion of relationship, plan of action developed for dealing with future situations established

Therapeutic use of self

The ability to use one's personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions

Six steps of the nursing process

assess, diagnose, outcomes, plan, interventions, evaluate

effective communication - restating

restating what the patient just said to make sure statement was understood

reflecting

directs question back to patient to identify how they feel

non-therapeutic communication techniques

reassurance, rejecting, approving or disapproving, giving advice, defending, requesting an explanation, stereotyping

Active listening - SOLER

Sit quietly facing the client, Open body posture, Lean toward client, Eye contact, Relax

nurse care management

negotiates with several health care providers to obtain services for the client

Critical pathway of care (CPCs)

standard plans of care to achieve specific outcome, times, used by interdisciplinary team. Ex - PUP, prevention of DVTs

Anger

flushed face, clenched fists, speak in a low tone, yelling and shouting - may be part of the grieving process

Aggression

verbal/physical threats, threats of homicide or suicide, disturbed thought process - intent!

Nursing priorities when dealing with anger/aggression management

maintain safety of others and self, be aware of past history of violence, diffuse person as anger, don't allow to escalate to aggression

prodromal syndrome

Behaviors: rigid posture, clenched fists and jaw, grim defiant affect, talking in a rapid raised voice, arguing and demanding, using profanity and threatening verbalization, agitation and pacing, pounding and slamming

Delirium

acute, rapid change in cognitive function/consciousness. Impairment in memory, disoriented to time and place, hallucinations. Fight or flight responses with vital signs. Can be the result of fever, medications, infections, electrolyte imbalances

Dementia

slow, progressive decline in cognitive function, personality change is common, impaired judgment and impulse control, loss of inhibition, , apraxia, aphasia, moodiness with sudden outbursts, incontinence

Primary Dementia

the result of organic brain disease. ex- Alzheimer's

Secondary dementia

occurs as a result of trauma, head injury, CVS

Causes of dementia

Alzheimer's, lewy's disease, Huntington's, HIV, alcohol withdrawal (lack of thiamine), MS, CJD,

Amnesia

loss of short term memory, unable to learn new information, confabulation (making up false stories to fill in memory gaps). Short term amnesia can be caused by ECT

wernicke's encephalopathy

severe thiamine deficiency

korsakoff's psychosis

confusion, loss of memory in alcoholics

withdrawal for short acting opioid (ex - heroin)

symptoms occur 6-12 hours after drug, last 5-7 days

withdrawal for long-acting opioid (ex - methadone)

symptoms occur 1-3 days after drug, last 10-14 days

withdrawal symptoms for short acting drugs (ex - demerol)

8-12 hours, last 4-5 days

Cluster A personality disorders

odd, eccentric behaviors - paranoid, schizoid, schizotypal

Cluster B personality disorders

dramatic, emotional, erratic - antisocial, borderline, histrionic, narcissistic

Cluster C personality disorders

anxious, fearful - OCD, avoidant, dependent

Severe depression

can't get out of bed - feel worse at the start of the day and gets better as the day progresses

Moderate depression

feel best at the start of the day, get worse as the day progresses

Dysthymic disorder

symptoms persist for two years or more with depressive symptoms not necessarily occurring every single day (but more so than not). No more than two symptom free months.

Major depressive disorder

disorder causing periodic disturbances in mood that affect concentration, sleep, activity, appetite, and social behavior, characterized by feelings of worthlessness, fatigue, and loss of interest that persist for 2 or more weeks

mild depression

part of the grieving process, anxiety, tearful, inability to concentrate but can still function

What are the 4 phases in the Cycle of Battering / Abuse?

Phase I - tension building phase, Phase II - battering incident, Phase III - honeymoon phase - calm, loving period

side effects of antipsychotics

EPS side effects, tremors, dry mouth, constipation, increased appetite and weight gain, ECG changes, hyperglycemia and diabetes

side effects of SSRIs

insomnia, headaches, agitation, weight loss, serotonin syndrome

examples of antipsychotics

risperidone, haldol, thorazine, clozapine

examples of anticonvulsants

dilantin (phenytoin), valproic acid

examples of ADHD medications

clonidine (catapress), Ritalin, adderal

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