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Psychology/ Mental Health Nursing ATI
Terms in this set (640)
◯ Level of consciousness is described The Mental Status Examination (MSE)using the following terms, and observed behavior included in documentation.
■ Alert- The client is responsive and able to fully respond by opening her eyes and attending to a normal tone of voice and speech. She answers questions spontaneously and appropriately. ■ Lethargy - The client is able to open her eyes and respond but is drowsy and falls asleep readily.
■ Stupor - The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. She may not be able to respond verbally.
■ Coma - No response can be achieved from repeated painful stimuli:
Abnormal posturing in the client who is comatose: 1) Decorticate rigidity - flexion and internal rotation of upper-extremity joints and legs 2) Decerebrate rigidity - neck and elbow extension, wrist and finger flexion
The Mental Status Examination (MSE)using the following terms, and observed behavior included in documentation are?
◯ Physical appearance ◯ Behavior ☐ Mood ☐ Affect ◯ Cognitive and intellectual abilities
◯ Physical appearance
Examination includes assessment of personal hygiene, grooming, and clothing choice. Expected findings with regard to this assessment are that the client is well-kept, clean, and dressed appropriately for the given environment.
Examination includes assessment of voluntary and involuntary body movements, and eye contact
- A client's mood provides information about the emotion that she is feeling.
- A client's affect is an objective expression of mood, such as a flat affect or a lack of facial expression.
◯ Cognitive and intellectual abilities
■ Assess the client's orientation to time, person, and place.
■ Assess the client's memory, both recent and remote.
■ Assess the client's level of knowledge.
■ Assess the client's ability to calculate.
■ Assess the client's ability to think abstractly.
■ Perform an objective assessment of the client's perception of his illness
■ Assess the client's judgment based on his answer to a hypothetical question.
■ Assess the client's rate and volume of speech, as well as the quality of his language.
■ Assess the client's memory, both recent and remote.
☐ Immediate -
☐ Recent -
☐ Remote -
-Ask the client to repeat a series of numbers or a list of objects.
- Ask the client to recall recent events, such as visitors from the current day, or the purpose of the current mental health appointment or admission.
- Ask the client to state a fact from his past that is verifiable, such as his birth date or his mother's maiden
■ Assess the client's level of knowledge.
For example, ask him what he knows about his current illness or hospitalization.
■ Assess the client's ability to calculate.
For example, can he count backward from 100 in serials of 7?
■ Assess the client's ability to think abstractly.
For example, can he interpret a cliché such as, "A bird in the hand is worth two in the bush"? The ability to interpret this demonstrates a higher-level thought process.
■ Assess the client's judgment based on his answer to a hypothetical question.
For example, how would he answer the question, "What would you do if there were a fire in your room?" His response to the question should be logical.
■ Assess the client's rate and volume of speech, as well as the quality of his language.
His speech should be articulate and his responses meaningful and appropriate.
● Standardized Screening Tools
◯ Mini-Mental State Examination
◯ Glasgow Coma Scale
◯ Mini-Mental State Examination
■ This examination is used to objectively assess a client's cognitive status by evaluating the following: ☐ Orientation to time and place ☐ Attention span and ability to calculate by counting backward by seven ☐ Registration and recalling of objects ☐ Language, including naming of objects, following of commands, and ability to write
◯ Glasgow Coma Scale
■ This examination is used to obtain a baseline assessment of a client's level of consciousness, and for ongoing assessment. Eye, verbal, and motor response is evaluated, and a number value based on that response is assigned. The highest value possible is 15, which indicates that the client is awake and responding appropriately. A score of 7 or less indicates that the client is in a coma.
Children and Adolescent Assessment :
◯ Assess this age group for mood; anxiety; developmental, behavioral, and eating disorders; and risk for self-injury or suicide.
◯ Use the standardized assessment tool: Home, Education/employment, peer group Activities, Drugs, Sexuality, and Suicide/depression (HEADSS) psychosocial assessment, to evaluate risk factors in the adolescent.
◯Mentally healthy children and adolescents should trust others, view the world as safe, accurately interpret their environments, master developmental tasks, and use appropriate coping skills. ◯ Children and adolescents experience some of the same mental health problems as adults. ◯ Mental health and developmental disorders are not always easily diagnosed, potentially resulting in delayed or inadequate treatment interventions. Factors contributing to this include the following.
■ Lack of the ability or necessary skills to describe what is happening
■ A wide variation of "normal" behavior, especially in different developmental stages.
● The Older Adult
◯ In addition to the aforementioned assessments, a comprehensive assessment of the older adult client includes the following:
■ Functional ability, such as the ability to get up out of a chair ■ Economic and social status ■ Environmental factors, such as stairways in the home, that may affect the client's well-being and lifestyle ■ Physical assessment ◯ Standardized assessment tools that are appropriate for the older adult population, include: ■ Geriatric Depression Scale (short form) ■ Michigan Alcoholism Screening Test - Geriatric Version ■ Mini-Mental Status Exam ■ Pain assessments including visual analogue scales, Wong-Baker FACES Pain Rating Scale, the McGill Pain Questionnaire (MPQ), and the Pain Assessment in Advanced Dementia (PAINAD) scale
◯ Conduct an assessment of all clients, including older adult clients in the following manner:
■ Use a private, quiet space with adequate lighting to accommodate for impaired vision and hearing. ■ Make an introduction, and determine the client's name preference. ■ Stand or sit at the client's level to conduct the interview, rather than standing over a client who is lying in bed or sitting in a chair. ■ Use touch to communicate caring as appropriate. However, respect the client's personal space if he does not wish to be touched■ Be sure to include questions relating to difficulty sleeping, incontinence, falls or other injuries, depression, dizziness, and loss of energy. ■ Include the family and significant others as appropriate. ■ Obtain a detailed medication history. ■ Following the interview, summarize and ask for feedback from the client.
Mental Health diagnoses
● The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), published by the American Psychiatric Association, is used as a diagnostic tool to identify mental health diagnoses. It is used by mental health professionals for clients who have mental health disorders.
● Nurses use the DSM-5 in the mental health setting to
identify diagnoses and diagnostic criteria to guide assessment; to identify nursing diagnoses; and to plan, implement, and evaluate care.
therapeutic strategies in the Mental Health setting: Mental Health Nursing Interventions include:
Using therapeutic communication skills
Assisting with problem solving
› Crisis intervention
› Stress management Milieu therapy
› Orienting the client to the physical setting
› Identifying rules and boundaries of the setting
› Ensuring a safe environment for the client
› Assisting the client to participate in appropriate activities
PROMOTION OF SELF-CARE:
› Offering assistance with self-care tasks
› Allowing time for the client to complete self-care tasks
› Setting incentives to promote client self-care
› Administering prescribed medications
› Providing teaching to the client/family about medications
› Monitoring for adverse effects and effectiveness of pharmacological therapy COGNITIVE AND BEHAVIORAL THERAPIES:
› Operant conditioning
› Systematic desensitization Health teaching
› Teaching social and coping skills Health promotion and health maintenance
› Assisting the client with cessation of smoking
› Monitoring other health conditions
› Coordinating holistic care to include medical, mental health, and social
1. A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?A. "To assess cognitive ability, I should ask the client to count backward BY 7"
B. "To assess affect, I should observe the client's facial expression."
C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects."
1. A. INCORRECT: This statement does not require further teaching. Counting backward by 7 is an appropriate technique to assess a client's cognitive ability.
B. INCORRECT: This statement does not require further teaching. Observing a client's facial expression is appropriate when assessing affect.
C. INCORRECT: This statement does not require further teaching. Writing a sentence is an indication of language ability.
D. CORRECT: This statement requires further teaching. Asking the client to repeat a list of objects is appropriate to assess immediate, rather than remote, memory.
2. A nurse is planning care for a client who has a mental health disorder. Which of the following is appropriate to include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of medications.
2. A. INCORRECT: Assisting with systematic desensitization therapy is a cognitive and behavioral, rather than a psychobiological intervention.
B. INCORRECT: Teaching appropriate coping mechanisms is a counseling or health teaching, rather than a psychobiological intervention.
C. INCORRECT: Assessing for comorbid health conditions is health promotion and maintenance, rather than a psychobiological, intervention.
D. CORRECT: Monitoring for adverse effects of medications is an example of a psychobiological intervention.
3. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following is the highest priority action?
A. Respect the client's need for personal space.
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client about her current mental health disorder.
A. INCORRECT: It is appropriate to respect the client's need for personal space. However, it is not the highest priority action when taking the nursing process approach to client care.
B. CORRECT: Assessment is the priority action when taking the nursing process approach to client care. Identifying the client's perception of her mental health status provides important information about the client's psychosocial history.
C. INCORRECT: If the client wishes, it is appropriate to include the client's family in the interview. However, it is not the highest priority action when taking the nursing process approach to client care.
D. INCORRECT: It is appropriate to teach the client about her disorder. However, it is not the highest priority action when taking the nursing process approach to client care.
4. A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of the following is an expected finding?
A. The client arouses briefly in response to a sternal rub.
B. The client has a Glasgow Coma Scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place.
4. A. CORRECT: A client who is stuporous requires vigorous or painful stimuli to elicit a response.
B. INCORRECT: A GCS score of less than 7 indicates a comatose, rather than stuporous, level of consciousness.
C. INCORRECT: Abnormal posturing is associated with a comatose, rather than stuporous, level of consciousness.
D. INCORRECT: A client who is stuporous is not alert.
5. A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following is appropriate to include in the discussion? (Select all that apply.)
A. The DSM-5 is used to identify mental health disorders.
B. The DSM-5 establishes diagnostic criteria.
C. The DSM-5 indicates recommended pharmacological treatment.
D. The DSM-5 assists nurses in planning care.
E. The DSM-5 indicates expected assessment findings.
5. A. CORRECT: The DSM-5 is used as a diagnostic tool to identify mental health diagnoses.
B. CORRECT: The DSM-5 establishes diagnostic criteria for mental health disorders.
C. INCORRECT: The DSM-5 is a diagnostic tool for the diagnosis of mental health disorders but does not indicate pharmacological treatment.
D. CORRECT: Nurses use the DSM-5 to plan, implement, and evaluate care.
E. CORRECT: The DSM-5 identifies expected findings for mental health disorders.
6. A nurse is using therapeutic communication while counseling a client who has a mental health disorder. Use the ATI Active Learning Template: Basic Concept and the Fundamentals review module to complete this item to include the following sections:
A. Topic Descriptor: Define therapeutic communication.
B. Underlying Principles: Identify the characteristics of therapeutic communication.
C. Underlying Principles: Identify at least three essential components of therapeutic communication.
D. Nursing Interventions: Identify at least three specific therapeutic communication techniques.
6. Using ATI Active Learning Template: Basic Concept and the Fundamentals review module
A. Topic Descriptor: Therapeutic communication is the purposeful use of communication to build and maintain helping relationships with clients, families, and significant others.
B. Underlying Principles: Characteristics of therapeutic communication ● Client-centered ● Purposeful, planned, and goal-directed
C. Underlying Principles: Essential components of therapeutic communication ● Plan for and allow adequate time for communication. ● Demonstrate active listening. ● Demonstrate a caring attitude. ● Be honest. ● Establish trust. ● Demonstrate empathy. ● Have a nonjudgmental attitude.
D. Nursing Interventions ● Silence ● Open-ended questions ● Clarifying techniques, such as restating, reflecting, paraphrasing, and exploring ● Offering general leads or broad opening statements ● Showing acceptance and recognition ● Focusing ● Asking questions ● Giving information ● Presenting reality ● Summarizing ● Offering self
A nurse who works in the mental health setting is responsible for practicing ethically, competently, safely, and in a manner consistent with all local, state, and federal laws.
● Nurses must have an understanding of ethical principles and how they apply when providing care for clients in mental health settings. ● Nurses are responsible for understanding and protecting client rights.legal Rights of Clients in the Mental Health setting ● Clients who have been diagnosed and/or hospitalized with a mental health disorder are guaranteed the same civil rights as any other citizen.
Civil Rights include the following:
◯ The right to humane treatment and care, such as medical and dental care
◯ The right to vote
◯ The right to due process of law, including the right to press legal charges against another person
◯ Informed consent and the right to refuse treatment
◯ Confidentiality (The client's right to privacy is protected by the Health Insurance Portability and Accountability Act (HIPAA) of 2003.)
◯ A written plan of care/treatment that includes discharge follow-up, as well as participation in the care plan and review of that plan
◯ Communication with people outside the mental health facility, including family members, attorneys, and other health care professionals
◯ Provision of adequate interpretive services if needed
◯ Care provided with respect, dignity, and without discrimination
◯ Freedom from harm related to physical or pharmacologic restraint, seclusion, and any physical or mental abuse or neglect
◯ Provision of care with the least restrictive interventions necessary to meet the client's needs without allowing him to be a threat to himself or others ●
Some legal issues regarding health care may be decided in court using a specialized civil category called a tort.
A tort is a wrongful act or injury committed by an entity or person against another person or another person's property.
Torts can be used to decide liability issues, as well as intentional issues that may involve criminal penalties, such as abuse of a client.
Ethical issues are
philosophical ideas regarding right and wrong (morals and values)
● Nurses are frequently confronted with ethical dilemmas regarding client care Because ethics are philosophical and involve values and morals, there is frequently no clear-cut, simple resolution to an ethical dilemma.
● Ethical principles must be used to decide ethical issues. These include the following: Ethical principle definition examples
Beneficence › This relates to the quality of doing good and can be described as charity. (A nurse helps a newly admitted client who has psychosis feel safe in the environment of the mental health facility).
Autonomy › This refers to the client's right to make her own decisions. (But the client must accept the consequences of those decisions. The client must also respect the decisions of others and/or rather than giving advice to a client who has difficulty making decisions, a nurse helps the client explore all alternatives and arrive at a choice).
Justice › This is defined as fair and equal treatment for all. ( During a treatment team meeting, a nurse leads a discussion regarding whether or not two clients who broke the same facility rule were treated equally).
Fidelity (Non- Maleficence) › This relates to loyalty and faithfulness to the client and to one's duty. ( A client asks a nurse to be present when he talks to his mother for the first time in a year. The nurse remains with the client during this interaction).
Veracity › This refers to being honest when dealing with a client. (A client states, "you and that other staff member were talking about me, weren't you?" The nurse truthfully replies, "We were discussing ways to help you relate to the other clients in a more positive way.")
Health Insurance Portability and Accountability Act (HIPAA) of 2003.
● Information about the client, verbal and in writing, must be shared only with those who are responsible for implementing the client's treatment plan. ● Information may be shared with other persons not involved in the client treatment plan by client consent only.
Specific mental health issues include disclosing HIV status, the duty to warn and protect third parties, and the reporting of child and elder abuse. Resources for solving ethical Client issues
● Code of Ethics for Nurses, found at http://nursingworld.org ● Patient Care Partnership, found at www.aha.org ● The nurse practice act of a specific state ● Legal advice from attorneys ● Facility policies ● Other members of the health care team, including facility bioethics committee (if available) ● Members of the clergy and other spiritual or ethical counselors
Types of Commitment to a Mental Health Facility
● Voluntary commitment
● Involuntary (civil) commitment
● Emergency involuntary commitment
● Observational or temporary involuntary commitment
Long-term or formal involuntary commitment
● Voluntary commitment
The client or client's guardian chooses commitment to a mental health facility in order to obtain treatment. A voluntarily committed client has the right to apply for release at any time. This client is considered competent, and so has the right to refuse medication and treatment.
● Involuntary (civil) commitment
The client enters the mental health facility against her will for an indefinite period of time. The commitment is based on the client's need for psychiatric treatment, the risk of harm to self or others, or the inability to provide self-care. The need for commitment could be determined by a judge of the court or by another agency. The number of physicians, which is usually two, required to certify that the client's condition requires commitment varies from state to state.
●Emergency involuntary commitment
A type of involuntary commitment in which the client is hospitalized to prevent harm to self or others. Emergency commitment is usually temporary (may be up to 10 days). This type of commitment is usually imposed by primary care providers, mental health providers, or police officers.
● Observational or temporary involuntary commitment
A type of involuntary commitment in which the client is in need of observation, a diagnosis, and a treatment plan. The time for this type of commitment is controlled by state statute and varies greatly between states. This may be imposed by a family member, legal guardian, primary care provider, or a mental health provider.
●Long-term or formal involuntary commitment
A type of commitment that is similar to temporary commitment but must be imposed by the courts. Time of commitment varies, but is usually 60 to 180 days. Sometimes, there is no set release date.
Clients admitted under involuntary commitment are still considered competent and have the right to refuse treatment, unless they have gone through a legal competency hearing and have been judged incompetent.
The client who has been judged incompetent has a temporary or permanent guardian, usually a family member if possible, appointed by the court. The guardian can sign informed consent for the client. The guardian is expected to consider what the client would want if he were still competent.
Client Rights Regarding Seclusion and Restraint ● Nurses must know and follow federal/state/facility policies that govern the use of restraints. ● Use of seclusion rooms and/or restraints may be warranted and authorized for clients in some cases.
● In general, seclusion and/or restraint should be ordered for the shortest duration necessary, and only if less restrictive measures are not sufficient. They are for the physical protection of the client and/or the protection of other clients and staff. ● A client may voluntarily request temporary seclusion in cases in which the environment is disturbing or seems too stimulating. ● Restraints can be either physical or chemical, such as neuroleptic medication to calm the client. ● Seclusion and/or restraint must never be used for: ◯ Convenience of the staff ◯ Punishment of the client ◯ Clients who are extremely physically or mentally unstable ◯ Clients who cannot tolerate the decreased stimulation of a seclusion room ● When all other less restrictive means have been tried to prevent a client from harming self or others, the following must occur in order for seclusion or restraint to be used: ◯ The treatment must be ordered by the primary care provider in writing. ◯ The order must specify the duration of treatment. ◯ The provider must rewrite the order, specifying the type of restraint, every 24 hr or the frequency of time specified by facility policy. ◯ Nursing responsibilities must be identified in the protocol, including how often the client should be: ■ Assessed (including for safety and physical needs), and the client's behavior documented ■ Offered food and fluid ■ Toileted ■ Monitored for vital signs ◯ Complete documentation includes a description of the following: ■ Precipitating events and behavior of the client prior to seclusion or restraint ■ Alternative actions taken to avoid seclusion or restraint ■ The time treatment began ■ The client's current behavior, what foods or fluids were offered and taken, needs provided for, and vital signs ■ Medication administration ● An emergency situation must be present for the charge nurse to use seclusion or restraints without first obtaining a provider's written order. If this treatment is initiated, the nurse must obtain the written order within a specified period of time (usually 15 to 30 min).
Intentional Tort Example
false imprisonment › Confining a client to a specific area, such as a seclusion room, is false imprisonment if the reason for such confinement is for the convenience of the staff. assault › Making a threat to a client's person, such as approaching the client in a threatening manner with a syringe in hand, is considered assault. battery › Touching a client in a harmful or offensive way is considered battery. This would occur if the nurse threatening the client with a syringe actually grabbed the client and gave an injection.
sign of anorexia
signs of bulimia
Russell's sign= callused knuckles from self induced vomitting
what lab value do you expect with alcohol cardiomyopathy
which PD- pt needs external input to make everyday decisions
a client that demonstrates a dedication to his job that excludes time for leisure activitites
adheres to a rigid set of rules
a client who has trouble starting new relationships unless he feels accepted
avoidant personality disorder
healthy adolescnet behavior
realistic self concept
healthy preschool behavior
displays an egocentric apprach to problem solving
toddler healthy behavior
requires literal explanations
who displays mistrust of others
what should you teach parents about autism spectrum disorder
does an autistic kid have fear of abandonment
nope- a kid with separation anxiety does
does an autistic kid have hostile behavior
no- a kid with oppositional defiant disorder does
what demonstrates active listening
attention to body language (identifying verbal and nonverbal communication)
a pt is getting a new Rx of haldol- what symptom should you tell them to report
(dry mouth and blurred vision are common- also teach the client to stay out of sun)
the nurse is caring for a client who has anorexia- which criteria requires hospitalization
weight loss of over 30% in 6 months
hypothermia- less than 96.8
K less than 3
HR less than 40
how often should you offer the client food in seclusion
also document behavior every 15-30 min
a nurse is planning DC teaching to a family member of a pt newly diangosed with depression= what should the nurse teach about relapse
early identification of changes such as decreased social involvement is important
is this true= medication compliance will prevent further need for inpatient hospitalization
intoxication of _____
intoxication of _____
would a high BP and HR be common if intoxicated with inhalants
nope- these are depressants
SE of imipramine (4)
mild tachycardia (not brady)
increased appetite and wt gain
signs of PTSD
exaggerated startle response
(not delusions and compulsions)
purpose of attending support group
provide assurance that others have a similar problem
sign of delerium
sudden onset- rapid inappropriate speeach
do clients with delerium have slow speech
do clients with delerium have a flat affect
do they have normal moods?
no- mood swings
can ECT increase risk of parkisnons
how often does ECT happen
2-3 times a week for 6 to 12 treatments so 4-6 weeks
should you move a pt with depression to a private room
no- they are risk of self harm and isolated
better to move the bipolor patient
what lab should you do if patient is getting risperidone
glucose- can cause diabetes
defense mechanism of conversion
uncosciously converting anxiety into physical symptoms
transferring feeling about illness to another less threatening situations
client demonstrates opposite action of what she is really feelings
priority goal for a client with borderline personality disorder
client will refrain from self mutiliation
in the presence of low ____ levels renal excretion of lithium is reduced and client is at risk for toxicity
so less than 135 is bad
what is tranylcypromine
is bologna okay to eat with MAOI
no- processed meet
can you have avocodos
can a client with MD make informed health desicions and give consent
who can not give consent
kids less than 18
intoxicated- blood alcohol level of .08
client with a dose of morphine
what should you do to help encourage a silent group member to participate in group
divide the group into pairs to discuss a topic, then summarize the discussion to the group
wht should you do if people try to monopolize the discussion
encourage the group that everyone should have a chance to participate
ask the group to share observations of other group members (dont do this for the silent patient)
what should you do if a patient exhibits demoralizing or negative behavior
focus on the group member and emphasize their helpfullness
___ increases the likelyhood of family violence
"my son has a few drinks each night to unwind" is a sign
clinical findings of mild anxeity
restless, irritable, nail biting, fidgeting
tensions, palpitation, increase heart rate, sweating
sense of impending doom
uncoordinated impulsive behavior
sign that valporic acid is working
less pressured speech (remember for bipolar)
a client was admitted as involuntary for substance abuse and is refusing the lorazepam- what do you do
dont give it- they still have the right to refuse treatment
when the client maintains eye contact and leans forward
shows he trusts the nurse
child with conduct disorder is behaving in a destructive manner- throwing things and kicking people- what is highest priority intervention
1. encourage kid to express feelings
2. promote attendance at an assertive training group
3. try relaxing breathing
4. use a therapeutic holding technique
4- hold- need to maintain safety
to establish a trusting nurse relationship th enurse should first
inform the client that her admission will be confidential (express confidentiality in the initial phase or relationships)
what should you do in working phase
introduce clients to others in the day room
assist the client to make behavioral changes
determine coping strategies the client has used in the past
what indicates a risk for complicated grief (cmplicated when it affects daily functioning)
when a client has trouble carrying on normal activities after a loss "I feel so empty without my wife, its hard to get up every morning"
dementia patient- useful to help orient them to reality
place a large calendar on the wall
the tx plan is for a pt with schizo to gain autonomy from his parents. Prior to DC the nurse should plan to
schedule a family conference
not stress to the client that he needs to be more independent
in group a bipolar patient begins bragging and dominating the situation- what should the nurse do
tell the client to calm down or he will dismiss him from the group
example of situational crisis
lost a grandparent in a motor vehicle crash
an unexpected even
town hit by tornado
son leaves for college or fear of upcoming retirement
natural life event
a nurse is developing a plan of care for a patient who exhibits anger, aggression, and violent behavior, what is the priority nursing intervention
create a large personal space- this helps provide safety
not use therapeutic communiciton (this only prevent escalation of agression and is a part of ongoing therapy)
prupose of AA
to use peer support to maintain abstinence
client in group gets angry and yells "listening to you people is making me worse. how do you respond
you sound angry and frustrated. tell us more about how you are feeling
what drug should you give for alcohol withdwaral
chlordiazepocide (librium)- benzo
does the code of ethics esure the right to tx and individualized care
the duty to protect third parties requires a nurse to testify about a client
no- only if she is given info regarding potential harm
a nurse is caring for a client with a hx of agression, the client is playing cards and throws them at other patients- what should you do
ask the client how he is feeling (therapeutic cmcn)
not take the cards away (this will increase aggression)
explaining unit rules will not help either
SE of lithium that causes them to stop takin it
hand tremors- prevents them from doing ADLs
if you overhear another nurse talking bad about a client what should you do
do not confont that person directly
report it to charge nurse
anorexic client who needs to increase oral intake- what interventions should the nurse take
restrict caffiene - diuretic
should you increase or decrease fiber
increase to prevent constipation
should you offer rewards for the amt of weight gained
no- for the amt of calories taken in though can reward
should you increase daily intake to 2500 cals
initial intake should not go below 1200 but 2500 may be too overwhelming (want small frequent meals)
a nurse in a 24 hr mental health facility is planning DC for a client with a long history of alcohol use disorder- what postdischarge activity should the nurse plan to inlcude
attending a relapse prevention group several times each week
like AA 12 steps
is buprenorphine for alcohol
no- opioids- heroin
is methadone for alcohol
a client is experiencing alcohol withdrawal delerium- which roommate is most appropriate for this patient
one with depression- will allow client to rest
pt with acl withdrawal needs uninterrupted rest
why would a hypervigilant roommate not be good
this pt will not let the pt with alcohol withdrawal get the most rest he needs
example of the displacement defese mechanism
the client critizises the nurse each med administration time (really mad about meds but taking it out on nurse)
what defense mechanism is (the client reports a HA each day when group therpay is scheduled)
what defense mech (client always talks about healthy eating habbits)
defense mech (the pt complains about the taste of the food)
good statement that shows that suicide risk has decreased
"it is easier to talk about my feelings now"
"im relieved now that my finanical affairs are in order"
more at risk when afairs are in order
"thank you for taking such good care of me"
more at risk- people show an appreciation for loved ones when contemplating suicide
who is at great risk for injury when doin gADLS
stage 6 alzheimers disease
maintenanc ephase of schizo
calm and able to preform self care
how can you help with OCD behaviors
assist the lcient to set limits of behaviors
should the client with OCD monitor the number of times he has obsessive thoughts
no- this can be ven more time consuming
how should you assess spirituality
discuss spiritual issues in a conversational manner not in a formal manner (this should be done by a pastor)
a client is taking an SSRI like paroxetine- what should you tell the client to report to you if they notive
FEVER- Serotnonin syndrome
not sex dysfunciton- this is normal
priority assessment finding for a client taking valporic acid
pt has not slept in 24 hours
not fine hand tremors (this is normal effect)
highest priority intervention for a pt with OCD
help client id sources of anxiety
not teach client focused relaxation techniques (good but not better that identifying sources of anxiety)
could also use + reinforcement for nonritual behavior but not best
admitting a pt experiencing alcohol withdrawal, is nauseas, shaking, and irritable- priority interventin
date and time of last drink (worst withdrawal 24-48 hrs after last drink)
when client is unable to openly acknowledge nd express grief
what do you expect with masochism
fantasized being humiliated and bound
recurrent, sex urges of being beaten, bound, and humiliated
exposing genitals to strangers
sex fantasies about non living objects
urges to touch and rub against non consenting individuals
exaple of enmeshed boundaries
children taking care of their younger siblings
what do you say if a pt becomes verbally abuseive
i am leaving now but returning in a few minutes to see if you are calmer
which label worries us with clozapine
WBC of 2500
intervention for patient with delerium
permit the client daily rituals to decrease anxiety
dont keep lighting dim (want to be able to see invironment)
dont give too man decisions because may get frustrated
teach about light therapy for SAD
wear sunglasses when go outside- bc light therapy can cause eye strain and sensitivity to light
(dont need to increase fluids bc will not cause dehydration)
should you get a no suicide contract from a pt who recently attempted suicide and is angry over being admitted
no- should wait til pt is no longer angry and you can develop rapport first
so what should you do with this patient (just attempted suicide and is angry about admission)
1 to 1 observation
a client says about ECT "I will be able to stop taking my antidepressants after the tx"
nope= sorry need maintenacne
planning teaching about relapse prevention to a client who just began an outpatient substance use disorder tx program- what should you teach at the beginning
simple rules and objectives or program (pt still may have cog impairment RT detix)
teach about resperidone
1. may cause high blood sugar
2. mestrual irregularities may occur while on this med
3. you make experience dizziness while taking this med
(no increase in hair or excess sexual desire)
how do you use simple restitution as a behavior managment technique for a child with conduct disorder
make the child pick up books after he threw them all over the room
"Im not going to my family reunion because no one asked me to help plan it"
sign of uselessness is a sign of depression
refer families to a grief counselor following suicide
work with nurse to determine students at risk for suicide
primary (preventing suicide)
establish a telephone hotline for individuals experiencing a suicide crisis
review suicide precautions with nursing staff
secondary (involves treating a client during suicide crisis)
an impotant consideration in promoting client adherence to treatment regiment
providing care to a clients physical health needs
teach about buspar
dont take with grapefruit bc will intensify effects
takes 3-4 weeks to work
will not cause withdrawal
early stage of grief= denial
"i think my labs got mixed up with someone elses"
highest priority intervention for a kid with ADHD
remove unesarry stuff from childs surroundings cb greatest risk if injury to impulsive behabior
not use + reinforcement when the pt gets a task done
behavior that indicates that the client shoul dhave restraints removed
listens to nurses directions
sign of recovery for someone who was sexually assulted
client expresses interest in intimate relationships
signs of depression
which lab value of a pt on lithium should make you hold med and call dr
BUN of 45- lithium is hard on kidneys
BUN normal is 6-20
promoting self esteem
administering meds to minimize long term efects of violence
what shoul dyou do if one pt is talking too much in group
ask the clients to discuss their feelings about the monopolizing behavior
important teaching need for a pt on olonazpine
do not drive after initial doses- will make you drowsy and dizzy
order the phases of the nurse client relationship
1. pre-orientation= identify safety risks
2. orientation phase= set parameters
3. workin gphase= promote problem solving skills
4. summarize goals
secondary dementia caused by thiamine def.
korsakoff's syndrome- be sure to help client with ambulation
first action when you witness one client with dementia slap another
call team members for help
do not try to go by self
priority action by nurse to client just admitted with bipolar
provide frequent high calorie snacks
voluntary admission- doing initial assessment and pt says "I've lost control of everything in my life"
are you having thoughts of killing yourself
How do you set limits for a patient
1. Tell the patient calmly and directly what he must do a particular situation, such as, "I need you to stop yelling and walk with me to the dayroom where we can talk"
2. Use physical activity, such as walking, to de-escalate anger and behaviors
3. Inform the patient of the consequences of his behavior, such as loss of privileges
What are olanzapine and ziprasidone used for
They are atypical antipsychotics used to control aggressive and impulsive behaviors. They are used more frequently than haloperidol because of the severity of side effects of haloperidol
When a patient is taking haloperidol what should you monitor the patient for
One. Parkinsonian and anti-cholinergic side effects
Two. Keep the patient hydrated, check vital signs and test for muscle rigidity due to risk of neuroleptic malignant syndrome
What are some signs that you might see in a patient in the preassaultive stage of violence
Defensive responses to questions
What are two factors that increase the risk for abuse towards a child
One. The child is under three years of age
2. The perpetrator precedes the child is being different such as the child is disabled
Cycle of violence: what is the tension building phase
The abuser has minor episodes of anger and may be verbally abusive and responsible for some minor physical violence. The victim is tense during this stage and tends to except the blame for what is happening
Cycle of violence: acute battering phase
The tension becomes too much to bear and serious abuse takes place. The victim may try to cover up the injury or may get help
Cycle of violence: what is the honeymoon phase
The situation is defused for a while after the violent episode
What do you assess the baby for when there is suspected shaken baby syndrome
Increase in head circumference
What is veracity
Refers to being honest when dealing with a patient
What is the usual time period For an emergency involuntary commitment
Up to 10 days
Long term or formal involuntary commitment is a type of commitment that is similar to temporary commitment but must be imposed by the courts. Time of commitment varies but is usually between blank and blank days however sometimes there's no release date
60 to 180
Patients admitted under involuntary commitment are still considered competent and have the right to refuse treatment unless
They have gone through a legal competency hearing and have been judged incompetent
What are the guidelines for restraints or seclusion to be used
What are three examples of intentional torts
False imprisonment, assault and battery
What is an example of assault and battery
Assault would be threatening a client with a syringe in hand and battery would be actually giving that injection against the patients will
What is the example of a maintenance role in group therapy
The harmonizer who attempts to prevent conflict in the group
What is an example of a task role in group therapy
Someone who takes notes or records the session
What is an example of an individual role in group therapy
Someone who prevents teamwork such as the dominator or the recognition seeker
What are three concepts related to family dysfunction
What is a democratic group leader
This style supports group interaction and decision-making to solve problems
What type of group leader involves the group process progresses without any attempt by the leader to control the direction
What type of group leader completely controls the direction and structure of the group without allowing group interaction or decision-making to solve problems
What is oppositional defiant disorder
It is characterized by recurrent pattern of antisocial behaviors (negativity, disobedience, hostility, limit testing, etc.)
What is disruptive mood dysregulation disorder
Patients who have this disorder exhibit recurrent temper outbursts that are severe and do not correlate with the situation
Patients that demonstrate a persistent pattern of behavior that violates the rights of others or rules and norms of society would be categorized as having
What are ways to promote positive behavior in a child that has oppositional defiant disorder
Develop a reward system for acceptable behavior
Encourage the child to participate in school sports
Be consistent when addressing unacceptable behavior
What are three expected findings of a patient who has depression
What are three expected findings of a 12-year-old who has conduct disorder
Bullying of others
Threats of suicide
Law breaking activities
What are medications that support detoxification from alcohol
What are three medications that can be given to help a patient abstain from using alcohol
Disulfiram, Naltrexone, and Acamprosate
What is a situational/external crisis
Often unanticipated loss or change
What is a maturational/internal crisis
Achieving new developmental stages, which requires learning additional coping mechanism
What is an adventitious crisis
The occurrence of natural disasters, crimes or national disasters
What are the different phases of a crisis
What are symptoms of mild anxiety
Restlessness, increased motivation, irritability
What are symptoms of moderate anxiety
Agitation, muscle tightness
What are symptoms of severe anxiety
Inability to function, ritualistic behavior, and unresponsive
What are symptoms of panic
Distorted perception, loss of rational thought, immobility
What is acute stress disorder
Exposure to a Traumatic event causes numbing, detachment and amnesia about the event for at least three days but for no more than one month following the event
What does modeling therapy do
Allows a client to see a demonstration of appropriate behavior in a stressful situation. The goal of therapy is that the client will imitate the behavior
What is flooding therapy
Involves exposing the patient to a great deal of an undesirable stimulus in the attempt to turn off the anxiety response
What is response prevention
Focuses on preventing the patient from performing a compulsive behavior with the intent that anxiety will diminish
What is thought stopping
Teaches a patient to say stop when negative thoughts or compulsive behaviors arise and substitute a positive thoughts
What are two defense mechanisms that are always healthy
What is altruism
Dealing with anxiety by reaching out to others (volunteering)
What is sublimation
Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression (using exercise as a release of anxiety)
What is suppression
Voluntarily denying unpleasant thoughts and feelings (A person who has lost his job states he will worry about paying his bills next week)
What is repression
Putting unacceptable ideas, thoughts and emotions out of conscious awareness (A person who has a fear of dentists drill continually "forgets"his dental appointments)
What is displacement
Shifting and feelings related to an object, person, or situation to another less threatening object, person or situation (A person who is angry about losing his job destroys his child's favorite toy)
What is reaction formation
Overcompensating or demonstrating the opposite behavior of what is felt (A person who dislikes her sister's daughter offers to babysit so that her sister can go out of town)
What is undoing
Performing an act to make up for prior behavior
What is dissociation
Temporarily blocking memories and perceptions from consciousness
What is splitting
Demonstrating an inability to reconcile negative and positive attributes of self or others (A patient tells the nurse that she is the only one who cares about her, yet the following day, the same patient refuses to talk to the nurse)
What is a regression
Demonstrating behavior from an earlier developmental level. Often exhibited as childlike or immature behavior (A school age child begins wetting the bed and sucking his thumb after learning that his parents are separating)
Different levels of anxiety
If I were to have a patient that has mild to moderate levels of anxiety what can I do to help this patient
1. Use active listening to demonstrate willingness to help and use specific communication techniques (Open ended questions, exploring, etc)
2. Provide a calm presence
3. Evaluate past coping mechanisms
4. Explore alternatives to problem situations
5. Encourage participation in activities such as exercise
What can I do for a patient that is having trouble with severe to panic levels of anxiety
1. Provide an environment that meets the physical and safety needs of the patient. Remain with the patient
2. Provide a quiet environment
3. Use medications and restraint if necessary
4. Encourage gross motor activities, such as walking or other forms of exercise
5. Set limits by using firm, short and simple statements
6. Direct the patient to acknowledge reality and focus on what is present in the environment
A nurse should use open ended questions to obtain the following information for the nursing history of the patient who has a substance-abuse problem
1. Type of substance or addictive behavior
2. Pattern and frequency of substance use
3. Amount of substance used
4. Age at onset of substance use
5. Changes in occupational or school performance
6. Changes in use patterns
7. Periods of abstinence in history
8. Previous withdraw manifestations
9. Date of last use
Anabolic steroids can have negative long-term effects such as
Liver damage, hypertension and infertility
What are medications for alcohol withdrawal
Benzo's, Tegretol, clonidine, librium
What are medications for alcohol abstinence
Disulfiram, naltrexone, Acamprosate
What are medications for opioid withdrawal
Methadone, clonidine, buprenorphine
What are medications for nicotine withdrawal
Bupropion (zyban), and nicotine replacement products
What is intrapersonal communication
Communication that occurs within an individual
What is interpersonal Communication
Communication that occurs between two or more people
What is transpersonal communication
Communication that addresses an individuals spiritual needs and provides interventions to meet those needs
Content of the message chart
Effective skills and techniques of communication chart
A nurse is conducting therapy with several clients and their families. Effective communication with clients and families is based on
Attending to verbal and nonverbal behaviors
A therapeutic nurse - client relationship is what four things
1. Purposeful and goal directed
2. Well defined with clear boundaries
3. Structured to meet the clients needs
4. Characterized by an interpersonal process that is safe, confidential, reliable and consistent
Phases and tasks of a therapeutic relationship chart
What are four medications commonly used for bipolar disorder
Lithium, valproic acid, tegretol and lamictal
How does lithium work
Produces neurochemical changes in the brain, including serotonin receptor blockade
What are some adverse effects of lithium
G.I. upset, fine hand tremors, polyuria, mild thirst, weight gain, renal toxicity, goiter and hypothyroidism, Bradydysrhythmias, hypotension and electrolyte and imbalances
Adverse effects and nursing intervention chart for lithium
What are some signs of lithium toxicity
Diarrhea, vomiting, slurred speech, tremors, mental confusion, muscle weakness, blurred vision, severe hypotension and seizures
What are medications that interact with lithium
Diuretics, NSAIDs and anticholinergics
Plasma levels of lithium greater than blank can result in toxicity
What are some things to nurse should be aware of when administering lithium
Adverse effects of carbamazepine and Lamotrigine
Adverse effects of valproic acid
All of the medications including lithium are contraindicated in
Carbamazepine is contraindicated in patients who have
Bone marrow suppression or bleeding disorders
Valproic acid is contraindicated in patients who have
Medication/food interactions of carbamazepine, valproic acid and lamictal
What three letters do tricyclic antidepressants end in
ine with the exception of doxepin
How did Tricyclic antidepressants work
Block reuptake of norepinephrine and serotonin in the synaptic space, thereby intensifying the effects of these neurotransmitters
Adverse effects chart of tricyclic antidepressants
Amitriptyline is a pregnancy risk category C medication. It is also contraindicated in patients who have
Medication/food interaction chart with tricyclic antidepressants
What are adverse effects of SSRIs
Sexual dysfunction, CNS stimulation, weight loss in the beginning and then weight gain, withdrawal syndrome, hyponatremia, rash, sleepiness, lightheadedness, G.I. bleeding and bruxism
What are food/medication interactions with SSRIs
If a patient is taking MAOIs what should they avoid in their diet
Tyramine (can cause hypertensive crisis)
What are some side effects of MAOIs
What are manifestations of a hypertensive crisis
Increased HR and BP
Food/medication interactions with MAOIs
How does Wellbutrin work
By inhibiting dopamine uptake
What are side effects of Wellbutrin
What are some other atypical antidepressants other then Wellbutrin
What is a sign of toxicity with TCAs
When should you administer TCAs
At bedtime due to sedation and risk for orthostatic hypotension
When should SSRIs be taken
In the morning to minimize sleep disturbances
Should SSRIs be taken with or without food
For older adults taking diuretics and SSRIs what should you obtain
Baseline sodium levels
What type of antidepressant is most commonly used for seasonal pattern depression
Wellbutrin (atypical antidepressant)
Wellbutrin should not be administered to patients with a high risk for seizures such as a patient who sustained
A head injury
What are some MAOIs
Positive symptoms of schizophrenia are related to behavior, thought and speech such as
Agitation, delusions, hallucinations, tangential speech patterns
Negative symptoms of schizophrenia are things like
Social withdrawal, lack of emotion, lack of energy, flattened affect, decreased motivation and decreased pleasure in activities
First generation of antipsychotic medications are used mainly to control what kind of symptoms
Positive symptoms and a reserved for clients who use them successfully or who are violent or particularly aggressive
Second-generation (atypical) antipsychotic medications are choice for patients receiving
Initial treatment and for treating breakthrough episodes for patients on conventional medicine
What are advantages of atypical antipsychotic agents
First-generation antipsychotic medications generally end in zine. What are some first generation antipsychotic medications
How do first-generation antipsychotic medications work
Block dopamine, acetylcholine, histamine and norepinephrine in the brain and periphery
What are complications of first-generation antipsychotic medications
Agranulocytosis (look for fever or sore throat)
Neuroleptic malignant syndrome
What are the extrapyramidal symptoms of first-generation antipsychotic medications
Use of conventional antipsychotic medications is contraindicated in older adults who have
What are food/medication interactions with first-generation antipsychotic medications
What are manifestations of neuroleptic malignant syndrome
Sudden high fever
Blood pressure fluctuations
Changes in LOC
What are six anticholinergic symptoms
What are nursing considerations for administering first-generation antipsychotic medications
Second generation antipsychotic medications typically end in done or pine. What are some examples of these medications
How do second-generation antipsychotic medications work
Mainly by blocking serotonin and to a lesser degree dopamine. They also block receptors for norepinephrine, histamine and acetylcholine
What are adverse effects of risperidone
What should patients avoid while on second-generation antipsychotic medication
Pregnancy risk category C and alcohol
Other atypical antipsychotic medications chart 1
Other atypical antipsychotic medications chart 2
What are some medication/food interactions associated with atypical antipsychotics
Risperidone is available as what kind of injection
IM every two weeks for patients who have difficulty adhering to a medication schedule. Therapeutic effect occurs 4 to 6 weeks after first injection
Patients taking asenapine should avoid eating or drinking blank minutes after each steps
What should you administer lurasidone with
Bipolar phase versus treatment chart
What is rapid cycling
Four or more episodes of acute mania within a year
What is bipolar one disorder
The patient has at least one episode of mania alternating with major depression
What is bipolar 2 disorder
The patient has one or more hypomanic episodes alternating with major depressive episodes
What is cyclothymia
The patient has at least two years of repeated hypomanic manifestations that do not meet the criteria for hypomanic episodes alternating with minor depressive episodes
What are four comorbidities that are associated with bipolar disorder
Substance use disorder
Bipolar disorder clinical manifestations
What is schizophrenia
The patient has psychotic thinking or behavior present for at least six months
What is schizotypal personality disorder
The patient has impairments of personality functioning. However, impairment is not as severe as with schizophrenia
What is delusional disorder
The patient experiences delusional thinking for at least one month
What is schizophreniform disorder
The patient has manifestations similar to those of schizophrenia but the duration is from 1 to 6 months
What is schizoaffective disorder
The patient's disorder meets both the criteria for schizophrenia and depressive or bipolar disorder
Characteristic dimensions of psychotic disorders
Examples of delusions
What are four standardized screening tools for patients with psychotic disorders
1. GAF scale
2. Scale for assessment of negative symptoms
3. Brief psychiatric rating scale (BPRS)
4. Abnormal involuntary movement scale (AIMS)
What are some alterations in behavior
Teaching and types of medications for psychotic disorders
What are risk factors and protective factors of suicide
How do you assess the patient's suicide plan
1. Does the patient have a plan
2. How lethal is the plan
3. Can the patient described the plan exactly
4. Does the patient have access to the intended method
5. Has the patient's mood changed
Classifications of medications to prevent suicide
Free patient on suicide precautions how often should you document the patient's location, mood, quoted statements and behavior
Every 15 minutes or per the study protocol
Suicide precautions within the facility should be
What is primary prevention in reference to community care of patients with mental health illnesses
Promotes health and prevent mental health problems from occurring (such as teaching a class)
What is secondary prevention
Focuses on early detection of mental illness (such as screenings)
What is tertiary prevention
Focuses on rehabilitation and prevention of further problems impatiens previously diagnosed (A nurse leads a support group for patients who have completed a substance use disorder program)
Community based mental health programs
Different types of loss
Theories of grief
Types of grief
Patients that have depression along with anxiety disorders have a poor prognosis with a higher risk for
Suicide and disability
Depressive disorders recognized and defined by the DSM - 5
What is dysthymic disorder
A milder form of depression that usually has an early onset and last at least two years in length for adults and one year in length for children
Different phases of depression
When a person is experiencing depression it is better to make observations rather than asking blank
Direct questions. For example the nurse might say "I noticed that you attended the unit group meeting today" rather than asking "did you enjoy the group meeting"
Medication classifications/examples for depression
What is an herb that can be used for mild depression but should not be mixed with other antidepressants especially SSRIs or foods containing tyramine
St. John's wort
What is the first line treatment for seasonal affective disorder
Transcranial magnetic stimulation (TMS) uses electric magnetic stimulation of the brain. It is indicated for depressive disorders that are
Resistant to other forms of treatment
Vagus nerve stimulation (VNS) uses an implanted device that stimulates the Vagus nerve. It can be used for patients who have depression that is
Resistant to at least four antidepressant medications
Objective assessment findings for eating disorders
What are patients with bulimia at a higher risk for
What are three common electrolyte imbalances that are associated with bulimia
What is a type of medication that may be used for patients with eating disorders
What is refeeding syndrome
Potentially fatal complication that can occur when fluids, electrolytes and carbohydrates are introduced to a severely malnourished patient
Lanugo on the face is an expected finding of
Benzodiazepine sedative hypnotic anxiolytics
Complications of benzodiazepines
What is an atypical anxiolytic
What are four therapeutic uses of buspirone
Social anxiety disorder
What are complications of buspirone
CNS effects such as dizziness, nausea, headache, lightheadedness, agitation
If buspirone is mixed with MAOIs what might occur
What are food/medication interactions with buspirone
St. John's wort
How should buspirone be taken and when does it take effect
With food and 3 to 6 weeks to reach full therapeutic benefit
What are some SSRIs that are used for anxiety disorder
What is the first line treatment for trauma and stress related disorders such as PTSD
Therapeutic uses for SSRIs
Adverse side effects of SSRIs
Contraindications and food/medication interactions with SSRIs
When should you take paroxetine
In the morning with food
What are symptoms of serotonin syndrome
redirecting of thoughts feelings and impulses from an object that gives rise to anxiety to a safer, more acceptable one.
the refusal to accept reality and to act as if a painful event, thought, or feeling did not exist
the reversion to an earlier stage of development in the face of unacceptable impulses
attribution of one's undesired impulses onto another.
this is the defense mechanism that is operative in delusional thinking
test taking strategy
ALWAYS PICK ANSWER THAT FOCUSES ON CLIENTS FEELINGS
what is usually a parent's first response to terminal illness in children
denial and disbelief
sharing of memories of past experiences and events
the phenomenon of the nurse unconsciously attributing feelings about another to the client
the client attributing feelings to the nurse
nurse's self reflection of feelings and attitudes as they relate to a client or group of clients
when one idea or object comes to stand for another
unconsciously removing something from one's awareness
not progressing beyond a given level of development
core issues surrounding anorexia nervosa
alterations in self image and self-identity
relating to others as if they are all good or all bad
expressing an attitude that is the direct opposite of one's true feelings and wishes
overestimating admired qualities of another person
adopting characteristics of a loved one
conversion of unacceptable drives into socially sanctioned activities
when a client detaches emotional or behavioral processes from usual conscious behavior patterns or identity
What is the defense mechanism that is operative in delusional thinking?
the performance of a symbolic act that cancels out an unacceptable act or idea. it is an unconscious defense mechanism that negates a painful feeling or unacceptable act. rituals in OCD are form of undoing to reverse or negate unacceptable impulses
somatoform disorder in which the individual expresses his anxiety in the form of sensorimotor symptoms
example: eyewitness to violent crime complains of headaches when looking at mugshots
one side effect of tricyclic antidepressants that should be brought to provider attention promptly?
urinary retention (nurse should monitor I & O), nurse should also check for any abdominal distension
Drug of choice to counteract EPS
bentropine mesylate (Cogentin)
eps side effect muscle spasms
eps side effect restlessness
eps side effect hand tremor (symptoms similar to Parkinsons)
irreversible EPS involuntary movement, lip smacking
ocd disorder, behaviors alleviate anxiety
repeating words together that rhyme
pathologic, consistent repeating of anothers words by imitation. seen in autism and tourettes
forceful, rapid speech that exudes energy. seen in mania
mixture of phrases and words strung together without meaning
how does the nurse help a client obtain relief?
speak in calm manner and remain with client
most common SE of tricyclic antidepressants
filling in gaps in memory by fabrication
a misinterpretation of a real sensory experience. it is not associated with a memory problem
false, fixed belief. seen with schizophrenia and other psychotic disorders
fear of being in crowded places
anxiety is displaced from the original source to another object or situation, resulting in the phobia. displacement
offering a socially acceptable or logical explanation for otherwise unacceptable impulses, feelings, behaviors
antipsychotic that will help calm a patient, it is not a sedative
characterized by the unconscious repression of the anxiety feelings which are then manifested as physical illness
exaggerated preoccupation with physical health
benzos side effects
anticholinergic effects (dry mouth, blurred vision), dizziness, drowsiness, sedation. withdrawal (gradually decrease dose)
client has physical symptoms suggesting a medical problem (such as blindness or paralysis) but no organic pathology can be diagnosed
characterized by recurrent panic attacks that are not associated with any specific stimulus or situation but seem to occur spontaneously
characterized by recurrent obsessional thoughts and/or ritualistic behavior
newer antipsychotic that targets both positive and negative manifestations of schizophrenia with fewer side effects. weight gain is LESS common
frequently prescribed, in low doses, for elderly clients to control agitation and promote sleep
antisocial personality disorder
client will exhibit a pattern of irresponsible behavior that lacks morals and ethics and brings the client into conflict with society. the most common response of clients with antisocial behavior is a lack of concern about their situations, as well as an absence of sensitivity to the feelings of persons whom they have harmed
post traumatic stress disorder
a disorder in which an overwhelming traumatic event is re-experienced, causing intense fear, helplessness, horror, and avoidance of stimuli associated with trauma
most common side effect of BuSpar
drowsiness, headaches, dry mouth, agitation
potent CNS depressants
antianxiety agents (Valium, Ativan, Librium)
long-acting CNS depressants that are used to manage symptoms of alcohol withdrawal
Wernicke Korsakoff syndrome
a brain disorder involving loss of specific brain functions due to vitamin B1 deficiency (Thiamine) usually occurring in clients with long-standing alcoholism who have poor nutrition. symptoms include short term memory loss, confusion, disorientation
mood swings, suicidal ideation
symptoms of borderline personality disorder, antisocial personality disorder
aggression and impulsiveness
test taking strategy
always address clients feelings first!
does not prevent progression of alzheimer's but prolongs time and functioning of the individual in the early stages of diseases. given in the pm
most common early manifestations in anorexia
amenorrhea, bradycardia, disturbed body image, and loss of 15% pre-illness body weight
type of behavioral therapy where client is gradually exposed to the feared situations under controlled conditions and learns to overcome the anxious response
depakote (valproic acid) what instructions should nurse give patient?
anti seizure med that can cause severe hepatic dysfunction. nurse should monitor liver function and hematology levels
cocaine effect on pupils
early signs of heroin withdrawal
restlessness, irritability, piloerection (goose bumps), tremors, loss of appetite
what anti seizure drug can be safely administered with lithium
depakote (Valproic acid)
alzheimer's early manifestation
short term memory problems
most common side effects of benzos
sedation, dizziness, drowsiness
symptoms of delirium
acute confusion and inattention
symptoms of alzheimer's
disorientation, impaired judgement, personality change, apathy, anxiety, and memory loss
what makes a schizo pt at the greatest risk for self injury or injury to others?
restlessness, irritability, nail biting, fidgeting
imipramine side effect
urinary retention, tinnitus, tachy, weight gain
risperidone. what lab test should the nurse monitor?
blood glucose, can cause DM to develop
two drugs that help with sleep disordrs
benzos and nonbenzos
relieve anxiety, insomnia, help with moderate sedation, relax muscle spasms, treat status epilepticus
Benzos end with
benzos drug action
enhance inhibitory effects of GABA, CNS depressant
benzos signs of toxicity
weakness, slurred speech, ataxia, resp depression
benzos pregnancy category
do not give benzos with..
other cns depressant, kava kava, valerian, cimetidine, smoking (decreases effects)
non benzo used to treat sleep disorder
zolpidem (ambien) admin on empty stomach for best effect. take before bedtime and no with other cps depressants
drowsiness, headaches, anxiety, dizziness, confusion, amnesia,
treatment for ADHD
amphetamines (adderall prototype)
amphetamine drug action
increase release of neurotransmitters NE and dopamine in brain and peripheral nervous system
insomnia, HTN, Tachy, Palpitations, schedule 2 drug, can suppress child growth (use "holidays" for children to allow growth)
amphetamines - what drugs can you take to increase or decrease effects?
sodium bicarb - increase effects
vit C/ammonium chloride - decrease effects
orthostatic Hypotension is a side effect of...
imipramine (tricyclic antidepressant). change positions slowly
Buproprion (Wellbutrin) SE
nausea, vomiting, headache, insomnia
Valproic acid SE
amitriptyline teaching instruction
med for major depression
change positions slowly
do not stop taking abruptly
take at bedtime
increase fiber/fluid intake
Xanax nurse teaching
avoid other CNS depressants like alcohol. Xanax is a benzo
HCP should monitor an older patient taking xanax for...
tolerance, anxiety, resp depression, sedation
Patient taking Lithium should avoid
chlorpromazine nurse teaching
can cause photosensitivity, wear sunscreen when exposed to sunlight
Buspirone nurse teaching
allow 2-4 weeks before expecting to feel better
depression, seasonal affective disorder, nicotine addiction
Inappropriate for patients with seizure disorders, CNS tumor, or history of head trauma
IV Chlorpromazine precautions
must monitor BP, at risk for hyptotension
tremors, confusion, nausea, muscle weakness
what can risperidone cause in the patient?
atypical antipsychotic, can cause new onset of DM
Valium - benzodiazepine
Xanax - benzodiazepine
Librium - benzodiazepine
Tranxene - benzodiazepine
Serax - benzodiazepine
Klonopin - benzodiazepine
Romazicon - benzodiazepine toxicity antidote
Paxil - SSRI
Zoloft - SSRI
Lexapro - SSRI
Prozac - SSRI
Luvox - SSRI
Cymbalta - SSNRI
BuSpar - atypical anxiolytic
Wellbutrin, Zyban - atypical antidepressant, decrease craving/withdrawal from nicotine
Elavil - TCA
Trofranil - TCA
Sinequan - TCA
Aventyl - TCA
Asendin - TCA
Surmontil - TCA
Lithane, Eskalith, Lithobid - Mood stabilizer
Tegretol - mood stabilizing anti-epileptic
Depakote - mood stabilizing anti-epileptic
Lamictal - mood stabilizing anti-epileptic
Thorazine - conventional antipsychotic
Haldol - conventional antipsychotic
Prolixin - conventional antipsychotic
Moban - conventional antipsychotic
Loxitane - conventional antipsychotic
Mellaril - conventional antipsychotic
Navane - conventional antipsychotic
Risperdal - atypical antipsychotic
Zyprexa - atypical antipsychotic
Seroquel - atypical antipsychotic
Abilify - atypical antipsychotic
Geodon - atypical antipsychotic
Clozaril - atypical antipsychotic
Ritalin, Methylin - CNS stimulant
Focalin - CNS stimulant
Dexedrine - CNS stimulant
Adderal - CNS stimulant
Stratterra - SNRI (ADHD)
Antabuse - alcohol aversion therapy
ReVia - suppress alcohol craving, opioid withdrawal
Campral - abstinence maintenance, decrease anxiety
Dolophine - substitution
Catapres - reduction of diarrhea, n/v (withdrawal)
Subutex or suboxone - detox maintenance, craving reduction
Benzodiazepine Sedative Hypnotic Anxiolytics
Benzodiazepine Sedative Hypnotic Anxiolytics
Benzodiazepine Sedative Hypnotic Anxiolytics
Benzodiazepine Sedative Hypnotic Anxiolytics
Benzodiazepine Sedative Hypnotic Anxiolytics
Benzodiazepine Sedative Hypnotic Anxiolytics
Atypical Anxiolytic/Nonbarbituate Anxiolytic
A nurse is caring for a client who states, " I am so stressed at work because of my coworker. He expects me to finish all of his work!" When discussing appropriate communication, which of the following statements indicates client understanding?
D. When I have to pick up extra work I feel overwhelmed. I need to focus on my own responsibilites."
General Adaptation syndrome
body's response to an increased demand created by stressors
Stage 1 Alarm Reaction
body's initial adaptive response to a stressor. Also known as fight or flight. elevated BP, heart rate, increased epinephrine and norepinephrine
Stage 2 Resistance Stage
body function normalizes while responding to stressor
Stage 3 Exhaustion stage
body functions are no longer able to maintain an adaptive response to the stressor
A nurse is discussing acute vs. prolonged stress with a client. Which of the following should the nurse identify as an acute stress response?
A. Decreased appetite. B. Depressed immune system C. Increased BP E. Unhappiness
major depressive disorder that is not responsive to medications, actively suicidal or homicidal, psychotic manifestations
ECT and Bipolar
used with rapid cycling of four or more episodes of acute mania within a year
Recent MI, history of CVA, lesion on brain, increased ICP
Meds and ECT
any meds that decrease seizure threshold must be discontinues, MAOI's and lithium stopped 2 weeks before ECT
given 30 minutes prior to decrease secretions and counteract vagal stimulation
ECT expected findings
Memory loss, nausea, tachycardia
Vagus nerve stimulation
Voice changes, dysphagia, neck pain
induces seizure activity, which increases neurotransmitters in the brain
stop MAOI's and lithium 2 weeks before, stop any meds that decrease seizure threshold several days, admin atropine or glycopyrrolate, establish IV access
bite guard, intubation, cardiac monitoring, place cuff on leg to monitor distal seizure activity, monitor vitals and seizure activity
restless, increased motivation, irritability
agitation, muscle tightness
can't function, ritualistic behavior, unresponsive,
distorted perception, loss of rational thought, immobility
Generalized anxiety disorder
exhibits uncontrollable, excessive worry for more than 3 months
Obsessive compulsive disorder
intrusive thoughts of unrealistic obsessions and tries to control these thoughts with compulsive behaviors
Acute stress disorder
exposed to traumatic event causes numbing, detachment, and amnesia for atleast 3 days but for not more than 1 month
exposed to trauma that causes intense fear, horror, flashbacks, detachment, foreboding, restricted affect for longer than a month after even
more likely to occur in women
has equal prevalence in men and women
attacks usually last 15 to 30 minutes, palpitations, shortness of breath, choking or smothering, chest pain, nausea, depersonalization, fear of dying
fear of embarrassment, unable to perform in front of others, has a dread of social situations, believes others are judging him
client avoids being outside and has impaired ability to work
client is afraid of snakes, spiders, strangers, flying, being in the dark,
Manifestations of GAD
restlessness, muscle tension, avoiding stressful events, increased time and effort required to prepare for stressful event, procrastination in decision making, seeks repeated reassurance
Onset of Acute stress disorder
begin immediately following the trauma persist for atleast 3 days lasting for a month
indications of increased arousal such as irritability, difficulty concentrating, sleep problems, avoiding anything associated with the trauma
exposes clients to increasing levels of an anxiety producing stimulus
Major depressive disorder
depressed mood, sleeping problems, indecisiveness, decreased ability to concentrate, suicidal ideation, increase or decrease in motor activity, inability to feel pleasure, increase or decrease in weight over 1 month
MDD with psychotic features
presence of auditory hallucinations
begins within 4 weeks of childbirth, may include delusions which may put the baby at high risk of being hurt by the mom
occurs during winter and may be treated with light therapy
milder form of depression usually has early onset, such as in childhood or adolescent and last at least 2 years in length for adults and 1 year for kids. contains atleast 3 of the clinical findings of depression
Premenstrual dysphoric disorder
depressive disorder associated with the luteal phase, emotional lability, severe anger, irritability, lack of energy, overeating and hard time concentrating
severe clinical findings, treatment is 6 to 12 weeks long, hospitalized, assess suicide risk
Continuation of MDD
increased ability to function, treatment is 4 to 9 months, relapse prevention through education, medication therapy, and psychotherapy
remission of manifestations, this phase may last for years, prevent future depressive episodes
Depression and dementia
memory loss, confusion, behavior issues, social isolation, agitation
Make observations, don't ask questions
communication in depression
do not discontinue, several weeks to notice effects, avoid hazardous activities, notify provider if any thoughts of suicide, avoid alcohol
change positions slowly, increase fluid intake to 2 to 3 L per day
hypertensive crisis avoid tyramine
avocados, figs, smoked meats, liver, fish, most cheeses, some beers and wine, protein dietary supplements
observe for headache, dry mouth, GI, constipation, increased heart rate, monitor food intake for appetite suppression, avoid in clients with seizures
adverse effects include nausea, weight gain, and sexual dysfunction
St Johns Wort
adverse effects include photo sensitivity, skin rash, rapid heart rate, GI distress, ABD pain, fatal serotonin syndrome, avoid tyramine foods
Acute bipolar phase
Acute mania, hospitalization may be required, reduction of mania and safety, risk of harm to self determined
remission of clinical manifestations, treatment generally 4 to 9 months, relapse prevention
treatment continues through lifetime, prevention is the goal
abnormally elevated mood, expansive or irritable, usuallly requires hospitalization
less severe than mania, last atleast 4 days
a manic episode and an episode of depression experienced at the same time
should not be used in clients with sleep apnea, respiratory depression, and glaucoma
hallucinations, diaphoresis, and agitation
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