Psych Exam 1,
Terms in this set (82)
While assessing your patient, Simon, a 63-year-old man in the psychiatric unit with a diagnosis of generalized anxiety disorder, he asks you, "Can you tell me why my family thinks that I am just acting sick to get attention?" Drawing from your knowledge of the impact of mental illness on families, which of the following would you include in your discussion to help Simon see his illness as a real illness? (Select all that apply.)
A. Mental health is fundamental to health.
B. Mental disorders are real health conditions that have an immense impact on individuals and families.
C. The efficacy of mental health treatment is well documented.
D. A range of treatments exists for most mental disorders.
¬ Pleasure seeking principle
¬ Reflex action
¬ Primary process
¬ Problem solver
¬ Reality tester
¬ Sense of self
¬ Defense mech
¬ Moral component
Levels of Awareness
¬ Conscious-current awareness
¬ Preconscious- hiding emotions that can easily be accessed
¬ Unconscious- primitive feelings, trauma experiences
¬ Develop anxiety.
¬ Operate on an unconscious level.
¬ Deny, falsify, or distort reality to make it less threatening.
Freud's Psychoanalytic Theory
Experiences during the early stages of life determine an individual's lifetime adjustment patterns and personality traits.
Over connection with a caregiver as the caregiver resembles a familiar person
Redirect and be firm
Explicitly explain the inappropriate behaviors
Provider is responsible for the connection to pt
ID and remove self
Sullivan's Interpersonal Theory
The purpose of all behavior is to get needs met through interpersonal interactions and to decrease or avoid anxiety.
Therapists ("participant observers") actively guide and challenge maladaptive behaviours and distorted views.
Pavlov's classical conditioning
¬ Bells and dogs
¬ Involuntary behaviors are conditioned to respond to a stim
¬ Personality can be mal and healthy
¬ All behaviors are learned
Skinner's operant conditioning
Voluntary behaviors are learned thro reinforcement
¬ ID behavior good vs bad
¬ Fixing bad
¬ Promoting relaxation first
¬ Slow increasing exposure
¬ Good for phobias
Results from anxiety
exposing a substance that react with bad behavior causing a unpleasant reaction
Learn physiological responses by using relaxation techniques
¬ Exposing client while with therapist to concur phobia stimuli
Humanism and Maslow's Hierarchy of Needs
(e.g., air, water, food)
(e.g., esteem needs)
Maslow's Theory and Nursing
Emphasizes human potential and the patient's strengths.
Prioritizes nursing actions in the nurse-client relationship.
Carl Rogers' Person-Centered Therapy
People have innate self-actualizing tendencies.
¬ Emphasis on self-awareness
¬ Emphasis on the present
Therapist as Facilitator
¬ Congruence (genuineness)
Rational-Emotive- Behavior Therapy (Ellis)
¬ Aims to eradicate irrational beliefs
¬ Recognizes thoughts that are not accurate
Cognitive-Behavioral Therapy (Beck)
¬ Tests distorted beliefs and changes way of thinking.
Biological Theories and Nursing
Consider other influences that play a role in the development and treatment of mental disorders.
¬ Social, environmental, cultural, and economic
Focus on the qualities of a therapeutic relationship.
Apply the newest findings of the biological model in nursing practice.
How do the body and brain interact to create the following?
Piaget: Cognitive Development-
¬ Progression from primitive awareness to complex thought
Stages of Cognitive Development
¬ Sensorimotor (birth to 2 years): Object permanence
¬ Preoperational (2 to 7 years): Language; egocentric thinking
¬ Concrete operational (7 to 11 years): Conservation, logic, abstract problem solving; patterns; reversibility
¬ Formal operational (11 to adult): Conceptual reasoning; problem solving like an adult
Erikson's Eight Stages of Development
Trust vs. Mistrust
Autonomy vs. Shame/Doubt
Initiative vs. Guilt
Industry vs. Inferiority
Adolescent Identity vs. Role Confusion
Young Adult Intimacy vs. Isolation
Middle-Age Adult Generativity vs. Stagnation
Older Adult Integrity vs. Despair
Erikson's Theory and Nursing
Developmental model is an important part of nursing assessment.
Helps determine what types of interventions are most likely to be effective
The Art of Nursing
¬ Provide care, compassion, and advocacy.
¬ Enhance comfort and well-being.
The Science of Nursing
¬ Apply knowledge to:
¥ Understand the broad range of human problems and psychosocial phenomena.
Intervene in relieving patients' suffering, and promote growth
Influence of Theories and Therapies on Nursing Care
Behavioral: Promoting adaptive behaviors through reinforcement
Cognitive: Helping patients identify negative thought patterns
Psychosocial development: Providing structure for understanding critical junctures in development
Hierarchy of needs: Prioritizing nursing care
Meeting Face-to-Face over Time for a Common Purpose
Keys to Efficacy:
¬ Size 6-10 ppl
¬ Give termination info in beginning
¬ Setting: private and comfortable
¥ Not classroom type
¬ Group content (dialogue)
¬ Group process
¥ Nonverbal comms
¬ Group development (growth)
¬ Group dynamics
¬ Group leadership style: autocratic, democratic, or laissez-faire
Tuckman's Five Group Stages
¬ Forming, storming, norming, performing, and adjourning (mourning)
To reduce dysfunctional behaviour
To resolve or reduce intra-family conflicts
To mobilize family resources
To encourage adaptive family problem solving
To improve family communication skills
To heighten awareness and sensitivity to others' emotional needs
To help family members meet their needs
To strengthen the family's ability to cope with major stressors and traumatic events
To improve integration of the family system into the societal system
Which theory is most likely to help the nurse respond appropriately to the needs of an aging patient experiencing frustration after a stroke?
C. Psychosocial development
D. Hierarchy of needs
C. *Psychosocial development
D. Hierarchy of needs
Mental status exams
To be performed on all those with psych issues
a. Excessive or reduced movements
c. Eye contact
5. Affect/ Mood
a. Flight of ideas
7. Perceptual disturbances
i. Misinterpretation of stimuli
b. Short v long
d. Abstract thought
e. Insight to dx
¥ Voluntary admission
¥ Sought by patient or guardian- write application
¥ Voluntarily consents to hospitalization
¥ Can request release
Must have MD evaluation prior to release
¥ Involuntary admission - without patient's consent 302
¥ Cannot meet basic needs
¥ Judicial- police/jury -need 2 MDs
¥ Involuntary outpatient admission
The police brought a homeless patient with a long history of mental illness and arrests for vagrancy to a state psychiatric hospital after the patient attempted suicide while in jail. To determine the need for involuntary admission, the nursing assessment should focus on the...
1. Patient's degree of social support in the community
2. Patient's risk for self-inflicted injury
3. Records from previous hospitalizations.
1. Accuracy of the current police report
1. Answer: Patient's risk for self-injury
Involuntary Commitment "In Harm's Way"
¥ Criteria for commitment:
¥ Danger to oneself or others
¥ Unable to provide for basic needs
¥ Mentally ill
¥ Suicidal ideation
¥ "Command" Voices
Involuntary Commitment: EMERGENCY:
¥ For acutely ill patients; used to control an immediate threat to self/others
¥ Length of Stay (LOS) varies according to state law
¥ Commitment paperwork must be initiated upon admission
¥ Patient must have a probable cause hearing to continue hospitalization - timeframe varies per state law
Involuntary Commitment: Civil or Judicial
¥ Can be longer term (months)
¥ Patient has the right to an attorney
¥ Legal basis for this lies in the parens patriae power of the state to protect and care for ill individuals and the police power of the state to protect the community from harm
¥ Mandatory outpatient treatment legislation in 35 states to prevent constant re-admissions to acute care facilities
¥ Informed Consent
¥ Must be competent
¥ Must have a Tx program; not just need for custodial care
¥ Least restrictive environment*
¥ Can refuse treatment
¥ Involuntary or Voluntary commitment patients can refuse treatment
¥ Rights must be maintained unless incompetent or "in harm's way"- ie medicating if pt is suicidal or homicidal
Right to Refuse Treatment
¥ Voluntary and involuntary patients can refuse medication, threats can't be used
¥ In emergency situations, if potential danger is present, patients can be medicated against their will; protocols must be followed with specific documentation
¥ ECT (Electroconvulsive Therapy)
¥ Requires informed consent
¥ State laws vary regarding refusal
¥ Behavioral restraint and seclusion are authorized as interventions if:
¥ Behavior is physically harmful to the patient or another party
¥ Alternative, less-restrictive measures are insufficient in protecting the patient and others from harm
¥ Decrease in sensory overstimulation is needed (seclusion only).
¥ Patient requests seclusion
¥ Document q2 and ROM - indlucing bathroom
¥ Assess q20-30 min
¥ Use of seclusion and restraint is permitted only under the following circumstances:
¥ Written order of a physician
¥ Confined to specific, time-limited periods (e.g., 1 to 4 hours)
¥ Patient's condition is reviewed and documented regularly (e.g., every 15 minutes).
¥ Legal and patients' rights are suspended when a client is hospitalized involuntarily.
¥ Not sure
¥ A client plans to have electroconvulsive therapy (ECT). Which member of the team is responsible for obtaining the client's informed consent?
¥ Case manager
¥ Registered nurse
¥ A nurse was the case manager for a client with serious mental illness for 6 years. The client died by suicide 1 week ago. Today, the client's spouse asks, "I always wondered if my spouse was a victim of sexual abuse in childhood. What can you tell me about that?" Can the nurse disclose information to the surviving spouse?
¥ Not sure
¥ Which individual with mental illness may need involuntary hospitalization?
¥ A person with alcoholism who has been sober for 6 months but begins drinking again
¥ An individual with schizophrenia who stops taking prescribed antipsychotic drugs
¥ An individual with bipolar disorder, manic phase, who has not eaten in 4 days
¥ Someone who repeatedly phones a national TV broadcasting service with news tips
no nomming! (hasn't eaten)
¥ A patient says, "My disability check will arrive next week, and I plan to give half of it to Praise Be Ministries." The nurse knows this action will result in the patient being unable to buy groceries by the end of the month.
¥ Select the nurse's best response.
¥ a. "It's your legal right to donate your money according to
¥ what you think is important."
¥ b. "Let's discuss how much you could donate and still be able to buy your groceries."
¥ c. "Why do you want to donate so much money to that organization?"
¥ d. "Let's talk to the social worker about appointing a guardian to manage your money."
"Let's discuss how much you could donate and still be able to buy your groceries.
¥ A hospitalized patient diagnosed with major depression tells the nurse, "I need my belt to keep my pants up. They keep falling down." Which response should the nurse provide?
¥ "Your belt is locked in the business office for safekeeping, along with all your other valuables."
¥ "For safety reasons, hospitalized clients are not allowed to keep certain personal possessions."
¥ "I cannot provide your belt, but I will help you get some pants with an elastic waistband."
¥ "I will ask the psychiatric technician to get your belt for you."
"I cannot provide your belt, but I will help you get some pants with an elastic waistband."
¥ 1996: Mental Health Parity Law
¥ Problematic coverage for mental illnesses:
¥ - Annual and lifetime caps
¥ All states must provide:
¥ - Inpatient care, primary care physician services, treatment for those younger than age 21 years of age
¥ What will/would you observe/experience working with in-patient unit psychiatric nurses?
¥ Admission assessment
¥ Physical health assessment
¥ Therapeutic groups
¥ Medication management
¥ Psychiatric emergencies
¥ Medical emergencies
¥ Preparation for discharge to community
¥ Managing behavioral crises
¥ Safety! Examples....
¥ Manage - Suicide risk or potential physical acting out
¥ Provides structure and predictability
¥ Patients are active participants
When individuals feel stressed out, they may have trouble:
Experience headache or back pain
Lose interest in favorite activities
Feel tense and become irritable
Assess s/s and how are they coping
Chemical changes occur resulting in symptoms
¥ and influenza
¥ Stomach ulcers
¥ Eczema and other skin disorders
¥ Heart disease
Eliciting the relaxation response
Social supports (e.g., close family ties, acquaintances, spouses, friends)
For more on selected stress reduction techniques, refer to 123 Box 10-1 in the textbook.
Posttraumatic Stress Disorder (PTSD)
Usually occurs after a traumatic event outside the range of usual human experience.
HPA system is abnormal.
Major depression frequently occurs.
If left untreated or undertreated, painful repercussions can result.
Posttraumatic Stress Disorder
Examples of Traumatic Events
Childhood physical abuse, torture, or kidnapping; military combat; sexual assault; natural disasters; human disasters
Crime-related events: terror attacks, assault, mugging, rape, incest, taken hostage
Diagnosis of a life-threatening illness
The common element in these experiences (traumatic events) is extraordinary
Memories of event
Avoidance of stimuli associated with trauma
Persistent negative alterations in mood and cognition: guilt; detachment
Persistent symptoms of increased arousal (angry outbursts, self-destructive behavior, startling, sleep difficulties)
Assess for triggers
Assess for flashbacks
Teach stress reduction tech
Redirect not argue
Stay very calm and do not escalate anxiety
Traumatic Brain Injury
Besides PTSD, the military estimates that up to 19%-20% of our combat veterans in both Afghanistan and Iraq suffer some degree of traumatic brain injury (TBI).
TBI is also found in people involved in contact sports, accidents, and falls, and in patients diagnosed with shaken baby syndrome and Alzheimer dementia.
Psychotherapeutic Treatment Strategies
Critical Incident Debriefing
Debriefing—valuable in ameliorating symptoms of acute stress response
Benzodiazepines—to treat daytime anxiety
Sedative hypnotics—for sleep
Medications—short-term, in conjunction with crisis intervention and other psychologic treatments
Self-Care for Nurses
Jon, an emergency department (ED) nurse, has just worked an 8-hour shift in the ED. After a five-car wreck during his midshift, five patients have been transported to the hospital with multiple injuries and one fatality. Jon looks exhausted, and his hands are tremulous. He insists that he is scheduled to work another 6 hours. As the nurse manager, what is your best action?
A. Tell him that he needs to end his shift right away.
B. Tell him he needs to nap for 30 minutes and then return to work.
C. Tell him to go to the cafeteria, relax, and drink strong coffee.
D. Tell him to eat a high carbohydrate snack, take a 30-minute break, and then return to work.
A. Your role as nurse manager of patient care includes deciding who is safe to work, and Jon is not safe.
Discuss how health care workers are vulnerable to compassion stress and compassion fatigue and describe the steps.
Compassion fatigue: Same as secondary stress trauma.
Cumulative physical, emotional, and psychologic effect of working closely with those suffering from the consequences of heart-wrenching/traumatic events.
"Compassion stress," when not managed properly, can lead to compassion fatigue.
Behaviors: isolation, depression, self-medication.
Prevention: Practice self-care.
Acute Stress Disorder
Witnessing or experiencing a violent or gruesome death of or by an intimate
Repeated exposure to aversive details of the event
¬ Example: First responders who collect body parts, or police officers repeatedly exposed to details of child abuse
¬ Occurs immediately after trauma and lasts a month
Acute Stress Disorder (Cont.)
Intrusive symptoms- distressing thoughts
Dissociative symptoms - detachment, numbness
Avoidance symptoms- avoid triggers
Arousal symptoms- physical symptoms
By definition, acute stress disorder resolves within 1 month.
Compare and contrast the differences between posttraumatic stress disorder (PTSD) and acute Stress disorder (ASD).
Similarity: Same triggers (violent events or repeatedly witnessing violent or traumatic events); same or similar manifestations.
Difference: Only acute stress disorder (ASD) resolves within 1 month
Andrew, a hospice nurse for 5 years and a member of your nursing team, is demonstrating a blunted affect and is not completing patient care documentation in the required time frame. As a peer, what is your best action?
Avoid mentioning these observations because you are only a peer.
B. Ask Andrew what he feels is causing him to fall behind in his work.
C. Immediately report your concerns to the nurse manager in charge of your team.
D. Take Andrew to lunch and keep the conversation light and humorous.
*B. Developing a trusting relationship with peers and being honest allows for openness and promotes beneficial dialog.
Assess triggers, safety, MSE, gather data
Anxiety is main problem with PTSD- altered thought process
ASD- aggression, headaches, anxiety
Expected outcomes- manage and reduce anxiety, effective coping
Let them know typical reaction to trauma
Reorient to reality
Help pt make connections with s/s and trauma
Teach replacing with positive thoughts
ID repressed feelings
No false reassurance
Do not exculpate- stay calm
Seven-stage model of crisis intervention helps in acute situational crisis and acute stress disorder.
Which statement about crisis theory provides a basis for nursing intervention?
A. A crisis is an acute, time-limited phenomenon experienced as an overwhelming emotional reaction to a problem perceived as unsolvable.
B. A person in crisis usually has had adjustment problems and has inadequately coped in his or her usual life situations.
C. Crisis is precipitated by an event that enhances the person's self-concept and self-esteem.
D. Nursing intervention in crisis situations rarely has the effect of ameliorating the crisis.
. A crisis is an acute, time-limited phenomenon experienced as an overwhelming emotional reaction to a problem perceived as unsolvable.
1. Every age group has own crisis- when new level is achieved
2. Not anticipated
5. Critical life issues
1. Adventitious (disasters)
Separation of those who need rapid medical care from those with more minor injuries
Rescue, evacuate, meet physiological needs, safety
Phases of Crisis
Phase 1: Person confronted by conflict that threatens self-concept responds with increased anxiety.
Phase 2: If the usual defensive response fails and if threat persists, then anxiety escalates. Trial-and-error begins.
Phase 3: If the trial-and-error attempts fail, then anxiety can escalate to severe and panic levels.
Intervene by this point!
Phase 4: If the problem is not solved and new coping skills are ineffective, then anxiety can overwhelm the person and lead to serious illness; assess for suicidal thoughts.
Ms. T., a single mother of four, comes to the crisis center 24 hours after an apartment fire in which all the family's household goods and clothing were lost. Ms. T. has no family in the area. Her efforts to mobilize assistance have been disorganized, and she is still without shelter. She is distraught and confused. The nurse assesses the situation as which of the following types of crisis?
B. Situational crisis
Assessment and Interventions: Crisis
Assess for suicidal and homicidal ideation or plans.
Make the patient feel safe, and lower the anxiety.
Maintain directive and creative approaches.
Assess the patient's support systems.
Identify the needed social supports and rally them.
Identify the needed coping skills.
Plan acceptable interventions (to patient and nurse).
Schedule regular follow-up to assess progress.
Sample questions that may facilitate the assessment include the following:
Has anything particularly upsetting happened to you within the past few days or weeks?
What was happening in your life before you started to feel this way?
What leads you to seek help now?
Describe how you are feeling right now.
How does this situation affect your life?
How do you see this event as affecting your future?
With whom do you live?
To whom do you talk when you feel overwhelmed?
Whom can you trust?
Who is available to help you? Do you have a partner or significant other?
Do you have spiritual beliefs or attend a place of worship?
Do you attend school or any activities, groups, or clubs?
During difficult times in the past, who was there to help you?
In crisis situations, evaluating the person's level of anxiety is important.
Have you thought of killing yourself or someone else?
If yes, have you thought about how you would do this?
What do you usually do to feel better?
Did you try it this time? If so, what was different?
What helped you through difficult times in the past?
What do you think might happen now?
Foundations of Crisis Intervention
A crisis is self-limiting and is usually resolved within 4 to 6 weeks.
The goal of crisis intervention is to return the individual to the pre-crisis level of functioning.
The resolution of a crisis results in the achievement of one of three different functional levels. The person will emerge at one of the following levels:
Levels of Nursing Care in Crisis Intervention
Primary care promotes mental health and reduces mental illness to decrease the incidence of crisis.
Secondary care establishes the intervention during an acute crisis to prevent prolonged anxiety from diminishing personal effectiveness and personality organization.
Tertiary care provides support for those who have experienced a severe crisis and are now recovering from a disabling mental state.
Critical Incident Stress Debriefing
For a nurse working in crisis intervention, which belief would be least helpful?
A. A person in crisis is incapable of making his or her own decisions.
B. The crisis counseling relationship is one between partners.
C. Crisis counseling helps the patient refocus to gain new perspectives on the situation.
D. Anxiety reduction techniques are used to enable the patient's inner resources to be accessed.
A. A person in crisis is incapable of making his or her own decisions.