Chapter 1-15 questions Mental health
Terms in this set (100)
1. In which scenario is it most urgent for the nurse to act as a patient advocate?
a. An adult cries and experiences anxiety after a near-miss automobile accident on the way to work.
b. A homeless adult diagnosed with schizophrenia lives in a community expecting a category 5 hurricane.
c. A 14-year-old girl's grades decline because she consistently focuses on her appearance and social networking.
d. A parent allows the prescription to lapse for 1 day for their 8-year-old child's medication for attention-deficit/attention-deficit/ hyperactivity disorder.
While all of the scenarios present opportunities for a nurse to intervene, the correct response presents an imminent danger to the patient's safety and well-being.
2.The nurse interacts with a veteran of World War II. The veteran says, "Veterans of modern wars whine and complain all the time. Back when I was in service, you kept your feelings to yourself." Select the nurse's best response.
a. "American society in the 1940s expected World War II soldiers to be strong."
b. "World War II was fought in a traditional way but the enemy is more difficult to identify in today's wars."
c. "We now have a better understanding of how trauma affects people and the importance of research-based, compassionate care." d. "Intermittent explosive devices (IEDs), which were not in use during World War II, produce traumatic brain injuries that must be treated."
Trauma occurs in many forms, including physical, sexual, and emotional abuse; war; natural disasters; and other harmful experiences. Trauma-informed care provides guidelines for integrating an understanding of how trauma affects patients into clinical programming.
4.The nurse prepares outcomes to the plan of care for an adult diagnosed with mental illness. Which strategy recognizes the current focus of treatment services for this population?
a. The patient's diagnoses are confirmed using advanced neuroimaging techniques.
b. The nurse confers with the treatment team to verify the patient's most significant disability.
c. The nurse prioritizes the patient's problems in accordance with Maslow's hierarchy of needs.
d. The patient and family participate actively in establishing priorities and selecting interventions.
The correct response recognizes the recovery model, which has the following tenets: Mental health care is consumer and family driven, with patients being partners in all aspects of care; care must focus on increasing the consumer's success in coping with life's challenges and building resilience; and an individualized care plan is at the core of consumer-centered recovery.
5.Which scenario best demonstrates empathetic caring?
a. A nurse provides comfort to a colleague after an error of medication administration.
b. A nurse works a fourth extra shift in 1 week to maintain adequate unit staffing.
c. A nurse identifies a violation of confidentiality and makes a report to an agency's privacy officer.
d. A nurse conscientiously reads current literature to stay aware of new evidence-based practices.
Caring is evidenced by empathic understanding, actions, and patience on another's behalf; actions, words, and presence that lead to happiness and touch the heart; and giving of self while preserving the importance of self. Comforting is a part of caring, which includes social, emotional, physical, and spiritual support.
Key points Chapter 1
Practicing the Science and the Art of Psychiatric Nursing
• Nursing integrates both scientific knowledge and caring arts into a holistic practice.
• Evidence-based practice (EBP) is a process by which the best available research evidence, clinical expertise, and patient preferences are synthesized while making clinical decisions.
• The 5 A's process of integrating best evidence into clinical practice includes (1) asking, (2) acquiring, (3) appraising, (4) applying, and (5) assessing.
• Application of the recovery model assists people with psychiatric disabilities to effectively manage symptoms, reduce psychosocial disability, and find a meaningful life in a community of their choosing.
• Trauma-informed care recognizes that various traumas contribute to mental illness and substance abuse. Awareness of trauma can assist health care providers in giving appropriate care and avoiding retraumatization of patients.
• Some sources for obtaining research findings are (1) Internet resources, (2) clinical practice guidelines, (3) clinical algorithms, and (4) clinical/ critical pathways. • Three specific areas are inherent within the art of nursing: (1) caring, (2) attending, and (3) patient advocacy.
3.A patient reports to a primary care provider about sleeplessness, constant fatigue, and sadness. In our current health care climate, what is the most likely treatment approach that will be offered to the patient?
a. Group therapy
b. Individual psychotherapy
c. Complementary therapy
d. Psychopharmacological treatment
The patient's report suggests that depression is occurring. With the increased understanding of the biology of psychiatric illnesses, treatment approaches have evolved rapidly into more scientifically grounded methods, particularly psychopharmacology.
KEY POINTS CHAPTER 2:
MENTAL HEALTH AND MENTAL ILLNESS
Mental illness can be difficult to define. The DSM-5 and cultural norms must be considered in evaluating mental health and illness. There are many myths surrounding mental illness, which contribute to stigmatization of individuals. The stereotyping, discrimination, and rejection accompanying stigma contribute to poor self-image, isolation, and mental anguish. Stigma erects barriers to obtaining employment, housing, and health services. Nurses can use sensitivity and compassion to bridge the shame patients feel and encourage them to seek care.
• Mental health can be conceptualized along a continuum, from mild to moderate to severe to a profound degree of impairment in functioning. • There are various components and influences that contribute to mental health, which are identified in Figure 2-1.
• The study of epidemiology can help identify high-risk groups and behaviors and lead to enhanced understanding of causes and best treatment. Prevalence rates help us identify the proportion of a population with a mental disorder at a given time.
• With the current knowledge that many common mental disorders are biologically based, they are now recognized as medical diseases.
• Nursing diagnoses help to systematically target symptoms patients may experience.
• The way symptoms are expressed may reflect a person's
1. A mentally ill gunman opens fire in a crowded movie theater, killing six people and injuring others. Which comment about this event by a member of the community most clearly shows the stigma of mental illness?
a. "Gun control laws are inadequate in our country."
b. "It's frightening to feel that it is not safe to go to a movie theater."
c. "All these people with mental illness are violent and should be locked up."
d. "These events happen because American families no longer go to church together."
Stigma refers to the array of negative attitudes and beliefs regarding mental illness. Bias, prejudice, fear, and misinformation contribute to stigma.
The nurse presents a class about mental health and mental illness to a group of fourth graders. One student asks, "Why do people get mentally ill?" Select the nurse's best response.
a. "There are many reasons why mental illness occurs."
b. "The cause of mental illness is complicated and very hard to understand."
c. "Sometimes a person's brain does not work correctly because something bad happens or they inherit a brain problem."
d. "Most mental illnesses result from genetically transmitted abnormalities in cerebral structure; however, some are a consequence of traumatic life experiences."
In the correct response, the nurse answers rather than evades the question, provides accurate information, and uses terminology a 9- or 10-year-old child can understand. Many of the most prevalent and disabling mental disorders have been found to have strong biological influences, including genetic transmission.
3. An adult experienced a spinal cord injury resulting in quadriplegia 3 years ago and now lives permanently in a skilled care facility. Which comment by this person best demonstrates resiliency?
a. "I often pray for a miracle that will heal my paralysis so I will be whole again."
b. "I don't know what I did to deserve this fate or whether I am tough enough to endure it."
Resiliency is the ability to recover from or adjust successfully to trauma or change. A successful transition through a crisis builds resiliency for the next difficult trial. In the correct response, the person demonstrates acceptance of the paralysis and a focus on his or her abilities and assets.
A nursing assistant says to the nurse, "The schizophrenic in room 226 has been rambling all day." When considering the nurse's responsibility to manage the ancillary staff, which response should the nurse provide?
a. "It is more respectful to refer to the patient by name than by diagnosis."
b. "Thank you for informing me about that. I will document the behavior."
c. "It is not unusual for schizophrenics to do that. It's just part of their illness."
d. "You have a difficult job. I'm glad you are so accepting of our patients' behaviors."
Diagnoses classify disorders that people have, not the person. For this reason, it is important to avoid use of expressions such as "a schizophrenic" or "an alcoholic." The nurse has a responsibility to educate the coworker.
5. Which scenario meets the criteria for "normal" behavior?
a. An 8-year-old child's only verbalization is "No no no."
b. A 16-year-old girl usually sleeps for 3 or 4 hours per night.
c. A 43-year-old man cries privately for 1 month after the death of his wife.
d. A 64-year-old woman has difficulty remembering the names of her grandchildren.
Many biological, cultural, and environmental factors influence mental health. Persons who are normal also may experience dysfunction during their lives. The death of a spouse is a difficult experience, so crying is expected.
Which institution specific clinical practice resource will the nurse use to integrate evidence-based practice (EBP) into the care of a client hospitalized for the purpose of the evaluation of his or her current therapy plan?
1.Researching current medication options using Internet resources
2.Reviewing decision points for therapy planning provided by clinical practice guidelines
3.Using a clinical algorithm in the form of a decision tree to review treatment approaches
4.Implementing a clinical pathway to provide expected outcomes using a measurable format
In order to demonstrate the integration of evidence-based practice (EBP) into the care of a client who has been hospitalized for severe depression and prescribed a selective serotonin reuptake inhibitor (SSRI), the novice nurse will include which action into the plan of care?
1.Assess the client for the presence of suicidal ideations with a plausible plan
2.Ask the health provider to prescribe the medication to be administered orally
3.Acquire the advice of a proficient nurse about implementing suicide precautions
4.Apply restraints when the client repeatedly attempts to cut his or her wrists with a plastic knife
Which statement by the nurse best demonstrates a dilemma associated with the utilization of evidence-based practice (EBP) in the mental health clinical setting?
"The client can't afford the cost of the medication he's being prescribed."
"The client doesn't see the benefit of changing to this new form of therapy."
"I really hated that the in-service on that new therapy modality was filled up."
"It's hard to review the literature about this new treatment when we are so short staffed."
The decision to intervene as a patient advocate is clearly identified by the American Nurses Association's (ANA) code of ethics in which situation?
1.A client's need for assistance while ambulating post-surgery
2.A suspicion that a staff member is unfit to provide client care
3.Working with a client to identify triggers for aggressive behavior
4. Providing emotional support to a client experiencing a loss of a parent
Considering the administration of medications, the nurse applying evidence-based nursing practice will engage in which nursing activity?
1.Educating the client regarding the side effects of a newly prescribed antidepressant
2.Confirming the client's identity prior to administering a prescribed PRN medication
3.Determining the client's preference about when a medication prescribed once daily is administered
4.Assessing the client for allergies prior to the administration of a newly prescribed mood stabilizing medication
Which client statement supports the nurse's assessment that the client has demonstrated resiliency?
"Losing a parent is a natural part of life."
"I know I'm not the first person to lose a loved one."
"I've learned from experiencing other losses that I'll be okay."
"Losing my mother is the hardest thing I've ever experienced."
"I've learned from experiencing other losses that I'll be okay."
When considering prevalence, the nurse will focus on which disorder(s) when identifying the focus of a community mental health screening?
1. Anxiety disorders
2. Affective disorders
3. Any substance abuse
The nurse, striving to minimize the bias of a Western view on what is considered acceptable behavior, will consult which mental health associated resource?
-Cultural Formulation Interview (CFI)
-The client's past and present mental health assessment
-Glossary of Cultural Concepts of Distress
-The Diagnostic and Statistical Manual of Mental Disorders
Cultural Formulation Interview (CFI)
The nurse recognizes that the greatest barrier to successful mental health treatment and recovery is demonstrated by which client?
The teenager who fears being rejected by his peers
The young homeless adult who cannot keep clinic appointments
The elderly Syrian immigrant who speaks only minimal English
The middle-aged adult who cannot afford prescription medication
The teenager who fears being rejected by his peers
Which question will the nurse ask in order to assess a client's ability to think clearly?
"Are you employed full time?"
Do you feel guilty about your recent divorce?"
How do you plan to afford getting your own apartment?"
What do you think is your most valuable personal characteristic?"
How do you plan to afford getting your own apartment?"
CHAPTER 3 KEY POINTS
THEORIES AND THERAPIES
• Theoretical models and therapeutic strategies provide a useful framework for the delivery of psychiatric nursing care.
• The psychoanalytic model is based on unconscious motivations and the dynamic interplay between the primitive brain (id), the sense of self (ego), and the conscience (superego). The focus of psychoanalytic theory is on understanding the unconscious mind.
• The interpersonal model maintains that the personality and disorders are created by social forces and interpersonal experiences. Interpersonal therapy aims to provide positive and repairing interpersonal experiences.
• The behavioral model suggests that because behavior is learned, behavioral therapy should improve behavior through rewards and reinforcement of adaptive behavior.
• The humanist model is based on human potential, and therapy is aimed at maximizing this potential. Maslow developed a theory of personality that is based on the hierarchical satisfaction of needs. Rogers's person-centered theory uses self-actualizing tendencies to promote growth and healing.
• The cognitive model posits that disorders, especially depression, are the result of faulty thinking. Cognitive behavioral therapy is empirically supported and focuses on the recognition of distorted thinking and the replacement with more accurate and positive thoughts.
• The biological model is currently the dominant model and focuses on physical causation for personality problems and psychiatric disorders. Medication is the primary biological therapy.
• A variety of nursing theories are useful to psychiatric nursing. Hildegard Peplau developed an important interpersonal theory for the provision of psychiatric nursing care.
• Group therapy offers the patient significant interpersonal feedback from multiple people.
• Groups transition through predictable stages, benefit from therapeutic factors, and are characterized by members filling specific roles.
• Family therapy is based on various theoretical models and aims to decrease emotional reactivity among family members and encourage differentiation among individual family members.
1. A nurse plans a group meeting for adult patients in a therapeutic milieu. Which topic should the nurse include?
a. Coping with grief and loss
b. The importance of hand washing
c. Strategies for money management
d. Staffing shortages expected over the next 3 days
A therapeutic milieu provides a healthy social structure within an inpatient setting or structured outpatient clinic. Groups aim to help increase patients' self-esteem, decrease social isolation, encourage appropriate social behaviors, and educate patients in basic living skills, such as good hand washing.
2. Considering Maslow's pyramid, which comment indicates an individual is motivated by the highest level of need?
a. "Even though I'm 40 years old, I have returned to college so I can get a better job."
b. "I help my community by volunteering at a thrift shop that raises money for the poor."
c. "I recently applied for public assistance in order to feed my family, but I hope it's not forever."
d. "My children tell me I'm a good parent. I feel happy being part of a family that appreciates me."
Maslow's hierarchy of needs are placed conceptually on a pyramid, with the most basic and important needs on the lower level. The higher levels, the more distinctly human needs, occupy the top sections of the pyramid. When lower-level needs are met, higher-level needs are able to emerge. Self-actualization and esthetics are the highest-level needs.
3. Which patient is likely to achieve maximum benefit from cognitive behavioral therapy (CBT)?
a. Older adult diagnosed with stage 3 Alzheimer's disease
b. Adult diagnosed with schizophrenia and experiencing delusions
c. Adult experiencing feelings of failure after losing the fourth job in 2 years
d. School-age child diagnosed with attention-deficit/ hyperactivity disorder (ADHD)
The goal of cognitive behavioral therapy (CBT) is to identify the negative patterns of thought that lead to negative emotions. Once the maladaptive patterns are identified, they can be replaced with rational thoughts. A person must be able to engage in meaningful dialogue to benefit from CBT.
4. An adult plans to attend an upcoming tenth high school reunion. This person says to the nurse, "I am embarrassed to go. I will not look as good as my classmates. I haven't been successful in my career." Which comment by the nurse addresses this cognitive distortion?
a. "You look fine to me. Do think you will have fun at your reunion?"
b. "Everyone ages. Other classmates have had more problems than you."
c. "Do you think you are the only person who has aged and faced difficulties in life?"
d. "I think you are doing well in the face of the numerous problems you have endured."
Rapid, unthinking responses are known as automatic thoughts. Often these automatic thoughts, or cognitive distortions, are irrational because people make false assumptions and misinterpretations. Once the negative patterns of thought that lead to negative emotions are identified, they can be replaced with rational thoughts.
5. A distraught 8-year-old girl tells the nurse, "I had a horrible nightmare and was so scared. I tried to get in bed with my parents but they said, 'No.' I think I could have gone back to sleep if I had been with them." Which family dynamic is likely the basis of this child's comment?
a. Boundaries in the family are rigid.
b. The family has poor differentiation of roles.
c. The girl is enmeshed in part of a family triangle
. d. Generational boundaries in the family are diffuse.
Rigid or disengaged boundaries are those in which the rules and roles are followed despite the consequences.
A patient is diagnosed with an abscess in the cerebellum. Which nursing diagnosis has priority for the plan of care?
a. Risk for falls related to loss of balance and equilibrium
b. Unilateral neglect related to impairments to perception
c. Impaired physical mobility related to spasticity and changes in muscle tone
d. Risk for impaired cerebral tissue perfusion related to obstruction secondary to infection
The cerebellum is critical in both motor and cognitive functions. Alterations in cerebello-thalamo-cortical circuits may manifest as disturbances of coordination, balance, and gait. Safety is the nurse's first concern.
2. A patient begins a new prescription for risperidone (Risperdal). Which intervention should the nurse include in the plan of care?
a. Monitor intake and output daily.
b. Educate patient about foods that contain tyramines.
c. Assess sitting, standing, and lying blood pressure daily.
d. Administer with food to reduce gastrointestinal irritation.
Risperidone blocks α1- and H1 receptors. It can cause orthostatic hypotension and sedation, which can lead to falls.
3. Systematic measurement of body weight, body mass index (BMI), waist circumference, and glucose levels would be most important for a patient beginning a new prescription for which medication?
a. Aripiprazole (Abilify)
b. Olanzapine (Zyprexa)
c. Ziprasidone (Geodon)
d. Quetiapine (Seroquel)
Olanzapine (Zyprexa) has metabolic side effects, particularly weight gain. Metabolic monitoring for all patients receiving atypicals is recommended, although risperidone (Risperdal) and quetiapine (Seroquel) have a lower weight gain. Ziprasidone (Geodon) and aripiprazole (Abilify) are considered weight neutral. Metabolic monitoring usually includes measurements of body weight,
body mass index (BMI), waist circumference, fasting plasma glucose level, and fasting lipid profile.
4. A patient tells the community mental health nurse, "I told my health care provider I was having trouble sleeping and he prescribed trazodone 50 mg every night. I read on the internet that drug is an antidepressant, but I'm not depressed. What should I do?" Which response by the nurse is correct?
a. "I will help you contact your health care provider for clarification regarding this new prescription."
b. "Insomnia and depression usually go hand-in-hand. If your depression is relieved, your sleep will improve."
c. "In low doses, trazodone helps relieve insomnia. Higher doses are needed for antidepressant effects to occur."
d. "Information on the internet is often misleading and incorrect. It's more important to trust the judgment of your health care provider."
At lower doses, trazodone loses its antidepressant action while retaining hypnotic effects through histamine receptor antagonism; therefore it is useful for insomnia. Fifty milligrams is a low dose. High doses of trazodone are required for the serotonergic action to relieve depression.
5. Which patient would the nurse expect to have the most difficulty with problem solving and decision making?
a. An 18-year-old diagnosed with bulimia nervosa at age 14; has taken oral doses of fluoxetine (Prozac) daily for 3 years
b. A 46-year-old diagnosed with schizophrenia at age 24; has taken oral doses of clozapine (Clozaril) daily for 18 years
c. A 62-year-old diagnosed with bipolar disorder at age 28; has taken oral divalproex sodium (Depakote) daily for 16 years
d. A 52-year-old diagnosed with schizophrenia at age 21; has taken monthly injections of haloperidol (haldol decanoate) for 12 years
Executive functions occur in the cerebrum. Loss of cortical tissue has been associated with schizophrenia as well as with treatment involving haloperidol and other typical antipsychotics. In contrast, newer atypical antipsychotics and antidepressants have been found to increase brain volume and structural synaptic/ neuronal plasticity.
KEY POINTS CHAPTER 4 : BIOLOGICAL BASIS FOR UNDERSTANDING PSYCHOPHARMACOLOGY
All actions of the brain— sensory, motor, intellectual— are carried out through the interactions of nerve cells involving impulse conduction, transmitter release, and receptor response. Alterations in these basic processes can lead to mental disturbances and physical manifestations.
• In particular, it seems that excess activity of dopamine, among other factors, is involved in the thought disturbances of schizophrenia, and deficiencies of norepinephrine, serotonin, or both underlie depression and anxiety. Insufficient activity of GABA also plays a role in anxiety.
• Pharmacological treatment of mental disturbances is directed at the suspected transmitter-receptor problem. Antipsychotic drugs decrease dopamine levels, antidepressant drugs increase synaptic levels of norepinephrine and/ or serotonin, and antianxiety drugs increase the effectiveness of GABA or increase 5-HT and/ or norepinephrine levels.
• Because the immediate target activity of a drug can result in many downstream alterations in neuronal activity, drugs with a variety of chemical actions may show efficacy in treating the same clinical condition. Thus, newer drugs with novel mechanisms of action are being used in the treatment of schizophrenia, depression, and anxiety.
• Unfortunately, agents used to treat mental disease can cause various undesired effects. Prominent among these can be sedation or excitement, motor disturbances, muscarinic blockage, α-adrenergic antagonism, sexual dysfunction, and weight gain. There is a continuing
CHAPTER 5 KEY POINTS: SETTINGS FOR PSYCHIATRIC CARE
• Compared to seeking care for physical disorders, finding care for psychiatric disorders can be complicated by a two-tiered system of care provided in the private and public sectors.
• Nonspecialist primary care providers treat a significant portion of psychiatric disorders.
• Psychiatric care providers are specialists who are licensed to prescribe medication and conduct therapy. They include psychiatrists, advanced practice psychiatric nurses, physicians' assistants, and, in some states, psychologists.
• Community mental health centers are state-regulated and state-funded facilities that are staffed by a variety of mental health care professionals.
• Other outpatient settings include psychiatric home care, intensive outpatient programs, and partial hospitalization programs.
• Inpatient care is used when less restrictive outpatient options are insufficient in dealing with symptoms. It can be provided in general medical centers, private psychiatric centers, crisis units, and state hospitals.
• Nurses provide the basis for inpatient care and are part of the overall unit milieu that emphasizes the role of the total environment in providing support and treatment.
• Specific populations such as children, veterans, geriatrics, and forensics benefit from treatment geared to their unique needs.
• Financing psychiatric care has been complicated by lack of parity, or equal payment for physical as compared to psychiatric disorders. Legislation has been proposed and passed to improve mental health parity.
1. A patient diagnosed with major depressive disorder tells the community mental health nurse, "I usually spend all day watching television. If there's nothing good to watch, I just sleep or think about my problems." What is the nurse's best action?
a. Refer the patient for counseling with a recreational therapist.
b. Ask the patient, "What kinds of program do you like to watch?"
c. Suggest to the patient, "Are there some friends you could call instead?"
d. Advise the patient, "Watching television and thinking about problems makes depression worse."
answer : A
5-1). The patient's comments indicate problems with use of leisure time. Recreational activities improve emotional, physical, cognitive, and social well-being. A recreational therapist is the best member of the treatment team to provide these services.
2. The nurse admits a patient experiencing hallucinations and delusional thinking to an inpatient mental health unit. The plan of care will require which service occurs first?
a. Social history
b. Psychiatric history
c. Medical assessment
. Psychological evaluation
Begins with a medical assessment to rule out or consider co-occurring/ comorbid conditions.
3. A nurse working in an acute care unit for adolescents diagnosed with mental illness says, "Our patients have so much energy. We need some physical activities for them." In recognition of needs for safety and exercise, which activity could the treatment team approve?
a. Badminton tournament
b. Competitive soccer matches
c. Intramural basketball games
d. Line dancing to popular music
Safety is a key consideration in selection of activities. The correct response identifies an activity likely to appeal to the population but without physical contact between patients or equipment, which may be associated with injury. 4. Answer
4. As Election Day nears, a mental health nurse studies the position statements of various candidates for federal offices. Which candidate's commentary would the nurse interpret as supportive of services for persons diagnosed with mental illness?
a. "Full parity insurance coverage for mental illness"
b. "Coverage for biologically based mental illnesses"
c. "Reimbursement for initial treatment of addictions"
d. "Managed care oversight for mental illness services"
Mental health parity refers to third-party (insurance) coverage of care for mental illness and addictions similarly to care of physical illness. Federal and state legislation apply, but coverage varies by state. Some states offer full parity for mental illness insurance coverage.
5. An experienced nurse in a major medical center requests a transfer from a general medical unit to an acute care psychiatric unit. Which organizational feature would best support this nurse's successful transition?
a. Assignment to medication administration for the first 6 months
b. Working with a seasoned mental health technician for the first month
c. Co-assignment with a knowledgeable psychiatric nurse for an extended orientation
d. Staff development activities focused on developing therapeutic communication skills
The nurse's skills from the medical unit will be valuable, but this nurse will need to expand his or her skill set to effectively care for a psychiatric population. Working with an experienced psychiatric nurse will provide opportunities for learning.
1. A nurse's sibling happily says, "I want to introduce you to my fiancé. We're getting married in six months." The nurse has encountered the fiancé in a clinical setting and is aware of the fiancé's diagnosis of schizophrenia. What is the nurse's best response? a. In private, tell the sibling about the fiancé's diagnosis. b. Encourage the sibling to postpone the wedding for at least a year. c. Ask the fiancé, "Have you told my sibling about your mental illness?" d. Say to the sibling and fiancé, "I hope you will be very happy together."
Varcarolis, Elizabeth M.. Essentials of Psychiatric Mental Health Nursing - E-Book: A Communication Approach to Evidence-Based Care (p. 72). Elsevier Health Sciences. Kindle Edition.
The patient's thyroid problems may have reemerged and can mimic depression.
2. A patient has been disruptive to the therapeutic milieu for two days. A certified nursing assistant says to the nurse, "We need to seclude this patient because this behavior is upsetting everyone on the unit." Considering patients' rights, the nurse should respond,
a. "Seclusion is not part of this patient's plan of care."
b. "Let's think of some new ways to help this patient be less disruptive."
c. "Thank you for that suggestion. I will discuss it with the health care provider."
d. "Disruptive behavior is expected with mental illness. We must respond therapeutically."
The focus of the question is the caregiver. Demands associated with the care of three elderly persons who live at a distance have the potential of overwhelming the caregiver. Because there is no evidence of role strain, a risk diagnosis is formulated.
3. A day shift nurse contacts a nurse scheduled for night shift at home and says, "Ourunit is full and there are eight patients in the emergency department waiting for a bed." The night shift nurse replies, "Thanks for telling me. I am calling in sick." Which type of problem is evident by the night shift nurse's reply?
a. Ethical problem of fidelity
b. Legal problem of negligence
c. Legal problem of an intentional tort
d. Violation of the patients' right to treatment
Fidelity is an ethical principle that involves maintaining loyalty and commitment to patients
4. In a staff meeting at an inpatient mental health facility for persons, the administrator announces that psychiatric technicians will now be supervised by the milieu director rather than by nurses. What is the nurse's best action?
a. Confer with colleagues about their opinions regarding the proposed change.
b. Volunteer to participate on a committee charged with defining job responsibilities of unlicensed assistive personnel.
c. Ask the administrator to delay implementation of this change until the decision can be reviewed by an interdisciplinary team.
d. Advise the administrator of regulations in the state nurse practice act regarding supervision of unlicensed assistive personnel.
Institutional policies and practices do not absolve an individual nurse of responsibility to practice on the basis of professional standards of nursing care. State nurse practice acts specify that unlicensed assistive personnel (UAP) work under a nurse's supervision.
5. A colleague tells the nurse, "I have not been able to sleep for the past three days. I feel like a robot." What is the nurse's best action?
a. Direct the colleague to leave the facility immediately.
b. Observe the colleague closely for evidence of impaired practice.
c. Offer to administer medications to patients assigned to the colleague.
d. Confer with the supervisor about the nurse's ability to safely deliver care.
Sleep deprivation causes impaired practice, which jeopardizes patient safety. The colleague's comments indicate that impairment is likely. The nurse should confer with the supervisor to determine the appropriate action.
CHAPTER 6 KEY POINTS:
LEGAL AND ETHICAL BASIS
• States' power to enact laws for public health and safety and for the care of those unable to care for themselves often pits the rights of society against the rights of the individual.
• Psychiatric nurses frequently encounter problems requiring ethical choices. • The nurse's privilege to practice nursing carries with it the responsibility to practice safely, competently, and in a manner consistent with state and federal laws
. • Knowledge of the law, the ANA's Code of Ethics for Nurses with Interpretive Statements, and the ANA's standards of care from Psychiatric- Mental Health Nursing: Scope and Standards of Practice is essential to provide safe, effective psychiatric nursing care and will serve as a framework for decision making when the nurse is presented with complex problems involving competing interests.
CHAPTER 7 KEYPOINTS
NURSING PROCESS AND QSEN
• The nursing process is a six-step problem-solving approach to patient care to help secure safety and quality care for patients.
• The Institute of Medicine (IOM) and QSEN faculty have established mandates to prepare future nurses with the knowledge, skills, and attitudes (KSAs) necessary for achieving quality and safety as they engage in the six competencies of nursing: patient-centered care, teamwork and collaboration, evidence-based practice (EBP), quality improvement (QI), safety, and informatics.
• The primary source of assessment is the patient. Secondary sources of information include the family, neighbors, friends, police, and other members of the health team.
• The assessment interview includes gathering objective data (mental or emotional status) and subjective data (psychosocial assessment). A number of tools are provided in this textbook for the evaluation of cultural, spiritual/ religious, and mental status.
• Medical examination, history, and systems review complete a comprehensive assessment.
• An important part of planning patient-centered care is to understand how spiritual/ religious beliefs play a part in a person's life and how they deal with stress.
• Caregivers should also have an awareness of the person's cultural background and social attachments, and how these issues affect the way a person experiences healing in his or her culture.
• Assessment tools and standardized rating scales may be used to evaluate and monitor a patient's progress. Emphasis needs to be placed on further evaluation of progress and sharing of this information with other members of the health care team.
• Self-assessment is an important part of the assessment process. There are a number of ways that novice interviewers can gain valuable feedback, support, and supervision.
• Determination of the nursing diagnosis (NANDA-I) defines the practice of nursing, improves communication between staff members, and assists in accountability for care.
• A nursing diagnosis consists of (1) an unmet need or problem, (2) an etiology or probable cause, and (3) supporting data.
• Outcomes are variable, measurable, and stated in terms that reflect a patient's actual state. NOC provides 330 standardized outcomes. Planning involves determining desired outcomes.
• Behavioral goals support outcomes. Short- and long-term outcomes are measurable, indicate the desired patient behavior( s), include a set time for achievement, and are short and specific.
• Planning nursing actions (NIC or other sources) to achieve the stated outcomes include the use of the following specific principles: the plan should be (1) safe, (2) evidence based whenever possible, (3) realistic, and (4) compatible with other therapies. NIC provides nurses with standardized nursing interventions that areapplicable for use in all settings
• Practice in psychiatric nursing encompasses basic-level interventions: coordination of care; health teaching and health promotion; milieu therapy; and pharmacological, biological, and integrative therapies.
• Advanced practice interventions are carried out by a nurse who is educated at the master's level or higher. Nurses certified for advanced practice psychiatric mental health nursing may be additionally prepared to practice psychotherapy, prescribe certain medications, and perform consulting work.
• The evaluation of care is a continual process of determining to what extent the outcome criteria have been achieved. The plan of care may be revised on the basis of the evaluation.
• Documentation of patient progress through evaluation of outcome criteria is crucial. The patient's record is a legal document and should accurately reflect the patient's condition, medications, treatment, tests, responses, and any untoward incidents.
• Simply documenting a patient's noncompliance/ nonadherence to medical treatment no longer protects nurses, doctors, other health care professionals, and/ or institutions from lawsuits when further harm to the patient presents itself. Careful documentation of what has been done to help the individual understand the instructions, understand the reasons behind the medical advice, and follow-up on compliance issues should be included.
1. A nurse assesses a new patient whose chief concern is "daily crying spells." Which comment from the patient would prompt the nurse to suspect a medical reason is causing the problem rather than depression?
a. "I usually drink two or three cups of coffee in the morning."
b. "I often have headaches, especially when the pollen count is high."
c. "Years ago I had thyroid problems but they cleared up and I stopped the medicine."
d. "I recently had three moles removed because my doctor thought they were suspicious."
The patient's thyroid problems may have reemerged and can mimic depression.
2. A 55-year-old lives 100 miles from her parents and mother-in-law. In the past year, her father had back surgery, her mother broke her hip, and her mother-in-law had a cardiac event. Which nursing diagnosis is most applicable to the 55-year-old?
a. Risk for complicated grieving related to impending deaths of parents
b. Risk for injury related to frequent long drives to care for aging parents
c. Risk for chronic low self-esteem related to overwhelming responsibilities
d. Risk for caregiver role strain related to responsibilities for care of aging parents
The focus of the question is the caregiver. Demands associated with the care of three elderly persons who live at a distance have the potential of overwhelming the caregiver. Because there is no evidence of role strain, a risk diagnosis is formulated.
3. A patient asks the psychiatric mental health registered nurse, "I'm having so much anxiety. I think hypnosis would help me. Will you do that for me?" When determining a response, which factor should the nurse consider? a. The patient's current medication regime b. State regulations regarding scope of practice c. The patient's level of participation within the therapeutic milieu d. The plan of care the multidisciplinary team has developed for the patient
Varcarolis, Elizabeth M.. Essentials of Psychiatric Mental Health Nursing - E-Book: A Communication Approach to Evidence-Based Care (p. 90). Elsevier Health Sciences. Kindle Edition.
Hypnosis is not within the scope of practice of a staff level registered nurse. The state nurse practice act details regulations regarding scope of practice. Hypnosis is an advanced practice intervention
4. The nurse plans care for a newly hospitalized patient experiencing panic level anxiety after an automobile accident. The patient has no physical injuries. When selecting goals from the Nursing Outcomes Classification (NOC), the nurse will
a. Select outcomes related to patient learning.
b. Focus first on the long-term goals for the patient.
c. Individualize outcomes based on the patient's needs.
d. confer with the patient about which outcomes the patient wants to achieve
Outcomes, as well as interventions, must always be individualized to the patient and should reflect the patient's multidimensional needs. While it is important to confer with the patient about which outcomes are desirable, a patient experiencing panic is unable to engage in decision making or learning activities
5. On an inpatient unit, one patient assaults another patient resulting in a small laceration. Considering the patients' right to confidentiality, how will the nurse effectively document this event?
a. Ensure unit safety by documenting the hostile and combative characteristics of the assaulting patient.
b. Document in each patient's medical record the events and actions taken, using initials of other patients involved.
c. Document in both patients' medical records that an occurrence (incident) report was prepared according to agency policy.
d. Verbally report the events to other team members and minimize written documentation in order to reduce potential legal consequences.
It is important to document the events and actions taken in both patients' records; however, confidentiality must be maintained. Using the initials of patients involved is one way to ensure that confidentiality is maintained.
CHAPTER 8 KEY POINTS:
• Knowledge of communication and interviewing techniques is the foundation for development of any patient-centered partnership. Goal-directed professional communication is referred to as therapeutic communication.
• Communication is a complex process. Berlo's communication model has five parts: stimulus, sender, message, medium, and receiver. Feedback is a vital component of the communication process for validating the accuracy of the sender's message.
• Effective/ therapeutic communication in nursing points to "increased recovery rates, a sense of safety and protection, improved levels of patient satisfaction, and greater adherence to treatment options" (Neese, 2015). Poor communication skills (non-therapeutic) were responsible for 80% of 440,000 medical deaths in the United States in 2013.
• A number of factors can minimize or enhance the communication process. For example, differences in culture, language, and knowledge levels; noise; lack of privacy; the presence of others; and expectations can all influence communication.
• There are verbal and nonverbal elements in communication; the nonverbal elements often play the larger role in conveying a person's message. Verbal communication consists of all words a person speaks. Nonverbal communication consists of the behaviors displayed by an individual, in addition to the actual content of speech.
• Communication has two levels: the content level (verbal) and the process level (nonverbal behavior). When content is congruent with process, the communication is said to be healthy. When the verbal message is not reinforced by the communicator's actions, the message is ambiguous; we call this a double-bind (or mixed) message.
• Cultural background (as well as individual differences) has a great deal to do with what nonverbal behavior means to different individuals. The degree of eye contact and the use of touch are two nonverbal aspects that can be misunderstood by individuals of different cultures.
• There are a number of communication techniques that nurses can use to enhance their nursing practices. Many widely used communication enhancers are cited in Table 8-2.
• There are also a number of nontherapeutic techniques that nurses can learn to avoid to enhance their effectiveness with people. Some are cited in Table 8-3 along with suggestions for more helpful responses.
• Most nurses are most effective when they use nonthreatening and open-ended communication techniques. • Effective communication is a skill that develops over time and is integral to the establishment and maintenance of a therapeutic alliance.
• The application of information communication technologies in the psychosocial sciences is relatively new, but it is viewed as an invaluable tool for helping people with mental health and issues in behavioral health and medicine. It is particularly well suited for individuals in rural areas and for those to whom assessing health care/ mental health clinics is not possible either physically or financially. The emergence of apps for those with anxiety, depression, and other mental health issues (e.g., posttraumatic stress disorder, bipolar, etc.) can provide greater accessibility to psychiatric care. The one caveat is that an app should be approved and well accepted within the mental health community
1. An adult experiencing a recent exacerbation of ulcerative colitis tells the nurse, "I had an accident while I was at the grocery store. It was so embarrassing." Select the nurse's therapeutic response.
a. "Most grocery stores have public restrooms available."
b. "Tell me more about how you felt when that happened."
c. "People usually have compassion about those types of events."
d. "Your disease is now in remission so that is not likely to happen again."
2. A nurse counsels a widow whose husband died 5 years ago. The widow says, "If I'd done more, he would still be alive." Select the nurse's therapeutic response.
a. "I understand how you feel after such a terrible loss."
b. "That was a long time ago. Now it's time to move on with your life."
c. "You did a very good job of caring for him, especially since he was sick so long."
d. "Your husband was 82 years old with severe chronic obstructive pulmonary disease."
3. A patient has been out of work 3 weeks with a major illness and anticipates another month of recovery. The patient tells the nurse, "I'm trying to keep up with my work email from home. They hired a new person in my department but the person has no experience." Select the nurse's therapeutic response.
a. "It sounds like you're saying you are worried about your job security."
b. "No one expects you to keep pace with your job while you're recovering."
c. "Your employer is required to hold your job for you while you're on sick leave."
d. "Don't worry about your job right now. It's more important for you to recover."
4. In which nurse-patient interaction would it be appropriate for the nurse to consider using touch?
a. Comforting a tearful patient of Japanese heritage
b. Counseling a child who was physically abused by a parent
c. Welcoming a person of Hispanic heritage to a new group session
d. Interacting with a Native American who has a hearing impairment
5. A nurse prepares a patient in a rural community for an initial telehealth visit with the health care provider. Select the nurse's priority action.
a. Ensure that the patient's rights to privacy are respected.
b. Ask the patient, "How much do you know about the Internet?"
c. Inform the patient, "This experience will be like appearing on television."
d. Advise the patient,
CHAPTER 9 KEY POINTS :
THERAPEUTIC RELATIONSHIPS AND THE CLINICAL INTERVIEW
• The nurse-patient relationship/ partnership is well defined, and the roles of the nurse and the patient must be clearly stated.
• It is important that the nurse be aware of the differences between a therapeutic relationship and a social or intimate relationship. In a therapeutic nurse-patient relationship, the focus is on the patient's needs, thoughts, feelings, and goals. The nurse is expected to meet personal needs outside this relationship in other professional, social, or intimate arenas.
• Genuineness, positive regard, and empathy are personal strengths in the helping person that foster growth and change in others.
• Although the boundaries of the nurse-patient relationship generally are clearly defined, they can become blurred; this blurring can be insidious and may occur on an unconscious level. Usually, transference and countertransference phenomena are operating when boundaries are blurred.
• It is important to have a grasp of common countertransferential feelings and behaviors and of the nursing actions to counteract these phenomena
. • Supervision aids in promoting the professional growth of the nurse as well as in the nurse-patient relationship, allowing the patient's goals to be addressed and met.
• The phases of the nurse-patient relationship include the orientation, working, and termination phases, which are in reality very fluid.
• The clinical interview is a key component of psychiatric mental health nursing. Presented are considerations needed for establishing a safe setting and planning for appropriate seating, introduction, and initiation of the interview.
• Attending behaviors (e.g., eye contact, body language, vocal qualities, and verbal tracking) are a key element in effective communication
Cultural background (as well as individual values and beliefs) has a great deal to do with what nonverbal behavior means to different individuals. The degree of eye contact and the use of touch are two nonverbal aspects that can be misunderstood by individuals of different cultures.
• A meaningful therapeutic relationship is facilitated when values and cultural influences are considered. It is the nurse's responsibility to seek to understand the patient's perceptions.
1. Which comment by the nurse would be appropriate to begin a new nurse-patient relationship?
a. "Which of your problems is most serious?"
b. "I want you to tell me about your problems."
c. "I'm an experienced nurse. You can trust me."
d. "What would you like to tell me about yourself?"
2. A neighbor telephones the nurse daily, giving lengthy details about multiple somatic complaints and relationship problems. Which limit-setting strategy should the nurse employ?
a. Suggest the neighbor call other people in the community.
b. Say to the neighbor, "I can talk to you for 15 minutes twice a week."
c. Use the telephone's caller identification to screen calls from the neighbor.
d. Tell the neighbor, "You should discuss these concerns with your personal physician rather than me."
3. A patient has been oppositional, demanding, and resistant to working on goals. A mental health nurse tells the nursing supervisor, "We finally had a serious talk. I let that patient know it's time to get right with God and stop this behavior." Recognizing the nurse's actions were not acceptable, select the supervisor's responding action.
a. Review the facility policies regarding patient's rights with the nurse.
b. Ask the nurse about documentation related to this patient interaction.
c. Schedule the nurse for a staff development activity on cultural sensitivity.
d. Work with the nurse to prepare and analyze a process recording of the interaction.
4. A nurse participating in a community health fair interviews an adult who has had no interaction with a health care professional for more than 10 years. The adult says, "I like to keep to myself. Crowds make me nervous." Which action should the nurse employ?
a. Refer the adult for a full health assessment.
b. Explore the adult's family and social relationships.
c. Ask the adult, "How do you feel about the quality of your life?"
d. Explain to the adult, "We can help you feel better about yourself."
5. A group of nurses privately discuss patients under their care. Which nurse's comment indicates the need for clinical supervision regarding countertransference?
a. "My patient is always asking my permission to do something, just like a child."
b. "When our unit is understaffed, it seems like we have more incidents of disruptive behavior."
c. "My patient tries to tell me what to do all the time. I got a divorce because my spouse used to do that."
d. "Our patients have had so many traumatic life experiences. I find myself feeling sympathetic sometimes."
CHAPTER 10 KEY POINTS
TRAUMA AND STRESS RELATED DISORDERS
• Some stress is useful in our lives; eustress is stress that makes us strive to reach our goals, repair important relationships, improve our work, and stimulate creative problem-solving processes and improve critical thinking.
• Stress is common in our lives, but when stress is prolonged and increased it may be experienced more as distress, which is a negative experience. When stress becomes chronic it can cause physiological harm and emotional difficulties.
When we are confronted with a serious stressor, our autonomic nervous system reacts with the fight-or-flight response. This response involves a complex network of nerve pathways, brain structures, and glands to help our bodies and mind deal with the stressor.
• The second part of the fight-or-flight response is caused by the hypothalamus-pituitary-adrenal (HPA) cortex, which activates the response.
• When the stress response is prolonged and becomes chronic, it can have damaging effects on the body by lowering the resistance of the immune system and contributing to both physical illness and mental trauma (e.g., depression, hopelessness, helplessness, increased sustained anxiety).
• Posttraumatic stress disorder (PTSD) usually occurs after a severe traumatic event (e.g., childhood abuse, torture/ kidnap, military combat, sexual assault, incest, natural disasters, and life-threatening illness). It is estimated that up to 20% of our combat veterans returning from combat have PTSD.
• If PTSD is not treated, serious consequences often result, including severe depression, alcohol/ substance abuse, suicide, inability to trust, and social and occupational disruptions, as well as a host of mentally damaging symptoms and/ or disorders.
• The major symptoms of PTSD and acute stress disorder have been addressed in this chapter.
• Pharmacological and therapeutic interventions that have proven successful with PTSD have been identified.
• Nurses, physicians, and first responders are cautioned to be alert for secondary traumatic stress and practice self-care since they also can be at risk for compassion fatigue/ posttraumatic stress disorder if not properly managed
. • Symptoms a health care worker might experience are included in this chapter. Health care workers who might be vulnerable to compassion fatigue stress/ compassion fatigue/ PTSD have been identified; however, this is not an exclusive list.
1. A mature, professional couple plans a large wedding in a city 100 miles from their home. Which response is most likely to be associated with this experience?
c. Acute stress
2. A college student has been experiencing significant stress associated with academic demands. Last month, the student began attending yoga sessions three times a week. Which outcome indicates this activity has been successful?
a. The student reports improved feelings of well-being
. b. The student increases use of caffeine to enhance concentration.
c. The student reports, "Now I am sleeping about 10 hours every day."
d. The student says, "I withdrew from two courses to reduce my academic load.
" 3. An adult required a heart transplant 5 years ago. Multiple medical complications followed, resulting in persistent irritability, depression, and insomnia. The adult's spouse says, "I've walked on eggshells for five years, never knowing when something else will go wrong." What is the nurse's priority intervention regarding the spouse?
a. Explore the spouse's feelings, showing care and compassion.
b. Encourage the spouse to attend a community support group.
c. Teach stress reduction and relaxation techniques to the spouse.
d. Refer the spouse to the primary care provider for health assessment.
4. A veteran of the war in Afghanistan tells the nurse, "Everyday, something happens that makes me feel like I'm still there. My family has grown impatient with me. They say it's time for me to move on from that time in my life but I can't." What is the nurse's first priority?
a. Assess the veteran for suicide risk.
b. Refer the veteran for specialized mental health services.
c. Assess the veteran for evidence of traumatic brain injury.
d. Refer the veteran's family to a posttraumatic stress disorder group.
5. An individual lives in a community adjacent to a military base. Loud jets fly overhead multiple times daily. The person tells the nurse, "They're so loud I can't hear myself think." What is the nurse's best first action?
a. Direct the individual to report the jet noise to local authorities.
b. Teach relaxation and stress reduction techniques to the individual
. c. Assess the individual for sensory impairments, particularly auditory
. d. Encourage the individual to form a community action group to oppose noise pollution. References
CHAPTER 11 KEY POINTS:
ANXIETY,ANXIETY DISORDERS,OCD, AND RELATED DISORDERS
• A simple explanation for the difference between anxiety and fear is that anxiety has an unknown or unrecognized source, whereas fear is a reaction to a specific threat.
• Anxiety can be normal, acute, or chronic, as well as adaptive or maladaptive. • Peplau operationally defined four levels of anxiety. The patient's perceptual field, ability to learn, and physical or other characteristics are different at each level (see Table 11-1).
• Effective psychosocial interventions are different for people experiencing mild to moderate levels of anxiety and for individuals experiencing severe to panic levels of anxiety. Effective psychosocial nursing approaches are suggested in Tables 11-2 and 11-3.
• Defenses against anxiety can be adaptive or maladaptive. Defenses are presented in a hierarchy from healthy to intermediate to immature. Table 11-4 provides examples of adaptive and maladaptive uses of many of the more common defense mechanisms.
• Anxiety disorders are the most common psychiatric disorders in the United States and frequently co-occur with major depression and/ or substance use disorders; OCD and BDD also have high rates of co-occurring with major depression
. • Research has identified genetic and biological factors in the etiology of anxiety disorders and OCD. • Psychological theories, cultural influences, and socioeconomic status also are pertinent to the understanding of anxiety disorders.
• Patients with anxiety disorders suffer from panic attacks, irrational fears, excessive worrying, uncontrollable rituals, or severe reactions to stress.
• People with anxiety disorders and hoarding disorder are often too embarrassed or ashamed to seek psychiatric help. People with anxiety disorders may consult their primary care providers about multiple somatic complaints. • One form of psychotherapy that is effective for treating anxiety disorders, OCD, and milder forms of BDD is cognitive behavioral therapy (CBT) in conjunction with medication. • Interventions include counseling, milieu therapy, promotion of self-care activities, psychobiological intervention, and health teaching
1. Friends invite an adult diagnosed with type 2 diabetes to go on a mountain hike next week. The adult replies, "I can't go because I don't have any hiking shoes." In actuality, this adult fears difficulty with blood glucose management during strenuous activity. Which defense mechanism is evident?
c. Passive aggression
d. Reaction formation
2. A nurse analyzes reports from four adult patients of frightening events they encountered. Which patient's report most clearly indicates that the resulting fear was mentally healthy?
a. "I saw a large spider crawling along my kitchen wall."
b. "I was at the mall when a gunman began firing an assault weapon."
c. "I was at home when a storm with heavy thunder and lightning lasted over an hour."
d. "I was trapped on an elevator that stopped between floors when the power went out."
3. A nursing student arrives late for a clinical experience and is not wearing the correct attire. When the instructor privately criticizes the behavior, the student responds, "I'm always the one who gets caught. You're going to cause me to fail." Select the instructor's best response.
a. "Other students get caught as well."
b. "I am not trying to cause you to fail. I am here to help you."
c. "I am sorry you feel that way. I try to treat all my students equally."
d. "The requirements for this experience were discussed during our orientation."
4. Select the best example of altruism.
a. After recovering from a gunshot wound, a police officer attends a local support group.
b. After recovering from open heart surgery, an individual plays tennis three times a week.
c. An individual who received a liver transplant volunteers at a local organ procurement agency.
d. An individual with a long-standing fear of animals volunteers at a community animal shelter.
5. An outpatient psychiatric nurse assesses a patient diagnosed with hoarding disorder. The patient has lost 12 pounds in the past two months, appears disheveled, and is wearing dirty clothing with poor hygiene. What is the nurse's priority action?
a. Review the patient's medication regimen.
b. Ask the patient, "What types of foods have you been eating?"
c. Refer the patient to a psychologist for cognitive behavioral therapy (CBT).
d. Schedule a home visit to assess the safety of the patient's living conditions.
CHAPTER 12 KEY POINTS:
SOMATIC SYMPTOM DISORDERS AND DISSOCIATIVE DISORDERS
• Somatic symptom disorders are characterized by the presence of multiple, real physical symptoms for which there is most often no evidence of medical illness.
• Dissociative disorders involve a disruption in consciousness with a significant impairment in memory, identity, or perceptions of self.
• Emergences of both somatic symptom disorders and dissociative symptoms are believed to be responses to extreme psychological stress, which may result in faulty coping patterns. • Patients with somatic symptom disorders and dissociative disorders often have a number of comorbid psychiatric illnesses, primarily depression, anxiety, substance abuse, and borderline personality disorder.
• A suicide assessment should be performed with any psychiatric patient. Somatic symptom disorders and related disorders and also dissociative disorder patients may be especially prone to self-harm behaviors.
• Because these patients may not seek psychiatric treatment, the nurse may often see these patients in a medical setting first.
• The nursing assessment is especially important to clarify the history and course of past symptoms, as well as to obtain a complete picture of the current physical and mental status.
• Although these patients do respond to crisis intervention, they usually require referral for long-term psychiatric treatment.
1. A patient at a general medical clinic tells the nurse, "I have so many ailments that I need to see six different doctors. None of them has discovered what is really wrong with me." Which comment should the nurse offer next?
a. "Let's review all the medications you currently take."
b. "Tell me about allergic reactions you've had to medication."
c. "Selecting one primary care provider would be better for you."
d. "I'm not sure I understand how you can afford these expenses."
2. A combat veteran from two tours of the war in Afghanistan tells the nurse, "Some guys in my unit have posttraumatic stress disorder, but I never had any problems other than my hearing is not as good as it once was." Which explanation for this comment should the nurse consider?
a. The veteran wants to demonstrate toughness and strength.
b. The veteran shows indicators of derealization and depersonalization.
c. The veteran may be rationalizing this reaction to memories of combat.
d. The veteran may have amnesia associated with the combat experience.
3. A patient diagnosed with dissociative identity disorder is hospitalized on an acute care psychiatric unit after a suicide attempt. During a team meeting, which staff nurse's comment should prompt the nursing supervisor to intervene?
a. "I have never taken care of a patient diagnosed with this disorder."
b. "I think this patient was misdiagnosed and probably has schizophrenia."
c. "I find myself more fascinated and
engaged with this patient than others."
d. "I recently read an autobiographical book about someone with this problem."
4. A nurse in an outpatient medical clinic talks to a patient with a long history of malingering and doctor-shopping. The patient continues to express complaints of multiple problems. Select the nurse's best comment to the patient.
a. "The treatment team believes you would benefit more from seeing a mental health professional."
b. "The treatment team discussed your case and wants to begin a special case management program for you."
c. "Because you take a number of medications, it would be safer to have them all filled at the same pharmacy."
d. "Diagnostic testing has shown no medical problems and you are using more than your fair share of health care services."
5. A patient in the emergency department was seen for the third time in a month with complaints of tremors and paresthesia in the lower extremities. Conversion disorder was diagnosed. While preparing for discharge, the patient says, "Now I'm having chest pain but it's probably nothing." How should the nurse respond?
a. Assess the patient's most current laboratory values.
b. Interrupt the discharge and arrange additional medical evaluation of the patient.
c. Remind the patient, "The diagnostic tests showed you did not have a medicalproblem."
d. Tell the patient, "Being in the emergency department a long time can be very distressing."
CHAPTER 13 KEY POINTS
• People with personality disorders (PDs) present with the most complex, difficult behavioral challenges for themselves and the people around them.
• People with PDs have inflexible and maladaptive ways of handling stress; demonstrate disabilities in both work and intimate relationships; evoke strong, intense personal conflict with those around them; and have difficulty managing impulses
. • PDs often co-occur with other mental health disorders (e.g., depression, substance use disorder, somatization, eating disorders, PTSD, anxiety disorders), other personality disorders, and general medical conditions.
• It is unlikely there is any single cause for any of the personality disorders— most seem to have genetic and environmental risk factors. • People with these disorders respond to stress (e.g., frustration, anger, loneliness) with more primitive defenses, resulting in outrageous behaviors unmodified by "normal" defenses.
• Needs are experienced as rage, and sexuality and dependency are confused with aggression.
• Self-assessment is an important part of assessment when working with a person with a PD. When personal feelings are not recognized or confronted, substantial interpersonal conflict will ensue.
• Determining if there is a history of suicide/ homicide/ self-mutilation, and if there are co-occurring disorders as well, is a vital part of the initial assessment interview. •
Nursing diagnoses are given and reflect the problematic behaviors of the PD at the time.
• Communication guidelines for manipulative and impulsive behaviors are outlined.
• Careful evaluation for antidepressants, anticonvulsants (for aggressive and impulsive behaviors), and antipsychotics (for stress-induced psychotic thinking) may offer the patient relief.
• Therapy has been used for patients with PDs; however, there is little evidence-based research comparing the efficacy of different therapies with different disorders, except for dialectical behavior therapy (DBT), which has been extremely effective in people with borderline PD.
1. A person shoplifts merchandise from a community cancer thrift shop. When confronted, the thief replies, "All this stuff was donated, so I can take it." This comment suggests features of which personality disorder?
2. After a power outage, a facility must serve a dinner of sandwiches and fruit to patients. Which comment is most likely from a patient diagnosed with a narcissistic personality disorder?
a. "These sandwiches are probably contaminated with bacteria."
b. "I suppose it's the best we can hope for under these circumstances.
" c. "You should have ordered a to-go meal from a local restaurant for me.
" d. "I would rather wait to eat until the dietary department can prepare a meal."
3. A nurse plans care for a patient diagnosed with borderline personality disorder. Which nursing diagnosis is most likely to apply to this patient?
a. Ineffective relationships related to frequent splitting
b. Social isolation related to fear of embarrassment or rejection
c. Ineffective impulse control related to violence as evidenced by cruelty to animals
d. Disturbed thought processes related to recurrent suspiciousness of people and situations
4. The nurse assesses a new patient suspected of having a schizotypal personalitydisorder. Which assessment question is this patient most likely to answer affirmatively?
a. "Do some types of situations frighten you?"
b. "Do you often have episodes of prolonged crying?"
c. "Is anyone in your family diagnosed with a mental illness?"
d. "Is it ever very important for you to do everything correctly?"
5. A mental health nurse assesses a patient diagnosed with an antisocial personality disorder. Which comorbid problem is most important for the nurse to include in the assessment? '
a. Generalized anxiety
b. Alcohol use and abuse
c. Compulsions and phobias
d. Dysfunctional sleep patterns
CHAPTER 14 KEYPOINTS
• A number of theoretical models help explain risk factors for the development of eating disorders. • Neurobiological theories identify an association between eating disorders, depression, and neuroendocrine abnormalities.
• Psychological theories explore issues of control in anorexia and affective instability and poor impulse control in bulimia, but these are not considered causes of eating disorders.
• Genetic theories postulate the existence of vulnerabilities that may predispose people toward eating disorders, and increasingly twin studies confirm genetic liability, which perhaps interacts with environmental mechanisms.
• Sociocultural models look both at our present societal ideal of being thin and at the ideal feminine role model in general.
• Families may serve as important allies in treatment.
• Eating disorders are now appearing in populations in which they had been rare. The dynamics— the stress of acculturation versus identification with the new culture— are being examined.
• Anorexia nervosa is a possibly life-threatening eating disorder that includes being severely underweight; having low blood pressure, pulse rate, and temperature measurements; being dehydrated; and having low serum potassium level and dysrhythmias. Anorexia may be treated in an inpatient treatment setting— in which milieu therapy, psychotherapy (cognitive), development of self-care skills, and psychobiological interventions can be implemented.
• Eating disorders, thought to occur only in preteen or teen-age groups, are now being diagnosed in people ages 35 to 65.
• Long-term treatment is provided on an outpatient basis and aims to help patients maintain healthy weight; it includes treatment modalities such as individual therapy, family therapy, group therapy, psychopharmacology, and nutrition counseling.
• Individuals with bulimia nervosa are typically within the normal weight range, but some may be slightly below or above ideal body weight.
• Assessment of a patient with bulimia may show enlargement of the parotid glands, dental erosion, and dental caries if the patient has induced vomiting.
• Acute care may be necessary when life-threatening complications are present, such as gastric rupture (rare), electrolyte imbalance, and cardiac dysrhythmias.
• The primary goal of interventions for a patient with bulimia is to interrupt the binge/ purge cycle. • Psychotherapy as well as self-care skill training is included.
• Long-term treatment focuses on therapy aimed at addressing any coexisting depression, substance abuse, and/ or personality disorders that are causing the patient distress and interfering with quality of life. Self-worth and interpersonal functioning eventually become issues that are useful to target.
Other specified feeding or eating disorder (OSFED), formerly eating disorder not otherwise specified (EDNOS) in DSM-IV, includes a variety of subthreshold patterns that do not meet full criteria as set forth in DSM-5.
• Binge eaters report a history of major depression significantly more often than non- binge eaters.
• Effective treatment for obese binge eaters integrates modification of the disordered eating, improvement of depressive symptoms, and achievement of an appropriate weight for the individual. Applying Critical Judgment
1. The school nurse assesses four adolescents, all of whom outwardly appear healthy. Which adolescent meets one criterion for anorexia nervosa with mild severity?
a. 5'2" tall; weight 104 pounds
b. 5'7" tall; weight 110 pounds
c. 5'5" tall; weight 114 pounds
d 5'8" tall; weight 127 pounds
2. A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa?
a. "I look good because whenever I overeat, I purge myself."
b. "I love sweets. I make myself throw up so I can eat more."
c. "I've lost 60 pounds but I'm still a size 2. I want to be a size 0."
d. "I've hidden my eating disorder from everyone, even my parents."
3. While weighing patients on an eating disorders unit, the nurse overhears a psychiatric technician say, "I wish I had an eating disorder; maybe I'd lose a little weight." What is the nurse's best action?
a. Report the clinical observation to the nursing supervisor.
b. Ask the psychiatric technician, "What did you mean by that comment?"
c. Privately discuss the importance of sensitivity with the psychiatric technician.
d. Immediately interrupt the interaction between the patient and psychiatric technician
4. Shortly after hospitalization, an adolescent diagnosed with anorexia nervosa says to the nurse, "Being fat is the worst thing in the world. I hope it never happens to me." Which response by the nurse is appropriate?
a. "You need to gain weight to become healthier."
b. "Your world would not change if you gained a few pounds."
c. "Tell me how your world would be different if you were fat."
d. "Your attractiveness is not defined by a number on the scales."
. 5. A patient is hospitalized with a diagnosis of anorexia nervosa. The nurse reviews the patient's laboratory results below. Sodium 143 mEq/ L Potassium 3.1 mEq/ L Chloride 102 mEq/ L Magnesium 2.2 mEq/ L Calcium 8.4 mg/ dL Phosphate 3.0 mg/ dL The nurse should take which action next?
a. Measure the patient's body temperature.
b. Inspect the patient's skin and sclera for jaundice.
c. Assess the patient's mucous membranes for erosion.
d. Auscultate the patient's heart rate, rhythm, and sounds.
CHAPTER 15 KEY POINTS:
• Depression is the most commonly seen psychiatric syndrome in the health care system.
• There are a number of subtypes of depression and depressive clinical phenomena. Two primary depressive disorders are major depressive disorder (MDD) and chronic depressive disorder (dysthymic disorder). Bipolar disorder is the third major depressive disorder and is covered in Chapter 16
. • The symptoms in MDD are usually severe enough to interfere with a person's social or occupational functioning (inability to experience pleasure [anhedonia], significant weight loss, insomnia or hypersomnia, extreme fatigue [anergia], psychomotor agitation or retardation, diminished ability to think or concentrate, feelings of worthlessness, recurrent thoughts of death).
• A person with MDD may or may not have psychotic symptoms, and the symptoms a person usually exhibits during a major depression are different from the characteristics of the normal premorbid personality.
• In persistent depressive disorder (PDD) the symptoms last for at least 2 years and are usually considered mild to moderate. Usually, a person's social or occupational functioning is not as greatly impaired as they are in MDD, although they may cause significant distress or some impairment in these areas. The symptoms in a chronic/ dysthymic depression (PDD) are often congruent with the person's usual pattern of functioning.
• Many theories exist about the cause of depression. The most accepted is the psychophysiological theory; however, cognitive theory, learned helplessness theory, and psychodynamic and life events issues help explain triggers to depression and maintenance of depressive thoughts and feelings. •
Nursing assessment includes the evaluation of affect, thought processes (especially suicidal thoughts), feelings, physical behavior, and communication. The nurse also needs to be aware of the symptoms that mask depression.
• Nursing diagnoses can be numerous. Depressed individuals are always evaluated for Risk for suicide. Some other common nursing diagnoses are Anxiety, Hopelessness, Impaired social interaction, Chronic low self-esteem, Imbalanced nutrition, Constipation, Disturbed sleep pattern,Ineffective coping, Spiritual distress, Disabled family coping, and others.
• Interventions with patients who are depressed involve several approaches, including using specific principles of communication, planning activities of daily living, administering or participating in psychopharmacological therapy, maintaining a therapeutic environment, and teaching patients about the biochemical aspects of depression and medication teaching.
• Several short-term psychotherapies are effective in the treatment of depression, including IPT, CBT, and some forms of group therapy.
• Electroconvulsive therapy (ECT) is an effective treatment for people with major depression with psychotic features and for patient's refractory to other treatments. Vagus nerve stimulation (VNS) can be a valuable adjunctive treatment in treatment-resistant depression. Light therapy is the first line of treatment for seasonal affective disorder.
• Evaluation is ongoing throughout the nursing process, and patients' outcomes are compared with the stated outcome criteria and short-term and intermediate goals. The care plan is revised by use of the evaluation process when desired outcomes are not being met.
1. A 28-year-old second-grade teacher is diagnosed with major depressive disorder. She grew up in Texas but moved to Alaska 10 years ago to separate from an abusive mother. Her father died by suicide when she was 12 years old. Which combination of factors in this scenario best demonstrates the stress-diathesis model?
a. Cold climate coupled with history of abuse
b. Current age of 28 coupled with family history of depression
c. Family history of mental illness coupled with history of abuse
d. Female gender coupled with the stressful profession of teaching
2. A patient tells the nurse, "No matter what I do, I feel like there's always a dark cloud following me." Select the nurse's initial action.
a. Assess the patient's current sleep and eating patterns.
b. Explain to the patient, "Everyone feels down from time to time."
c. Suggest alternative activities for times when the patient feels depressed.
d. Say to the patient, "Tell me more about what you mean by 'a dark cloud'."
3. A patient experiencing depression says to the nurse, "My health care provider said I need 'talk' therapy but I think I need a prescription for an antidepressant medication. What should I do?" Select the nurse's best response.
a. "Which antidepressant medication do you think would be helpful?"
b. "There are different types of talk therapy. Most patients find it beneficial."
c. "Let's consider some ways to address your concerns with your health care provider."
d. "Are you willing to give 'talk therapy' a try before starting an antidepressant medication?"
4. The nurse cares for a hospitalized adolescent diagnosed with major depressive disorder. The health care provider prescribes a low-dose antidepressant. In consideration of published warnings about use of antidepressant medications in younger patients, which action should the nurse employ?
a. Notify the facility's patient advocate about the new prescription.
b. Teach the adolescent about Black Box warnings associated with antidepressant medications.
c. Monitor the adolescent closely for evidence of adverse effects, particularly suicidal thinking or behavior.
d. Remind the health care provider about warnings associated with the use of antidepressants in children and adolescents.
5. Over the past 2 months a patient made eight suicide attempts with increasing lethality. The health care provider informs the patient and family that electroconvulsive therapy (ECT) is needed. The family whispers to the nurse, "Isn't this a dangerous treatment?" How should the nurse reply?
a. "Our facility has an excellent record of safety associated with use of electroconvulsive therapy."
b. "Your family member will eventually be successful with suicide if aggressive measures are not promptly taken."
c. "Yes, there are hazards with electroconvulsive therapy. You should discuss these concerns with the health care provider."
d. "Electroconvulsive therapy is very effective when urgent help is needed. Your family member was carefully evaluated for possible risks.
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