NSG 221 Exam 1 Blueprint

Mental Health Factors influencing a person's mental health can be categorized as individual, interpersonal, and social/cultural. Individual, or personal, factors include a person's biologic makeup, autonomy and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities. Interpersonal, or relationship, factors include effective communication, ability to help others, intimacy, and a balance of separateness and connectedness. Social/cultural, or environmental, factors include a sense of community, access to adequate resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive yet realistic view of one's world.

Click the card to flip 👆

1 / 121

Terms in this set (121)

...

Mental Health Factors influencing a person's mental health can be categorized as

individual, interpersonal, and social/cultural.

individuals or personal Factors influencing a person's mental health

person's biologic makeup, autonomy and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities.

Interpersonal, or relationship, Factors influencing a person's mental health

effective communication, ability to help others, intimacy, and a balance of separateness and connectedness.

Social/cultural, or environmental, Factors influencing a person's mental health

factors include a sense of community, access to adequate resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive yet realistic view of one's world

...

Factors contributing to mental illness can also be viewed within individual, interpersonal, and social/cultural categories. Individual factors include biologic makeup, intolerable or unrealistic worries or fears, inability to distinguish reality from fantasy, intolerance of life's uncertainties, a sense of disharmony in life, and a loss of meaning in one's life. Interpersonal factors include ineffective communication, excessive dependency on or withdrawal from relationships, no sense of beloning, inadequate social support, and loss of emotional control. Social/cultural factors include lack of resources, violence, homelessness, poverty, an unwarranted negative view of the world, and discrimination such as stigma, NSG221.01.0 1.01. NSG 221 Exam 1 Blueprint racism, classism, ageism, and sexism. It is important to note that some of these social/cultural factors can result in isolation, feelings of alienation, and maladaptive, violent, or criminal behavior.

Factors contributing to mental illness

individual, interpersonal, and social/cultural categories.

Individual factors contributing to mental illness

Individual factors include biologic makeup, intolerable or unrealistic worries or fears, inability to distinguish reality from fantasy, intolerance of life's uncertainties, a sense of disharmony in life, and a loss of meaning in one's life.

Interpersonal factors contributing to mental illness

include ineffective communication, excessive dependency on or withdrawal from relationships, no sense of beloning, inadequate social support, and loss of emotional control.

Social/cultural factors contributing to mental illness

include lack of resources, violence, homelessness, poverty, an unwarranted negative view of the world, and discrimination racism, classism, ageism, and sexism. It is important to note that some of these social/cultural factors can result in isolation, feelings of alienation, and maladaptive, violent, or criminal behavior.

Cerebrumdivided into two hemispheres; all lobes and structures are found in both halves except for the pineal body, or gland, which is located between the hemispheres.pineal bodyendocrine gland that influences the activities of the pituitary gland, islets of Langerhans, parathyroids, adrenals, and gonads.The corpus callosum isa pathway connecting the two hemispheres and coordinating their functions.The left hemisphere controlsthe right side of the body and is the center for logical reasoning and analytic functions such as reading, writing, and mathematical tasksThe right hemisphere controlsthe left side of the body and is the center for creative thinking, intuition, and artistic abilities.The cerebellumlocated below the cerebrum and is the center for coordination of movements and postural adjustments.The cerebellum receives and integrates information fromall areas of the body, such as the muscles, joints, organs, and other components of the CNS.Research has shown that inhibited transmission of dopamine, a neurotransmitter, in cerebellum is associated with.the lack of smooth coordinated movements in diseases such as Parkinson disease and dementia.The brain stem includesthe midbrain, pons, and medulla oblongata and the nuclei for cranial nerves III through XII.The medulla, located atthe top of the spinal cord, contains vital centers for respiration and cardiovascular functions.Above the medulla and in front of the cerebrum,the pons bridges the gap both structurally and functionally, serving as a primary motor pathway.The midbrain connectsthe pons and cerebellum with the cerebrum. It measures only 0.8 in (2 cm) length and includes most of the reticular activating system and the extrapyramidal system.The reticular activating systeminfluences motor activity, sleep, consciousness, and awareness.The extrapyramidal systemrelays information about movement and coordination from the brain to the spinal nerves.The locus coeruleussmall group of norepinephrine-producing neurons in the brain stem, is associated with stress, anxiety, and impulsive behavior.The limbic system is anarea of the brain located above the brain stem that includes the thalamus, hypothalamus, hippocampus, and amygdala (although some sources differ regarding the structures this system includes).thalamusregulates activity, sensation, and emotion.The hypothalamusinvolved in temperature regulation, appetite control, endocrine function, sexual drive, and impulsive behavior associated with feelings of anger, rage, or excitement.The hippocampus and amygdala are involved inemotional arousal and memory.Disturbances in the limbic systemhave been implicated in a variety of mental illnesses, such as the memory loss that accompanies dementia and the poorly controlled emotions and impulses seen with psychotic or manic behaviorsMajor Neurotransmitters Type Mechanism of Action Physiologic Effects Dopamine Excitatory Controls complex movements, motivation, cognition; regulates emotional response Norepinephrine (noradrenaline) Excitatory Causes changes in attention, learning and memory, sleep and wakefulness, mood Epinephrine (adrenaline) Excitatory Controls fight or flight response Serotonin Inhibitory Controls food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions Histamine Neuromodulator Controls alertness, gastric secretions, cardiac stimulation, NSG 221 Exam 1 Blueprint peripheral allergic responses Acetylcholine Excitatory or inhibitory Controls sleep and wakefulness cycle; signals muscles to become alert Neuropeptides Neuromodulator s Enhance, prolong, inhibit, or limit the effects of principal neurotransmitters Glutamate Excitatory Results in neurotoxicity if levels are too high γ-Aminobutyric acid Inhibitory Modulates other neurotransmittersMajor Neurotransmittersdopamine, norepinephrine, epinphrine serotonin, histamine, Acetylcholine,Neuropeptides, Glutamate and γ-Aminobutyric aciddopamineexatory Controls complex movements, motivation, cognition; regulates emotional responsenorepinephrineCauses changes in attention, learning and memory, sleep and wakefulness, moodepinphrine(adrenaline) Excitatory Controls fight or flight responseserotoninInhibitory Controls food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotionsHistamineNeuromodulator Controls alertness, gastric secretions, cardiac stimulation, NSG 221 Exam 1 Blueprint peripheral allergic responsesAcetylcholineExcitatory or inhibitory Controls sleep and wakefulness cycle; signals muscles to become alertNeuropeptidesNeuromodulator s Enhance, prolong, inhibit, or limit the effects of principal neurotransmittersGlutamateExcitatory Results in neurotoxicity if levels are too highγ-aminobutyric acid (GABA)Inhibitory Modulates other neurotransmittersexcitatory neurotransmittersdopamine, norepinephrine, epinphrine ,Acetylcholine, Glutamateinhibitory neurotransmittersinhibit the next cell from firinginhibitory neurotransmittersserotonin and γ-Aminobutyric acid Acetylcholine work also as exitatoryneuromodulator neurotransmittershave less rapid effects; not the primary NT; work to modulate activity at the synapseneuromodulator neurotransmittersNeuropeptides and histamineSigmund Freud: The Father of Psychoanalysis Sigmund Freud (1856-1939; Fig. 3.1) developed psychoanalytic theory in the late 19th and early 20th centuries in Vienna, where he spent most of his life. Several other noted psychoanalysts and theorists have contributed to this body of knowledge, but Freud is its undisputed founder. Many clinicians and theorists did not agree with much of Freud's psychoanalytic theory and later developed their own theories and styles of treatment.who developed psychoanalytic theorySigmund Freud: The Father of Psychoanalysis Sigmund Freudwho developed Therapeutic Nurse-Patient RelationshipsHildegard PeplauHildegard Peplau: Therapeutic Nurse-Patient Relationships Hildegard Peplau (1909-1999; Fig. 3.2 ) was a nursing theorist and clinician who built on Sullivan's interpersonal theories and also saw the role of the nurse as a participant observer. Peplau developed the concept of the therapeutic nurse-patient relationship, which includes four phases: orientation, identification, exploitation, and resolutionhow many phases the concept of the therapeutic nurse-patient relationship hasorientation, identification, exploitation, and resolutionOrientation Patient's problems and needs are clarified. Patient asks questions. Hospital routines and expectations are explained. Patient harnesses energy toward meeting problems. participation is elicited. Identification Patient responds to persons he or she perceives as helpful. Patient feels stronger. Patient expresses feelings. Interdependent work with the nurse occurs. Roles of both patient and nurse are clarified. Exploitation Patient makes full use of available services. Goals such as going home and returning to work emerge. Patient's behaviors fluctuate between dependence and independence. Resolution Patient gives up dependent behavior. Services are no longer needed by patient. Patient assumes power to meet own needs, set new goals, and so forth.orientation phasePatient's problems and needs are clarified. Patient asks questions. Hospital routines and expectations are explained. Patient harnesses energy toward meeting problems. participation is elicited.Identification phasePatient responds to persons he or she perceives as helpful. Patient feels stronger. Patient expresses feelings. Interdependent work with the nurse occurs. Roles of both patient and nurse are clarified.exploitation phasePatient makes full use of available services. Goals such as going home and returning to work emerge. Patient's behaviors fluctuate between dependence and independenceresolution phasegives up dependent behavior. Services are no longer needed by patient. Patient assumes power to meet own needs, set new goals, and so forth.orientation phasePatient's problems and needs are clarified. Patient asks questions. Hospital routines and expectations are explained. Patient harnesses energy toward meeting problems. Patient's full participation is elicited. Patient responds to persons he or she perceives as helpful. Patient feels strongerPhase: Exploitationis the phase during which the client proceeds to take full advantage of the services offered to him or her. Having learned which services are available, feeling comfortable within the setting, and serving as an active participant is his or her own health are, the client exploits the services available and explores all possibilities of the changing situationPhase resolutionOccurs when the client is freed from identification with helping persons and gathers strength to assume independence. Resolution is the direct result of successful completion of the other three phases.Roles of the Nurses in the Therapeutic Relationship. Peplau also wrote about the roles of the nurses in the therapeutic relationship and how these roles help meet the client's needs. The primary roles she identified are as follows: Stranger—offering the client the same acceptance and courtesy that the nurse would to any stranger. Resource person—providing specific answers to questions within a larger context Teacher—helping the client learn either formally or informally Leader—offering direction to the client or group Surrogate—serving as a substitute for another, such as a parent or sibling Counselor—promoting experiences leading to health for the client, such as expression of feelingsroles of the nurses in the therapeutic relationshipStranger Resource person Teacher Leader Surrogate sibling CounselorStranger roles of the nurses in the therapeutic relationshipoffering the client the same acceptance and courtesy that the nurse would to any stranger.Resource person roles of the nurses in the therapeutic relationshipproviding specific answers to questions within a larger contextTeacher roles of the nurses in the therapeutic relationshiphelping the client learn either formally or informallyLeader roles of the nurses in the therapeutic relationshipoffering direction to the client or group Surrogate—serving as a substitute for another, such as a parent or sibling Counselor—promoting experiences leading to health for the client, such as expression of feelingssurrogate roles of the nurses in the therapeutic relationshipserving as a substitute for another, such as a parent or siblingCounselor roles of the nurses in the therapeutic relationshippromoting experiences leading to health for the client, such as expression of feelingsroles of the nurses in the therapeutic relationshipStranger. Resource person Teacher Leader Surrogate Counselorhumanistic theoriesHumanism represents a significant shift away from the psychoanalytic view of the individual as a neurotic, impulse-driven person with repressed psychic problems and away from the focus on and examination of the client's past experiences. Humanism focuses on a person's positive qualities, his or her capacity to change (human potential), and the promotion of self-esteem. Humanists do consider the person's past experiences, but they direct more attention toward the present and future.Behavioral, Humanistic, existential theoriesExistential TheoriesExistential theorists believe that behavioral deviations result when a person is out of touch with him or herself or the environment. The person who is self-alienated is lonely and sad and feels helpless. Lack of self-awareness, coupled with harsh self-criticism, prevents the person from participating in satisfying relationships. The person is not free to choose from all possible alternatives because of self-imposed restrictions. Existential theorists believe that the person is avoiding personal responsibility and is giving in to the wishes or demands of others. All existential therapies have the goal of helping the person discover an authentic sense of self. They emphasize personal responsibility for oneself, feelings, behaviors, and choices. These therapies encourage the person to live fully in the present and to look forward to the futuPsychopharmac ology Adherence Major ADR Neurotransmit er targets for antipsychotics, antianxiety, antidepressantsNSG221.01.0 4.01.when the clients are dangers to themselves or otherswe hold them against their willSome clients, however, do not wish to be hospitalized and treated. Health care professionals respect these wishes unless clients are dangers to themselves or others (i.e., they are threatening or have NSG221.02.0 1.01. NSG 221 Exam 1 Blueprint Confidentialityexceptions Crisis- types and Treatmen t Modalitie s, Settings, and Therapeu tic Programs attempted suicide or represent a danger to others). Clients hospitalized against their will under these conditions are committed to a facility for psychiatric care until they no longer pose a danger to themselves or to anyone else. Each state has laws that govern the civil commitment process, but such laws are similar across all 50 states. Civil commitment or involuntary hospitalization curtails the client's right to freedom (the ability to leave the hospital when he or she wishes). All other client rights, however, remain intact. A person can be detained in a psychiatric facility for 48 to 72 hours on an emergency basis until a hearing can be conducted to determine whether or not he or she should be committed to a facility for treatment for a specified period. Many states have similar laws governing the commitment of clients with substance abuse problems who represent a danger to themselves or others when under the influence.Civil commitment or involuntary hospitalization curtails the client's right to freedom (the ability to leave the hospital when he or she wishes). All other client rights, however, remain intact. A person can be detained in a psychiatric facility for 48 to 72 hours on an emergency basis until a hearing can be conducted to determine whether or not he or she should be committed to a facility for treatment for a specified period. Many states have similar laws governing the commitment of clients with substance abuse problems who represent a danger to themselves or others when under the influence.ConfidentialityThe protection and privacy of personal health information is regulated by the federal government through the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The law guarantees the privacy and protection of health information and outlines penalties for violations. Mandatory compliance with the final HIPAA Privacy Rule took effect on April 14, 2003, for all health care providers, including individuals and organizations that provide or pay for care. Both civil (fines) and criminal (prison sentences) penalties exist for violation of patient privacy. Protected health information is any individually identifiable health information in oral, written, or electronic form. Mental health and substance abuse records have NSG 221 Exam 1 Blueprint additional special protection under the privacy rules. Some believe that these strict confidentiality policies may pose a barrier to collaboration among providers and families (Mork, Price, & Best, 2016). In community settings, compliance with the privacy rule has decreased communication and collaboration among providers and communication with family caregivers, which may have a negative impact on patient care as well as the rights of families. Education programs for clients and families about the privacy regulation as well as establishment of open lines of communication between clients and families before a crisis occurs may help decrease these difficulties. Also, dealing with the distress of relatives directly can be beneficial and help families feel included, rather than excludedMath calc IV drip rate Conversions ounces to mNSG221.01.0 4.01.Nursing LiabilityNurses are responsible for providing safe, competent, legal, and ethical care to clients and families. Professional guidelines such as the American Nurses Association's (ANA's) Code of Ethics for Nurses with Interpretive Statements and the ANA's Psychiatric- Mental Health Nursing: Scope and Standards of Practice outline the nurse's responsibilities and provide guidance. Nurses are NSG221.02.0 1.02. NSG 221 Exam 1 Blueprint and Therapeu tic Programs expected to meet standards of care, meaning the care they provide to clients meets set expectations and is what any nurse in a similar situation would do. Standards of care are developed from professional standards (cited earlier in this paragraph), state nurse practice acts, federal agency regulations, agency policies and procedures, job descriptions, and civil and criminal laws.standards of care, meaningthe care they provide to clients meets set expectations and is what any nurse in a similar situation would do. Standards of care are developed from professional standards (cited earlier in this paragraph), state nurse practice acts, federal agency regulations, agency policies and procedures, job descriptions, and civil and criminal laws.A tort isa wrongful act that results in injury, loss, or damage. Torts may be either unintentional or intentional.Negligence isan unintentional tort that involves causing harm by failing to do what a reasonable and prudent person would do in similar circumstances.Not all injury or harm to a client can be prevented, nor do all client injuries result from malpractice. The issues are whether or not the client's actions were predictable or foreseeable (and therefore preventable) and whether the nurse carried out the appropriate assessment, interventions, and evaluation that met the standards of care. In the mental health setting, lawsuits are most often related to suicide and suicide attempts. Other areas of concern include clients harming others (staff, family, or other clients), sexual assault, and medication errors.the client or family needs to prove four elementsduty breach of duty injury or damage causationDuty:A legally recognized relationship (i.e., physician to client, nurse to client) existed. The nurse had a duty to the client, meaning that the nurse was acting in the capacity of a nurse.Breach of DutyThe nurse (or physician) failed to conform to standards of care, thereby breaching or failing the existing duty. The nurse did not act as a reasonable, prudent nurse would have acted in similar circumstances.injury or damageThe client suffered some type of loss, damage, or injury.CausationThe breach of duty was the direct cause of the loss, damage, or injury. In other words, the loss, damage, or injury would not have occurred if the nurse had acted in a reasonable, prudent manner.Intentional Torts.Psychiatric nurses may also be liable for intentional torts or voluntary acts that result in harm to the client. Examples include assault, battery, and false imprisonment.Assaultinvolves any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority. Examples include making threats to restrain the client to give him or her an injection for failure to cooperate.Batteryinvolves harmful or unwarranted contact with a client; actual harm or injury may or may not have occurred. Examples include touching a client without consent or unnecessarily restraining a client.False imprisonment isthe unjustifiable detention of a client, such as the inappropriate use of restraint or NSG 221 Exam 1 Blueprint seclusion.Ethics isa branch of philosophy that deals with values of human conduct related to the rightness or wrongness of actions and to the goodness and badness of the motives and ends of such actions. Ethical theories are sets of principles used to decide what is morally right or wrong.Utilitarianism isa theory that bases decisions on "the greatest good for the greatest number." Decisions based on utilitarianism consider which action would produce the greatest benefit for the most people. Deontology is a theory that says decisions should be based on whether an action is morally right with no regard for the result or consequences. Principles used as guides for decision-making in deontology include autonomthe client or family needs to prove four elements: 1. Duty: A legally recognized relationship (i.e., physician to client, nurse to client) existed. The nurse had a duty to the client, meaning that the nurse was acting in the capacity of a nurse. 2. Breach of duty: The nurse (or physician) failed to conform to standards of care, thereby breaching or failing the existing duty. The nurse did not act as a reasonable, prudent nurse would have acted in similar circumstances. 3. Injury or damage: The client suffered some type of loss, damage, or injury. NSG 221 Exam 1 Blueprint 4. Causation: The breach of duty was the direct cause of the loss, damage, or injury. In other words, the loss, damage, or injury would not have occurred if the nurse had acted in a reasonable, prudent manner.Autonomya person's right to self-determination and independence. .Beneficenceone's duty to benefit or to promote the good of others.Nonmaleficencethe requirement to do no harm to others, either intentionally or unintentionally.Justicefairness, treating all people fairly and equally without regard for social or economic status, race, sex, marital status, religion, ethnicity, or cultural beliefs.Veracitythe duty to be honest or truthful.Fidelitythe obligation to honor commitments and contractsMalpracticeFailure by a health professional to meet accepted standardsgroup therapy,clients participate in sessions with a group of people. The members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in return. Group rules are established, which all members must observe. These rules vary according to the type of group. Being a member of a group allows the client to learn new ways of looking at a problem or ways of coping with or solving problems and also helps him or her learn important interpersonal skills. For example, by interacting with other members, clients often receive feedback on how others perceive and react to them and their behavior. This is extremely important information for many clients with mental disorders, who often have difficulty with interpersonal skills.The therapeutic results of group therapy (Yalom & Leszcz, 2005) include the followingGaining new information or learning Gaining inspiration or hope Interacting with others Feeling acceptance and belonging Becoming aware that one is not alone and that others share the same problems Gaining insight into one's problems and behaviors and how they affect others Giving of oneself for the benefit of others (altruism)Therapy groups vary with different purposes, degrees of formality, and structures. Our discussion includes psychotherapy groups, NSG 221 Exam 1 Blueprint family therapy, family education, education groups, support groups, and self-help groups.An important concept in any inpatient treatment setting isdischarge planning. Environmental supports, such as housing and transportation, and access to community resources and services are crucial to successful discharge planning. Discharge plans that are based on the individual client's needs, including medication management, education, timely outpatient appointments, and telephone follow-up, are more likely to be successful. In fact, the adequacy of discharge plans is a better predictor of how long the person could remain in the community than are clinical indicators such as psychiatric diagnosesImpediments to successful discharge planning include causes marginal planalcohol and drug abuse, criminal or violent behavior, noncompliance with medication regimens, and suicidal ideation. For example, optimal housing is often not available to people with a recent history of drug or alcohol abuse or criminal behavior. Also, clients who have suicidal ideas or a history of noncompliance with medication regimens may be ineligible for some treatment programs or services. Therefore, clients with these impediments to successful discharge planning may have a marginal discharge plan in place because optimal services or plans are not available to them. Consequently, people discharged with marginal plans are readmitted more quicklyOne essential component of discharge planning isrelapse prevention, or early recognition of relapse. Education about relapse involves both clients and families or significant others. Interventions include symptom education, service continuity, and establishment of daily structure. Clients and families who can recognize signs of impending relapse and seek help, participate in outpatient appointments and services, and have a daily plan of activities and responsibilities are least likely to require rehospitalization.Creating successful discharge plans that offer optimal services and housing is essential if people with mental illness are to be integrated intothe community.A holistic approach to reintegrating persons into the community is the best way to preventrepeated hospital admissions and improve quality of life for clients..Community programs after discharge from the hospital should includesocial services, day treatment, and housing programs, all geared toward survival in the community, compliance with treatment recommendations, rehabilitation, and independent livingAssertive community treatment (ACT) programsprovide many of the services that are necessary to stop the revolving door of repeated hospital admissions punctuated by unsuccessful attempts at community living.Psychiatric rehabilitation( psychosocial rehabilitation)services designed to promote the recovery process for clients with mental illness (Box 4.3 ). Recovery goes beyond symptom control and medication management to include personal growth, reintegration into the community, empowerment, increased independence, and improved quality of life as the beginning of the recovery process. However, it does not stop there. Higher level goals and expectations characterize later stages of recovery (Box 4.4 ), not unlike those for any person—which is the point of recovery.Goals of Psychiatric RehabilitationRecovery from mental illness Personal growth Quality of life Community reintegration Empowerment Increased independence Decreased hospital admissions Improved social functioning Improved vocational functioning Continuous treatment Increased involvement in treatment decisions Improved physical health Recovered sense of selfCharacteristics of Later RecoveryAccepting illness Managing symptoms effectively Being actively engaged in the community Having meaningful social contact Coping with family relationship Valuing self and othersOne of the challenges of moving toward a recovery model of care is creating and managing the change this requires, both for individual staff and throughout the organization. The organization must make a commitment to ongoing quality improvement, provide necessary resources and technologic support, and reward creative thinking. The work environment needs to anticipate, manage, and celebrate change for a "recovery culture" to flourish. Community support programs and services provide psychiatric rehabilitation to varying degrees, often depending on the resources and the funding available. Some programs focus primarily on reducing hospital readmissions through symptom control and medication management, while others include social and recreation services. Too few programs are available nationwide to meet the needs of people with mental illnesses. Psychiatric rehabilitation has improved client outcomes by providing community support services to decrease hospital readmission rates and increase community integration. At the same time, managed care has reduced the "medically necessary" services that are funded. For example, because skills training was found to be successful in assisting clients in the community, managed care organizations defined psychiatric rehabilitation as NSG 221 Exam 1 Blueprint only skills training and did not fund other aspects of rehabilitation such as socialization or environmental supports. Clients and providers identified poverty, lack of jobs, and inadequate vocational skills as barriers to community integration, but because these barriers were not included in the "medically necessary" definition of psychiatric rehabilitation by managed care, services to overcome these barriers were not funded. Another aspect of psychiatric rehabilitation and recovery is the involvement of peer counselors or consumer providers. Programs employing peers found improvement in client functioning satisfaction with programming, selfconfidence, and hope for recovery. A review of several studies involving peer support of varying types showed that peers were better able to reduce inpatient use and improve many recovery outcomes (Vayshenker et al., 2016). Sharing on social media provided informal or naturally occurring peer support via YouTube videos. Persons with severe mental illness who shared in this manner found that this provided peer support, minimized social isolation, provided hope, shared day-to-day coping strategies, connected them to peers, and shared experiences of medication use and seeking mental health care. Peer counselors can also be part of more structured delivery of services, including education about illness, recovery, medication, and services; topics of hope, selflove, pleasure, and finding happiness; and responding to crisis calls. An added benefit of peer counseling is the peer counselor pursues his or her own recovery by giving back or making meaningful contribution to the communitypositive regard and implies respect. Calling the client by name, spending time with the client, and listening and responding openly are measures by which the nurse conveys respect and positive regard to the client. The nurse also conveys positive regard by considering the client's ideas and preferences when planning care. Doing so shows that the nurse believes the client has the ability to make positive and meaningful contributions to his or her own plan of care. The nurse relies on presence, or attending, which is using nonverbal and verbal communication techniques to make the client aware that he or she is receiving full attention. Nonverbal techniques that create an atmosphere of presence include leaning toward the client, maintaining eye contact, being relaxed, having arms resting at the sides, and having an interested but neutral attitude. Verbally attending means that the nurse avoids communicating value judgments about the client's behavior. For example, the client may say, "I was so mad, I yelled and screamed at my mother for an hour." If the nurse responds with, "Well, that didn't help, did it?" or "I can't believe you did that," the nurse is communicating a value judgment that the client was "wrong" or "bad." A better response would be "What happened then?" or "You must have been really upset." The nurse maintains attention on the client and avoids communicating negative opinions or value judgments about the client's behavior.The working phase of the nurse-client relationship is usually divided into two subphases.problem identification exploitationproblem identification of nursing working phasethe client identifies the issues or concerns causing problems. Duringexploitation of nursing working phasethe nurse guides the client to examine feelings and responses and develop better coping skills and a more positive self-image; this encourages behavior change and develops independence. (Note that Peplau's use of the word exploitation had a very different meaning than current usage, which involves unfairly using or taking advantage of a person or situation. For that reason, this phase is better conceptualized as intense exploration and elaboration on earlier themes that the client discussed.) The trust established between the nurse and the client at this point allows them to examine the problems and to work on them within the security of the relationship. The client must believe that the nurse will not turn away or be upset when the client reveals experiences, issues, behaviors, and problems. Sometimes, the client will use outrageous stories or acting-out behaviors to test the nurse. Testing behavior challenges the nurse to stay focused and not to react or to be distracted. Often, when the client becomes uncomfortable because he or she is getting too close to the truth, he or she will use testing behaviors to avoid the subject. The nurse may respond by saying, "It seems as if we have hit an uncomfortable spot for you. Would you like to let it go for now?" This statement focuses on the issue at hand and diverts attention from the testing behavior. The nurse must remember that it is the client who examines and explores problem situations and relationships. The nurse must be nonjudgmental and refrain from giving advice; the nurse should allow the client to analyze situations. The nurse can guide the client in observing patterns of behavior and whether or not the NSG 221 Exam 1 Blueprint expected response occurs. For example, a client who suffers from depression complains to the nurse about the lack of concern her children show her. With the assistance and guidance of the nurse, the client can explore how she communicates with her children and may discover that her communication involves complaining and criticizing. The nurse can then help the client explore more effective waysNonverbal communicationis the behavior a person exhibits while delivering verbal content. It includes facial expression, eye contact, space, time, boundaries, and body movements. Nonverbal communication is as important as verbal communication, if not more so. It is estimated that one-third of meaning is transmitted by words and two-thirds is communicated nonverbally. The speaker may verbalize what he or she believes the listener wants to hear, while nonverbal communication conveys the speaker's actual meaning. Nonverbal communication involves the unconscious mind acting out emotions related to the verbal content, the situation, the environment, and the relationship between the speaker and the listenerNonverbal behaviors are used with verbal messages to convey meaning. Some people use hand gestures to emphasize the words they are saying. A nod may indicate agreement, while a quizzical look conveys confusion. It is important to validate the meaning of nonverbal behaviors because misinterpretation or assumptions can lead to misunderstanding.