Mental Health Exam 4

Covert Comment (Suicide)

"Everything is look pretty grim for me"

Overt Comment (Suicide)

"There is just no reason for me to go on"

tension building phase of violence

- Abuser has minor episodes of anger and may be verbally abusive - Responsible for some minor physical violence - Victim is tense during this stage and tends to accept the blame for what is happening.

Medications for ADHD

- Psychostimulants (methylphenidate and amphetamine salts) -Nonstimulant selective norepinephrine reuptake inhibitor (SNRI) (atomoxetine)

manifestations of conduct disorder

- demonstrates lack of remorse or care for feelings of others - bullies ,threatens, intimidates others - believes aggression is justified - low self-esteem, irritability, temper outbursts, reckless behavior - signs of suicide ideation - concurrent learning disorders or impairments in cog func - physical cruelty to others and/or animals - used weapon that could cause serious injuries - destroys property of others - has run away from home - often lies, shoplifts and is truant from school

risk factors for anger

- past history of aggression, poor impulse control, and violence - poor coping skills, limited support systems - comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders) - living in a violent environment - limit setting by the nurse within the therapeutic milieu

medications for intermittent explosive disorder

-SSRIs (fluoxetine) -Mood stabilizers (lithium) -Antipsychotics (clozapine and haloperidol) -Beta blockers

post-traumatic stress disorder

-experiencing, witnessing, or learning of a traumatic event -anxiety, depression, phobia, or conversation reactions -can show irritability and aggression with family, friends, poor academic performance, somatic reports, belief life will be short, difficulty sleeping -small children show decrease in play or engage in play that involves aspects of the traumatic event

Engel 5 stages of grief

1. shock and disbelief 2. developing awareness (aware of the new reality and feels grief) 3. restitution (religious ritual such as funeral) 4. resolution of the loss (client preoccupied and over 12 mo. period it decreases) 5. recovery

Kubler 5 stages of grief

1.Denial 2.Anger 3.Bargaining 4.Depression 5.Acceptance

4 phases of a crisis

1: escalating anxiety from threat of activates increased defense responses 2: anxiety continues escalating as defense responses fail, functioning becomes disorganized, client resorts to trial and error attempts to resolve anxiety 3: trial and error methods fail, client's anxiety escalates to severe/panic level, leading to fight or flight or withdrawal behaviors 4: experiences overwhelming anxiety that can lead to anguish and apprehension, feelings of powerlessness and being overwhelmed, dissociative findings (depersonalization, detachment from reality), depression, confusion, and/or violence against others/self

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client? A.) "stop screaming and walk outside with me" B.) "why are you so angry and screaming at everyone" C.) "you will not get your way by screaming" D.) "what was going through your mind when you started screaming"

A

adventitious crisis

A major natural or man-made disaster or a crime of violence

a nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following statements as an overt comment about suicide? (select all) A.) "My family will be better if I'm dead" B.) "The stress in my life is too much to handle" C.) "I wish my life was over" D.) "I don't feel like I can ever be happy again" E.) "If I kill myself then my problems will go away"

A, C, E

a nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (select all) A.) conducting a suicide risk screening on all new clients B.) creating a support group for family members of clients who completed suicide C.) educating high school teens about suicide prevention D.) initiating one-on-one observation for a client who has current suicidal ideation E.) teaching middle-school educators about warning indicators of suicide

A, C, E

impulsive behavior is associated with what disorder?

ADHD

a nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A.) insist the client stop yelling B.) request other staff members remain close by C.) move as close to the client as possible D.) walk away from client

B

a nurse is caring for a client who states, "I plan to commit suicide". Which of the following assessments should the nurse identify as the priority? A.) client's educational and economic background B.) lethality of the method and availability of means C.) quality of the client's social support D.) client's insight into reasons for the decision

B -determine how lethal, available, and detailed the plan is

a nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the pre assaultive stage of violence? (select all) A.) lethargy B.) defensive responses to questions C.) disorientation D.) facial grimacing E.) agitation

B, D, E

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (select all) A.) lithium carbonate B.) paroxetine C.) Risperidone D.) Haloperidol E.) Lorazepam

B, E

a nurse caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A.) encourage the client to express feelings out loud B.) maintain eye contact with the client C.) move the client away from others D.) tell the client that behavior is not acceptable

C

a nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? A.) assign the client to a private room B.) document the client's behavior every hr C.) allow client to keep perfume in her room D.) ensure client swallows medications

D

a nurse is conducting a class for a group of newly licensed nurses caring for clients who are at risk for suicide. Which of the following info should the nurse include in the teaching? A.) client's verbal threat of suicide is attention-seeking behavior B.) interventions are ineffective for clients who really want to commit suicide C.) using the term suicide increases the client's risk for a suicide attempt D.) a no-suicide contract decreases client's risk for suicide

D

a nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A.) "I wish you would not make me angry" B.) "I feel angry when you leave me" C.) "it makes me angry when you interrupt me" D.) "You better listen to me)

D

conduct disorder (childhood or adolescent onset)

Demonstrate a persistent pattern of behavior that violates the rights of others or rules and norms of society -aggression to people/animals, destruction of property, deceitfulness or theft, serious violations of rules -childhood onset= before 10y/o (males more common) -adolescent onset= after 10y/o (males/females equally as common)

Seperation Anxiety Disorder

Excessive anxiety over separation from home or someone who is attached, can transform into school phobia or phobia of being left at home -can develop after a stressor (losing a pet, relative, illness, move, assault)

risk factors for violence

Female partner, pregnancy, older adults -family groups -children= under 4, perpetrator perceives child as different (unwanted pregnancy, physically disabled)

Worden 4 tasks of Mourning

I - accept the inevitability of the loss II - Use coping mechanisms to experience the pain of the loss III - Chang environment to accommodate the absence of the deceased IV - Readjust emotional ties to new people, move thoughts of deceased to less prominent place in everyday thoughts

acute battering phase of violence

In a violent relationship, the second phase in the cycle of abuse. It is characterized by multiple incidents of battering, such as hitting, slapping, kicking, choking, and using objects or weapons, as well as sexual abuse and verbal threats and abuse. -victim may provoke the perpetrator to reduce unbearable tension -most violent stage and shortest

medications for oppositional defiant disorder

Medications not generally prescribed

Bowlby 4 stages of grief

Numbness of protest= denial over loss and feels shocked disequilibrium= focus on loss with intense desire to regain what is lost disorganized/despair= hopelessness that impacts everyday life reorganization= reaches acceptance -can be present as young as 6 months of age

postassaultive stage

Once the patient no longer requires seclusion or restraints, the staff should review the incident with the patient as well as among themselves. -Discussion with the patient is an important part of the therapeutic process. -allows the patient to learn from the situation, identify stressors that precipitate the out-of-control behavior, and plan alternative ways of responding to these stressors in the future

somatic problems are associated with what disorder?

PTSD

tools to access for suicide risk

SAD PERSONS scale or other standardized assessment tool

medications for autism spectrum disorder

SSRIs, antipsychotic meds (risperidone, olanzapine, quetiapine, aripiprazole)

intellectual developmental disorder

Significantly below average intellectual functioning (IQ<70) paired with deficits in adaptive functioning such as self-care or occupational activities, appearing prior to age 18. Previously called mental retardation

Oppositional Defiant Disorder

a childhood disorder in which children are repeatedly argumentative and defiant, angry and irritable, and in some cases, vindictive -behaviors: negative, disobedient, hostility, defiant behaviors, stubbornness, argumentative, limit testing, unwilling to compromise, refusal to accept responsibility for misbehavior -do not see themselves as defiant -children= low self-esteem, irritability, low frustration threshold -can develop into conduct disorder

Disruptive Mood Dysregulation Disorder (DMDD)

a childhood disorder involving chronic irritability and significantly exaggerated anger reactions -temper outbursts manifested verbally/physically and may be aggressive -not appropriate for child's developmental level -outbursts present 3+ times a week in at least 2 settings (school/home) -onset= 6-18y/o -not due to another mental health disorder (BPD)

Autism Spectrum Disorder

a disorder that appears in childhood and is marked by significant deficiencies in communication and social interaction, and by rigidly fixated interests and repetitive behaviors -more common in boys -present in early childhood -physical difficulties= sensory integration dysfunction, sleep disorders, digestive disorders, feeding disorders, epilepsy, allergies

specific learning disorder

a marked deficit in a particular area of learning that is not caused by an apparent physical disability, or by an unusually stressful home environment -difficulty in acquiring reading, writing, math skills -performance in 1+ academic areas are lower than expected range for age, level of intelligence, or educational level

maturational/internal crisis

achieving new developmental stages, which requires learning additional coping mechanisms (getting married/retiring)

medications for crisis management

antianxiety (alprazolam, diazepam, oxazepam) a antidepressants (paroxetine, bupropion, fluoxetine)

medications for disruptive mood dysregulation disorder

antidepressant therapy

medications to prevent suicide

antidepressants: SSRI (citalopram, fluoxetine, sertraline) sedative hypnotic anxiolytics- Benzos (diazepam, lorazepam) mood stabilizers (lithium carbonate) second-generation antipsychotics (risperidone, olanzapine) -can also use ECT

A nurse is teaching a group of guardians about manifestations of conduct disorder. Which of the following findings should the nurse include? (select all) A.) bullying of others B.) threats of suicide C.) law-breaking activities D.) narcissistic behavior E.) flat affect

bullying behavior, suicidal ideation, law/rule breaking -others: low self-esteem, irritability and temper outbursts A, B, C

preassultive stage

client begins to become angry and exhibits increasing anxiety, tension, hyperactivity, and verbal abuse

secondary care for crisis management

collaborate with client to identify interventions while in an acute crisis that promote safety

primary care for crisis management

collaborate with client to identify potential problems; instruct coping mechanisms; assist in lifestyle changes

tertiary care for crisis management

collaborate with client to provide support during recovery from a severe crisis that include outpatient clinics, rehab centers, crisis stabilization centers, short-term residential services, and workshops

assaultive stage

commits act of violence -seclusion and physical restraints can be required

destructiveness is a behavior associated with what disorder?

conduct disorder

honeymoon phase of violence

defused for a while after violent episode -becomes loving, promises to change, sorry for behavior -vulnerable person wants to believe this and hopes for change -cycle begins again eventually

Comorbidities for anger

depression substance use disorders BPD PTSD Alzheimer's personality/ Psychotic disorders individuals who are easily overwhelmed have marginal coping skills

complicated grief- delayed or inhibited grief

does not demonstrate expected behaviors of normal grief process -cultural expectations can influence -may remain in denial stage for extended period -due to inability to progress, a subsequent minor loss (even years later) can trigger grief response

complicated grief- disenfranchised grief

entails a loss that cannot be publicly shared or is not socially acceptable -ex. abortion, suicide

Intermittent Explosive Disorder

episodes during which a person acts on aggressive impulses that result in serious assaults or destruction of property -as early as 6y/o (typically 13-21y/o) -more males affected -verbal/physical aggression followed by feelings of shame/guilt -prevents healthy relationships/employment -can lead to chronic diseases (hypertension, diabetes mellitus)

depressive disorders risk factors

family/personal history -physical/ sexual abuse/neglect -homelessness -disputes among parents, conflicts with peers/family, and rejection by peers/family -bullying, either as the aggressor or victim, including traditional bullying and cyberbullying -engaging in high-risk behaviors -learning disabilities -chronic illness

risk factors for suicide

females more likely to attempt suicide but males more likely to complete it -military -lesbian/gay/bi/trans -comorbid mental illness (depressive, substance use, schiz, BPD, personality disorders) -loss of employment/ finances -feeling isolated/powerless -prior attempts -older adults more likely to succeed -change in functional ability -declining physical health -loss of loved ones -family history of suicide -physical disorders -sense of hopelessness -intense emotions -poor interpersonal relationships -developmental stressors -Hx of trauma/abuse -American Indian and Alaskan Native ethnic groups have highest suicide rate -access to lethal methods (firearms) -lack of access to mental health care

anticipatory grief

grief experienced prior to a loss -"letting go" of object or person before the actual loss

ADHD & types

inattention, impulsivity, hyperactivity -must be present before 12y/o and be present in more than one setting Types= ADHD predominantly inattentive, ADHD predominantly hyperactive-impulsive, combined type: client exhibits both inattentive and hyperactive-impulsive behaviors

A nurse in a pediatric clinic is caring for a pre-K age child with a new diagnosis of ADHD. When teaching the guardian about this disorder, which of the following statements should the nurse include in the teaching? A.) "Behaviors associated with ADHD are present prior to the age 3" B.) "this disorder is characterized by argumentativeness" C.) "below-average intellectual functioning is associated with ADHD" D.) "because of this disorder, your child is at an increased risk for injury"

inattentive or impulsive behavior increases risk of injury with ADHD D also: behavior associated with ADHD are present before age 12

physical assessment findings for suicide

lacerations, scratches, scars (could indicate self harm)

A nurse is reviewing the medical records of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis? A.) rape B.) marriage C.) severe physical illness D.) job loss

marriage is a naturally occurring event during the life span B rape= adventitious crisis severe physical illness= situational crisis loss of job= situational crisis

complicated grief- chronic or prolonged grief

may be different lengths of time required by clients to work through stages of grief -can remain in denial stage and remain unable to accept reality of the loss -chronic or prolonged grief can result in client's inability to perform ADLs

A nurse is assisting the guardians of school-aged child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following strategies should the nurse recommend? (Select all) A.) allow the child to choose which behaviors are unacceptable B.) use role-playing to act out unacceptable behavior C.) develop a reward system for acceptable behavior D.) encourage the child to participate in school sports E.) be consistent when addressing unacceptable behavior

method to reward for acceptable behavior, encourage physical activity, set clear limits and be consistent -focus on acceptable behavior and demonstrate this through modeling C, D, E

care after discharge for suicide

no-suicide contract -verbal, written agreement made not to harm themselves, but to instead seek help -not legally binding and should only be used according to facility policy -should not replace other suicide prevention strategies -tool to maintain trust b/w nurse and pt -discouraged for clients in crisis, under influence of substances, psychotic, very impulsive, and/or very agitated/angry

medications for anxiety disorder

none are FDA approved for kids, SSRI may be prescribed

situational/external crisis

often unanticipated loss or change experienced in every day, often unanticipated, life events (divorce/job change)

medications for aggressive behaviors

olanzapine, ziprasidone -most common atypical antipsychotics -aggressive/impulsive behaviors haloperidol -antipsychotic agent -aggressive/impulsive behaviors (more side effects) -monitor for parkinsonian/anticholinergic adverse effects others= antidepressants (SSRI), mood stabilizers (lithium), sedative/hypnotic medications (Benzos)

argumentativeness is associated with what disorder?

oppositional defiant disorder

contributing factors to conduct disorder

parental rejection/neglect difficult infant temperament inconsistent child-rearing practices w/ harsh discipline physical/sexual abuse lack of supervision early institutionalization frequent changing caregivers large family size association w/ delinquent peer groups parent w/ Hx of psychological illness chaotic home life lack of male role model

A nurse is assessing a 4 y/o child for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess? A.) impulsive behavior B.) repetitive counting C.) destructiveness D.) somatic problems

repetitive actions and strict routines are an indication of autism spectrum disorder B

complicated grief- distorted or exaggerated grief

same feelings and somatic manifestations as normal but exaggerated -unable to perform ADLs -can remain in anger stage and may direct it towards self or others -can develop clinical depression

are most rape victims raped by strangers or someone they know?

someone they know

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following findings are expected for this disorder? (select all) A.) fear of being alone B.) substance use C.) weight gain D.) irritability E.) aggressiveness

substance use, irritability, aggressiveness -also: loss of appetite and weight loss, solitary play or work B, D, E

leading cause of death for kids 10-24

suicide

medications for PTSD

targets specific problems (depression, ADHD)

cycle of violence

tension-building phase acute battering phase honeymoon phase periods of escalation/de escalation

Normal Grief

uncomplicated, can include anger/ resentment/ withdrawal/ hopelessness/ guilt but should change to acceptance -should feel some acceptance by 6 months -somatic manifestations: chest pain, palpitations, headaches, nausea, changes in sleep, fatigue

periods of escalation and deescalation of violence

usually cont. with shorter periods of time b/w the 2 w/o intervention -emotions increase in intensity -repeated episodes of violence lead to feelings of powerlessness

Is a crisis time limited?

yes, it is an acute time limited event (usually 4-6 weeks) that cannot be managed with your normal coping mechanisms -subjective event

Suicide precautions within the facility

● Initiate one‑on‑one constant supervision around the clock, always having the client AT ARM'S LENGTH AWAY ● Document the client's location, mood, quoted statements, and behavior every 15 min or per facility protocol (suicide observation) ● Search the client's belongings with the client present. Remove all potentially harmful items from the client's room and vicinity. ● Allow the client to use only plastic eating utensils. Count utensils when brought into and out of the client's room. ● Check the environment for possible hazards (such as windows that open, overhead pipes that are easily accessible, non‑breakaway shower rods, non‑recessed shower nozzles). ● Ensure that the client's hands are always visible, even when sleeping. ● Do not assign to a private room and keep door open at all times. ● Ensure that the client swallows all medications. Clients can try to hoard medication until there is enough for a suicide attempt. ● Identify whether the client's current medications can be lethal with overdose. If so, collaborate with the provider to have less dangerous medications substituted if possible. ● Restrict visitors from bringing possibly harmful items to the client.

medications for conduct disorder

♣Target specific behaviors (i.e.: depression, anxiety) ♣Antipsychotics 2nd/3rd generation (risperidone, olanzapine, quetiapine, aripiprazole) ♣Tricyclic antidepressants (only time use TCAs instead of SSRIs for kids) ♣Anxiolytics ♣Mood stabilizers