MH Lesson 3

What are Caplan's Four Phases of Crisis?

*Phase 1:* Exposure to a stressful situation causes anxiety and you try to cope based on past experience. *Phase 2:* Trial-and-error attempts to solve the problem, anxiety builds. *Phase 3:* Anxiety escalates to panic levels, automatic relief behaviors like withdrawal and flight may occur. Some resolution may be made here. *Phase 4:* Every idea fails so you become distressed and unable to cope (serious personality disorganization, depression, confusion, suicidal thoughts, etc).

Interventions for patients in Crisis. Table 20.2 pg 337 MH

1. Assess for safety 2. Take steps to make patient feel safe(therapeutic environment) and lower anxiety, (build rapport) 3. Assist with problems incurred by the crisis 4. Use social supports and coping skills 5. Plan interventions w/ patient and plan regular follow up

What are the steps in Robert's 7 steps in Crisis intervention?

1. Crisis intervention assessment(risk for harm), 2. Establish rapport 3.Identify major problems (Like last straw situations 4.

Assessment guidelines for schizophrenia

1. Rule out medical/ substance-induced psychosis 2, Assess for Command hallucinations (these can be a huge safety risk) 3. Review patient Belief system- is it fragmented, poorly organized, unsupported by reality? (with this determine patient intentions, the belief of illness or lack thereof 4. Assess for Co Occurring disorders 5. Assess family response to symptoms and family interaction and support systems

Box 20.1 MH pg 332 Key points for crisis intervention

A crisis is self-limiting and should be resolved within 4 to 6 weeks. The goal is to return to a previous or higher stage of functioning. A nurse must be willing to take a more directive role in intervention initially in crisis.

What is an adventitious crisis?

A large scale event causing a crisis for a community,

What is schizophrenia?

A spectrum of disorders causing psychosis, mood/behavior changes, and cognitive impairment.

What is a situational crisis?

A stressful event on an individual such as divorce, or death of a loved one.

What is delirium

A temporary disturbance in attention, awareness, cognition, and language. Onset will be rapid and symptoms will fluctuate in severity

5. Three weeks after being assaulted by a patient, a nurse develops headaches, insomnia, and gastrointestinal problems. The nurse has had four absences from work over a two-week period. Which action should the nursing supervisor employ? a. Refer the nurse for counseling and support b. Ask the nurse about current personal problems c. Direct the nurse to take paid vacation for the following week. d. Schedule the nurse for administrative tasks rather than patient care

A.

Which nursing intervention is generally included in the plan of care for any hospitalized client experiencing a severe psychotic episode associated with schizophrenia to address safety issues? A. Implementing institution's suicide precautions B. Identifying theme of any identified hallucinations C. Assessing for the presence of feelings of guilt D. Setting boundaries to manage aggressiveness

A. A person who is psychotic is intensely anxious, lonely, dependent, and distrustful. These characteristics tend to increase the risk for self-harm. Suicide precautions are necessary to keep the client safe. None of the other options address the issue of patient safety.

An older client has been diagnosed with infection-induced delirium. Which statement by the nurse to the client's family best demonstrates an understanding of the disorder while addressing the family's concerns? A. "Delirium isn't permanent when treated appropriately. The prescribed medication should eliminate the infection causing the symptoms." B. Infections commonly cause delirium in older clients. You'll see improvement in just a few days." C. "The symptoms of delirium can be very difficult to watch in a loved one. Try not to worry since the condition is not permanent." D. "The symptoms will come and go during the next few days. It's a common condition."

A. Delirium can be a result of an infection especially among older adult clients. The condition is reversible when appropriately treated. A common concern is whether the symptoms are permanent since ineffective treatment of the underlying cause can lead to dementia if not reversed. Providing an explanation that identifies cause, treatment, and positive outcomes best demonstrates an understandin g of the disorder while meeting the needs of the family. None of the remaining options provide all the required information.

A client has been prescribed an antipsychotic medication for the management of symptoms associated with schizophrenia. Which behaviors will show improvement as a result of adhering to the medication therapy? (Select all that apply.) Select all that apply. A. Fears being abducted by alien creatures. B. Consistently avoids the dayroom when other clients are there. C. Regularly discusses his or her alter identity as a spy for Hitler. D. Acknowledges regularly hearing voices. E. Stays in his or her room most of the day staring out the window.

A. D. The negative symptoms (poor social adjustment, lack of motivation, withdrawal) are more debilitating and do not respond as well to antipsychotic drug therapy. The remaining symptoms are positive symptoms and are more florid (hallucinations, delusions, looseness of associations) and respond to antipsychotic drug therapy.

Which interventions should be considered appropriate for a patient in the withdrawn phase of catatonia? (Select all that apply.) Select all that apply. A. Perform passive range of motion once each shift. B. Administer nasogastric feedings as prescribed. C. Require autonomy regarding activities of daily living. D. Arrange for group activities. E. Reposition every 2 hours.

A. E. During catatonia's withdrawn phase, the person may not move or eat, thus becoming vulnerable to pressure ulcers, contractures, malnutrition, and circulatory issues. The patient would be incapable of autonomous care or group interaction.

1. While entering the building an elementary school nurse observes a person in the distance emerging from a forest and approaching the school. The person is dressed in black from head to toe; wearing a backpack; and carrying a long, narrow, dark object. Which action should the nurse take first? a. Move to a secure location. b. Observe the intruder's features. c. Take note of the intruder's location. d. Activate the school code for an intruder.

A. First priority is safety After becoming safe then the school alarm can be activated

Grief therapy was prescribed for a client who recently experienced tremendous grief upon the death of a parent. Which statement best demonstrates that a client is moving toward the healthy resolution of that grief? A. "I've enjoyed going to the book club my sister suggested." B. "My mother would want me to get back to living my life again." C. "I'm going to stop being sad and rely on my faith to support me." D. "I'm considering it's time to go back to work."

A. Ongoing evaluation will be performed until the crisis has resolved sufficiently to allow a return to normal pre-crisis functioning. As the patient's anxiety level reduces from severe to moderate to mild through successful interventions, the patient will need less support and return to independence. The correct option demonstrates independence, social engagement, and a return of enjoyment to one's life. The remaining options demonstrate consideration associated with returning to the familiar life situations (work, faith-based comfort).

2. A patient diagnosed with schizophrenia says, "I hear the voices every day. They always say bad things about me." Which action by the nurse has the highest priority? a. Assess the patient for suicidal thinking and plans. b. Review the patient's medication regimen and adherence c. Educate the patient about symptoms associated with schizophrenia d. Suggest distractors for the patient to use when auditory hallucination occur

A. The daily experience of negativity creates a scenario in which the risk for suicide is high. Depressive symptoms occur frequently, Suicide is most common cause of premature death in schizo patients

Which newly hospitalized patient should the nurse monitor closely for development of delirium? a. 48-year-old who usually drinks a six-pack of beer daily b. 68-year-old who takes aspirin 650 mg twice daily for arthritic pain c. 72-year-old who says, "I have a glass of wine every evening to stimulate my appetite." d. 78-year-old diabetic whose blood glucose levels are consistently greater than 250 mg/dL

A. Withdrawal from alcohol, anxiloytics, opioids, and CNS stimulants increase risk for Delirium

A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Which treatment strategy should the nurse discuss with the patient and health care provider? a. Use of long-acting antipsychotic injections b. Addition of a benzodiazepine, such as lorazepam c. Adjunctive use of an antidepressant, such as amitriptyline d. Inpatient hospitalization because of the high risk for exacerbation of symptoms

ANS: A Medications such as paliperidone, fluphenazine decanoate, and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for nonadherence. The incorrect options do not address the patient's dislike of taking pills.

A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option, yet important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.

13. A patient presenting with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allow the patient to have supervised access to food vending machines. b. Allow the patient to telephone a local restaurant to deliver meals. c. Offer to taste each portion on the tray for the patient. d. Begin tube feedings or total parenteral nutrition.

ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are considered aggressive and usually promote violence. Patients often perceive foods in sealed containers, packages, or natural shells as being safe.

4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The patient now says, "I stopped taking those pills. I didn't like how it made me feel." What likely side effects did the patient experience? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance. The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.

1. A 23-year-old male veteran of the war in Iraq is admitted with a diagnosis of posttraumatic stress disorder (PTSD) following his arrest for destroying his girlfriend's apartment. This is not his first angry outburst resulting in destruction of property. Which interventions by the nurse will be most helpful to this patient? (Select all that apply.) a. Allow opportunities for him to express his anger. b. Provide patient and family teaching regarding PTSD. c. Tell the patient that hurting himself will solve nothing. d. Report him to the authorities. e. Exhibit a nonjudgmental attitude. f. Reassure him that everything will be all right.

ANS: A, B, E Allowing appropriate opportunities for him to express his anger will help him learn how to control his emotions or express them in a socially acceptable manner. Providing education to the patient and family will help them learn why he behaves the way he does and how to prevent or redirect his anger. Options C, D, and F are nontherapeutic in that they undermine the nurse-patient relationship. Being nonjudgmental in interactions with patients is a basic tenet of developing a therapeutic relationship.

2. In discussing disease prevention with a 15-year-old boy and his mother, the nurse identifies which of the following as risk factors for psychosis? (Select all that apply.) a. Father diagnosed with paranoid schizophrenia b. Rural residence c. Recent immigration from Ecuador d. Occasional cannabis use e. January birth date f. Physical abuse by the father

ANS: A, C, E, F Genetic predisposition has been identified as a risk factor for development of schizophrenia. Immigration, winter birth, and family difficulties such as abuse have also been identified as risk factors. Urban residence, not rural, and chronic cannabis use, not occasional, have also been identified.

3. Clients who are psychotic because of underlying psychiatric illness are treated with antipsychotic medications. Typical antipsychotic medications can improve positive symptoms in clients with schizophrenia. Positive symptoms include which of the following? (Select all that apply.) a. Hallucinations b. Disorganized speech and behavior c. Anhedonia d. Delusions e. Agitation

ANS: A, D, E Positive symptoms of schizophrenia include the distortion or exaggeration of normal behavior, such as when the client experiences hallucinations, delusions, or agitation. Negative symptoms are those that cause a loss of normal function, such as when the client exhibits disorganized speech and behavior and anhedonia.

6. A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places

ANS: B Clues to hallucinations include looking around the room as though to find the speaker; tilting the head to one side as though intently listening; and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

3. The nurse is planning discharge teaching for a patient taking clozapine. Which information is essential to include in the teaching plan? a. Caution about sunlight exposure b. Reminder to call the clinic if fever, sore throat, or malaise develops c. Instructions regarding dietary restrictions d. A chart to record patient weight

ANS: B Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

2. A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this as what classic behavior? a. Echolalia b. An idea of reference c. A delusion of infidelity d. An auditory hallucination

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, abirb.com/test the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

A patient diagnosed with schizophrenia is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. voluntarily accept tube feeding by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing the patient's ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by the nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities; they are difficult to measure and are unrelated to maintaining nutrition.

9. A patient diagnosed with schizophrenia is demonstration catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiological c. Self-actualization d. Safety and security

ANS: B Physiological needs must be met to preserve life. A patient who is catatonic may need to be fed by hand or tube, toileted, and given range-of-motion exercises to preserve physiological integrity. The assessment findings do not suggest safety concerns. Higher-level needs (psychosocial and self-actualization) are of lesser concern.

1. A person diagnosed with schizophrenia has had difficulty keeping a job because of severe paranoia. Today the person shouts, "They're all plotting to destroy me." Select the nurse's most therapeutic response. abirb.com/test a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help if you will let them." abirb.com/test d. "Staff members are health care professionals who are qualified to help you."

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This abirb.com/test strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument

1. A client previously diagnosed as psychotic expresses to the nurse that he is seeing spiders climbing up the walls in his room and he is concerned that they will get into his bed. What is the nurse's best response? a. Ignore his remarks and remain silent when providing care. b. Express doubt that there are spiders on the wall. c. Ask the client if he also sees spiders in the day room. d. Tell the client there are no spiders and he should stop worrying about it.

ANS: B The client is experiencing visual hallucinations. Appropriate care for this client would not include reinforcing his hallucinations, being dismissive of him, or ignoring him. Expressing reasonable doubt is the correct answer.

A nurse observes a patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

4. Which side effect is highest priority for the nurse to assess for when diphenhydramine is administered to a patient also taking antipsychotic medication? a. Increased pychosis b. Cognitive impairment c. Respiratory depression d. Impaired memory

ANS: C Diphenhydramine is an anticholinergic medication that may induce drowsiness or even respiratory depression taken along with anti-psychotic medication. Respiratory depression and airway are always highest priorities of care. While increased psychosis may occur, respiratory depression is highest priority. Cognitive impairment and impaired memory are not well known effects of diphyenhydramine.

17. A patient diagnosed with schizophrenia has taken fluphenazine 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling, propulsive gait; a masklike face; and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

16. A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I will stay with you. Focus on what we are talking about, not the voices." d. "Forget about the voices. Ask some other patients to sit and talk with you."

ANS: C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Asking other patients to talk incorrectly shifts responsibility for intervention from the nurse to other patients.

7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight. Which drug should the nurse advocate? a. Clozapine b. Ziprasidone c. Olanzapine d. Aripiprazole

ANS: D Aripiprazole is an atypical antipsychotic medication that is effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol levels, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.

2. A client with schizophrenia has relapsed and has been identified as being in stage four of relapse. The nurse expects to observe which behavior that most consistent with this stage of relapse? a. Expressing feelings of anxiety b. Expressing feelings of being overwhelmed c. Bizarre behaviors and speech d. Presence of hallucinations

ANS: D Schizophrenic clients who relapse go through five stages. Correctly identifying which stage the relapsing client is in is important so that interventions can be specific to the behavior. Expressing feelings of anxiety would be part of stage two, expressing feelings of being overwhelmed would be part of stage one, and bizarre behaviors and speech would be part of stage three. Presence of hallucinations is consistent with stage four, psychotic disorganization.

12. Which patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years c. 19 years old; diagnosed with schizophreniform disorder 6 months ago d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed

ANS: D The 40-year-old patient who has been diagnosed with schizophrenia since 18 years of age could logically be expected to have the lowest overall level of functioning secondary to deterioration associated with frequent relapses. The 39-year-old patient who has had paranoid ideation since 35 years of age could be expected to have a higher-level because schizophrenia of short duration may be less impairing than other types. The patient who has had episodes of catatonia since the age of 24 years has been stable for more than 3 years, suggesting a higher functional ability. The 19-year-old patient diagnosed with schizophreniform disorder has been ill for only 6 months, and disability is likely to be minimal.

8. A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts, and then tell me again." d. "I am having difficulty understanding what you are saying."

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory.

15. Patients diagnosed with schizophrenia who are suspicious and withdrawn generally present with what additional characteristic? a. Universally fear sexual involvement with therapists. b. Are socially disabled by the positive symptoms of schizophrenia. c. Exhibit a high degree of hostility as evidenced by rejecting behavior. d. Avoid relationships because they become anxious with emotional closeness.

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. No evidence suggests that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is not considered true that withdrawn patients with schizophrenia are socially disabled by the positive symptoms of schizophrenia or exhibit a high degree of hostility by demonstrating rejecting behavior.

What are some important areas to assess in Patients with Delirium

Ability to take care of self, ways to increase orientation to reality, present physiologic conditions, and risk for harm

What is the treatment focus of the Maintenance phase with Schizophrenia?

Achieving optimal wellness, Lessening residual or secondary disability Done by continued support and teaching, cognitive and social skills enhancement, vocational rehabilitation, medication maintenance.

Secondary Crisis intervention

Address safety issues, lower acute anxiety, Immediate goals to address current issues.

Adverse effect of Second Generation Antipsychotics

Agranulocytosis

What is a crisis?

An acute time-limited phenomenon is experienced as an overwhelming emotional reaction to a problem perceived as unsolvable.

Side effects of Second generation Antipsychotics

Anticholinergic ( Urinary retention, dry mouth, blurry vision, constipation, tachycardia.) EPS, Increase prolactin levels, Sexual dysfunction Metabolic syndrome (HTN, hypercholesteremia, increased insulin resistance) Seizures,

Interventions for delusions table 17.7

Assess if external controls are needed( patient may believe someone is trying to harm them) Shift focus and engage in reality based activities such as walking, yoga, exercises, Don't argue with patients or touch them

An 84-year-old tells the nurse, "I do four or five number puzzles everyday to keep my brain healthy and sharp." When considering a holistic approach to maintaining mental health, the nurse should respond: A. "It is more important for you to have physical activity B. "Let's think of some other activities we can add to your daily routine." C. "repetition of the same activity is not helpful for for keeping your brain healthy." D. "There are some herbal preparations that will also help keep your brain sharp."

B.

Which intervention is best associated with minimizing the effects of dementia-induced aphasia? A. Speaking in a slow, deliberate manner B. Increasing reliance on nonverbal communication methods C. Delivering information in short, simple phrases d. Which intervention is best associated with minimizing the effects of dementia-induced aphasia?

B. Aphasia presents with the client having difficulty in expressing oneself verbally, understanding speech, and with reading and writing. When aphasia starts to hinder communication, nonverbal communication becomes important. Cognitive dysfunction results in issues with processing information that are assisted by presenting information in a slow, deliberate manner using simple, short phrases. Reminiscing therapy is appropriate when addressing memory loss.

Which client statement reflects resiliency associated with a situational crisis he or she is experiencing? A. "I wasn't planning on another pregnancy but I would never consider an abortion." B. "Losing my son is so hard but when my father died, grief counseling really helped." C. "Retirement is something I had always dreaded but so far it's been pretty enjoyable." D. "When my son died in the flood, I depended on my family and friends for support."

B. Situational crises are somewhat common, and at least some of them, like experiencing a loss through death, will be experienced by all individuals during their lifetime. Response to the situation depends in part upon the degree of support available. The existence of caring friends, family members, and groups as well as previous success in navigating life events (resiliency), and the overall physical and emotional health of the individual all contribute to an individual's resiliency. The correct option represents both a situational crisis and resiliency based in a past experience. Retirement is a maturational crisis, and the option demonstrates acceptance but not resiliency. While the pregnancy is a situational crisis, the option demonstrates a value but not resilience. The death of a loved one in a flood is an example of an adventitious crisis and the option doesn't demonstrate a past experience upon which to rely.

3. The nurse in a high school meets with a small group of students the day after a school bus accident resulted in the death of five students. Which comment should the nurse use to begin the session? a. "Sometimes life is not fair. Yesterday's tragedy is an example of just how unfair it can be." b. "We're grateful that you are safe. Our discussion is to talk about feelings associated with yesterday's tragedy." c. 'We've had a terrible loss. I also feel your pain. You need to talk about your feelings associated with the event." d. "Thank you for coming today. As school leaders, we know it is very important to respond to yesterday's tragedy."

B. In Phase 1 of crisis, a person faces a conflict or problem that threatens self-concept and respond with increased anxiety. Nurse should first assure students are safe and then specify reason for session

4. A patient diagnosed with schizophrenia complains to the nurse about persistent feelings of restlessness and says, "I feel like I need to move all the time." What is the nurse's next action? A. Add activity group to pt. plan of care B. Assess the patient for other Extrapyramidal symptoms C. Perform a full mental status eval of patient D. Educate the patient about the psychomotor agitation associated with Schizophrenia

B. Patients comment suggests akathisia is occurring. Which is an Extrapyramidal symptom

1. A patient smiles broadly at the nurse and says, "Look at my clean teeth. I brushed them with scouring powder because the label said, "It brightens and whitens everything." Which term should the nurse include when documenting the encounter? a. Circumstantiality b. Concrete thinking c. Poverty of speech d. Associative looseness

B. Concrete thinking refers to literal interpretations with an inability to comprehend abstract concepts

. A patient diagnosed with schizophrenia says, "My coworkers are out to get me. I also saw two doctors plotting to overdose me." What term identifies how this patient is perceiving the environment? a. Disorganized b. Unpredictable c. Dangerous d. Bizarre

C

A client has recently lost all his or her possessions in a fire a month ago. Which assessment data suggests that hospitalization should be considered? A. Has gained 10 pounds since the fire. B. Drinks a six pack of beer daily. C. States, "The fire made my life so hopeless." D. Reports, "I really do need someone to talk to."

C In crisis situations, it is important to evaluate the person's level of anxiety. Common coping mechanisms may be overeating, drinking, smoking, withdrawing, seeking out someone to talk to, crying, yelling, sleeping too much, praying, or engaging in other physical activity. The potential for suicide or homicide must be assessed. If the patient is thinking of harming themself or someone else, or is unable to take care of personal needs, hospitalization should be considered. The correct option demonstrates a potential risk for suicide.

Which assessment question will provide the nurse with information concerning the client's perception of the situational crisis of losing their job? A. "Do you have a plan for meeting your financial obligations while unemployed?" B. "Have you ever been out of a job before?" C. "How much will being unemployed for several months affect your life?" D. "Who can you rely upon for help while you are looking for a job?"

C Whether an event is perceived as a crisis is, in part, dependent on the outlook and strengths of the patient. Therefore it is important to view the event through the eyes of the patient. The nurse's initial task is to assess the individual's and possibly the family's perception of the problem. The correct option directly assesses the client's perception of the crisis. While the other options are not inappropriate, they don't focus on perception.

Which nursing intervention best meets the unique needs of the client diagnosed with delirium? A. Reassuring the client during periods of fearfulness B. Keeping environment well lighted C. Frequently assessing level of consciousness and orientation D. Concisely explaining why an intervention is going to occur

C. Because levels of consciousness can change throughout the day, the patient needs to be checked for orientation (time, place, and person) frequently during different times of the day. While appropriate the remaining options address needs of any client experiencing either dementia or delirium.

Which statement made by the client demonstrates an understanding of clozapine? A. "It will provide me with some protection against a heart attack." B. "It will help keep me from developing type 2 diabetes." C. "I'm at a risk for developing infections." D. "This medication cost less than the first-generation antipsychotic types."

C. Clozapine is an example of a second-generation antipsychotic (SGA) atypical medication. Unfortunately, the incidence of neutropenia (neutrophil count (ANC) less than 1500/µL) among clozapine-treated patients is 2% and agranulocytosis (white blood cell count (WBCs) below 3,500 WBCs per microliter of blood (mcL). 0.8%. These abnormalities can lead to serious infection or death. However, the SGAs in general have a higher risk for metabolic syndrome (weight gain, diabetes, and dyslipidemia) than the first-generation antipsychotics. As well, the SGAs lead to more cardiovascular events and premature deaths than the first-generation antipsychotics. The SGAs are also considerably more expensive than the more traditional FGAs.

While interacting with a 62-year-old adult diagnosed with a progressive neurocognitive disorder, the nurse observes that the adult has slow responses and difficulty finding the right words. What is the nurse's best initial action? a. Suggest words that the adult may be trying to remember. b. Ask the adult, "Are you having problems saying what you mean?" c. Use silence to allow the adult an opportunity to compose responses. d. Discontinue the interaction to prevent further frustration for the adult.

C. Silence is a therapeutic communication technique. It is respectful and provides an opportunity for the adult to compose responses

5. A family member asks the nurse, "I know my Uncle's Alzheimer's disease has progressed, but is there any medication that can help him now? Which response by the nurse is correct? A. "I'm sorry, but there are no medications that help with severe Alzheimer's disease." B. "Alzheimer's disease sometimes stabilizes, Let's hope that happens in this situation." C. "There are a few medications that may help. Let's discuss it with the Health Care Provider." D. "It sounds like you're having difficulty accepting that your uncle's disease is irreversible. Would you like to talk about those feelings."

C. Memantine, an NMDA antagonist, and some cholinsterase inhibitors may be prescribed to treat symptoms of moderate to severe Alzheimers disease

What assessment history data indicates that a client is at increased risk for developing Alzheimer's disease (AD)? A. Re-occurring bladder infections B. Currently being treated for anorexia nervosa C. Has sustained two serious concussions D. Current hypotension

C. There is little known about the actual causes of AD. There are a number of risk factors, including advancing age, head trauma, obesity, diabetes, unmanaged hypertension, low socioeconomic status and educational levels, and the presence of apolipoprotein E4 (APOE E4 allele), among others. Infection is a risk factor for delirium. There is no known connection between AD and anorexia nervosa.

3. Three days after beginning a new regime of haloperidol (Haldol), the nurse observes that a hospitalized patient is drooling, has stiff and extended extremities, and has skin that is damp and hot to the touch. The patient has difficulty responding verbally to the nurse. What is the nurse's correct analysis and action in this situation? a. A seizure is occurring place the patient in a lateral recumbent position and monitor b. Serotonin syndrome has developed; place an intravenous line and rapidly infuse D51/2 normal saline c. Neuroleptic malignant syndrome has developed; prepare the patient for immediate transfer to a medical unit d. An acute dystonic reaction is occurring; promptly administer an intramuscular injection of diphenhydramine (Benadryl).

C. NMS is characterized by decreased LOC, greatly increased muscle tone, autonomic dysfunction(hyperpyrexia, labile HTN, tachycardia, tachypnea, diaphoresis, and drooling.

2. An adult has had long-term serious medical problems and has just started a new medication resulting in decreased libido and sexual performance. The adult's spouse privately says to the nurse, "I don't feel loved anymore. I feel sexual urges, but my partner is not interested." Select the nurse's therapeutic response. a. "Tell me about how your partner shows love for you." b. "You're describing a scenario that many couples face." c. "Let's consider some other ways you can satisfy your needs." d. "I'm glad you are able to talk about and accept your situation."

C. Situation presents a maturational crisis, helping to consider other options is the most therapeutic response

A nurse begins a therapeutic relationship with a patient diagnosed with schizophrenia. The patient has severe paranoia. Which comment by the nurse is most appropriate? a. "Let's begin by talking about the goals you have for yourself." b. "I understand that you have problems with fear and suspiciousness of others." c. "As you get to know me better, I hope you will feel comfortable talking to me." d. "I am part of your treatment team. Our goal is to help stabilize your symptoms."

C. paranoia causes an inability to trust the actions of others. The focus of therapy is to decrease anxiety and defensive patterns. Application of said principles is helpful for establishing trust and rapport

Common Causes of delirium

CNS stimulants, dehydration, hypoxia, infections, Wernicke's, hypo/hyperthermia, metabolic disorders, sleep deprivation, Drugs

What are some other specific mental alterations in schizophrenia?

Concrete thinking( inability to think figuratively) Ex: What brought you to the Er today? "A cab." illogical, haphazard, and confused thinking, "Then the world became embryonic in Africa, -and there was no need for communication." Circumstantiality- excessive detail Tangentiality- wandering off in conversation w/o return to subject @Mrs. Herring jk Neogolisms- made up words Word Salad Echolalia- repeating other person's words Clang association- meaningless rhyming of words

4. A patient on an acute psychiatric unit removed the cap from the ceiling sprinkler, resulting in rapid flooding of the unit. After moving patients to a safe area, which action should the nurse take next? a. Conduct individual sessions with patients regarding the experience b. Increase the volume of overhead music to distract patients from the event c. Implement a psychomotor activity to reduce anxiety associated with the event d. Lead a group session with patients to discuss feelings associated with the event

D. After addressing safety concerns, the nurse should take steps to help patients feel safe and lower anxiety, such as providing quiet, building rapport, and acknowledging their crisis experience. A group session will allow patients who are unable to articulate their feelings to hear from patients who can.

Which statement best demonstrates a client's understanding of how years of addiction have affected their ability to mature normally? A. "My years of addiction allowed me to avoid being a mature person." B. "Taking on grown-up responsibilities is certainly a challenge." C. "I don't think I've ever had to think like an adult before." D. "I've got to learn how to address my problems like an adult would."

D. Ongoing evaluation will be performed until the crisis has resolved sufficiently to allow a return to normal pre-crisis functioning. As the patient's anxiety level reduces from severe to moderate to mild through successful interventions, the patient will need less support and return to independence. The correct option demonstrates independence, social engagement, and a return of enjoyment to one's life. The remaining options demonstrate consideration associated with returning to the familiar life situations (work, faith-based comfort).

What is secondary dementia

Dementia caused by a reversible component

Triage-

Determining which patients need rapid care and which have more minor injuries

Example questions of assessment of Support systems

Do you have a spiritual community or place of worship? Whom do you talk to when you are overwhelmed?

What is Catatonia?

Extreme motor agitation or severe psychomotor retardation(which is a slowing down of thoughts and reduction in physical movements The onset of this condition is typically abrupt

What are delusions?

False fixed beliefs that can't be corrected by reasoning

What is Stage 4 (late/end stage) like?

Family/self recognition may disappear, nonambulatory, forgets how to eat, problems associated with immobility ex: pneumonia, pressure injuries, contractures Severe regression

How should a nurse respond when patients present with delusions

First address the feeling, present reality-based info, and express empathy Ex: Patient "I see now.. you are an ISIS fighter who wants me destroyed." Nurse: "I don't want to hurt you, Tom. I am your nurse for the day. Thinking others want to destroy you must be very frightening. Don't try arguing with the patient

In crisis what must we assess for in a patient?

First we must determine whether the client is at risk for harm. Then we will assess patient's perception of event(crisis or anxiety//depression), patient's available support, and patient's usual coping skills

Example questions of assessment of Event perception

Has anything traumatic happened to you in past? How does this situation affect your life? What would need to be done to resolve this situation?

What is the treatment focus during the Acute phase of Schizophrenia

Immediately intervene on the crisis, establish safety, and Stabilize symptoms This will be done by Medication, Psychiatric eval, Supportive care and involving family in treatment decisions In the Sub acute phase we want the patient to be abe to take care of own needs, use social supports, have living arrangements and access economic resources

Primary care for Crisis intervention

Improving mental health and good coping strategies to improve resilience to crisis events improve

Interventions for patients with Delirium?

Introduce self and role with every interaction; assign same personnel Adress reality based ideas, such as weather and time Avoid restraints use sitters Enforce sleep period Set limits on abusive behaviors validate feelings and clarify perceptions Promote activity during the day time

What are delusions of reference?

Misconstruing of trivial events/ remarks and giving them personal significance

What puts patients at a huge risk for delirium

Past instances of delirium and other neurocognitive issues

What is the main goal during the acute phase of Schizophrenia

Patient Safety and Medical Stabilization

Example conversation of how to talk to someone with a schizophrenic hallucination

Patient: "I hear my mother's voice saying terrible things about me. She says I am a horrible person and that I should've never been born." Nurse: "That must be very upsetting (no shit shirlock) Are you feeling upset? Patient: Yes she makes me feel very bad Nurse: Tell your voice to go away. (The nurse then suggests a reality-based activity.) I hear you are very good at cards. Lets go over to the table and play a game of cards

Interventions for Paranoia Table 17.7

Place youself beside patient not face to face Avoid direct eye contact, use matter of fact approach, offer prepackaged foods Engage in reality based activities, Use least restrictive measures first if anxiety escalates

Which symptoms are typically associated with the onset of acute phase of schizophrenia

Positive Symptoms

What are the different kinds of symptoms in schizophrenia

Positive symptoms: hallucinations, delusions, bizzare behavior, paranoia Negative Symptoms: Lack of symptoms, Anhedonia, lack of motivation, apathy. Cognitive symptoms: impairment in memory, disruption in social learning, Mood Symptoms: depression, anxiety, dysphoria, suicidality

What are the four phases of schizophrenia?

Prodromal phase: These are S/Sx that precedes an acute exacerbation including social withdrawal, deterioration in functioning, depressive mood, perceptual disturbances, magical thinking, and peculiar thinking. These S/Sx can occur a month or year before the first psychotic break Acute Phase: A period of severe symptoms in four categories Positive symptoms: hallucinations and delusions, Negative Symptoms: Apathy, withdrawal, lack of motivation, Cognitive symptoms- Attention problems, impairment of memory, and decision making, And mood symptoms- Depression, anxiety and mania Stabilization phase: Period in which acute symptoms decrease in severity. Maintenance phase: Period in which symptoms are in remission(there may be residual symptoms)

What is Stage 2 of Alzheimers like?

Progressive memory loss, memory interferes w/ abilities Withdrawn, denial, fears losing ones mind, depression, declines in abilities to care for self

Tertiary Nursing Interventions for crisis

Recovery from a disabling mental state from the crisis. Use community resources as well as social support, management of mental state from a crisis.

What are some psychoeducational points that schizophrenic patients and families need to be aware of regarding Information

S/sx, causes, course of disease Acknowledge and lessen stigma of the disease Minimize comorbid symptoms such as drug use,

What is Stage 3 (moderate to Severe) Alzheimers like

Shows adl deficits Loss of reasoning evident, decline in verbal communication reduced stress threshold

What are some early warning signs of relapse into schizophrenia?

Social withdrawal, increased/decreased sleeping, increased bizarre thinking

What is stage 1 like in Alzheimers?

Stage 1(mild) forgetfullness: short term memory loss, loses things, forgets often. Pt. Aware of problem, depression common. Loses energy and drive

S/Sx of agranulocytosis

Sudden fever, sore throat, mouth ulcers, bleeding gums, and weakness.

Diagnostic Criteria for Schizophrenia

Two (or more) of the following, each present for a significant portion of time during a 1-month period. Delusions Hallucinations Disorganised speech & behaviour Negative symptoms For a significant portion of time since onset of disturbance level of functioning must decrease below previous level of functioning Continuous signs of disturbance must persist for 1 month or more Secondary issues must be ruled out

What is the treatment focus during the Stabilization phase

Understanding and accepting of illness and developing a strategy to manage the illness This is done by Identification of prodromal and acute symptoms, relapse prevention, assistance with situational problems, medication teaching and management

Table 17.6 interventions for delusions

Watch for cues of hallucinations( Eyes darting, muttering, staring sideways) Ask directly if they are having hallucinations and if so what are they saying Accept that they are real to the patient, but that we don't hear or see them. Ask them to tell the voices to go away Decrease stimulation and keep the patient focused on simple reality-oriented things like games or such assess for anxiety.

What is existential crisis?

When one is questioning life purpose or entire spiritual reality. This can happen with the situational crisis. Can have positive effects such as new motivation, higher goals for self-actualization Could make life uncertain and make depression.

What is Alzheimer's disease?

a progressive degenerative disease of the brain that results in dementia

What does Clozapine carry a risk for

agranulocytosis, seizures, and myocarditis this drug is used treatment refractory patients

What is erotomania?

delusion that someone is in love with or infatuated with you

extrapyramidal side effects

difficulty speaking or swallowing, loss of balance control, pill rolling of hands, masklike face, shuffling gait, rigidity, tremors; and dystonic- muscle spasms, twisting motions, twitching, inability to move eyes, weakness of arms or legs

Illusion definition

errors in perception of accurate sensory stimuli ex: the folds in the blankets are rats

Hallucinations

false sensory experiences

neuroleptic malignant syndrome

fever, muscle rigidity, altered mental status, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, loss of bladder control

What are the goals of the stabilization and maintenance stage

improve functional ability, anxiety control, and relapse prevention

Anhedonia

inability to experience pleasure

avolition

lack of motivation

What is a developmental crisis?

occurs as a person moves through the stages of life. This is often due to having to learn new coping skills, anxiety with change, and interruptors to development such as druv and alcohol addiction, or inability to develop new coping mechanisms.

dysphoria

sense of great unhappiness or dissatisfaction(feeling emotionally unwell