connie mental health test 3

Which patient statement would be best documented as a subjective assessment finding supporting a psychiatric diagnosis of dissociative fugue?

"I cannot recall why I'm living in this town." The patient in a fugue state frequently relocates and assumes a new identity while not recalling his or her previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.

The son of an elderly client with dementia is talking to the nurse about discharge. He indicates that his father's physician has given him 48 hours to decide on a living situation. The nurse discusses possible living arrangements and provides contact information. The nurse knows that the son requires further teaching when he says:

"I want the social worker to make this decision so Dad won't blame me." Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.

Which of the following is the best example of all-or-nothing thinking, a common cognitive distortion of patients with an eating disorder?

"If I allow myself to gain weight, I'll become immense." Out of the choices provided the BEST answer that is an example of all-or-nothing thinking is: #1 "If I allow myself to gain weight, I'll become immense."

A patient referred to the eating disorders clinic has lost 35 pounds during one summer. Which of the following questions would be best if the nurse wished to assess the patient's eating patterns?

"What do you eat in a typical day?" Rationale: While each of the questions might be appropriate to ask, only option 3 focuses on the client's eating pattern. Option 1 focuses on distortions in body image. Option 2 is unrelated to eating pattern. Option 4 explores the client's feelings about weight.

CNS Stimulants Withdrawal (Table 19-6)

(CNS) stimulants produce an imbalance of dopamine and norepinephrine. A patient withdrawing from heavy cocaine use can experience depression, paranoia, lethargy, anxiety, insomnia, nausea and vomiting and sweating and chills. Safety is the most important nursing intervention. o Fatigue, depressed, agitation, apathy, anxiety, sleeping, disorientation, lethargic, cravings, dilated pupils know what nursing interventions are important. Suicide is important to be aware of.

A client is admitted for acute alcohol withdrawal. Which of the following clinical manifestations indicate the need for treatment of acute alcohol withdrawal?

-appear within 4-12 hrs -abd cramping -vomiting -tremors -restlessness -inability to sleep -TACHYCARDIA -HTN -transient hallucinations or illusions -anxiety -increased RR, temp -tonic clonic seizures -diaphoresis

The nurse working on a memory care unit hears her client in a group of his peers reminiscing about his past. How might this behavior affect the client's daily functioning on the unit?

1. NURSE SHOULD:​ Encourage Reminiscing about Happy Times. (Rationale: remembering accomplishments and shared joys help distract patient from deficit and gives meaning to existence Encourage reminiscing about happy times in life-remember accomplishments and shared joys help distract patient from deficit and give meaning to existence o Make patient feel less lonely

The nurse is assessing a patient who has been diagnosed with hypochondriasis. Which clinical manifestation would the nurse most likely assess in this patient?

high level of anxiety and alarm about their health lasting at least 6 months excessively check for problems avoid medical care other possible diagnoses such as anxietydisorders.

Nurses working in a family planning clinic for women routinely ask clients about whether they have experienced domestic violence. The purpose of having this question in the assessment tool is that:

???? Ask the client about the injuries and if they are related to abuse. Encourage the client to leave the batterer immediately. Set up an appointment with a domestic violence counselor. Ask the suspected abuser about the victim's injuries.

Which nursing intervention(s) would be most likely included in a plan of care for a patient with bulimia nervosa? Select all that apply.

A. Teach that fasting sets one up to binge eat B. Assist client to identify trigger foods D. Teach client to plan and eat regularly scheduled meals ??? ▪ #1 Priority​ = stabilization of HEART and ELECTROLYTES!!! imbalanced nutrition, deficit fluid volume 1. Medical stabilization is always the FIRST priority ● Problems resulting from purging are disruptions in electrolyte and fluid balance and cardiac function. Medical examination is VITAL! Make sure to check: ▪ Electrolyte levels ▪ Glucose level ▪ Thyroid function test ▪ Complete blood count ▪ Electrocardiogram (ECG) 2. Psychiatric evaluation- (depression and suicide concerns) 3. Besides assessment of use of diuretics/laxatives ask about diet pills, amphetamines, energy pills.

Which of the following interventions are included as part of milieu management in the plan of care for a patient with anorexia who is admitted for inpatient treatment? Select all that apply.

Adherence to a selected menu Observation during and after meals Monitoring during bathroom trips Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the patient's eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe patients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

The nurse is caring for a client who is receiving treatment for an overdose of phencyclidine piperidine (PCP). Which of the following interventions would the nurse expect to see as part of a collaborative plan of care?

Administer ammonium chloride.?????? ------------------------------------------ **Put in room with minimal stimuli. **Do not attempt to talk down patient! **Speak slowly, clearly, and in a low voice. **Administer diazepam.

Alcohol Withdrawal - Symptoms & when they peak

Alcohol Withdrawal (ETOH): Symptoms and Peak times: o *Early signs of Withdrawal:* ​develop within a few hours after cessation of reduction and peak​ after 24 to 48 hours and then rapidly disappear. Patient will experience being hyper alert, jerky movements, irritability, startle easy, experience subjective distress. *Early symptoms of withdrawal*: ​appear 7 to 48 hours after cessation and continue for 5 to 7 days. Patients will experience intense tremors, cramps, vomiting, increase HR, increased BP and temperature, and possibly grand-mal seizures. Tremors, restless, cramps, vomiting, insomnia, tachycardia, increase blood pressure, seizures o 2-3 days after use of alcohol ------------------ -appear within 4-12 hrs -abd cramping -vomiting -tremors -restlessness -inability to sleep -TACHYCARDIA -HTN -transient hallucinations or illusions -anxiety -increased RR, temp -tonic clonic seizures -diaphoresis

A patient is referred to the mental health center by the family health care provider. Over the past year, the patient has cooked gourmet meals for family members, but eats only tiny portions of the food. The patient wears layers of loose clothing, saying, "It's just my style." The patient's weight has dropped from 130 to 95 pounds. The patient has amenorrhea. Which medical diagnosis are the history and symptoms are most consistent with?

Anorexia Nervosa

A patient admitted yesterday for injuries sustained in a fall while intoxicated believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe?

Benzodiazepine, such as lorazepam (Ativan)

An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?

Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

A nursing care plan contains the intervention "monitor for complications of refeeding syndrome." Which body system should a nurse most closely monitor for clinical manifestations of dysfunction?

Cardiovascular Refeeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the refeeding syndrome.

A child with ADHD will begin medication therapy. Which of the following classifications of medications should the nurse prepare to teach the patient and family about?

Central nervous system stimulants Central nervous system stimulants, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with attention deficit hyperactivity disorder. The other medication categories listed would not be appropriate.

Violent Behavior - Highest Risk (Box 24-1)

Childhood aggression, Males aged 15-24, Setting fires, animal cruelty during childhood, diagnosis of conduct disorder, Childhood family history of violence, Abuse of alcohol and/or other substances, Low socioeconomic status/Poor population, Learned angry reactions [societal norms], Genetics, Neurobiological factors and brain structure. Understand that potential violent​ behavior toward others may be seen in clients with delusions of others out to cause harm. People feel persecuted. Violent Behavior - Highest Risk (Box 24-1) o Acts on violence, leads to significant physical and psychological harm to others, restless, slamming doors, pacing, does the patient wish to harm? Highest Risk: ▪ Irritability, pacing around the room, slamming doors, clenching fists, tense facial expression, mumbles to self, uses profanity, loud voice, suspiciousness, ETOH, possession of a weapon o Nurse should ask patient, "What will help now?" Risk for other-directed violence- ​history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. ● Social learning theory, or intergenerational violence theory of family violence purports that behaviors are developed through role modeling, identification, and human interaction. o A child who witnesses abuse or is abused in the family of origin learns that violence is an acceptable reaction to stress and internalizes the violent behavior as a behavioral norm. Intergenrational abuse is considered a contributing factor in many cases of intimate partner violence (IPV), elder abuse and child abuse.

An elderly client with cognitive impairment is combative and pulled out a nasogastric tube, intravenous line, and indwelling urinary catheter. What can the nurse anticipate that the health care provider will most likely prescribe?

Cholinesterase inhibitors- galantamine, donepezil, rivastigmine, NMDA antagonist-memantine Typical daily life may suffer. Ensure the home is safe for the patient so the family members may attend to necessary activities of daily life. For Cognitive impairment: o physostigmine (Antilirium), o tacrine (Cognex), o donepezil hydrochloride (Aricept), o rivastigmine tartrate (Exelon), o galantamine hydrobromide (Razadyne), o Memantine hydrochloride (Namenda). For agitation, aggression, hallucinations, thought disturbances, and wandering o risperidone [Risperdal], o olanzapine [Zyprexa], o quetiapine fumarate [Seroquel], o ziprasidone [Geodon o haloperidol [Haldol] *Medications given for Behavioral Symptoms/Combativeness in Alzheimer's Patients* o "Start low and go slow" o Aricept - helps brain function longer o Atypical antipsychotics such as Risperidone [Risperdal], Olanzapine [Zyprexa], Quetiapine Fumarate [Seroquel] - they are effective for the short-term only. You need to TAPER OFF these meds - NOT COLD TURKEY! o Insulin is also effective for Alzheimer's o Rivastigmine, Donepezil and Memantine = used to help brain function longer

A patient with a history of cocaine use reports a concurrent history of using other drugs in order to counteract the effects of cocaine. Which drug is this patient likely to have abused?

Cocaine Abuse & Alcohol​: How are they related? Alcohol is a depressant and cocaine is a stimulant. So alcohol diminishes the effect cocaine has by softening the intense letdown of withdrawal. o Cocaine is a stimulant, alcohol is depressant, balances each other out Cocaine is a stimulant and alcohol is a depressant. The majority of people with a cocaine abuse disorder they have an alcohol abuse disorder. Alcohol can neutralize the effects of cocaine. They balance each other out.

Cocaine Abuse & Alcohol - How are they related?

Cocaine Abuse & Alcohol​: How are they related? Alcohol is a depressant and cocaine is a stimulant. So alcohol diminishes the effect cocaine has by softening the intense letdown of withdrawal. o Cocaine is a stimulant, alcohol is depressant, balances each other out Cocaine is a stimulant and alcohol is a depressant. The majority of people with a cocaine abuse disorder they have an alcohol abuse disorder. Alcohol can neutralize the effects of cocaine. They balance each other out. alcohol number one drug of abuse

A nurse is preparing a care plan for a newly admitted patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be highest priority for the plan of care?

Disturbed body image Signs and Symptoms -Symptoms of depersonalization; feelings of unreality or body image distortions Nursing Diagnoses (NANDA) -Disturbed body image

An 11-year-old is absent from school to stay at home and care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "I don't think my parents like me very much. They call me stupid and say I never do anything right." Which type of abuse is most likely?

Emotional Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

Which of the following nursing interventions is the highest priority while working with a patient who has a somatoform disorder for the first time?

Health Teaching and Health Promotion When somatization is present, the patient's ability to perform self-care activities may be impaired. In general, nursing interventions involve the use of a straightforward approach to support the highest level of functioning. For example, the patient who demonstrates arm paralysis can be encouraged to eat using the other arm. The patient who is experiencing blindness can be told where foods are located on his or her plate by comparing the plate to a clock face. These strategies are effective in reducing secondary gain. Assertiveness training is often appropriate to teach a direct means of meeting needs and thereby decreases the need for somatic symptoms. Teaching an exercise regimen, such as doing range-of-motion exercises for 15 to 20 minutes daily, can help the patient feel in control, increase endorphin levels, and help decrease anxiety.

A patient is admitted with a heart rate of 53 bpm, respirations 6/min, temp 96.8 and pinpoint pupils. Based on these clinical manifestations, what substance did this patient most likely overdose on?

Heroin Overdose​: opiod

Which of the following clinical manifestations should the nurse expect to assess in a 2-year-old with suspected autistic disorder?

Failure to develop interpersonal skills Rationale: Distortion in the development of interpersonal skills and language.

Nursing Interventions: Somatoform Disorders

GOAL: To get feelings OUT, so the symptoms aren't there anymore Offer explanations during testing to reduce anxiety Assess if patient can meet Basic Human Needs and Safe & Security Assess for Triggering event/trauma/crisis (ex: divorce, Avoid further reinforcement (ex: taking vitals each time the patient complains of chest palpitations. This is negative reinforcement.) NEVER state that their symptoms aren't real....to the patient they are real. Focus on things other than their symptoms, such as their interests, favorite things to do during the holidays, etc. Be straightforward when the patient is angry to avoid power-struggles Somatoform Disorder Nursing Interventions • offer explanations and support- reduces anxiety (don't reinforce illness) • avoid further reinforcement- direct focus away • observe and record frequency and intensity of somatic symptoms- establishes baseline • DO NOT imply symptoms are not real (they are real to pts) • Assess secondary gains • Use straightforward approach- avoid power struggle • Reinforce pts strengths and problem-solving abilities- contributes to positive self esteem • Stress reduction- provides alternative coping strategies and reduces need for meds 1. Offer explanations and support during diagnostic testing. 2. After physical complaints have been investigated, avoid further reinforcement of the somatic complaints. 3. Spend time with the patient at times other than when he/she is expressing a physical complaint (e.g., when talking about a pet or TV program and give the "reward" of extra attention during those times). 4. Observe and record frequency and intensity of somatic symptoms. 5. Do not imply that symptoms are not real. 6. Shift focus from somatic complaints to feelings or to neutral topics. 7. Assess secondary gains that physical illness provides for patient, such as attention, lack of work responsibility, or guilt of a spouse causing them to stay rather than leave the patient. 8. Use straightforward approach to patient exhibiting resistance or covert anger. 9. Have patient direct all requests to a designated nurse or clinician. 10. Show concern for patient, but avoid fostering dependency needs. 11. Reinforce patient's strengths and problem-solving abilities. 12. Teach assertive communication skills and techniques. 13. Teach patient stress reduction techniques, such as meditation, relaxation, and mild physical exercise.

A client with vascular dementia is experiencing agnosia. She sits at her dining table looking at her food, but doesn't pick up a utensil and try to eat. Which intervention is most appropriate for the nurse to try first?

Hand the fork to the client and say, "Use this fork to eat your green beans." Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do with it. Feeding the client does not address the agnosia or give the client specific directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate unless identifying the fork and explaining or feeding the client are not successful.

A nurse is working with a patient with a histrionic personality disorder. Which of the following nursing interventions must be implemented throughout the inpatient stay?

Interventions for Manipulation 1. Assess your own reactions toward patient. If you feel angry, discuss with peers ways to reframe your thinking to defray feelings of anger. 2. Assess patient's interactions for a short period before labeling as manipulative. 3. Set limits on any manipulative behaviors, such as • Arguing or begging • Flattery or seductiveness • Instilling guilt, clinging • Constantly seeking attention • Pitting one person, staff, group against another • Frequently disregarding the rules • Constant engagement in power struggles • Angry, demanding behaviors 4. Intervene in manipulative behavior. • All limits should be adhered to by all staff involved. • Objective physical signs in managing clinical problems should be carefully documented. • Behaviors should be documented objectively (give time, dates, circumstances). • Provide clear boundaries and consequences. • Enforce the consequences. 5. Be vigilant; avoid: • Discussing yourself or other staff members with the patient • Promising to keep a secret for the patient • Accepting gifts from the patient • Doing special favors for the patient

A 70-year-old client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!" The most therapeutic response by the nurse would be:

It's Tuesday and you are in the hospital. I'm Anne, a nurse."

Which of the following nursing interventions are necessary after administration of naloxone (Narcan)?

Monitor airway. Vital signs every 15 minutes. Narcotic antagonists such as naloxone quickly reverse CNS depression, but because the narcotics have a longer span of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The remaining options are measures unrelated to naloxone use.

Which is an important nursing intervention when giving care to a patient withdrawing from a CNS stimulant?

Observe for depression and suicidal ideation. Rebound depression occurs with withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying all requests is inappropriate; maintaining established limits will suffice.

PCP Overdose - Nursing Interventions (Table 19-10) Phencyclidine Piperidine (PCP)​ or angel dust Overdose:

PCP overdose, nursing Interventions: ● Strong and violent, SAFETY, place in room with minimal stimuli ● Do not attempt to talk down to pt ● Speak slowly, clearly and in a low voice ● Administer Ativan or Haldol for severe behavioral disturbances PCP Overdose - Nursing Interventions (Table 19-10) o Nursing intervention: room with minimal stimuli o Don't talk down to patient o Speak slow, clear, low voice o Diazepam, Ativan, Haldol o SAFETY **Put in room with minimal stimuli. **Do not attempt to talk down patient! **Speak slowly, clearly, and in a low voice. **Administer diazepam. If alert: **Caution: Gastric lavage can lead to laryngeal spasms or aspiration. Haloperidol may be used for severe behavioral disturbance (not a phenothiazine). Acidify urine (cranberry juice, ascorbic acid); in acute stage, ammonium chloride acidifies urine to help excrete drug from body—may continue for 10-14 days. Institute medical intervention for: • Hyperthermia • High blood pressure • Respiratory distress • Hypertension *S/SX* of overdose:​ psychosis, possible hypertensive crisis, cardiovascular accident, respiratory arrest, hyperthermia, and seizures, Pupils: RAPID *Nursing Interventions*:​ If patient is alert—give cranberry juice, ascorbic acid, or ammonium chloride to acidify urine to help the drug excrete from the body, put in room with minimal stimuli; do not attempt to talk down patient!!! Speak slowly, clear voice, and in a low tone. Administer Diazepam or Haloperidol may be used for severe behavioral disturbances

Which scenario bet predicts the highest risk for a patient who may direct violent behavior toward others?

Paranoid delusions of being followed by alien monsters Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. The patient in the correct response has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability.

Nursing Assessment should include: Somatoform Disorders

Patient's level of ability to voluntarily control symptoms Results of patient's diagnostic laboratory tests Patient's limitations in carry out activities of daily living

Alcohol Withdrawal Delirium

Peaks 2 to 3 days (48 to 72hrs) after cessation or reduction of alcohol intake. acute delirium associated with withdrawal from alcohol after prolonged heavy consumption; characterized by intense anxiety, tremors, fever and sweating, and hallucinations *Signs & Symptoms:* ​hallucinations, delusions, insomnia, tachycardia, diaphoresis, htn elevated BP, disorientation. Can result in death from sepsis, MI, fat embolism, peripheral vascular disease, electrolyte imbalances, and aspiration pneumonia. *Medications:* Benzodiazepines: Chlordiazepoxide (Librium): safe withdrawal and anticonvulsant effects. Diazepam (valium), Oxazepam (Serax), Lorazepam (Ativan) *Seizure Control:* Carbamazepine (tegretol) & Valproic acid (Depakote): reduce seizure risk and withdrawal symptoms. Magnesium sulfate: increase effectiveness of Vitamin B1 Thiamine (vitamin B1): IM or IV to prevent Wernicke's encephalopathy. *Alleviation or Autonomic Nervous System:* Propranolol: beta-blocker. Reduce tremor, tachycardia, elevated BP, sweating. Same for Clonidine: alpha-blocker. *When alcohol withdrawal isn't controlled* o Peaks 2-3 days after cessation or reduction of intake and last 2-3 days o S/S: hallucinate, hypertension, cardiac dysrhythmias, delirium

Which of the following statements best indicates a client is utilizing an individualized relapse prevention plan as part of recovery from alcohol dependence?

Relapse prevention plan: Pharmacological: o Disulfiram (Antabuse)- helps relapse of alcohol abuse ▪ If ingested with combination of alcohol, will cause nausea, vomiting, headache and flushing. MUST BE ALCOHOL FREE FOR AT LEAST 14 DAYS o Naltrexone (ReVia)- diminishes alcohol cravings, possibly by reducing reinforcing effects of alcohol ▪ Helpful in acute recovery (first 12 weeks) o Vivitrol (Naltrexone for Extended-Release, Injectable Suspension) ▪ Alcohol abuse only ▪ May be easier for patients recovering form alcohol dependency to use consistently o Acamprosate (Campral)- diminishes alcohol cravings, possibly by reducing intensity of prolonged withdrawal syndrome ▪ Benefit emerges after 30-90 days ▪ Need to be abstinent at least 7 days before use

What is a nurse's legal responsibility if child abuse or neglect is suspected?

Report the suspicion according to state regulations. Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts.

A health care provider writes these new prescriptions for a nursing home resident: 2-g sodium diet; restraints as needed for behavioral problems; limit fluids to 2000 mL daily; continue antihypertensive medication; milk of magnesia 30 mL orally one time as needed if no bowel movement for 3 days. Which of the following is most appropriate for the nurse to do first?

Restraint

Restraint & Seclusion

Restraints may be imposed only on the written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. Only written by HCP others must be considered and documented before restraints o 24 hour one to one observation of patient Each team member is assigned a limb or function to stabilize and hold down. o Chemical Restraints: ​IM Haldol (neuroleptic), IM risperidone, olanzapine or ziprasidone (atypical antipsychotics). Benzodiazepines (Lorazapam): used in acute rage and aggression. o Seclusion or restraint​ is used in the following circumstances: ▪ The patient presents a clear and present danger to self. ▪ The patient presents a clear and present danger to others. ▪ The patient has been legally detained for involuntary treatment and is thought to pose an escape risk. ▪ The patient requests to be secluded or restrained. Restraints and seclusion ● Restraints may be imposed only on written order of the health care provider that specifies the duration during which the restraints can be used. ● The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. ● Refers to any manual method or physical or mechanical device, material or equipment that immobilizes or reduces the ability of a person to move his or her arms, legs, body or head freely or Drug or medication​ when it is used as a restriction to manage a persons behavior or restrict the persons freedom of movement and is not a standard treatment or dosage for the person's condition. ● The least restrictive means of restraint is ALWAYS tried first, and seclusion or restraint is used only after alternative interventions have been attempted (trauma- informed approach, verbal interventions, medications, decrease in sensory stimulation, removal of problematic stimulus, use of sitter.) ● Seclusion/ restraints are used in following situations: o Pt resents a clear danger to self or others o Pt has been legally detained for involuntary treatment and is thought to impose an escape risk o The Pt requests to be secluded or restrained ● Seclusion: ​disruptive, uncooperative, but not a danger to others ● Restraints: ​immediate danger to others

What is the priority nursing diagnosis for a patient who is experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?

Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgement or when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities

A patient is admitted for psychiatric observation after being arrested for breaking windows in the home of a former girlfriend who had refused to see him. His history reveals childhood abuse by a punitive father, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority in the plan of care?

Risk for other-directed violence The defining characteristics for risk for violence directed at others include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control.

An older adult patient with Alzheimer's disease lives with family and goes to day care on weekdays. The nurse at the center observed poor hygiene and discussed this observation with the caregiver, the patient's adult child. The caregiver became defensive and said, "It takes all my time and energy to care for my mother. She's awake all night. Last night she fell down the stairs." Which nursing intervention takes highest priority in this case?

Secure additional resources for the mother's evening and night care. The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

Comorbidities of anorexia

Social phobia, Depression, Bipolar, OCD, anxiety

***Know the difference between Objective and Subjective data in the nursing assessment***

Subjective:​ What the patient tells you. Pain Rating ("PQRST") Objective:​ What you can see, feel, smell, hear and measure (labs, diagnostic testing, etc) know the difference between Objective and subjective data in the nursing assessment*** *** remember to watch for words/statements like: except, requires further teaching, all, priority, first, collaborative vs. nursing

A patient admitted for a heroin overdose received naloxone, which improved her breathing pattern. Two hours later the patient reports muscle aches, abdominal cramps, and gooseflesh, and says, "I feel terrible." Which is the correct analysis of this assessment?

Symptoms of narcotic abstinence are present. The symptoms given in the question are consistent with narcotic withdrawal. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly seen in alcohol withdrawal syndrome.

Common Symptoms: Somatoform Disorders

TMJ, Teeth Grinding @ night, Hypertension, Tension H/A Symptoms: pain gastric or intestinal distress palpitations dizziness shortness of breath sexual dysfunction neurological symptoms fatigue

Which child shows behaviors that are most indicative of a potential mental illness?

The child has been raised by a parent with chronic major depression. Children raised by a depressed parent have an increased risk of developing an emotional disorder. Familial risk factors correlate with child psychiatric disorders, including severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. The chronicity of the parent's depression means it has been a consistent stressor. The other factors are not as risk- enhancing.

Which behavior best describes physical aggression?

These behaviors reflect rage, hostility, and potential for physical assault or verbal destructiveness and can be directed at others or oneself; aggression is a hostile reaction that occurs when control over anger is lost. . Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient standing by the pool table Anger, Aggression and Violence ● Physical Aggression - Signs/Symptoms o Rage, hostility, potential of physical assault, or verbal destructiveness ● Violent Behavior - Highest Risk (Box 24-1) o Acts on violence, leads to significant physical and psychological harm to others, restless, slamming doors, pacing, does the patient wish to harm? ● Restraint & Seclusion o Only written by HCP others must be considered and documented before restraints o 24 hour one to one observation of patient Anger:​ an emotion/feeling. Aggression:​ physical act of hostility Violence:​ force that is intended to harm, damage or violate ● Ensure YOUR SAFETY FIRST as a nurse! (Also, don't wear jewelry, necklaces or anything they can grab, pull or use to strangle you) ● Anger & Aggression are preceeded by feelings of Vulnerability. ● Physical Aggression - Signs/Symptoms o RED FLAGS​: setting fires, animal cruelty during childhood, or conduct disorder o Has a history of violence (#1 predictor), impulsive behavior, ETOH (alcohol or drug abuse go hand-in-hand) Anger vs Aggression ● Aggression:​ is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. AGGRESSIVE BEHAVIOR VIOLATES THE RIGHTS OF OTHERS o Aggression is INTENDED to inflict harm or destruction o Identified by a cluster of characteristics including: pacing/ restlessness, verbal/ physical threats, threats of homicide/ suicide, loud voice; argumentative, tense facial expression and body language. o Aggression may also be appropriate ▪ Self-protective, as in protecting oneself or family ▪ Protective, as in protecting self from being bullied. ● Anger​- an emotional response to a frustration of desires, threat to ones needs (emotional or physical) or a challenge o Anger is a normal and not always logical human emotion o No judgment needs to be passed on to it. o Varies in intensity from mild irritations to intense fury and rage Aggression Know when a patient may be exhibiting clues to potential aggression. When a patient is pacing the halls and swearing loudly, acknowledge the patient and determine the reason behind the outburst. Know the characteristics of nursing diagnoses Risk for Injury, Post-Trauma Syndrome, Disturbed Thought Processes, and Risk for Other -Directed Violence. IF offered a scenario, be able to pick the correct diagnosis. Understand that potential violent​ behavior toward others may be seen in clients with delusions of others out to cause harm. People feel persecuted. Know what behaviors are representative of physical aggression. Aggressive behavior violates the rights of others.

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful to the patient in managing these illusions?

Using the patient's glasses and hearing aids Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

Emotional Abuse

a pattern of attacking another person's emotional development and sense of worth Belittling, criticizes, insults, name calls and undermines. Humiliation & Threatening are common. o The Abused/Patient starts to believe the words their abusers say to them. o Destroys the person's spirit & ability to succeed in life. Emotional abuse- ​includes name calling, excessive criticism, ignoring accomplishments, yelling and swearing, mocking, isolating, locking the victim in a room, threats and intimidation and denying abuse and blaming the victim. ● Examples: having ad adult demean a childs worth or frequently criticize or belittle the child Emotional Abuse o Belittle, criticizes, insults, name calling o STAY WITH PATIENT o Neglected: no food, water, clean

Which of the following are primary characteristics of a person with borderline personality disorder?

assess for suicidal and self-mutilating behaviors. One of the primary nursing guidelines/interventions for clients with a personality disorder is to assess for suicidal and self-mutilating behaviors, especially during times of stress. emotional lability, that is, rapidly moving from one emotional extreme to another. Impulsivity is another top characteristic, along with antagonism. Characteristics: unstable and intense relationship, and instability of affect, marked by frequent mood changes ● Poor impulse control: recurrent suicide attempts, SELF MUTILATION and destructive behaviors. Chronic depression is also common. Shows separation anxiety Manifests ideas of reference Impulsive (suicide, self-mutilation) Engages in splitting (adoring then devaluing persons)

A patient is pacing the hall near the nurses' station, swearing loudly. Which of the following best describes how the nurse should address this situation in a therapeutic manner?

c. "You seem upset. Tell me about it." Intervention should begin with analysis of the client and the situation. With this response the nurse is attempting to hear the client's feelings and concerns. This leads to the next step of planing an intervention.

therpuetic communication

clarification summarizing restaing -------------------------------------------------------- non therapuetic do not advise and dont ask y

Which intervention is most effective in managing excessive demands from a client with borderline personality disorder?

d. be consistent in response to client demands

Child Abuse - Nurse's Legal Responsibility & Potential Nursing Dx (Table 21-2)

deliberate action that is harmful to a child's physical, emotional, or sexual well-being o Highest at Risk: Children under the age of 4 o *Nursing Priority:​ Child's safety and wellbeing!* o Physical Symptoms: ▪ Bruises in different stages of healing ▪ Bite marks, welts, scratches, broken bones ▪ Poor hygiene, malnourished, school problems, missing school, UTI's, bloody clothing or underwear, can't sit/walk due to abuse, lag in development. *Behavioral Symptoms* ▪ Excessively scared/fearful of parents or authoritative figure ▪ Constant efforts to please ▪ Truancy, distorted views of sex, begging/stealing food ▪ Inappropriate behavior (too adult/childlike) ▪ Mistrusts adults, hides bruises *Nursing Assessment* ▪ *DO*:​ private interview,​ sit NEXT​ to child, tell them it is confidential, use language they can understand. Use Dolls/Puppets to have the child reenacts the situation (great for preschoolers)​. Use body map to indicate areas of abuse. Kids may not want to "betray" their parents - even when abused. ▪ *DO NOT*:​ ​press/poke for answers, let them feel "at fault", group interview, have them remove clothing, display emotions of shock (remain neutral) *Nursing Responsibilities* ▪ Nurse has legal responsibility to report abuse/neglect when proven or suspected. Reports are confidential & vary by state. ▪ SAFETY of the child is your FIRST and most IMPORTANT priority!! ▪ Safety, Risk for Injury, & Injury are primary nursing diagnosis Child abuse ● Physical abuse- bruises, wounds, injuries in different stages of healing, bald patches on scalp, retinal hemorrhage o Behavioral: excessive fear of parents or constant effort to please, wary of adult contact, nightmares or anxiety, obvious attempts to hide bruises/injuries, regressive behavior, withdrawn, depressed or aggressive/disruptive behavior ● Neglect- (MOST COMMON REPORTED ABUSE) malnourished, underweight, poor hygiene, unattended physical problems, educational neglect/ lack of education o Behavioral: soiled clothing, begging, stealing food, emaciated or distended belly, arrives early or stays late at school, alcohol or dug abuse, psychosomatic complaints ● Sexual abuse- difficulty walking or sitting, itching in private areas, UTI, painful urination, torn, stained or bloody underclothing, STI, especially in preteens, swollen private areas or discharge o Behavioral: mistrust of adults, delinquency or running away, mental orders may develop, advanced or unusual sexual behavior, phobias: dark, men, strangers, leaving the house ● Emotional or psychological abuse-speech disorders, lag in physical development o Behavioral: difficulty in learning and living up to potential, lack of self-confidence, poor social skills, dramatic behavioral changes such as aggressiveness, drug use, change in friends/clothing Potential Nursing Diagnosis and Nurse's legal responsibility -MOST IMMEDIATE CONCERN IS TO ENSURE THE CHILDS SAFETY AND WELL-BEING ● Nursing diagnosis: o Safety and risk for injury o Disabled family coping o Post-trauma syndrome o Anxiety/ fear o Impaired parenting o Acute pain o Delayed growth and development o Imbalanced nutrition: less than body requirements Outcome of the care plan is that the physical, emotional, sexual abuse or neglect has discontinued. Short-term goals: ● Receiving medical care within 1 hour ● Notification of proper authorities ● Maintaining the childs safety Legal responsibility​- responsible for reporting to the appropriate child protective agency, proof is not necessary, but if there is suspicion or the child says something is happening, there is enough ground to report. Once reported the CPS agency investigates and makes determination Speculation should not be documented, only the facts. (what patient states) Legal responsible for reporting o Call child protective agency o Not necessary to have proof, only suspicion

A nurse in the emergency department tells the daughter of an older adult woman, "Your mother had a severe stroke." The daughter tearfully says, "Who will take care of me now? My mother always tells me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious." This behavior could best be assessed as:

dependent

A patient sat in silence for 20 minutes after a therapy appointment. The patient appeared tense and vigilant. The patient abruptly stood up and paced back and forth across the day room, clenching and unclenching his fists. Next, he stopped and stared intently into the face of a psychiatric technician. Which of the following best explains the nurse's observations of this patient?

exhibiting clues to potential aggression. The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing.

A patient has blindness related to conversion disorder. In order to assist the patient with eating, which of the following interventions should the nurse implement?

expect the patient to feed him- or herself after explaining the arrangement of the food on the tray. The patient is expected to maintain some level of independence by feeding self, while the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support.

Potential Medications given for alcohol withdrawal, cravings or substance abuse (Table 19-2 & 19-4)

lorazepam ativan benzo o Diazepam, phenobarbital, naltrexone, lorazepam, tegrotol, Librium, clonidine *Disulfiram (Antabuse):*​ helps prevent relapse. Will produce N/V, headache, and flushing if person drinks alcohol while on it. Useful for pt. who have maintained sobriety but have a history of relapse. *Risks*:​ metallic aftertaste, dermatitis, death from high alcohol ingestion. *Naltrexone (Revia)*:​ helps with alcohol cravings and block effects of opiates by reducing the feelings "high." Free from opiates before use 7 to 10 days. Useful in the acute phase of alcohol dependence (first 12 weeks) *Risks*:​ nausea, abdominal pain, constipation, dizziness, headache, anxiety, and fatigue. *Vivitrol (Naltrexone for Extendend-Release, Injectable Suspension​):* used for alcohol abuse only, do not use if pt. has opioid dependence. Easier for pt. recovering from alcohol dependency to use consistently. *Risks*:​ Do not use with pt. that is also using opioids, such as heroin. *Acamprosate (Campral)*:​ helps w/alcohol cravings, by reducing intensity of prolonged withdrawal syndrome. Benefits seen 30 to 90 days later. Reasonably safe w/hepatic impairment. Must be abstinent for 7 or more days. *Risks:*​ diarrhea, decreased libido *Buprenorphine Hydrochloride (Buprnex)(Subutex)(Suboxone)*: ​treatment for outpatient detoxification and maintenance by trained personal. Can prevent symptoms of withdrawal in pt. addicted to opiates. Is an alternative to methadone. *Risks*:​ dizziness, nausea, and respiratory depression

Rationlization

making excuses for bad behavior.

Conversion disorder- (also called Functional Neurobiological Symptom Disorder) - define and nursing interventions

mrs a pt is blind or paralysed, o organic dz process. you manage this pt by putting there food in front of them. the pt is not eating what are you going to do? - show them the food arrangements and they can feed themselves. NEVER FOR U TO FEED THE PT! for you to show the arrangement so they can feed themselves. ------------------------------------ Support the patient but promote independence. For instance, instruct the blind patient on the locations of clothing laid out on the bed and allow the patient to dress independently. o Most common Somatic Symptom Disorder (elderly & women highest risk) o Symptoms are due to stress, insomnia, loss of control/loss of grip on their lives o One or more symptoms of impaired motor or sensory function weakness, or paralysis abnormal movement, speech and difficulty swallowing, seizures • Presents with one or more symptoms of impaired motor or sensory function • Incompatible or exaggeration of recognized neurological conditions, not explained by another mental or medical disorder • Causes significant distress to the patient and impaired social or occupational functioning • Symptoms: (episodes are typically brief but may become chronic) o weakness or paralysis o abnormal movement o swallowing or speech difficulties o seizures or attacks o sensory loss or anesthesia o symptoms involving the senses (blindness or loss of smell) • symptoms are not voluntarily controlled or created. • La bella indifference: patients who are highly distressed or show lack of emotional concern. • Comorbidities include: childhood abuse, depression, anxiety and personality disorders *Nursing intervention: * • Behavioral therapy • Family therapy • Hypnosis • Anxiolytics- used to reduce anxiety • observe and record freq. of somatic symptoms and shift to feelings *Symptoms*: • Patient has motor/sensory deficits, but no medical illness to prove why (Ex: blindness, abnormal gait, seizures, paralysis, can't move a limb, deafness, anesthesia) • Patient may show lack of emotional concern: "La Belle Indifference" • Patient wants medical care, but not really concerned about their symptoms weakness or paralysis abnormal movement abnormal swallowing speech difficulties seizures or attacks sensory loss or anesthesia, symptoms involving the senses (blindness or loss of smell). Symptoms can also be mixed with elements of more than one specifier. this disorder presents with one or more symptoms of impaired motor or sensory function. Findings are incompatible with or an exaggeration of recognized neurological conditions and are not better explained by another mental or medical disorder. *The symptoms are not voluntarily controlled or created. Patients may be highly distressed or show a lack of emotional concern known as la belle indifference*

Borderline Personality - characteristics & nursing interventions

mrs a demonstrates self defeating cycle of behavior, also needs consistency in there care. ---------------- unstable and intense relationship, and, instability of affect, marked by unstable and frequent mood changes. Feelings of anxiety, dysphonia, and irritability can be intense though short lived (emotional lability). Poor impulse control is evidenced by recurrent suicide attempts, self-mutilation, and other self-destructive behaviors (chronic depression is common) Frantic to avoid real or imagines abandonment o Unstable and intense interpersonal relationship o Assess own reaction toward patient o Set limits on manipulation behavior, be vigilant These clients require one to be consistent in responses as these people test boundaries. These patients are often causing personal harm socially. This is known as self-defeating cycle of behavior. Be able to select the behavior based on a scenario offered. self-defeating cycle of behavior is a hallmark of borderline personality disorder, creating difficulties at work, social and family relationships. Individuals with a borderline personality are inflexible and do not compromise easily. Socially inappropriate behavior is common, as is an unwillingness to change and learn new coping skills. BPD desperately seek relationships to avoid feelings of abandonment and chronic feelings of emptiness, while excessive demands, behavior and uncontrollable anger drives people away. Experiences dissociative states under stress. SPLITTING- inability to integrate positive and negative qualities of individual into one person- thinks in EXTREMES (really good or really bad) *Characteristics*: unstable and intense relationship, and instability of affect, marked by frequent mood changes ● Poor impulse control: recurrent suicide attempts, SELF MUTILATION and destructive behaviors. Chronic depression is also common. *NURSING INTERVENTION:* o Nursing intervention is aimed at protection of client from self-harm o Firm, yet supportive approach and consistent care to help build therapeutic relationship o limit-setting and consistency o psychotherapy, group therapy, cognitive/behavioral therapy o dialectical behavior therapy helps with self-harm *Interventions Impulsive behavior:* 1. Identify the needs and feelings preceding the impulsive acts. 2. Discuss current and previous impulsive acts. 3. Explore effects of such acts on self and others. 4. Recognize cues of impulsive behaviors that may injure others. 5. Identify situations that trigger impulsive, and discuss alternative behaviors. 6. Teach or refer patient to appropriate place to learn needed coping skills (e.g., anger management, assertive skills). *Interventions for Manipulation* 1. Assess your own reactions toward patient. If you feel angry, discuss with peers ways to reframe your thinking to defray feelings of anger. 2. Assess patient's interactions for a short period before labeling as manipulative. 3. Set limits on any manipulative behaviors, such as • Arguing or begging • Flattery or seductiveness • Instilling guilt, clinging • Constantly seeking attention • Pitting one person, staff, group against another • Frequently disregarding the rules • Constant engagement in power struggles • Angry, demanding behaviors 4. Intervene in manipulative behavior. • All limits should be adhered to by all staff involved. • Objective physical signs in managing clinical problems should be carefully documented. • Behaviors should be documented objectively (give time, dates, circumstances). • Provide clear boundaries and consequences. • Enforce the consequences. 5. Be vigilant; avoid: • Discussing yourself or other staff members with the patient • Promising to keep a secret for the patient • Accepting gifts from the patient • Doing special favors for the patient *Symptoms:* ▪ Emotional instability ▪ Separation Anxiety ▪ Self-mutilation & Suicide-prone behaviors (Make sure you don't let them go alone somewhere if agitated...they may self-harm in private to relieve anxiety and gain back some feeling of control). ▪ Seek relationships constantly to avoid feeling abandoned and empty ▪ Products of homes in which they were belittled, devalued, or invalidated. ▪ Defense Mechanism: Splitting *Affective Instability:* ▪ Occurs in Borderline Personality ▪ Brief shifts in mood (from depressed → irritable → anxiety) Lasts up to 2 hours or so ▪ Triggers impulsive, aggressive behaviors such as: ● Drug use, reckless driving, suicidal attempts, and destructive behaviors.

Personality Disorders - describe

mrs a key thing for management is consistency. Consider social relationships o Rigid and unhealthy pattern of thinking, functioning, behaving o Attend daily activities o SET LIMITS • most people with personality disorder do not respond well to stress and are generally inflexible and poor compromisers. • People with personality disorders tend not to seek help on their own (unless a severe crisis) due to a variety of factors such as: o Adaptions make them feel that they are functioning well o Have little desire to change o Have overall distrust of others • Involve long-term and repetitive use of maladaptive and often self-defeating behaviors. All personality disorders have 4 characteristics in common: o Inflexible and maladaptive responses to stress o Disability in working and loving o Ability to evoke personal conflict o Capacity to frustrate others. *Personality defined*: Your style/way of interaction ("shy as a mouse" or "life of the party") Ex: passive aggressive, timid, rigid, dry, seductive, full of energy *Personality Disorder:* Personality traits that are exaggerated to the point in which they cause severe dysfunction in people's lives. They often have difficulty working & loving. 2 Common characteristics of a person with "PD": 1. Inflexible (difficult to the changing demands of life. It is "their way or the highway") 2. Serious issues with work and relationships (can't hold a job or a relationship for very long) *Symptoms* o They will be your "Difficult Patient" o Patients don't see their behavior as a problem o They believe everyone else has the problem and that they are the "normal ones" (Patient might say, "You're the problem, not me") o Blame others; don't take responsibility/accountability for their actions, demanding, untrusting, avoid fear/rejection, MANIPULATIVE behavior, insensitive to other's emotions/feelings. *Nursing Assessment:* o Assess for Suicidal & homicidal thoughts #1!!!! o R/O medical diagnosis vs. Mental Diagnosis o Any recent losses/crisis? o Any drug or alcohol use? *Nursing Rationales*: Helpful Items o Have frequent staff meetings (so you are all on the same page) o Set limits on patient's behavior and be consistent! (This must be an ongoing NURSING PRIORITY!) o Rotate nursing staff if one nurse is overwhelmed with a pt. o Assess your own reactions toward the patient *Primitive Defenses* (inadequate defenses) o Primitive Defenses are attempts to control inner chaos *Dialectical Behavior Therapy* o Quick, short-term process to stabilize, achieve behavioral control, regulate emotions, and is used during a crisis situation o Targeted Behaviors: suicidal behaviors, therapy-interfering behaviors, and quality of life-interfering behaviors. o Extremely helpful in helping patients gain HOPE and a better Quality of Life. *Medication used for Personality Disorders* o NO BENZO's, unless its for emergency situations only (because of dependency and overdose) o SSRI's ok o Trazodone & Venlafaxine - OK, also help with sleep o Carbamazepine - targets impulsivity & self-harm o Lithium/Anticonvulsants - minimize aggression o Atypical Antipsychotics (Clozapine) - helps with psychotic episodes

Secondary Gains (associated with Somatoform Disorders) gainsxl

mrs a secondary gains means when an individual, gains from this behavior for ex if a pt is suffering from somatic disorder meaning they have neck pain, weakness, different symptoms and they're family members are always there to help them do things. anytime they complain of something this person is there for them. so they gain secondary from there disorder. Benefits the patient receives because of their symptoms: Extra attention Freedom from responsibilities (family duties, social events) Financial Rewards (disability, PTO, FLMA) o Offer support and explain to reduce anxiety o Observe and record frequently o Assess secondary gains o Have a straight forward approach o Secondary gains: benefits derived from symptoms alone • Benefits derived from the symptoms alone. Ex: in the sick role, patient is not able to perform normal family, work, and social functions and receives extra attention from loved ones. If pts derives personal benefit from the symptoms, relinquishing the symptoms is more difficult. • Approach to identifying presence of secondary gains is to ask questions such as: o What abilities have you lost since the development of your symptom(s) ? o How has this problem affected your life? Are there things you can no longer do? o Depending upon the individual patient and your rapport, the nurse might gently approach whether there is anything positive obtained because of the disorder. Secondary gains are those benefits derived from the symptoms alone. For example, in the sick role, the patient is not able to perform normal family, work, and social functions and receives extra attention from loved ones • What abilities have you lost since the development of your symptom(s)? • How has this problem affected your life? Are there things you can no longer do? • Depending upon the individual patient and your rapport, the nurse might gently approach whether there is anything positive obtained because of the disorder. Nurse can identify if this is present by asking 2 questions: 1. What abilities have you lost since the development of your symptoms? 2. How has this problem affected your life?

Medications given for Behavioral Symptoms/Combativeness in Alzheimer's Patients

ms.a small doses -------------------------------- Cholinesterase inhibitors- galantamine, donepezil, rivastigmine, NMDA antagonist-memantine Typical daily life may suffer. Ensure the home is safe for the patient so the family members may attend to necessary activities of daily life. *For Cognitive impairment:* o physostigmine (Antilirium), o tacrine (Cognex), o donepezil hydrochloride (Aricept), o rivastigmine tartrate (Exelon), o galantamine hydrobromide (Razadyne), o Memantine hydrochloride (Namenda). *For agitation, aggression, hallucinations, thought disturbances, and wandering* o risperidone [Risperdal], o olanzapine [Zyprexa], o quetiapine fumarate [Seroquel], o ziprasidone [Geodon o haloperidol [Haldol] *Medications given for Behavioral Symptoms/Combativeness in Alzheimer's Patients* o "Start low and go slow" o Aricept - helps brain function longer o Atypical antipsychotics such as Risperidone [Risperdal], Olanzapine [Zyprexa], Quetiapine Fumarate [Seroquel] - they are effective for the short-term only. You need to TAPER OFF these meds - NOT COLD TURKEY! o Insulin is also effective for Alzheimer's o Rivastigmine, Donepezil and Memantine = used to help brain function longer

Dependent Personality - describe

mrs. a ind. that depends on someone for everything. even if the person is sick that they depend on, they are always thinking about themselves ex pt who has his mom and dad as the caregiver and helps them with everything. the mom is the one who drives them to work, the mom pays for the groceries, the parents do everthing for them, if that mom gets sick and go to the hospital, even though mom is sick. theyre only concern is who is going to help do this/that. so dependent on other ppl that when the person is sick they still ask who is going to help them with something. ------------------------------------- Believe they are incapable of surviving, if left alone and have an excessive need to receive care, they are clingy and excessively submissive o Emotionally dependent on other people and spend effort trying to please others People with dependent personality disorder traits believe they are incapable of surviving if left alone and have an excess need to receive care. They solicit caretaking by clinging and being perversely and excessively submissive *tolerate poor behavior* Characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. ● Inability to make daily decisions without advice and reassurance. ● Client has a notable lack of SELF-CONFIDENCE that is often apparent in posture, voice and mannerism ● Typically passive and acquiescent to desire of others ● Overly generous and thoughtful while underplaying own attractiveness and achievements ● Avoids position of responsibility and becomes anxious when forced into them *Symptoms*: ▪ Believe they are incapable of surviving if left alone ▪ Cant work alone, function alone ▪ Will stay in abusive relationships so that they aren't alone. When they break up, patient will jump right into another relationship. ▪ High Anxiety = cant make decisions unless there is excessive reassurance from another person. *Nursing Interventions:* ▪ Let them "feel" like they are in control (giving the patient the option of coming to their appointment in the AM or in the PM) ▪ Building up their current skills (because they are so absorbed with themselves already) ▪ Reorient them to reality ▪ Be honest about their limitations ▪ Dissect the situation with them (Ask them: What happened, where it happened, and how it happened. This will help them realize the severity of the situation)

Antisocial Personality - describe

mrs. a they dont obey the norms of society. they dont follow rules or ethics/ etiquetts of society= antisocial. dont obey societal norms ---------------------------------- It is essential to limit verbal or physical abuse directed toward others. Antisocial personality disorder is characterized by persistent disregard for and violation of the rights of others with an absence of remorse for hurting others (APA, 2013, p. 659). People with antisocial PD have a sense of entitlement, which means they believe they have the right to hurt others, take what they want, treat others unfairly, destroy the property of others, and so on (callousness). o Sense of entitlement o No remorse o Sociopathy o Ignores right and wrong A pattern of socially irresponsible, exploitative and guiltless behavior that reflects a disregard for the rights of others. ● Has superficial charm, lies, cheats, MANIPULATIVE! ● *LACKS GUILT, REMORSE AND EMPATHY.* ● Exploits and manipulates others for personal gain. Aggressive! ● Has general disregard for the law *Symptoms:* ▪ Patient does whatever they want and feels no remorse for their actions. ▪ They feel they have no responsibility, they might have used aliases in the past, lie often, con artists, steal and are reckless. ▪ ***Manipulators & Con-Artists*​ ** Do not​ let them be in a position of power (ex: a judge, a group leader, politician) *Nursing Interventions for Impulsive Behavior:* (Impulsive Behavior: short periods between thoughts and actions) ▪ What precedes the event? (Find the trigger) ▪ Teach patient coping skills ▪ Discuss alternative behaviors *Nursing Interventions for Manipulation* ▪ Set limits on behaviors (arguing, seductiveness, clinginess, flattery) ▪ Set clear rules and follow through with consequences ▪ DON'T make promises ▪ DON'T accept gifts from a patient ▪ DON'T do "special favors" for a patient ▪ Things the nurse can say to a patient if any of these happen: ● "I cannot keep secrets from the others staff. If you tell me something, I may have to share it." ● "I am here to focus on you." ● "I cannot accept gifts, but I am wondering what this means to you." ● "You are to return to the unit by 4PM, period.

Chapter 14 - Eating Disorders Anorexia - signs/symptoms, assessment, milieu management

mrs. a anorexia= weight loss, ammorhea, ------------------------------------------- Monitor/observe meals, bathroom trips, and adherence to diet. Dramatic weight loss, feels fat o Fixation on body image o Denies being thin o Assessment: PMH, PQRST, Family history, patient will often not disclose complaint *S/S:* o Terror of gaining weight o View self as fat even when emaciated o Preoccupation with thoughts of food o Development of rigorous exercise regimen o Controls what he/she eats to feel powerful to overcome feelings of helplessness *Assessment:* o CACHETIC- severely underweight with muscle wasting o LANUGO- growth of fine, downy hair on the face and back o Mottled, cool skin on the extremities, low blood pressure, pulse rate and body temperature. (consistent with malnourished and dehydrated state) o BMI thought to be between 19 and 25 o Electrolyte imbalance as result of PURGING- come as form of vomiting, abusing laxatives or diuretics or enemas o *Mileu management*: observe before and after meals, encourage meal intake, structured o Program provided by an interdisciplinary team and consisting of a combination of therapeutic modalities. Designed to normalize eating patterns and to begin to address the issues raised by the illness. o Milieu of an eating disorder unit is purposely organized to assist the patient in establishing more adaptive behavioral patterns, including normalization of eating. Set PRECISE meal times ▪ Observation BEFORE and AFTER meals ▪ Regularly scheduled weights ▪ Monitor patient in the bathroom to ensure no laxatives/diuretics are taken.

All-or-Nothing Thinking- Cognitive Distortions

mrs. a does not have a middle ground for anything. if i gain weight i will keep going until im huge, so there is no middle ground. ---------------------------------- One cannot see any middle ground between extremes. reasoning is absolute and extreme, in mutually exclusive terms of black or white, good or bad o cognitive distortion related to eating disorder o "if I have one popsicle, I must eat 5" o "If I allow myself to gain weight, I'll blow up like a balloon" Reasoning is absolute and extreme o Ex: "If I eat one Popsicle, I must eat 5". "If I allow myself to eat, I will blow up like a balloon". Reasoning is absolute and extreme, in mutually exclusive terms of black or white, good or bad, successful or failure o If I have one popsicle, I'll have 5

Body Dysmorphic Disorder- THINK SAFETY!! HIGHEST PRIORITY (ineffective coping- nursing diagnosis)

mrs. a fixated about a problem ex skin color, they do not like theyre skin color, they go all out to make sure theyre is a change. if they dont like theyre nose they try everything possible to change that structure. so they had repeated plastic sx. These patients are at high risk of suicide. o Stablish therapeutic alliance by acknowledging and accept expression of feelings of frustration, dependency, anger, grief and hostility o SET LIMITS o Person has a body part that they feel is "defective" and causes severe distress o Nose & Breasts are most common appendage worried over • Highly distressing and impairing disorder than ranges along the continuum from distressing to delusional severity. • Pts usually have a normal appearance, but small # show minor defects. Average age of onset is >20 • Frequently concerned with face, skin, genitalia, thighs, hips and hair. (BDD) is a highly distressing and impairing disorder that ranges along the continuum from distressing to delusional severity A DSM-5 diagnosis includes preoccupation with an imagined "defective body part"; obsessional thinking (e.g., thinking they are ugly or deformed) and compulsive behaviors (e.g., such as mirror checking, skin picking, or excessive grooming); and impairment of normal social activities related to academic or occupational functioning. Individuals with BDD are frequently concerned with the face, skin, genitalia, thighs, hips, and hair. Usually the person feels great shame and hides or withdraws from others. wrongly perceiving themselves as being ugly or having "hideous physical flaws. *Symptoms* • Many patients may camouflage the body part, check the mirror frequently, feel shame/guilt about that body part • Multiple cosmetic surgeries but no relief of their obsessive thinking about that body part o DSM-5 diagnosis includes preoccupation with imagined "defective body part" o Obsessive thinking- thinking they are ugly or deformed o Compulsive behavior- mirror checking, skin picking, excessive grooming. o Impairment of normal social activities related to academic or occupational functioning o Usually shows great shame and hides/withdraws from others -Many will alter appearance their appearance with plastic surgeries (multiple) which often does not relieve the symptoms. • Pts who have plastic surgery have co-occurring disorders including: • Major depression • Substance abuse disorder • Social phobia • Higher rates of suicidal ideation, suicide attempts and completed suicides. • Disorder is usually kept secret for years and does not respond to reassurance *Treatment:* o Pharmacological agents: • SSRIs- (a second generation antipsychotic added to an SSRI may help in more severe delusional form of BDD) • Antidepressants • Clomipramine (tricyclic antidepressant) • Cognitive behavioral therapy (CBT) *Nursing Interventions* • Assess for suicide • Safety is #1 priority • Treatment: SSRI's, TCA's (clomipramine), CBT (cognitive behavioral therapy) *highest priority suicidal ideation, suicide attempts, and completed suicides* SSRIs, antidepressants, and clomipramine (a tricyclic antidepressant) and cognitive behavioral therapy (CBT). A second-generation antipsychotic added to an SSRI may help in the more severe delusional form of BDD.

Refeeding Syndrome - Clinical Manifestations

mrs.a overload pt who has not been eating with alot of food. = cardiavascular complications ----------------------------------- Refeeding is hard on the cardiac system because rapid weight gain causes undue stress. Ileus, cardiac arrest, heart problems, paralysis, respiratory depression,seizures o A catastrophic treatment complication which demands replenished circulatory system overwhelm capacity of nutritionally depleted muscle which leads to collapse of cardiovascular *Clinical Manifestations:* o A potentially catastrophic treatment complication in which the demands of a replenished circulatory system overwhelms the capacity of a nutritionally depleted cardiac muscle, which results in cardiovascular collapse When the heart muscle has been nutritionally depleted for so long and how the re-fed body needs increased demands - the heart cannot keep up and can result in cardiovascular collapse.

Histrionic Personality - nursing interventions

mrs.a want to be noticed, they act seductive, they are so close, they want attention. to manage them you SET LIMITS! *Narcissistic Personality* ind. who are very arrogant, full of themselves, they never say sorry. there way or the highway stubborn ppl and want to cntrl everything. key is to SET LIMITS! -------------------------------- dramatic, extroverted, unable to maintain longterm relationships.. ramatic, rapidly shifting, charming, flamboyant, and sexually seductive behaviors These patients require solid limit setting is necessary when working with these patients. o Distorted self-image o Intense unstable emotions Excitable, emotional, colorful, dramatic, extroverted in behavior ● Patients are highly distractible, have difficulty paying attention to detail, and are highly influenced by others. ● Possible learned behavior pattern. Effects persons social/romantic relationships, changes jobs frequently, craves new and exciting things- putting them in risky situations. All factors heightens chance for depression ● *NURSING INTERVENTIONS:* set limits, teach social skills, provide factual feedback o psychotherapy (treatment of choice)- gives ability to talk about mood, feelings thoughts and behaviors. Individual or group therapy. o Social training skills- allows patient to gain insight to knowledge to maintain symptoms and reduce behaviors that interfere with relationships o MAINTAIN PROFESSIONAL BOUNDARIES AND COMMUNICATION AT ALL TIMES!!! (especially with patients who are excessively flirtatious) *Interventions for Manipulation* 1. Assess your own reactions toward patient. If you feel angry, discuss with peers ways to reframe your thinking to defray feelings of anger. 2. Assess patient's interactions for a short period before labeling as manipulative. 3. Set limits on any manipulative behaviors, such as • Arguing or begging • Flattery or seductiveness • Instilling guilt, clinging • Constantly seeking attention • Pitting one person, staff, group against another • Frequently disregarding the rules • Constant engagement in power struggles • Angry, demanding behaviors 4. Intervene in manipulative behavior. • All limits should be adhered to by all staff involved. • Objective physical signs in managing clinical problems should be carefully documented. • Behaviors should be documented objectively (give time, dates, circumstances). • Provide clear boundaries and consequences. • Enforce the consequences. 5. Be vigilant; avoid: • Discussing yourself or other staff members with the patient • Promising to keep a secret for the patient • Accepting gifts from the patient • Doing special favors for the patient Histrionic Personality o *Symptoms:* ▪ Manipulates others through flamboyant, sexually seductive behaviors (Ex: A woman putting on a ton of make-up and wearing super tight/short skirts, revealing shirts) ▪ Behavior attempts to seek constant attention, love, and admiration. ▪ May act out in a temper tantrum or tears if they aren't getting the attention that they require. ▪ Have short-term, superficial relationships *Treatment:* ▪ Psychotherapy and Cognitive Therapy *Schizotypal Personality* o Symptoms: ▪ Avoid interpersonal relationships, have odd/strange behavior ▪ Eccentric, Magical Thinking, believe they can control others, suspicious of others ▪ Illogical speech that may only make sense to them. (Ex: "It hasn't snowed yet, that means the coast is clear.") *Narcissistic Personality* o Symptoms: ▪ Attention seeking, expect things, arrogant ▪ Lack empathy for others, short tempters, impatient, fragile self-esteem ▪ Grandiosity = sense of entitlement ▪ Shallow relationships focused only on what the other person can do for them. ▪ Usually very successful people in life ▪ Defense Mechanism: Splitting *Avoidant Personality* o Symptoms: ▪ High Anxiety = avoidance of any situation in which they will have to socialize. ▪ Withdrawn from society, and they feel inferior to other people ▪ Strong desire for attention, yet they feel rejected ▪ (Example Patient: The coworker you ask to come to Happy Hour after work. He retreats to his desk, alone, after making an excuse as to why he cannot come.) *Obsessive Compulsive Personality* o Symptoms: ▪ Concerned with order, neatness, perfectionism, control ▪ Obsessed with following rules ▪ Keeps trying to do something, even after several failed attempts ▪ Usually High Achievers (smart people) ▪ Lack sense of humor ▪ Intimacy in relationships is superficial

Dissociative Fugue

mrs.a ind. forgets who theyre. assumes a new personality and functions under that new personality as far aas theyre consent ex mrs a. today, the next day, you see them in ny with a different identity under another name, profession, another person entirely. in that moment is the fugue and it happens when somebody has a somatoform disorder, but in a way to deal with that problem they assume a different identity. usually therapy will help take care of this. ------------------------------ o Patient temp loses their senses of identity and may wander or travel away from home/work These patients relocate a lot and assume new identities and forget prior locales and identities. o Sudden, unexpected travel from current location to another and unable to recall one's identity or where they came from (Amnesia) o Unconscious Defense Mechanism - trauma is too big to handle (death, crisis, wedding cancelled, past child abuse) and anxiety is overwhelming and they Dissociate to get away from those bad feelings & memories o Affects Limbic System & Hippocampus (where memories are stored & processed) • patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with paranoid schizophrenia, generalized anxiety disorder, or bipolar disorder • rather lead simple lives not calling attention to themselves, as time progresses the person may remember their former identity and then become amnesic of the time in the fugue state. USUALLY PRECIPITATED BY A TRAUMATIC EVENT *Implementation*: Dissociative disorders is treated in the community, but may be admitted to a psychiatric unit when suicidal or in need of crisis stabilization *Teaching*: teaching about illness and instructions in coping skills and stress management. Patients keep a daily journal to increase awareness of feelings and to identify triggers *Treatment*: psychotherapy- primary and most effective treatment. Therapy needs to be flexible. Techniques include: o Psychoeducation o Processing memories and trauma through talking o Traumatic reenactment o Safety planning o Journaling, o Relaxation techniques o Hypnosis & artwork There are no specific medications for dissociative disorder, but appropriate antidepressants or anxiolytic medications are given for comorbid symptoms. *Nursing interventions* o Look at missing persons ads to see if patient is on there o Basic Needs & Safety are #1 priority (think Maslow.....) o #1 effective treatment is Psychotherapy o Allow person to progress at their own pace until memory is back o Don't overwhelm them with data about their past o Provide simple routines o Writing in journals & art therapy is great is a disturbance in the normally well-integrated continuum of consciousness, memory, identity, and perception. Dissociation is an unconscious defense mechanism to protect the individual against overwhelming anxiety related to past trauma, and ranges from minor to severe in presentation. Patients with dissociative disorders have intact reality testing, meaning they are not delusional or hallucinating

Bulimia - prioritize nursing interventions (health teaching)

mrs.a they binge eat they eat they throw up s/s of hypokalemia also oral care bc they keep vomiting. -------------------------------------------------------- what are nursing interventions to be included in the plan of care? Examples would center on identifying triggers, offer teaching, and assess for signs impulsive eating. Do not punish the client. prioritize nursing interventions (health teaching) o Nursing intervention: imbalanced nutrition, deficit fluid volume o Assess mood and presence of suicidal thoughts o Monitor weight, and physiological parameters (VS, electrolyte levels) o Educate o Monitor before and after meals Binge eating behaviors ● Self induced vomiting after bingeing ● Depressive S/S ● Problems with interpersonal relationships, self-concept & impulsive behaviors *Signs/Symptoms:* ▪ Binge/Purge cycles, self-induced vomiting, controls weight by bingeing, feelings of emptiness, person feels shame after binge/purge cycles ▪ Easier to treat than Anorexia *Physical/Medical Complications:* ▪ Cardiac Dysrhythmias, Cardiac Arrest (from electrolyte imbalances), GERD, Teeth Erosion (from vomiting), Russell's Sign (calluses on knuckles from purging), prominent Parotid/Salivary Glands (from purging), hypokalemia, severe stomach pain. *Nursing Interventions* ▪ #1 Priority​ = stabilization of HEART and ELECTROLYTES!!! imbalanced nutrition, deficit fluid volume 1. Medical stabilization is always the FIRST priority ● Problems resulting from purging are disruptions in electrolyte and fluid balance and cardiac function. Medical examination is VITAL! Make sure to check: ▪ Electrolyte levels ▪ Glucose level ▪ Thyroid function test ▪ Complete blood count ▪ Electrocardiogram (ECG) 2. Psychiatric evaluation- (depression and suicide concerns) 3. Besides assessment of use of diuretics/laxatives ask about diet pills, amphetamines, energy pills. ● Labs: CBC, Glucose, ECG, electrolytes, thyroid, ect. ▪ Assess mood & suicidal thoughts ▪ Monitor patient before and after meals so they cannot purge ▪ Have patient keep a journal of thoughts and feelings *Health Teaching* ▪ Meal planning, healthy exercise regimen. Once this is established, the patient can go out on a "Pass", have a meal and come back to the unit to discuss their experience. Monitor weight, and physiological parameters (VS, electrolyte levels) Monitor before and after meals Teach about importance of meal planning, relaxation techniques, maintenance of a healthy diet and exercise, implementation of coping skills and knowledge of physical and emotional effects of bingeing and purging. *Prescription Medications for Eating Disorders* o SSRI's:​ (Fluoxetine/Prozac) a​ re the #1 FIRST medication used to maintain weight and prevent relapse. o 2​ nd​ Generation Antipsychotics:​ (Olanzapine/Zyprexa)​ used to help patient gain weight.

Pervasive Developmental Disorders/Autism - Signs/Symptoms

ms a child does not like to have contact with others they like to stay on there on they do not like to play with others, they dont like to make eye contact, they dont like hugs whn you come close to them they flinch away Severe problems in development -Cognitive, emotional, & social •Want to be alone •Sameness •Echolalia: Repeating what has been said to them. Non-communicative speech Pervasive Developmental Disorder (AUTISM)- o Presents with deficits in social and communication interactions, as well as repetitive patterns of behavior, interests or activities. ▪ Twirl, walk on tippy toes, flap their arms or rock o Mannerism may progress from self-stimulation to self-injurious ▪ Head banging, biting o Children/ adults tend to become focused on a particular subject and perseverate on it ▪ Gain a profound amount of knowledge about the preferred interest, but are delayed in most other academic and life domains o Lack of interest in social interaction is often the key symptom that is noticed initially Pervasive Developmental Disorders/Autism - Signs/Symptoms o Lack of interest in social interaction and communication o Repetitive patterns of behavior, interests, and activities o Children tend to twirl, walk on tippy toes, and flap arms, rock back and forth Decreased social skills (avoids eye contact, plays alone, doesn't share interests with others, doesn't respond to name by 12 months old) o Delayed Speech (echolalia, robot-like voice, doesn't understand joke, few/no gestures, can't name objects the nurse points to) o Repeated behaviors/Routines (rocks body, flaps hands, spins in circles, turns lights on/off, when routine changes - throws tantrums o Unusual eating habits, aggression, unusual reactions to the way things smell, sound, look, feel. Cannot pretend play, doesn't like to be cuddled, lacks friends

Chapter 26 - Children & Adolescents ADHD - medications (CNS Stimulants)

ms a CNS Stimulants to stimulate area of cns to help the ind. focus. behavior therapy + methylphenidate or amphetamines (both phenethylamines), or atomoxetine (NeRI) ● ADHD - medications (CNS Stimulants) o Methylphenidate (Ritalin) o Dextroamphetamine (Adderall) o Lisdeamefetamine (Vyvanse) ● Pervasive Developmental Disorders/Autism - Signs/Symptoms o Lack of interest in social interaction and communication o Repetitive patterns of behavior, interests, and activities o Children tend to twirl, walk on tippy toes, and flap arms, rock back and forth Always assess for abuse in children with developmental problems ● ADHD - medications (CNS Stimulants) o Ritalin (methylphenidate) - stimulant, most commonly used. Available PO and Transdermal Patch only. o Concerta - is Extended Release Ritalin (used for 1 time/day dosing). Good for kids who have a hard time remembering to take pills BID o Adderall - calms the patient and comes in Extended Release form. ● Pervasive Developmental Disorders/Autism - Signs/Symptoms o Decreased social skills (avoids eye contact, plays alone, doesn't share interests with others, doesn't respond to name by 12 months old) o Delayed Speech (echolalia, robot-like voice, doesn't understand joke, few/no gestures, can't name objects the nurse points to) o Repeated behaviors/Routines (rocks body, flaps hands, spins in circles, turns lights on/off, when routine changes - throws tantrums o Unusual eating habits, aggression, unusual reactions to the way things smell, sound, look, feel. Cannot pretend play, doesn't like to be cuddled, lacks friends ADHD- ​the essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity- impulsivity that is more frequent and severe than is typically observed in people at a comparable level of development ● S/S: o problems concentrating making careless mistakes o difficulty remaining focused o being easily distracted by things going on around the individual o appears not to listen when spoken to, lack of following through o struggling with organizational and time management skills, and forgetfulness ● Medications (affect CNS) o Nonstimulants- (not appropriate) ▪ atomoxetine (Strattera) ▪ guanfacine (tenex) o Stimulants- increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adults with ADHD ▪ Methylphenidate (Ritalin) ▪ Dextroamphetamine/levoamphetamine (Adderall)

Caregiver Fatigue - Nursing Interventions (Health Teaching & Promotion)

ms a caregivers gets exhaused and tired. help family members identify resources to help in the care of the loved one ---------------------------- Interventions: Respite care, support groups, assistance from agencies, support to maintain personal life. *Caregiver Fatigue​: Nursing Interventions* o Proactive in minimizing the disease's effects, as well as teaching and providing guidelines to caregivers and loved ones. Reducing stress will help to minimize burnout. Stress reducing techniques will include ▪ 1. Having a realistic understanding of the disease ▪ 2. Establishing realistic outcomes ▪ 3. Maintaining good self-care such as adequate sleep and rest, eating a nutritious diet, exercising, engaging in relaxing activities, and addressing their own spiritual needs. *Nursing intervention*: have right to ease of access to services, respite care, full involvement in decision making o Assess needs

Chapter 24 - Anger, Aggression and Violence Physical Aggression - Signs/Symptoms

ms a getting physically aggressive remove from environment- dx is to include other ppl and keep everyone safe staff/ppl violent ind saying getting agitated, someone wants to kill me saying they are afraid- ORDER DIRECTED VIOLENCE= AFRAID. ppl around them are jeopardizes bc voices person hear answer- at risk for hurting someone else These behaviors reflect rage, hostility, and potential for physical assault or verbal destructiveness and can be directed at others or oneself; aggression is a hostile reaction that occurs when control over anger is lost. Anger, Aggression and Violence ● Physical Aggression - Signs/Symptoms o Rage, hostility, potential of physical assault, or verbal destructiveness ● Violent Behavior - Highest Risk (Box 24-1) o Acts on violence, leads to significant physical and psychological harm to others, restless, slamming doors, pacing, does the patient wish to harm? ● Restraint & Seclusion o Only written by HCP others must be considered and documented before restraints o 24 hour one to one observation of patient Anger:​ an emotion/feeling. Aggression:​ physical act of hostility Violence:​ force that is intended to harm, damage or violate ● Ensure YOUR SAFETY FIRST as a nurse! (Also, don't wear jewelry, necklaces or anything they can grab, pull or use to strangle you) ● Anger & Aggression are preceeded by feelings of Vulnerability. ● Physical Aggression - Signs/Symptoms o RED FLAGS​: setting fires, animal cruelty during childhood, or conduct disorder o Has a history of violence (#1 predictor), impulsive behavior, ETOH (alcohol or drug abuse go hand-in-hand) Anger vs Aggression ● Aggression:​ is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. AGGRESSIVE BEHAVIOR VIOLATES THE RIGHTS OF OTHERS o Aggression is INTENDED to inflict harm or destruction o Identified by a cluster of characteristics including: pacing/ restlessness, verbal/ physical threats, threats of homicide/ suicide, loud voice; argumentative, tense facial expression and body language. o Aggression may also be appropriate ▪ Self-protective, as in protecting oneself or family ▪ Protective, as in protecting self from being bullied. ● Anger​- an emotional response to a frustration of desires, threat to ones needs (emotional or physical) or a challenge o Anger is a normal and not always logical human emotion o No judgment needs to be passed on to it. o Varies in intensity from mild irritations to intense fury and rage Aggression Know when a patient may be exhibiting clues to potential aggression. When a patient is pacing the halls and swearing loudly, acknowledge the patient and determine the reason behind the outburst. Know the characteristics of nursing diagnoses Risk for Injury, Post-Trauma Syndrome, Disturbed Thought Processes, and Risk for Other -Directed Violence. IF offered a scenario, be able to pick the correct diagnosis. Understand that potential violent​ behavior toward others may be seen in clients with delusions of others out to cause harm. People feel persecuted. Know what behaviors are representative of physical aggression. Aggressive behavior violates the rights of others.

Heroin Overdose - Clinical Manifestations; Signs/Symptoms (Table 19-6) Know about Narcan - why it's given, side effects after it's given and nursing interventions after given

ms a narcan for morphine overdose- OBSERVE CLOSELY w/in the 1st 15min of giving narcan bc it is critical to remove od drug from system. -Narcotic- resp depression, seizures, dysrhythmias, euphoria, then anxiety, sadness, insomnia, sexual indifference, pinpoint pupils, stupor, coma.... -Maintain airway, control seizures, check LOC & VS, start IV, bolus glucose, tx of hyperthermia, narcan for resp depression... first action check o2/airway Typical symptoms are flu like such as body aches. Withdrawal effects: ▪ Yawning, insomnia, irritability, panic, diaphoresis, cramps, N/V, muscular aches, chills and fever, diarrhea, ▪ Symptoms occur within 6-12 hours and subside in 5-7 days o Naloxone (Narcan)- ​an opioid antagonist that can dramatically reverse the signs of overdose, essentially respiratory and certain CNS depression. ▪ Disadvantages that Narcan is short acting and must be re administered every few hours or until opioid levels are nontoxic- which can take days. *Triad symptoms* o Cardiac arrest, death, shock, convulsions, pinpoint pupils o Narcan: short acting, re-administer every few house o Can become aggressive o Safe distance o Assess vomiting and restless, abdominal cramps, increase blood pressure, temp *Cocaine-* dilated pupils ● Cocaine exerts two main effects on the body: anesthetic and stimulant. As an anesthetic, it blocks the conduction of electrical impulses within the nerve cells that are involved in sensory transmission, primarily pain transmission. It also acts as a stimulant for both sexual arousal and violent behavior. Cocaine produces an imbalance of neurotransmitters (dopamine and norepinephrine) that is most likely responsible for many of the physical withdrawal symptoms reported by heavy, chronic cocaine users: depression, paranoia, lethargy, anxiety, insomnia, nausea and vomiting, and sweating and chills—all signs of the body struggling to regain its normal chemical balance. ● Cocaine and alcohol related-have same withdrawal symptoms o Alcohol can neutralize the effects of cocaine, alcohol is a depressant and cocaine is a stimulant **early symptoms of narcotic withdrawal are flulike in nature​** *Heroin Overdose​:* Signs & Symptoms: ​Triad of symptoms (pinpoint pupils, respiratory depression/arrest, coma). ​Cardiac arrest/death, shock, convulsions. Pupils: PINPOINT Antidote: ​Narcan (naloxone) Treatment of opioid toxicity is an opioid antagonist that can reverse the respiratory and CNS depression. Is short acting and must be readministered every few hours until opioid levels are nontoxic. *Side effects after administration:​* reverses analgesia, s/sx of withdrawal can include-muscle aches, abdominal cramps, insomnia, irritability, and diaphoresis. *Nursing Interventions:* ​ monitor the patient closely; monitor VS every 15 minutes (especially respirations). Keep resuscitation equipment close.

Opioid Overdose - Clinical Manifestations; Signs/Symptoms (Table 19-6)

ms a pinpoint pupils constricted pupils, clammy skin, nausea, drowsiness, resp depression Narcan *Opiate overdose* ● Oxycodone, morphine, heroin, Fentanyl ● S/S: Triad symptoms (coma, respiratory depression/arrest, pinpoint pupils) o Possible dilation of pupils as a result of anorexia o Cardiac arrest and death o Shock o Convulsions o Overdose is treated with antagonist naloxone (Narcan) ● Opioid use S/S: o Euphoria o Constricted pupils o Decreased respirations, increased blood pressure o Slurred speech o Drowsiness, psychomotor retardation o Impaired concentration, judgment and memory Opioid Overdose - Clinical Manifestations; Signs/Symptoms (Table 19-6) o Pinpoint pupils o RR 4-6/minute o Cardiac arrest o Convulsions o Shock o Death *Clinical Manifestations*: Triad symptoms (coma, respiratory depression o Possible dilation of pupils as result of anorexia o Cardiac arrest and death *Opioid Overdose:* ​ ​Oxycodone, Heroin, Morphine, Methadone, Codeine Signs & Symptoms: ​Triad of symptoms (pinpoint pupils, respiratory depression/arrest, coma). ​Cardiac arrest/death, shock, convulsions, Pupils: PINPOINT Antidote: ​Narcan (naloxone)

Agnosia

ms a pt forgets use of basic things esp utensils. for pts with this, you put there food in front of them, they will not know what to do. feeding the pt is not the right answer. the right response is to TEACH THEM BACK, go back to basics and teach them how to use utensils. you can say this is ur fork..use it to get ur meat balls. teach back how to use basic things. ------------------------------------------- the inability to recognize familiar objects. - loss of sensory ability to recognize objects- does not know what the object is used for, need of direction o Does not recognize object or understand what they're used for o Concrete directions Know these patients do not recognize objects or understand what they are used for. Offer clear direction and promote independence. For instance, show the client the tooth brush and tell him/her how to brush teeth.

Chapter 12 - Somatoform Disorders somatoformxl

ms a the first encounter with this patient, is important bc you do a complete assessment. CHECK EVERYTHING. w.e they tell you do a total assessment on the initial visit. manifest w/ physical symptoms that have psychological origin. o Defined as experiencing physical symptoms as a result of psychological stress (no physical explanation for the pain). Commonly found in patients with Depression & Anxiety & Drug Abuse. Symptoms cause significant distress in one's life. o Most common in women, poor educated, non-whites, living in rural areas o Factitious & Malingering Disorders needed to be r/o before patient can be diagnosed with Somatoform Disorder o "Doctor Shopping" is common (they want a pill for every symptom they have) Somatic symptom disorder can pre-sent with pain as the predominant symptom; is persistent in nature, lasting longer than 6 months; and is specified as mild, moderate, or severe. Somatic Symptom Disorder- NON INTENTIONAL • people with this disorder are extremely persistently preoccupied with and distressed by their perceived health issues • demand unnecessary tests, noncompliant with provider recommendations • significant life impairment, preoccupation and high anxiety • "doctor shopping" when they do not receive the answers from physicians, undergo unnecessary surgeries, invasive diagnostic procedures & drug trials • usually diagnosed with depressive and/or anxiety disorders

Alcohol Dependence - Relapse Prevention Plan (Health Teaching Box 19-5)

ms a when ind. find situations difficult, if they can identify that situation that they cannot handle, that is the beg of prevention for the alcoholic ind. ------------------------------------------------- Be able to select an example of a patient utilizing this method. Patients should understand what triggers are so that periods of sobriety may be lengthened over time. *Alcohol Dependence​:* Relapse Prevention Plan The goal of relapse prevention is to help individuals identify their "trigger situations" to drinking alcohol so that periods of sobriety can be lengthened over time and lapses and relapses are not viewed as total failures. Strategies include recognizing and learning how to avoid or cope with threats to recovery, changing lifestyle, learning how to participate fully in society w/o drugs, and securing help from other for social support. Alcohol Dependence - Relapse Prevention Plan (Health Teaching Box 19-5) o Disulfiram- no alcohol due to violence - decrease blood pressure, nausea, vomiting, flushed o IDENTIFY TRIGGERS SITUATIONS Benzodiazepines *Stages of alcohol withdrawal:* ● Minor: anxiety, tremor, insomnia, headache, palpitations, gastrointestinal disturbances, diaphoresis, orientation to time, place and person ● Moderate to severe: mild symptoms and diaphoresis, increased systolic blood pressure, tachypnea, tachycardia, confusion, mild hyperthermia, hallucinations and illusions, although remains oriented to time, place and person. ● Symptoms can continue for 5-7 days- ● GRAN mal seizures occur in 7 to 48 hours after cessation ** seizures more common in alcohol withdrawal symptoms** *Relapse prevention plan:* Pharmacological: o Disulfiram (Antabuse)- helps relapse of alcohol abuse ▪ If ingested with combination of alcohol, will cause nausea, vomiting, headache and flushing. MUST BE ALCOHOL FREE FOR AT LEAST 14 DAYS o Naltrexone (ReVia)- diminishes alcohol cravings, possibly by reducing reinforcing effects of alcohol ▪ Helpful in acute recovery (first 12 weeks) o Vivitrol (Naltrexone for Extended-Release, Injectable Suspension) ▪ Alcohol abuse only ▪ May be easier for patients recovering form alcohol dependency to use consistently o Acamprosate (Campral)- diminishes alcohol cravings, possibly by reducing intensity of prolonged withdrawal syndrome ▪ Benefit emerges after 30-90 days ▪ Need to be abstinent at least 7 days before use *Alcohol withdrawal Delirium*- MEDICAL EMERGENCY- also referred to as delirium tremens or DTs ● Can result in death, even if treated ● State of delirium usually peaks 2-3 days after cessation or reduction of intake (although it can occur later) and lasts 2-3 days o Hallucinations are terrifying o Anxiety, insomnia, anorexia, delirium o Autonomic hyperactivity (tachycardia, diaphoresis, elevated blood pressure) o Severe disturbances in sensorium (disorientation, cloudiness of consciousness) o Perpetual disturbances (illusions, visual/tactile hallucinations) o Fluctuating levels of consciousness (hyperexcitiability to lethargy) o Delusions, agitated behavior, fever (100-103F) o ALWAYS LOOK FOR SAFETY FIRST

Chapter 28 - Older Adults Risk for suicide

ms a when interviewing these pt factor in there physical status bc they have tendency to fall, pee the bed incont, agism- sterotype that older adults are not able to understand --------------------- Depressed mood; feelings of hopelessness and worthlessness; anger turned inward in the self; misinterpretations of reality; suicidal ideation, plan, and available means Risk for suicide o 65+ age- 17th leading cause of death ● Interview techniques o 70% of elder patient have visited pcp within month of committing suicide ● Risk for abuse- types of abuse o Physical, psychological, financial, neglect, sexual Facts about Aging o Vision, hearing, touch, taste and smell decline with age o Muscle strength decreases with age o 50% of restorative sleep is lost with age o Increased Depression is common ● Nursing Assessment o Call patient by formal name (Mrs. Jones, or Mr. Smith) o Private interview, sit at same level as patient, low noise, good lighting o Don't​ use "Elderspeak"​ (talking to them like they are children. Ex: "Did WE want a bath today?") ● Advance Directive​ - indicates preferences for medical care if they become incapacitated either physically or mentally. ● Living Will​- personal statement of how and where one wishes to die. Can be altered at any time by the patient. ● Directive to Physician​ - a physician is appointed by the individual to serve as proxy. (Good in cases where the patient has no family) ● Durable Power of Attorney (POA)​ - a person other than the physician is appointed to act as the patient's agent. The patient does not have to be terminally ill or incompetent to allow the person to act on their behalf. ● PSDA (Patient Self-Determination Act) - ​Keeping patients informed about their rights, options, refusal of surgery/treatment, and allowing them to formulate written procedures for their own rights (allows autonomy & dignity in death) ● Medications and the Elderly o Anticholinergics found to correlate with reduced brain function and early death. o Nurse should assess any medications and OTC items o "Start low, go slow" (elderly need LOWER doses) o TCA's #1 drug of choice, then SSRI's (due to increased bone fracture risk) ● Depression in Older Adults o Forgetful, agitated, chronic aches/pains, fatigue, paranoia, anxiety without cause o Nurse should assess for suicide ● Restraints in the Older Adult o Shouldn't be used unless absolutely necessary (risk of harm to self or others) Other options are: door alarms, chair alarms, bed alarms, making the environment safer, better lighting, lower beds to floor, keep furniture in same place, increase hearing aids and visual devices. (The older adult may have cognitive issues or problems with senses which make them wander or frightened) Illusions are sensory misperceptions- glasses and hearing aids help clarify sensory perceptions ● Round the clock lighting promotes sensory overload and sensory perceptual alterations ● Aggressive behavior can be safely managed by antipsychotic medication o Initial dosing should be small and raised cautiously until behavior is controlled o SSRI are not indicated for aggressive behavior o If a Benzodiazepine is used- the initial dose should be low o Buspirone is not effective if given on as-needed basis, ▪ It is administered in small divided doses daily to control agitation. ● Depression is the most common, most debilitating, and also most treatable psychiatric disorder in the older adult. Depression in later life creates pain, suffering, poor quality of life and spiritual anguish. o Lower dosages are initiated, often half of a usual adult dosage, and medication is advanced gradually. ▪ "Start low, go slow" for young adults and elderly patients

Delirium - orientation

ms a disoriented- 1st step is reorientation, tell them today is this, today is that. my name is... today is monday, feb,5th 2017. *1st step is reorientation* in a disoriented pt -------------------------------------------------- o Can have difficulty with orientation, to time, place and person. Aware of self-identity orient the client to time of day, place, and people. Do not rationalize or argue with the patient. Orient is the key Slow onset, over months to years. Marked by impaired cognitive function and slowly deteriorating social and occupational functioning. Level of alertness is typically not disturbed. ● Amnesia or memory impairment ● Aphasia- loss of language ability ● Apraxia- loss of purposeful movement in the absence of motor or sensory impairment ● Agnosia- loss of sensory ability to recognize objects- does not know what the object is used for, need of direction. ● There are no disturbances in executive functioning *Symptoms:* ▪ Sudden onset ("Oh my gosh, what happened to Mom?") ▪ Comes out of nowhere ▪ Disorganized thinking ▪ Disturbances in cognition, attention and memory, disorientated and ▪incoherent. Patient may wander off. Ideas of reference are common. Is always secondary to another condition. If secondary condition resolves, so does delirium. *Orientation*: ​ because levels of consciousness can change throughout the day patient might need to be checked for orientation to first the time, place, and person. Nurse:​ Use Clocks, Calendars, Familiar Pictures/objects, talk about familiar history, use natural lighting *Nursing Interventions for Delirium* ▪ Speak in slow, simple statements ▪ Keep head of bed elevated & room lighted sufficiently ▪ Set limits on bad behavior (Ex: "Mr. Smith, you are not to hit me or anyone else. Tell me how you are feeling.") ▪ Try to keep staff the same (keep things familiar) *Contributing factors*: o Primary dementia: dementia itself is the major sign of some organic brain disease not related to any other organic illness (Alzheimer's disease) o Secondary dementia: caused or related to another disease or condition (HIV, cerebral trauma) ● Incoherent, slow, inappropriate, rambling and repetitious language and speech ● Not reversible; progressive *Family teaching*: ● People with alzheimer's disease are at higher risk for diabetes, cardiovascular disease and high blood pressure. ● Lower socioeconomic levels appear to be more prone to AD than people with a higher standard of living. ● Identifying level of functioning and assessing caregivers needs. o Transportation, supervision, support groups, residential services, home health aides ● Additional teaching or psychopharmaceudical aid to manage distressing or harmful behaviors for both client and family. ● Guidelines for loved ones/ caregivers to relieve stress by: o Have realistic understanding of the disease & establish realistic outcomes ● "support programs for caregivers and patients with dementia significantly decrease the odds of institutionalization and improved well-being" o its important to not only take care of the patient with dementia, but also the families as well o The Alzheimers Association- agency that provides assistance to patients and families ● CHOLINESTERASE inhibitors- used for treatment of Alzheimer's disease o Donepezil, rivastigmine, galantamine *Delirium* ● Sudden onset, over hours to days ● Essential feature is disturbed consciousness coupled with cognitive difficulties o Thinking, memory, attention, and perception o Common in hospitalized patients- especially older adults. o Is always secondary to another physiologic condition, if underlying condition is corrected, then complete recovery should occur. o Transient disorder ● Contributing factors: hypoglycemia, fever, dehydration, infection, disruption of homeostasis, adverse drugs reaction, head injury, pain, emotional stress, change in environment (ex: hospitalization) ● Visual hallucinations are common in delirium, illusions can occur as well- errors in perception in what they are seeing. ● Impaired memory, judgment, calculations, attention span, can fluctuate throughout the day o "sundown syndrome"- symptoms usually get worse as it gets closer to night. *Common symptoms:* o Autonomic hyperactivity (increased vital signs) o Hypervigilance (constant alert or scanning room) o Labile mood swings o Agitation and/or anger *Know difference between dementia and delirium* ● Dementia- slow onset and non-reversible ● Delirium- sudden and can be reversed

Visual & Tactile Hallucinations - Priority Nursing Dx

ms a when they see something, they misread it , to dimish illusions, give them something that might magnify correctly like glasses, hearing aid ex a picture on the wall they might read it and call it something else. ----------------------------------- Priority Nursing Dx= The physical safety of the patient is of highest priority. Patients experiencing hallucinations may experience fluctuating levels of consciousness disturbed orientation and visual and tactile hallucinations. *Visual (see) & Tactile (feel) Hallucinations​*: o The physical safety is the nurse's highest priority o Clarify reality, "I know you are frightened; I do not see spiders on your sheets. I'll sit with you for a while." *Nursing Dx:* ​ Impaired Environmental Interpretation, Powerlessness, or Fear o Watch for patient's eyes darting about the room, or facial expressions Risk for injury is greatest consideration. ● Self-care deficit, ● *impaired environmental interpretation syndrome (if delusions, illusions or hallucinations are present)* o Clarify reality o I know you are frightened but there are no spiders on the bed, I'll stay with you for a while

Chapter 18 - Neurocognitive Disorders Memory Care - Reminiscing (Table 18-5)

ms. a the big thing about Reminiscing is good for pts with neurocog disorders. helps them feel less isodated and less lonely Memory Care​ - Reminiscing (Table 18-5) 1. NURSE SHOULD:​ Encourage Reminiscing about Happy Times. (Rationale: remembering accomplishments and shared joys help distract patient from deficit and gives meaning to existence Encourage reminiscing about happy times in life-remember accomplishments and shared joys help distract patient from deficit and give meaning to existence o Make patient feel less lonely

Dementia - Family Teaching/Education

ms.a if family relies on social worker that means they are not ready. Confabulation-making up stories to handle problems ----------------------------------------- orient the client to time of day, place, and people. Do not rationalize or argue with the patient. Orient is the key. Dementia: Alzheimer's Disease (Permanent - NOT REVERSABLE) Develops more slowly and is characterized by multiple cognitive deficits that include impairment in memory without impairment in consciousness. o Patients Like to eat the 3 S's​: Sugary, Salty and Spicy things 4 A's Of Dementia: ▪ Amnesia: memory impaired ▪ Aphasia: loss of language ▪ Apraxia: loss of purposeful movements ▪ Agnosia: loss of ability to recognize objects Stages of Dementia: 1. Stage 1: mild/forgetfulness 2. Stage 2: moderate/confusion 3. Stage 3: severe/unable to identify objects/people 4. Stage 4: late/end-stage *Defense mechanism*:​ Confabulation (making up stories or answers to maintain self-esteem when they do not remember), Perseveration (repetition of phrases or behavior) *Nursing Interventions:* ​Always introduce yourself, call patient by name with every contact, expectations should be clear and explained in simple, step-by-step instructions, simple appropriate choices. Example "Do you want to wash your face before or after you brush your teeth." *Family teaching/education:* ​Nurses need to teach the families about dementia, where to get help, community resources, etc. Gradually take the car away, NO throw rugs, tape cords to the floors, mattress on the floor/bed alarms, keep it simple & Familiar as possible. o Protect self and others o Maintain orientation to reality o Minimize confusion, fulfill basic needs o Assist and educate

Hypochondriasis - signs/symptoms hypochonxl

ms.a misinterpretation of physical sensation, as evidence of serious illness. for ex a pt may have a mosquito bite and the pt may interpret this as having cancer. These patients suffer from somatic symptoms o Preoccupation with having a serious disease or with fear of having a serious disease, last 6 months, fake symptoms constantly check for problems, high anxiety level • Preoccupied with having or eventually developing a serious illness • May or may not present with somatic symptoms, and if so- usually mild. o Unintentional and not under conscious control o Significant distress or dysfunction • Preoccupied with belief of having a devastating sickness or disease • Inability to function in personal, social, and occupational roles are often impaired They are more alarmed by the potential implications of any disorder than with the disorder itself, and are alarmed with any new bodily sensations *Signs:* • Person sincerely believes they have a devastating health condition (ex: "my headaches, so I must have terminal brain cancer") • Usually have Anxiety or Depressive Disorder as well sweating abdominal cramping awareness of heartbeat All are indicative of disease to hypochondriasis *Symptoms*: • Severe distress/preoccupation with health causes issues w/social life, relationships, work, etc. • Symptoms are exacerbated during times of stress • May or may not have somatic symptoms Example Patient Scenario: "Mark lost his wife to colon cancer last year. He saw his doctor recently and sincerely believes he has Colon Cancer, regardless that the diagnostic testing does not show he does. He has stopped seeing his friends/family and when asked why he stays home, he states, "I am resting my liver.

Visual & Auditory Illusions - Nursing Interventions

o Are errors in perception of sensory stimuli. The stimulus is a real object in the environment; however, it is misinterpreted and the patient becomes fearful (Ex: The cords from the window shades are "white snakes"). o Clarify reality, "This is a coat rack, not a man with a knife...see? You seem frightened I'll stay with you for a while." clarify reality- "This is a coat rack, not a man with a knife.. see? You seem frightened Ill stay with you for awhile." ● NEVER leave a patient with hallucinations alone o When hallucinations are present, clarify reality o When they see coat rack as a man Know that glasses and hearing aids help clarify sensory perceptions. Are errors in perception of sensory stimuli. The stimulus is a real object in the environment; however, it is misinterpreted and the patient becomes fearful (Ex: The cords from the window shades are "white snakes"). o Clarify reality, "This is a coat rack, not a man with a knife...see? You seem frightened I'll stay with you for a while."

Chapter 21 - Child, Partner and Elder Violence Domestic Violence

our responsiblity to report acts of violence involving family members give shelter, this type of abuse the nurse does not have to report except if they are children or elders Domestic Violence o 4 categories: emotional, physical sexual, neglect o give shelter, doesn't have to report unless child or elder *Domestic Violence* o *Symptoms/Signs*: ▪ Recurrent visits to ED for being "clumsy" or "accident prone" ▪ Story doesn't match up with the injury ▪ Bruises in various stages of healing ▪ Panic Attacks, Anxiety, Depression, GI Issues, Hypertension, Insomnia ▪ Ex: Nurse may touch female patient's shoulder and she might automatically pull away and "guard"/"shield" herself. o Children see this behavior and think abuse is acceptable (Monkey See, Monkey Do) Violence is a LEARNED behavior used by a person to CONTROL others. o Intimate Partner Abuse = #1 cause of ED visits by women o Patient Teaching for Episodes of Violence: ▪ Move to a room with more than 1 exit (preferably a room w/o weapons). Know the quickest route out of the house ▪ Have safe words that you can use with the kids so that they can get out of the house immediately and get help. Have a safe house/place to go. ▪ Keep a packed bag hidden with your essentials for emergencies. o Survivor: One who has experienced abuse/assault and worked through issues and is moving forward with their life o Victim: One how has experienced an assault, but hasn't yet worked through issues. Domestic Violence: ● Intimate partner violence (IPV): "a pattern of assault and course of behaviors that include physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation and threats" between current or former partners in an intimate relationship, o #1 cause of emergency department visits by women and primary cause of homelessness in women as well. Characteristics of violent partner: ● denial and blame: denies abuse occurred, shifts responsibility onto self. ● Emotional abuse- belittles, criticizes, insults, name calling ● Control through isolation- limits family or friends, controls activities and social events ● Control through intimidation: uses behavior to instill fear ● Control through economic abuse: controls money, makes partner account for all money spent ● Control through power: makes all the decisions, defines roles in relationships, treats spouse like a servant.

Sexual Violence Sexual Assault - Nursing Interventions (Table 22-2) sexxl

provide referral information verbally and in writing. any type of sexual contact or behavior that occurs without the explicit consent of the recipient Sexual Assault - Nursing Interventions (Table 22-2) o STAY WITH PATIENT- pt is safe Tell them not their fault o Empathic manner o Approach with non-judgmental manner o Confidentiality is crucial Preservation of Rape Evidence: o Don't PEE, wash your face or hands, shower or change clothing. ● Rape-Trauma Syndrome (2 Phases): o Acute Phase (Immediate): ​shock, numbness disbelief, calm, difficulty making decisions, solving problems or concentrating. Crying or hysteria. *Long-Term Phase* (2 weeks long): ​re-experiencing the event through nightmares/flashbacks, feeling "numb", avoiding talking about anything that brings them back to the rape/event/location, exaggerated startle response, fears being alone, fears sexual encounters with anyone including their partner, insomnia (sleep issues) *Sexual Assault* - Nursing Interventions (Table 22-2) o NEVER​ leave the patient alone (have someone stay with them) o Remain emotionally neutral - VERY IMPORANT - don't judge them! o Confidentiality is crucial​ - tell them you wont share the information they give you with anyone else besides medical personnel unless they give their consent o DO NOT USE WORDS​: Alleged, refused, intercourse. These minimize the devastation of the event. o Use words: Reported, Declined, & Penetration o Assess signs and symptoms of abuse o Ask for permission to take photos and specimens o Explain all procedures (Ex: "We are going to do a vaginal examination and swab now. Have you had one of those before?") o Take specimens: from under nails, in hair, semen samples, blood, urine samples, etc. Also Test for HIV, Hep B and syphilis​.

When a victim of sexual assault is discharged from the emergency department, which of the following interventions should the nurse perform?

provide referral information verbally and in writing. Immediately after the assault, rape victims are often disorganized and unable to think well or remember instructions. Written information acknowledges this fact and provides a solution. The distracters violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

While providing health teaching for a patient with binge-purge bulimia, what information is most important for the nurse to prioritize?

recognizing the symptoms of hypokalemia. Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia. ??? ▪ Meal planning, healthy exercise regimen. Once this is established, the patient can go out on a "Pass", have a meal and come back to the unit to discuss their experience. Monitor weight, and physiological parameters (VS, electrolyte levels) Monitor before and after meals Teach about importance of meal planning, relaxation techniques, maintenance of a healthy diet and exercise, implementation of coping skills and knowledge of physical and emotional effects of bingeing and purging.

The student nurse is asked to provide a general and concise description of persons with personality disorders. Which of the following would be the best description?

rigid and inflexible. The behavior of clients with personality disorders is enduring and inflexible and pervades a wide range of personal and social contexts. o Rigid and unhealthy pattern of thinking, functioning, behaving o Attend daily activities o SET LIMITS • most people with personality disorder do not respond well to stress and are generally inflexible and poor compromisers. • People with personality disorders tend not to seek help on their own (unless a severe crisis) due to a variety of factors such as: o Adaptions make them feel that they are functioning well o Have little desire to change o Have overall distrust of others • Involve long-term and repetitive use of maladaptive and often self-defeating behaviors. All personality disorders have 4 characteristics in common: o Inflexible and maladaptive responses to stress o Disability in working and loving o Ability to evoke personal conflict o Capacity to frustrate other

A patient being assessed for somatoform pain disorder says, "My pain is from an undiagnosed injury. I can't perform my own activities of daily living or walk 20 minutes. I have to take pain medicine six or seven times a day. I feel like a baby because my family has to provide so much care for me." Which of the following does the nurse understand is most important to include as part of this assessment?

secondary gain

A nurse reports to the interdisciplinary team that a patient with an antisocial personality disorder lies to other patients, verbally abuses a patient with Alzheimer's disease, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting?

verbal abuse of another patient