Mental Health Disorders

A client who has completed an alcohol withdrawal program is prescribed disulfiram 250 mg daily. The client calls the nurse and reports severe vomiting. The client denies any use of alcohol. Which essential question does the nurse ask the client?

"Did you take any cough medicine?" Alcohol can be found in disguised forms, such as in sauces, vinegars, cough mixtures, and aftershave lotions. Explanation Disulfiram An alcohol antagonist drug Mechanism of Action Produces a sensitivity to alcohol, leading to a highly unpleasant reaction when clients ingest even small amounts Awareness of Alcohol Content in Common Products Clients should be aware that several everyday products contain small amounts of alcohol, enough to cause a disulfiram reactionExamples: aftershave, cologne, perfume, antiperspirant, mouthwash, antiseptic astringent skin products, hair dyes, and more

A client who is known to exhibit ideas of reference tells the nurse a visitor who is on the phone is calling the police to arrest the client. How does the nurse respond?

"Do you know the person who is on the phone right now?"

The nurse talks with a client with schizophrenia. What statement by the client does the nurse document as demonstrating depersonalization?

"Does my left hand look different to you? It doesn't look like my hand." Feeling a body part is not their own is evidence the client is experiencing the symptom of depersonalization. note: 1/"Do you feel the electricity in here? I feel it in the air and on my skin." This is an example of a tactile hallucination. 2/"I will receive my next mission through a message on the radio." This is an example of a delusion (or idea) of reference. 3/"I know important, powerful people, and they are going to make you release me!" This is an example of a delusion of grandeur. Key Takeaway Depersonalization in schizophrenia is characterized by feeling that a body part is not one's own. Explanation Schizophrenia: Confusion Symptoms Derealization Perception that the environment has changed or is unreal. Depersonalization -Feeling of being different or unreal -Loss of identity -Sensation that body parts don't belong to them -Belief that body has drastically changed

The nurse educates a student about caring for clients in a manic state. Which comment by the student indicates to the nurse that further education is needed?

"Encourage the client to join group activities." Clients in a manic state should be kept away from bright lights, loud noises, and groups of people. The client should avoid group activities to help maintain a low level of stimulation which decreases the escalation of stress and anxiety. Key Takeaway The nurse works to minimize factors that worsen mania, including protecting them from situations of increased stimuli (lights, sounds, voices, etc.).

The nurse works with a client diagnosed with bipolar disorder. The nurse documents what statement by the client as evidence of mania?

"I am special. I have been chosen by God." During mania, religiosity is common, and the client has an inflated sense of self. note: "My mother spoke to me through the radio." This is an example of an auditory hallucination that is associated with psychotic conditions such as schizophrenia. "I don't see the point of doing any of this." Expressing hopelessness is characteristic of depressed mood rather than mania. "This is not the hospital. Where did you take me?" Feeling like the environment is not "real" or has changed somehow is a symptom of psychotic disorders known as derealization. Explanation Manic Phase of Bipolar Disorder 1/Characteristics Flight of ideas Inflated self-esteem Unusual talkativeness Increased social or sexual activity Physical restlessness Decreased need for sleep Increased distractibility Excessive involvement in high-risk activities 2/Common Symptom Religious preoccupation (e.g., feeling of becoming "one with God")

A nurse cares for a client in the psychiatric unit who reports several phobias. The nurse recognizes signs of social anxiety in which statement?

"I do not speak in business meetings, because I might say something stupid or wrong." Clients with social anxiety may fear being judged by others and will, therefore, avoid situations in which they feel they may incur judgement, such as not talking during a business meeting. Key Takeaway Social anxiety involves fear of being judged negatively in social situations. Explanation Social Anxiety Disorder Also known as social phobia Causes severe anxiety or fear in social or performance situations Client worries about doing something embarrassing or being judged negatively Common Forms and Symptoms Fear of public speaking: most prevalent form of social anxiety Symptoms include: Sweating Trembling Rapid heart rate Nausea Feeling self-conscious Fear of being judged Avoiding places with other people Treating Social Anxiety Medication: prescribed drugs to help manage anxiety Psychotherapy: talk therapy to address emotional and behavioral challenges Support groups: group sessions for sharing experiences and coping strategies

The nurse admits a client with severe anxiety following a home invasion and burglary (ke an trom). During the initial assessment, which statement by the client indicates to the nurse the possible diagnosis of post-traumatic stress disorder?

"I keep reliving the burglary." "I see the thief's face everywhere I go." "I might have died over a few dollars in my pocket." Explanation Post-Traumatic Stress Disorder Occurs after experiencing a psychologically traumatic event Individual becomes prone to re-experiencing the event Common Symptoms Recurrent and intrusive dreams Flashbacks Reliving the event Emotional numbness Facing possible death Seeing the same face everywhere (associated with the event)

A client with antisocial personality disorder says to the charge nurse, "I want Jane to be my nurse today." How does the charge nurse respond?

"We follow the set guidelines in creating the nursing assignment."

The spouse of a client with dementia and new onset delirium expresses an inability to take care of the client at home. How does the nurse respond first?

"What part of taking care of your spouse is most concerning?" The nurse should explore the spouse's concerns using open-ended questions to gather more information about the home situation prior to making suggestions. Explanation Addressing Needs of a Client's Significant Other Explore concerns: Understand their issues Use open-ended questions: Foster detailed responses Encourage expression: Create a safe, judgment-free environment Avoid being dismissive: Listen carefully and show empathy Don't make assumptions: Treat each situation as unique Avoid premature suggestions: Understand needs before offering advice

The nurse in a mental health clinic provides care for a 28-year-old who has experienced the death of an infant child. The nurse recognizes the nursing interventions require additional explanation when the client makes which 3 statements?

"With the medication I can stop going to therapy and support groups." The use of antidepressants can help physiologically. This allows the client to get better outcomes from therapy and groups. "If I don't take trazodone every night I don't have to worry about dependence." The client should not be worried about this at this time. Sleep is crucial to healing. "After being on medication for 6 weeks I will have recovered from my grief." It is important for clients to have realistic expectations regarding their medication and its role in their condition.

A client admitted to the behavioral unit for substance use disorder (SUD) and recent heroin use refuses to take methadone and states, "I want to kick this habit without any drugs in 1 week!" Which response by the nurse is best?

"Without methadone, you are at a higher risk of dangerous physical side effects from withdrawal." Key Takeaway To ensure refusal of methadone is an informed choice, teach clients about withdrawal process and benefits of methadone. Explanation To make an informed decision related to methadone refusal, the client should be aware of the manifestations and risks of opioid withdrawal. Once informed about the withdrawal and recovery process, the nurse explores treatment options acceptable to the client. Manifestations of Opioid Withdrawal hyperthermia insomnia hyperreflexia piloerection (goosebumps) tachypnea excessive tearing, yawning muscle spasms, abdominal cramps nausea, vomiting, diarrhea bone and muscle pain increased anxiety Role of Methadone long-acting opioid that reduces withdrawal symptoms does not result in euphoric effects of other opioids like heroin can be taken once daily

The nurse cares for a client with a phobia of being alone. What actions does the nurse incorporate into the plan of care?

1.Assess level of anxiety and administer prescribed antianxiety agent PRN. Appropriate use of pharmacotherapy reduces anxiety and allows the client to use coping skills. 2.Encourage the client to make a list of strengths that can be applied to combat anxiety. Self-assessment and focusing on strengths can empower the client to develop positive coping mechanisms and self-acceptance. 3.Have the client verbalize the worst-case scenario that could develop if left alone. Asking the client to apply logic to the phobia can promote accurate cognition and reduce irrationality. Key Takeaway Assess anxiety levels, use anti-anxiety medications, and promote positive coping in clients with phobia. Explanation Treating Phobias 1Treatment Approaches Pharmacotherapy Cognitive behavioral therapies (offering coping mechanisms) 2Role of the Nurse Provide reassurance and support Counter the client's feelings of loss of control 3Specific Phobia Persistent, irrational fear of an object, activity, or situation Leads to a desire for avoidance or actual avoidance of the trigger

The nurse cares for a client with an anxiety disorder. The nurse assesses for what behaviors as evidence the client is experiencing a panic attack?

1.Disoriented to surroundings The client experiencing panic is unable to attend to the environment and may even experience derealization where the environment seems unfamiliar to them. 2.Disorganized thinking When in panic levels of anxiety, the client is unable to process what is happening and displays disorganized or irrational reasoning. 3.Visual hallucinations Hallucinations and delusions may occur during a severe panic attack. Key Takeaway Visual hallucinations, disorientation, and disorganized thinking indicate a severe panic attack. Explanation Panic in Anxiety Disorders Panic: Characteristics Extreme level of anxiety Possible loss of touch with reality Hyperactive behavior or withdrawal from others Potential hallucinations (false sensory perceptions) Erratic behavior Client cannot be reasoned with Nursing Focus Ensure client's safety Manage and address panic symptoms

The nurse cares for an adult client with severe separation anxiety disorder. The anxiety is focused on the client's mother. What does the nurse include in the plan of care?

1.Offer reassurance when the client is anxious, reminding of previous visits, and referring to pictures of the two together. The client will experience fear that the mother may experience a devastating event that will result in permanent separation. This anxiety can be so intense that it will interfere with any other activities, so the nurse needs to attempt to make the client feel secure and offer evidence that the mother is safe if necessary and within established set limits. 2.Establish good sleep hygiene and monitor quality and quantity of sleep closely. Clients with separation anxiety often fixate on the worry when attempting to fall asleep, which creates increased anxiety and prevents sleep. When not getting adequate sleep, the client will be less able to participate in treatment and more susceptible to higher levels of anxiety. 3.Help the client's mother learn how to set healthy boundaries with the client. The subject of the anxiety must be involved in the treatment plan, and the nurse will work with other team members to support the mother in limit setting and helping the client feel more secure through consistency and predictability of interactions when the mother is not present.

The nurse assesses a client being treated for bulimia nervosa. What assessment finding does the nurse attribute to bulimia nervosa?

1/ Bilateral facial swelling Parotid gland hypertrophy due to excessive vomiting results in bilateral enlargement of the cheeks in approximately 10 to 25 percent of clients with bulimia nervosa. 2/Dependent edema Due to chronic hypokalemia and metabolic alkalosis, clients develop edema once vomiting is stopped. Sometimes referred to as "rebound" edema. note: Potassium 5.8 mEq/L (3.5-5 mEq/L) Excessive stomach acid and potassium losses can lead to metabolic alkalosis; therefore, a low potassium is expected. Body mass index of 15 If bulimia is the only pathology, the client has usually a normal to slightly underweight body mass index (BMI) between about 17.5-20. A BMI of 15 is extremely low and would suggest a diagnosis of anorexia nervosa. Blood pressure 155/85 mmHg Hypotension can occur due to dehydration and electrolyte imbalances. Explanation Bulimia Nervosa Characteristics Binge eating Inappropriate compensatory behavior to prevent weight gain Excessive concern about body weight Physical Manifestations Edema and parotid gland hypertrophy (can give false appearance of rapid weight gain) Nursing Intervention Explain that symptoms are temporary -Edema: Resolves if purging is stopped for a few weeks -Parotid gland enlargement: Resolves if purging is stopped for a few months

The nurse discusses interventions with the parents of a pediatric client who has oppositional defiant disorder. Which intervention should the nurse suggest to the parents? Select All That Apply

1/"Allow the child 30 minutes of video games each day when behavioral guidelines are followed." Introducing a stimulus that was not previously present, such as allowing video games, is a positive reinforcer because something is added. 2/"Allow the child out of the child's room when the child has controlled behavior." An example of a negative reinforcer is when an undesirable stimulus, such as being confined to one's room, is removed in the hopes of motivating an increase in the desired behavior. Explanation Operant Conditioning and Reinforcers Positive Reinforcers: Introduce a stimulus to increase desired behavior (e.g., rewards). Negative Reinforcers: Remove an undesirable stimulus to increase desired behavior (e.g., allowing a child out of their room). Both positive and negative reinforcers aim to increase desired behaviors without causing negative effects on the subject. If an action has a negative effect, it is considered a punishment. Punishments and Counter-Aggression: Punishments involve introducing an undesired stimulus to decrease unwanted behaviors. However, punishments can lead to counter-aggression, which may increase oppositional behaviors and aggression in clients with disorders like oppositional defiant disorder.

A client is being treated for mania with lithium. What teaching does the nurse include? Select All That Apply

1/"You will require frequent blood tests." Lithium has a narrow therapeutic index and requires monitoring to avoid toxic or subtherapeutic levels. It also affects serum sodium levels, so these may also need to be monitored. 2/"Maintain an intake of 1.5-3 liters of fluid a day." Dehydration slows the GFR and can lead to increased serum lithium levels. The client should maintain a healthy glomerular filtration rate (GFR) to improve renal clearance of lithium. 3/"This medication can cause weight gain." Lithium is associated with weight gain, so the client should be encouraged to monitor for this side effect and take efforts to minimize the negative impact to their health. Key Takeaway Educate client to maintain fluid intake, monitor blood levels, and watch for weight gain while taking lithium medication.

The nurse cares for a client with avoidant personality disorder. What interventions does the nurse apply in the plan of care? Select All That Apply

1/Assertiveness training Assertiveness training is seen as helpful in gaining the skills needed to engage in social situations for the client with avoidant personality disorder. 2/Group therapy Individual and group therapy are both recommended as a way of learning how to process anxiety-provoking symptoms and develop techniques for handling anxiety-provoking situations. 3/Self-esteem building Low self-esteem is a defining characteristic of avoidant personality disorder and a target of therapy. Explanation Avoidant Personality Disorder Characteristics Social discomfort Low self-esteem Difficulty with negative interactions Avoidance of social interaction Impaired functioning due to feelings of inferiority Treatment Psychotherapy Cognitive behavioral techniques Building trust and self-esteem Pharmacotherapy Antidepressants Anti-anxiety agents

The nurse cares for a client who has seasonal affective disorder (SAD). The nurse recognizes which most common signs or symptoms as associated with this condition? Select All That Apply

1/Changes in appetite or weight Symptoms commonly associated with SAD include changes in appetite or weight, especially a craving for sweet or starchy foods. 2/Sleep problems Hypersomnia is more common, but sleeplessness or insomnia may occur. 3/Difficulty concentrating Symptoms commonly associated with SAD include difficulty concentrating. 4/Low energy Having low energy and feeling sluggish are common. Explanation Seasonal Affective Disorder (SAD) A type of depression related to changes in seasons. Winter-Pattern SAD Symptoms In addition to typical depression signs, people may experience: Hypersomnia: excessive sleepiness Overeating: consuming food in larger quantities than needed Weight gain: increased body weight Social withdrawal: avoiding social interactions. Seasonal Pattern of SAD Symptoms usually appear during late fall or early winter. They typically subside during the sunnier days of spring and summer.

The nurse assesses a client diagnosed with bipolar I disorder. What aspects of the client's recent history or current behavior does the nurse document as possible evidence of a state of euphoric mania?

1/Client reports life is going "great." In euphoric mania, the client does not acknowledge negatives, such as unpaid bills or strained family relationships. 2/Reports starting a new romantic relationship. The client is more outgoing and often more sexually active when in a manic phase of the illness. 3/Hobbies include online gambling. Get rich quick schemes, gambling, and overspending are frequently seen in clients who are experiencing mania. Key Takeaway Euphoric mania is characterized by new romantic relationships, online gambling, and feeling great. Explanation Bipolar I Disorder 1Characteristics Mood disorder with at least one weeklong manic episode Excessive activity and energy May alternate with depression, hypomania, or mixed states 2Euphoric Mania Exaggerated emotions Reckless behavior Reduced need for sleep Inflated sense of personal abilities 3Common Behaviors Gambling or giving money away Increased sexual promiscuity Perception of life without issues

The parent of an adolescent client who has just been diagnosed with schizophrenia says to the nurse, "I don't like the idea of medications. Can't psychotherapy work?" The nurse includes what information in the response? Select All That Apply

1/Clients with schizophrenia have physically different brain structures. 2/A multifaceted approach with medication and other approaches is usually needed. 3/This is considered a neurobiological condition and is not purely psychological.

The nurse develops a plan of care for a client who has lithium prescribed for the manic phase of bipolar disorder. Which nursing intervention does the nurse include in the plan of care? Select All That Apply

1/Drink 3,000 mL of fluid daily. A normal diet with normal salt and fluid intake (1,500-3,000 mL/day or six 12-oz glasses of fluid) should be consumed daily. 2/Avoid drinking large amounts of coffee and tea. Coffee and tea contain caffeine, which have a diuretic effect. 3/Tell client that lithium can cause weight gain. Weight gain is a side effect of taking lithium. Key Takeaway Lithium requires fluid intake, caffeine avoidance, and may cause weight gain. Explanation Lithium treats and prevents mania episodes in clients with bipolar disorder. Dietary Recommendations -Maintain a normal diet -Ensure normal salt intake -Consume 1,500-3,000 mL/day (equivalent to six 12-oz glasses) of fluid Lithium and Sodium Balance Lithium affects sodium reabsorption in the kidneys Imbalance may result in lithium toxicity Low sodium intake can lead to increased lithium retention Clinical reasoning tip: When you encounter a question or real-life situation in which the client has comorbidities, you will need to think of how the treatments interact. This patient is at risk of lithium toxicity if they have a fluid imbalance or a low sodium diet. Examples include: vomiting or poor oral intake heart failure hypertension chronic kidney disease syndrome of inappropriate antidiuretic hormone release (SIADH)

The nurse cares for a school age child diagnosed with separation anxiety. What symptoms of this condition does the nurse identify for the child's parents? Select All That Apply

1/Reports of head or stomach aches Somatic symptoms are common and may be physical (somatic) manifestations of anxiety. Pain symptoms worsen the psychological symptoms which worsens the pain symptoms. 2/School avoidance The child may try to find ways to avoid being separated from the parent by avoiding going to school. 3/Excessive worry For example, this child may fixate on concerns about the safety of the parents that manifests as unreasonable. Key Takeaway Symptoms of separation anxiety in school-age children include excessive worry, somatic complaints, and school avoidance. Explanation Separation anxiety is normal in infants. Inappropriate in School-Age Children Developmentally inappropriate levels of concern over being away from a significant another (usually one or both parents) Common Fears Fear of something terrible happening to the parent(s) Manifestations Sleep disruptions Physical symptoms (e.g., gastrointestinal disturbances, headaches)

A nurse cares for a client with a specific phobia. What approaches does the nurse use to reduce the client's anxiety level while working on exposure to the source of the phobia?

1Explore behaviors that have worked to relieve anxiety in the past. (coping mechanisms) 2Tell the client in advance that the source of the phobia will be presented. 3Ask the client to rate the anxiety they are experiencing during the exposure. Key Takeaway When working with a client's phobia, explore past coping mechanisms, inform them of exposure, and assess anxiety levels. Explanation Specific Phobia Persistent, irrational fear of a specific object, activity, or situation Leads to desire for avoidance or actual avoidance of the trigger. Treatment Plan Pharmacotherapies: Medications to manage anxiety Cognitive Behavioral Therapies: Offers alternative, healthier coping mechanisms. Exposure: May be used, but only with client's agreement and after developing healthy coping mechanisms first

A nurse cares for a client with a personality disorder. Based on the common characteristics of personality disorders, what actions will the nurse incorporate into the plan of care? Select All That Apply

1Offering rewards for honesty and adhering to the treatment plan 2Encouraging client to identify behavior that resulted in hospitalization 3Establishing non-negotiable consequences for unwanted behavior Explanation Characteristics of Personality Disorders Abnormal moral development Maladaptation in social situations Altered interpersonal functioning Abnormal ways of perceiving and interpreting oneself, others, and events Lack of Insight Clients often do not accept responsibility for their actions Tendency to blame others for negative behaviors Nursing Interventions Set clear limitations Discourage debate Reward positive behavior Encourage acceptance of personal accountability

The nurse in a mental health clinic provides care for a 28-year-old who has experienced the death of an infant child. The nurse is most concerned by which 5 assessment findings? Select All That Apply

1Personal hygiene practices 2Feelings of guilt 3Sitting in infant's room alone 4History of depression 5Social interactions

A nurse assesses a school-age child who has just been removed from the parental home due to abuse. The health care provider has diagnosed a dissociative disorder. The nurse includes what interventions in the plan of care? Select All That Apply

1Teach the child self-soothing techniques, such as listening to music. 2Encourage caregivers to set limits and maintain normal behavior expectations. 3Tell the child the events that happened to them were not the child's fault. Key Takeaway Encourage caregivers to set limits, teach self-soothing techniques, and reassure child's worth. Explanation Early Stages of Recovery from Childhood Trauma: Nursing Focus 1Establishing Safety Make the child feel safe 2Reassurance Reassure the child's worth 3Normalization Normalize the child's experiences and symptoms 4Emotion Regulation Strategies Help the child learn strategies to regulate emotion and arousal levels 5Caregiver Involvement Teach caregivers to reinforce self-soothing techniques Assist caregivers in setting healthy boundaries for the child's behavior

A client with schizophrenia is displaying loose associations when speaking to the nurse, and the nurse is unable to make sense of what the client is trying to say. How does the nurse respond? Select All That Apply

1Tell the client, "I am having trouble understanding what you are trying to say to me." 2Summarize or paraphrase what parts the nurse does understand that the client is saying. 3Encourage the client to come to a quiet area and continue the conversation there.

The nurse cares for a client experiencing delusions who has shown recent improvement in the ability to engage in reality testing. What actions does the nurse include related to the client's delusional thinking? Select All That Apply

1Validate if parts of the delusion are based in reality without reinforcing the misconceptions. 2Focus discussion on the client's feelings that are associated with the delusion. 3Teach the client how to reflect on thoughts and recognize possible delusional thinking. Key Takeaway Teach clients experiencing delusions to reflect on their delusional thinking, validate reality, and focus on associated feelings. Explanation Interacting with Clients Experiencing Delusions Delusions: Result from impaired thought processes, client's attempt to make sense of poorly understood experiences Client's Ability to Test Reality: If unable, nurse should not debate delusion If able, nurse should encourage client to: Identify delusional thinking Consider alternate explanations based in reality Nurse's Role: Adapt interaction based on client's insight and ability to question delusions

A nurse works on a psychiatric unit with several clients. When working with which client does the nurse take the greatest precautions due to there being the highest risk for physical aggression?

A 45-year-old female client with psychosis and paranoid delusions Key Takeaway Clients with psychosis and paranoid delusions have the highest risk for physical aggression. Explanation Aggression in Clients Importance: Nurse's knowledge of individual client and their aggression history more crucial than diagnosis alone Behaviors Linked to Higher Violence Risk: Delusional Hyperactive Impulsive Paranoid Delusions: Fear accompanying delusions may increase likelihood of aggressive actions Other Conditions Associated with Aggression: Post-traumatic stress disorder (PTSD) Substance use disorders Personality disorders

The client with a somatic symptom disorder says to the nurse, "I keep having all these symptoms and no one believes me." The nurse should use which of these approaches in responding to the client?

Acknowledge the client's symptoms as an accurate description. Explanation Somatic Symptom Disorder Characteristics -Distressing symptoms and maladaptive response -No significant physical findings or medical diagnosis -Symptoms are genuinely experienced -Differs from malingering: no fabrication of symptoms for personal gain Nursing Approach -Avoid challenging the client's experiences to maintain therapeutic relationship -Accept the client's account of symptoms -Do not reinforce belief in a specific medical diagnosis as the cause of symptoms

The nurse cares for a client with antisocial personality disorder. What common characteristics of this disorder might the nurse observe in this client?

Aggressive actions toward other clients Impulsive behaviors A history of repeated arrests Explanation Antisocial Personality Disorder (ASPD): Cluster B personality disorder Pattern of disregard and violation of others' rights Also known as sociopathy Key Characteristics: Impulsive behaviors: Failure to plan ahead, risk-taking Aggressive actions: Hostile acts for personal gain, manipulation, deceit History of repeated arrests: Disregard for lawful behaviors, lack of responsibility Lack of empathy: Limited capacity for intimacy, manipulative in relationships No remorse or guilt: Unaffected by punishment, neglects obligations Treatment: Challenging due to lack of insight and motivation for change Mood-stabilizing medications Therapy focused on behavior modification and coping skills

The nurse admits a client with major depression. The nurse develops a plan of care for this client. The nurse implements which priority intervention?

Asks the client if suicide has been planned

The nurse in a mental health clinic provides care for a 28-year-old who has experienced the death of an infant child. The nurse will include which 5 interventions in the plan of care for the client experiencing complicated grief?

Assess client's available support system Acknowledge and allow the client to share their loss Arrange follow-up with a psychiatric healthcare provider Assist client to develop a daily schedule Provide client with grief support group options Explanation Interventions for this client should include psychiatric care, support systems, and helping to manage daily tasks. Complicated grief plan of care explore psychiatric services -counseling with someone trained in the grieving process -engage in cognitive-behavioral therapy -consider family therapy outline the support system available -provide opportunities to talk through the loss -assess friend and relationship support -use grief support groups develop a daily schedule for structure -schedule daily activities -write down appointment -incorporate self-care activities -include a medication tracker monitor medication therapy -medications can take days to weeks to reach therapeutic effects -other strategies are necessary until effectiveness is known use alternate supports -practice meditation -schedule massage therapy -Try art therapy -read self-help literature

The nurse in a mental health clinic provides care for a 28-year-old who has experienced the death of an infant child. For each assessment finding, indicate which grief response(es) it is associated with.

Assessment 1Finding Typical Grief Process 2Complicated 3Grief Brief Psychotic Episode Recent social interactions 123 Sitting in infant's room 2 Personal hygiene practices 23 Feelings of guilt 12

A client with schizophrenia is admitted due to paranoia and altered thought processes. The charge nurse instructs colleagues to take what action when interacting with related to this client?

Avoid having staff interactions near the client's room.

A client with schizophrenia is admitted due to paranoia and altered thought processes. The charge nurse instructs colleagues to take what action when interacting with related to this client?

Avoid having staff interactions near the client's room. Due to paranoid delusions and altered thought processes, the client is at high risk for ideas or delusions of reference where the client wrongly assigns personal meaning to events in the environment. Interacting near the client's room can be interpreted as the staff speaking about or even conspiring against the client.

The nurse assesses a client being treated for bulimia nervosa. What assessment finding does the nurse attribute to bulimia nervosa?

Bilateral facial swelling Dependent edema WRONG: Potassium 5.8 mEq/L (3.5-5 mEq/L) Excessive stomach acid and potassium losses can lead to metabolic alkalosis; therefore, a low potassium is expected. Body mass index of 15 If bulimia is the only pathology, the client has usually a normal to slightly underweight body mass index (BMI) between about 17.5-20. A BMI of 15 is extremely low and would suggest a diagnosis of anorexia nervosa. Blood pressure 155/85 mmHg Hypotension can occur due to dehydration and electrolyte imbalances. Explanation Bulimia Nervosa Characteristics Binge eating Inappropriate compensatory behavior to prevent weight gain Excessive concern about body weight Physical Manifestations Edema and parotid gland hypertrophy (can give false appearance of rapid weight gain) Nursing Intervention Explain that symptoms are temporaryEdema: Resolves if purging is stopped for a few weeksParotid gland enlargement: Resolves if purging is stopped for a few months

The nurse cares for a client with a personality disorder. What aspect common to personality disorders will the nurse accommodate for when creating a plan of care?

Clients with personality disorders often lack insight and accountability, which may lead to blaming others. Lack of insight is common for clients with personality disorders and makes treatment challenging. Key Takeaway Traits of personality disorders include inconsistency, labile relationships, and lack of a realistic view of themselves and their impact on others. Explanation Personality disorders involve a persistent pattern of maladaptive patterns of thinking, behavior, and mood. Impact Impairment in social or occupational functioning Insight Often lack understanding of how their thoughts and actions are a problem Challenges Self-identity or self-direction issues Problems with empathy or intimacy in relationships Onset Early adulthood, may lessen with age Classifications 3 major groups10 disorders Cluster A: odd or eccentric Paranoid, Schizoid, Schizotypal Cluster B dramatic or erratic Antisocial, borderline, histrionic, narcissistic Cluster C anxiety or fearful Avoidant, obsessive- compulsive, dependent

The nurse assesses a client in the manic phase of bipolar disorder. The nurse expects to observe which likely client behavior?

Delusions and distractibility Explanation Bipolar Disorder Bipolar Disorder Characteristics Extreme mood swings Includes depressive and manic states Manic State Symptoms Euphoria High energy levels Increased activity Racing thoughts Distractibility Poor decision-making Neglected Self-Care during Manic State Grooming Toileting Sleep Intervention Hospitalization may be necessary for client protection during manic episodes

A nurse cares for a client that just experienced an extremely stressful event and cannot recall anything from the day on which the event occurred. The nurse incorporates interventions for what type of disorder when caring for the client?

Dissociative amnesia Dissociative amnesia is the inability to recall important personal information, often of a traumatic or stressful nature. Key Takeaway Dissociative amnesia is an inability to recall events surrounding trauma. Explanation Dissociative Amnesia Inability to remember details related to a traumatic event Not the same as forgetfulness Dissociative Amnesia vs. Generalized Amnesia Generalized Amnesia: Client is unable to recall information on a more global scale Types of Dissociative Amnesia Localized: Client is unable to remember all events in a certain period Selective: Client is able to recall some but not all events in a certain period

The nurse calculates the body mass index (BMI) of an adult client. The client's BMI measures 32. The nurse implements which nursing intervention?

Encourage the client to record meals, snacks, and emotions in a journal. Behavioral management of obesity helps the client change eating habits and lose weight. Keeping a food journal encourages the client to log food while recognizing feelings and situational factors that may influence the type and amount of food eaten. Key Takeaway Encouraging a client to keep a food journal helps change habits and lose weight. Explanation Body Mass Index (BMI) Screening tool estimating total body fat Formula: weight (kg) / height (m)2 BMI Measurements for Adults Underweight: BMI below 18.5 Normal or healthy weight: BMI 18.5-24.9 Overweight: BMI 25-29.9 Obesity: BMI 30-39.9 Morbid obesity: BMI above 40 Health Consequences of High BMI Hypertension Dyslipidemia Type 2 diabetes Coronary artery disease Sleep apnea Osteoarthritis Interventions for Obesity Diet programs Exercise programs Drug therapy Behavioral therapy Surgical management

A client with antisocial personality disorder suddenly gets angry at the nurse for not being allowed in the staff lounge. How does the nurse respond?

Enforce the limit calmly, but firmly, and redirect the client to another activity.

A nurse cares for a client with obsessive-compulsive disorder (OCD). What goal does the nurse establish as most appropriate for this client?

Identify and apply three effective coping strategies to manage anxiety.

The nurse cares for a client with a history of alcohol misuse. The nurse assesses for which early signs or symptoms of withdrawal?

Irritability Tachycardia Tremors Explanation Manifestations of alcohol withdrawal result from excessive excitability of the central nervous system (CNS) Alcohol is a CNS depressant Chronic use leads to compensatory mechanisms to counter alcohol's CNS depressive effects Within 6 hours of stopping alcohol signs of CNS overstimulation may develop Early Signs of Withdrawal: Irritability: Difficulty modulating reactions due to increased CNS stimulation Tachycardia: Increased heart rate due to excitatory state Tremors: Evidence of increased excitatory activity in the CNS Withdrawal Progression: Within 48-96 hours, withdrawal can progress to delirium tremens. hallucinations disorientation hypertension hyperthermia agitation diaphoresis seizures

A client with obsessive-compulsive disorder takes hours to get ready each morning due to indecisiveness. The nurse takes what action?

Limit the choices the client needs to make when getting ready. Explanation Managing OCD Symptoms Indecisiveness: Common with bathing or clothing Solution: Limit clothing choices or give simple directions Elimination Patterns: Affected by rituals Solution: Create a bathroom schedule Interference with Tasks: Rituals disrupt completion of tasks Solution: Set expectations and time limits OCD Issues: Doubts & checking Ordering & arranging Unacceptable & taboo thoughts Contamination & washing Desired Outcome: Reduced anxiety

A client is brought in by the police after being found wandering around a grocery store and unable to recall any personal information. What assessment findings does the nurse document as supporting a dissociative fugue?

Military background with diagnosis of post-traumatic stress disorder Key Takeaway History of post-traumatic stress disorder is key in supporting dissociative fugue. Explanation Dissociative Fugue Fugue is a dissociative process involving loss of identity, specific personal memories, and sudden travel away from familiar environments Dissociation acts as a subconscious defense mechanism to protect a person's emotional self from traumatic events or memories Physical Causes Rule out physical causes when a client presents with abrupt personality or memory changes Relevant Supporting Evidence A history of post-traumatic stress disorder supports the presence of dissociative fugue

A nurse cares for a newly admitted client with obsessive-compulsive disorder (OCD) on an inpatient unit who refuses to drink the tap water being offered due to fears of contamination. What action does the nurse take?

Offer the client an alternate fluid that the client is willing to drink.

The nurse assesses a client with borderline personality disorder. Which assessment does the nurse expect to see?

Periods of stress-related paranoia Impulsive and risky behavior Recurrent suicidal behavior Inappropriate, intense anger Key Takeaway Borderline personality disorder is characterized by impulsive and risky behavior, intense anger, paranoia and recurrent suicidal behavior. Explanation Borderline Personality Disorder A chronic condition often linked to a history of trauma or abuse Characterized by mood instability, difficulty in relationships, and high rates of self-injury and suicidal behavior Impact of Borderline Personality Disorder Affects how one feels about themselves, relates to others, and behaves Behavioral Challenges Clients with borderline personality disorder may display manipulative behaviors toward staff and others

The nurse develops a plan of care for a client who has had an overdose of heroin. Which priority nursing intervention does the nurse include in the plan of care?

Place an airway at client's bedside. The priority goal is to ensure that the client's airway is maintained. Key Takeaway Maintaining the client's airway is the priority intervention for heroin overdose. Explanation Heroin Overdose Major cause of premature death and morbidity among heroin users Consequences of Heroin Overdose Severely suppresses respirations Can lead to respiratory failure Medical Intervention Client may need to be intubated to assist with breathing

The nurse cares for a client diagnosed with antisocial personality disorder. What trait will the nurse attribute to this disorder?

Poor judgment Poor judgment is typical in antisocial personality disorder and manifests as risk-taking and criminal behaviors. NOTE: 1Dependence and self-criticism A dependent and self-critical attitude is manifested in clients with dependent personality disorder. 2Unstable self-image Unstable self-image is present with borderline personality disorder 3Memory lapses Memory lapses are found in clients with cognitive disorders. Explanation Antisocial Personality Disorder Characteristics: Poor judgment, risk-taking, criminal behavior Pathological Traits: Antagonistic behaviors, deceitful, manipulative Behavior Patterns: Disregard for responsibility, impulsivity Common Issues: Criminal misconduct, substance abuse

The nurse developes a nursing care plan for a client who is in the manic phase of bipolar disorder. Which intervention does the nurse include in the plan of care?

Provide the client with finger foods. Providing high-calorie finger foods and fluids is needed to help prevent dehydration and electrolyte imbalances. Explanation Bipolar Disorder: Managing Nutrition Characteristics of Bipolar Disorder Exhibits episodes of mania and depression Normal mood and activity levels occur in between episodes Importance of Fluid and Calorie Replacement Clients need constant fluid and calorie replacement Activity levels may make it difficult to sit at meals Nutritional Strategy Finger foods allow for "eating on the run" while maintaining nutrition

A nurse at a community health clinic provides education to a intravenous drug user. The nurse educates the client on which option related to the addiction?

Referral to a place where new syringes and needles can be obtained. Key Takeaway Syringe service programs reduce needle sharing and disease spread among people who inject drugs. Explanation Harm Reduction Strategies for People who Inject Drugs (PWID) 1Syringe services and injection site care -reduces spread of blood borne disease such as hepatitis C and HIV -offers a point of contact where counselling can occur 2Safe injection practices education -not sharing needles to avoid disease transmission -asepsis to reduce risk for bacterial infection 3Naloxone distribution -available without prescription to treat opioid overdose -may be given intranasally or parenterally

The nurse cares for a client who has just been admitted to a mental health unit. The client has been diagnosed with schizophrenia and has been exhibiting severe social withdrawal. The nurse enters the client's room and says, "hello" and sits down next to the client. Without responding, the client stands up and starts to leave the room. The nurse takes which most appropriate nursing intervention?

Remains silent and allows the client to leave Social isolation and impaired social interaction are common negative symptoms of schizophrenia. The client will seek to be alone to relieve anxiety associated with being around others. Accepting the client unconditionally by minimizing expectations and demands is the priority. Key Takeaway Allowing the client to leave minimizes demands and anxiety in schizophrenia. Explanation Understanding Schizophrenia Schizophrenia and Anxiety Clients with schizophrenia may experience anxiety around others Often seek solitude to relieve anxiety Impaired Social and Interpersonal Functioning Social withdrawal and poor social interaction skills are common negative symptoms These challenges are more difficult to treat than positive symptoms (e.g., hallucinations and delusions) Impact on Quality of Life Negative symptoms contribute to a poor quality of life for individuals with schizophrenia

The nurse cares for a client whose son recently died. The client is unable to recall the circumstances of her son's death. The nurse incorporates interventions for what form of defense mechanism?

Repression Repression is an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. The client is demonstrating repression, as she does not have a conscious memory of the stressful event NOTE: Suppression Suppression is the conscious choice to block out unacceptable thoughts and feelings from awareness. Example: Telling oneself not to worry about an issue until after a stressful event has passed. Undoing Undoing is when a person attempts to make up for a negative act or communication. Example: Taking a child out for ice cream after losing one's temper and slapping him

The nurse admits a client with severe anxiety. The nurse implements which intervention when planning client care?

Role-play situations that the client finds anxiety-provoking. Role playing or modeling behaviors helps the client to try alternative behaviors and solutions to anxiety-provoking situations.

A client with a history of multiple job conflicts with work superiors and physical assaults on others tells the practical nurse (PN), "Things would be better if people were not so critical of me." The PN recognizes that the client's conflicts with authority may indicate which type of personality disorder?

Schizotypal and antisocial note: Histrionic A client with histrionic personality disorder prefers to be the center of attention. This client requires constant approval and might dress provocatively and use dramatic displays of emotion to gain and maintain others' attention. Dependent A client with dependent personality disorder is afraid of being alone and does not like being in charge. Narcissistic A client with narcissistic personality disorder has little or no empathy and desires to be admired by those around them. Their assumption is that they are better than those with whom they work or associate and should be treated in special ways.

The nurse cares for a client with schizoid personality disorder who is withdrawn. How does the nurse approach the client?

Sit quietly with the client and occasionally ask questions. Sitting quietly with the client and occasionally asking open-ended questions is the best approach. This demonstrates to the client that they are not alone, that the nurse has time for him or her, and the nurse is willing to meet the client where they are. Key Takeaway When caring for clients with schizoid personality disorder, sit quietly, ask occasional open-ended questions, and avoid forcing socialization. Explanation Caring for Clients with Schizoid Personality Disorder Schizoid Personality Disorder Characteristics Lack of interest in social relationships Lack of pleasure Introspection Disinterest in approval or rejection from others Nursing Approach Sit quietly with the client Ask open-ended questions occasionally Demonstrates presence and willingness to meet the client where they are Avoid being overly "nice" Do not attempt to increase socialization

The nurse works with a client who refuses to take medications from anyone but the nurse. The nurse feels a sense of superiority due to this situation. The nurse should take what action?

Speak to colleagues about these feelings and develop a plan to address the client's behavior. The nurse is at risk of developing an unhealthy relationship that is outside the boundaries of a professional nurse-client relationship.

A client with antisocial personality disorder is admitted to the unit. The nurse uses what approach when setting limitations on behaviors?

State clear unacceptable behaviors and the non-negotiable consequences for these behaviors. The nurse needs to establish clear boundaries that limit the client's ability to manipulate established rules or make excuses for behaviors. Explanation Antisocial Personality Disorder Antagonistic behaviors: Deceitful and manipulative Primary focus: Personal power and self-gratification Management: Establish non-negotiable and clear boundaries

When prompted by the nurse to attend a group therapy session, a client with agoraphobia reports a choking feeling and begins to cry uncontrollably. Which is the appropriate response by the nurse?

Stay with the client and speak in short, simple sentences. The client's response is similar to a panic attack. The nurse remains with the client, speaking in clear short sentences, remaining calm and rational.

Coping Defense Mechanisms A client with a recurring compulsion to organize has founded a successful closet organizing business. The nurse documents this history as an example of what phenomenon?

Sublimation This is an example of sublimation. The client is subconsciously applying the abnormal need for order into an activity that is more socially acceptable. note: 1/Projection Projection refers to the unconscious rejection of personal attributes and assigning them to others instead. 2/Reaction formation Reaction formation is when a person develops an opposite behavior to control unacceptable feelings or behaviors. 3/Displacement Displacement is the transferring of emotions associated with one person to a (usually less threatening) person. Key Takeaway Sublimation is the unconscious application of negative personality traits to a socially accepted activity. Explanation Sublimation Unconscious transformation of negative personality traits into socially accepted positive activities. Nature of sublimation: Always constructive

The nurse cares for a client with an elevator phobia. Which approach does the nurse anticipate can be used to reduce the client's anxiety?

Systematic desensitization Systematic desensitization is a form of behavior therapy. It attempts to reduce anxiety and thereby eradicate the phobia through gradual exposure to anxiety-producing stimuli note: Psychoanalytic therapy Psychoanalytic therapy, sometimes called "talk therapy," is not as effective in the short term to decrease the client's anxiety, although it may be effective for helping the client discover why the phobia developed. Electroconvulsive therapy Electroconvulsive therapy is used for resistant depression and is not a recognized therapy for anxiety disorders such as phobia disorder. Explanation Systematic desensitization is a form of behavior therapy used to reduce anxiety and eliminate phobias Gradual exposure to anxiety-producing stimuli in a controlled, stepwise manner, known as graduated exposure Teaches clients anxiety-reduction techniques to cope with each level of exposure Progression to the next step occurs when the client can manage anxiety at the current level

The nurse cares for a client reporting paralysis of both legs. The client is diagnosed with conversion disorder. Which nursing intervention does the nurse implement?

Teach client deep breathing techniques for relaxation. The physical symptoms of conversion disorder are often associated with stress. Teaching the client ways to manage stress, such as deep breathing and mild exercise, provides the client with knowledge of alternate coping strategies. Key Takeaway Physical symptoms of conversion disorder are stress-related. Teach deep breathing for relaxation . Explanation Conversion Disorder Also known as functional neurological disorder Neurological symptoms without a clear neurological basis Symptoms Paralysis, blindness, movement disorders, gait disorders Numbness, paresthesia, hearing loss, epilepsy Emotional conflicts or stressors often associated with symptoms Clients experience symptoms as real Characteristics Dramatic lack of concern called "la belle indifference" or "the grand indifference" Risk Factors Low socioeconomic status, fewer years of education History of physical or sexual abuse, rural settings Comorbidities Anxiety and depression Treatment Therapy, education, and support groups

The nurse cares for a client with a history of malingering. The nurse documents what behavior as supporting evidence of malingering?

The client only displays discomfort when there are other persons in the room.

The nurse on a mental health unit becomes aware of some client situations. Which client does the nurse assess first?

The client with paranoid schizophrenia who is yelling, "I will do it, I will do it" When clients experience auditory hallucinations, it is critical to determine if their voices are commanding them to harm themselves or others. This would be the priority client to assess first.

The nurse works on a psychiatric unit. What client does the nurse anticipate as most likely to experience delusions of grandeur?

a client in the manic phase of bipolar I disorder The client with mania is the most likely of those listed to exhibit beliefs of inflated self that meet the criteria for delusional thinking. An example is someone believing they are responsible for relaying important messages from a deity or world leader. NOTE: 1a client with bipolar II disorder and hypomania Delusions and hallucinations are not present during hypomania. Hypomania involves a noticeable increase in activity, energy, or confidence 2a client with post-traumatic stress disorder Post-traumatic stress disorder has the potential to result in depressive and irritable behavior but is not associated with grandiosity. 3a client diagnosed with dissociative disorder Dissociative disorders involve an unconscious defense mechanism that protects the client from excessive anxiety often related to a past traumatic event. Dissociation may look like daydreaming, spacing out, switching between emotions, or changing tone of voice. Key Takeaway Grandiosity is often seen with mania and may focus on exaggerated self-importance or persecution. Explanation Clients may experience delusions or hallucinations during a manic phase. -Hallucinations involve the senses. A person may hear, see, smell, or feel things that are not factually occurring. -Delusions are false beliefs that the individual thinks are real. -Delusions of grandeur are false beliefs that involve a great deal of power or importance. Common Themes of Delusions of Grandeur Religion Fame Possessing special powers There are several other types of delusional disorders: Persecutory: Believing they are being stalked, spied upon, poisoned, conspired against Jealousy: Beliefs around a partner's fidelity Love: Believing that someone else is in love with them Somatic: beliefs that something is wrong with them, such as

A client with schizophrenia has not bathed or changed clothes in over a week. The nurse attributes this finding to what characteristics of schizophrenia? Select All That Apply

anergia, anhedonia and avolition Explanation Schizophrenia Symptoms Positive Symptoms Delusions Hallucinations Grossly disorganized thinking, speech, and behavior Negative Symptoms Flat affect Avolition Social withdrawal or discomfort Impact of Negative Symptoms Decreased productivity Self-neglect

A nurse discusses smoking cessation and nicotine withdrawal with a client. Which statement about nicotine withdrawal symptoms does the nurse include in the discussion? Select All That Apply

anxiety, irritability, and depression. sleep disturbances. Explanation Nicotine Withdrawal Marked by mood changes and physiological changes Psychological Symptoms Strong desire or craving for nicotine Irritability Low mood Difficulty concentrating Depression Anxiety Mood swings Physical Symptoms Headaches Sweating Restlessness Tremors Difficulty sleeping Waking at night Increased appetite Abdominal cramps Difficulty concentrating (also a psychological symptom)

The nurse in a mental health clinic provides care for a 28-year-old who has experienced the death of an infant child. Complete the following sentence by using the list of options. Based on history and assessment, the client is most likely experiencing... as evidenced by the client ...

complicated grief sitting alone in infant's room.

The nurse cares for a client who is experiencing delirium tremors (DTs) from alcohol withdrawal. Which assessment does the nurse find consistent with delirium tremors?

confusion, hallucinations, and paranoia Explanation Delirium Tremens (DTs) Severe form of ethanol withdrawal Characterized by altered mental status and autonomic hyperactivity. Can progress to cardiovascular collapse. Severity and Clinical Manifestations Most severe manifestation of alcohol withdrawal Symptoms include: Agitation Global confusion Disorientation Hallucinations Fever Hypertension Diaphoresis (sweating) Tachycardia (fast heart rate) Hallmark Symptom Profound global confusion is the key characteristic of delirium tremens.

A nurse cares for a client diagnosed with schizoaffective disorder. The nurse assesses for what signs or symptoms typical of this disorder?

depressed mood, manic episodes, and hallucinations. Explanation Schizoaffective Disorder (DSM-V) Combination of psychotic/schizophrenic symptoms and mood disorder elements (e.g., mania or depression) Presentation Clients may exhibit: Mania or depressive symptoms Fluctuation between the two Schizophrenia features: Delusions Hallucinations

A nurse works with a client who has a history of an opioid-use disorder. What assessment findings does the nurse apply as evidence of opioid withdrawal?

diarrhea, tachycardia, and runny nose Explanation Opioid Withdrawal Being Alert for Opioid Withdrawal Signs Nurses should stay vigilant for signs of opioid withdrawal Effective treatments are available to reduce negative effects during withdrawal Opioid Withdrawal vs. Intoxication Withdrawal signs are primarily opposite to opioid intoxication signs Common Signs and Symptoms of Opioid Withdrawal Hyperthermia: increased body temperature Insomnia: difficulty sleeping Hyperreflexia: overactive reflexes Piloerection:"goosebumps" or hair standing on end Tachypnea: rapid breathing Excessive tearing: watery eyes Yawning: frequent, involuntary yawning Muscle spasms: sudden, involuntary muscle movements Abdominal cramps: stomach pain and discomfort Nausea, vomiting, diarrhea: gastrointestinal issues Bone and muscle pain: aching and discomfort in bones and muscles Increased anxiety: heightened feelings of worry and nervousness

The nurse cares for a client with post-traumatic stress disorder (PTSD). What interventions does the nurse include? Select All That Apply

establish routines, sleep hygiene, and engage in support groups.

A parent of a school-age client asks a nurse what symptoms are common with attention deficit/hyperactivity disorder (ADHD). The nurse includes which symptoms of ADHD in response?

impulsivity, hyperactivity, and inattention Explanation Attention Deficit/Hyperactivity Disorder (ADHD): neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity. three subtypes: Hyperactive, Inattentive, and Combined. ADHD Symptoms: Inattention: Difficulty following directions, sustaining attention, completing tasks, and staying organized. Easily distracted. Impulsivity: Acting without thinking, interrupting, and struggling with tasks requiring patience, such as waiting for a turn in a game. Hyperactivity: Excessive physical activity, talkativeness, fidgeting, difficulty staying seated, and intruding on others. It is important to recognize that ADHD symptoms can manifest differently in each individual, depending on the subtype and severity of the disorder.

The nurse cares for a client diagnosed with dissociative identity disorder. During the examination, the nurse would expect which symptoms?

inability to recall events unstable relationships. Inconsistent performance on assessments note: Preoccupation with physical appearance Preoccupation with physical appearance is associated with body dysmorphic disorder rather than dissociative identity disorder. Intense egocentrism Intense egocentrism and sense of superiority and exhibitionism are seen in certain personality disorders, such as antisocial and narcissistic, but is not a feature of dissociative personality disorder. Explanation Dissociative Identity Disorder -Previously called multiple personality disorder -Clients have two or more distinct personalities, each with unique behavior and attitudes Assessment Strategies Ask specific questions to determine recall, such as: "Have you ever found clothing you don't recall buying?" "Have strangers called you by a different name?" Inquire about the presence of personalities with differing attributes: "Does your ability to engage in athletics, art, or other activities seem to change from time to time?"

Parents suspect their child has attention deficit hyperactivity disorder (ADHD) and ask the nurse the main characteristics of ADHD. What characteristics does the nurse include?

inattention, impulsivity, and hyperactivity Explanation Attention Deficit Hyperactivity Disorder (ADHD) Symptoms: Inattentiveness and/or hyperactivity, impulsivity Impact: Developmentally inappropriate, causing problems in various settings (home, school, community) ADHD Treatment Medications: Primarily stimulants Therapies: Behavioral therapies

The healthcare provider prescribes amitriptyline 150 mg orally daily for a client with major depression. Which intervention does the nurse implement when administrating amitriptyline?

inform client of photosensitivity, to administer with meals, and possibility of dry mouth. WRONG: Teaches the client that the appetite will be diminished Teach the client that the appetite will be increased, not diminished. Monitors the client for hypertension Amitriptyline can cause the client to experience hypotension, not hypertension. The client should watch for dizziness when changing positions. Explanation Amitriptyline A tricyclic antidepressant medication Function in Treating Depression Affects chemicals in the brain that may be unbalanced in clients with depression Mechanism of Action Enhances the effect of serotonin and norepinephrine in the central nervous system

The nurse works with a group of clients with mental illness. In what order does the nurse identify each client's risk for suicide? (Place each option in order from most at risk to least at risk.)

major depression, substance abuse, schizophrenia, OCD, antisocial personality

The nurse in a mental health clinic provides care for a 28-year-old who has experienced the death of an infant child. Complete the following sentence by choosing from the list of options. After reviewing the 3-week follow-up assessment, the nurse addresses the client's priority needs by providing education regarding...and instruction on ...

medication managing hyperventilation.

The nurse assesses a client with a history of mental illness. The nurse documents which behaviors as evidence of mania?

pressured speech, flight of ideas, and impulsivity. note: During episodes of mania, clients sleep less. During episodes of mania, clients are generally outgoing and personable. Explanation Behaviors Supporting Mania Pressured speech: Urgent, rapid speech not appropriate for the situation Flight of ideas: Abrupt topic changes, making conversation hard to follow Impulsivity: Poor decision-making, overspending, poorly planned projects Bipolar I Disorder: Bipolar disorder I is a mood disorder May alternate with depression, hypomania, or mixed states

The nurse cares for a client at risk for alcohol withdrawal. What assessments does the nurse complete to identify physical effects of acute alcohol withdrawal?

temperature, BP, blood glucose, and fluid balance. Explanation Alcohol Withdrawal Can produce mild symptoms or be life-threatening if delirium tremens (DT) occurs Mild Symptoms Insomnia Tremulousness Anxiety Gastrointestinal upset Diaphoresis Delirium Tremens (DT) Timeframe: 48-96 hours after last drink, lasts 1-5 days Symptoms: hallucinations, disorientation, tachycardia, hypertension, hyperthermia, agitation, diaphoresis Nursing Interventions Monitor for serious symptoms Institute immediate interventions if necessary Risks: seizures and circulatory collapse

The nurse cares for an adolescent-aged client in the hospital. Which finding indicates the need for education regarding suicide prevention?

transgender, minority, alcoholic, and gay clients