Mental Health Test 4 [Monday 4/27/17] 60 questions total

Predisposing Factors to OCD - Biochemical

*The neurotransmitter serotonin may be influential in the etiology of OCD!* - A decrease in the neurotransmitter serotonin may be influential in the etiology of obsessive-compulsive disorder.

*Predisposing Factors to Phobias - Psychoanalytical theory*

*Unconscious fears may be expressed in a symbolic manner as phobia!* - Freud believed that during the Oedipal period, the child becomes frightened of the aggression he fears the same sex parents feels for him. This fear is repressed, and displaced on to something safer, which becomes the phobic stimulus.

What is Responsibility?

*Was patient able to conform conduct to requirements of the law at the time of the crime?* the state or fact of having a duty to deal with something or of having control over someone. - the state or fact of being accountable or to blame for something. - the opportunity or ability to act independently and make decisions without authorization. - CRIMINAL RESPONSIBILITY (Mental State at Time of Offense) - *a person is NOT responsible for criminal conduct if at the time of such conduct, as a result of mental illness or retardation, he lacks substantial capacity either to appreciate the criminality of his conduct or to conform his conduct to the requirements of law*

*Panic and generalized anxiety disorders - Cognitive theory*

- *Faulty, distorted, or counterproductive thinking patterns* accompany or precede maladaptive behaviors and emotional disorders - This theory places emphasis on distorted cognition, which results in anxiety that is maintained by mistaken or dysfunctional appraisal of a situation.

*anxiety*

- *provides the motivation for achievement*, a necessary force for survival - is often used interchangeably with the word stress; however, *they are NOT the same* - may be distinguished from fear in that anxiety is an *emotional process*, whereas fear is *cognitive*, basically feelings vs. something you think about

Why is it important to teach forensic nursing in mental health?

- Violence is epidemic in the U.S. and is considered a major public health issue. - The health care system and the legal system have joined in an effort to respond to the increasing needs of crime victims. - forensic nursing is an example of a nursing role that is rapidly increasing in its scope of practice - 1 in every 31 adults in the US is in jail or on supervised release - The role of forensic nursing has expanded from concerns solely with death investigation to include the living—the survivors of violent crime- as well as the perpetrators of criminal acts

*Table 22-3 | CARE PLAN FOR CLIENT WITH EATING DISORDERS: ANOREXIA NERVOSA AND BULIMIA NERVOSA* NURSING DIAGNOSIS: IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS/DEFICIENT FLUID VOLUME (RISK FOR OR ACTUAL) RELATED TO: Refusal to eat/drink; self-induced vomiting; abuse of laxatives/diuretics EVIDENCED BY: Loss of weight; poor muscle tone and skin turgor; lanugo; bradycardia; hypotension; cardiac arrhythmias; pale, dry mucous membranes Short-Term Goal 1. Client will gain x pounds per week (amount to be established by client, nurse, and dietitian). 2. Client will drink 125 mL of fluid each hour during waking hours. Long-Term Goal 1. By time of discharge from treatment, client will exhibit no signs or symptoms of malnutrition or dehydration.

1. For the client who is emaciated and is unable or unwilling to maintain an adequate oral intake, the physician may order a liquid diet to be administered via nasogastric tube. Nursing care of the individual receiving tube feedings should be administered according to established hospital protocol. 1. Without adequate nutrition, a life-threatening situation exists. 2. For the client who is able and willing to consume an oral diet, the dietitian will determine the appropriate number of calories required to provide adequate nutrition and realistic weight gain. 2. Adequate calories are required to allow a weight gain of 2-3 pounds per week. 3. Explain to the client that privileges and restrictions will be based on compliance with treatment and direct weight gain. Do not focus on food and eating. 3. The real issues have little to do with food or eating patterns. Focus on the control issues that have precipitated these behaviors. 4. *Weigh client daily, immediately upon arising and following first voiding. Always use same scale, if possible. Keep strict record of intake and output. Assess skin turgor and integrity regularly. Assess moistness and color of oral mucous membranes!* 4. These assessments are important measurements of nutritional status and provide guidelines for treatment. 5. *Stay with client during established time for meals (usually 30 min) and for at least 1 hour following meals!!!* 5. Lengthy mealtimes put excessive focus on food and eating and provide client with attention and reinforcement. The hour following meals may be used to discard food stashed from tray or to *engage in self-induced vomiting.* 6. If weight loss occurs, enforce restrictions. 6. Restrictions and limits must be established and carried out consistently to avoid power struggles, to encourage client compliance with therapy, and to ensure client safety. 7. *Ensure that the client and family understand that if nutritional status deteriorates, tube feedings will be initiated. This is implemented in a matter-of-fact, nonpunitive way!* 7. *This intervention is carried out for the client's safety and protection from a life-threatening condition.* 8. *Encourage the client to explore and identify the true feelings and fears that contribute to maladaptive eating behaviors.* 8. Emotional issues must be resolved if these maladaptive responses are to be eliminated.

*Predisposing Factors to PTSD - Biological aspects*

*It has been suggested that a person who has experienced previous trauma is more likely to develop symptoms after a stressful life event.* - Disregulation of the opioid, glutamatergic, noradrenergic, serotonergic, and neuroendocrine pathways may be involved in the pathophysiology of PTSD. - It is suggested that the symptoms related to the trauma are maintained by the production of endogenous opioid peptides that are produced in the face of arousal, and which result in increased feelings of comfort and control. When the stressor terminates, the individual may experience opioid withdrawal, the symptoms of which bear strong resemblance to those of PTSD.

Preservation of Evidence

*Medical stabilization (ALWAYS #1)* Then examination of wounds *Careful preservation of clothing*

Planning and Implementation somatic symptom disorder

*Nursing care of the individual with a somatic symptom disorder is aimed at relief of discomfort from the physical symptom!* - Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than preoccupation with physical symptoms. - Nursing care of the individual with a somatoform disorder is aimed at relief of discomfort from the physical symptom. Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than preoccupation with physical symptoms.

Medical Treatment Modalities for Somatic Symptom Disorders - Psychopharmacology

*Pain disorder may be treated with venlafaxine (Effexor)!!!* *Body dysmorphic disorder may be treated with clomipramine (Anafranil)!!!*

Individuals with anorexia nervosa have a "*distorted body image*." What does this mean?

*Perception that they are fat even though they are severely emaciated! *

Forensic What does forensic mean?

*Pertaining to the law*; legal - anything belonging to, or pertaining to, the law - relating to or dealing with the application of scientific knowledge to legal problems - ex: forensic medicine, forensic science, forensic pathologist, forensic experts

eating disorders

*The hypothalamus contains the appetite regulation center within the brain!* - It regulates the body's ability to recognize when it is hungry, and when it is not hungry, and when it has been sated. - Eating behaviors are influenced by: 1. Society 2. Culture - Historically, society and culture also have influenced what is considered desirable in the female body. - Have a great deal of influence on how we think and how we look

*generalized anxiety disorder!* (GAD) What differentiates them from other people?

A disorder characterized by chronic (at least 6 months), unrealistic, and excessive anxiety and worry- excessive worry or anxiety about multiple issues which lingers 6 months or more can indicate generalized anxiety disorder - Characterized by *CHRONIC, unrealistic, and excessive anxiety and worry* - interferes w/ ADLs, they can't function as a productive member of society because of this disorder

panic disorder

A disorder characterized by recurrent panic attacks, the onset of which are unpredictable and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort. - Characterized by recurrent panic attacks, the onset of which are unpredictable and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort - *Depersonalization is commonly seen in panic disorder and absent in generalized anxiety disorder!!!*

*social anxiety disorder!!!*

A disorder in which the individual experiences extreme fear of doing something embarrassing or being negatively evaluated by others in a social situation.

hoarding disorder

A disorder in which the individual has extreme difficulty parting with possessions, regardless of their value, and may also be accompanied by excessive acquisition of material possessions.

*Anxiety*

A feeling of discomfort, apprehension, or dread related to anticipation of danger, the source of which is often nonspecific or unknown. Anxiety is considered a disorder (or pathological) when fears and anxieties are excessive (in a cultural context) and there are associated behavioral disturbances such as interference with social and occupational functioning - It is a necessary force for survival. It is NOT the same as stress. - Stress (or stressor) is an external pressure that is brought to bear on the individual. Anxiety is the subjective emotional response to that stressor. - Anxiety is distinguished from fear in that *anxiety is an emotional process whereas fear is a cognitive one.*

Predisposing Factors for DID - Psychological trauma

A growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelms the individual's capacity to cope by any means other than dissociation. These experiences usually take the form of severe physical, sexual, or psychological abuse by a significant other in the child's life. DID is thought to serve as a survival strategy for the child in this traumatic environment.

Nursing Diagnosis for eating disorders

1. Imbalanced nutrition: less than body requirements related to refusal to eat 2. Deficient fluid volume (risk for or actual) related to decreased fluid intake, self-induced vomiting, and laxative and/or diuretic abuse. 3. Ineffective denial related to delayed ego development and fear of losing the only aspect of life over which he or she perceives some control (eating) 4. Imbalanced nutrition: More than body requirements related to compulsive overeating 5. Disturbed body image/low self-esteem related to retarded ego development, dysfunctional family system, or feelings of dissatisfaction with body appearance 6. *Anxiety* (moderate to severe) related to feelings of helplessness and lack of control over life events. Most eating disorder pts will have anxiety.

nursing diagnoses trauma care

1. Impaired tissue integrity (#1 always) 2. Risk for post-trauma syndrome 3. Fear 4. Anxiety 5. Risk for self-mutilation (Bc person feels "marked for life") 5. Risk for suicide 6. Risk for complicated grieving

Planning and Implementation

1. In most instances, individuals are treated on an outpatient basis, but in some cases hospitalization may become necessary. (*malnutrition, dehydration, severe electrolyte imbalance, cardiac arrhythmia, severe bradycardia, hypothermia, hypotension, suicidal ideation*) 2. Nursing care of the patient with an eating disorder is aimed at restoring nutritional balance! 3. Emphasis is also placed on helping the patient gain control over life situation in ways other than inappropriate eating behaviors. 4. Self-esteem and positive self-image are promoted in ways that relate to aspects other than appearance. 5. *Stay with the client during established time for meals (usually 30 minutes) and for at least 1 hour afterwards. Lengthy mealtimes put excessive focus on food. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting!!*

*Fugue* (dissociative fugue)

A sudden, unexpected travel away from home or customary work locale with the assumption of a new identity and an inability to recall one's previous identity; usually occurring in response to severe psychosocial stress. - A sudden, unexpected travel away from home or customary place of daily activities - The individual is unable to recall personal identity and assumption of a new identity is common - Unlike dissociate amnesia, clients with dissociative fugue are *unaware of their memory loss* - The characteristic feature of dissociative fugue is a sudden, unexpected travel away from home or customary place of daily activities. - An individual in a fugue state is unable to recall personal identity, and assumption of a new identity is common.

binge and purge

A syndrome associated with eating disorders, especially bulimia nervosa, in which an individual consumes thousands of calories of food at one sitting and then purges through the use of laxatives or self-induced vomiting.

*systematic desensitization!!!*

A treatment for phobias in which the individual is taught to relax and then asked to imagine various components of the phobic stimulus on a graded hierarchy, moving from that which produces the least fear to that which produces the most.

habit reversal therapy

A type of behavior therapy in which the individual develops awareness of unhealthy habits and learns to substitute more adaptive coping strategies in an effort to extinguish unwanted behaviors.

A client experiencing lower extremity paralysis is admitted to a medical unit. Extensive tests confirm disability but rule out any underlying organic pathology. The nurse concludes that this is most suggestive of which disorder? A) Conversion disorder B) Hypochondriasis C) Malingering D) Somatization disorder

A) Conversion disorder Conversion disorder is a loss or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder. The situation presented in the question describes a conversion disorder.

A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), spends 1 hour packing and unpacking, folding and refolding personal belongings. What is the most likely reason for this behavior? A) It relieves anxiety. B) It fosters organizational skills. C) It delays meeting unfamiliar people in the dayroom. D) It makes the client feel good.

A) It relieves anxiety. OCD is characterized by recurrent thoughts or ideas (obsessions) that an individual is unable to put out of his or her mind, and actions that an individual is unable to refrain from performing (compulsions). This behavior directs the client away from the underlying anxiety and focuses the client on a repetitive activity such as packing and unpacking, folding and refolding personal belongings.

*Pseudocyesis!!!*

A condition in which an individual has nearly all the signs and symptoms of pregnancy but is not pregnant; a conversion reaction. - the false belief that one is pregnant!

What should the nurse plan to teach a client who is taking alprazolam (Xanax) three times a day? A) That there is a potential for dependence and tolerance. B) The importance of discontinuing Xanax immediately if addiction is suspected. C) That increased caffeine consumption can enhance the effectiveness of Xanax. D) That Xanax is not habit forming.

A) That there is a potential for dependence and tolerance. Xanax is a *benzodiazepine* and has addictive properties. Should not be prescribed for people with history of alcohol dependence. It is the responsibility of the nurse to teach the client about dependence, tolerance, and other signs and symptoms of addiction; also teach *not to drink alcohol (with any benzodiazepine i.e. Librium)*; and *not to take extra doses (may result in overdose)*

Q May be related to issue of control

A, B

Antianxiety agents - Action

Depress subcortical levels of the CNS Potentiate the inhibitory effects of GABA Exception: *Buspirone* Buspirone does not depress the CNS It is thought to produce its effects through interactions with serotonin, dopamine, and other neurotransmitter receptors

*Special concerns*

Detoxification frequently occurs in jails and prisons. Overcrowding and violence Sexual assault - % very high in men and women HIV infection/Hep C in the prison population *Female offenders* *Re-offenders*

What is a common dual diagnosis in forensic settings?

Ex: schiz and substance, personality and substance, MDD and substance, etc. - About 1/3 of all people experiencing mental illnesses and about 1/2 of people living with severe mental illnesses also experience substance abuse. These statistics are mirrored in the substance abuse community, where about a 1/3 of all alcohol abusers and more than 1/2 of all drug abusers report experiencing a mental illness. Men are more likely to develop a co-occurring disorder than women. Other people who have a particularly high risk of dual diagnosis include individuals of lower socioeconomic status, military veterans and people with more general medical illnesses.

Q Abuse of substances is not uncommon

B

Q Erosion of tooth enamel

B

Q Takes in enormous amounts of food w/o gaining weight

B

Q Weight is close to normal

B

*Predisposing Factors to Phobias - Transactional model of stress/adaptation*

Etiology of phobic disorders is most likely influenced by multiple factors. - *Treatment options for clients with disorders such as claustrophobia include systematic desensitization and imploding (flooding)!!!!* - rhe etiology of phobic disorders is most likely influenced by multiple factors.

*When caring for a client who is experiencing a panic attack, which of the following nursing actions should be implemented?!!!* A) Leave the client alone to maintain privacy. B) Instruct the client regarding unit rules and regulations. C) Sit with the client in the day room to provide comfort. D) Communicate with simple words and brief messages.

D) Communicate with simple words and brief messages. When communicating with a client experiencing a panic attack, the nurse needs to *use simple words and brief messages, spoken calmly and clearly* Any communication that is loud and demanding would only escalate anxiety Talk down, softly If you escalate, they will escalate with you

When working with a client diagnosed with a somatization disorder, which is the most appropriate nursing action? A) Avoid discussing social and personal problems B) Focus on the physical symptoms C) Always meet the client's dependency needs D) Gradually minimize time focusing on physical symptoms

D) Gradually minimize time focusing on physical symptoms - The nurse's attention should be on the client's social and personal problems, which are the underlying cause of the somatization disorder. - *Time focused on physical symptoms should be minimized to avoid reinforcement! *

According to psychodynamic theory, which primary defense mechanism would the nurse expect to find in an amnesic client? A) Suppression B) Sublimation C) Displacement D) Repression

D) Repression Repression, which is the involuntary blocking of unpleasant feelings and experiences from one's awareness, is the defense mechanism most used by clients experiencing amnesia. Freud believed that dissociative behaviors, including amnesia, occurred when individuals repressed distressing mental contents from conscious awareness. Freud believed that this mechanism protected the client from emotional pain

Nursing Diagnosis Correctional Facilities

Defensive coping Complicated grieving Anxiety/fear Disturbed thought processes Powerlessness *Low self-esteem* Risk for self-mutilation Risk for suicide Risk for other-directed violence Ineffective coping Risk for infection Rape-trauma syndrome

A client is experiencing pain that has no organic etiology. This pain allows the client to avoid an unpleasant activity. What best describes what this client is experiencing? A) Altered social interaction B) Disturbed thought processes C) Primary gain D) Secondary gain

C) Primary gain Primary gain describes the benefit to the client of avoidance of some unpleasant activity due to experiencing psychologically based pain. This avoidance directly decreases the client's anxiety. The situation presented in the question describes primary gain. *What are they getting out of it?!*

*Working phase*

Primary goal: promoting behavioral change Counseling and supportive psychotherapy Crisis intervention *Education* - Health teaching - HIV/AIDS education - Stress management - Substance abuse

An inmate tells the forensic nurse, "Yesterday we were all in 'lock-down'." Which interpretation of this prison slang is accurate? A. Prisoners have a free-movement period. B. Prisoners are confined to their cells. C. Prisoners are under constant suspicion. D. Prisoners are not allowed to use the recreation yard.

Prisoners are confined to their cells. When prisoners are confined to their cells it is referred to as a "lock-down."

Anorexia

Prolonged loss of appetite.

Substance-Induced Anxiety Disorder

Prominent anxiety symptoms that are judged to be due to the direct physiological effects of a substance - Symptoms may occur during substance intoxication or withdrawal, and may involve prominent anxiety, panic attacks, phobias, or obsessions or compulsions.

Psychological factors affecting medical condition

Psychological factors may play a role in virtually any medical condition. With this diagnosis, there is evidence of a general medical condition that has been precipitated by or is being perpetuated by psychological or behavioral circumstances.

obsessive-compulsive disorder (OCD)

Recurrent thoughts or ideas (obsessions) that an individual is unable to put out of his or her mind and actions that an individual is unable to refrain from performing (compulsions). The obsessions and compulsions are severe enough to interfere with social and occupational functioning. - Recurrent obsessions or compulsions that are severe enough to be *time-consuming or to cause marked distress or significant impairment.* - Clients diagnosed with OCD experience both obsessions AND compulsions; clients diagnosed with obsessive-compulsive personality disorder do not. - Lady who alphabetizes her vegetables They cant just let it sit there Ex: washing hands and germs If you have OCD you compulsions and obsessions

Compulsions

Repetitive ritualistic behaviors or mental acts that the individual feels driven to perform, which are intended to reduce the anxiety associated with obsessive thoughts - unwanted repetitive behavior patterns or mental acts that are intended to reduce anxiety, not to provide pleasure or gratification - Ex: Doors locked now im safe Packing and unpacking suitcase a lot Alphebetize veggies

symptoms of panic disorder

SOB or smothering sensations dizziness, unsteady feelings, or faintness palpitations or accelerated HR trembling or shaking sweating nausea choking depersonalization or derealization numbness or tingling sensations flushes (hot flashes) or chills *chest pain or discomfort* fear of dying fearing of going crazy or doing something uncontrolled palpitations

Anosmia

Inability to smell.

Aphonia

Inability to speak.

Common nursing diagnoses for clients with Somatic Symptom disorders include

Ineffective coping evidenced by numerous physical complaints (somatic symptom disorder) Deficient knowledge [psychological causes for physical symptoms] (all somatic symptom disorders) Chronic pain (pain disorder) Social isolation (all somatic symptom disorders) Fear [of having a serious disease] (hypochondriasis) Chronic low self-esteem (all somatic symptom disorders) Disturbed sensory perception (conversion disorder) Self-care deficit (conversion disorder) Disturbed body image (body dysmorphic disorder)

Interventions (for PTSD)

Integrating the trauma into the client's persona Renewing significant relationships Establishing meaningful goals for the future Progressing through the grief process Developing a sense of optimism and hope for the future - Nursing interventions for the client with PTSD are aimed at reassurance of safety, decrease in maladaptive symptoms (e.g., flashbacks, nightmares), demonstration of more adaptive coping strategies, and adaptive progression through the grief process.

*Obsessions*

Intrusive thoughts that are recurrent and stressful. Although they are recognized by the individual as irrational, they continue to be repetitive and cannot be ignored. - *unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress!*

Interventions for individuals experiencing anxiety disorders are aimed at

Maintaining anxiety at manageable level Problem-solving to increase client's level of personal control Helping the client learn to function in the presence of the phobic object without experiencing panic anxiety Assisting the client to overcome fear of leaving home alone - Nursing interventions for the client with panic or generalized anxiety disorder are aimed at relief of acute panic symptoms and assisting the client to take control of own life situation and accept situations over which he or she has not control.

*Nursing diagnoses commonly associated with anxiety disorders!!!*

Panic anxiety (panic disorder and GAD) Powerlessness (panic disorder and GAD) Fear (phobic disorder) Social isolation (phobic disorder) Ineffective coping (OCD) Ineffective role performance (OCD) Post-trauma syndrome (PTSD) Complicated grieving (PTSD)

Amnesia

Partial or total, permanent or transient loss of memory. The term is often applied to episodes during which patients forget recent events, although they may conduct themselves appropriately and after which no memory of the period persists. Such episodes may be caused by strokes, seizures, trauma, senility, alcoholism, or intoxication

pain disorder

Predominant disturbance in pain disorder is severe and prolonged pain that causes clinically significant distress or impairment in social, occupational, or other areas of functioning. - Even when organic pathology is detected, the pain complaint may be evidenced by the correlation of a stressful situation with the onset of symptoms. - Pain disorder may be maintained by primary gains, secondary gains, tertiary gains - Symptoms of depression and substance abuse are common.

Development of a Therapeutic Relationship

Preinteraction phase Orientation (introductory) phase Working phase Termination phase

Anxiety Disorder Due to General Medical Condition

Symptoms of this disorder are judged to be the direct physiological consequence of a general medical condition. - Symptoms may include generalized anxiety symptoms, panic attacks, or obsessions and compulsions.

*amnesia, generalized!!!* admission interview, what questions will you ask to confirm the diagnosis of generalized amnesia?

The inability to recall anything that has happened during the individual's entire lifetime. - inability to recall anything that has happened during the individual's entire lifetime, including personal identity. "Have you taken any new medications recently?" "Have you recently experienced any traumatic event?" "Have you had any history of memory problems?"

*amnesia, selective*

The inability to recall only certain incidents associated with a traumatic event for a specific time period following the event. - inability to recall only certain incidents associated with a traumatic event for a specific period following the event - The inability to recall only certain incidents associated with a traumatic event for a specific time period following the event.

Explain the role & responsibilities of the Clinical Forensic Nurse (CFN)

The management of crime victims from trauma to trial includes: 1. *Collection of evidence!* - Very important - Every little thing matters - *If the proper chain of evidence is broken it won't be able to be used in a court of law!* 2. Assessment of victims - Nursing - beginning to end in our care - Mentally, physically, emotionally care - Wounds always - Must get pt medically stable 1st then deal w/ emotions - Stay w/ pt 3. Investigation of death that occurs in the clinical setting - Anywhere on the unit - Staff, investigate

Investigation of wound characteristics

The nurse should be able to identify types of undiagnosed trauma injuries and the possible weapon involved.

2. The Maudsley approach to treatment of adolescents with anorexia nervosa advances which of the following fundamental concepts? a. Family should be actively involved in each phase of treatment. b. Parents should be prohibited from involvement in helping their child eat more because there are often control issues. c. Adolescents need to work on developing healthy self-identities before they can begin to gain weight. d. Individual psychotherapy is the most effective treatment for adolescents with anorexia nervosa.

a. Family should be actively involved in each phase of treatment.

What is the ultimate goal of therapy for a client with DID? a. Integration of the personalities into one b. For the client to have the ability to switch from one personality to another voluntarily c. For the client to select which personality he or she wants to be the dominant self d. For the client to recognize that the various personalities exist

a. Integration of the personalities into one

10. Joanne presents in the emergency department with complaints of suicidal ideation. The following data is collected by the nurse. Which of these assessment findings suggests that bulimia nervosa might be a health problem? Select all that apply. a. Joanne's parotid glands appear enlarged. b. Joanne's teeth have a "moth eaten" pattern of tooth decay. c. Joanne reports that she takes laxatives daily. d. Joanne's weight is within the expected range.

a. Joanne's parotid glands appear enlarged. b. Joanne's teeth have a "moth eaten" pattern of tooth decay. c. Joanne reports that she takes laxatives daily. d. Joanne's weight is within the expected range.

Lorraine has been diagnosed with Somatic Symptom Disorder. Which of the following symptom profiles would you expect when assessing Lorraine? a. Multiple somatic symptoms in several body systems b. Fear of having a serious disease c. Loss or alteration in sensorimotor functioning d. Belief that her body is deformed or defective in some way

a. Multiple somatic symptoms in several body systems

A client who is experiencing a panic attack has just arrived at the emergency department. Which is the priority nursing intervention for this client? a. Stay with the client and reassure the client of her safety. b. Administer a dose of diazepam. c. Leave the client alone in a quiet room so that she can calm down. d. Encourage the client to talk about what triggered the attack.

a. Stay with the client and reassure the client of her safety.

A client with OCD spends many hours each day washing her hands. What is the most likely reason she washes her hands so much? a. To relieve her anxiety b. To reduce the probability of infection c. To gain a feeling of control over her life d. To increase her self-concept

a. To relieve her anxiety

*Dissociative amnesia!!!*

an inability to recall important personal data that is too extensive to be explained by ordinary forgetfulness, and which is not due to the direct effects of substance use or a general medical condition - Not due to the direct effects of substance use or a general medical condition (such as dementia) - Onset usually follows *severe psychosocial stress!* - Ex: can't remembering your sister's name, mother's birthday - includes: localized, selective, continuous, generalized, and systematized amenisia

Somatoform disorders

are characterized by physical symptoms suggesting medical disease, but without demonstrable organic pathology or known pathophysiological mechanism to account for them - Historically, somatoform disorders have been identified as hysterical neuroses. Somatoform disorders are thought to occur in response to repressed severe anxiety. - Freud viewed dissociation as a type of repression, an active defense mechanism used to remove threatening or unacceptable mental contents from conscious awareness. - Somatoform disorders are more common in women than in men. They are more common in those who are poorly educated and those from the lower socioeconomic groups.

Janet has a diagnosis of Generalized Anxiety Disorder. Her physician has prescribed buspirone 15 mg daily. Janet says to the nurse, "Why do I have to take this every day? My friend's doctor ordered Xanax for her, and she only takes it when she is feeling anxious." Which of the following would be an appropriate response by the nurse? a. "Xanax is not effective for generalized anxiety disorder." b. "Buspirone must be taken daily in order to be effective." c. "I will ask the doctor if he will change your dose of buspirone to prn so that you don't have to take it every day." d. "Your friend really should be taking the Xanax every day."

b. "Buspirone must be taken daily in order to be effective."

6. Nurse Jones is caring for a client who has been hospitalized with anorexia nervosa and is severely malnourished. The client continues to refuse to eat. What is the most appropriate response by the nurse? a. "You know that if you don't eat, you will die." b. "If you continue to refuse to take food orally, you will be fed through a nasogastric tube." c. "You might as well leave if you are not going to follow your therapy regimen." d. "You don't have to eat if you don't want to. It is your choice."

b. "If you continue to refuse to take food orally, you will be fed through a nasogastric tube."

3. John has sought help for his concern that he is binge eating, and he feels it has "gotten out of control." He asks the nurse what can be done to help him. Which of the following is the most accurate response? a. "There is nothing that can be done." b. "There are some medications and psychological treatments that have demonstrated effectiveness in reducing binge eating behaviors." c. "The primary problem is obesity. I can help you set up a calorie-restricted diet." d. 'There are medications that can help with weight loss, but there are no medications effective for reducing binge eating."

b. "There are some medications and psychological treatments that have demonstrated effectiveness in reducing binge eating behaviors."

8. Jane is hospitalized on the psychiatric unit. She has a history and current diagnosis of bulimia nervosa. Which of the following symptoms would be congruent with Jane's diagnosis? a. Binging, purging, obesity, hyperkalemia b. Binging, purging, normal weight, hypokalemia c. Binging, laxative abuse, amenorrhea, severe weight loss d. Binging, purging, severe weight loss, hyperkalemia

b. Binging, purging, normal weight, hypokalemia

4. Nancy, age 14, has just been admitted to the psychiatric unit for anorexia nervosa. She is emaciated and refuses to eat. What is the primary nursing diagnosis for Nancy? a. Complicated grieving b. Imbalanced nutrition: Less than body requirements. c. Interrupted family processes d. Anxiety (severe)

b. Imbalanced nutrition: Less than body requirements.

In establishing trust with Ellen, a client with the diagnosis of DID, the nurse must do which of the following? a. Try to relate to Ellen as though she did not have multiple personalities. b. Listen nonjudgmentally and respond empathically when Ellen transitions to different personality states. c. Ignore behaviors that Ellen attributes to other subpersonalities. d. Explain to Ellen that he or she will work with her only if she maintains the status of the primary personality.

b. Listen nonjudgmentally and respond empathically when Ellen transitions to different personality states.

The ultimate goal of therapy for a client with DID is most likely achieved through which of the following interventions? a. Crisis intervention and directed association b. Psychotherapy and hypnosis c. Psychoanalysis and free association d. Insight psychotherapy and dextroamphetamines

b. Psychotherapy and hypnosis

Which of the following ego defense mechanisms describes the underlying psychodynamics of somatic symptom disorder? a. Denial of depression b. Repression of anxiety c. Suppression of grief d. Displacement of anger

b. Repression of anxiety

Lorraine, a client diagnosed with Somatic Symptom Disorder, states, "My doctor thinks I should see a psychiatrist. I can't imagine why he would make such a suggestion." What is the most common basis for Lorraine's statement? a. She thinks her doctor wants to get rid of her as a client. b. She does not understand the correlation of symptoms and stress. c. She thinks psychiatrists are only for "crazy" people. d. She thinks her doctor has made an error in diagnosis.

b. She does not understand the correlation of symptoms and stress.

The initial care plan for a client with OCD who washes her hands obsessively would include which of the following nursing interventions? a. Keep the client's bathroom locked so she cannot wash her hands all the time. b. Structure the client's schedule so that she has plenty of time for washing her hands. c. Place the client in isolation until she promises to stop washing her hands so much. d. Explain the client's behavior to her, since she is probably unaware that it is maladaptive.

b. Structure the client's schedule so that she has plenty of time for washing her hands.

9. A hospitalized client with bulimia nervosa has stopped vomiting in the hospital and tells the nurse she is afraid she is going to gain weight. Which is the most appropriate response by the nurse? a. "Don't worry. The dietitian will ensure you don't get too many calories in your diet." b. "Don't worry about your weight. We are going to work on other problems while you are in the hospital." c. "I understand that you are concerned about your weight, and we will talk about the importance of good nutrition; but for now, I want you to tell me about your recent invitation to join the National Honor Society. That's quite an accomplishment." d. "You are not fat, and the staff will ensure that you do not gain weight while you are in the hospital, because we know that is important to you."

c. "I understand that you are concerned about your weight, and we will talk about the importance of good nutrition; but for now, I want you to tell me about your recent invitation to join the National Honor Society. That's quite an accomplishment."

Lucille has a diagnosis of Illness Anxiety Disorder. Which of the following symptoms would be consistent with this diagnosis? a. Complains of a multitude of incapacitating physical symptoms b. Manifests with pseudoseizures or pseudocyesis c. Takes substances to induce vomiting in order to convince the nurse that she needs treatment d. Expresses persistent fears of having life-threatening disease. e. All of the above

d. Expresses persistent fears of having life-threatening disease.

Nursing care for a client with somatic symptom disorder would focus on helping her to do which of the following? a. Eliminate the stress in her life b. Discontinue her numerous physical complaints c. Take her medication only as prescribed d. Learn more adaptive coping strategies

d. Learn more adaptive coping strategies

Ms. T has been diagnosed with agoraphobia. Which behavior would be most characteristic of this disorder? a. Ms. T experiences panic anxiety when she encounters snakes. b. Ms. T refuses to fly in an airplane. c. Ms. T will not eat in a public place. d. Ms. T stays in her home for fear of being in a place from which she cannot escape.

d. Ms. T stays in her home for fear of being in a place from which she cannot escape.

With implosion therapy, a client with phobic anxiety would be: a. Taught relaxation exercises. b. Subjected to graded intensities of the fear. c. Instructed to stop the therapeutic session as soon as anxiety is experienced. d. Presented with massive exposure to a variety of stimuli associated with the phobic object or situation.

d. Presented with massive exposure to a variety of stimuli associated with the phobic object or situation.

Ellen has a history of childhood physical and sexual abuse. She was diagnosed with Dissociative Identity Disorder (DID) 6 years ago. She has been admitted to the psychiatric unit following a suicide attempt. What is the primary nursing diagnosis for Ellen? a. Disturbed personal identity related to childhood abuse b. Disturbed sensory perception related to repressed anxiety c. Impaired memory related to disturbed thought processes d. Risk for suicide related to unresolved grief

d. Risk for suicide related to unresolved grief

Nursing interventions for the client with phobias are aimed at

decreasing the fear and increasing the ability to function in the presence of the phobic stimulus.

Family Therapy

family intervention and support are *important in the client's recovery* - Involves educating the family about the disorder - Assesses the family's impact on maintaining the disorder. - Assists in methods to promote adaptive functioning by the client - Maudsley Approach - p. 584 evidence based treatment that is used now, Feller isn't asking specific questions on this approach - *90%* of these pts showed improvement compared to the 36% of those in individual therapies!

physiological effects of anxiety

fear breathlessness choking sensation palpations of the heart restlessness increased muscular tension

Lanugo

fine-neonatal like hair growth

Individual therapy

helpful when underlying psychological problems are contributing to the maladaptive behaviors.

What physiological signs may be associated with the excessive vomiting of the purging syndrome?

hypothermia, bradycardia, hypotension, edema, lanugo, and a variety of metabolic changes

Predisposing Factors Somatic Symptom disorders - Family dynamics

in dysfunctional families, when a child becomes ill, focus shifts from the open conflict to the child's illness and leaves unresolved underlying issues the family is unable to confront openly Somatization brings some stability to the family and positive reinforcement to the child (called *tertiary gain*).

continuous amnesia

inability to recall events occurring after a specific time up to and including the present - The inability to recall events occurring after a specific time up to and including the present.

systematized amnesia

inability to recall events relating to a specific category of information, such as one's family or one particular person or event Client may relate family memories but has no recollection of a particular brother - The individual cannot remember events that relate to a specific category of information (e.g., one's family) or to one particular person or event.

*malingering!*

is fabricating or exaggerating the symptoms of mental or physical disorders for a variety of "secondary gain" motives, which may include financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply to attract attention or sympathy - is different from somatization disorder and factitious disorder - Failure to detect actual cases of malingering imposes a substantial economic burden on the health care system, and false attribution of malingering imposes a substantial burden of suffering on a significant proportion of the patient population.

Recidivism

is the act of a person repeating an undesirable behavior after they had either experienced negative consequences of that behavior, or had been trained to extinguish that behavior. It is also used to refer to the percentage of former prisoners who are rearrested for a similar offense

Illness anxiety disorder (IAD) what symptoms do they exhibit?

know that they express personal worthlessness through physical symptoms bc physical problems are more acceptable than psychological problems

*signs and symptoms of a panic disorder* nursing diagnosis = anxiety

lightheadedness tremors diaphoresis tachycardia dyspnea (1) Palpitations, pounding heart, or accelerated heart rate (2) Sweating (3) Trembling or shaking (4) Sensations of shortness of breath or smothering (5) Feeling of choking (6) *Chest pain or discomfort* (7) Nausea or abdominal distress (8) Feeling dizzy, unsteady, lightheaded, or faint (9) Derealization (feelings of unreality) or depersonalization (being detached from oneself) (10) Fear of losing control or going crazy (11) Fear of dying (12) Paresthesias (numbness or tingling sensations) (13) Chills or hot flashes maybe somebody who has wet/sweaty hands all the time!

Eating disorders....

more people die from this than any other psychological illness

Explain how the nurse assesses wounds when investigating a crime for wound characteristics of dicing injuries

multiple, minute cuts and abrasions caused by contact w/ shattered glass (e.g. often occur in MVAs) - small angulated cuts produced by the cube-like fragments of tempered glass, from the side or rear windows

There is some speculation that anorexia nervosa may be associated with a primary dysfunction of which brain structure?

primary *hypothalamic* dysfunction in anorexia nervosa [Neuroendocrine abnormalities]

Assessment of panic disorder with agoraphobia

When panic disorder is accompanied by agoraphobia, the individual experiences the symptoms described above, but in addition, experiences a fear of being in places or situations from which escape might be difficult or embarrassing or in which help might not be available in the event of a panic attack. - Characterized by same symptoms characteristic of panic disorder - In addition, the individual experiences a fear of being in places or situations from which escape might be difficult (or embarrassing) or in which help might not be available in the event of a panic attack

Explain how the nurse assesses wounds when investigating a crime for wound characteristics of bite mark injuries

a type of patterned injury inflicted by human or animal - 'a pattern produced by human or animal dentitions and associated structures in any substance capable of being marked by these means' animal and/or people, long hx of sexual abuse

Somatization Disorder

a. A chronic syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from health care professionals. b. The disorder is chronic, and anxiety, depression, and suicidal ideation are frequently manifested. c. Drug abuse and dependence are common complications of somatization disorder. d. Personality characteristics: Heightened emotionality, strong dependency needs, and a preoccupation with symptoms and oneself.

Annie has hair-pulling disorder. She is receiving treatment at the mental health clinic with HRT. Which of the following elements would be included in this therapy? Select all that apply. a. Awareness training b. Competing response training c. Social support d. Hypnotherapy e. Aversive therapy

a. Awareness training b. Competing response training c. Social support

Abreaction

"Remembering with feeling"; bringing into conscious awareness painful events that have been repressed and reexperiencing the emotions that were associated with the events.

Panic and generalized anxiety disorders - Biological aspects

(1) Genetics. Panic disorder has a strong genetic element. (2) Neuroanatomical. Physiology of emotional states may be associated with the lower brain centers, including the limbic system, the diencephalon, and the reticular formation. Pathological involvement has been identified in the temporal lobes of individuals with panic disorder. (3) Biochemical. Abnormal elevations of blood lactate have been noted in clients with panic disorder. (4) Neurochemical. Evidence exists for the involvement of the neurotransmitter norepinephrine in the etiology of panic disorder. (5) Medical conditions. Various medical conditions, such as acute MI, hypoglycemia, mitral valve prolapse, and complex partial seizures, have been associated to a greater degree with individuals who suffer panic and generalized anxiety disorders than in the general population. (6) Transactional Model of Stress/Adaptation. Panic and generalized anxiety disorders are most likely cause by multiple factors. - may give Ativan to pt w/ chest pain that's had a MI before bc of feelings of doom, etc.

Predisposing Factors to PTSD - Psychosocial theory

(1) Seeks to explain why some individuals exposed to massive trauma develop PTSD while others do not. (2) Variables include characteristics that relate to the traumatic experience, the individual, and the recovery environment. The traumatic experience - Severity and duration of the stressor - Extent of anticipatory preparation before onset - Exposure to death - Numbers affected by life threat - Extent of control over recurrence - Location where trauma was experienced The individual - Degree of ego-strength - Effectiveness of coping resources - Presence of preexisting psychopathology - Outcomes of previous experiences with stress/trauma - Behavioral tendencies: eat healthy, exercise, deal w/ things in a positive manner - Current psychosocial developmental stage - Demographic factors: Where you live , Difference b/w states The Recovery Environment - Availability of social supports - Cohesiveness and protectiveness of family and friends - Attitudes of society regarding the experience - Cultural and subcultural influences

*Predisposing Factors to PTSD - Cognitive theory*

*A person is vulnerable to post-traumatic stress disorder when fundamental beliefs (beliefs, values) are invalidated by experiencing trauma that cannot be comprehended and when a sense of helplessness and hopelessness prevail!* - Takes into consideration the cognitive appraisal of an event and focuses on assumptions that an individual makes about the world.

*what is the treatment for GAD?!!!*

*Buspar* - *For clients with generalized anxiety disorder, long term treatment with buspirone (BuSpar) is appropriate.* - it is non-addictive - Valium & ativan ARE addictive so they aren't really good/better choices because they're harder to get off of

*what is particularly effective In treating panic disorder?*

*Clonazepam (Klonopin)* - Sadly it's addictive - "Short term it's okay, only PRN is good, really not good for long-term"

What is the IMPORTANCE of preserving evidence in a suspected crime or crime? nursing process trauma care - Assessment Preservation of Evidence

*Crime-related evidence must be safeguarded in a manner consistent with the investigation!* - Such evidence may include: Clothing, bullets, gunshot powder on the skin (GSR), bloodstains, hairs, fibers, grass small pieces of material such as fragments of metal, glass, paint, & wood

*Predisposing Factors to Phobias - Learning theory*

*Fears are conditioned responses and thus are learned by imposing reinforcements for certain behaviors!* - Learning theorists believe that fears are learned, and become conditioned responses when the individual escapes panic anxiety (a negative reinforcement) by avoiding the phobic stimulus.

Examples of antianxiety agents

*Hydroxyzine (Vistaril)* Alprazolam (Xanax) Chlordiazepoxide (Librium) *Clonazepam (Klonopin)* Clorazepate (Tranxene) Diazepam (Valium) Lorazepam (Ativan) Oxazepam Meprobamate *Buspirone (BuSpar)*

What differentiates any disorder from a typical person?

*Is that it interferes with their activities of daily living*. They can't function as a healthy member of society because the disorder keeps causing them problems.

s/s of bulimia nervosa

- An episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period (binging) - The episode is followed by *inappropriate* compensatory behaviors, purging behaviors, to rid the body of the excess calories (self-induced vomiting or the misuse of laxatives, diuretics, or enemas)! - Fasting or excessive exercise may also occur. - Most individuals with bulimia are *within a normal weight range*, some slightly underweight, some slightly overweight. Often there is a *persistent over concern* with personal appearance. - *Depression, anxiety and substance abuse are NOT uncommon!* - Gastric acid in the vomitus contributes to the erosion of tooth enamel. Vomit is acidic - Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalances. Can have serious problems w/ it. - Rare, but may have tears in the gastric or esophageal mucosa - *Russell's sign* - calluses on knuckles from self-induced vomiting - *Excessive exercise is usually NOT seen w/ bulimia*

Epidemiological Statistics of anxiety

- Anxiety disorders are the *MOST common of all psychiatric illnesses*, Jett "I think it's increasing" - More common in women than men. - Minority children and children from low socioeconomic environments at risk. - Afraid, parents who work a lot, can't afford daycare, etc. - A familial predisposition probably exists. - Can be environmental - We pattern behavior after people we live w/

historical aspects of anxiety

- Anxiety was once identified by its physiological symptoms, focusing largely on the cardiovascular system - Freud was the first to associate anxiety with neurotic behaviors. - For many years, anxiety disorders were viewed as purely psychological or purely biological in nature.

depersonalization disorder

- Characterized by persistent feelings of: Unreality Detachment from oneself or one's body Observing oneself from outside the body - Symptoms of depersonalization disorder are often accompanied by: Anxiety and depression Fear of going insane Obsessive thoughts Somatic complaints Disturbance in the subjective sense of time - Characterized by a temporary change in the quality of self-awareness, which often takes the form of feelings of unreality, changes in body image, feelings of detachment from the environment, or a sense of observing oneself from outside the body. - symptoms of depersonalization disorder are often accompanied by anxiety, depression, fear of going insane, obsessive thoughts, somatic complaints, and a disturbance in the subjective sense of time.

Panic and generalized anxiety disorders - Psychodynamic theory

- Ego unable to intervene between id and superego - Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety - An underdeveloped ego is not able to intervene when conflict occurs between the id and the superego, producing anxiety.

s/s of anorexia nervosa

- Symptoms include *gross distortions of body image*, preoccupation with food, and refusal to eat. The distortion in body image is manifested by the individual's perception of being "fat" when he or she is obviously underweight or even emaciated. - Weight loss is EXTREME, usually more than 15% of expected weight. - Other symptoms include *hypothermia, bradycardia, hypotension, edema, lanugo, and a variety of metabolic changes!* - Can have SEVERE electrolyte disturbances - *Severe bradycardia* is the most significant/important/common - Amenorrhea is typical and may even precede significant weight loss. - There may be an obsession with food. Will prepare elaborate meals and then not eat any of it. - *Feelings of anxiety and depression are common!!!* - Weight loss is usually accompanied by reduction in food intake and often excessive exercise. Self-induced vomiting and laxative or diuretic abuse may also occur. - Persistent lack of recognition of the seriousness of low body weight

trauma care nursing process - Assessment

- Victims of sexual assault, abuse and neglect, accidental trauma, and death investigation - ALL traumatic injuries in which liability is suspected are considered within the scope of forensic nursing

What does recidivism mean in relation to prisoners and substance addiction?

- use of substances and nonadherence to medication regimen are common obstacles to rehabilitation - *substance abuse has been shown to have a strong correlation with recidivism among the prison population!* - many individuals report they were under the influence of substances at the time of their criminal actions - detoxification frequency occurs in jails & prisons, and some inmates have died from the withdrawal syndrome because of inadequate treatment during the process - *Re-offender rate is high with alcohol and drugs! Like 70-80% bc not always educated & low poverty!!!* - It is estimated that 3/4 of those returning from prison have a history of substance abuse. Over 70% of prisoners with serious mental illnesses also have a substance use disorder. Nevertheless, only 7 to 17% of prisoners who meet DSM criteria for alcohol/drug dependence or abuse receive treatment. - Those involved in the criminal justice system have rates of substance abuse and dependence that are more than four times higher than the general population and fewer than 20% of federal and state prisoners who meet the criteria receive treatment. - Effectiveness studies have shown that inmates who participate in residential treatment programs while incarcerated have 9 to 18% lower recidivism rates and 15 to 35% lower drug relapse rates than their counterparts who receive no treatment in prison. Furthermore, inmates who receive aftercare (treatment after imprisonment) have an even greater chance of not recidivating. When combined with treatment that was given during incarceration aftercare can be a very useful tool in recidivism reduction. Some offenders have had a reduced risk of recidivism of up to eighty percent after undergoing aftercare treatment

NURSING DIAGNOSIS: DISTURBED BODY IMAGE/LOW SELF-ESTEEM RELATED TO: Dissatisfaction with appearance EVIDENCED BY: Verbalization of negative feelings about the way he or she looks and desire to lose weight Short-Term Goal Client will begin to accept self, based on self-attributes rather than on appearance. Long-Term Goal Client will pursue loss of weight as desired.

1. *Assess client's feelings and attitudes about being obese.* 1. *Obesity and compulsive eating behaviors may have deep-rooted psychological implications, such as compensation for lack of love and nurturing or a defense against intimacy!!* 2. Ensure that the client has privacy during self-care activities. 2. The obese individual may be sensitive or self-conscious about his or her body. 3. Have client recall coping patterns related to food in family of origin and explore how these may affect current situation. 3. Parents are role models for their children. Maladaptive eating behaviors are learned within the family system and are supported through positive reinforcement. Food may be substituted by the parent for affection and love, and eating is associated with a feeling of satisfaction, becoming the primary defense. 4. Determine client's motivation for weight loss and set goals. 4. The individual may harbor repressed feelings of hostility, which may be expressed inward on the self. Because of a poor self-concept, the person often has difficulty with relationships. When the motivation is to lose weight for someone else, successful weight loss is less likely to occur. 5. *Help client identify positive self-attributes. Focus on strengths and past accomplishments unrelated to physical appearance.* 5. It is important that self-esteem not be tied solely to size of the body. Client needs to recognize that obesity need not interfere with positive feelings regarding self-concept and self-worth. 6. *Refer client to support or therapy group.* 6. Support groups can provide companionship, increase motivation, decrease loneliness and social ostracism, and give practical solutions to common problems. Group therapy can be helpful in dealing with underlying psychological concerns.

Table 22-4 | CARE PLAN FOR THE CLIENT WITH AN EATING DISORDER: OBESITY NURSING DIAGNOSIS: IMBALANCED NUTRITION: MORE THAN BODY REQUIREMENTS RELATED TO: Compulsive overeating EVIDENCED BY: Weight of more than 20 percent over expected body weight for age and height; BMI . 30 Short-Term Goal 1. Client will verbalize understanding of what must be done to lose weight. Long-Term Goal 1, Client will demonstrate a change in eating patterns that results in a steady weight loss.

1. *Encourage the client to keep a diary of food intake.* 1. A food diary provides the opportunity for client to gain a realistic picture of the amount of food ingested and provides a database on which to tailor the dietary program. 2. *Discuss feelings and emotions associated with eating!* 2. This helps to identify when client is eating to satisfy an emotional need rather than a physiological one. 3. *With input from the client, formulate an eating plan that includes food from the required food groups with emphasis on low-fat intake. It is helpful to keep the plan as similar to client's usual eating pattern as possible.* 3. Diet must eliminate calories while maintaining adequate nutrition. Client is more likely to stay on the eating plan if he or she is able to participate in its creation and it deviates as little as possible from usual types of foods. 4. Identify realistic incremental goals for weekly weight loss. 4. Reasonable weight loss (1-2 pounds per week) results in more lasting effects. Excessive, rapid weight loss may result in fatigue and irritability and ultimately lead to failure in meeting goals for weight loss. Motivation is more easily sustained by meeting "stair-step" goals. 5. Plan a progressive exercise program tailored to individual goals and choice. 5. Exercise may enhance weight loss by burning calories and reducing appetite, increasing energy, toning muscles, and enhancing sense of well-being and accomplishment. Walking is an excellent choice for overweight individuals. 6. Discuss the probability of reaching plateaus when weight remains stable for extended periods. 6. Client should know this is likely to happen as changes in metabolism occur. Plateaus cause frustration, and client may need additional support during these times to remain on the weight-loss program. 7. *Provide instruction about medications to assist with weight loss if ordered by physician!* 7. Appetite-suppressant drugs and others that have weight loss as a side effect may be helpful to someone who is severely overweight. They should be used for this purpose for only a short period while the individual attempts to adjust to the new pattern of eating.

NURSING DIAGNOSIS: INEFFECTIVE DENIAL RELATED TO: Delayed ego development and fear of losing the only aspect of life over which client perceives some control (eating) EVIDENCED BY: Inability to admit the impact of maladaptive eating behaviors on life pattern Short-Term Goal 1. Client will verbalize understanding of the correlation between emotional issues and maladaptive eating behaviors (within time deemed appropriate for individual client). Long-Term Goal 1. By time of discharge from treatment, client will demonstrate the ability to discontinue use of maladaptive eating behaviors and to cope with emotional issues in a more adaptive manner.

1. *Establish a trusting relationship with the client by being honest, accepting, and available, and by keeping all promises. Convey unconditional positive regard!!!* 1. Trust and unconditional acceptance promote dignity and self-worth and provide a strong foundation for a therapeutic relationship. 2. Acknowledge the client's anger at feelings of loss of control brought about by the established eating regimen associated with the program of behavior modification. 2. Anger is a normal human response and should be expressed in an appropriate manner. Feelings that are not expressed remain unresolved and add an additional component to an already serious situation. 3. *Avoid arguing or bargaining with the client who is resistant to treatment. State matter-of-factly which behaviors are unacceptable and how privileges will be restricted for noncompliance.* 3. The person who is denying a problem and who also has a weak ego will use manipulation to achieve control. Consistency and firmness by staff will decrease use of these behaviors. 4. Encourage client to verbalize feelings regarding role within the family and issues related to dependence/independence, the intense need for achievement, and sexuality. *Help client recognize how maladaptive eating behaviors may be related to these emotional issues. Discuss ways in which he or she can gain control over these problematic areas of life without resorting to maladaptive eating behaviors.* 4. When client feels control over major life issues, the need to gain control through maladaptive eating behaviors will diminish.

NURSING DIAGNOSIS: DISTURBED BODY IMAGE/LOW SELF-ESTEEM RELATED TO: Retarded ego development and dysfunctional family system EVIDENCED BY: Distorted body image, difficulty accepting positive reinforcement, depressed mood and self-deprecating thoughts Short-Term Goal 1. Client will verbally acknowledge misperception of body image as "fat" within specified time (depending on severity and chronicity of condition). Long-Term Goal 1. By time of discharge from treatment, client will demonstrate an increase in self-esteem as manifested by verbalizing positive aspects of self and exhibiting less preoccupation with own appearance as a more realistic body image is developed.

1. *Help client to develop a realistic perception of body image and relationship with food. Compare specific measurement of the client's body with the client's perceived calculations.* 1. There may be a large discrepancy between the actual body size and the client's perception of his or her body size. Client needs to recognize that the misperception of body image is unhealthy and that maintaining control through maladaptive eating behaviors is dangerous—even life threatening. 2. Promote feelings of control within the environment through participation and independent decision-making. Through positive feedback, help client learn to accept self as is, including weaknesses as well as strengths. 2. Client must come to understand that he or she is a capable, autonomous individual who can perform outside the family unit and who is not expected to be perfect. Control of his or her life must be achieved in other ways besides dieting and weight loss. 3. Help client realize that perfection is unrealistic, and explore this need with him or her. 3. As client begins to feel better about self, identifies positive self-attributes, and develops the ability to accept certain personal inadequacies, the need for unrealistic achievement should diminish.

Explain the role & responsibilities of the Forensic Nurse Death Investigator (FNDI)

1. A RN with specialized education who can accurately determine the cause of death 2. Responds to scenes of deaths or accidents and works in collaboration with law enforcement 3. Works with forensic pathologists to collect additional evidence in the lab during autopsy

Forensic Nursing Specialties

1. Clinical Forensic Nursing 2. *Sexual Assault Nurse Examiner (SANE)* 3. Forensic Mental Health Nursing 4. Forensic Correctional Nursing 5. Legal Nurse Consultant 6. Forensic Nurse Death Investigator 7. *Nurses in General Practice*

*nursing interventions for GAD!!!*

1. Encourage client to recognize signs of escalating anxiety Teach pt to know when they are escalating 2. Encourage the client to employ newly learned relaxation techniques 3. Encourage clients to cognitively reframe thoughts about situations that generate anxiety Teach pt who is worried about money to reframe things... most people in America are poor so better off already. But it always goes back to something that happened in childhood, its hard to change 4. *Encourage clients to avoid caffeinated products*

Explain the role & responsibilities of the Legal Nurse Consultant (LNC)

1. is a RN who critically evaluates and analyzes healthcare issues in medically related lawsuits 2. The RN combines medical expertise with legal knowledge to assess compliance with accepted standards of health-care practices - We create and maintain a safe environment - #1 ANA standard of care of mental health RN - What do we want out of someone who is a perp? Treat perp with preventative studies & protection of human rights

Types of Somatoform Disorders

1. somatization disorder 2. pain disorder 3. hypochondriasis 4. conversion disorder 5. body dysmorphic disorder

Goals of forensic nursing

1. Empower victims of all races & cultures 2. Treatment of perpetrators in preventative studies 3. Protection of Human Rights

Predisposing factors associated with somatoform disorders

1. Genetic. There are possible hereditary factors associated with somatization disorder, conversion disorder, and hypochondriasis. 2. Biochemical. Decreased levels of serotonin and endorphins may play a role in the etiology of pain disorder. 3. Psychodynamic. This theory suggest that hypochondriasis is an ego defense mechanism. Physical complaints are the expression of low self-esteem and feelings of worthlessness. Conversion disorder may represent emotions associated with a traumatic event that is too unacceptable to express and so is not acceptably "converted" into physical symptoms. 4. Family Dynamics. In dysfunctional families, when a child becomes ill, a shift in focus is made from the open conflict to the child's illness, leaving unresolved the underlying issues that the family is unable to confront openly. Somatization brings some stability to the family and positive reinforcement to the child. 5. Learning Theory. Somatic complaints are often reinforced when the sick person learns that he or she may avoid stressful obligations or be excused from unwanted duties (primary gain); become the prominent focus of attention because of the illness (secondary gains); or relieve conflict within the family as concern is shifted to the ill person and away from the real issue (tertiary gain). Past experience with serious or life-threatening physical illness, either personal or that of close family members, can predispose an individual to hypochondriasis. 6. Transactional Model of Stress/Adaptation.The etiology of somatoform disorders is most likely influenced by multiple factors.

Predisposing Factors Associated with Dissociative Disorders

1. Genetics. Possible hereditary factors associated with DID. 2. Neurobiological. It is possible that dissociative amnesia and dissociative fugue may be related to neurophysiological dysfunction. EEG abnormalities have been observed in some clients with DID. 3. Psychodynamic Theory. Freud described amnesia as the result of repression of distressing mental contents from conscious awareness. Current psychodynamic explanations of dissociation are based on Freud's concepts..... that is, that behaviors such as amnesia, fugue, and depersonalization behaviors are a defense against unresolved painful issues. 4. Psychological Trauma. A growing body of evidence points to the etiology of DID as a set of traumatic experiences that overwhelms the individual's capacity to cope by any means other than dissociation. These experiences usually take the form of severe physical, sexual or psychological abuse by a parent or significant other in the child's life. DID is thought to serve as a survival strategy for the child in this traumatic environment.

Predisposing Factors for Anorexia and Bulimia Nervosa - Biological Influences

1. Genetics: A hereditary predisposition to eating disorders has been hypothesized. a. Anorexia Nervosa is more common among sisters and mothers of those with the disorder than it is among the general population. b. Possible chromosomal linkage sites have been suggested. 2. Neuroendocrine abnormalities: There has been some speculation about a primary hypothalamic dysfunction in anorexia nervosa. Amenorrhea usually comes BEFORE starvation and extreme weight loss. 3. Neurochemical influences: a. Bulimia nervosa may be associated with the neurotransmitters serotonin and norepinephrine. b. Anorexia nervosa may be associated with high levels of endogenous opioids. May contribute to denial of hunger. Common with Naloxone (an opioid antagonist).

Common behaviors observed among the mentally ill incarcerated include:

1. Hallucinations 2. Suspiciousness 3. Thought disorders 4. Anger/agitation 5. Impulsivity 6. *Denial of problems*

Outcome Criteria The following criteria may be used for measurement of outcomes in the care of the client with eating disorders: The Client

1. Has achieved and maintained an expected BMI for age with consideration for body build, weight history, and any physiological disturbances 2. Has vital signs, blood pressure, and laboratory serum studies within normal limits. 3. *Verbalizes importance of adequate nutrition.* 4. *Verbalizes knowledge regarding consequences of fluid loss caused by self-induced vomiting (or laxative/diuretic abuse) and importance of adequate fluid intake (anorexia nervosa, bulimia nervosa).* 5. Verbalizes events that precipitate anxiety and demonstrates techniques for its reduction. 6. *Verbalizes ways in which he or she may gain more control of the environment and thereby reduce feelings of powerlessness.* 7. (Expresses less preoccupation with own appearance (anorexia nervosa, bulimia nervosa).* 8. Demonstrates ability to take control of own life without resorting to maladaptive eating behaviors (anorexia nervosa, bulimia nervosa, BED). 9. Has established a healthy pattern of eating for weight control, and weight loss toward a desired goal is progressing (BED). 10. *Verbalizes plans for maintenance of weight control and relapse prevention (BED).* - Verbalizes that the image of body as "fat" was misperception and demonstrates ability to take control of own life without resorting to maladaptive eating behaviors. (anorexia nervosa) Example: *The client will perceive her recommended body weight and shape as normal by 4/15/17!* This is the big goal for anorexic pts. - Demonstrates ability to take control of own life without resorting to maladaptive eating behaviors (anorexia nervosa, bulimia nervosa, BED).

Predisposing Factors for Anorexia and Bulimia Nervosa - Family Influences (Feller likes this theory)

1. Historically, family influences were heavily considered as factors but there is not sufficient evidence to support these claims. 2. *Family members SHOULD be involved in treatment rather than blamed for the issue! Listen to them, support, encourage, DON'T judge them!* - If constantly under pressure to succeed in life, what's the 1 thing you can control? Eating. Person may do it to get even w/ parents. - It affects the whole family. - Parents can be the case but it's not always the case!

Areas within which a forensic nurse may intervene (work/practice):

1. Interpersonal violence [the family] 2. Sexual assault 3. Death investigation 3. Mass disasters 4. Forensic mental health 5. Correctional nursing 6. Legal nurse consulting 7. Public health and safety 8. Emergency/trauma services - Mugging, rape, violence, mass violence

How much anxiety is too much? Anxiety is pathological if:

1. It is out of proportion to the situation that is creating it. 2. The anxiety interferes with social, occupational, or other important areas of functioning. - When anxiety is out of proportion to the situation that is creating it - Its too much! - When anxiety interferes with social, occupational, or other important areas of functioning - If you can't leave the house from fear... it's too much - *Excessive worry - when is it abnormal? When it impairs our ability to complete ADLs!!!*

Deaths in the Emergency Department

1. Preservation of evidence: send it downtown or wherever it is supposed to go 2. Protection of the body: Postmortem care, Be respectful w/ the body 3. Anatomical gifts: Special people that talk to family members

*BOX 22-2 Diagnostic Criteria for Bulimia Nervosa!*

1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1A. *Eating, in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than most individuals would eat during a similar period of time and under similar circumstances.* 1B. *A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)!* 2. *Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise!* 3. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. 4. Self-evaluation is unduly influenced by body shape and weight. 5. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify if: In partial remission In full remission Specify current severity: Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

*BOX 22-1 Diagnostic Criteria for Anorexia Nervosa!!!* SATA Question on test

1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected. 2. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. 3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. Specify whether: - Restricting Type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. - Binge-Eating/Purging Type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Specify if: -In partial remission -In full remission Specify current severity: Mild: BMI ≥ 17 kg/m2 Moderate: BMI 16-16.99 kg/m2 Severe: BMI 15-15.99 kg/m2 Extreme: BMI < 15 kg/m2

*types of wounds*

1. Sharp injuries 2. Blunt-force injuries 3. Dicing injuries 4. Patterned injuries 5. Bite mark injuries 6. Defense wounds 7. Hesitation wounds 8. Fast-force injuries

SANE may be called in the event of a sexual assault. The forensic examination includes:

1. Treatment and documentation of injuries 2. Maintaining the proper chain of evidence 3. *Treatment and evaluation of STDs* - Put them on a broad-spectrum abx - If at risk of HIV or hep C - Birth control pill used to keep pt from getting pregnant 4. Pregnancy risk evaluation and prevention 5. Crisis intervention and arrangements for follow-up counseling

Derealization

An alteration in the perception or experience of the external world so that it seems strange or unreal. - an alteration in the perception of the external environment.

Q Is markedly underweight

A

Q Lanugo

A

Depersonalization

An alteration in the perception or experience of the self so that the feeling of one's own reality is temporarily lost. - a disturbance in the perception of oneself.

q Preoccupation w/ food

A

*sexual assault nurse examiner (SANE)*

A clinical forensic registered nurse who has received *specialized training* to provide care to the sexual assault victim.

The nurse notices that a client has injuries consistent with contact with shattered glass. How would the nurse document these injuries?* A. Dicing injuries B. Sharp force injuries C. Patterned injuries D. Defense wounds

A. Dicing injuries Dicing injuries are multiple, minute cuts and abrasions caused by contact with shattered glass. These injuries often occur in motor vehicle accidents.

Medication for specific disorders - OCD

Antidepressants *Luvox (fluvoxamine)* 300 mg daily may be needed OCD patients require higher dose than patients with depression only

Medication for specific disorders - PTSD

Antidepressants Anxiolytics Antihypertensives Others

What is the level of body mass index (BMI) that is associated with the definition of obesity?

30 or greater 40 or greater is morbid

Predisposing Factors for DID

Genetics Possible hereditary factors are associated with DID. Neurobiological Dissociative amnesia and dissociative fugue may be related to neurophysiological dysfunction. EEG abnormalities have been observed in some clients with DID.

Q Amenorrhea

A (it is only seen in 1 of the eating disorders!)

*Conversion disorder (Functional neurological symptom disorder (FNSD))* What kind of symptoms will you see in this pt? What will the be exhibiting?

A loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism. Can happen: Blindness, aphonia, paralysis etc. Some instances of conversion disorder may be precipitated by psychological stress. - The most obvious and "classic" conversion symptoms are those that suggest neurological disease and occur following a situation that produces extreme psychological stress for the individual. - Client often expresses a relative lack of concern that is out of keeping with the severity of the impairment. - This lack of concern is identified as *la belle indifference* and may be a clue to the physician that the problem is psychological rather than physical. - If client exhibits seizures, prognosis considered *poor* - A loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder or pathophysiological mechanism. - The most obvious and "classic" conversion symptoms are those that suggest neurological disease, and occur following a situation that produces extreme psychological stress for the individual. - The person often expresses a relative lack of concern that is out of keeping with the severity of the impairment. This lack of concern is identified as la belle indifference, and may be a clue to the physician that the problem is psychological rather than physical.

*Somatization*

A method of coping with psychosocial stress by developing physical symptoms.

specific phobia

A persistent fear of a specific object or situation, other than the fear of being unable to escape from a situation (agoraphobia) or the fear of being humiliated in social situations (social phobia). - Marked, persistent, and excessive or unreasonable (panic level) fear when in the presence of, or when anticipating an encounter with, a specific object or situation (may be overwhelming and unreasonable - A marked, persistent, and excessive or unreasonable fear when in the presence of, or when anticipating an encounter with, a specific object or situation.

Phobia

A persistent, intensely felt, and irrational fear of a specific object, activity, or situation that results in a compelling desire to avoid the feared stimulus. Responses typically include intense anxiety or panic attacks.

Body Image

A subjective concept of one's physical appearance based on the personal perceptions of self and the reactions of others.

Panic

A sudden, overwhelming feeling of terror or impending doom. This most severe form of emotional anxiety is usually accompanied by behavioral, cognitive, and physiological signs and symptoms considered to be outside the expected range of normalcy.

Q Self-induced vomiting

A, B (look at the charts for criteria)

Q Depression

A, B, O

Q Genetics may play a role in the cause

A, B, O

Predisposing Factors to OCD - Psychoanalytical theory

Clients with OCD have weak, underdeveloped egos. - Aggressive impulses are channeled into thoughts and behaviors that prevent the feelings of *aggression* from surfacing and producing intense anxiety fraught with guilt. - Individuals with this disorder have weak, underdeveloped egos. Regression to the pre-oedipal phase of development during times of anxiety produces the symptoms of obsessions and compulsions.

Termination phase

Closure is difficult in a setting where prisoners may be transferred from one institution to another on short notice. When possible, nurses may institute assistance for transition to the community setting.

*Signs and symptoms of GAD!!!*

Fatigue Insomnia Irritability (1) Excessive anxiety and worry about a number of events that the individual finds difficult to control (2) Restlessness or feeling keyed up or on edge (3) Being easily fatigued (4) Difficulty concentrating or mind "going blank" (5) Irritability (6) Muscle tension (7) Sleep disturbance Ex: have a ton of money but worried about not having enough money

*body dysmorphic disorder!!!*

An exaggerated belief that the body is deformed or defective in some specific way. - these people have a false beliefs that they are grotesque, know the symptoms they exhibit that support that diagnosis, what behaviors they will be doing - This disorder is characterized by an *exaggerated belief that the body is deformed or defective in some specific way!* - Symptoms of depression and characteristics associated with obsessive-compulsive personality are common.

anorexia nervosa

An illness characterized by *morbid* fear of obesity, distorted body image, prreoccupation with food, and refusal to eat. - Prevalence rate among young US women is approximately 1% - Occurs predominantly in females 12 to 30 years of age - Steady increase currently - Fewer than 10% are male - Certain male populations are at risk: involved in weight training, and involved in what the body looks like - Ballet training carries 7 times greater risk than other types of dance

bulimia nervosa

An illness characterized by recurrent binge eating followed by compensatory purging behaviors, such as vomiting, laxative use, excessive exercise, medication use, etc., to prevent weight gain. - More prevalent than anorexia nervosa, estimates of up to 4% of young females - Onset occurs in late adolescence or early adulthood - Occurs primarily in societies that emphasize thinness & where there is an abundance of food available

Dissociation

An unconscious defense mechanism in which there is separation of identity, memory, and cognition from affect; the segregation of ideas and memories about oneself from their emotional and historical underpinnings

types of specific phobias

Animal type Ex: snakes Natural environment type Blood-injection-injury type Situational type Other type

Question: Which assessment finding would you find in pt w/ bulimia?

Answer: Are often able to maintain a normal weight by purging after binging NOT below normal weight - that's anorexia They don't usually seek help on own. Usually the puking of blood and stuff scares family.

Q: What is the priority nursing diagnoses for this pt?

Answer: Client is malnourished and underweight due to self-induced vomiting and laxative abuse. Nutr status is compromised and this problem must be prioritized to establish physiological integrity.

Question: Which is characteristic of diagnosis of anorexia nervosa?

Answer: The distortion in body image by clients diagnosed w/ it is manifested by thoughts that they are fat when they are obviously underweight or even emaciated. May even have compulsion behaviors, they are usually perfectionists. NOT healthy family relationships bc the whole family is effected

Predisposing Factors to Phobias - Cognitive theory

Anxiety is the product of faulty cognitions or anxiety-inducing self-instructions. - *Negative self-statements* - *Irrational beliefs* - Cognitive theorists espouse that anxiety is the product of faulty cognitions or anxiety-inducing self-instructions.

Medication for specific disorders - Panic and generalized anxiety disorder & Phobic disorders

Anxiolytics Antidepressants Antihypertensive agents

Where are the individuals of Act 911 treated?

Arkansas State Hospital Those living in the State of Arkansas who are being charged with a felony of any kind who are then acquitted due to mental disease or defect become bound to a mental health law called the Act 911 of 1989 Statute; where they must be committed to the Akansas State Hospital and then released under a Conditional Release program where they must meet certain conditions for 5 years.

For the last year, a college student, continually and unrealistically worries about academic performance and love life performance. The student is irritable and suffers from severe insomnia. This behavior is associated with which Axis I diagnosis? A) Post-traumatic stress disorder (PTSD) B) Generalized anxiety disorder (GAD) C) Social phobia disorder D) Obsessive-compulsive disorder (OCD)

B) Generalized anxiety disorder (GAD) GAD may be diagnosed when *excessive, unrealistic worry and anxiety become chronic and last for at least 6 months!* The anxiety experienced is generalized rather than specific. The anxiety is not associated with a specific object as in phobia, or event as in PTSD.

Which of the following assignments falls within the context of forensic nursing? A. Working on the case of a woman who has just died in the ED of cardiac arrest B. Collaborating with authorities to manage the care of a victim of domestic abuse C. Caring for a depressed suicidal client on an inpatient unit D. Holding a group session on the physical effects of alcohol abuse

B. Collaborating with authorities to manage the care of a victim of domestic abuse The forensic nurse's function is to care for clients who have experienced interpersonal violence such as domestic violence, sexual assault, child abuse or neglect, or psychological abuse, and to manage public safety issues associated with drug and alcohol abuse.

Amenorrhea

Cessation of the menses; may be a side effect of some antipsychotic medications.

When a client has been assaulted, which nursing intervention is critical to protect the physical evidence of the crime? A. All client clothing should be shaken to expose any other evidence. B. All client clothing should be placed and sealed in a plastic bag. C. All client clothing should be collected, dated, timed, and signed. D. All client clothing should be stored together in a labeled evidence bag.

C. All client clothing should be collected, dated, timed, and signed. To protect the physical evidence of a crime, each separate item of the victim's clothing should be carefully placed in a paper bag by the forensic nurse. These bags should be sealed, dated, timed, and signed.

Outcomes (Dissociative Disorders) The client

Can recall events associated with stressful situation Can recall all events of past life Can verbalize anxiety that precipitated the dissociation Can demonstrate coping methods to avert dissociative behaviors Verbalizes existence of multiple personalities (be aware of it) Is able to maintain a sense of reality during stressful situations

Evaluation for anxiety disorders

Can the client recognize signs and symptoms of escalating anxiety, and interrupt before it reaches panic level? Can the client demonstrate activities that can be used to maintain anxiety at a manageable level? Can the client discuss the phobic object or situation without becoming anxious? Can the client function in the presence of the phobic object or situation *without experiencing panic anxiety*? Can the OCD client *refrain* from performing rituals when anxiety level rises, and demonstrate substitute behaviors to maintain anxiety at a manageable level? Can the PTSD client discuss the traumatic event *without experiencing panic anxiety*? Has the PTSD client *learned* new, adaptive coping strategies for assistance with recovery?

Predisposing Factors to Phobias - Biological aspects - Temperament

Characteristics with which one is BORN that influence how he or she responds throughout life to specific situations (e.g., innate fears) - Innate fears may represent a part of the overall characteristics or tendencies with which one is born that influence how he or she responds throughout life to specific situations.

Dissociative identity disorder (DID)

Characterized by existence of 2 or more personalities within a single individual - Transition from one personality to another usually sudden, often dramatic, and usually precipitated by *stress* - Serves to isolate painful events so that the primary self is protected when threatened. - Have a pt who has DID w/ diff personalities, what is goal in therapy w/ them? Merge their personalities, trying to get them to collaborate, be whole again - Why do they dissociate to begin w/? It helps them protect themselves, it's a survival strategy, it helps them not remember the painful events that happened to them so they can function as a member in society - Characterized by the existence of two or more personalities within a single individual. - The transition from one personality to another is usually sudden, often dramatic, and usually precipitated by stress.

What is Competency?

Competent to stand trial? - Ability to understand charges? - Can help/aide in preparing for defense? If not send to Restore Competency the ability of a criminal defendant to stand trial, as gauged by their mental ability to understand the proceedings and to assist defense lawyers. - ex: raised the issue of the defendant's competency to stand trial - is determined by whether the defendant can understand the nature and consequences of the criminal proceedings against him. Specifically, the Supreme Court has held that the defendant must (1) have the sufficient present ability to consult with his or her lawyer with a reasonable degree of rational understanding; and (2) he or she must have a rational as well as a factual understanding of the proceeding against him or her. - it determines whether a defendant will be able to appear at trial and understand the proceedings; sanity determines whether a defendant will be held responsible for his criminal actions.

Predisposing Factors to OCD - Learning theory

Conditioned response to a traumatic event *Passive avoidance* *Active avoidance* - Obsessive-compulsive behavior is viewed as a conditioned response to a traumatic event. The traumatic event produces anxiety and discomfort, and the individual learns to engage in behaviors that provide relief from the anxiety and discomfort associated with the traumatic event.

Outcomes (Somatic Symptom Disorders) The client

Copes effectively without resorting to physical symptoms Can redirect them in their thinking Verbalizes relief from pain Has decreased frequency of physical complaints and interprets bodily sensations rationally Is free of physical disability Verbalizes realistic perception of appearance and expresses positive body image - Paralyzed pt comes in but no tests show organic reason for paralysis, what do you focus on - get them off it, don't put emphasis on physical complaints, dig deeper, whats going on w/ them socially & mentally that causes them to want to be sick, look at primary gains, goal: DIMINISH PRIMARY GAIN THEY ARE GETTING FROM BEING SICK!

What is Culpability?

Culpable mental state is more of a legal issue than mental health issue. It refers to whether the patient was able to "consciously decide to commit the crime". responsibility for a fault or wrong; blame. - Culpable Mental State refers to the state of mind of an individual while committing a crime. - Generally, a crime requires that a guilty act or omission (the actus reus) be committed with the required degree of guilty mind. - Generally, certain acts are crimes only if done with a particular state of mind, and that a certain sort of criminal act is more or less serious depending on the perpetrator's state of mind at the time. - If we consider the killing of one person by another person, such conduct may be 1) no crime if done in self-defense, 2) a serious crime if done negligently and 3) the most serious sort of crime if done purposefully (murder). - It would be culpable (blameworthy) mental state if done with negligence, recklessness, knowledge and purpose. - The prosecution must prove beyond a reasonable doubt that, the accused did so with the state of mind required for the commission of that particular crime in order to convict the accused. - A very few acts that amounts to strict liability offenses are criminal, however they are done. The term, Culpable Mental State is synonymous with mens rea (guilty mind). - The effects of mental illness can sometimes make it impossible for the state to prove the culpability requirements for an offence. For example, an actor who hallucinates that a knife is a clothes brush may not have the required culpability for homicide if he kills someone thinking that he is brushing lint from the victim's chest. Similarly, mental illness can mitigate murder to a lesser form or to manslaughter if the actor killed under the influence of an 'extreme mental or emotional disturbance'. Finally, mental illness can form the basis for a general excuse, for example, the insanity defence. Unlike the other two doctrines, the insanity defence operates without regard to - that is, despite the defendant's satisfaction of - the elements of the offence definition (indeed, the excuse is only necessary if the defendant otherwise satisfies the offence requirements). In order to successfully raise the insanity defence, the actor need only satisfy the conditions set out in the defence provision. - If an actor is hallucinating and believes she is hitting moles, when she is in fact lethally beating her daughter, she does not have the culpable state of mind - knowingly causing death of another person - required for the offence of murder. The hallucination induced by her mental illness 'negates' (shows that she did not have) the culpable state of mind required for the offence.

The Sexual Assault Nurse Examiner (SANE) is preparing to use a colposcope. The client questions the nurse regarding the use of this equipment. Which is the most accurate nursing response? A. "This instrument takes photographs of your wounds." B. "This instrument helps me record the locations of your visible injuries." C. "This instrument assists in the collection of your urine." D. "This instrument allows me to examine for tears and abrasions inside your vaginal area."

D. "This instrument allows me to examine for tears and abrasions inside your vaginal area." A *colposcope* is an instrument used to examine the tissues of the vagina and cervix through a magnifying lens.

Post-Traumatic Stress Disorder (PTSD)

Development of characteristic symptoms following exposure to an extreme traumatic stressor involving a personal threat to physical integrity or to the physical integrity of others - Characteristic symptoms include re-experiencing the traumatic event, a sustained high level of anxiety or arousal, or a general numbing of responsiveness - Intrusive recollections or nightmares of the event are common (flashbacks of killing the enemy) - *Invega (paliperidone) is often prescribed for PTSD!* - The development of characteristic symptoms following exposure to an extreme traumatic stressor involving a personal threat to physical integrity or the physical integrity of others. - Symptoms may include a re-experiencing of the traumatic event, a sustained high level of anxiety or arousal, or general numbing of responsiveness. Intrusive recollections or nightmares of the event are common.

BOX 22-5 QSEN TEACHING STRATEGY Assignment: Using Evidence to Address Clinical Problems Intervention With a Client Who Fears Gaining Weight (Anorexia Nervosa) Competency Domain: Evidence-Based Practice Learning Objectives: Student will:

Differentiate clinical opinion from research and evidence summaries. Explain the role of evidence in determining the best clinical practice for intervening with clients who do not want to eat. Identify gaps between what is observed in the treatment setting to what has been identified as best practice. Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or other reasons. Participate effectively in appropriate data collection and other research activities. Acknowledge own limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practices. Strategy Overview Investigate the research related to intervening with a client who does not want to eat. Identify best practices described in the literature. How were these best practices determined? Compare and contrast staff intervention with best practices described in the literature. Investigate staff perceptions related to intervening with a client who is refusing to eat. How have they developed these perceptions? Do staff members view any problems associated with their practice versus best practice described in the literature? If so, how would they like to see the problem addressed? Describe ethical issues associated with intervening with a client who does not want to eat. What is your personal perception regarding the best evidence available to date related to intervening with a client who has anorexia nervosa? Are there situations that you can think of when you might deviate from the best practice model? What questions do you have about intervening with a client who has anorexia nervosa that are not being addressed by current researchers?

Common nursing diagnoses for clients with dissociative disorders include

Disturbed thought processes; impaired memory (dissociative amnesia) Powerlessness (dissociative amnesia) Ineffective coping (dissociative fugue) Risk for suicide (DID) Disturbed personal identity (DID) Disturbed sensory perception (depersonalization disorder)

Side effects of antianxiety agents

Drowsiness, confusion, lethargy Tolerance; physical and psychological dependence (does not apply to buspirone) Potentiates effects of other CNS depressants Orthostatic hypotension Paradoxical excitement Dry mouth; nausea and vomiting Blood dyscrasias 10 to 14 day delayed onset of action (with buspirone)

Predisposing Factors to Phobias - Life experiences

Early experiences may set the stage for phobic reactions later in life. - Certain early experiences may set the stage for phobic reactions later in life.

*Predisposing Factors to OCD - Physiology*

Electrophysiological, sleep electroencephalogram, and neuroendocrine studies have suggested that there are *commonalities between depressive disorders and OCD!* - Some individuals with obsessive-compulsive disorder exhibit nonspecific EEG changes. Commonalities in neuroendocrine studies between OCD and depressive disorders have been demonstrated

*social phobia!!!*

Excessive fear of situations in which the affected person might do something embarrassing or be evaluated negatively by others - *Differs from schizoid personality disorder in that clients diagnosed with social phobia avoid interactions ONLY in social settings; clients diagnosed with SPD avoid interactions in all areas of life!!!* - they are fine at work, home, school etc. unless you invite them out to lunch - *People w/ schizo disorder are uncomfortable around everybody* - Characterized by an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

Bulimia

Excessive, insatiable appetite.

Explain the role & responsibilities of the Nurses in General Practice, especially ED & Critical Care (NGP)

Forensic applications in the acute care setting, particularly in emergency rooms and in critical care units. 1. Assessment, documentation of care, and reporting of information to police or other law enforcement agencies 2. Collection and preservation of evidence! 3. Follow 2009 American Nurses Association - ANA Standards of Practice & Standards of Professional Performance for Forensic Nurses - ALL documentation is legal - Be VERY descriptive - Its our duty to work with law enforcement. We teach each other.

Predisposing Factors for DID - Psychodynamic theory

Freud described dissociation as repression of distressing mental contents from conscious awareness Current psychodynamic explanations reflect Freud's concepts that dissociative behaviors are a defense against unresolved painful issues.

Predisposing Factors - Somatic Symptom disorders

Genetic: hereditary factors are possibly associated with somatization disorder, conversion disorder, and hypochondriasis Biochemical: decreased levels of serotonin and endorphins may play a role in the etiology of pain disorder

Interventions (for OCD)

Helping the client learn new, more adaptive coping strategies without resorting to obsessive-compulsive behaviors Helping the client gain independence and greater *control* over life situations - Part of the reason they get sick is because they have no control - Rituals w/ OCD (like packing and repacking suitcases, washing hands 30 times, etc) - what can you do to help them stop, *the best thing you can do to help them stop/decrease activity, must get to the ROOT of the problem!!!* - Somebody w/ OCD admitted to psych unit has a routine they have to complete, what will you do initially? Sense of control from the routine, it soothes them - Nursing interventions for the client with OCD are aimed at helping him or her maintain anxiety at a manageable level without having to resort to use of ritualistic behavior. The focus is on development of more adaptive methods of coping with anxiety.

Outcomes for anxiety disorders The client:

Is able to recognize signs of escalating anxiety and intervene before reaching panic level (panic and GAD) Is able to maintain anxiety at manageable level and make independent decisions about life situation (panic and GAD) Functions adaptively in the presence of the phobic object or situation without experiencing panic anxiety (phobic disorder). Verbalizes a future plan of action for responding in the presence of the phobic object or situation without developing panic anxiety (phobic disorder). Is able to maintain anxiety at a manageable level without resorting to the use of ritualistic behavior (OCD) Demonstrates more adaptive coping strategies for dealing with anxiety than ritualistic behaviors (OCD) Is experiencing fewer flashbacks, intrusive recollections, and nightmares (PTSD) Demonstrates adaptive coping strategies and verbalizes desire to put the trauma in the past and progress with his or her life (PTSD)

Diagnosis depersonalization-derelization disorder (D-DD) what is it?

It's when the pt is out of touch w/ reality and they have impairment w/ social occupation and other areas of functioning

John, who was just admitted to the psychiatric unit with panic disorder, approaches the nurse with complaints of numbness in his fingers and shortness of breath. What would be some appropriate responses by the nurse?

John, I'd like to check your vital signs and then discuss how I can best help you feel more comfortable.

BOX 22-4 Topics for Client and Family Education Related to Eating Disorders

NATURE OF THE ILLNESS 1. Symptoms of anorexia nervosa 2. Symptoms of bulimia nervosa 3. Symptoms of BED 4. What constitutes obesity 5. Causes of eating disorders 6. Effects of the illness or condition on the body 7. Behaviors that may reinforce unhealthy responses, such as television and social media, peer focus on clothing sizes, eating, and weight. Internet sources have become a means for sharing information among people with anorexia about how the individual can distract parents and health-care providers from recognizing the extent of weight loss. Family members can learn more about some of these behaviors to look out for and may want to monitor their child's use of Internet and social media resources MANAGEMENT OF THE ILLNESS 1. Principles of nutrition (foods for maintenance of wellness) 2. Ways client may feel in control of life (aside from eating) 3. Importance of expressing fears and feelings, rather than holding them inside 4. *Alternative coping strategies (to maladaptive eating behaviors)!* For the obese client: 5. How to plan a reduced-calorie, nutritious diet 6. How to read food content labels 7. How to establish a realistic weight loss plan 8. How to establish a planned program of physical activity 9. Correct administration of prescribed medications Indication for and side effects of prescribed medications 10, Relaxation techniques Problem-solving skills Discuss the Maudsley approach for treatment of anorexia nervosa as an evidence-based option for family involvement in the recovery program *SUPPORT SERVICES!* 1. Weight Watchers International 2. Overeaters Anonymous 3. National Association of Anorexia Nervosa and Associated Disorders (ANAD) 4. National Eating Disorders Association

Client/Family Education for anxiety disorders

Nature of the illness: What is anxiety? What might it be related to? What is OCD? What is PTSD? Symptoms of anxiety disorders Management of the illness: Medication management Possible adverse effect Length of time to take effect What to expect from the medication Stress management Teach ways to interrupt escalating anxiety Teach relaxation techniques Support services: Crisis hotline Support groups Individual psychotherapy

Predisposing Factors to PTSD - Learning theory

Negative reinforcement leads to the reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior Avoidance behaviors Psychic numbing - The avoidance behaviors and psychic numbing in response to a trauma are mediated by negative reinforcement (behaviors that decrease the emotional pain of the trauma).

Predisposing Factors to OCD - Biological aspects

Neurobiological disturbances may play a role. - Neuroanatomy: Abnormalities in various regions of the brain have been implicated in the neurobiology of OCD. -Abnormalities in the region of the basal ganglia and orbitofrontal cortex of the brain have been implicated in the neurobiology of obsessive-compulsive disorder.

Psychopharmacology Feller is not testing over drugs for obesity Prozac is the common med

No medications are specifically indicated for eating disorders. - Various medications have been prescribed for associated symptoms such as anxiety and depression. Medications that have been tried with some success include - For anorexia nervosa: *fluoxetine (Prozac)*, clomipramine (Anafranil) cyprohepatadine (Pariactin), chlorpromazine (Thorazine), olanzapine (Zyprexia) - *fluoxetine has been useful in the txt of anorexia and bulimia! Bc it has the least number of side effects!!!* - For bulimia nervosa: *fluoxetine (Prozac)*, imipramine (Tofranil), desipramine (Norpramine), amitriptyline (Elavil),nortriptyline (Aventyl), Phenelzine (Nardil) - For BED with obesity: Topiramate (Topamax) - For obesity: *fluoxetine (Prozac)*, lorcaserin (Belvia), phentermine/topiramte (Osymia), various anorexiants (CNS stimulants)

What is Act 911 or 911 Program?

Not Guilty by Reason of Mental Disease or Defect or the AInsanity Defense Act 911 of 1989 pertains to the evaluation, commitment, and conditional release of individuals acquitted of a crime when found Not Guilty by Reason of Mental Disease or Defect. - The evaluation process, completed by a certified forensic psychologist or psychiatrist, assesses the defendant's fitness to proceed to trial and, if the defendant is found fit to proceed, mental state at the time of the crime. - If the defendant is found not fit to proceed, the proceedings against the defendant are suspended, and the court may commit him/her for detention, care, and treatment at the *Arkansas State Hospital (ASH)* until restoration of fitness to proceed. - Once fit to proceed, a re-evaluation includes an assessment of mental state at the time of the crime. - This opinion can result in acquittal if it is determined that, at the time of the conduct charged, the defendant lacked capacity—as the result of mental disease or defect—to conform his/her conduct to the requirements of the law or to appreciate the criminality of his/her conduct.

Preinteraction phase

Nurse must examine own feelings, fears, and anxieties about working with prisoners—possibly violent offenders.

Orientation (introductory) phase

Nurse works to establish trust with the client Sets limits on manipulative behavior Touch and self-disclosure NOT acceptable*

Planning and Implementation dissociative disorder nursing interventions/techniques you can use when initially treating the client to get them to deal w/ this issue

Nursing care for the client with a dissociative disorder is aimed at restoring normal thought processes. - Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than dissociation from the environment. - 2. Nursing care of the individual with a dissociative disorder is aimed at restoration of normal thought processes. Assistance is provided to the client in an effort to determine strategies for coping with stress by means other than dissociation from the environment

Q Fixed in oral stage of development

O

Q Is markedly over weight

O

Q May be related to hypothyroidism

O

Q Risk of DM

O (also with binge eating disorder)

After attending a group that discussed irrational thinking patterns, John asks the nurse, "How does this cognitive behavior therapy work?" What would be some appropriate responses to John's question?

Often, when people become very anxious they develop irrational thinking patterns that contribute to worsening their mood and impacting their behavior in negative ways. By becoming aware of thought patterns that increase your anxiety you can learn how to replace those automatic thoughts with more rational patterns in a way that improves your mood, symptoms, and behavior.

Explain the role & responsibilities of the *SANE* went to a special school for certification

Specialized training to care for sexual assault victims 1. *Physical and psychosocial examination of victims (long process)* 2. Collection and documentation of physical evidence - *Collect very carefully so chain of evidence isn't violated* 3. Testifies as expert legal witness - Usually won't happen for another year so take really good notes 4. May offer opinion as to whether a crime occurred - Nursing diagnosis uses judgement - 1 in 4 women have been sexually assaulted, rate is growing in men - Stay with patient or find someone to stay with pt, if it was a male perp keep men out of room - Decrease the chance of harming pt further - Rape kit: look for fine microscopic to look for tears and bruising, place anything collected in a paper bag NOT plastic - Pg. 342 in small book - say *"you're safe here*. I'm going to stay with you. There is a police person outside". Don't touch, keep your distance. Use soft/soothing voice. - Finish with "who is your support system or who supports you?" - Follow up with some kind of counseling ALWAYS

binge eating disorder (BED)

The DSM-5 identifies binge eating disorder as an eating disorder that can lead to obesity. - The individual binges on large amount of food, as in bulimia nervosa. - *BED differs from bulimia nervosa in that the individual does not engage in behaviors to rid the body of the excess calories!!*

Quality and Safety Education for Nurses (QSEN)

The Institute of Medicine (IOM), in its 2003 report Health Professions Education: A Bridge to Quality, challenged faculties of medicine, nursing, and other health professions to ensure that their graduates have achieved a core set of competencies in order to meet the needs of the 21st-century health-care system. These competencies include providing patient-centered care, maintaining safety, working in interdisciplinary teams, employing evidence-based practice, incorporating quality improvement, and utilizing informatics. A QSEN teaching strategy is included in Box 22-5. The use of this type of activity is intended to arm the instructor and the student with guidelines for attaining the knowledge, skills, and attitudes necessary for achievement of quality and safety competencies in nursing.

Purging

The act of attempting to rid the body of calories by self-induced vomiting or excessive use of laxatives or diuretics.

forensic nursing

The application of forensic science combined with the bio-psychological education of the RN, in the scientific investigation, evidence collection and preservation, analysis, prevention, and treatment of trauma and/or death related medical-legal issues - The ANA and the International Association of Forensic Nurses (*IAFN*) define it as, *"the practice of nursing globally when health and legal systems intersect"* - Learn if person is faking mental illness or not - Must evaluate the person to see if they are mentally ill or antisocial behavior (Cluster B, no empathy, kill for sake of killing)

amnesia, localized

The inability to recall all incidents associated with a traumatic event for a specific time period following the event. - inability to recall all incidents associated with the traumatic event for a specific period following the event - The inability to recall all incidents associated with the traumatic event for a specific time period following the event (usually a few hours to a few days)

formerly called Factitious Disorder by Proxy

The disorder may be imposed on another person under the care of the perpetrator

Predisposing Factors to OCD - Transactional model of stress adaptation

The etiology of OCD is most likely influenced by multiple factors.

Predisposing Factors to PTSD - Transactional model of stress adaptation

The etiology of PTSD is most likely influenced by multiple factors.

Agoraphobia

The fear of being in places or situations from which escape might be difficult (or embarrassing) or in which help might not be available in the event of a panic attack. - fear of open spaces of crowds - w/o hx of panic disorder: Fear of being in places or situations from which escape might be difficult or in which help might not be available if a limited-symptom attack or panic-like symptoms should occur - Examples Traveling in public transportation Being in open spaces Being in shops, theaters, or cinemas Standing in line or being in a crowd Being outside of the home alone in other situations

Explain the role & responsibilities of the Forensic Correctional Nurse (FCN)

The nurse works in secured settings, such as jails, prisons, and halfway houses The nurse provides treatment, rehabilitation, and health promotion to individuals convicted of crimes - Role includes: 1. Assessment of sociocultural influences 2. Assessment and care of mentally ill offenders 3. Help victims of crime cope with emotional wounds - Care of the mentally ill offender population is a highly specialized area of nursing practice.

integration

The process used with individuals with dissociative identity disorder in an effort to bring all the personalities together into one; usually achieved through hypnosis.

*primary gain*

The receipt of positive reinforcement for somaticizing by being able to avoid difficult situations because of physical complaint. - symptom enables the client to avoid some unpleasant activity. Ex: A patient feels guilty about not being able to perform a task, but if there is a medical condition justifying this inability, the guilt diminishes.

*tertiary gain!!!*

The receipt of positive reinforcement for somaticizing by causing the focus of the family to switch to the individual and away from conflict that may be occurring within the family. - in in dysfunctional families, the physical symptom may take such a position that the real issue is disregarded and remains unresolved even though some of the conflict is relieved Symptoms of depression and substance abuse are common. Example: the wife of an ill man may use her husband's illness to gain more power in their relationship

*secondary gain!!!*

The receipt of positive reinforcement for somaticizing through added attention, sympathy, and nurturing. - symptom promotes emotional support or attention for the client. Example: A patient is allowed to miss work and gets financial compensation as the result of a medical condition.

trichotillomania (hair pulling disorder)

The recurrent failure to resist impulses to pull out one's own hair.

How is forensics involved with mental health or psychiatry/psychology?

The role of forensic nursing has expanded from concerns solely with death investigation to include the living—the survivors of violent crime—as well as the perpetrators of criminal acts.

Emaciated

The state of being excessively thin or physically wasted.

Obesity

The state of having a body mass index of 30 or above. - This is NOT in the DSM-5 - Defined as a body mass index (BMI) of 30 or greater. (BMI= weight divided by height squared) - 68.5% of adult Americans are overweight, with 35% being in the obese range - Psych factors are involved in obesity - A BMI range for normal weight is 20-24.9. - Compulsive eating can result in obesity. - Obesity predisposes the individual to many health concerns. - Anorexia nervosa is characterized by a BMI of 17 or lower, or <15 in extreme cases. They are the ones who get hospitalized. They have electrolyte imbalances causing cardiac arrhythmias which means ICU.

*Systematic desensitization!*

Through a series of increasingly anxiety-provoking steps, the therapist gradually increases the patient's tolerance to anxiety/fear i.e. being home alone, crossing bridges, etc.

Explain the role & responsibilities of the Forensic Mental Health Nurse (FMHN) This is what's done at Arkansas State Hospital To be on forensics unit: must have committed a crime

Treatment of people whose mental illness has rendered them unable to conform their conduct to the requirement of the law 1. Assessment of sociocultural influences on clients - Religion, family, occupation, etc 2. Assessment and care of mentally ill offenders - Can be very manipulative - Help offenders get on meds 3. Help victims of crime cope with emotional wounds - Risk for self-directed violence 4. Help perpetrators and victims deal with the criminal justice system - Teach them the law, what court room looks like, walk them through it (competency school), ask them "How did court go?" - Nurse goes from court room to care for pt 5. Assessment of inmates for fitness, criminal responsibility, disposition, and early release 6. Provide mental health treatment for convicted offenders and those found not criminally responsible

*Hypochondriasis*

Unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease. - Even in the presence of disease, the symptoms are excessive in relation to the degree of pathology Anxiety and depression are common, and obsessive-compulsive traits frequently accompany the disorder It is thought that they express personal worthlessness through physical symptoms because physical problems are more acceptable than psychological problems Remember BETTY - past experience with serious or life-threatening physical illness, either personal or that of close relatives, can predispose the person to hypochondriasis - *When planning care, have the client focus on adaptive coping strategies to deal with their stress.*: Tell me what's REALLY bothering you today? Try to get them off that and onto something else - redirect them - a. Unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease. b. Even in the presence of medical disease, the symptoms are grossly disproportionate to the degree of pathology. c. Anxiety and depression are common, and obsessive-compulsive traits frequently accompany the disorder.

dissociative disorders

are defined by a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment - are thought to be rare. - Amnesia is the most common dissociative symptom. - DID is more prevalent in women than men. - Brief episodes of depersonalization symptoms appear to be common in young adults, particularly in times of severe stress. - conscious awareness becomes *separated (dissociated) from painful previous memories, thoughts, and feelings* symptoms: 1. having a sense of being unreal 2. being separated from the body 3. watching yourself as if in movie - are statistically quite rare, but when they do occur, they may present very dramatic clinical pictures of severe disturbances in normal personality functioning. Dissociative amnesia and dissociative identity disorder (DID) are more common in women than in men. Brief episodes of depersonalization symptoms appear to be common in young adulthood, particularly in times of stress.

Lorraine, a client diagnosed with Somatic Symptom Disorder, tells the nurse about a pain in her side. She says she has not experienced it before. Which is the most appropriate response by the nurse? a. "I don't want to hear about another physical complaint. You know they are all in your head. It's time for group therapy now." b. "Let's sit down here together, and you can tell me about this new pain you are experiencing. You'll just have to miss group therapy today." c. "I will report this pain to your physician. In the meantime, group therapy starts in 5 minutes." d. "I will call your physician and see if he will order a new pain medication for your side. The one you have now doesn't seem to provide relief. Why don't you get some rest for now?"

c. "I will report this pain to your physician. In the meantime, group therapy starts in 5 minutes." `

5. Which of the following physical manifestations would you expect to assess in a client suffering from anorexia nervosa? a. Tachycardia, hypertension, hyperthermia b. Bradycardia, hypertension, hyperthermia c. Bradycardia, hypotension, hypothermia d. Tachycardia, hypotension, hypothermia

c. Bradycardia, hypotension, hypothermia

Which of the following is the most appropriate therapy for a client with agoraphobia? a. 10 mg Valium qid b. Group therapy with other agoraphobics c. Facing her fear in gradual step progression d. Hypnosis

c. Facing her fear in gradual step progression

7. Which medication has been used with some success in clients with anorexia nervosa? a. Lorcaserin (Belviq) b. Diazepam (Valium) c. Fluoxetine (Prozac) d. Carbamazepine (Tegretol)

c. Fluoxetine (Prozac)

Joanie is a new patient at the mental health clinic. She has been diagnosed with Body Dysmorphic Disorder. Which of the following medications is the psychiatric nurse practitioner most likely to prescribe for Joanie? a. Alprazolam (Xanax) b. Diazepam (Valium) c. Fluoxetine (Prozac) d. Olanzapine (Zyprexa)

c. Fluoxetine (Prozac)

Sandy, a client with OCD says to the nurse, "I've been here four days now, and I'm feeling better. I feel comfortable on this unit, and I'm not ill-at-ease with the staff or other patients anymore." In light of this change, which nursing intervention is most appropriate? a. Give attention to the ritualistic behaviors each time they occur, and point out their inappropriateness. b. Ignore the ritualistic behaviors, and they will be eliminated for lack of reinforcement. c. Set limits on the amount of time Sandy may engage in the ritualistic behavior. d. Continue to allow Sandy all the time she wants to carry out the ritualistic behavior.

c. Set limits on the amount of time Sandy may engage in the ritualistic behavior.

1. Some obese individuals take amphetamines to suppress appetite and help them lose weight. Which of the following is an adverse effect associated with use of amphetamines that makes this practice undesirable? a. Bradycardia b. Amenorrhea c. Tolerance d. Convulsions

c. Tolerance

*Somatic symptom disorders!!!* What criteria differentiates the diagnosis of somatic symptom disorder from illness anxiety disorder what is their personality like? Look up the personality characteristics of somatic symptom disorder

characterized by physical symptoms *suggesting* medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to account for them. - were identified as hysterical neuroses and were thought to occur in response to repressed severe anxiety. Freud viewed dissociation as a type of repression, an active defense mechanism used to remove threatening or unacceptable mental contents from conscious awareness. - are more commonly found in Women than men, Less educated persons, Rural areas - chronic syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from health-care professionals Predominant symptom focuses on discomfort in one or more anatomical sites - The disorder is chronic. Anxiety, depression, and suicidal ideations are frequently manifested. Drug abuse and dependence are common. - Personality characteristics: 1. Heightened emotionality 2. Strong dependency needs 3. A preoccupation with symptoms and oneself

Explain how the nurse assesses wounds when investigating a crime for wound characteristics of blunt-force injuries

includes cuts and bruises resulting from the impact of a blunt object against the body - like through the skull, really blunt, tire tool or fire place thing - Injuries resulting from an impact with a dull, firm surface or object. Individual injuries may be patterned (eg ,characteristics of the wound suggest a particular type of blunt object) or nonspecific. blunt force trauma may cause contusions and lacerations of the internal organs and soft tissues, as well as fractures and dislocations of bony structures. - The major types of cutaneous blunt force injuries are as follows: abrasion, contusion, laceration, avulsion, fracture - These are the most commonly seen group of patterned injuries. Abrasions may preserve patterns well, especially if the force is applied at or near perpendicular to the skin surface. Bruises may also reproduce patterns well, particularly if they are mainly intradermal. Lacerations less frequently show a well defined reproduction of the shape of the injuring agent.

Explain how the nurse assesses wounds when investigating a crime for wound characteristics of sharp-force injuries

including stab wounds and other wounds resulting from penetration w/ a sharp object - maybe from a pieces of glass - Injuries produced by pointed objects or objects with sharp edges are referred to as "sharp force injuries." Sharp force injuries are characterized by a relatively well-defined traumatic separation of tissues, occurring when a sharp-edged or pointed object comes into contact with the skin and underlying tissues. Three specific subtypes of sharp force injuries exist, as follows: stab wounds, incised wounds, and chop wounds. - Improper description and interpretation of injuries may lead the police on a lengthy search for a knife or sharpened object when in fact they should be looking for a brick, angle iron, or other such angular object with a definite edge to it. Experience shows that sharp injuries (cuts and stabs) are better understood than blunt injuries (scrapes, bruises, tears, and fractures). - Sharp force trauma describes the mechanism of injury. It includes knife stab and slash wounds. - Knife wounds may show class characteristics of a specific type of blade (e.g., 'fish-tail' appearance of a stab wound). Stab wounds duetoother types ofpatterned instruments (e.g., Phillips head screwdrivers, scissors) may produce distinctive patterns.

Explain how the nurse assesses wounds when investigating a crime for wound characteristics of Defense wounds

injuries that reflect the victim's attempt to defend him or herself from attack - is an injury received by the victim of an attack while trying to defend against the assailant. Defensive wounds are often found on the hands and forearms, where the victim has raised them to protect the head and face or to fend off an assault, but may also be present on the feet and legs where a victim attempts defense while lying down and kicking out at the assailant. - The appearance and nature of the wound varies with the type of weapon used and the location of the injury, and may present as a laceration, abrasion, contusion or bone fracture. Where a victim has time to raise hands or arms before being shot by an assailant, the injury may also present as a gunshot wound. Severe laceration of the palmar surface of the hand or partial amputation of fingers may result from the victim grasping the blade of a weapon during an attack. In forensic pathology the presence of defense wounds is highly indicative of homicide and also proves that the victim was, at least initially, conscious and able to offer some resistance during the attack. - may be classified as active or passive. A victim of a knife attack, for example, would receive active defense wounds from grasping at the knife's blade, and passive defense wounds on the back of the hand if it was raised up to protect the face arms may be bloody from trying to defend self

Why must nurses that are employed at a correctional facility maintain a professional matter of fact (MOF) approach with offenders?

intervention for defensive coping: provide immediate, matter-of-fact, nonthreatening feedback for unacceptable behaviors. Client may lack knowledge about how he or she is being perceived by others. Direct the behavior in a nonthreatening manner to a more acceptable manner. - don't give up any personal information EVER Be very matter of fact when talking to them - interactions between correctional nurses and patients can take on a new quality within prison walls. While a hospital nurse wouldn't hesitate to tell a patient with a broken leg about her own similar experience, discussing such details is inappropriate in a correctional facility. "You really do not divulge anything personal to prisoners at all," she says. And while a hospital nurse might hug a patient with dementia, Weiskopf says, a correctional nurse wouldn't hug an inmate. "You really need to just focus on the care."

*Factitious Disorder (Munchausen syndrome)!!!*

involve conscious, intentional feigning of physical or psychological symptoms. Individuals with factitious disorder pretend to be ill in order to receive emotional care and support commonly associated with the role of "patient." - Illness when someone deliberately makes themselves sick - Individuals with factitious disorder comprise about 0.8 to 1.0% of psychiatry consultation clients. - Conscious, intentional feigning of physical and/or psychological symptoms. Some people do this to get on disability Individual pretends to be ill in order to receive emotional care and support commonly associated with the role of "patient." - *a relevant psychological stressor is often present but is NOT a requirement to establish the diagnosis!* - *malingered or feigned symptoms are NOT considered functional; however, proving the absence of feigning is not a requirement to establish the diagnosis!*

What is dual diagnosis? Explain dual diagnosis.

psychiatric diagnosis commonly identified at the time of incarceration: *schizophrenia, bipolar disorder, major depressive disorder, personality disorders, and substance use disorders, and many have dual diagnoses* - common psychiatric behaviors: hallucinations, suspiciousness, thought disorders, anger/agitation, and impulsivity - is the term used when a person has a mood disorder such as depression or bipolar disorder (also known as manic depression) and a problem with alcohol or drugs. A person who has a dual diagnosis has 2 separate illnesses, and each illness needs its own treatment plan. - is a term for when someone experiences a mental illness and a substance abuse problem simultaneously. Dual diagnosis is a very broad category. It can range from someone developing mild depression because of binge drinking, to someone's symptoms of bipolar disorder becoming more severe when that person abuses heroin during periods of mania. - Either substance abuse or mental illness can develop 1st. A person experiencing a mental health condition may turn to drugs and alcohol as a form of self-medication to improve the troubling mental health symptoms they experience. Research shows though that drugs and alcohol only make the symptoms of mental health conditions worse. Abusing substances can also lead to mental health problems because of the effects drugs have on a person's moods, thoughts, brain chemistry and behavior.

Predisposing Factors Somatic Symptom disorders - Learning theory

somatic complaints are often reinforced when the sick person learns that he or she may avoid stressful obligations or be excused from unwanted duties (*primary gain*). - *Think: what are you getting out of it?* - Somatic complaints are often reinforced when the sick person becomes the prominent focus of attention because of the illness (*secondary gain*). - Conflict is relieved within the family as concern is shifted to the ill person and away from the real issue (*tertiary gain*).

Explain how the nurse assesses wounds when investigating a crime for wound characteristics of patterned injuries

specific injuries that reflect the pattern of the weapon used to inflict the injury - injury which has a distinct pattern that may reproduce the characteristics of the object causing the injury. - The pattern may be caused by impact of a weapon or other object on the body, or by contact of the body with a patterned surface.

Predisposing Factors for Anorexia and Bulimia Nervosa - Psychodynamic Influences

suggest that eating disorders result from the very early and profound disturbances in mother-infant interaction resulting in delayed ego development and unfulfilled sense of separation-individuation.

*Flooding (implosion therapy)!!!* - technique used in behavior therapy;txt for claustrophobia, GAD

this technique is used to desensitize individuals to phobic stimuli. The individual is "flooded" with a continuous presentation (usually through mental imagery) of the phobic stimulus until it no longer elicits anxiety. client is flooded with experiences of a particular kind until becoming either averse to them or numbed to them

Predisposing Factors Somatic Symptom disorders - Psychodynamic theory

this theory suggests that hypochondriasis may be an ego defense mechanism - Physical complaints become the expression of low self-esteem, because it is easier to feel that something is wrong with the body than to feel something is wrong with the self. - Conversion disorder may represent emotions associated with a traumatic event that are too unacceptable to express and so are acceptably "converted" into physical symptoms.

Explain how the nurse assesses wounds when investigating a crime for wound characteristics of fast force injuries

usually gunshot wounds; may reflect previous patterns of injury

Explain how the nurse assesses wounds when investigating a crime for wound characteristics of hesitation wounds (or tentative) Give an example of a hesitation wound

usually superficial, sharp-force wounds; often found perpendicular to the lower part of the body and may reflect self-inflicted wounds - Any of a series of shallow cuts made by people considering a suicide attempt, or trying out the weapon to ascertain its effectiveness. These wounds are often multiple, parallel, non-lethal cuts. - any cut or wound that is self-inflicted after a decision is made not to commit suicide, or any tentative cut or wound that is made before the final cut that causes death. Such wounds are usually superficial, sharp, forced skin cuts found on the body of victims. These less severe cutting marks are often caused by attempts to build up courage before attempting the final, fatal wound. Non-fatal, shallow hesitation wounds can also accompany the deeper, sometimes fatal incisions. Although hesitation cuts are not always present in cases of suicide, they are typical of suicidal injuries. However, the presence of hesitation marks alongside or near to the final fatal mark usually indicates a forensic diagnosis of suicide over other possible causes of death. - are generally straight-line marks at the elbows, neck/throat, and wrists, although in a few cases they occur in the general area of the upper middle part of the abdomen (near the heart). Wounds made by people attempting suicide are typically made at an angle related to the hand that holds the weapon. The angle of such hesitation wounds is usually in a downward flowing direction because of the natural motion of the arm as it sweeps across the body. Hesitation wounds are often made under clothing, with particular parts of the clothing being parted to expose the target area of the body, a common feature seen by forensic experts examining suicidal wounds. Instruments used to inflict hesitation wounds are generally those found around the living quarters of the person attempting suicide. Such instruments include kitchen knives, single-edge and double-edge knifes, pocket knives, hatchets, razor blades, screwdrivers, and other sharp objects. People who have previously attempted suicide, but have not succeeded in their endeavor, will often carry visible scars from hesitation wounds. - Although usually used in association with attempted suicides, hesitation wounds are sometimes made in order to provide an alibi (a claim to have been elsewhere when a crime was committed) or to be seen as a victim (when in actuality the person was an active participant in the crime). most of the time perpendicular to the body, client changed their mind

Treatment Modalities - Behavior modification

will provide the client with *control* over behavioral choices. - *Issues of control are central to the etiology of these disorders!!!* - For the program to be successful, the client must perceive that he or she is in control of the treatment. - Successes have been observed when the client: a. Is allowed to contract for privileges based on weight gain b. *Has input into the care plan!!* c. Clearly see what the treatment choices are d. Is able to *demonstrate healthy coping mechanisms to decrease anxiety!!!* - The client has control over: a. Eating b. Amount of exercise pursued c. Whether to induce vomiting - Teach healthy coping strategies to replace these - Staff and client agree about goals and systems of rewards. - The client has a choice whether to *abid*e by the contract, gain weight, and earn the desired privilege. Personality traits that are common is clients with eating disorders: people pleasers, perfectionist, need for control - Restructure thinking, learn coping skills that DECREASE anxiety