Theories 3 - Exam 4

phases of major depressive disorder: continuation

- increased functional ability - treatment is normally 4-9 months - education, therapy, med management

nursing interventions: histrionic personality disorder

- keep communication professional - assess for suicidal ideation - help clarify feelings

nursing interventions: Obsessive-Compulsive Personality Disorder

- help to accept / tolerate less than perfect - help relinquish control - assist in identifying ineffective coping and replacing with more effective strategies

nursing interventions: borderline personality disorder

- identify feelings - no harm contract - boundaries / limit setting

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "Are the burns associated with chemicals used in the plant?" "Are the victims suffering from thermal burns?" "How many victims are anticipated for transport?" "Are any of the victims expected to have electrical burns?"

"Are the burns associated with chemicals used in the plant?" Explanation: If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel.

A client who is depressed states, "I think my family would be better off without me. They don't need to worry." Which is the most appropriate response by the nurse? "Where are you going?" "Are you planning to commit suicide?" "What do you think they are worried about?" "You don't mean that. Your family loves you."

"Are you planning to commit suicide?" Explanation: The nurse never ignores any hint of suicidal ideation regardless of how trivial or subtle it seems and the client's intent or emotional status. Asking clients directly about thoughts of suicide is important. Asking about the family's worries or their love for the client does not directly address the client's risk for suicide. Asking, "Where are you going?" is less direct and less effective than asking explicitly about suicide.

a nurse is caring for a client who has bipolar disorder and is experiencing acute mania. the client is doing calsthenics in the client dining room during lunchtime instead of eating. which of the following statements should the nurse make? "You are already too thin and exercise is not good for you. Go sit down somewhere and eat something." "Come with me. Here is a milkshake to drink." "We need you to decide what activities you will do today." "You will need to leave the dining room right now and go somewhere else to exercise."

"Come with me. Here is a milkshake to drink." When working with a client who is experiencing mania, the nurse should provide short, firm, and concise directions, which can provide a feeling of safety for the client and can distract the client from inappropriate activities, such as vigorous exercise. An appropriate activity for the client is to accompany the nurse to a quiet place away from the clients who are trying to eat. Client nutrition is important, but the client often needs foods that can be held in the hand and eaten easily while walking. The client is unlikely to be able to sit in one place for long enough to complete a meal when experiencing mania.

The nurse provides care for a client who is diagnosed with anorexia nervosa. Which question should the nurse ask to assess the client for neuropsychiatric complications associated with the diagnosed eating disorder? "Is your skin dry and your nails brittle?" "How often do you menstruate?" "Do you experience constipation or diarrhea?" "Do you experience abnormal taste sensations?"

"Do you experience abnormal taste sensations?" Explanation: There are many complications associated with eating disorders, including anorexia nervosa. The neuropsychiatric complications include abnormal taste sensations, often due to zinc deficiency. Other neuropsychiatric complications include apathetic depression, fatigue, mild organic mental symptoms, and sleep disturbances. Abnormal menstrual cycles and/or amenorrhea are reproductive complications associated with anorexia nervosa. Dermatologic complications include dry skin and brittle nails. Constipation and/or diarrhea are both gastrointestinal complications associated with anorexia nervosa.

The nurse is working with a client who has been diagnosed with depression. When performing a strength assessment with the client, what is the nurse's best statement or question? "Do you consider yourself to be a strong person overall?" "How have you dealt with feelings like this in the past?" "It's important that you remember that you're an exceptionally strong and capable person." "What can the care team do to help you become a stronger person?"

"How have you dealt with feelings like this in the past?" Explanation: A strength assessment is aimed at identifying the client's previous coping skills and strategies. Seeking suggestions for the care team does not achieve this purpose. Asking if the client considers himself or herself to be strong is likely to be answered with "no" in a person who is depressed. The nurse must avoid false reassurance.

A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client? "We do this every day. Why are you so angry with me this morning?" "I don't like it when you address me with that tone of voice." "I know you can, but are you going to read it or not?" "Fine. Here is the schedule, and I will expect you to be on time to your therapies."

"I don't like it when you address me with that tone of voice" BPD is described as an emotionally unstable personality. Clients who have BPD might show a wide range of impulsive behaviors in all aspects of their lives, including self-destructive behaviors. The client in this situation has overstepped a limit by addressing the nurse in a less-than-respectful tone of voice. This therapeutic response calls to the client's attention the inappropriate behavior and sets appropriate limits for further communication. This is the best approach to continue communication with this client.

After educating a client with bipolar disorder on his prescribed lithium therapy, the nurse determines that additional education is needed when the client states which of the following? "I can use sugarless candies to help with any metallic taste." "I need to report any problems with severe diarrhea or slurred speech." "I need to avoid drinking any alcohol." "I need to cut back on my salt intake when it's really hot outside."

"I need to cut back on my salt intake when it's really hot outside." Explanation: Clients should increase their intake of salt during periods of perspiration (e.g., when it is hot outside) and periods of increased exercise and dehydration. Severe diarrhea and slurred speech suggest moderate toxicity, which needs to be evaluated. Alcohol interacts with lithium, causing increased serum concentrations of the drug, placing the client at risk for toxicity. Sugarless candies and throat lozenges can help to combat metallic taste.

A client on an in-patient psychiatric unit has been diagnosed with bulimia nervosa. The client states, "I'm going to the bathroom and will be back in a few minutes." Which response by the nurse is most appropriate? "I will accompany you to the bathroom." "Let me know when you get back to the dayroom." "Thanks for checking in." "I'll stand outside your door to give you privacy."

"I will accompany you to the bathroom." Explanation: After each meal or snack, clients may be required to remain in view of staff for a period of time to ensure they do not empty the stomach by vomiting. Some treatment programs limit client access to bathrooms without supervision, particularly after meals, to discourage vomiting. The response "I will accompany you to the bathroom" is appropriate. Any client suspected of self-induced vomiting should be accompanied to the bathroom for the nurse to be able to deter this behavior. The response, "I'll stand outside your door to give you privacy" does not address the nurse's responsibility to deter the behavior. The nurse should accompany the client to the bathroom. Providing privacy is secondary to preventing further nutritional deficits.

A nurse is developing a nurse-client relationship with a client diagnosed with borderline personality disorder (BPD). Which statement by the nurse demonstrates that the nurse understands the client's fears of abandonment and intimacy? "We will work on things until your physician says you can go home." "I'm here to help you for as long as I can." "Let's see how things go first and then how long you need me." "I will be seeing you during the daytime this week."

"I will be seeing you during the daytime this week." Explanation: A key to helping clients with BPD is recognizing their fears of both abandonment and intimacy as they relate to the nurse-client relationship. Informing the client of the length of this relationship allows the client to engage in, and prepare for, termination with minimal pain of abandonment. Therefore the statement about seeing the client during the daytime for a week demonstrates understanding of this concept. The other statements are open ended and do not address the length of the relationship.

The nurse has been teaching a client about bulimia. Which statement by the client indicates that the teaching has been effective? "I'll limit my intake of carbohydrates and fats." "I'll eat small meals and snacks regularly." "I know if I eat pasta, I'll binge." "I'll take my medication when I feel the urge to binge."

"I'll eat small meals and snacks regularly." Explanation: Teaching is effective when the client recognizes the need to return to nutritious eating patterns, such as frequent intake of healthy types and quantities of food. Recognizing triggers, such as particular foods, can help reduce the incidence of binges but does not necessarily cause the development of healthy habits. Food restriction (limiting fats and carbohydrates) is a superficial approach that does not address the root causes of eating disorders. Similarly, reliance on medication as the key to recovery does not address these issues.

a nurse observes that a client who has depression is sitting alone in the room crying. as the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make? "It might help you feel better if you talk about it." "I'll just sit here with you for a few minutes then." "I understand. I've felt like that before, too." "Why are you feeling so down?"

"I'll just sit here with you for a few minutes then."

A client with a dependent personality disorder is receiving treatment on a medical unit. The client asks the nurse for assistance to open the tube of toothpaste so they can brush their teeth. Which is the best response by the nurse? "I'll stay here and you can show me what you've tried to do to get the top off" "Tell me why you feel you can't do it yourself" "Let me open that for you" "I feel you can get your family to help you with this when they come in"

"I'll stay here and you can show me what you've tried to do to get the top off" Explanation: A client with dependent personality disorder may look to others including the nurse to make everyday decisions and to assist with tasks both simple and complex. A helpful response by the nurse can integrate the typical challenges these clients face. The statement that validates the struggle, supports the client's individual efforts and supports the client by being present is the strongest response. Interventions that support dependency such as doing the task for the client or having someone else do it are not helpful. Offering a question using 'why' can contribute to defensiveness and a challenge to self-esteem.

a nurse is teaching a client who has bipolar disorder about lithium. which of the following statements should the nurse include in the teaching? "Decrease your fluid intake to 1 liter per day." "You might produce extra saliva while taking this medication." "Notify your provider if you experience vomiting or diarrhea." "Take the medication on an empty stomach."

"Notify your provider if you experience vomiting or diarrhea." - Vomiting and diarrhea are both manifestations of lithium toxicity and should be reported to the provider. Vomiting and diarrhea can also cause dehydration, which can result in lithium toxicity.

A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which is the most appropriate response by the nurse? "I'm glad you feel comfortable with me." "I cannot be your friend. We need to be clear on that." "You feel others don't understand you?" "I'm here to help you just as all the staff members are."

"I'm here to help you just as all the staff members are." Explanation: For the borderline personality disorder client, personal boundaries are unclear, and clients often have unrealistic expectations. Clients easily can misinterpret the nurse's genuine interest and caring as a personal friendship, and the nurse may feel flattered by a client's compliments. The nurse must be quite clear about establishing the boundaries of the therapeutic relationship to ensure that neither the client's nor the nurse's boundaries are violated. Stating that the nurse's role is no different from that of the other staff denies that the nurse is somehow "special" to the client. The nurse should not implicitly validate the client's view by thanking them or by exploring the lesser role of other staff with the client. Stating "I'm glad you feel comfortable with me" misses an opportunity to reinforce healthy boundaries. Conversely, stating "I cannot be your friend" is unnecessarily direct and is not empathic; such a response may jeopardize therapeutic rapport with the client. Redirection is preferred over confrontation.

The adult children of a client with narcissistic personality disorder meet with the therapist as part of their parent's treatment. The nurse is aware that which statement by the daughter is consistent with behavior typically associated with this personality disorder? "My parent never had any family or friends over to the house." "My parent was constantly threatening to commit suicide." "My parent was always timid and fearful." "My parent never really seemed to see me as a person with my own thoughts and problems."

"My parent never really seemed to see me as a person with my own thoughts and problems." Explanation: Clients with narcissistic personality disorder have a lifelong pattern of self-centeredness, self-absorption, inability to empathize with others, grandiosity, and extreme desire for the admiration of others. They feel that they are unusually special and often exaggerate their accomplishments to appear more important than they actually are. As sensitive as they are to the opinions of others, they are particularly insensitive to the needs or feelings of others and lack empathy.

An attractive and engaging client with antisocial personality disorder (ASPD) asks a nurse providing inpatient care to go out on a date. Which is the nurse's best response? "I'm just going to ignore that request." "No, my code of ethics prohibits me from dating clients." "We can discuss that later, closer to discharge." "I like you, but I can't. Unit policy prohibits it."

"No, my code of ethics prohibits me from dating clients." Explanation: One of the key interventions by the nurse with a client with ASPD involves facilitating self-responsibility. Establishing therapeutic relationship boundaries must be a priority. The nurse makes an effort to avoid bargaining with the client. The statement that starts with "no" clearly presents the nurse's decision. It's supported by the reason, which convincingly states dating (of any) clients is prohibited by the ethical standards for nursing. Ignoring the statement in words or by saying nothing, leaves the opportunity open for further requests by the client. Stating that the nurse "likes" the client or that the matter can be deferred until later gives a mixed message that offers hope for further negotiation by the client.

Which of the following is an acronym or mnemonic associated with Monoamine Oxidase Inhibitors (MAO-Is)? IM DAMN SHARP acronym "Takes Pride In Shanghai" HAART HAVOCS Mnemonic "GET SMASHHED" Mnemonic FRIEND Mnemonic

"Takes Pride In Shanghai" Sign The acronym MAO "Takes Pride In Shanghai" is used to recall the MAO-I drugs: Tranylcypromine, Phenelzine, Isocarboxazid and Selegiline.

The nurse working on a mental health unit is teaching a nursing student. The student asks the nurse about what constitutes a diagnosis for major depressive disorder. What is the nurse's best response? "The physician diagnoses depression when a client has feelings of sadness several times a year." "Feelings of anxiety and sadness as a response to a life event are the most important qualifiers for depression." "The primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present." "Depression is a mood variation to life events."

"The primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present." Explanation: Normal variations in mood (such as sadness, euphoria, and anxiety) occur in response to life events; they are time limited and not usually associated with significant functional impairment. The primary diagnostic criterion for major depressive disorder is one or more major depressive episodes (either a depressed mood or a loss of interest of pleasure in nearly all activities) for at least 2 weeks. Four of seven other symptoms must be present. Thus, the best response from the nurse is "the primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present."

The facilitator of a social skills training program contacts a mental health nurse about a client diagnosed with histrionic personality disorder attending the program. The facilitator feels the client has well-developed social skills and does not need assertiveness training. How does the nurse respond? "Their interactions are dramatic and this makes their interpersonal relationships fulfilling. The referral was inappropriate." "They have success establishing and maintaining interactions with others. This client would be better in a situation where they use their confidence to help others, such as a public speaking group." "Their interpersonal relationships tend to be shallow and their self-esteem is low. Having success interacting with others in group will help the client." "They develop few relationships due to their strong independence. Attending group will allow the facilitator to challenge their inflated self-esteem."

"Their interpersonal relationships tend to be shallow and their self-esteem is low. Having success interacting with others in group will help the client." Clients with histrionic personality disorder engage in superficial interpersonal relationships. In most cases their interactions are aimed at having their own needs addressed and they lack the levels of empathy and social intelligence to sustain relationships beyond the superficial level. These individuals may benefit from social skills training to better understand their capacities, improve their interpersonal approaches, and improve self-esteem in more mature ways. They do not have fulfilling or enduring relationships in general. They feel dependence and are not independent in their patterns. Their self-esteem is low and not inflated.

Which statement by a client with borderline personality disorder (BPD) is an example of catastrophizing? "This is the most awful thing that has ever happened to me." "I never get what I want." "If I had not made him mad, he wouldn't have hit me." "No one ever listens to me."

"This is the most awful thing that has ever happened to me." Explanation: An example of a statement using catastrophizing is, "This is the most awful thing that has ever happened to me." Examples of dichotomizing statements include, "No one ever listens to me" and "I never get what I want." A statement in which a self-attribution error has occurred is "if I had not made him mad, he wouldn't have hit me."

a nurse is teaching a client who has bipolar disorder about lithium. which of the following statements should the nurse include in the teaching? "This medication is addictive, so you will need to discontinue it in six months." "Weight gain should be reported to your provider as an indication of lithium toxicity." "Your provider may prescribe a diuretic if you have trouble urinating while taking lithium." "We will monitor your lithium levels closely while you are taking this medication."

"We will monitor your lithium levels closely while you are taking this medication."

A client who is depressed begins to cry and states, "I'm just really sick of feeling this way. Nothing ever seems to go right in my life." Which would be the most appropriate response by the nurse? "Nothing ever goes right?" "Don't cry. Try to look at the positive side of things." "Hang in there. Your medication will start helping in a few days." "You are feeling really sad right now. It's a hard time."

"You are feeling really sad right now. It's a hard time." Explanation: Do not cut off interactions with cheerful remarks or platitudes. Do not belittle the client's feelings. Accept the client's verbalizations of feelings as real, and give support for expressions of emotions, especially those that may be difficult for the client (like anger). Allow (and encourage) the client to cry. It is important that the nurse does not attempt to "fix" the client's difficulties.

a nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. the client comes to the nurses station at 0300 demanding that the nurse call the provider immediately. which of the following responses by the nurse is appropriate? "You are being unreasonable, and I will not call your doctor at this hour." "Go back to your room, and I'll try to get in touch with your doctor." "I can't call a doctor in the middle of the night unless it's an emergency." "You must be very upset about something."

"You must be very upset about something."

nursing management in emergent phase of burn

- ABCs - doppler pulses and for BP - elevate burned extremities - large bore IVs - foley - I&Os - calculate expected fluid requirements - monitor patients response - notifying the team of significant assessment findings and abnormal labs attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and GI and kidney function.

medical management in emergent stage of burn

- ABCs - remove secretions (cough or suction) - fluid resuscitation - assess cspine and head - check eyes - validate an account of the burn scenario (via patient, witnesses, and first responders) - foley catheter - NGT - clean sheets - baseline labs, height, weight, VS, ECG - tetanus prophylaxis - psychological needs of patient and family

clinical symptoms of ASPD

- Arrogant - Self-centered - Privileged - Entitled - Self-serving - Fine with exploiting others - Seek power over others - Often engaging and charming - Lack empathy - Unable to have compassion - Insensitive - Callous - Deceitful and manipulative - Behaviorally impulsive - Interpersonally irresponsible - Often times repeatedly perform acts that are grounds for arrest (destroying property, harassing others, stealing, pursuing other illegal occupations) - Act hastily and spontaneously - Temperamentally aggressive and shortsighted, fail to plan ahead or consider any alternatives - Fail to adapt to ethical and social standards of the community - Lack a sense of obligation to fulfill social and financial obligations, including being a spouse, parent, employee, friend, or member of community - Lack remorse for transgressions

at the scene: burns

- Basic Life Support--ABC's, CPR, AED - Cool the burn (water, NO ICE) - Remove clothes and jewelry - Clean, dry sheets or blankets. (not wet!)‏ - Irrigate chemical burns - Start IV x2 (LR), burned or unburned skin. - No wound care needed, at this time. - No food or drinks for the patient

causes of intellectual developmental disorder

- Brain injury or infection before, during or after birth. - Growth or nutrition problems. - Abnormalities of chromosomes and genes. - Premature birth - Poor diet and health care. - Drug misuse during pregnancy, including alcohol intake and smoking. - Child abuse, which can severely affect a child's socio-emotional development. - Autism spectrum disorder.

Major Depressive Disorder risks for suicide

- Family history of suicide - previous suicide attempts - inadequate support - violence/abuse in home - psychosis - substance abuse

factors to consider in determining burn DEPTH

- How the injury occurred - Causative agent (flame or scalding liquid) - Temperature of agent - Duration of contact with the agent - Thickness of the skin at the injury

What is an appropriate nursing diagnosis for a child/adolescent with an eating disorder?

- Imbalance nutrition: Less than body requirements - Deficient fluid volume - Risk for deficient fluid volume - Ineffective denial - Disturbed body image/low self-esteem

What is an appropriate nursing diagnosis for a child/adolescent with Attention Deficit Hyperactivity Disorder (ADHD)?

- Risk for injury - Impaired social interaction - Low self-esteem - Noncompliance (with task expectations)

What is an appropriate nursing diagnosis for a child/adolescent with Intellectual Developmental Disorder?

- Risk for injury - Self-care deficit - Impaired verbal communication - Impaired social interaction - Delayed growth and development - Anxiety - Defensive coping - Ineffective coping

What is an appropriate nursing diagnosis for a child/adolescent with Autism Spectrum Disorder?

- Risk for self-mutilation - Impaired social interaction - Impaired verbal communications - Disturbed personal identity

symptoms of borderline personality disorder

- affective instability - impulsivity - fear of abandonment - eruptions of rage - feelings of emptiness - unstable interpersonal relationships - chronic dysphoria - depression - heightened risk taking behaviors - self-harm behaviors - unstable self image - chronic feelings of emptiness and boredom - dichotomous thinking - dissociation - impaired problem solving - splitting

topical agents for burn wounds

- antimicrobial ointment - silver sulfadiazine 1% water-soluble cream - mafenide acetate 5% hydrophilic-based solution or cream - silver nitrate 0.5% aqueous solution - silver-impregnated dressings (sheets or mesh)

ways to address age considerations in elderly burn patients

- assess ability to safely perform ADLs - assists patient and family in modifying their environment to ensure safety - make referrals as needed - assess instrumental activities of daily living as well (more complex tasts such as meal prep and travel to appointments)

personality disorders are affected by

- biopsychosocial factors - brain anatomy - 1st degree relative with any of these disorders - adverse childhood events

antisocial personality disorder (cluster B) (special note)

- brain is wired differently - can be present from birth

nursing interventions: schizoid personality disorder

- build trust - prevent events ridicule / do not force them to socialize - improve functioning in the community

age related factors in burns: children

- children also have a higher morbidity due to thin skin causing deeper burns and more complications

nursing interventions: paranoid personality disorder

- counteract mistrust - simple language / neutral / not too friendly language - limit setting for threatening behavior

Name two medications used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD)?

- dextroamphetamine sulfate (Dexedrine; Dextrostat) - methamphetamine (Desoxyn) - lisdexamfetamine (Vyvanse) - dextroamphetamine/amphetamine (Adderall) - adzenys XR-ODT - methyphenidate (Ritalin; Methylin; Metadate; Concerta; Daytrana) - dexmethylphenidate (Focalin) - clonidine (Catapres) - guanfacine (Tenex; Intuniv) - atomoxetine (Strattera) - bupropion (Wellbutrin)

risks for depression

- genetics - illness - neurotransmitter deficiencies (serotonin, dopamine, norepinephrine, acetylcholine) - possible endocrine connections (TSH, T3 &T4) - previous episodes of depression - lack of coping abilities - lack of support systems - substance abuse - history of abuse / trauma

lithium

- gold standard mood stabilizer for bipolar disorder - a salt •Stabilizes mood, decreases incidence of suicide - super narrow therapeutic range •Competes with sodium at receptor sites •Affected by conditions that affect fluid levels (dehydration=increase, increased Na or water intake=decrease)

wellness strategies for patients with depressive disorders

- healthy diet - exercise - Cognitive Behavioral therapy - practice social skills they can use in their everyday life interactions - drug actions, dosing, and side effects - risk factors for recurrence of symptoms - importance of adhering to treatment plan - recovery strategies - sleep measures - goal setting and problem solving - follow up appointments - community support services

nursing interventions: narcissistic personality disorder

- nurse should avoid power struggle / defensiveness - be a role model for empathy - use therapeutic nurse / patient relationship to practice engaging in meaningful interactions

promotion of self-care activities

- offering assistance - allowing time for patient to complete self-care task - setting incentives to promote patient self-care - monitor ability to complete personal hygiene activities

age related factors in burns: elderly

- older adults have increased morbidity in burn injuries - thinner skin at this age leads to deeper burns with more complications - diminished mobility, postural stability, strength, coordination, sensation, visual acuity, and declining memory predispose older adults to burns - pneumonia is the most common complication in older adults post-burn, followed by UTI. - skin is thinner and less elastic; deeoer burn and harder time healing - pulmonary function impaired with age; affects airway gas exchange and lung elasticity and ventilation - decreased cardiac output; increased risk of complications and less CV compensatory mechanisms (increased risk of fluid overload) - decreased kidney and liver function; affects medication dosing due to med clearance - malnutrition - mental capacity may be varied so pain management, anxiety management, and delerium may be harder to treat

nursing interventions: schizotypal personality disorder

- perform careful assessment (assess cult, magical thinking) - increase functioning and ADLs - develop self-care skills

nursing interventions: antisocial personality disorder

- prevent / reduce manipulation (flattery, seductiveness, instilling guilt) - therapeutic communication (active listening / empathy) - enforce boundaries / limits

recovery oriented nursing interventions

- promotion of self-care activities - activity and exercise interventions - sleep interventions - nutrition interventions - relaxation interventions - hydration interventions - thermoregulation interventions - pain management - medication management - cognitive interventions - counseling interventions - conflict resolution and cultural brokering - bibliotherapy and social media - reminiscence - behavior therapy - behavior modification - token economy - psychoeducation - health teaching - spiritual interventions - social interventions - milieu therapy - containment - validation - structured interaction - open communication - promotion of patient safety - patient observation - de-escalation - home visits - community action

methods to estimate total body surface area (TSBA) burned

- rule of nines - lund and browder method - palmer method

phases of major depressive disorder: acute

- severe signs and symptoms - 6-12 weeks - goal is reduction of signs and symptoms

info about burn / burn patient needed

- valid account of burn scenario via patient, witnessess, and first responders - time of burn - source of burn - the scene of injury (especially if patient was in an enclosed space) - length of exposure - prior treatment - any history of additional traumatic injury - PMHx - allergies - medications - use of drugs, ETOH, tobacco

patient / family teaching when the child is taking fluoxetine (prozac)

- watch for signs of suicidal ideation - lock away weapons - store medications out of their reach

common comorbidities of depression

-anxiety disorders -psychotic disorders -substance use disorders -eating disorders -personality disorders

a nurse is caring for a client who has bipolar disorder. which of the following actions by the client should the nurse interpret as displaying manic behavior? (select all that apply) Talking in rapid, continuous speech Interacting with others in a flirtatious way Spending large sums of money Sleeping for long periods of time Dressing in black or grey clothing

-talking in rapid, continuous speech -interacting with others in a flirtatious way -spending large sums of money

antipsychotics for bipolar disorder

-these are given to help control symptoms DURING SEVERE MANIC EPISODES even if psychotic symptoms are absent. these are usually tapered down once they are out of psychosis. •Quetiapine •Risperidone •Aripiprazole •Olanzapine

appropriate urine output for fluid resuscitation in thermal and chemical injuries

0.5 - 1 mL / kg / hour

urine output standard for thermal / chemical burns

0.5 to 1 ml/kg/hr for thermal/chemical

safe lithium serum range:

0.6-1.2 mEq/L

burn patients have these issues because they leak plasma: (3)

1) Circulating volume is lost--so blood pressure drops 2) Hgb and Hct level increase--"thicker blood" 3) Fluid leaks into interstitial spaces causing edema

EMS role on the scene / emergent stage of burn

1. remove patient from source of injury and stop the burning process while preventing injury to rescuer - establishing airway - suppy O2 humidified 100% - place in position that will prevent aspiration of emesis - insert large bore IV - cool the burn - remove restrictive objects - cover wound with clean, dry cloth or gauze - begin continous irrigation of injury if its a chemical injury

A client who was receiving a monoamine oxidase inhibitor (MAOI) is to be switched to a selective serotonin reuptake inhibitor (SSRI). The nurse would expect to begin administering the SSRI how many days after the MAOI is discontinued? 7 days 21 days 28 days 14 days

14 days Explanation: To prevent possible interactions, 14 days should elapse between the discontinuation of the MAOI and the start of the SSRI.

A client with a diagnosis of antisocial personality disorder would exhibit a history of conduct disorder before which age? 7 years 12 years 15 years 10 years

15 years Explanation: For the diagnosis of antisocial personality disorder, a person would have evidence of a conduct disorder before 15 years of age.

An individual with which body mass index (BMI) would be classified as having mild anorexia nervosa? 16.2 kg/m2 20 kg/m2 17.4 kg/m2 15.4 kg/m2

17.4 kg/m2 Explanation: The severity of anorexia nervosa is classified as follows: mild: BMI ≥ 17 kg/m2; moderate: BMI 16-16.99 kg/m2; and severe: BMI 15-15.99 kg/m2. A BMI of 20 kg/m2 is considered normal.

A nurse is preparing a presentation for a group of staff nurses on personality disorders. When describing antisocial personality disorders (ASPD), the nurse would explain that for a person to be diagnosed with the disorder, the person must be at least which age? 25 years 18 years 15 years 21 years

18 years Explanation: To be diagnosed with ASPD, the individual must be at least 18 years old and must have exhibited one or more childhood behavioral characteristics of conduct disorder before the age of 15 years, such as aggression to people or animals, destruction of property, deceitfulness or theft, or serious violation of rules.

Thermal/Chemical Burn fluid resuscitation equation (volume to be given in 1st 24 hours)

2 mls LR x KG x % TBSA Burn (2nd, 3rd, 4th degree)

fluid formula for thermal / chemical burns in 1st 24 hours

2 mls LR x KG x % TBSA Burn (2nd, 3rd, 4th degree) give half the amount in first 8 hours, give the next half in the next 16 hours

Burns more than _____ may produce a local and systemic response and are considered major burns

20%

The mental health nurse appropriately provides education on light therapy to which client? 20-year-old college student who reports being "too tired, sad, and unfocused" to enroll for classes in the winter term 45-year-old lawyer whose medication therapy needs an additional treatment 50-year-old farmer whose major depression has not responded to any treatment modality 58-year-old showing signs of early Alzheimer's disease

20-year-old college student who reports being "too tired, sad, and unfocused" to enroll for classes in the winter term Explanation: Phototherapy—or the exposure to bright artificial light—can markedly reverse the symptoms of seasonal affective disorder, which occurs in the fall and winter. Phototherapy would be most appropriate for a 20-year-old college student who reports being "too tired, sad, and unfocused" to enroll for classes in the winter term.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? 27% 9% 18% 36%

27% Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 36% 45% 18% 27%

27% Explanation: The TBSA would be 27%. That is 18% of the body surface for the anterior trunk and 9% for the left arm.

at the scene hypovolemic shock: burns

2nd most common cause of death of burn patient in the first 24 hours Size of the burn, pre-existing conditions and care determine onset of shock Continuously monitor for signs of shock Hydration - lactated ringers oAdults - 500 mL/HR oChildren < 30kg - 250 mL/HR and D5 ½ NS v2 large bore Ivs or Ios

a nurse is admitting a client who has sustained severe burn injuries in a grease fire. the nurse shades in a diagram indicating the burned surface areas. using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (shaded in areas are the anterior portion of the chest, abdomen, left hand/forearm/upper arm, right hand/forearm and the posterior left hand/forearm/upper arm and right hand/forearm)

31.5% First, the nurse should determine the burned areas: Entire left arm Half of right arm Entire front torso Next, the nurse should use the Rule of Nines to estimate the percentage of burned surface area: Head 9% Torso 36% (front 18% and back 18%) Arm 9% each Leg 18% each Perineum 1% Then, the nurse should apply the Rule of Nines to the client's burns: Left arm = 9% 1/2 of right arm = 4.5% Front torso = 18% The total percent of the burned surface area is 9 + 4.5 + 18 = 31.5%.

a nurse is preparing for start an IV infusion of lactated ringer's for a client who sustained a burn injury. the client is prescribed 5,200 mL of fluid over the first 24 hr. how many Ml/hr should the nurse set the pump to infuse for the first 8 hr?

325 mL/hr Steps: 5,200 / 2 = 2,600 2,600 / 8 hr = 325 mL/hr

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 27% 36% 30% 18%

36% Explanation: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

Electrical Burn fluid resuscitation equation (volume to be given in 1st 24 hours)

4 mls LR x KG x % TBSA Burn (2nd, 3rd, 4th degree)

fluid formula for electrical burns in 1st 24 hours

4 mls LR x KG x % TBSA Burn (2nd, 3rd, 4th degree) give half the amount in first 8 hours, give the next half in the next 16 hours

Communication Styles

4 overall categories: - nonassertive - assertive - aggressive - passive-aggressive

acute or intermediate phase: goals

48 to 72 hours after injury (may begin as early as 36 hours as fluid shift resolves) Continue assessment maintain respiratory and circulatory support fluid and electrolyte balance GI and renal function nutritional support Prevention of infection burn wound care pain management modulation of the hypermetabolic response early positioning/mobility

Which of the following times or timeframes is most likely associated with stage 1 of burn care? 4 Weeks 7 Weeks 0-14 Days 15 min - 3 Hours 120 Minutes 48-72 hours

48-72 hours (40) Oz and (8) Ball to (70) Guy and (2) Tutu The emergent phase usually lasts 48-72 hours from the time the burn occurred. The beginning of diuresis marks the end of the emergent phase.

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame? 3 days 2 days 7 to 10 days 5 days

5 days Explanation: Acticoat antimicrobial barrier dressings can be left in place for up to 5 days thus helping to decrease discomfort to the client, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.

a nurse is admitting a client who has sustained severe burn injuries in a grease fire. the nurse shades in a diagram indicating the burned surface areas. using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (shaded in areas are the entire left and right leg, and posterior upper and lower back)

54% First, determine the burned areas: 1) Entire right and left leg 2) Entire rear torso Next, refer to the Rule of Nines for estimating body surface area Rule of Nines Head: 9% Torso: 36% total (front 18% & back 18%) Arm 9% each Leg 18% each Perineum 1% Apply the Rule of Nines to this client: Left leg = 18% Right leg = 18% Rear torso = 18% Then total all the burned areas: 18 x 3 = 54%

appropriate urine output for fluid resuscitation in electrical burn injuries

75 - 100 mL / hour

urine output standard for electrical burns

75-100 mls/hr for electrical burn

Histrionic Personality Disorder

Cluster B Craves attention Often sexually promiscuous Emotionally charged Dramatic Rapidly changing feelings Vulnerable/gullible Not diagnosed before 18 y/o May seek tx for somatic s/s, panic attacks, depression

Which of the following clients being treated for anorexia displays assessment values that warrant hospitalization? A 10-year-old whose weight has remained unchanged in spite of a 3-inch growth spurt A 25-year-old whose weight is 70% of ideal and who has a serum magnesium level 1.2 mg/dL A 16-year-old with serum potassium of 3.8 mEq/L and a BP of 98/66 mmHg A 32-year-old with a temperature of 98°F and a pulse rate of 54

A 25-year-old whose weight is 70% of ideal and who has a serum magnesium level 1.2 mg/dL Explanation: Criteria for hospitalization include: acute weight loss, <85% below ideal; heart rate near 40 beats/min; temperature,b <36.1°C; blood pressure, <80/50 mm Hg; hypokalemia; hypophosphatemia; hypomagnesemia. The client with a weight 70% of ideal and magnesium level of 1.2 mg/dL (low) fits the criteria.

Antisocial Personality Disorder (ASPD)

Cluster B Deceitful, with disregard for others' feelings Lack compassion/empathy Charming/manipulative Sense of entitlement Adept at controlling/exploiting others History of violence/criminality Blames others H/O behavior problems prior to age 15 Not diagnosed before age 18 Consider safety of other clients!

schizophrenia definition

A long-term mental disorder that involves a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation.

Mirtazapine (Remeron)

•Helps w/sleep, depression, OCD, anxiety, concentration, memory •Alpha2 antagonist •Increases norepinephrine, serotonin •Used as adjunct to anti-psychotics (for negative symptoms)

Valproate s/e

•Hepatotoxicity (jaundice, abd. pain, n/v, dec. appetite, elevated LFTs) •Pancreatitis, thrombocytopenia •GI (n/v/d, may go away with time) take with food •Wt gain

nursing interventions for depression

•Milieu therapy •Safety •Encourage self-care •Family education •Group therapy •Assertiveness training/conflict resolution

goals of treatment for bipolar disorder

•Minimize episodes •Maximize functional ability •Education •Safety

premenstrual dysphoric disorder (PMDD)

a condition associated with severe emotional and physical problems that are closely linked to the menstrual cycle •Mood swings, sadness, lack of concentration, anxiety, irritability •Lack of energy, appetite changes, sleep disturbances •S/S interfere with functioning

a nurse is admitting a client who is in the manic phase of bipolar disorder. the nurse should plan to make which of the following room assignments for the client? A private room in a quiet location on the unit A semi-private room with a roommate who has a similar diagnosis A private room close to the nursing station A seclusion room until the client's activity level becomes more subdued.

A private room in a quiet location on the unit

A client was abandoned by the parents at age 3, resulting in the client's perception of the world as a hostile place and the subsequent development of rage against men. This statement is an example of what? A biological explanation for the client's depressive disorder. A psychodynamic interpretation of the client's major depressive disorder. A reason the client has become lesbian at the age of 23. A feminist viewpoint of depression.

A psychodynamic interpretation of the client's major depressive disorder. Explanation: Psychodynamic theories postulate that clients with depression have unexpressed and unconscious anger about feeling helpless or dependent on others. Such anger begins in childhood when basic developmental needs are not met. Clients cannot express this anger toward the person or people on whom they feel dependent, so their anger turns inward.

attention-deficit/hyperactivity disorder (ADHD) in adolescents

A persistent pattern of inattention, hyperactivity, and impulsiveness that interferes with functioning (APA, 2013).

antisocial personality disorder diagnostic criteria

A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following: Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure Impulsivity or failure to plan ahead Irritability and aggressiveness, as indicated by repeated physical fights or assaults Reckless disregard for safety of self or others Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another The individual is at least age 18 years. There is evidence of conduct disorder with onset before age 15 years. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 10 mL/hr A urinary output of 100 mL/hr A urinary output of 80 mL/hr A urinary output of 30 mL/hr

A urinary output of 30 mL/hr Explanation: For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).

Disruptive Mood Dysregulation Disorder (DMDD)

a depressive disorder in children characterized by persistent irritability and frequent episodes of out-of-control behavior •Severe irritability/outbursts •Begins before age 10 (easily confused w/ pediatric bipolar disorder)

Which of the following is a characteristic most likely associated with stage 2 of burn care? Transition Phase Symptomatic Stage Subacute Phase Asymptomatic Stage Primary Stage Acute Phase

Acute Phase Acute-angle During the acute phase of burn management, wound care is the primary focus. This phase, which may last for weeks or months, starts with diuresis and ends with wound healing or skin grafting. Bowel sounds return and the patient may need psychosocial support as reality sets in. The patient's laboratory values, especially sodium, potassium, and glucose, should be closely monitored as capillary permeability restores to normal. As the burn wounds begin to heal, encourage the patient to stretch and move as much as possible to prevent painful contractures.

Wellness strategies for BPD pts

Adequate rest, good nutrition, stress management techniques (mindfulness, yoga, relaxation)

After teaching a group of nurses about borderline personality disorder, the leader determines that the education was successful when the group identifies that symptoms typically begin in which age group? Middle-age individuals Young adulthood Adolescence Late adulthood

Adolescence Explanation: Many children and adolescents show symptoms similar to those of BPD, such as moodiness, self-destruction, impulsiveness, lack of temper control, and rejection sensitivity. Because symptoms of BPD begin in adolescence, it makes sense that some of the children and adolescents would meet the criteria for BPD even though it is not diagnosed before young adulthood.

A client taking an antidepressant has experienced a 12-pound weight gain in 1 month as a side effect of the medication. Which of the following are nursing interventions to help this patient with this problem? Select all that apply. Recommend daily exercise. Recommend a nutritionally balanced diet. Remind the patient that weight gain is better than feeling depressed. Reassure the patient that the weight gain is not that significant. Advocate with the physician to consider changing the medication.

Advocate with the physician to consider changing the medication. Recommend a nutritionally balanced diet. Recommend daily exercise. To relieve the side effect of weight gain from an antidepressant, appropriate nursing interventions are to help the client explore a change in medication, promote a nutritionally balanced diet, and recommend regular exercise.

A client comes to the clinic for a follow-up visit. Despite being warm and friendly with the nurse on a previous visit, today the client presents with anger and sarcastic undertones with the same nurse. The client is presenting which behavior commonly seen in borderline personality disorder? Identity diffusion Dichotomous thinking Affective instability Depression

Affective instability Explanation: Affective instability is a rapid and extreme shift in mood and a core characteristic of borderline personality disorder. It is evidenced by erratic emotional responses to situations and intense sensitivity to criticism, perceived slights, or both.

What key term describes "harsh physical or verbal actions intended to harm or injure another"?

Aggression

a nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. while planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? Airway obstruction Infection Fluid imbalance Paralytic ileus

Airway obstruction When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.

The nurse provides care for a client with a new diagnosis of antisocial personality disorder (ASPD). What is the priority intervention for a client with ASPD? Initiating Selective Serotonin Reuptake Inhibitor (SSRI) therapy Administering benzodiazepine medication Making sure the client does not use alcohol or drugs Alteration of cognitive schemas (psychotherapy)

Alteration of cognitive schemas (psychotherapy) Explanation: The priority intervention for individuals with ASPD is to create new and more socially appropriate patters of thinking. The old schemas are challenged and replaced with ways of thinking to live with improved sensitivity toward the needs of others and societal expectations. There will be no long term benefit or change by receiving benzodiazepine medication. Similarly, a SSRI may help some individuals who also experience a concurrent depression, yet their initiation is not a priority. Clients with ASPD are likely to have concurrent substance use patterns however stopping the use of substances is not a priority intervention.

Bulimia Nervosa (BN)

An emotional disorder involving distortion of body image and an obsessive desire to lose weight, in which bouts of extreme overeating are followed by depression and self-induced vomiting, purging, and/or use of laxatives.

The nurse caring for clients with antisocial personality disorder (ASPD) has determined patterns that challenge her capacity to establish a therapeutic relationship with clients with ASPD. Which are challenges to the therapeutic relationship? Select all that apply. An initial bond that is only superficial The use of self-challenge strategies by the client A loss of trust when client is challenged by the nurse A commitment to therapeutic work between sessions Identification of future-oriented goals

An initial bond that is only superficial A loss of trust when client is challenged by the nurse Explanation: In early encounters, the individual with ASPD can establish warm and engaging relationships. In the therapeutic nurse-client relationship, these relationships can break down when the client is challenged to adhere to a policy or when the person is challenged to improve their health or lifestyle patterns. It is not typical for the person with ASPD to offer future-oriented plans. Neither do clients have the level of insight and self-motivation to initiate self-change interventions. Even in helping sessions, ASPD clients have a tendency to offer superficial engagement in therapy, yet fail to follow through with interventions.

Which of the following clinical findings best describes the physical changes typically seen in major depression? Exaggerated Fear of Being Unable to Care for Self Hypersexuality Anergia Hyperactivity Hypervigilance Fear of Gaining Weight

Anergia Anergia is defined by the ongoing lack of energy that patients feel with depression. Research has shown that 97% of patients with depression exhibit this condition

Which of the following clinical findings best describes the mood changes typically seen in major depression? Euphoria Excessive Dieting Delusions Anger and Irritability Anxiety Fear of Gaining Weight

Anger and Irritability Patients that are depressed are unable to cope with stress and end up expressing their frustration as anger. Anger involves a sense of powerlessness over the situation

What term describes "loss of appetite"?

Anorexia The medical complications seen in the eating disorder are of major concern and with anorexia the presence of metabolic and endocrine abnormalities result from the malnutrition associated with starvation.

Carbamazepine

Anticonvulsant good for mixed episodes and mania •Minimal effect on cognition start slowly and take at bedtime

A client has been diagnosed with bipolar disorder. After teaching the client about the different medication classifications used to help stabilize mood, the nurse determines that the teaching was successful when the client identifies which class of medications? Antianxiety Anticonvulsants Antibiotics Anticoagulants

Anticonvulsants Explanation: Several anticonvulsants traditionally used to treat seizure disorders have proved helpful in stabilizing the moods of people with bipolar illness.

Which of the following conditions are SSRIs prescribed for? Erectile Dysfunction Malingering Myoclonus Manic Episode Mental Agitation Anxiety

Anxiety These drugs are used to treat generalized anxiety disorder, social phobia, panic disorder and PTSD.

A nurse is reading a journal article about bipolar disorder and common comorbidities. The nurse demonstrates understanding of the article by identifying which condition as a common comorbidity? Select all that apply. Substance use Eating disorders Schizophrenia Personality disorders Anxiety disorders

Anxiety disorders Substance use Explanation: The two most common comorbid conditions are anxiety disorders and substance use. Individuals with a comorbid anxiety disorder are more likely to experience a more severe course. A history of substance use further complicates the course of illness and results in less chance for remission and poorer treatment compliance. Personality disorders, schizophrenia, and eating disorders are not the most common comorbid conditions.

Cluster C personality disorders (anxious, fearful)

Anxious and fearful 3 types: - Avoidant Personality Disorder - Dependent Personality Disorder - Obsessive Compulsive Personality Disorder

Which of the following measures can be used to cool a burn? Application of ice directly to burn Using cold soaks or dressings for at least 1 hour Wrapping the person in ice Application of cool water

Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? Application of ice Removal of hair Removal of clothing Irrigation of the wound

Application of ice Explanation: Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury. Clothing and hair are removed from perimeter of burned area in an effort to remove course of bacterial contamination. Irrigation of the wound assists in the removal of debris.

In a client with burns on the legs, which nursing intervention helps prevent contractures? Applying knee splints Performing shoulder range-of-motion exercises Hyperextending the client's palms Elevating the foot of the bed

Applying knee splints Explanation: Applying knee splints is one method which can help prevent leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs which is the focus for this individual's treatment and care.

Assertiveness Training

Assertive Communication: Direct Honest Appropriate Respectful Proper context Clarity Learned through: Role modeling Reinforcement Trial and error

priority interventions in burn patients

Assess ABC's. Start 100% O2. Coughing, Bronchospasm, hoarseness (late sign). ABG. Carboxyhemoglobin level. (affinity between carbon monoxide and hemoglobin is over 200 times stronger than it's affinity with oxygen). We want it less than 10%. Facial burns, soot. POX >30% burn will probably need to be intubated even if no visible sign of inhalation injury. The large amount of fluid that these patients will receive will cause edema! (plus if large enough burn they probably did receive an inhale smoke)

A client diagnosed with anorexia nervosa is newly admitted to an in-patient psychiatric unit. When creating the plan of care, which nursing intervention takes priority? Assess and monitor vital signs and lab values. Assess knowledge of selective serotonin reuptake inhibitors used in treatment. Assess early disturbances in parent-child interactions. Assess family issues and health concerns.

Assess and monitor vital signs and lab values. Explanation: The immediate priority of nursing interventions in eating disorders is to restore the client's nutritional status. Major life-threatening complications that indicate the need for hospital admission include severe fluid, electrolyte, and metabolic imbalances; cardiovascular complications; severe weight loss and its consequences. The assessment and monitoring of vital signs and lab values to recognize and anticipate these medical problems must take priority. When the physical condition is no longer life threatening, other treatment modalities may be initiated.

A client's depression is being treated in the community with phenelzine. The client has presented to the clinic stating, "I had a few beers and I'm feeling absolutely miserable." What is the nurse's best action? Assess the client's jugular venous pressure Perform a Mini Mental Status Examination (MMSE) Call an emergency code Assess the client's blood pressure

Assess the client's blood pressure Explanation: Combining phenelzine with beer can precipitate a hypertensive crisis. There is no immediate indication that an emergency code is needed. The client's jugular venous pressure is less likely to be affected and is not a priority for assessment. Performing the MMSE is not a short-term priority.

Which disorder has a persistent pattern of inattention or hyperactivity/impulsivity?

Attention-Deficit / Hyperactivity Disorder These children are highly distractible and unable to handle stimuli. Motor activity is excessive and movements are random and impulsive. It is most often recognized and diagnosed when the child enters school. will show difficulty in performing age-appropriate tasks. They are highly distractible, have a limited attention span and will shift from one uncompleted activity to another. They will also have difficulty in forming satisfactory interpersonal relationships and may appear aggressive or oppositional or become regressive with immature behaviors. These children also have a low tolerance for frustration with excessive levels of energy, activity, and restlessness. They may appear to be fidgety, in constant motion a exhibit a greater incidence of accidents.

Which of the following is an indication for Monoamine Oxidase Inhibitors (MAO-Is) usage? Atypical Depression Neuroleptic Malignant Syndrome Schizotypal Personality Disorder Seizures Avoidant Personality Disorder Bedwetting

Atypical Depression Monoamine oxidase inhibitors are indicated for the treatment of atypical depression. Other reported uses include hypochondriasis, anxiety, bulimia and personality disorders.

Name a disorder that is characterized by impairment in several areas of development, including social interaction skills and interpersonal communication.

Autism Spectrum Disorder ASD is characterized by a withdrawal of the child into the self and into a fantasy world of his or her own creation. They have markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interests. Activities and interests are restricted and may be considered somewhat bizarre.

The nurse 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 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."

Marissa 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 Marissa'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

Emma, age 14, has just been admitted to the psychiatric unit for anorexia nervosa. She is emaciated and refusing to eat. What is the primary nursing diagnosis for Emma? 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 an effort to help the child with mild to moderate intellectual developmental disorder develop satisfying relationships with others, which of the following nursing interventions is most appropriate? a. Interpret the child's behavior for others b. Set limits on behavior that is socially inappropriate c. Allow the child to behave spontaneously, for he or she has no concept of right or wrong d. This child is not capable of forming social relationships

B. Set limits on behavior that is socially inappropriate

Which is a food that might be incorporated into the plan of care for a client diagnosed in the manic phase of bipolar disorder? Broccoli Steak Spaghetti Bananas

Bananas Explanation: For a client who is unable to sit long enough to eat, snacks and high-energy foods that can be eaten while moving should be provided.

fluid resuscitation in burns

Begin IV fluid as soon as possible Two large bore IV's Extension set if possible Thread catheter deep in vessel Suture to secure if necessary Lactated Ringer's LR (Lacated Ringers) is Isotonic. NS (Normal Saline) has a large volume of Chloride. Due to the large volume that the patients will receive, can cause increase in chloride, which can cause acidosis. IO's, burned sites, fluid warmers You can start an IV through burned skin. Securing it might be a problem.

behavior therapy

Behavior therapy interventions focus on reinforcing or promoting desirable behaviors or altering undesirable ones. The basic premise is that because most behaviors are learned, new functional behaviors can also be learned. Behaviors—not internal psychic processes—are the targets of the interventions.

The nurse is assisting a client with an eating disorder to accept their body image and use effective coping skills. Which will the nurse discuss with the client in relation to body acceptance and coping skills?

Being able to cope in healthy ways improves the ability to accept a realistic body image. Explanation: When clients experience relief from emotional distress, have increased self-esteem, and can meet their emotional needs in healthy ways, they are more likely to accept their weight and body image. Coping skills can be learned and honed even if the client's upbringing was less than supportive. Changes in body image result from enhanced coping; they do not cause enhanced coping. Eating disorders have biologic elements to their etiology, but this does not rule out the development of positive coping.

a nurse is caring for a client who has Paranoid Pesonality disorder. which of the findings should the nurse expect? (select all that apply) Believes that others are deceiving him Desires to be the center of attention Views himself as inferior to others Demonstrates a grandiose sense of self-importance Persistently holds onto grudges

Believes that others are deceiving him Persistently hold onto grudges A client who has a paranoid personality disorder believes, without evidence, that others are deceiving him and worries constantly about trusting those that are close to him. A client who has histrionic personality disorder always desires to be the center of attention, has shallow expression of emotions, and demonstrates self-dramatization. A client who has avoidant personality disorder views himself as inferior to others, worries constantly about being criticized, and does not fully engage in new interpersonal relationships. A client who has narcissistic personality disorder has a grandiose sense of self-importance, lacks empathy, and has a sense of entitlement. A client who has a paranoid personality disorder persistently holds onto grudges and finds hidden demeaning meanings in benign remarks.

A patient with severe depression is being treated with medications and is told to increase activity and to exercise at least 4 times a week. Which of the following domains would these nursing interventions address?

Biologic Explanation: Biologic interventions center around education, pharmacologic interventions, and other somatic interventions. Activity and exercise are directly related to the body or somatic experience.

A nurse is caring for a client receiving a tricyclic antidepressant and is monitoring for anticholinergic side effects. Anticholinergic effects include which of the following? Urinary incontinence Hyperactive bowel sounds Moist skin Blurred vision

Blurred vision Explanation: Anticholinergic effects are prominent with tricyclic antidepressants. These include potentiation of central nervous system drugs, dry mucous membranes, warm and dry skin, blurred vision, decreased bowel motility, and urinary retention.

What key term describes an "excessive, insatiable appetite"?

Bulimia Bulimia nervosa is characterized by eating binges typically followed by efforts to purge calories. It is more common than anorexia and is more common in high school and college students with the age of onset typically late adolescence or early adulthood. The medical complications seen in the eating disorder are of major concern. Potassium depletion and hypokalemia are a result of vomiting and laxative or diuretic abuse.

nutirional support in burns

Burn injuries produce profound metabolic abnormalities, and patient with burns have great nutritional needs related to stress response, hypermetabolism, and requirement for wound healing Goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization Nutritional support is based on patient preburn status and % of TBSA burned Enteral route is preferred. Jejunal feedings are frequently used to maintain nutritional status with a lower risk of aspiration in a patient with poor appetite, weakness, or other problems

pain management in burns

Burn pain has been described as one of the most severe forms of acute pain Pain accompanies care and treatments such as wound cleaning and dressing changes Types of burn pain Background or resting Procedural Breakthrough Analgesics: - IV use during emergent and acute phases - Morphine - Fentanyl (used IV or PO usually for pre-procedures and dressing changes bc they are extremely painful) - Other - Role of anxiety in pain - Effect of sleep deprivation on pain - Nonpharmacologic measures

burn injuries are caused by

Burns are caused by: oChemical injury oHeat transfer from one site to another Thermal (includes electrical) oSkin and mucosa of upper airway most common site vRadiation

a nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. which of the following client prescriptions should the nurse realize is rexpected to reduce the clients mania? Fluvastatin Carbamazepine Lorazepam Propranolol

Carbamazepine RATIONALE:-an antiseizure medication and mood stabilizer-prescribed to treat and prevent mania in clients with bipolar disorder

The nursing history and assessment of an adolescent with a conduct disorder might reveal all of the following behaviors except: a. Manipulation of others for fulfillment of own desires b. Chronic violation of rules c. Feelings of guilt associated with the exploitation of others d. Inability to form close peer relationships

C. Feelings of guilt associated with the exploitation of others

antisocial personality disorder treatment

Can only treat s/s Usually don't seek help Poss. antipsychotics, antidepressants, mood stabilizers Non-compliance is big issue

A client with bipolar disorder has been ordered a medication that is classified as an anticonvulsant. Which drug does the nurse know falls within this class of medications? Carbamazepine Lithium Mannitol Methyldopa

Carbamazepine Explanation: Carbamazepine is an anticonvulsant with mood-stabilizing effects. Lithium is a mood stabilizer. Mannitol and methyldopa are not used in the treatment of bipolar disorder.

contraindications for ECT

Cardiac disease compromised pulmonary status h/o brain injury stroke brain tumor anesthesia medical complications

Which of the following is a common complication of an electrical burn injury? Loss of mobility Localized edema Absent bowel sounds Cardiac dysrhythmias

Cardiac dysrhythmias Explanation: Cardiac dysrhythmias and central nervous system complications are common among victims of electrical burns; localized edema, absent bowel sounds, and loss of mobility are not.

Cluster B personality disorders (dramatic, emotional, or erratic)

Dramatic - ASPD may lack emotions 4 types: - Borderline Personality Disorder - Antisocial Personality Disorder - Histrionic Personality Disorder - Narcissistic Personality Disorder

Use of the Nursing Process in the Care of the Patient in the Acute Burn Care—Collaborative Problems and Potential Complications

Heart failure and pulmonary edema Sepsis Acute respiratory failure Visceral damage (electrical burns)

substance induced depressive disorder

Clinical findings of depression that are associated with the use of, or withdrawal from, drugs and alcohol.

3 clusters of personality disorders

Cluster A Cluster B Cluster C

Borderline Personality Disorder

Cluster B - very dependent on others, impulsive - have problems with avoiding impulsive or destructive behavior - seek validation - affective instability - chronic dysphoria or depression - heightened risk-taking behaviors - lack self-identity - affection can change quickly to anger / disappointment - may have co-occurring psychiatric disorders - Splitting (see only in binary choices) (may see someone as ideal one day and awful the next day; no gray areas) - very commonly have self-harm behaviors, like cutting - self-harm threats should be taken very seriously!!!!!!!!!!! - assosciated with a high mortality rate by suicide - pattern of undermining self at the moment a goal is to be realized - possible psychotic like symptoms during times of stress - recurrent job losses, interrupted education, broken marriages - history of physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation

Narcissitic Personality Disorder

Cluster B Expansive mood with grandiose view of self Arrogant/entitled Does not notice effect of actions Constantly needs admiration Requires fidelity/loyalty but does not reciprocate Overly sensitive to criticism/correction

Avoidant Personality Disorder

Cluster C Avoids social situations Desires relationships Extreme fear of rejection/criticism Become isolated May be subject of teasing/disregard Very low self-esteem

Dependent Personality Disorder

Cluster C Constant need for relationships Indecisive/helpless Extreme fear of abandonment May be in abusive relationship H/O trauma possible

cognitive interventions

Cognitive interventions are based on the concept of cognition. Cognition can be defined as an internal process of perception, memory, and judgment through which an understanding of self and the world is developed. Cognitive interventions aim to change or reframe an individual's automatic thought patterns that have developed over time and that interfere with the individual's ability to function optimally. The skills and techniques developed based on cognitive theory result in a new view of self and the environment.

The nurse is planning the inpatient care of a client who has been admitted with major depression. The client's plan of care includes regular exercise, but the client is reluctant to participate due to a lack of energy and motivation. What is the nurse's best action?

Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort Explanation: In general, a good approach is to collaborate with the client to find an agreeable solution. Energy levels do not change in the short term following antidepressant administration. Threatening the loss of privileges is an inappropriate and unnecessary approach. The nurse should not accommodate the client's remaining in bed unless it is a necessity.

The nurse is planning the inpatient care of a client who has been admitted with major depression. The client's plan of care includes regular exercise, but the client is reluctant to participate due to a lack of energy and motivation. What is the nurse's best action? Describe the benefits of exercise to the client and state that privileges will be lost if the client does not participate Teach the client isometric exercises that the client can complete while in bed Arrange for the client to exercise approximately 1 hour after antidepressant administration Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort

Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort Explanation: In general, a good approach is to collaborate with the client to find an agreeable solution. Energy levels do not change in the short term following antidepressant administration. Threatening the loss of privileges is an inappropriate and unnecessary approach. The nurse should not accommodate the client's remaining in bed unless it is a necessity.

What quick assessment technique should the nurse use to assess the percentage of burn injury? Observe the client's level of consciousness Check the client's vital signs Observe the color of the client's wound Compare the client's palm with the size of the burn wound

Compare the client's palm with the size of the burn wound Explanation: A quick technique to assess the percentage of burn injury is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's total body surface area. Observing the color of the client's wound, checking the client's vital signs, and observing the client's level of consciousness determine the client's health status but do not help assess the percentage of burn injury.

The nurse is aware that for some personality disorders, denial of symptoms is common. Which therapeutic approach does the nurse choose to address this denial? Sympathy Compassion Self-disclosure Judgment

Compassion Explanation: Several personality disorders include denial in their cluster of symptoms. These clients do not identify that their disorder interferes with social or occupational functioning, nor do they see their symptoms as others do. The expression of compassion by the nurse is called for to support those individuals who do not have insight into their disorder. Offering sympathy, being judgmental and disclosing personal information are not therapeutic approaches that would challenge the client's denial of their symptoms and still offer caring and support to these individuals.

Which disorder presents with a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated?

Conduct Disorder Childhood onset- is before age 10 and more frequent in boys. These are more likely to develop antisocial personality disorder Adolescent onset- occurs after age 10 and has less physically aggressive behaviors and less disturbed peer relationships. The ratio of boys to girls in this one is lower and they are less likely to develop antisocial personality disorder.

conflict resolution

Conflict resolution is a process of helping an individual or family identify a problem underling a disagreement or dispute and developing alternative possibilities for solving the conflict. Conflict can be positive if individuals see the problem as solvable and providing an opportunity for growth and interpersonal understanding. The nurse may be in the position of teaching family members how to resolve their own conflicts positively. Key elements of any conflict resolution process are collaboration, motivation to seek a solution, and the ability to see the other person's point of view. Conflict resolution strategies are commonly taught to adolescents who are experiencing cyberbullying and to adults in marital or romantic relationships. Nurses are often in leadership positions and use conflict resolution skills to settle employee disputes.

In response to a client's manipulative behavior, the nurse should provide ... Relaxation exercises Reasonable punishment Consistent limits Feedback about behavior

Consistent limits Explanation: Limit setting is the most effective way of dealing with manipulative behavior.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? Document the findings and instruct the client to report numbness of the extremity. Elevate the leg on pillows and reassess the leg in 1 hour. Contact the primary care provider and prepare for an escharotomy. Apply an elastic stocking to the extremity and administer SQ heparin per order.

Contact the primary care provider and prepare for an escharotomy. Explanation: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.

When working with the client with bulimia, the nurse should be aware that the nurse's own feelings and needs may affect care. Feelings that may be aroused in the nurse may include what? Depression Control Anxiety Dependency

Control Explanation: Often, nurses feel the need to offer control for a client who is helpless in controlling food, anxiety, and life. This client should not evoke feelings of depression any more than any other client should. The client is likely to experience an accompanying depressed state. Although anxiety may arise in the nurse, this is not the best answer. The client is likely to be dependent in this hospital setting. Control or rescue issues are more likely to surface in the nurse.

Individuals with anorexia nervosa concentrate on which body cue?

Controlling food intake Explanation: Individuals with anorexia nervosa ignore body cues, such as hunger and weakness, and concentrate all efforts on controlling food intake.

During your assessment of a patient taking Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), which of the following side effects is most likely to be seen? Biliary Tract Inflammation Distant Heart Sounds Blowing Murmur Absent Insulin Production Brittle Nails and Dry Skin Decreased Libido

Decreased Libido Patients commonly complain of decreased sexual desire (decreased libido), as well as an inability to reach sexual climax (anorgasmia)

Which of the following clinical findings best describes the physical changes typically seen in major depression? Normal appetite Acceptance of Oneself Decreased Libido Disorganized Thinking Exaggerated Fear of Being Unable to Care for Self Paresthesias

Decreased Libido A decrease in a patient's sex drive or libido occurs in some individuals. Several factors could influence a patient's libido, such as medication side effects, deficiency of neurotransmitters, or hormonal disturbances.

Which of the following is most likely an indication for Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)? Acute Pancreatitis Schizotypal Personality Disorder Depression CHF Schizoid Personality Disorder Gastroenteritis

Depression This drug is used for its antidepressant properties in patients with major depressive disorder

Which of the following conditions are SSRIs prescribed for? Alcoholism Hypomania Schizophrenia Psychosis Depression Sexual Dysfunction

Depression SSRIs are frequently used to treat various forms of depression.

Which of the following is most likely an indication for Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)? Lymphatic Cancer Pneumonia Diabetic Peripheral Neuropathy Rhabdomyolysis Pulmonary Embolism Pseudogout

Diabetic Peripheral Neuropathy The SNRI duloxetine is indicated for diabetic peripheral neuropathy and related neuropathic pain.

a nurse is planning discharge for a client who has Borderline Personality disorder. which of the following interventions should be included for this client? Dialectical behavior therapy Behavioral contract Bibliotherapy Safety plan

Dialectical behavior therapy Rationale: Dialectical behavior therapy is appropriate for the treatment of clients with borderline personality disorder and is often a part of the discharge plan.

Cultural brokering

Differences in cultural values and languages among patients and health care organizations contribute to feelings of powerlessness. For example, immigrant families, migrant farm workers, people who are homeless, and people who need to make informed decisions under stressful conditions may be unable to navigate the health care system. The nurse can help to resolve such conflicts through cultural brokering, the act of bridging, linking, or mediating messages, instructions, and belief systems between groups of people of differing cultural systems to reduce conflict or produce change. For the "nurse as broker" to be effective, the nurse establishes and maintains a sense of connectedness or relationship with the patient. In turn, the nurse also establishes and cultivates networks with other health care facilities and resources. Cultural sensitivity enables the nurse to be aware of and sensitive to the needs of patients from a variety of cultures. Cultural competence is necessary for the brokering process to be effective.

A client with a personality disorder is upset and calls the nurse a "stupid cow." Which is an effective initial response to this client's behavior? Discuss displacement of anger and set limits. Report the behavior to the health care provider so that consistency and consequences can be followed. Walk away from the client. Demonstrate empathy by reaching out to touch the client.

Discuss displacement of anger and set limits. Explanation: It is important to maintain open and clear lines of communication. The nurse should calmly set limits for the client's inappropriate expressions of anger. The client may view touch as a threat. Reporting the behavior to the health care provider would not be an initial response to the client's anger. Walking away and leaving the client does not help the client to learn to recognize anger without losing control.

Which of the following features is most likely present in a patient with attention deficit hyperactivity disorder? Anergia Blurred Vision Slow Cognitive Decline Aphasia Apraxia Disruptive

Disruptive Disruption-eruption Patients with ADHD can be disruptive, especially in social situations. For example, a school-aged child may cause disruptions in the classroom, blurt out answers without being called on, or interrupt others before they are finished speaking

DSM 5 criteria: BPD

Distressed/frantic to avoid abandonment Relationships based on devaluation/idealization Unstable self-image Impulsive/disruptive behavior patterns Recurring SI/threats of self-harm Affective instability Feelings of emptiness/perceived abandonment Misplaced/uncontrolled anger Periods of paranoia/dissociation

Which of the following is most likely associated with stage 2 of a burn? Foot Drop Injury to Return of Capillary Permeability Cardiac Muscle Injury Injury to Nerves, Bone, and Blood Vessels Diuresis to Near Wound Closure Wound Closure to Return of Optimal Level

Diuresis to Near Wound Closure Die-rocket Near Wound Closure Fluid mobilization results in diuresis and the patient becomes less edematous. Necrotic tissue surrounding the wound sloughs off as fibroblasts begin the process of forming granulation tissue. Partial-thickness burn wounds will heal within 10-21 days as long as kept moist and free of infection. However, full-thickness burn wounds require the surgical excision of burn eschar and application of skin grafts for healing.

lithium interactions

Diuretics - encourage 1.5-3L of fluid a day but caution if pt is losing too much sodium (sweat, frequent diarrhea, polyuria ect) this inhibits lithium excretion. Can lead to toxicity. NSAIDs- concurrent use increases renal abosorption and can lead to toxicity. (Aspirin as a mild analgesic is ok) Anticholinergenics (antihistamines and antidepressants) - combined use can lead sodium imbalances which result in toxicity.

A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as: Broken epidermis that is weeping. Dry and pale white. Reddened; blanches with pressure. Blistered with a mottled red base.

Dry and pale white. Explanation: The wound appearance for a full-thickness burn would be dry, pale white, leathery, or charred.

Which of the following SNRIs is indicated for diabetic peripheral neuropathy? Bupropion Sumatriptan Pregabalin (Lyrica) Fluconazole Duloxetine Buspirone

Duloxetine Duloxetine is used to treat peripheral diabetic neuropathic pain, and can also used for depression. Other indications for this drug include anxiety, chronic pain and fibromyagia. This drug has a greater effect on NE reuptake inhibition

A 35-year-old client with bipolar disorder has a history of discontinuing medication when feeling well and then becoming manic again. During the client's last episode of mania, the client lost several thousand dollars in risky investments. Which intervention will be most helpful in achieving medication adherence? Point out that each time the client stops taking medication, the client becomes manic again. Remind the client that the client owes it to the client's spouse and children to stay well. Ensure that a family member takes responsibility for administering medications. During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse.

During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse. Explanation: To help link the importance of taking medication with relapse prevention, the nurse lists target symptoms and identifies signs of imminent relapse. The nurse engages in problem solving with the client about early management of symptoms so severity does not increase.

Which disorder is characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode? Cyclothymic disorder Hypomania Dysthymic disorder Seasonal affective disorder

Dysthymic disorder Explanation: Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode. Cyclothymic disorder is characterized by 2 years of numerous periods of hypomanic symptoms that do not meet the criteria for bipolar disorder. Seasonal affective disorder occurs in the winter or spring. Hypomania is a period of abnormally and persistently elevated, expansive, or irritable mood lasting 4 days.

lithium toxicity signs / ranges

Early Indication 1.5 or less slurred speech lethargy,. diarrhea, tremors, weakness or polyuria. Advanced Indications: 1.5 -2 mental confusion, sedation, coarse tremors, ongoing GI Distress/diarrhea Withold the Medication Severe Toxicity 2-2.5 Extreme polyuria, tinnitus, giddy, jerking, blurred vision, ataxia, severe hypotension, stupor, coma, seizures 2.5 or greater leads to rapid progression of symptoms can be fatal. Hemodialysis may be necessary.

Which of the following features is most likely present in a patient with attention deficit hyperactivity disorder? Apraxia Easily Distracted Urinary Frequency and Urgency Amnesia Abnormal Pupils Drowsiness

Easily Distracted Easily Distracted by Easy-button Patients with ADHD have a very limited attention span and are easily distracted from the task at hand

What term describes "a parrot-like repetition, by an individual?

Echolalia Vocalization tics may be curse words that create problems in the classroom as well as in the home environment. The treatment of choice is determined by the amount of interference in daily living that the vocalizations and tics cause. Although psychopharmacology is not the first choice of treatment neuroleptic medication such as Haldol and Orap have been used successfully to control vocalizations and tics.

A client with a diagnosis of bipolar disorder is described by a family member as "flip-flopping between being happy and loving to irritable and hostile." Which characteristic symptoms of this disorder is the family member referring to? Manic episode Emotional lability Grandiosity Euthymic mood

Emotional lability Explanation: Emotional lability is alterations in moods with little or no change in external events. It is a term used for the rapid shifts in moods that often occur in bipolar disorder.

A client diagnosed with schizoid personality disorder is described by family members as what? Emotionless and a loner Nervous and fearful Dramatic and emotional Tired and sad

Emotionless and a loner Explanation: A client diagnosed with schizoid personality disorder is described by family members as lacking emotion and a loner, not dramatic and emotional, nervous and fearful, or tired and sad

A client who has experienced the recent loss of an infant child and recent immigration to the United States is admitted to the inpatient psychiatric unit with severe symptoms of depression. The client has expressed thoughts of suicide. Which is the nurse's priority intervention for this client? Encouraging attendance at group cognitive-behavioral therapy on the unit. Exploring the grief and loss issues concerning the baby's death. Encouraging the client to express feelings of isolation following the recent immigration. Ensuring that the client is not permitted to use anything that would be potentially dangerous.

Ensuring that the client is not permitted to use anything that would be potentially dangerous. Explanation: Although grief, loss, and isolation may be influencing the client's depressed state, the priority intervention is to prevent self-harm. All the interventions listed are appropriate, but ensuring safety from potential danger is the priority.

Intermittent Explosive Disorder (IED)

Episodes of aggressiveness that result in assault or destruction of property characterize people The severity of aggressiveness is out of proportion to the provocation. The episodes can have serious psychosocial consequences, including job loss, interpersonal relationship problems, school expulsion, divorce, automobile accidents, or jail. This diagnosis is given only after all other disorders with aggressive components (e.g., delirium, dementia, head injury, BPD, ASPD, substance use) have been excluded. Little is known about this disorder, but it is a more common condition than previously thought. Aggression is a destructive behavior that imposes a considerable burden on individuals and society. In clinical settings, recurrent problematic aggression is identified as IED. Intermittent explosive disorder is associated with significantly more aggression than are BPD or ASPD alone.

Which of the following SSRIs is most likely to be used for post-stroke cognitive recovery? Varenicline Bupropion Escitalopram Milnacipran Mirtazapine Venlafaxine

Escitalopram Escitalopram has a wide variety of uses, and is indicated for cognitive recovery post-stroke. It can also be used for depression and anxiety treatment

a nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. the nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? BP Heart rate Urine output Weight

Heart rate When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.

A nursing student learning about mood disorders correctly identifies which of the following to mean exaggerated feelings of well-being? Expansiveness Euphoria Irritability Paranoia

Euphoria Explanation: An elevated mood can be expressed as euphoria, which is exaggerated feelings of well-being or elation. Examples include feeling high, ecstatic, and on top of the world. An expansive mood is characterized by lack of restraint in expressive feelings. Paranoia is rooted in suspicions about others, or delusions of persecution. For some, an irritable mood is feeling easily annoyed and provoked to anger, especially when their wishes are challenged or thwarted.

Which of the following clinical features is most common among patients with bipolar disorder in a manic phase? Decreased Libido Euphoric Mood Paresthesia Syncope Constipation Blindness

Euphoric Mood When patients are manic, there is euphoria and elation. This person appears to be on a continuous "high." With this said, the patient's mood is always subject to frequent variation.

The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder? Excessive exercise Moist skin Tachycardia Wearing tight-fitting clothing

Excessive exercise Explanation: Clients with eating disorders utilize excessive exercise to burn as many calories as possible. Medical complications of eating disorders include bradycardia, hypotension, and dry, cracking skin due to dehydration. The client will wear loose-fitting clothes to hide his or her body.

On admission to the psychiatric unit, a client is dressed in a red leotard and exercise bra, with an assortment of chains and brightly colored scarves on the client's head, waist, wrists, and ankles. The client's first words to the nurse are, "I'll punch you, munch you, crunch you," as the client dances into the room, shadow boxing. The client shakes the nurse's hand and says cheerfully, "We need to become better acquainted. I have the world's greatest intellect, and you are probably an intellectual midget." How can the nurse document the client's mood? Suspicious and paranoid. Anxious and unpredictable. Expansive and grandiose. Belligerent and blunted.

Expansive and grandiose. Explanation: The client is demonstrating an expansive and grandiose mood state. Although the client also exhibits aspects of belligerence, the client does not have a blunted affect. The client is not demonstrating anxious or unpredictable behavior, suspicion, or paranoia.

A nurse in a mental health facility is caring for a young adult client. History Client admitted to facility by court order for evaluation following arrest for driving under the influence of alcohol, disorderly conduct, and resisting arrest. Client has history of criminal behavior since they were a teenager, including shoplifting and possession and sale of marijuana. Client spent 6 months in a juvenile detention facility at 17 years old following auto theft. Client has no permanent home after being evicted for failure to pay rent. They are currently employed by a food delivery service. Client is estranged from family members. Nurses Notes Day 1: Client oriented, angry with rigid posture, restless and pacing around the room. Client reports they do not like being "locked up with crazies." They also state, "That car wreck was not my fault! That judge just has it out for me." Client refuses to go to dining room for dinner. States, "I'm not sitting down with a bunch of nuts. Bring my food to me!" Day 2: Client attempts to intimidate other clients during group therapy. Snickers when other clients share their feelings. When confronted about their behavior, client refers to the other group members as "losers." And states, "They don't have a clue what life is like." Client works out in the gym with free weights followed by running on treadmill. Requests to run outside on the grounds, states "running helps me not feel so angry." Which of the following findings in the client's medical record are consistent with antisocial personality disorder? Click to highlight the findings that are consistent with antisocial personality disorder. To deselect a finding, click on the finding again. Experience with legal system since teenage years Adhering to financial responsibilities Employment status Relationship with family Acceptance of responsibility Substance use Compassion toward others Rechanneling anger with physical activity

Experience with legal system since teenage years Adhering to financial responsibilities Relationship with family Acceptance of responsibility Substance use Compassion toward others

a nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. the nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity? Experiencing diarrhea Exercising moderately Increasing sodium intake Drinking green tea

Experiencing diarrhea

behavioral components of communication for assertiveness training

Eye contact Body language/gestures Distance Voice Timing Facial expressions Listening

priority care issues for bipolar disorder: family support

Family support •Emotional merry-go-round •Deal with consequences of manic behavior (legal, financial issues, sexual infidelities)

A client has recently had a change in job position and a nurse asks the client how they like the new job. The client states, "Oh everything is great. I can really see myself going far in this new position." However, the client's voice was monotone and their face was nearly absent of affective expression. How does the nurse describe the client's facial expression? Inappropriate Flat Constricted Blunted

Flat Explanation: Several terms are used to describe affect, including flat, which is the absent or nearly absent affective expression; inappropriate, which is the discordant affective expression accompanying the content of speech or ideation; blunted, which is significantly reduced intensity of emotional expression; and restricted or constricted, which is mildly reduced in the range and intensity of emotional expression.

Which of the following clinical features is most common among patients with bipolar disorder in a manic phase? Metallic taste Night Sweats Flashes of Light Blindness Bitemporal Hemianopsia Flight of Ideas

Flight of Ideas They have a heightened sense of perception and cognition, but these patients are easily distracted. Thinking is flighty, with a rapid flow of ideas and disjointed logic.

Which of the following best describes a patient with attention deficit hyperactivity disorder? Enjoys Social Isolation Vivid Hallucinations grandiose Incomplete Tasks Isolated Quiet

Incomplete Tasks Incomplete Task-list Individuals with ADHD have difficulty completing tasks and will often fail to complete chores, homework, or other obligations in the workplace. It is important to note that failure to complete tasks is not a result of rebellion or disobedience, but rather inattention.

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client Fluid resuscitation Strict intake and output Prevent infection Endotracheal tube placement

Fluid resuscitation Explanation: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.

Which of the following SSRIs is most likely to be used for panic disorder? Buspirone Milnacipran Duloxetine SSRIs Are Not Indicated for Panic Disorder Fluoxetine Bupropion

Fluoxetine Fluoxetine is indicated for depression. This medication can also be used for OCD, bulimia and panic disorder

rehabilitation phase of burns: focus

Focus is on: - wound healing - psychosocial support - self-image - lifestyle - restoring maximal functional abilities so that the patient can have the best quality life, both personally and socially

Which type of burn injury requires skin grafting? Superficial Deep partial-thickness Full-thickness Superficial partial-thickness

Full-thickness Explanation: A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

Burns: fluid and electrolyte shifts emergent phase

Generalized dehydration Reduced blood volume and hemoconcentration Decreased urine output Trauma causes release of potassium into extracellular fluid: hyperkalemia Sodium traps in edema fluid and shifts into cells as potassium is released: hyponatremia Metabolic acidosis

predisposing factors of adhd

Genetics—Studies have shown that there is strong evidence of genetic influence in the etiology of ADHD. Many studies show that parents who demonstrated symptoms of hyperactivity during their own childhood have children who are hyperactive. Biochemical: dopamine, norepinephrine, and possibly serotonin. Dopamine is thought to play a role in sensory filtering, memory, concentration, controlling emotions, locomotor activity and reasoning, Norepinephrine is thought to play a role in the ability to perform executive functions such as analysis and reasoning and in the cognitive alertness essential to processing stimuli and sustaining attention and thought. Anatomical influences--Recent studies has shown alterations in the frontal lobes, basal ganglia, caudate nucleus, and cerebellum Prenatal, perinatal & postnatal factors—Prematurity, low birth weight and perinatal asphyxia and low apgar scores Environmental Influences—The big one is toxic lead exposure. Dietary there has been no correlation between high sugar diets, however food-additive allergies is still being studied.

The nurse is talking with family members of a client with an eating disorder that state, "What is the best way for us to show support during this time?" Which will the nurse inform the family as the most supportive action they can take? Focus on food intake, calories, and weight. Give positive reinforcement for weight gain. Give the client emotional support. Give the client unlimited access to foods that the client enjoys.

Give the client emotional support. Explanation: The nurse explains to family and friends that they can be most helpful by providing emotional support, love, and attention. They can express concern about the client's health, but it is rarely helpful to focus on food intake, calories, and weight. Structure around eating is more therapeutic than providing constant, unlimited access to food. Positive reinforcement can be beneficial but this must be framed in a context of support, love, and attention in order for the client to accept it.

A client in the clinic appears to have elevated self-esteem, is more talkative than usual, and is easily distracted. This client is exhibiting symptoms of what? Depression Anxiety Anorexia Grandiosity

Grandiosity Explanation: Grandiosity is elevated self-esteem and may range from unusual self-confidence to grandiose delusions. Speech is pressured; the person is more talkative than usual and at times is difficult to interrupt. There is often a flight of ideas or racing thoughts.

Which of the following clinical findings best describes the mood changes typically seen in major depression? Euphoria Magical Thinking Excessive worrying Fear or Aversion Normal appetite Guilt

Guilt Patients can feel guilty about being depressed, guilt related to a loss, or guilt for something in the past. Guilt can be a powerful emotion that can lead a patient to self-doubt or even self-harm. Encourage the patient to talk about their feelings.

how much of the fluid volume is given in the first 8 hours? how much next 16 hours?

Half volume given in first 8 hours, and second half over next 16 hours.

rule of nines description

Head: anterior 4.5%, posterior 4.5% chest: anterior 9%, posterior 9% abdomen: anterior 9%, posteior 9% left arm: anterior 4.5%, posterior 4.5% right arm: anterior 4.5%, posterior 4.5% genitals: 1% left leg: anterior 9%, posterior 9% right leg: anterior 9%, posterior 9%

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. Oxygen saturation Skin turgor Percentage of meals eaten Hourly urine output Daily weights

Hourly urine output Daily weights Skin turgor Explanation: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Skin turgor is a sign of fluid loss (dehydration). Percentage of meals eaten, and oxygen saturation would not be reliable indicators of fluid volume status in the client.

Which of the following features is most likely present in a patient with attention deficit hyperactivity disorder? Suicidal Ideation Leg Cramps Tachypnea Syncope Hyperactivity Extreme Thirst

Hyperactivity Hyperactive Hiker Patients with ADHD may display symptoms of hyperactivity. This can include an inability to sit still without fidgeting, excessive talking, and difficulty with tasks involving patience and waiting.

Which behavior is the priority concern as the nurse begins a care plan for a client in the manic phase of bipolar disorder? Grandiose thinking and poor concentration Insulting, provocative behavior directed at staff Bizarre, colorful, inappropriate dress Hyperactivity, dismissing meals, and sleep disturbance

Hyperactivity, dismissing meals, and sleep disturbance Explanation: Safety needs are always the first priority in care planning. A client who has not eaten or slept for several days and has been extremely hyperactive may be at risk for exhaustion and malnutrition and the implications of those states. Although thought disorder, expansive mood, and dress are important assessment information, priority interventions must center on the basic needs of hyperactivity, dismissing meals, and sleep disturbance.

a nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. which of the following laboratory results should the nurse expect? Metabolic alkalosis Hypervolemia Hyperkalemia Low hemoglobin

Hyperkalemia The nurse should expect a client who has a burn injury to experience hyperkalemia due to the release of potassium from damaged cells.

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? Hypokalemia Hypernatremia Hypercalcemia Hyperkalemia

Hyperkalemia Explanation: Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. During burn shock, serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. Hyponatremia may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hyperkalemia. Hypocalcemia. Hypernatremia. Hypoglycemia.

Hyperkalemia. Explanation: Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

During your assessment of a patient taking Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) which of the following side effects is most likely to be seen? Flaccid Bullae on Skin Gower Sign Bradycardia Alopecia Heart Failure Hypertension

Hypertension Hypertension is a side effect of SNRIs, which is attributed to the increased circulating amounts of NE.

a nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping strategies. which of the following statements by the clients indicate adaptive coping? (select all that apply) "I exercise aerobically three times a day for 30 minutes at a time." "I get 7 hours of sleep at night by skipping afternoon naps." "I think about being on my favorite beach vacation when I get anxious." "I tense and release my muscles, starting with my feet." "I see the glass as half-full when it starts looking empty."

I get 7 hours of sleep at night by skipping afternoon naps I think about being on my favorite beach vacation when i get anxious I tense an release my muscles starting with my feet I see the glass as half full when it starts looking empty

a nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. which of the following responses by the nurse is therapeutic? "Everyone feels better after showering." "You must be getting better. You look great!" "I see you have done some grooming today." "Why are you all dressed up today? Is it a special occasion?"

I see you have done some grooming today

Which of the following medications is associated with stage 1 of burn care? Glyburide and Glipizide (2nd Generation Sulfonylureas) Wet Sterile Dressing Protein Limitation Replace Potassium (K+) IV Fluid Replacement No Dextrose or Lactated Ringers

IV Fluid Replacement Fluids being Replaced by IV Patients with 15% TBSA or more will need at least two large bore IV access sites for infusing large volumes of fluid (refer to the Picmonic on "Rules of 9s"). After calculating the patient's fluid needs using the Parkland (Braxton) formula, crystalloid solutions (Lactated Ringer's) or colloidal solutions (albumin) are infused as scheduled. Colloidal solutions are recommended after the first 12-24 hours postburn when capillary permeability returns to normal and the fluid stays in the vasculature for circulation. The rate of fluid administration is titrated hourly based on patient response such as urine output or vital signs.

A child tips a pot of boiling water onto his bare legs. The mother should: Avoid touching the burned skin and take the child to the nearest emergency department. Liberally apply butter or shortening to the burned areas. Immerse the child's legs in cool water. Cover the child's legs with ice cubes secured with a towel.

Immerse the child's legs in cool water. Explanation: The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage.

Which of the following features is most likely present in a patient with attention deficit hyperactivity disorder? Leg Cramps Sweating Suicidal Ideation Aphasia Constipation Impulsiveness

Impulsiveness Impulsive M-pushing Individuals with ADHD exhibit impulsive, unpredictable behavior. Impulsivity is especially noticeable when compared to other individuals of the same developmental level.

What key term describes "the urge or inclination to act without consideration to the possible consequences of one's behavior"?

Impulsivity

splitting

In BPD, a defense mechanism in which the person views the world in absolutes, alternately categorizing people as all good or all bad; also used to describe a person manipulating one group against another.

Which of the following features is most likely present in a patient with attention deficit hyperactivity disorder? Psychomotor Retardation Slow Cognitive Decline Morning Stiffness Inattention Leg Cramps Amnesia

Inattention Inattentive N-not-paying-attention Difficulty paying attention, or inattention, is a predominant trait in these patients. Individuals with ADHD often have difficulty completing tasks and are easily distracted

What mechanism of action or pharmacological action is best associated with Monoamine Oxidase Inhibitors (MAO-Is)? Acts on BZ1 GABA receptor Increase Levels of Amine Neurotransmitters Inhibits Reuptake of Serotonin and NE GABA Analog Block Dopamine Receptors Increase Frequency of Cl- Channel Opening

Increase Levels of Amine Neurotransmitters MAO-Is inhibit the activity of monoamine oxidase, preventing the breakdown of monoamine neurotransmitters and thereby increasing the availability of serotonin, NE, and dopamine.

Homeostasis is disrupted: ____________ capillary permeability, diffusion of vascular components into extravascular tissue, imbalance of electrolytes and decrease blood volume.

Increased

cognitive schemata of BPD

Individuals with BPD develop dysfunctional beliefs and maladaptive schemata early in life, leading them to misinterpret environmental stimuli continuously, which, in turn, leads to rigid and inflexible behavior patterns in response to new situations and people. Because those with BPD have been conditioned to anticipate rejection and disappointment in the past, they become entrenched in a pattern of fear and anxiety regarding encountering new people or situations. They have fears that disaster is going to strike at any minute. The work of cognitive therapists is to challenge distortions in thinking patterns and replace them with realistic ones.

Which of the following clinical findings best describes the cognitive changes typically seen in major depression? Visual Hallucinations Normal appetite Hemineglect Disorganized Thinking Paranoia Ineffective Problem Solving

Ineffective Problem Solving Because of the lack of motivation and the decrease ability to manage stress, depressed patients find it hard to problem solve. Issues go unresolved, which can add to guilt or feelings of worthlessness.

What mechanism of action or pharmacological action is best associated with Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)? Decoy TNF- Alpha receptor Inhibits Thyroid Peroxidase Inhibits Platelet Aggregation Alpha-Blocker Beta Agonist Inhibits Reuptake of Serotonin and NE

Inhibits Reuptake of Serotonin and NE The mechanism by which SNRIs work by inhibiting the reuptake of the neurotransmitters serotonin and norepinephrine. This leads to an increase in neurotransmission by increasing the availability of extracellular concentrations of serotonin and norepinephrine.

Which of the following is a characteristic most likely associated with stage 1 of a burn?

Injury to Return of Capillary Permeability Injured Returning to Caterpillar As quickly as 20 minutes after the burn occurs, injury to the capillaries can cause major fluid and electrolyte shifts from the vasculature into the interstitial tissues. The primary concern is hypovolemic shock, as the vascular fluids move into interstitial spaces (second-spacing) and areas that normally have no fluid (third-spacing), leading to vascular volume loss. Examples of third-spacing include blisters and edema. Capillary permeability is restored by adequate fluid replacement. As interstitial fluid gradually returns to the vascular space, edema disappears and diuresis begins.

During your assessment of a patient taking Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), which of the following side effects is most likely to be seen? Nutmeg Liver Koplik Spots Gower Sign Bradycardia Insomnia Heart Failure

Insomnia The side effect of SNRI associated insomnia is believed to be caused by increased circulating NE.

a nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. which of the following is the priority action the nurse should take? Insert an indwelling urinary catheter. Inspect the mouth for signs of inhalation injuries. Administer intravenous pain medication. Draw blood for a complete blood cell (CBC) count.

Inspect the mouth for signs of inhalation injuries. Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time.

What disorder includes both intellectual and adaptive functioning deficits in conceptual, social and practical domains?

Intellectual Developmental Disorder frequently called developmental disability. It must include both the cognitive as well as the functionality component.

Evaluation: BPD

Is patient safe? Has self-injurious behavior decreased? Have communication skills increased? Interpersonal relationship changes? Improved self-care

Which of the following medications is associated with Monoamine Oxidase Inhibitors (MAO-Is)? Trifluoperazine Fluoxetine Desipramine Duloxetine Clomipramine Isocarboxazid

Isocarboxazid Isocarboxazid is a non-selective MAO-I drug indicated for depression, anxiety and panic disorders.

a nurse is monitoring the fluid replacement of a client who has sustained burns. the nurse should administer which of the following fluids in the first 24 hr following a burn injury? Dextrose 5% in water Dextrose 5% in 0.9% sodium chloride 0.9% sodium chloride Lactated Ringer's

Lactated Ringer's Lactated Ringer's is used in the first 24 hr following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.

A nurse is developing a plan of care for a client with bipolar disorder. When preparing to administer medications, which agent would the nurse anticipate as being prescribed as the mainstay of pharmacotherapy? Select all that apply. Lamotrigine Fluoxetine Lithium carbonate Divalproex Carbamazepine

Lithium carbonate Divalproex Carbamazepine Lamotrigine Explanation: The mainstays of pharmacotherapy for bipolar disorder are mood-stabilizing drugs, including lithium, divalproex, carbamazepine, and lamotrigine. Antidepressants, such as fluoxetine, are not recommended in those with bipolar depression because of a risk of switching to mania.

A client is prescribed lithium to treat mania. The client also has a history of hypertension for which the client takes lisinopril and hydrocholorothiazide. When monitoring this client, the nurse would be especially alert for signs and symptoms of which condition? Hypernatremia Hypokalemia Lithium toxicity Hypertensive crisis

Lithium toxicity Explanation: Lisinopril is an ACE inhibitor; hydrochlorothiazide is a thiazide diuretic. Both drugs interact with lithium to increase serum lithium levels. Therefore, the nurse should be especially alert for signs and symptoms of lithium toxicity. Hypokalemia and hyponatremia are possible effects of hydrochlorothiazide when given alone but these wouldn't be as great a concern as the increased risk for lithium toxicity. Hypertensive crisis would be more commonly associated with the use of MAOIs and tyramine foods.

A patient with bipolar disorder is prescribed divalproex. Before initiating this therapy, which laboratory test would be most important for the nurse to obtain? Blood glucose level Liver function tests Renal function tests Clotting function tests

Liver function tests Explanation: For clients who are prescribed divalproex, baseline liver function tests and a complete blood count with platelets should be obtained before starting therapy because of the increased risk for hepatotoxicity. Clotting function tests, renal function tests, and blood glucose level are not needed prior to initiating therapy.

a nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. which of the following factors is the nurse's priority when assessing the severity of the client's burns? Age of the client Associated medical history Location of the burn Cause of the burn

Location of the burn When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to assess the location of the burns that can lead to respiratory distress.

management of shock: fluid resuscitation

Maintain blood pressure of greater than 100 mm Hg systolic and urine output of 30 to 50 mL/hr; maintain serum sodium at near-normal levels LR crystalloid of choice Thermal/Chemical Burn (volume 1st 24 hours) 2 mls LR x KG x % TBSA Burn (2nd, 3rd, 4th degree) Electrical Burn (volume 1st 24 hours) 4 mls LR x KG x % TBSA Burn (2nd, 3rd, 4th degree) Half volume given in first 8 hours, and second half over next 16 hours. Urine output standard o0.5 to 1 ml/kg/hr for thermal/chemical o75-100 mls/hr for electrical burn

A client taking lithium therapy has a serum therapeutic level of 0.8 mEq/L. What priority dietary instruction should the nurse include in the teaching plan? Monitor weight pattern. Switch to a DASH diet. Limit fluid intake to 6-8 oz (180-340 mL) glasses a day. Maintain daily sodium intake.

Maintain daily sodium intake. Explanation: Consistent sodium intake is critical with lithium therapy. A serum therapeutic level of 0.8mEq/L is within the therapeutic range of 0.6-1.2 mEq/L. Fluid intake on lithium therapy should be increased to 2 L/day. Switching to a DASH diet is used to treat HTN. Monitoring weight pattern should be included but it is not the current priority.

a nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. what is the nurse's priority intervention for this client during the resuscitation phase of injury? Initiate fluid resuscitation. Medicate for pain. Insert an indwelling urinary catheter. Maintain the airway.

Maintain the airway. The client is at risk for respiratory obstruction. Using the airway, breathing, circulation approach to client care is the first action the nurse should take to ensure that the client has a patent airway.

A nurse caring for a client with borderline personality disorder (BPD) consistently informs the client of the length of the relationship and routinely prepares the client for termination and the end of hospitalization. Which is the nurse trying to prevent? Maladaptive expression of emotions Depression Mania Poor social skills

Maladaptive expression of emotions Explanation: Informing the client of the length of the relationship as much as possible allows the client to engage in and prepare for termination with a safe and adaptive expression of the emotions attached to the ending of the relationship.

home care instructions for burns

Mental health (PTSD, OCD, Self-image) Skin and wound care (pts with massive burns typically end up with compression stockings - 23 hrs a day) Exercise and activity Nutrition Pain management Thermoregulation and clothing Sexual issues

seasonal affective disorder (SAD)

a mood disorder caused by the body's reaction to low levels of sunlight in the winter months •occurs in winter months or areas with little sunlight; light therapy first-line tx

A client has been diagnosed with major depression. The client reports of waking up during the night and has trouble returning to sleep. A nurse interprets this finding as suggesting what? Hypersomnia Initial insomnia Middle insomnia Terminal insomnia

Middle insomnia Explanation: The most common sleep disturbance associated with major depression is insomnia, which is categorized according to three categories: initial insomnia (difficulty falling asleep), middle insomnia (waking up during the night and having difficulty returning to sleep), and terminal insomnia (waking too early and being unable to return to sleep). Less frequently, the sleep disturbance is hypersomnia (prolonged sleep episodes at night or increased daytime sleep).

alternative therapies for depression

Mindfulness, yoga, meditation, relaxation, herbal supplements

A client with bipolar disorder takes lithium 300 mg 3 times daily. The nurse is educating the client on its use, side effects, and need for compliance. Which outcome does the nurse evaluate that indicates the dose is having the beneficial response for the client? Feels sleepy and less energetic Weight gain of 7 pounds in the last 6 months Minimal mood swings Increased feelings of self-worth

Minimal mood swings Explanation: Mood-stabilizing drugs are used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Weight gain is a common side effect, and fatigue and lethargy may indicate mild toxicity. Inflated self-worth is a target symptom of bipolar disorder, which should diminish with effective treatment.

A client who has been taking lithium for bipolar disorder is admitted to the hospital with the following symptoms: dry mouth, nausea and vomiting, blurred vision, dizziness, and muscle twitching. What should the nurse suspect? Common side effects of the drug Need for an increased dose of medication Moderate lithium toxicity Interaction of lithium with another medication

Moderate lithium toxicity Explanation: Side effects associated with moderate lithium toxicity include severe diarrhea, dry mouth, nausea and vomiting, mild to moderate ataxia, lack of coordination, dizziness, slurred speech, tinnitus, blurred vision, increasing tremors, muscle rigidity, asymmetric deep tendon reflexes, and increased muscle tone.

what to monitor with Sodium Valproate

Monitor serum levels for toxicity, baseline liver functions, then q 6 months

a nurse is caring for a client who has full-thickness burns over 75% of his body. the nurse should use which of the following methods to monitor the cardiovascular system? Auscultate cuff blood pressure. Palpate pulse pressure. Obtain a central venous pressure. Monitor the pulmonary artery pressure.

Monitor the pulmonary artery pressure. Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. The pulmonary artery pressure provides an accurate assessment of the cardiovascular system by detecting changes in both right and left heart pressure which can indicate possible development of pulmonary edema, as well monitor overall fluid status.

Which of the following clinical features is most common among patients with bipolar disorder in a depressive phase? Rapid Speech Extreme Thirst Mood Changes Heat Intolerance Anosmia Dry Mouth

Mood Changes Patients have mood swings, going from episodes of mania to depression. With depressive episodes, feelings of hopelessness, worthlessness and despair can arise. Often, their mood and functioning usually returns to normal between episodes of mania and depression

Which medication classification is considered first-line drug therapy for bipolar disorder? Mood stabilizers Antidepressants Antipsychotics Anticonvulsants

Mood stabilizers Explanation: Mood stabilizers are first-line drugs for bipolar disorders. They stabilize depressive and manic cycles.

at the scene -- inhalation injury

Most common cause of death from a burn in 24 hours is due to inhalation injury Coughing, Bronchospasm, hoarseness (late sign) Facial burns, soot POX 30% or more burns get intubated Once AT hospital: o ABG. Carboxyhemoglobin level. (affinity between carbon monoxide and hemoglobin is over 200 times stronger than it's affinity with oxygen). We want it less than 10%.

a nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. which of the following manifestations should the nurse include as an indication of mild toxicity? Constipation Urinary retention Muscle weakness Hyperactivity

Muscle Weakness Muscle weakness is one of the side effects indicating toxicity levels from lithium.

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? Music therapy may provide reality orientation, distraction, and sensory stimulation. Humor therapy has not proven effective in the management of burn pain. Pet therapy has proven effective in the management of burn pain. Music therapy diverts the client's attention toward painful stimulus.

Music therapy may provide reality orientation, distraction, and sensory stimulation. Explanation: Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain.

Obsessive Compuslive Personality Disorder: DSM 5 Criteria

Must have four or more s/s: Perfectionism that affects task completion Neglects relationships Hoarding Obsesses over values/ethics Doesn't want to assign tasks w/o guarantee it will be completed Stubborn/rigid Obsessed with rules, lists, and staying on schedule

During your assessment of a patient taking Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), which of the following side effects is most likely to be seen? Nausea and Vomiting Bradycardia Flu-like symptoms Coronary Aneurysm Fasciculations Heart Failure

Nausea and Vomiting Nausea and vomiting are typically the most common side effects related to SNRI therapy.

Which would a nurse assess in a client suspected of having paranoid personality disorder? Select all that apply. Need to be in a position of power in a relationship Suspiciousness and guarded behavior Warm, funny demeanor Overly forgiving Outwardly argumentative

Need to be in a position of power in a relationship Suspiciousness and guarded behavior Outwardly argumentative Paranoid personality disorder is characterized by a long-standing suspiciousness and mistrust of people in general. Individuals with these traits refuse to assume personal responsibility for their own feelings, assign responsibility to others, and avoid relationships in which they are not in control of or lose power in. These individuals are suspicious, guarded, and hostile. They are consistently mistrustful of others' motives, even relatives and close friends. Actions of others are often misinterpreted as deception, deprecation, and betrayal, especially regarding the loyalty or trustworthiness of friends and associates. People with paranoid personality disorder are unforgiving and hold grudges; their typical emotional responses are anger and hostility. They distance themselves from others and are outwardly argumentative and abrasive; internally, they feel powerless, fearful, and vulnerable. Their outward demeanor often seems cold, sullen, and humorless.

Which of the following options best describes the pathophysiology of bipolar disorder? Proteasome Dysfunction Posterior Pituitary Stimulated Through Neural Control Neurotransmitter Dysregulation and Genetic Factors Bilateral Amygdala Lesion Growth and Sex Hormone Imbalances Unilateral Amygdala Lesion

Neurotransmitter Dysregulation and Genetic Factors The exact cause of bipolar disorder has yet to be determined, and most theories implicate a combination of neurotransmitter dysregulation and genetic factors. For example, it is believed that there is excess cholinergic transmission during depressive phases, which decreases during mania. Mania may also be associated with excess dopamine and serotonin transmission. Genetic predisposition also likely contributes to the development of bipolar disorder, with multiple different genes currently being investigated.

Which of the following clinical features is most common among patients with bipolar disorder in a manic phase? Somnolence Social Isolation Unilateral Headache Night Sweats Nonstop Physical Activity Unilateral headache

Nonstop Physical Activity In the manic phase, patients have excessive psychomotor activity. They have poor impulse control and their energy seems inexhaustible. They have a diminished need for sleep and may seem very extroverted.

When the nurse is not informed of developmental and cultural issues related to the client's background, which of the following may be expected? The nurse should rely on personal values and standards. The meaning of the client's behavior can be derived from conventional wisdom. The nurse should request a change of assignment. Normal patterns of behavior may be labeled as deviant, immoral, or insane.

Normal patterns of behavior may be labeled as deviant, immoral, or insane. Explanation: If the nurse does not remain culturally sensitive, it is possible that symptoms or behaviors that are observed might be misinterpreted as deviant or immoral. Client behavior is always based upon client history and cultural background; understanding of behavior cannot be obtained simply from conventional wisdom.

Obsessive Compulsive Personality Disorder (OCPD)

Not the same as OCD Affects thoughts, mood, behaviors Lifelong pattern and routine that is very strict. Inflexible lifestyle Desires perfection

community action

Nurses have a unique opportunity to promote mental health awareness and support humane treatment for people with mental disorders. Activities range from being an advisor to support groups to participating in the political process through lobbying efforts and serving on community mental health boards. These unpaid activities are usually outside the realm of a job. However, an important role of professionals is to provide community service in addition to service through income-generating positions.

obsessive-compulsive disorder (OCD) in adolescents

OCD is characterized by intrusive thoughts that are difficult to dislodge (obsessions) or ritualized behaviors that the child feels driven to perform (compulsions).

Which of the following criteria is the most appropriate in the diagnosis of attention deficit hyperactivity disorder? Onset by 6 Years Symptoms > 2 Months Onset by Age 12 Onset by Age 18 Symptoms > 6 Years Symptoms > 12 Months

Onset by Age 12 (12) Dozen Egg Carton Behavioral patterns consistent with an attention deficit and/or hyperactivity disorder will manifest in children by the age of twelve. Typically, ADHD is not identified or diagnosed until the child enters school.

What disorder is characterized by a persistent pattern of angry mood and defiant behavior?

Oppositional Defiant Disorder

A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale? As soon as lunch is over, the client will calm down. Other clients need to be protected from the intrusive behavior. The client's behavior is not an imminent threat to anyone's physical safety. The client needs food and fluids in any way possible.

Other clients need to be protected from the intrusive behavior. Explanation: The nurse must set limits on this intrusive behavior because other clients have the right to be protected. The client is in the manic phase; the client may not calm down after lunch. Answers C and D are incorrect rationale for the situation.

Which of the following is most likely an indication for Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)? Panic and Anxiety Lyme disease Stable Angina MEN 2B (Multiple Endocrine Neoplasia) Lambert-Eaton Syndrome Kluver-Bucy Syndrome

Panic and Anxiety Generalized panic and anxiety disorders are indications for use of the SNRI drug, Venlafaxine.

A client is admitted with a diagnosis of schizotypal personality disorder. Which characteristic would this client exhibit during social situations? Trusting behaviors Dependency needs Paranoid thoughts Perfectionism

Paranoid thoughts Explanation: A schizotypal client would have paranoid thoughts in social situations. They experience acute discomfort in social situations and have cognitive or perceptual distortions.

Cluster A personality disorders (odd/eccentric)

Paranoid—fear that others are seeking to harm/deceive Schizoid—flat affect, detached, uncooperative Schizotypal—ideas of reference, magical thinking, eccentricities interfere with life - they dont usually seek treatment unless they experience more severe symptoms or are made to - medications are more for symptom control, but not curative treatments - usually have a stable course

Which of the following is likely the etiologic basis of the compulsive patterns seen in people with obsessive-compulsive personality disorder (OCPD)? Hyperactivity as a child Substance use within the family Parental overcontrol Lack of nurturing

Parental overcontrol Explanation: The basis of the compulsive patterns seen in OCPD is parental overcontrol and overprotection that is consistently restrictive and sets distinct limits on the child's behavior. Lack of nurturing is not implicated in this disorder, nor is substance use within the family. Clients diagnosed with paranoid personality disorder may have been hyperactive as a child.

a nurse is reviewing medication records for several clients who have bipolar disorder. the nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (select all that apply) Paroxetine Lithium Donepezil Valproate Carbamazepine

Paroxetine Lithium Valproate Carbamazepine

Which of the following SSRI is most commonly used to treat social phobia? Duloxetine Imipramine Paroxetine Milnacipran Desvenlafaxine Venlafaxine

Paroxetine Paroxetine is an SSRI which is indicated for treating social phobia. It is also indicated for use with panic attacks, depression, OCD and PTSD.

emotional vulnerability (BPD)

Person experiences a pattern of pervasive difficulties in regulating negative emotions, including high sensitivity to negative emotional stimuli, high emotional intensity, and slow return to emotional baseline.

unrelenting crises (BPD)

Person experiences pattern of frequent, stressful, negative environmental events, disruptions, and roadblocks—some caused by the individual's dysfunctional lifestyle, others by an inadequate social milieu, and many by fate or chance.

active passivity (BPD)

Person fails to engage actively in solving of own life problems but will actively seek problem-solving from others in the environment, learned helplessness, hopelessness.

self-invalidation (BPD)

Person fails to recognize one's own emotional responses, thoughts, beliefs, and behaviors and sets unrealistically high standards and expectations for self. May include intense shame, self-hate, and self-directed anger. Person has no personal awareness and tends to blame social environment for unrealistic expectations and demands.

Inhibited grieving (BPD)

Person tries to inhibit and overcontrol negative emotional responses, especially those associated with grief and loss, including sadness, anger, guilt, shame, anxiety, and panic.

Which of the following medications is associated with Monoamine Oxidase Inhibitors (MAO-Is)? Lithium Paroxetine Phenelzine Haloperidol Venlafaxine Naltrexone

Phenelzine This is a nonselective MAO-I indicated for major depressive disorder. Phenelzine has been known to be effective in patients who have failed first and second line treatments for depression.

nursing assessment for bulimia nervosa

Physical Assessment •Muscle weakness and fatigue due to hypokalemia •Cardiac arrythymia, palpitations, and/or conduction defects •Fluid and electrolyte imbalance •Tooth enamel erosion •Poor concentration and attention span •Sleep disturbances - Assess knuckles for scarring due to purging Psychosocial Assessment •Cognitive distortions •Knowledge deficits

nursing assessment: anorexia nervosa

Physical Health Assessment •Evaluate the body systems due to starvation. •Determine the patient's weight using a scale and BMI. •History of menses Behavioral Responses •Symptoms of body distortion •Avoidance of conflict and expressing negative emotions such as anger Self-Concept •Determine self-concept and self-esteem. Many patients come across as competent but often feel they are not good enough. Stress and Coping Patterns •Individuals are often coping with stress and anxiety by controlling their eating patterns Social Assessment •Focus should be on family interaction, influence, and peer relationships

Police officers bring a client to the mental health unit for admission. The client had been directing traffic on a busy city street, shouting rhymes such as "to work, you jerk, for perks" and making obscene gestures at cars that came close to the client. When the client's spouse is contacted at work, the spouse reports that the client stopped taking lithium 3 weeks ago and has not slept or eaten for 3 days. With which two features characteristic of the manic phase of bipolar disorder can the nurse identify? Disinhibition and elevated mood Vegetative signs and poor grooming Poor judgment and hyperactivity Increased muscle tension and anxiety

Poor judgment and hyperactivity Explanation: Symptoms of poor judgment (e.g., directing traffic, making obscene gestures at cars) and hyperactivity (e.g., not sleeping or eating) are assessment findings in this scenario that relate to mania. Increased muscle tension and anxiety are symptoms of anxiety disorders, and vegetative signs and poor grooming are notable in major depressive episodes. Although disinhibition and elevated mood can be assessed in the manic phase of bipolar disorder, these symptoms are not described in this scenario.

A visitor comes to see a client who is suicidal. Upon entering the unit, the nurse notices that the visitor has brought the client a can of the client's favorite soda. Which action should the nurse take at his time? Pour the soda into a plastic cup. Ask the visitor to place the soda can at the nurse's desk until he or she leaves. Confiscate the soda can as a restricted item. Ask the visitor not to bring outside items on the unit in the future.

Pour the soda into a plastic cup. Explanation: For clients who are suicidal, staff members remove any item they can use to commit suicide, such as sharp objects, shoelaces, belts, lighters, matches, pencils, pens, and even clothing with drawstrings. The client could tear open the soda can and commit self-harm with the sharp metal edges. The soda itself is not a threat so there is no need to withhold the beverage from the client.

A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client? Elevation of blood pressure and heart rate Partial-thickness burns to hands and wrists Presence of soot around nasal passages Fracture of the fibula with displacement

Presence of soot around nasal passages Explanation: If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed.

at the scene: burns priorities

Prevent injury to rescuer - Stop injury: extinguish flames, cool the burn, irrigate chemical burns Basic Life Support--ABC's, CPR, AED Remove clothes and jewelry - Remove restrictive objects and cover the wound Clean, dry sheets or blankets. (not wet!) - Can loose 5% of body heat in 10 min. Remember Children loose most from head. ‏Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history - How did accident occur? (House fire, MVC, abuse)‏ - Closed space, Noxious fumes? - Chemical, electrical burns? (we will discuss later) ‏ Start IV x2 (LR), burned or unburned skin. No wound care needed, at this time. No food or drinks for the patient Note: Treat patient with falls and electrical injuries as for potential cervical spine injury These should be done at the scene depending on the skill level of the responders.

a nurse in an acute mental health facility is creating a plan of care for a new client who has Histrionic Personality disorder. which of the following is the priority intervetion for the nurse to make? Promote appropriate behavior during group therapy sessions. Encourage client input in the treatment plan. Communicate with the client using concrete language. Demonstrate assertive behavior.

Promote appropriate behavior during group therapy sessions. Rationale: Managing the client's behavior within the group is the priority intervention for the client who has histrionic personality disorder because these clients display extreme attention-seeking behaviors and are often impulsive, which can be extremely disruptive in a group setting with other members.

a nurse in a mental health clinic is caring for a client who has bipolar disorder and a prescription for an antipsychotic medication. the provider and nursing staff suspect the client is not adhering to his medication therapy. which of the following interventions should the staff use to encourage the client's adherence? (select all that apply) Perform mouth checks following the administration of the medication. Provide for once-daily dosing. Use sustained-release forms. Engage the client in conversation following medication administration. Rotate staff that administer the medications.

Provide for once-daily dosing Once-daily dosing of medications simplifies the therapy, making it easier for the client to comply. Use sustained-release forms Sustained-release forms remain in the client's system longer, requiring less frequent dosing. Engage the client in conversation following medication administration If the client is speaking, he will be less likely able to hide the medication in his mouth.

Upon admission, a client with a personality disorder identifies areas of concern for which the client would like help. The nurse is aware that which will most likely be addressed by the health care team? Psychological distress Sexual expression Self-care Budgeting

Psychological distress Explanation: Even though clients with personality disorders have diverse and multiple needs, psychotic symptoms and psychological distress are often the only areas addressed by health-care providers. In many cases, important needs such as self-care, sexual expression and budgeting go unaddressed in the health care system.

Which of the following clinical features is most common among patients with bipolar disorder in a depressive phase? Psychomotor Retardation intention tremor Disinhibited Behavior Hyperirritability Dysuria Blurring of Vision

Psychomotor retardation Patients in the depressive phase of bipolar disorder have physical symptoms. They show psychomotor retardation that is manifested as loss of energy, slow movements, and sleep problems.

A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to the client's feelings of sadness and hopelessness, the nurse would expect to assess what? Increased energy level Psychomotor retardation Increased focus Decreased complaints of pain

Psychomotor retardation Explanation: Associated signs and symptoms of depression include an inability to think or concentrate, increased complaints of pain, psychomotor retardation, and lack of energy and fatigue.

The nurse provides care to clients who have a tendency toward antisocial and criminal behavior. Which term was used in the past to describe people with this disorder? Schizophrenic Irresponsible Habitual criminal Psychopath

Psychopath Explanation: There is a concern that nurses will perpetuate the stigma about people with mental illnesses including personality disorders. The terms psychopath and sociopath are used to describe individuals with antisocial personality disorder. These terms are no longer used in DSM-5 and they carry stigma when used in a way to associate clients with evil and criminality. The terms outlined as distractors may be used in stigmatizing mays but these terms have never formally been used to describe the disorder.

narcissistic personality disorder treatment

Psychotherapy CBT: Reframe perceptions Stop generalizing Mindfulness Poss. meds Family therapy

other major care issues in burns

Pulmonary care Psychological support of patient and family Patient and family education Restoration of function

acute phase of burns concerns:

Pulmonary complications can take 48 hours to develop r/t edema, inhalation injury with sloughing Cardiac overload oFluid reenters the vascular space from the interstitial space oPotassium shifts from extracellular fluid into cells: potential hypokalemia Hemodilution Diuresis begin Hyperthemia

Which of the following clinical features is most common among patients with bipolar disorder in a manic phase? Rapid Speech Bitemporal Hemianopsia Blindness Flashes of Light Metallic taste Urinary Incontinence

Rapid Speech Speech may be rapid, and can be displayed as a continuous flow of accelerated speech. The sentence structure may be disorganized and incoherent, and speech can seem pressured.

A nurse is educating a client with borderline personality disorder to reshape thinking patterns. Which cognitive restructuring technique that would be helpful for this client will the nurse educate the client about? Recognize negative thoughts and replace them with positive ones. Learn to look at situations realistically rather than assuming the worst. Express needs using "I" statements. When negative thoughts begin, tell yourself "stop."

Recognize negative thoughts and replace them with positive ones. Explanation: Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feelings and to replace them with positive patterns of thinking. Thought stopping is a technique to alter the process of negative or self-critical thought patterns. When the thoughts begin, the client may actually say "Stop!" in a loud voice to stop the negative thoughts. Decatastrophizing is a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen. Assertive communication involves using "I" statements.

mood disorders in adolescents

Recurrent disturbances or alterations in mood that cause psychological distress and behavioral impairment. •Children may not express their feelings verbally and are more likely to act out through their behavior. •May exhibit changes in sleep patterns, appetite, activity level, and interests. (Report from parents)

Social media

Using the internet can be helpful to patients, but it also has drawbacks. Some websites can help patients gain insight into their problems through acquiring new knowledge and interacting with others in the privacy of their own surroundings. Web materials and chat groups are variable in quality and accuracy. Nurses should carefully evaluate the quality of the website.

rehabilitation phase of burns

Rehabilitation is begun as early as possible in the emergent phase and extends for a long period after the injury The patient may need reconstructive surgery to improve function and appearance Vocational counseling and support groups may assist the patient

When reviewing the history of a client with antisocial personality disorder, which would the nurse expect to find? Select all that apply. Episodes involving scams for personal gain Lack of remorse for actions Consistent regular work history Detailed plans for future actions Repeated incidents involving assaults

Repeated incidents involving assaults Lack of remorse for actions Episodes involving scams for personal gain Explanation: A client with antisocial personality disorder shows a pervasive pattern of disregard for and violation of the rights of others. History may reveal repeated incidents of physical fights or assaults demonstrating irritability and aggressiveness, repeated failure to sustain consistent work behavior or honor financial obligations, lack of remorse for actions, conning others for personal profit or pleasure, and impulsivity or failing to plan ahead.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: Replace lost fluids and electrolytes. Monitor cardiac status. Prevent renal shutdown. Measure hourly urinary output.

Replace lost fluids and electrolytes. Explanation: After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula.

BPD treatment

Requires interdisciplinary approach Long-term psychotherapy or Dialectical Behavior Therapy (DBT -- focus on problem-solving, self-soothing, distress tolerance, core mindfulness, enhancing motivation, and improving competence) or Mentalization-Based Therapy (MBT -- ability to understand the mental states of onseself with a goal to improve patient's capacity to accurately understand others actions and develop self-awareness skills through a therapeutic relationship) Medications: SSRIs Mood stabilizers Anti-psychotics Sleep meds Anxiolytics

The nurse is attempting to establish a therapeutic nurse-client relationship with a client diagnosed with borderline personality disorder. Which action is most important for the nurse to do to establish this relationship? Tell the client the relationship will last as long as the client wishes. Aggressively confront the client about boundary violations. Limit interactions to 10 minutes at a time. Respect the client's boundaries at all times.

Respect the client's boundaries at all times. Explanation: Clients with borderline personality disorder have issues with boundaries; by respecting the client's boundaries, the nurse can assist the client to develop better boundary control and directly address the most significant characteristic of this personality disorder. Aggression by the nurse is never appropriate or necessary. Ensuring brief interactions has no particular benefit for the client; prolonged engagement can better facilitate rapport. The nurse-client relationship does not carry on after the client's current treatment is complete.

2 types of anorexia nervosa

Restricting- dieting and exercising with no binge eating or misuse of laxatives, diuretics, or enemas Binge eating and purging- binge eating and misuse of laxatives, diuretics, or enemas

Which of the following is a characteristic most likely associated with stage 1 of burn care? Latency Stage Primary Stage Asymptomatic Stage Acute Phase Resuscitative/Emergent Phase Subacute Phase

Resuscitative/Emergent Phase Emergency-lights The emergent (resuscitative) phase of burn management begins at the time of burn injury. The focus of this phase is to address the immediate and potentially fatal problems caused by the burn injury. Assessing the patient's burns will determine the plan of treatment (refer to the Picmonic "Burns Assessment"). The main concerns include hypovolemic shock and edema formation.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? Altered Tissue Perfusion Infection Risk Acute Pain Risk for Impaired Gas Exchange

Risk for Impaired Gas Exchange Explanation: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.

Which would be the priority nursing diagnosis for a client diagnosed with borderline personality disorder (BPD)? Disturbed thought process Risk for self-mutilation Ineffective coping Personal identity disturbance

Risk for self-mutilation Explanation: One of the first diagnoses to consider is risk for self-mutilation because protection of the client from self-injury is always a priority. Disturbed thought process, ineffective coping, and personal identity disturbance are all potential nursing diagnoses, but they would not be the priority.

A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has priority? Risk for suicide related to highly lethal plan Spiritual distress related to conflicting thoughts about suicide and sin Ineffective coping related to inadequate stress management Hopelessness related to recent divorce

Risk for suicide related to highly lethal plan Explanation: Safety is the priority. The overall goals for the client who is suicidal is first to keep the client safe and later to help him or her develop new coping skills that do not involve self-harm. Hopelessness related to recent divorce, ineffective coping related to inadequate stress management, and spiritual distress related to conflicting thoughts about suicide and sin would not be the priority diagnosis for this client.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? Place the client with the head positioned slightly below the rest of the body. Avoid immediate IV fluid therapy. Cover the client with a wet cloth. Roll the client in a blanket.

Roll the client in a blanket. Explanation: When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

Which type of antidepressants are rarely fatal in overdose? SSRIs Atypical MAOIs Tricyclics

SSRIs Explanation: SSRIs are rarely fatal in overdose, but cyclic and MAOI antidepressants are potentially fatal. Prescriptions may need to be limited to only a 1-week supply at a time if concerns linger about overdose.

Which of the following clinical features is most common among patients with bipolar disorder in a depressive phase? Rapid Speech Seductive Behavior Euphoric Mood Bitemporal Hemianopsia Sad Affect Homicidal Thoughts

Sad Affect Just like they can develop mania, patients can also develop depressive episodes. Patients display sadness, crying, and a sense of worthlessness.

Which of the following clinical findings best describes the mood changes typically seen in major depression? Hemineglect Paranoia Hypervigilance Sad Affect Exaggerated Fear of Being Unable to Care for Self Fear of Gaining Weight

Sad Affect Patients typically have a sad affect while depressed. It has been hypothesized that due to the deficiency of the neurotransmitters norepinephrine, serotonin, and dopamine that the brain does not function adequately leading to the patient feeling unhappy.

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? Ligaments, tendons, muscles, and bone are not involved. Skin grafting will be necessary. Pain management will be a challenge. The wound will take up to 3 weeks to heal.

Skin grafting will be necessary. Explanation: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.

Which of the following medications inhibits serotonin reuptake by presynaptic cells? Atypical Antipsychotics Lithium Selective Norepinephrine Reuptake Inhibitors Tricyclic Antidepressants Quetiapine Selective Serotonin Reuptake Inhibitors

Selective Serotonin Reuptake Inhibitors Selective These drugs specifically inhibit the reuptake of the neurotransmitter serotonin by the presynaptic cells. Because of this class of drug's mechanism of action, serotonin stays in the synaptic gap longer than it normally would, and may repeatedly stimulate the receptors of the post-synaptic cell. This class of medications typically requires 4-8 weeks of compliance before they have an effect

A client with major depression is prescribed paroxetine. The nurse develops an education plan for the client based on the understanding that this drug belongs to which class of drugs? Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors Tricyclic antidepressants Serotonin norepinephrine reuptake inhibitors

Selective serotonin reuptake inhibitors Explanation: Paroxetine is a selective serotonin reuptake inhibitor. Serotonin norepinephrine reuptake inhibitors include venlafaxine, nefazodone, duloxetine, and desvenlafaxine. Amitriptyline is an example of a tricyclic antidepressant. Monoamine oxidase inhibitors include phenelzine, tranylcypromine, isocarboxazid, and selegiline.

A psychiatric-mental health nurse is conducting a pharmacology review class for a group of nurses. The topic is antidepressant medications. The nurse determines that the review was successful when the group identifies which class of antidepressant as associated with fewer side effects? Tricyclic antidepressants (TCAs) Selective serotonin reuptake inhibitors (SSRIs) Serotonin norepinephrine reuptake inhibitors (SNRIs) Monoamine oxidase

Selective serotonin reuptake inhibitors (SSRIs) Explanation: Of the classes listed, SSRIs tend to be safer and have fewer side effects than the other medications, such as TCAs, MAOIs, and SNRIs.

medication intervention for anorexia

Selective serotonin reuptake inhibitors (SSRIs) are useful in the treatment especially if OCD is present. •Fluoxetine (Prozac) is approved by the FDA for the treatment of anorexia

Which of the following medications is associated with Monoamine Oxidase Inhibitors (MAO-Is)? Selegiline Clozapine (Clozaril) Pregabalin (Lyrica) Triazolam (Halcion) Naltrexone Venlafaxine

Selegiline Selegiline selectively inhibits MAO-B at low doses, which preferentially metabolizes dopamine, over NE and serotonin. This leads to increased levels of dopamine availability. It is typically used as an adjunct to L-Dopa for Parkinson's treatment, as it enhances effects of L-Dopa treatment and decreases motor complications. At high doses, however, this drug loses its selectivity for MAO-B.

Which of the following clinical findings best describes the physical changes typically seen in major depression? Self Neglect Visual Hallucinations Fear of Gaining Weight Excessive Dieting Repetitive and Intrusive Thoughts Magical Thinking

Self Neglect Neglected behavior could be contributed to the individual having anergia. Individuals with depression show a lack of care towards oneself. Grooming and personal hygiene are not maintained.

Nursing Assessment: BPD

Self-Injurious behaviors/thoughts Nutritional status Sleep patterns Medications Losses/traumatic events Mood/Affect Impulsivity Views of other people (dichotomous thinking) Dissociation History of psychotic episodes Social support Interpersonal skills Self-esteem Coping skills

The nurse is reviewing the history of a client diagnosed with bipolar I disorder. The history reveals that the client, in between manic episodes, consistently uses self-negating statements when describing the self, expresses feelings of being ashamed, and describes self as being unable to deal with events. The client also demonstrates little to any eye contact during interactions. The nurse interprets this information as reflecting a problem in which area? Anxiety Self-esteem Coping Denial

Self-esteem Explanation: These characteristics reflect issues related to self-esteem, or more specifically low self-esteem. The findings are unrelated to anxiety, coping, or denial.

The most serious consequence of behaviors seen in borderline personality disorder includes what? Impulsivity Self-injury Identity diffusion Dissociation

Self-injury Explanation: The turmoil and unsuccessful interpersonal relationships and social experiences associated with borderline personality disorder may lead the person to undermine the self when a goal is about to be reached. The most serious consequences are suicide attempts and parasuicidal behaviors. Identity diffusion occurs when a person lacks aspects of personal identity or when personal identity is poorly developed. Impulsivity occurs in people who have difficulty delaying gratification or thinking through the consequences before acting on their feelings. Dissociation occurs when thinking, feeling, or behaviors occur outside a person's awareness.

A client has been diagnosed with bulimia. Which cognitive behavioral technique would be useful for the client? Music therapy Self-monitoring Guided imagery Distraction

Self-monitoring Explanation: Self-monitoring is a type of behavioral therapy. It is designed to help the client with bulimia. Guided imagery, distraction, and music therapy can be used to manage emotions, such as anxiety, by using relaxation techniques.

A client in the emergency department has self-inflicted wounds on both arms. Assessment reveals that the client was diagnosed with borderline personality disorder 6 months ago, for which the client has been receiving outpatient treatment. The client tells the nurse that the client recently found out the client's therapist is moving and will no longer be able to work with the client. What is the priority nursing diagnosis for this client? Anxiety Self-mutilation Stress Loneliness

Self-mutilation Explanation: Although all the above are problems for this client, the highest priority nursing diagnosis is self-mutilation. If left untreated, self-mutilation can lead to suicide attempts.

Which of the following is the most likely side effect of SSRIs? Premature Ejaculation Hypertensive Crisis Serotonin Syndrome Priapism Weight Loss QT Prolongation

Serotonin Syndrome Serotonin syndrome is a risk with patients taking SSRI medications, while concurrently taking TCAs, SNRIs, MAOIs (any medications increasing serotonin availability). Serotonin syndrome is a rapidly progressive, potentially life-threatening syndrome which can be caused by a drug interaction. It has a wide range of clinical findings, where patients may display hyperthermia, hypertension, myoclonus, mydriasis, overactive bowels and mental agitation.

Which of the following SSRIs is most commonly used to treat PTSD? Lithium Venlafaxine Sertraline Levomilnacipran Nortriptyline Doxepin

Sertraline Sertraline is another SSRI which has numerous uses. It is often indicated for PTSD, and can be remembered by the image of a soldier saying "SIR!" This medication can also be used to treat anxiety disorders, depression, OCD and panic disorder.

Which of the following is the most likely side effect of SSRIs? Cardiotoxicity Premature Ejaculation Sexual Dysfunction Neuroleptic Malignant Syndrome Priapism Hypertensive Crisis

Sexual Dysfunction SSRIs are known to cause sexual dysfunction, such as erectile dysfunction, anorgasmia and decreased libido.

a nurse is planning on a unit orientation for a newly admitted client who has severe depression. which of the following should be the nurse's response? Sit with the client and offer simple, direct information. Have the client attend group therapy immediately. Explain the unit policies to the client and answer any questions he might have. Take the client on a tour of the unit and introduce him to all the staff members on duty.

Sit with the client and offer simple, direct information.

Before a client became depressed, the client was an active, involved parent with three children, often attending their school functions and serving as a volunteer. The client is hospitalized for a major depressive episode and now reveals that the client feels like an unnecessary burden on the client's family. Which nursing diagnosis is most appropriate? Ineffective coping related to marital disagreements Ineffective activity planning related to depression Anxiety related to side effects of medication Situational low self-esteem

Situational low self-esteem Explanation: The client does not express anxiety, issues with marital disagreements, or problems with activity planning. Instead, the client has experienced a change from being an involved, interested parent to feeling as though the client is a burden, which would be reflective of a disturbance of self-esteem. The self-esteem changes the client is experiencing are related to feelings of worthlessness brought on by the depressive episode.

Nursing Interventions: BPD

Sleep hygiene Prevention of self-injury Pharmacology- used to treat symptoms Teach: Instructions Side effects Effects of meds Importance of compliance Therapeutic relationship Establish length of relationship/prepare for termination phase Maintain personal boundaries Consistency among staff Do NOT give personal information Neutral, non-judgmental manner Thought stopping Management of psychotic episodes: What s/s to report Where to seek help Social skills Self-esteem/resilience Encourage individuality

Which of the following clinical findings best describes the cognitive changes typically seen in major depression? Flight of Ideas Slowed Thinking Acceptance of Oneself Fear of Gaining Weight Anxiety Disorganized Thinking

Slowed Thinking Patients with depression can have a slower demeanor. Their memory can be called at times "patchy" and there may be selective disorientation, along with a lack of being able to concentrate. The patient may dwell on perceived faults and failures and be unable to focus on strengths and successes.

bibliotherapy

Sometimes referred to as bibliocounseling, is the reading of selected written materials to express feelings or gain insight under the guidance of a health care provider. The provider assigns and discusses with the patient a book, story, or article. The provider makes the assignment because they believe that the patient can receive therapeutic benefit from the reading. (It is assumed that the provider who assigned the reading has also read it.) The provider needs to consider the patient's reading level before making an assignment. If a patient has limited reading ability, the provider should not use bibliotherapy. Literary works serve as a projective screen through which people see themselves in the story. Literature can help patients identify with characters and vicariously experience their reality. The use of bibliotherapy has been shown to improve depression when used with cognitive behavioral therapy. It can also expose patients to situations that they have not personally experienced—the vicarious experience allows growth in self-knowledge and compassion. Bibliotherapy can also support recovery in inpatient units through reading books written in first person. Through reading, patients can enrich their lives in the following ways: Catharsis: expression of feelings stimulated by parallel experiences Problem-solving: development of solutions to problems in the literature from practical ideas about problem-solving Insight: increased self-awareness and understanding as the reader explores personal meaning from what is read Anxiety reduction: use of self-help written materials that can reduce concerns about a diagnosed problem and treatment

a nurse is caring for a client who is hospitalized for the treatment of severe depression. which of the following nursing approaches is therapeutic to include in the client's plan of care? Encouraging decision-making Giving the client choices of activities Playing a game of chess with the client Spending time sitting with the client

Spending time sitting with the client

When clients diagnosed with borderline personality disorder (BPD) see nurses as either all good or all bad, the client is using which primitive defense? Splitting Invalidating Projective identification Defending

Splitting Explanation: Because clients with BPD view the world in absolutes, nurses and other treatment team members are alternately categorized as all good or all bad. This primitive defense is called splitting, and it presents clinicians with a challenge to work openly with each other, as well as the client, until the issue can be resolved through team meetings and clinical supervision. This is not an example of defending, invalidating, or projective identification.

communication techniques for assertiveness training

Stand up for oneself Take responsibility for content Persistence Admit errors Question appropriately Defusing Use "I" statements

A nurse is assessing a client who is brought to the emergency department. The nurse suspects that the client is experiencing mania. Which finding would support the nurse's suspicion? Select all that apply. Slowness of speech Flight of ideas Easily distractible Sleepiness Statements of self-importance

Statements of self-importance Flight of ideas Easily distractible Explanation: Mania is one of the primary symptoms of bipolar disorders. It is evidenced by an elevated, expansive, or irritable mood. Elevated self-esteem is expressed as grandiosity (exaggerating personal importance) and may range from unusual self-confidence to grandiose delusions. Speech is pressured (push of speech) the person is more talkative than usual and at times is difficult to interrupt. There is often a flight of ideas (illogical connections between thoughts) or racing thoughts. Distractibility increases.

To confirm that a client is experiencing a manic episode, the nurse must eliminate the possibility that the client's symptoms are related to which problem? Overexcitment Insomnia Substance use Inflated self-esteem or grandiosity

Substance use Explanation: The effects of illicit substance use can mimic the symptoms of mania. The use of substances must be ruled out through the use of blood and urine diagnostics. Once determined that the signs and symptoms are not the result of substances, the client can be further investigated for mania.

Which of the following clinical features is most common among patients with bipolar disorder in a depressive phase? Paranoid Delusions Auditory hallucinations Repetitive and Intrusive Thoughts Homicidal Thoughts Visual Hallucinations Suicidal Thoughts

Suicidal Thoughts This depressive phase of bipolar disorder can lead to suicidal thoughts in patients. Caregivers should be attentive to bipolar patients experiencing suicidal thoughts during a depressive stage.

Which of the following criteria is the most appropriate in the diagnosis of attention deficit hyperactivity disorder? Symptoms > 2 Months Onset by 2 Years Onset by 6 Years Symptoms > 6 Years Symptoms > 12 Months Symptoms > 6 Months

Symptoms > 6 Months Greater-than Sign with (6) Sax and Month Moon Patients with ADHD must have displayed relevant symptoms for at least the past 6 months. In addition, the symptoms must not be better explained by a psychotic disorder or mood disorder (such as anxiety or depression), and must be negatively impacting the patient's home or school life

a nurse is developing a plan of care for a client who is rehabilitating from major burns. which of the following interventions should the nurse include to provide emotional support? Assign assistive personnel to keep his room neat and clean. Rotate nursing staff so he can have varied interactions. Talk with the client during wound care. Keep family members aware of his condition.

Talk with the client during wound care. Talking with the client while providing care assists in the development of the nurse-client relationship and demonstrates caring.

apparent competence (BPD)

Tendency for the individual to appear deceptively more competent than they actually are, usually because of failure of competencies to generalize across expected moods, situations, and time. Person fails to display adequate nonverbal cues of emotional distress.

a nurse is assessing a client who is brought to the emergency room with burn injuries. which of the following findings should the nurse identify as a deep partial-thickness burn? The burned area is black in color and pain is absent. The burned area is pink in color with blisters present. The burned area is red in color with eschar present. The burned area is yellow in color with severe edema.

The burned area is red in color with eschar present. This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain. At this stage, the eschar that is present is soft and dry.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? The client has experienced extensive full-thickness burns. The client is in hypovolemic shock. The client has experienced partial-thickness burns. The paramedic administered high doses of opioids during transport.

The client has experienced extensive full-thickness burns. Explanation: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.

A client with major depression is scheduled to receive electroconvulsive therapy. The nurse understands that this treatment is typically used in which situation? The client is experiencing catatonia. The client is tolerating the initial drug therapy. Suicidality is of little concern. The level of depression is mild to moderate.

The client is experiencing catatonia. Explanation: Electroconvulsive therapy is an effective treatment for clients with severe depression. It is generally reserved for those whose disorder is refractory or intolerant to initial drug treatments and who are so severely ill that rapid treatment is required (e.g., clients with malnutrition, catatonia, or suicidality).

Which of the following is the best approach to managing a patient with serotonin syndrome? Treat with Dantrolene Treat with Cyproheptadine Treat with Protamine Sulfate Replace Selective Serotonin Reuptake Inhibitor with Tricyclic Antidepressant Reduce Dose of Selective Serotonin Reuptake Inhibitor Treat with Bromocriptine

Treat with Cyproheptadine Cyproheptadine is a medication used to treat serotonin syndrome. This drug acts as a serotonergic (5-HT2) receptor antagonist.

The nurse is creating a plan of care for a client with major depressive disorder. Which outcome will the nurse assign as the highest priority?

The client will independently carry out activities of daily living. Explanation: The most realistic and measurable outcome is for the client to be able to attend to self-care needs independently such as hygiene, nutrition, etc. This will indicate that medications and therapy have been effective. Avoiding agitation and stress is not a realistic goal since these are not possible to avoid. The client should learn techniques for management of stress and agitation. It is less likely that a client that has major depressive disorder will be harmful to others.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? The client's urinary output is 0.5 to 1 mL/kg/hour. The client's breathing is unlabored, and skin is clammy. The client is alert and conscious. The client's heart rate is rapid and regular.

The client's urinary output is 0.5 to 1 mL/kg/hour. Explanation: Successful fluid resuscitation is gauged by a urinary output of 0.5 to 1 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? The client's condition is likely to deteriorate after 72 hours. The early appearance of the burn injury may change. It helps determine the percentage of the total body surface area (TBSA) that is burned. The wound is susceptible to infections.

The early appearance of the burn injury may change. Explanation: The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.

A client who has just been prescribed lithium for bipolar disorder is being given education from the nurse about this medication. Which is important for the nurse to include in teaching? The higher the potassium level, the lower the lithium level will be. Changes in diet will not affect lithium levels. Lithium has few interactions with other drugs. The higher the sodium level, the lower the lithium level will be.

The higher the sodium level, the lower the lithium level will be. Explanation: Lithium is a salt, so the interaction between lithium and sodium levels in the body and between lithium level and fluid volume in the body are crucial issues to consider. The higher the sodium levels, the lower the lithium level will be and vice versa. The other options do not represent correct information.

a charge nurse is conducting a staff education in-service about depressive disorders. which of the following should the nurse identify as a risk factor for depression? Being married Pregnancy Male gender Chronic illness

chronic illness

anticonvulsants for bipolar disorder

Usually the 1st line treatment choice (if they don't respond to these, then they go to Lithium) •Stabilizes mood •Treats/prevents relapse of mania and depression (useful in mixed mania, rapid cycling) -- Sodium Valproate -- Carbamazepine -- Lamotrigine

Which is a possible explanation for the increased risk of suicide in persons who have had a relative who committed suicide? The relative's suicide caused the family members to realize that suicide is emotionally harmful to the ones left behind and vow not to consider suicide. The relative's suicide offers a sense of "permission" or acceptance of suicide as a method of escaping a difficult situation. Many people with depression who have suicidal ideation lack the energy to implement suicide plans, but antidepressant treatment can actually give clients with depression the energy to act on suicidal ideation. Suicide is more likely to occur in April when natural energy from increased sunlight may give the client the energy to act on suicidal ideation.

The relative's suicide offers a sense of "permission" or acceptance of suicide as a method of escaping a difficult situation. Explanation: Those with a relative who committed suicide are at increased risk for suicide: the closer the relationship, the greater the risk. One possible explanation is that the relative's suicide offers a sense of "permission" or acceptance of suicide as a method of escaping a difficult situation. Treatment with antidepressants and spring increase in sunlight and energy may give a person with suicidal ideation the energy to act on it. If a relative commits suicide, the family members may recognize that suicide is emotionally harmful to the ones left behind and vow not to consider suicide—this does not increase the risk of suicide.

social interventions

The social domain includes the individual's environment and its effect on their responses to mental disorders and distress. Interventions within the social domain are geared toward couples, families, friends, and large and small social groups, with special attention given to ethnicity and community interactions. In some instances, nurses design interventions that affect a patient's environment, such as helping a family member decide to admit a loved one to a long-term care facility. In other instances, the nurse modifies the environment to promote positive behaviors.

token economy

This applies to behavior modification techniques to multiple behaviors. In a token economy, patients are rewarded with tokens for selected desired behaviors. They can use these tokens to purchase meals, leave the unit, watch television, or wear street clothes. In less restrictive environments, patients use tokens to purchase additional privileges, such as attending social events. have been especially effective in reinforcing positive behaviors in people who are developmentally disabled or have severe and persistent mental illnesses. There is good evidence that the use of token economy for behavior and symptom management is effective in adults who are hospitalized, but there is little evidence to support transfer of the new behaviors outside the inpatient settings. The strategy has been expanded to treatment programs for children and cocaine addiction

A nurse is careful to provide a quiet, comfortable, safe environment when conducting an assessment interview. What is the reason this is particularly important when working with a client believed to be exhibiting characteristics of a personality disorder? A high stimulus environment will cause the client to exhibit exacerbated behaviors that are loud and attention seeking. These clients are generally experiencing chronic depression and are severely impaired socially. The client is easily intimidated and may become so withdrawn that the assessment will be difficult if not impossible to complete. This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the client feels threatened.

This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the client feels threatened. Explanation: Personality disorders are diagnosed when there is impairment of personality functioning and personality traits that are maladaptive. Individuals have identity problems such as egocentrism or being self-centered, and their sense of self-esteem comes from gaining power or pleasure that is often at the expense of others. Their behavior often fails to conform to cultural, social, or legal norms, and they are motivated by personal gratification. Individuals with these disorders are often withdrawn, defensive, guarded, and impulsive, and may demonstrate an escalation of anger or make hostile or threatening comments. The remaining options are specific to certain types of personality disorders.

lithium nursing considerations

This med takes effect in 5-7 days but max benefit will not happen for 2-3 weeks. Short half life of med means it is usually rx at 3x a day Take with food/milk to minimize GI distress. Start of treatment ranges must be monitored every 2-3 days until stable then every 1-3 months.

Which is a technique used to help the client with borderline personality disorder gain control over self-critical thoughts? Communication triad Delay gratification Thought stopping Affective instability

Thought stopping Explanation: Thought stopping is a practice that may help the client control the a technique to alter the process of negative or self-critical thought patterns such as "I'm dumb, I'm stupid, I can't do anything right."

When completing a baseline assessment of a client with depression, which diagnostic tests would the nurse anticipate? Thyroid function tests Abdominal ultrasound Renal function tests Coagulation profile

Thyroid function tests Explanation: A physical examination is recommended with baseline vital signs and baseline laboratory tests, including a comprehensive blood chemistry panel, complete blood counts, liver function tests, thyroid function tests, urinalysis, and electrocardiograms. These physical examinations can help to rule out any underlying medical conditions that may be causing or exacerbating an existing depression. The other diagnostic tests indicated in the options are not related to identifying underlying medical conditions that are commonly found comorbid to depression.

a nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. before administering the medication, the nurse should check to see that which of the following tests have been completed? Thyroid hormone assay Liver function tests Erythrocyte sedimentation rate Brain natriuretic peptide

Thyroid hormone assay

tourette and tic disorders in adolescents

Tic Disorder- encompasses several syndromes that are characterized by motor and/or phonic tics. •Motor tics- quick jerky movements of the eyes, face, neck, and shoulders. May involve other muscles as well. •Phonic tics- repetitive clearing of the throat, grunting, or other noises. May include more complex sounds, words, parts of words, and obscenities. Tourette disorder- most severe tic disorder and is defined by multiple motor and/or phonic tics that have occurred for at least 1 year

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? To keep fire and smoke from airway To prevent collapse and further injuries To extinguish flames more quickly To promote blood flow to the brain and vital organs

To keep fire and smoke from airway Explanation: The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

Which of the following medications is associated with Monoamine Oxidase Inhibitors (MAO-Is)? Fluoxetine Amitriptyline Aripiprazole (Abilify) Duloxetine Tranylcypromine Clozapine (Clozaril)

Tranylcypromine Tranylcypromine is a nonselective MAO-I, with its main indication being for the treatment of major depressive disorder. It has also been used uncommonly for mood disorders.

The nurse is caring for a client that is experiencing mania that is pacing, cannot sit, with pressured speech. Which meal will the nurse provide to best meet the nutritional needs of this client? Peanut butter sandwich, chips, cola Turkey sandwich, cheese slices, milk Spaghetti, garlic bread, salad, tea Fried chicken, mashed potatoes, milk

Turkey sandwich, cheese slices, milk Explanation: Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible. Sandwiches and cheese are finger foods and are calorie-dense. Chips and cola are not nutritious, even though they are high in calories. Fried chicken, potatoes, and spaghetti cannot be eaten while the client is moving.

Which of the following patterns of behavior best describes the diagnostic criteria for attention deficit hyperactivity disorder? Three Areas of Life Occurs at School Only Two Areas of Life Occurs at Home Only Occurs at night One Area of Life

Two Areas of Life Home and School In order to meet the criteria for ADHD, the pattern of behavior characteristic of these conditions must be present in two settings, at home and at school

medication treatment of tourette and tic disorders in adolescents

Two drug classifications commonly used. •Antipsychotics- aripiprazole is replacing the use of haloperidol and pimozide •a-adrenergic receptor agonists- example: clonidine

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn? Use client's palm size Lund and Browder burns assessment Rule of nines Parkland formula

Use client's palm size Explanation: A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Browder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of nines quantitates burns that involve entire sections of the body, not scattered burns.

Which of the following clinical findings best describes the physical changes typically seen in major depression? Paresthesias Fear of Impending Doom Repetitive and Intrusive Thoughts Hemineglect Disorganized Thinking Vegetative Signs

Vegetative Signs Patients may experience a change in their eating habits, elimination patterns, or sleeping schedule. Remember that every patient is different. With depression one patient could have hypersomnia, anorexia, and constipation, while another patient may display insomnia, overeating, and diarrhea

Which of the following SNRIs is indicated for panic disorder and anxiety? Sumatriptan Trazodone Buspirone Bupropion Lamotrigine Venlafaxine

Venlafaxine Venlafaxine is a medication that works on serotonergic and noradrenergic receptors, when administered at moderate doses, to help treat anxiety and panic disorders.

a nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. which of the following statements by the client indicates an understanding of the teaching? "I will report any loss of appetite." "Increased flatulence is an indication of toxicity." "Vomiting is an indication of toxicity." "I will call my provider if I experience any headaches."

Vomiting is an indication of toxicity. Rationale: Since vomiting and diarrhea are early signs of lithium toxicity, the client should omit the next dose of lithium and call the provider.

Which of the following clinical findings best describes the mood changes typically seen in major depression? Worthlessness Disorganized Thinking Fear or Aversion Visual Hallucinations Normal appetite Excessive Dieting

Worthlessness patients can experience the feelings of worthlessness and/or hopelessness. Encouraging a patient to be self-efficient can help decrease these feelings.

Which of the following is most likely associated with stage 3 of a burn? Wound Closure to Return of Optimal Level Cardiac Muscle Injury Injury to Return of Capillary Permeability Diuresis to Near Wound Closure Delayed Wound Healing Implementation of Wound Drainage Devices

Wound Closure to Return of Optimal Level Wound Closure Returned to Fame During the final stage of burn care management, wounds have healed and the patient begins to engage in self-care. The patient works toward rehabilitation and reintegration into society. Teaching and psychosocial support will help the patient manage changes in body image. Since newly-healed areas of skin may be hypersensitive to sun, teach the patient to avoid direct sunlight for the next 3 months to prevent hyperpigmentation and sunburns. Teach the patient how to complete dressing changes and wound care. If necessary, refer the patient to home care nursing services for follow-up care after discharge.

burn wound care

Wound cleaning oHydrotherapy Use of topical agents Wound debridement oNatural debridement - weeks to months oMechanical debridement - Surgical tools oSurgical debridement - remove tissue and close area Wound dressing, dressing changes, and skin grafting

As the first priority of care, a patient with a burn injury will initially need: pain medication administered. an indwelling catheter inserted. fluids replaced. a patent airway established.

a patent airway established. Explanation: Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen.

behavior modification

a specific, systematized behavior therapy technique that can be applied to individuals, groups, or systems. The aim of behavior modification is to reinforce desired behaviors and extinguish undesired ones. Desired behavior is rewarded to increase the likelihood that patients will repeat it, and over time, replace the problematic behavior with it. Behavior modification is used for various problematic behaviors, such as dysfunctional eating, addictions, anger management, and impulse control and often is used in the care of children and adolescents.

Bipolar II Disorder

a type of bipolar disorder marked by mildly manic (hypomanic) episodes and major depressive episodes

priority care issues for bipolar disorder: client protection

client protection •Poor judgment and impulsivity •Risky behavior, believe they have extra abilities, grandiose thinking •Unable to predict consequences •Can become delusional, psychotic

a nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. which of the following interventions should the nurse perform first? Clean and dress the wound. Administer pain medication. Administer a tetanus booster. Administer IV fluids.

administer IV fluids Using the airway, breathing, circulation framework, the priority action the nurse should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids.

risk for depression is much greater in

adolescent and adult females

for burns: hydration is a key role in preventing hypovolemia - may need blood products - adults need ______________ mL/hr - children: aggressive hydration keeps deep areas of burns from converting.

adults: 500ml/hr Childen: <30 kg is 250 ml.hr and D5 ½ NS

Predictor of mortality for anorexia

alcohol use during the course of care

De-escalation

an interactive process of calming and redirecting a patient who has an immediate potential for violence directed toward self or others. This intervention involves assessing the situation and preventing it from escalating to one in which injury occurs to the patient, staff, or other patients. After the nurse has assessed the situation, the nurse calmly calls to the patient and asks the individual to leave the situation. The nurse must avoid rushing toward the patient or giving orders. Nurses can use various interventions in this situation, including distraction, conflict resolution, and cognitive interventions.

A psychiatric-mental health nurse is assessing a client who is suspected of experiencing depression. During the interview, the client says, "I just don't care any more. I used to enjoy doing all sorts of things outdoors, but now, I don't. Nothing seems to make me happy." The nurse interprets this statement as: aphasia. labile mood. anhedonia. affect.

anhedonia. Explanation: The patient's statement reflects a loss of interest or pleasure in activities that previously brought enjoyment . This is termed anhedonia. Labile mood is the outward emotional expression that is varied, rapid, and abruptly shifts. Affect is the outward emotional expression of a person that gives clues to the person's mood. Aphasia involves a difficulty with speaking or communicating.

types of eating disorders

anorexia nervosa bulimia nervosa binge eating disorder

Validation

another process that affirms patient individuality. Staff-patient interactions should constantly reaffirm the patient's humanity and human rights. All interaction a staff member initiates with a patient should reflect their respect for that patient. Patients must believe that staff members truly like and respect them.

lamotrigine

anticonvulsant/mood stabilizer rapid-cycling bipolar depression, bipolar disorder type I maintenance

zone of stasis is the ________ __ _____________ __________ that may remain viable but with persisitent ischemia will undergo necrosis within 24-48 hours.

area of injured cells

medication management

assess effectiveness and side effects of meds and consider drug-drug interactions.

sleep interventions

communicate to patients that they should go to bed when sleepy, establish a bedtime routine, avoid stimulating foods / drinks before bed, eat lightly before retiring to bed and limit fluids, use your bed only for sleep or intimacy, avoid emotional stimulation before bedtime, use behavioral relaxation techniques, limit distractions

The genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should ... encourage the client to seek genetic counseling before considering a pregnancy. assess for depression in the client's family history. educate the client regarding the symptoms of related physical disorders. prepare the client for diagnostic genetic testing to confirm the diagnosis.

assess for depression in the client's family history. Explanation: The genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should assess for depression in the client's family history.

3 major states of mood disorders

depressive - Dysthymic - premenstrual dysphoric - Seasonal affective disorder - disruptive mood dysregulation - substance-induced mania - elevated mood bipolar - cyclic moods

spiritual interventions

based on an assessment of the patient's spiritual needs. Some interventions require actions such as listening, requesting a chaplain's presence, or providing readings; other interventions involve use of personal abilities and characteristics such as the use of the therapeutic relationship in supporting patient well-being. A nonjudgmental relationship and just "being with" (not doing for) the patient are key spiritual interventions. To assist people in spiritual distress, the nurse should know and understand the beliefs and practices of various spiritual groups. Spiritual support, assisting patients to feel balance and connection within their relationships, involves listening to expressions of loneliness, using empathy, and providing patients with desired spiritual articles.

what med to avoid with history of seizures

bupropion

schizophrenia clinical courses of progression: Relapses

can occur at any time during treatment and recovery

pathophysiologic changes with severe burns: cardiovascular

cardiac depression, edema , hypovolemia decrease cardiac output due to the plasma volume loss. Systemic inflammation causes plasma loss and then peripheral edema due to the third spacing water shift. Sympathetic nervous system compensates by releasing catecholamines that increases vasoconstriction and then increase heart rate and decreases tissue perfusion. IV fluids help overcome the hypovolemic shock and we do it immediately becawue the greatest volume of intravascular fluid leak happens in the first 24-36 hours after injury with a peak around 6-8 hours.

treatment of 1st degree burns

cool compress, skin lubricants

burns: Systemic response includes release of _____________ and other mediators into systemic circulation

cytokines

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to increase glucose demands. increase metabolic rate. increase skeletal muscle breakdown. decrease catabolism.

decrease catabolism. Explanation: The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

Lithium Contraindications

dehydration, known sodium imbalance, renal or cardiovascular disease. - schizophrenia Birth Defect risk for pregnancy Breastfeeding Cardiac, hepatic or renal disease schizophrenia caution use in older clients

bipolar 1 disorder diagnostic criteria

depression (severe) alternating with mania, or mixed episode •Distinct period of mania, inc. activity/energy nearly every day for > 1 week •With 3 or more of the following (must have 4 s/s if mood is only irritability) •Inflated self-esteem or grandiosity •Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) •More talkative than usual or pressure to keep talking •Flight of ideas or subjective experience that thoughts are racing •Distractibility, as reported or observed •Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity) •Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

rapid cycling bipolar disorder

diagnosis given when a person has four or more cycles of mania and depression within 1 year •Mania or hypomania •Resistant •Increased recurrence rate

relaxation interventions

distraction, guided imagery. breathing exercises. do not use relaxation techniques with physical touch!

most common ways to test peripheral vascular status is burned limbs:

dopplers

personality disorders onset:

during early adulthood / adolescence

pathophysiologic changes with severe burns: fluid and electrolytes

edema happens. Burns greater than 20% stimulate local and systemic reactions that cause shift of fluids electrolytes protein into surrounding space. Severe edema results in decrease circulation requiring cutting of the eschar, or decompressing the edema via fasciotomy. Potassium is affected due to cell destruction and fluid replacement, Sodium due to fluid replacement and plasma loss. Decrease RBC due to damange, hemoconcentrated due to fluid loss, changes in coags increase clotting times and decrease platelets.

thermoregulation interventions

education about problems of thermoregulation, identifying potential extremes in temperatures, developing strategies to protect the patient from the adverse effects of temp changes. remind patients to wear coats in winter and lightweight clothes in summer may prevent frostbite or heat exhaustion.

characteristics of BPD

emotional vulnerability: : Person experiences a pattern of pervasive difficulties in regulating negative emotions, including high sensitivity to negative emotional stimuli, high emotional intensity, and slow return to emotional baseline. self-invalidation: Person fails to recognize one's own emotional responses, thoughts, beliefs, and behaviors and sets unrealistically high standards and expectations for self. May include intense shame, self-hate, and self-directed anger. Person has no personal awareness and tends to blame social environment for unrealistic expectations and demands. unrelenting crises: Person experiences pattern of frequent, stressful, negative environmental events, disruptions, and roadblocks—some caused by the individual's dysfunctional lifestyle, others by an inadequate social milieu, and many by fate or chance. inhibited grieving: Person tries to inhibit and overcontrol negative emotional responses, especially those associated with grief and loss, including sadness, anger, guilt, shame, anxiety, and panic. active passivity: person fails to engage actively in solving of own life problems but will actively seek problem-solving from others in the environment, learned helplessness, hopelessness. apparent competence: Tendency for the individual to appear deceptively more competent than they actually are, usually because of failure of competencies to generalize across expected moods, situations, and time. Person fails to display adequate nonverbal cues of emotional distress.

activity and exercise interventions

encouraging regular activity and exercise and identify realistic goals. nurses can also delegate activity and exercise interventions to PCTs or CNAs

2nd degree burns (partial thickness)

epidermis and upper dermis are damaged, skin is red with blisters - blisters, mottled base, weeping, edema - blanches - should heal on own in 2-3 weeks may require grafting - can convert to 3rd degree - can be dry, pale, and dark petechiae, but blanchable

glycosuria

glucose in the urine common finding in early postburn hours resulting from the release of liver glycogen stores in response to stress

a nurse is caring for a client who has bipolar disorder. the client states, "I feel like superman. I can do anything. I can fly home today and then become a US senator." which of the following findings is the client exhibiting? Flight of ideas Grandiosity Reality testing Derealization

grandiosity

a nurse is planning care for a client who is in the manic phase of bipolar disorder. which of the following interventions should the nurse include in the client's plan of care? Provide a stimulating environment. Have consistent unit routines. Discourage daytime napping. Schedule daily seclusion times.

have consistent unit routines

pathophysiologic changes with severe burns: thermoregulatory

have lower body temps in early hours of burn due to IV fluids, exposure, and evaporating heat.

Systemic inflammatory response signals release of proinflammatory/anti-inflammatory cytokines, prompting ___________________.

hypermetabolism

Fluid shifts and shock result in tissue ____________ and organ ______________________.

hypoperfusion hypofunction

Burns: Fluid shifts and shock result in tissue ___________ and organ _______________

hypoperfusion and organ hypofunction

burns are an ____________ destruction of skin. It eleminates the body's _________ to water evaporation and allows fluid loss.

immediate barrier

pathophysiologic changes with severe burns: GI

impaired motility and absorption, vasoconstriction, loss of mucosal barrier function with bacterial translocation, incereased pH altered motility. Paralytic ileus, curling's ulcer. Large burns at risk for abdominal compartment syndrome resulting in organ ischemia.

Mediators of the inflammatory process produce vasodilation and ________________ ___________________ ______________. Fluid shifts from the intravascular (in the blood vessels) to the extravascular (interstitial) space. Almost ____ of fluid infused shifts out of the vascular space. This means that patients with significant burns need larger quantities of intravenous fluids.

increased capillary permeability. 50%

antimicrobial ointment for burns

indication: Antibacterial coverage and promotion of a moist wound environment application: Apply 1/16-inch layer of ointment with a clean glove daily. nursing implications: 1. Ensure removal of residual ointment at the time of wound cleaning prior to applying a new layer. 2. Monitor closely for signs and symptoms of local infection

mafenide acetate 5% hydrophilic-based solution or cream

indications: Antimicrobial agent for gram-positive and gram-negative organisms Diffuses through eschar and avascular tissue (e.g., cartilage) application: Apply twice a day with a clean glove. nursing implications: 1. Is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. 2. Application may cause considerable pain initially

Silver sulfadiazine 1% water-soluble cream for burns

indications: Bactericidal agent for many gram-positive and gram-negative organisms, as well as yeast and Candida albicans Minimal penetration of eschar application: Apply 1/16-inch layer of cream with a clean glove 1-3 times daily. nursing implications: 1. Anticipate formation of pseudoeschar (proteinaceous gel), which can be removed.

Silver-impregnated dressings (sheets or mesh)

indications: Broad antimicrobial effects (product specific) Delivers a uniform, antimicrobial concentration of silver ions to the burn wound. application: Apply directly to wound. Cover with absorbent secondary dressing if needed. nursing implications: 1. May produce a pseudoeschar from silver after application. 2. Can be left in place for several days (product specific).

Silver nitrate 0.5% aqueous solution

indications: Effective against most strains of Staphylococcus and Pseudomonas and many gram-negative organisms. Does not penetrate eschar application: Apply solution to gauze dressing and place over wound. Keep the dressing wet but covered with dry gauze and dry blankets to decrease vaporization. nursing implications: 1. Monitor serum sodium (Na+) and potassium (K+) levels and replace as prescribed. Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. 2. Protect bed linens and clothing from contact with silver nitrate, which stains everything it touches.

kleptomania

individuals cannot resist the urge to steal, so they independently steal items that they could easily afford. These items are not particularly useful or wanted. The underlying issue is the act of stealing. These individuals experience an increase in tension and then pleasure and relief at the time of the theft. Severity of kleptomania behaviors is associated with having more frequent urges to steal, feeling excited by stealing, having a current eating disorder, and having a current diagnosis of OCD. Furthermore, worse symptom severity was associated with a shorter transition time (between first stealing and developing kleptomania), as well as with more chance of stealing from relatives and seeking treatment at some point. The association of worse kleptomania severity with stealing-related reward and disorder of compulsivity (OCD, anorexia nervosa) may provide clues for appropriate targets for cognitive behavioral therapy or pharmacotherapy. Some shoplifting appears to be related to anxiety and stress in that it serves to relieve symptoms. In a few instances, brain damage has been associated with kleptomania. Depression is the most common symptom identified in a compulsive shoplifter.

counseling interventions

interactions between a nurse and a patient, family, or group experiencing immediate or ongoing difficulties related to their health or well-being. Counseling is usually short term and focuses on stabilizing symptoms, supporting personal recovery goals, improving coping abilities, reinforcing healthy behaviors, fostering positive interactions, or preventing illness and disability.

pyromania

irresistible impulses to start fires characterize pyromania, repeated fire setting with tension or arousal before setting fires; fascination or attraction to the fires; and gratification when setting, witnessing, or participating in the aftermath of fire. These individuals often are regular "fire watchers" or even firefighters. They are not motivated by aggression, anger, suicidal ideation, or political ideology. Little is known about this disorder because only a small number of deliberate fire starters are apprehended, and of those individuals, only a few undergo a psychiatric evaluation. The prevalence of fire setting in the general population is about 1%, but most fire setting is not done by people with pyromania, which occurs infrequently, mostly in men. However, those with a history of fire setting are most likely male, young, and never married and are more likely to have other psychiatric issues such as ASPD, substance use, and impulsivity. Prevalence rates are lower among African Americans and Hispanics. Early research demonstrated low serotonin and norepinephrine levels associated with arson. Little is known about treatment, and as with the other impulse-control disorders, no approach is uniformly effective. Historically, fire starters generally possess poor interpersonal skills, exhibit low self-esteem, battle depression, and have difficulty managing anger. Education, parenting training, behavior contracting with token reinforcement, problem-solving skills training, and relaxation exercises may all be used in the management of the patient's responses.

Cyclic mood disorder

labile mood with no obvious cause

skin coverings for burn wound care: wound grafting

large areas, graft can be from self or others

common features of mania

leads to •Indebtedness •Job loss •Divorce •General problems in daily life •Mean age of onset is 21-30 y/o •Interferes with social, occupational, and interpersonal relationships

SAD treatment

light therapy

The nurse provides care to a client who is diagnosed with major depressive disorder (MDD). The current treatment modalities of medication and psychotherapy have been ineffective. Which traditional Western medicine option should the nurse explore for inclusion in the plan of care with the client's practitioner? Select all that apply. light therapy electroconvulsive therapy (ECT) acupuncture repetitive transcranial magnetic stimulation massage therapy

light therapy electroconvulsive therapy repetitive transcranial magnetic stimulation For clients who do not respond as expected to medication and psychotherapy, other medical options are available, including ECT, light therapy, and repetitive transcranial magnetic stimulation. If the depressive episodes are cyclic and seasonal, light therapy can be very effective. Although acupuncture and massage therapy may by appropriate therapies for MDD, these are classified as alternative or complementary therapies for the treatment of depression.

Burns more than 20% may produce a local and systemic response and are considered ________ burns

major burns

schizophrenia clinical courses of progression: Recovery

medication has diminished the symptoms

side effects of risperidone

neuroleptic malignant syndrome, tardive dyskinesia, hyperglycemia, and diabetes, gynecomastia

treatment for lithium toxicity

no antidote - DC lithium - IV fluids - possible hemodialysis

urine output standard for burns

o 0.5 to 1 ml/kg/hr for thermal/chemical o 75-100 mls/hr for electrical burn

phases of burn injury: acute or intermediate phase

o From beginning of diuresis to wound closure

phases of burn injury: rehabilitation phase

o From wound closure to return to optimal physical and psychosocial adjustment

phases of burn injury: emergent or resuscitative phase

o Onset of injury to completion of fluid resuscitation Priorities: - primary survey: ABCDE - prevention of shock - prevention of respiratory distress - detection and treatment of concomitant injuries - wound assessment and initial care

important thing to do with 2nd degree burns

o Proper nutrition/hydration important o Needs enough hydration to keep o2 in tissue to prevent converting to 3rd

4th degree burns

oDeep burn necrosis oExtends into deep tissue, muscle, or bone oCharred oAmputation likely

rule of nines

oMost common way to estimate for TBSA burned oBased on anatomic regions

lund and browder method

oRecognizes % of TBSA of various anatomic parts - more detailed chart

3rd degree burns (full thickness)

oTotal destruction of the epidermis, dermis, and underlying tissue oDry, pale, white/brown charred oFluid loss trapped under eschar, edema oDoes not BLANCH oNot painful (nerves dead) oNon- painful burns are more serious! oGrafting - Loss of contour and function

palmer method

oUsed to estimate extent of scattered burns oSize of patient's hand, including fingers is 1% TBSA - commonly used on the scene or ED

health teaching

one of the standards of care for the psychiatric nurse. Teaching methods should be appropriate to the patient's development level, learning needs, readiness, ability to learn, language preference, and culture. Based on principles of learning, health teaching involves transmitting new information to the patient and providing constructive feedback and positive rewards, practice sessions, homework, and experimental learning. Health teaching is the integration of principles of teaching and learning with the knowledge of health and illness. Thus, in health teaching, the psychiatric nurse attends to potential health care problems other than mental disorders and emotional problems. For example, if a person has diabetes mellitus and is taking insulin, the nurse provides health care teaching related to diabetes and the interaction of this problem with the mental disorder.

1st degree burns

only epidermis is damaged, skin is red and swollen - painful - red and blanchable, dry ex: sunburn

carbamazepine interactions

oral contraceptives warfarin grapefruit juice

burn patients leak __________, not whole blood.

plasma

skin coverings for burn wound care: synthetic skin

plastic / silicone

schizophrenia clinical course of progression: Prodromal period

precursor to disorder that may begin in early childhood. Symptoms: tension, nervousness, lack of interest in eating, difficulty concentrating, disturbed sleep, decreased enjoyment, loss of interest, social withdrawal, more thinking about religion, feeling bad for no reason, feeling too excited, hearing voices, seeing things

red-color urine in burns

presence of hemochromogens from damage to RBCs and myoglobin (by-product of muscle damage) typical in deep burns caused by electrical injury or prolonged contact with heat or flame

the most important thing you can do for a burn patient

the same as you do for anyone else--ABCs The burn may look like the worst thing you have ever seen but it is not the most life-threatening thing going on with the patient most likely. It's pretty hard to burn to death. People very rarely do. If a burn patient dies (especially in the first few hours) it will be from an inhalation injury, or heart attack or some other trauma but not from the burn to their skin.

milieu therapy

provides a stable and coherent social organization to facilitate an individual's treatment. (The terms milieu therapy and therapeutic environment are often used interchangeably.) In milieu therapy, the design of the physical surroundings, structure of patient activities, and promotion of a stable social structure and cultural setting enhance the setting's therapeutic potential. A therapeutic milieu facilitates patient interactions and promotes personal growth. Milieu therapy is the responsibility of the nurse in collaboration with the patient and other health care providers. The key concepts of milieu therapy include containment, validation, structured interaction, and open communication.

structured interaction

purposeful interaction that allows patients to interact with others in a useful way. For instance, the daily community meeting provides structure to explain unit rules and consequences of violations. Ideally, patients who either are elected or volunteer for the responsibility assume leadership for these meetings. In the meeting, the group discusses behavioral expectations, such as making beds daily, appropriate dress, and rules for leaving the unit. Usually, there are other rules, such as no fighting or name calling. In some instances, the treatment team assigns structured interactions to specific patients as part of their treatment. Specific attitudes or approaches are directed toward individual patients who benefit from a particular type of interaction. Nurses consistently assume indulgence, flexibility, passive or active friendliness, matter-of-fact attitude, casualness, watchfulness, or kind firmness when interacting with specific patients. For example, if a patient is known to overreact and dramatize events, the staff may provide a matter-of-fact attitude when the patient engages in dramatic behavior.

nutrition interventions

recommend daily nutritional allowances. Sometimes nurses may have to address patient's suspicions about foods if they are hesitant about them. encourage adequate food intake. allow patients to participate in food preparations and test the safety of the meal by eating it slowly or eating it after everyone else finishes eating. for paranoid patients, sometimes they prefer prepackaged foods.

pain management

relaxation techniques, stress management, hypnosis, biofeedback. education is focused on the pain, use of meds for treatment, and development of cognitive skills

wound debridement: surgical

remove tissue and close the area

Name a medication given to treat irritability associated with Autism Spectrum Disorder (ASD).

risperidone (Risperdal) (5-16) aripiprazole (Abilify) (6-17)

anorexia nervosa (AN)

serious mental illness with intense and irrational beliefs about one's shape and weight, including fear of gaining weight.

what to monitor for carbamazepine

serum levels of drug CBC signs of rash (risk for SJS)

mixed episodes

severe symptoms of both mania and depression within the same week •Mania and depression appear together •Extreme irritability

pathophysiologic changes with severe burns: immunological

skin is largest barrier to infection. When compromised they are at risk for constant exposure to the environment.

biggest thing for serotonin syndrome

stop the med

what are the leading causes of death for individuals with anorexia nervosa?

suicide cardiopulmonary arrest

big caution when treating children / adolescents with fluoxetine (prozac)

suicide!!!!!!!

wound debridement: mechanical

surgical tools

zone of hypermia ______________ __________ _________ and may recover fully over time.

sustains minimal injury

big side effect with fluoxetine

sweating, a large amount

anorexia nervosa symptoms

symptoms:: -significantly low body weight - intense fear of gaining weight or becoming fat - disturbance in experiencing body weight or shape

a nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. which of the following intervetnions should the nurse take? Turn on a dance video so the client can burn off excess energy. Offer the client a low-calorie snack in return for stopping the behavior. Take the client outside and sit with her in the garden area. Observe the client closely for the development of aggressive behavior.

take the client outside and sit with her in the garden area RATIONALE: it is appropriate to remove the client from the stimulating environment and to use instruction, rather than bargaining, to decrease the activity level

hydration interventions

teach patients the importance of adequate fluid intake, especially those that are taking Lithium!)

biggest teaching point for lithium

teach patients the signs of lithium toxicity - hand tremors - vision changes -Extreme polyuria •Tinnitus •Giddiness •Ataxia •Seizures •Hypotension •Stupor •Coma, poss. death

skin coverings for burn wound care: biological

temporary grafts from self or others

A nurse is caring for a school-age child who has full-thickness burns to 30% of the total body surface area (TBSA). Vital Signs Oral temperature 38⁰ C (100.2⁰ F) Respiratory rate 34/min Heart rate 115/min Blood pressure 86/54 mm Hg SaO2 94% Nurses' Notes Awake, alert, oriented x 3 for age. Lung sounds clear to auscultation. Tachypnea, rate 34/min. Oxygen infusing at 2 L/min bi-nasal cannula. Telemetry intact. Sinus tachycardia, rate 118/min. Lactated Ringer's infusing to left forearm at 88 mL/hr. Bowel sounds hypoactive in all four quadrants. Abdomen soft, non-tender. Nasogastric tube intact to right nare with low intermittent suction, small amount of bile noted. Bilateral lower extremities with full-thickness burns noted anteriorly and posteriorly. Skin dry with white coloring anteriorly to thighs with erythema noted on shins anteriorly and posterior legs. No blanching. 4+ edema noted to bilateral lower extremities. Pedal pulses nonpalpable. FACES scale rating of 8 for lower extremity pain. Urinary catheter intact draining 35 mL/hr. Weight 27.2 kg (60 lb). Medication Administration Record Lactated Ringer's IV to maintain urine output of 30 mL/hr. Fentanyl 28 mcg IV every hour prn severe pain. Apply thin layer silver sulfadiazine topically to burns twice per day Physical Examination Skin: Approximately 30% of TBSA full-thickness burns to bilateral lower extremities sustained in house fire. 4+ edema noted to bilateral lower extremities. Capillary refill sluggish to bilateral lower extremity nailbeds. Pedal pulses nonpalpable. HEENT: Head normocephalic. No tenderness. PERRLA. No soot noted to nares. No singed nasal hair noted. Nares are patent bilaterally. Oral mucosa is pink and moist. Pharynx within normal limits in appearance. Neck: Neck is supple, no adenopathy. Thyroid gland has no palpable masses. Trachea midline. Carotid pulse palpated bilaterally. Cardiac: Cardiac monitoring in progress revealing sinus tachycardia, rate 115/min, regular in rhythm. Respiratory: Airway is patent. No singed nasal hairs noted. No soot noted to nares. No laryngeal edema noted. Respiratory rate 34/min. Lung sounds clear to auscultation. No cough noted. No sputum noted. No accessory muscle use noted. Abdomen: Abdominal soft, nondistended. Bowel sounds present and hypoactive in all four quadrants. No masses, splenomegaly, or hepatomegaly noted. Renal: Urinary catheter intact draining 35 mL/hr. Neurological: Awake, alert, and oriented for age. Genital/Rectal: Within normal limits. A nurse is initiating the client's plan of care. Complete the following sentence by using the list of options. The client is at highest risk for developing __________ as evidenced by the client's ______________. 1st space: acute kidney injury compartment syndrome ileus duodenal ulcer smoke inhalation injury 2nd space: urine output airway edema bowel sounds oxygen saturation

the client is at highest risk for developing COMPARTMENT SYNDROME as evidenced by the client's EDEMA. Compartment syndrome is caused by severe edema following burns that decreases blood supply distally. The client has 4+ edema to bilateral lower extremities, nonpalpable pedal pulses, and sluggish capillary refill. The client's assessment reveals 4+ edema noted to lower extremities, sluggish capillary refill to lower extremities, and nonpalpable pedal pulses. These are manifestations of compartment syndrome, which are very concerning. This is the highest risk for this client.

A nurse is caring for a client who was admitted 48 hr ago with a burn injury. Client admitted through emergency department after experiencing full thickness burns to hands and face and partial thickness burns to chest. Diagnostic Results 24 hr Following Admission: Sodium: 139 mEq/L (136 to 145 mEq/L) Potassium: 4.8 mEq/L (3.5 to 5 mEq/L) Glucose: 100 mg/dL (74 to 106 mg/dL) BUN: 16 mg/dL (10 to 20 mg/dL) Creatinine: 0.8 mg/dL (0.5 to 1 mg/dL) WBC Count: 9,500/mm3 (5,000 - 10,000/mm3) Hemoglobin: 15 g/dL (12 to 16 g/dL) Hematocrit: 46% (37% to 47%) 48 hr Following Admission: Sodium: 136 mEq/L (136 to 145 mEq/L) Potassium: 4.2 mEq/L (3.5 to 5 mEq/L) Glucose: 189 mg/dL (74 to 106 mg/dL) BUN: 10 mg/dL (10 to 20 mg/dL) Creatinine: 0.5 mg/dL (0.5 to 1 mg/dL) WBC Count: 18,000/mm3 (5,000 to 10,000/mm3) Hemoglobin: 12 g/dL (12 to 16 g/dL) Hematocrit: 36% (37% to 47%) Vital Signs 24 hr Following Admission: Temperature: 37.2° C (99° F) Heart rate: 102/min Respiratory rate: 24/min BP: 126/48 mm Hg Oxygen saturation: 95% on 4 L/min nasal cannula Weight: 80.7 kg (178 lb) 48 hr Following Admission: Temperature: 39.2° C (102.6° F) Heart rate: 122/min Respiratory rate: 30/min BP: 176/78 mm Hg Oxygen saturation: 95% on 4L/min nasal cannula Weight: 83.9 kg (185 lb) Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing ____________ and _________________. choices: hypoglycemia infection hyperkalemia fluid overload

the client is at risk for developing FLUID OVERLOAD and INFECTION. During the emergent/resuscitative phase of a burn injury, hypovolemia can occur as fluid is lost due to capillary leakage. The acute/intermediate phase begins 48 to 72 hr after the burn injury. During this time, fluid shifts are occurring within the vascular compartment and fluid overload becomes a risk. Indications of fluid overload include increased pulse rate, elevated blood pressure, weight gain, and decreasing levels of sodium, BUN, hematocrit, and hemoglobin. Clients who experience a burn injury are also at high risk for infection as the protective skin barrier is lost, allowing micro-organisms to invade the tissue.

a nurse in an acute mental health unit is admitting a client who has bipolar disorder. which of the following findings supports the admitting diagnosis of acute mania? The client's spouse reports that client has recently gained weight. The client is dressed in all black. The client responds to questions with disorganized speech. The client reports that voices are telling him to write a novel.

the client responds to questions with disorganized speech RATIONALE:clients who are experiencing acute mania exhibit disorganized speech such as a flight of ideas

clinical depression scales

•Hamilton Depression Scale •National Institute of Mental Health Diagnostic Interview Schedule

a nurse in an acute care mental health facility is assessing a client who has bipolar disorder. which of the following findings indicates the client is at risk for suicide? The client has begun playing basketball with several other clients during the past month. The client identifies with problems expressed by other clients. he client's behavior has become impulsive in the past few weeks. The client states she wants to go home to be with her children and partner.

the client's behavior has become impulsive in the past few weeks RATIONALE:the presence of impulsive behavior is a primary risk factor for suicide and clients who have mania can act in a manner which is hostile, aggressive, and impulsive

home visits

the delivery of nursing care in the patient's living environment, is to maximize the patient's functional ability within the nurse-patient relationship and with the family or partner as appropriate. The psychiatric nurse who makes home visits needs to be able to work independently, is skilled in teaching patients and families, can administer and monitor medications, and uses community resources for the patient's needs. Home visits are especially useful in certain situations, including helping reluctant patients enter therapy, conducting a comprehensive assessment, strengthening a support network, and maintaining patients in the community when their condition deteriorates. Home visits are also useful in helping individuals comply with taking medication. The home visit process consists of three steps: the previsit phase, the home visit, and the postvisit phase. During previsit planning, the nurse sets goals for the home visit based on data received from other health care providers or the patient. In addition, the nurse and patient agree on the time of the visit. As the nurse travels to the home, the nurse should assess the neighborhood for access to services, socioeconomic factors, and safety. 4 parts during the visit: - Greeting phase (establish rapport w family) - Establishes focus of visit (patient and family must be clear regarding the purpose of the visit) - Implementation of service (med administration, health teaching, counseling. This should take up the most time.) - Closure (time to summarize and clarify important points, schedule any additional visits and reiterate patient expectations between visits.) Postivisit phase includes documenting, reporting, and follow up planning.

patient observation

the ongoing assessment of the patient's mental status to identify and subvert any potential problem. An important process in all nursing practice, observation is particularly important in psychiatric nursing. In psychiatric settings, patients are ambulatory and thus more susceptible to environmental hazards. In addition, judgment and cognition impairment are symptoms of many psychiatric disorders. Often, patients are admitted because they pose a danger to themselves or others. In psychiatric nursing, observation is more than just "seeing" patients. It means continually monitoring them for any indication of harm to themselves or others. All patients who are hospitalized for psychiatric reasons are continually monitored. The intensity of the observation depends on their risk to themselves and others. Some patients are merely asked to "check in" at different times of the day, but others have a staff member assigned to only them, as in instances of potential suicide. Often "sharps," such as razors, are locked up and given to patients at specified times. Mental health facilities and units all have policies that specify levels of observation for patients of varying degrees of risk.

Containment

the process of providing safety and security and involves the patient's access to food and shelter. In a well-contained milieu, patients feel safe from their illnesses and protected against social stigma. The physical surroundings are also important in this process and should be clean and comfortable, with special attention paid to promoting a noninstitutionalized environment. Pictures on walls, comfortable furniture, and soothing colors help patients relax. Most facilities encourage patients and nursing staff to wear street clothes, which help decrease the formalized nature of hospital settings and promote nurse-patient relationships. Therapeutic milieus emphasize patient involvement in treatment decisions and operation of the unit; nurses should encourage freedom of movement within the contained environment. Patients participate in maintaining the quality of the physical surroundings, assuming responsibility for making their own beds, attending to their own belongings, and keeping an acceptable living area. Families are viewed as a part of the patient's life, and ties are maintained. In most inpatient settings, specific times are set for family interaction, education, and treatment. Family involvement is often a criterion for admission for treatment, and the involvement may include regular family attendance at therapy sessions.

open communication

the staff and patient willingly share information. Staff members invite patient self-disclosure within the support of a nurse-patient relationship. In addition, they provide a model of effective communication when interacting with one another as well as with patients. They arrange an environment to facilitate optimal interaction and resocialization. Support, attention, praise, and reassurance given to patients improve self-esteem and increase confidence. Patient education is also a part of this support, as are directions to foster coping skills.

Reminiscence

the thinking about or relating of past experiences, is used as a nursing intervention to enhance life review in older patients. Reminiscence encourages patients, either in individual or in group settings, to discuss their past and review their lives. Through reminiscence, individuals can identify past coping strategies that can support them in current stressful situations. Patients can also use reminiscence to maintain self-esteem, stimulate thinking, and support the natural healing process of life review. Activities that facilitate reminiscence include writing an account of past events, making an audio recording and playing it back, explaining pictures in old family albums, drawing a family tree, and writing to old friends.

dissociation

times when thinking, feeling, or behaviors occur outside a person's awareness. It is a coping strategy for avoiding disturbing events. In dissociating, the person does not have to be aware of or remember traumatic events.

schizophrenia clinical courses of progression: Stablization

treatment has begun and symptoms are stabilized. Treatment is intense as medication regimens are established.

Name a medication that is FDA approved for the treatment of Conduct Disorder.

trick question girl! There is not a specific medication approved by the FDA for the treatment of Conduct Disorder.

T or F: Less blood, thicker blood and edema cause circulation problems for the burn patient. The bigger the burn the worse the problem

true

T/F personality disorders may stablize with age

true

True or False? if you are not successful on one type of SSRI, it is very likely that another type of SSRI will work better for you.

true

true or false: Female patients at greater risk for depression and rapid cycling than male patients

true

true or false: Male patients at greater risk for manic episodes

true

Psychoeducation

uses educational strategies to teach patients the skills they lack because of a psychiatric disorder. The goal of psychoeducation is a change in knowledge and behavior. Nurses use psychoeducation to meet the educational needs of patients by adapting teaching strategies to their disorder-related deficits. As patients gain skills, functioning improves. Some patients may need to learn how to maintain their morning hygiene. Others may need to understand their illness and cope with hearing voices that others do not hear. Specific psychoeducation techniques are based on adult learning principles, such as beginning at the point where the learner is currently and building on their current experiences. Thus, the nurse assesses the patient's current skills and readiness to learn. From there, the nurse individualizes a teaching plan for each patient. They can conduct such teaching in a one-to-one situation or in a group format. Psychoeducation is a continuous process of assessing, setting goals, developing learning activities, and evaluating for changes in knowledge and behavior. Nurses use it with individuals, groups, families, and communities. Psychoeducation serves as a basis for psychosocial rehabilitation, a service delivery approach for those with severe and persistent mental illness.

schizophrenia clinical course of progression: Acute Illness

usually occur in late adolescence to early adulthood. Symptoms: episodes of staying up all night for several nights incoherent conversations, aggressive acts against oneself or others. May become delusional and have hallucinations. Substance abuse is common at this stage and risk of suicide is high.

pathophysiologic changes with severe burns: pulmonary

vasconstriction, edema inhalation injuries, due to thermal or chemical irritants. 2-14% have inhalation injuries. Edema upper airway obstructions.. Smoke causes increase mucosal edema and bronchospasms. Carbon monoxide and hydrogen cyanide are poison gases and causes fatalities because it combines with hemoglobin to form carboxyhemoglobin that we treat with 100% O2 to displace the CO in the hemoglobin.

pathophysiologic changes with severe burns: kidney

vasoconstriction decrease blood volume and release of myoglobin from muscle cell damage is excreted by the kidneys causes urine to appear red or dark. If we don't fluid resuscitate then it will casue acute kidney injury.

biggest thing with tricyclic antidepressants

very deadly if they are overdosed

Anorexia Nervosa: Recovery is possible but chronicity can occur with a lifetime of symptoms of ____________, ____________, and ____________ ______________ ______________ symptoms which tends to produce a poorer prognosis.

vomiting, purgings and obsessive-compulsive personality

wound debridement: natural

weeks to months

mirtazapine biggest side effect

weight gain increased cholesterol and triglycerides

a nurse is caring for a client who has bipolar disorder and is taking lithium. the client reports blurred visoin and ataxia. which of the following actions should the nurse take? Withhold the medication. Prepare to administer propranolol. Administer the next dose as prescribed. Plan to administer levothyroxine.

withhold the medication - The nurse should withhold the medication, because the client is displaying manifestations of toxicity, which includes ataxia, confusion, large output of dilute urine, blurred vision, clonic movements, seizures, stupor, severe hypotension, and coma. Pulmonary complications may lead to death.

central area in burns is termed ____________ ___ _______________ due to characteristic coagulation necrosis of cells.

zone of coagulation

Epidemiology of Autism Spectrum Disorder in adolescents

•1.1% of children ages 3-17 years •Occurs more often in boys •Intellectual disability and seizures often exist •Research shows higher levels of lead and mercury than control groups

mania

•Abnormal, persistent mood for at least 1 week May be: Elevated—euphoric Expansive—extreme, dramatic, superior Irritable decreased need for sleep increased energy pressured speech - can be demanding, manipulative - flight of ideas - racing thoughts - clouded judgment/reasoning - poor attention span - denial of mania - people-seek, crave interaction - lack boundaries - easily annoyed - alternating euphoria w irritability, or euphoria w sadness - alienated friends and family

managing anti-cholinergic side effects (dry mouth, blurred vision, constipation, orthostatic hypotension, urinary retention)

•Adequate fluids/ice chips, hard candies •Rise slowly •Fiber

epidemiology and etiology of ADHD in adolescents

•Affects approximately 6.8% of children aged 3 to 17 years old •Twice as high in boys than in girls •A familial history of ADHD, bipolar disorder, substance abuse, exposure to pesticides and lead at a young age, and/or tobacco use during pregnancy increase the risk of ADHD. •Hypersensitivity to foods such as artificial dyes

medications for bipolar disorder

•Antipsychotics - first and second generation (lurasidone, quetiapine) •Useful in acute phase for sleep, decreased agitation •Anticonvulsants (usually tried before Lithium) •Lithium (mood stabilizer) •Antidepressants-SSRIs (may be risky) •Anxiolytics - Benzos

bipolar comorbities

•Anxiety disorders (panic disorder and social phobia) •Substance use •ODD, BPD, phobias, ADHD

lamotrigine s/e and warnings

•Avoid hazardous activities s/e: •Double or blurred vision •Dizziness •n/v/d •Rash, poss. SJS

self-report depression scales

•Beck Depression Inventory •General Health Questionnaire •PRIME-MD •PHQ-9

repetitive transcranial magnetic stimulation (rTMS)

•Can drive home, takes 30-45 min. •Mild discomfort and muscle tension •Contraindicated w/cochlear implants, brain stimulators, med. pumps

cautions with ECT

•Caution for CV issues, increased ICP, stroke, brain tumor, subdural hematoma •Increases stress on heart secondary to seizure activity •Increases ICP and blood flow in brain •S/E (confusion, memory loss, insomnia, HA) •But effects are not permanent

Autism Spectrum Disorder (ASD) in adolescents

•Characterized by persistent impairment in social communication and social interaction with others •May or may not have an intellectual disability •May exhibit delayed and deviant language development including echolalia (repetition of words or phrases by others) •Repetitive rocking and/or hand flapping •May exhibit self-harm such as head banging, biting, and hitting •Fixation on items may occur (require structured environment)

cyclothymic disorder

•Chronic for at least 2 years •Hypomania and depressed mood •Not severe enough to dx bipolar I or II

Treatment of Autism Spectrum Disorder in adolescents

•Consists of designing academic, interpersonal, and social experiences that support the child's development •Outpatient services including family counseling, home care, and medication •Residential care may be necessary as the child reaches adulthood •Structured physical environment

pharmacology goals for bipolar disorder

•Control s/s and prevent future episodes •Will change depending on phase •Find effective meds •Acute manic stage, poss. mood stabilizer, antidepressant, antipsychotic, sleep med •In maintenance phase, mood stabilizer cont. but antipsychotic may be dc'd

Bipolar Disorder theories and risks

•Cycles increase in frequency Possible causes: •Chronic abnormalities of neurotransmitters, esp. serotonin •Inflammation, chronic stress, kindling •Genetics •Psychological theories—mind's attempt to overcompensate for depression •Exposure to stress in individuals with predisposition •ADHD (common comorbid disorder), may be precursor

Persistent Depressive Disorder (Dysthymia)

•DSM-5 characteristics--must have 3 or more s/s of depression •Pervasive (2 or more years; 1 year in children) •Lifelong struggle •Milder, more chronic •Poor appetite, overeating •Insomnia •Low energy •Low self-esteem

Epidemiology of Bulimia Nervosa

•Data reports indicate a lifetime prevalence to be as high as 2% •Typical age of onset is 15-24 years •Females are 10 times more likely than males to experience it •Hispanic and Caucasian women have higher rates than Asian and African American women

phases of major depressive disorder: maintenance

•Decrease or absence of s/s can last for years •Relapse/recurrence always a risk •May require lifelong medication regimen •Prevention is goal

bipolar disorder in children and adolescents

•Depression usually first •Intense rage •Symptoms reflective of developmental level

ADHD diagnostic criteria in adolescents

•Difficulty handling one task at a time •Easily distracted •Impulsive (risk-taking behaviors) •Fail to consider the consequences of their behavior

nursing diagnoses for bulimia nervosa

•Disturbed Body Image •Disturbed Sleep Pattern •Deficient Knowledge •Risk for Dysfunctional Gastrointestinal Motility •Powerlessness

Goals for depression treatment

•Early recognition •Safety •Improved functional status •Remission/recovery •Compliance

nursing diagnoses of autism spectrum disorder in adolescents

•Enhanced Self-Care •Risk for Delayed Development •Disturbed Sleep Pattern •Anxiety •Acute Confusion •Social Isolation

epidemiology and etiology of OCD in adolescents

•Estimated to effect 1% to 2% •Two peaks across the lifespan. One in preadolescent children and the other in early adult life. •More than half of all cases in youth have a comorbid disorder such as a tic, mood, or anxiety disorder. •Studies show a link between infection with B-hemolytic streptococci •Occurs more often in people with first-degree family members with OCD or Tourette Syndrome •Less common among African Americans than non-Hispanic whites

electroconvulsive therapy (ECT)

•For MDD, depression w/psychotic manifestations, schizophrenia w/catatonia, schizoaffective disorder, bipolar w/rapid cycling, unresponsive to meds •Brief electrical current (25-150 seconds) causes seizure •Procedure (2-3 x week for 6-12 treatments) •Need generalized workup (ECG, lab, cxr) •Discontinue benzos (inhibits seizures) •Informed consent or court order •NPO after MN •Atropine or glycopyrrolate pre-op •CRNA for IV paralytic, sedation •Tourniquet on ankle to watch for twitch •IV, EEG electrodes, 100% O2 •VS, ECG, O2 sats before and after

Sodium valproate

•Good esp. in maintenance phase •More effective than lithium with longer time between cycles

norepinephrine dopamine reuptake inhibitors / atypical: s/e and warnings bupropion

•HA •Dry mouth •GI probs, N/V, constipation •Increased HR •Restlessness, insomnia •Decreased appetite, weight loss •Avoid if H/O seizures

interventions for bipolar disorder: acute manic phase

•Hospitalization/meds •May need one-to-one supervision •Monitor fluid intake •High energy snacks/nutrition •Sleep, rest periods •May sleep for days •Protection of client/other clients •May irritate other clients •May need to redirect to other activities

nursing diagnoses: anorexia nervosa

•Imbalanced Nutrition: Less Than Body Requirements •Anxiety •Disturbed Body Image •Ineffective Coping

nursing diagnoses for ADHD in adolescents

•Imbalanced Nutrition: Less Than Body Requirements •Risk for Injury •Disturbed Sleep Pattern •Anxiety •Defensive Coping •Impaired Social Interaction •Ineffective Role Performance •Compromised Family Coping

treatment of mood disorders in adolescents

•Improve the mood •Restore sleep and appetite •Improve self-care •Antidepressants for depression •Antipsychotics for bipolar disorder

nursing diagnoses for OCD in adolescents

•Ineffective Coping •Compromised Family Coping •Ineffective Role Performance

nursing diagnoses of tourette and tic disorders in adolescents

•Ineffective Coping •Impaired Social Interaction •Anxiety •Compromised Family Coping

nursing diagnoses in mood disorders of adolescents

•Ineffective Coping •Risk for Suicide •Chronic Low Self-esteem •Self-Neglect •Imbalanced Nutrition: Less Than Body Requirements •Disturbed Sleep Pattern

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (venlafaxine, duloxetine) s/e and warnings

•Insomnia •Dizziness •N/V, appetite changes •Weight gain •Diaphoresis •Sexual dysfunction •Caution in clients with HTN

depression in children

•Irritable •Changes in sleep •Anxiety •Somatic complaints •Won't play or join in •Suicidal •Harder to diagnose

Major Depressive Disorder expected findings

•Lack of energy •Poor posture, slowed speech, lack of hygiene •Anhedonia •Anxiety/irritability •Changes in sleep, appetite, libido

Hypomania

•Less severe than mania •At least 4 days •3 or more manifestations of mania •Less impaired •Hospitalization not required •Can progress to full blown mania

tricyclic antidepressants (amitriptyline, imipramine) s/e and warnings

•Lethal overdose risk •Weight gain •Drowsiness •Anti-cholinergic effects •Dizziness/orthostatic hypotension •No 90 day rxs

interventions for bipolar disorder: maintenance phase

•Lifelong •Therapy •Resistance to recovery, vulnerability to relapse •Life changes •Social functioning/training •Groups (support, family, vocational training) •Community mental health

epidemiology and etiology of mood disorders in adolscents

•Major public health concern •14.3% of adolescents effected by a mood disorder with depression representing the largest percentage at 11.7% and bipolar I and bipolar II comprising 2.9% •More prevalent in girls

Monoamine Oxidase Inhibitors - MAOIs (phenelzine, selegiline, isocarboxazid) s/e and warnings

•Many drug interactions; poss. serotonin syndrome •Muscle twitching/forceful jerks, rigidity •Can cause hypertensive crisis if tyramine consumed - always teach about dietary restrictions of TYRAMINE

patient education / teaching for anorexia

•Medication •Nutrition and eating patterns •Effect of restrictive eating or dieting •Weight monitoring •Safety and comfort measures •Avoidance of triggers •Self-monitoring techniques •Trust •Realistic goal setting •Resources

interventions for bipolar disorder: continuation phase (4-9 months)

•Medication management/surveillance •Strategies to decrease agitation/restlessness •Weight control/exercise •Once mood is stabilized, teach to identify triggers •Teaching r/t self care, self monitoring •Changes to report (have someone help monitor—physician, friend, family) •Therapy •Activities

patient education / teaching for bulimia nervosa

•Medications •Binge-purge cycles and the effects it has on the body •Nutrition and eating patterns •Hydration •Avoidance of cues •Cognitive distortions •Limit setting •Appropriate boundary setting •Assertiveness •Resources •Behavioral interventions •Realistic goal setting

Serotonin syndrome symptoms

•Mental status changes, agitation, ataxia, hyperreflexia, fever, diaphoresis, diarrhea •Client/family education •Develops within hours of administration •Stop the drug •Not as deadly as neuroleptic malignant syndrome

pharmacologic treatment of ADHD in adolescents

•Methylphenidate (Ritalin)- psychostimulant •Concerta, Ritalin LA, Metadate ER (longer acting Ritalin) •Amphetamine-dextroamphetamine (Adderall XR) •Atmoxetine (Strattera)- non stimulant (less likely to disrupt sleep) BOOK WILL SAY THIS IS THE FIRST LINE TREATMENT OF ADHD (but this shit don't work fr)

bipolar disorder in older adults

•More neurologic and cognitive disturbances •Incidence of mania decreases with age

Tyramine containing foods

•Most cheese, red wine, chocolate •Ripe avocados/figs •Smoked meat, dried/cured fish, liver •Protein supplements

treatment of bulimia nervosa

•Multimodal treatment approach •Cognitive Behavioral Therapy (CBT)- setting boundaries •Antidepressants •Nutritional counseling •Group therapy •Support groups •Medication- Fluoxetine 60mg per day is the most common but other antidepressants are used.

mirtazapine side effects

•N/V -wt. gain -HA -fatigue -anti-cholinergic effects -bowel changes -increased cholesterol/triglycerides

client / family education for all antidepressants

•Never DC suddenly •May take weeks to see full effects •Do not mix with other meds unless directed •No alcohol or other CNS depressants •Avoid hazardous machinery/driving until sure of effects •Notify provider/nurse of any SI •Compliance is key

care roadblocks in bipolar disorder

•Non-compliance big issue •Self-medication •Elevated sense of abilities, poor judgment and cognition •Delusions, hallucinations common •Fragmented thinking

What is an appropriate nursing diagnosis for a child/adolescent with Oppositional Defiant Disorder (ODD)?

•Noncompliance with therapy •Defensive coping •Low self-esteem •Impaired social interaction

carbamazepine s/e

•Nystagmus, double vision •Vertigo •HA •Staggering gait •Rash, poss. Stevens Johnson syndrome (teach Pt to report signs of rash immediately)

epidemiology and etiology of tourette and tic disorders in adolescents

•Occurs in approximately 0.2% of children ages 3 to 17 years of age •Boys are affected more than girls •OCD is frequently present •Primarily inherited disorder

nursing assessment for depression

•Physical assessment/history •Sleep patterns/appetite (important) •Mood/Affect •Thought content •SI/HI •Cognition •Memory •Developmental history •Family history •Relationships/support systems •Work/social/education history •H/O abuse •Spiritual dimension

epidemiology and etiology of schizophrenia

•Present in 0.7% of the worldwide population •Tend to cluster in the lowest social classes •Many become homeless •Hereditary •Environmental factors including migrant status, having an older father, Toxoplasma gondii antibodies, prenatal famine, lifetime cannabis use, obstetric complications •Usually diagnosed in late adolescence •Boys tend to be diagnosed earlier and have a poorer prognosis than women •First degree biologic relatives of an individual with schizophrenia have a 10 times greater risk for developing schizophrenia than the general population •Onset before age 13 is very rare

mental heath disorders of childhood and adolescence

•Psychiatric disorders in children are less easily recognized •13%-20% of children in the U.S. experience a mental disorder in a given year •Only a fraction receive mental health services

depression in older adults

•Respond more slowly to tx •Poly-pharmacy •Differential dx •Dementia •S/E of meds •May seek treatment for physical complaints •SI

Binge Eating Disorder (BED)

•Separate eating disorder listed in the DSM-5 •Individuals binge but do not purge or compensate for the binges •Most individuals are obese •10%-30% of obese individuals have BED •Treatment is still in the investigative stage and most experts use interventions similar to those used to treat bulimia nervosa

Lithium toxicity symptoms

•Serum levels for toxicity (0.6-1.2 mEq/L) •May be symptomatic at different level than others, may be toxic at 2.2, other pt. at 1.5, etc. Advanced toxicity: •Extreme polyuria •Tinnitus •Giddiness •Ataxia •Seizures •Hypotension •Stupor •Coma, poss. death

psychological characteristics r/t anorexia

•Sexuality conflict or fears •Maturity fears •Ritualistic behaviors •Perfectionism •Emotional Dysregulation- emotional dysregulation refers to the inability of a person to control or regulate their emotional responses to provocative stimuli. It can also be termed "emotional hyperreactivity."

DSM-5 Major Depressive Disorder

•Single or recurrent episodes not accompanied by mania, significant functional changes •5 or more of these s/s for 2 weeks, most days, lasts most of the day •Depressed mood •Insomnia/Hypersomnia •Indecisiveness •Decreased ability to concentrate •S/I •Increased or decreased motor activity •Anhedonia •Wt change of 5% or more within one month •Not due to substance abuse

nursing assessment of bipolar disorder

•Sleep pattern/changes •Appetite, malnutrition, and fluid imbalances •Labs-thyroid/endocrine problems might be cause •STD screening, pregnancy test •Drug screen •Medication history •Previous episodes/psych dx •Assess mood, thoughts, perceptions, affect •Observe behavior •Ask family about their observations •Grooming, appearance •Hypersexual behavior •Mood disorders questionnaire -- Standardized tool places mood on continuum -- Hypomania to acute mania to delirious mania •Acute phase of mania (mental status abnormal, thought processes disturbed) •Antecedent often stressful event •Job loss •Financial issues •Relationship changes •Assess coping skills (aggression, substance abuse, or running away)

ongoing care / goals for bipolar disorder

•Stabilization, quality of life •Client/family teaching •Hosp (usually brief) •F/U in outpt setting •Therapy to provide psychosocial support •Once DC'd, need continuous care

Lithium administration considerations

•Start slow, gradually increase as needed for control of s/s •Reduction in salt intake will retain lithium, increase in lithium retention, leading to toxicity •Decreased salt intake causes wash out of lithium •Once stabilized, salt intake should remain constant •Increase salt intake during periods of dehydration •Monitor wt gain/reduction strategies

comorbities of bulimia nervosa

•Substance abuse •Depression •OCD •High risk of suicide •Self-mutilation •High levels of impulsivity (shoplifting & overspending)

Selective Serotonin Reuptake Inhibitors (SSRIs) (fluoxetine, citalopram, sertraline, escitalopram) s/e and warnings

•Sweating •Dizziness •N/V •Appetite changes/weight gain •Sexual dysfunction •Serotonin syndrome—withhold med and notify provider •No St. John's Wort

managing anti-histamine side effects (drowsiness)

•Take at night •Avoid driving, dangerous activities

patient teaching with lithium

•Teach to keep sodium or water intake stable unless a condition necessitates increase

treatment for PMDD

•Treatment is exercise, diet, relaxation therapy •Poss. SSRIs

characteristics of bulimia nervosa

•Usually a normal weight •Present as "social butterflies" •Difficulty setting limits and establishing appropriate boundaries •Set enormous amount of rules regarding food and food restriction •May show signs of impulsivity (spending habits)

Name a medication used in the treatment of anorexia nervosa.

•fluoxetine (Prozac) •imipramine (Tofranil) •desipramine (Norpramin) •amitriptyline (Elavil) •nortriptyline (Aventyl) •phenelzine (Nardil)

What two antipsychotic medications are approved by the FDA for treatment of tics associated with Tourette's Disorder?

•haloperidol (Haldol) •pimozide (Orap) - often not the first-line choice of therapy due to the potential for severe adverse side effects.