Mental Health Exam 1
Somatic disorder
(Hypochondriasis) persistent psychological problem that converts to physical symptoms, no apparent physical cause
S/S of panic disorder
*Fear of impending doom, fear of future panic attacks, SOB* -tachy -sweating -chills -problems with breathing -tingling/numbness -chest pain -nausea/dizzy
The nurse should plan which goals of the termination stage of group development?
- the group evaluates the experience. - The group explores members' feelings about the group and the impending separation.
The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.
-Battery -Assault -False imprisonment
A patient is experiencing anxiety and alcohol addiction. What are the best courses of treatment?
-Buspar -Clonidine -Propranolol -Cognitive behavior therapy
Treatment for somatic disorder
-CBT -group
Treatment for PTSD
-EMDR (eye movement desensitization and reprocessing) -Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) -Benzos -Clonidine -Propranolol -antipsychotics (only for severe)
EMDR
-Eye-movement Desensitization & Reprocessing. -For PTSD -client imagines the traumatic event and processes it in a non-threatening manner.
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.
-Restating - Listening - Maintaining neutral responses - Providing acknowledgment and feedback
Aspects of therapeutic milieu
-Safety (most important) -Structure (environment and regulations) -Normal (expectations) -Limit setting (limits to behaviors & consequences) -Balance (independence and dependence)
S/S of benzo withdrawal
-agitation -tremors -irritability -vomiting -convulsions -psychotic episodes
S/S of Xanax withdrawal
-agitation -tremors -irritability -vomiting -convulsions -psychotic episodes -insomnia -sweating
When to seek consent from guardians?
-change in meds -if pt needs to be admitted involuntarily
Laws affecting mental health nursing
-constitution -statutory law (state/federal) -common law (legal cases) -administrative law (joint commission) -centers for Medicare
S/S of PTSD
-nightmares -flashbacks -intrusive thoughts -hypervigilance -hyperarousal -irritability -angry outbursts
OCD is characterized by...
-repetition -ritualistic activities -recurrent intrusive thoughts -fear of losing control -interference with regular activities
If you stop a benzo you have been on for years, the nurse should initiate what type of precautions?
-weaning do not stop all the sudden. May cause seizures
Restraint/seclusion guidelines
1. Staff must be trained 2. Alternatives must be considered first 3. Physician order required within 1 hour of restraint or seclusion 4. Least restrictive method must be chosen 5. Nurses should complete all documentation 6. Orders must contain restraint type, rationale, and time limitations 7. PRN orders not permitted. Each episode based on eminent risk 8. Restraint/seclusion for shortest possible time; reevaluate every 2 hrs 9. Constant observation and Q15min documentation 10. Pts must be debriefed after 11. Pts have right to notify family 12. Death of pt in restraints must be recorded to FDA
Age of identity vs role confusion? Favorable/unfavorable outcomes?
13-21y Favorable: seeing oneself as unique and integrated Unfavorable: confusion over who and what really is
Age of autonomy vs shame and doubt? Favorable/unfavorable outcomes?
18 months to 3 years Favorable: sense of self/control and adequacy Unfavorable: feelings of shame/self-doubt
Buspar (buspirone)
1st line Anti-anxiety Long term Treat alcohol addiction
When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continued contact with a crisis counselor 4. Eliminating all anxiety from daily situations
2
When do SSRI's begin to work? When does it reach full potential?
2 weeks 4-6 weeks
How long does Ativan take to work?
20-30 min
Age of intimacy vs isolation? Favorable/unfavorable outcomes?
21-39y Favorable: ability to make commitments to others/love Unfavorable: inability to form affectionate relationships
Age of initiative vs guilt? Favorable/unfavorable outcomes?
3-5yrs Favorable: able to be self starter Unfavorable: sense of guilt/inadequacy to be on ones own
Age of generativity vs stagnation? Favorable/unfavorable outcomes?
40-65y Favorable: concern for family and society Unfavorable: concern only for self and ones prosperity
Age of industry vs inferiority? Favorable/unfavorable outcomes?
5-13y Favorable: ability to learn, understand and organize Unfavorable: sense of inferiority at understanding and organizing
Age of integrity vs despair? Favorable/unfavorable outcomes?
65+ Favorable: sense of fulfillment and willing to face death Unfavorable: dissatisfaction with life and despair over prospect of death
When does buspar begin to work? When does it reach full potential?
7-10 days 1-6 weeks
Client with GAD presents with restlessness, irritability, bp 140/90, pulse 96, RR 20. On the basis of these assessed data, which assumption would be correct?
A physical exam is needed to determine the etiology of the clients symptoms
Nurse doesn't speak, but he/she does maintain eye contact and nod their head when the patient speaks.
Active listening
Why is ativan only given PRN/when patient has panic attack?
Addicting and short acting
How does OCD affect the brain?
Affects surface area and thickness of the cortex in the brain unregulated serotonin
Silence (therapeutic communication)
Allow pts to think and say more
Goal of erikson model
Analyze developmental issues, fears, and barriers to growth to master skills
Client diagnosed with OCD. Which nursing diagnosis takes priority?
Anxiety R/T regression of ego development AEB ritualistic behaviors
A pt starts talking about spirits and how they talk to them. What should you ask?
Ask if they are spiritual. Do not assume they are hallucinating
Clarification (therapeutic communication)
Asking pts to restate, elaborate, or give examples of ideas or feelings
1st line treatment for panic disorder?
Benzos
Goal of Freud model
Bringing unconscious into the conscious
"What do you mean by..."
Clarification
Making observations (therapeutic communication)
Commenting on what is seen or heard to encourage discussion
Defense mechanism: Malcolm who is depressed and unable to share his feelings with others, writes and becomes known for his expression poetry.
Compensation
Factitious disorder
Condition in which a person acts as if he or she has a physical or mental illness when he or she is not really sick.
Pt States, "I really want to find ways to relax, but I don't have time for yoga or massages." Nurse states, "On one hand you want to relax, but on the other hand you are saying you don't have time. How do you feel about this conflict?"
Confrontation
Rationalize
Conscious or unconscious attempts to make or prove that one's feeling/actions are justifiable
Internationalization
Consciously or unconsciously using only logical explanations without feelings or an affective component
A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?
Contact HCP
Defense mechanism: Student wakes up with a migraine the morning of a final exam and feels too ill to take a test. If she doesn't pass the exam, she will flunk out of nursing school.
Conversion
What is the guide book for working with psych patients?
DSM-5
Defense mechanism: Max who is alcohol dependent believes he can control his drinking if he desires
Denial
Goal of attachment model
Develop safe/secure emotional bonds
Defense mechanism: Mrs. Adams recalls that when her husband was yelling at her she didn't feel anything inside, she just went numb
Disassociation
Defense mechanism: A husband comes home from a hard day at work and yells at his wife and kids
Displacement
Tarasoff vs. region to the University of California
Duty to warn of threats of harm to others
How to respond to a patient regarding unit milieu
Educate pt on unit orientation -safety first
Attachment model
Emotion centered treatment method by developing safe and secure emotional bonds in relationships' "How does that make you feel"
Nurse states, "This must be very painful for you to discuss."
Empathy
Goal of recovery model
Empower consumer/family to manage treatment
A patient begins to have a panic attack. What is the first thing you do? What med do you give as next step?
Ensure they are safe and be there for them Ativan
Developmental model
Erikson Analyzing developmental issues, fears, and barriers to growth to facilitate mastery of developmental tasks "I can help you look at ways to develop your ability to trust others"
Norms
Expected behavior in milieu to promote safety and trust -hygiene -dont harm self -attend group -focus on treatment plan
Involuntary patients can be forced to take psych meds even if they refuse T/F
False
Least restrictive environment helps avoid what?
False imprisonment
Which S/S would nurse expect from client with agoraphobia?
Fear of standing in line Fear of being outside of home alone Fear of traveling in a car
Benzo overdose antidote
Flumazenil (Romazicon)
"explain more about..."
Focusing
Psychoanalytical model
Freud Personality centered treatment method Bringing unconscious to conscious by enhancing awareness of self and ones effect on others "Tell me about your relationship with your mother"
When a patient in the mileu requires seclusion, what should you consider for the other patients?
Heightened anxiety from the situation may require medication Ensure they are safe and doing okay
Confrontation (therapeutic communication)
Helping patient become aware of inconsistencies in his feelings, attitude, beliefs, behaviors
Defense mechanism: Kelly states to the nurse "When I get out of the hospital, I want to be a nurse just like you"
Identification
McNaughten Rule
If individual is declared insane they cannot be legally accountable for murder
Age of trust vs. mistrust? Favorable/unfavorable outcomes?
Infant-18 m Favorable: faith in environment/Future Unfavorable: suspicion/fear
The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship?
Inquiring about and examining the client's feelings for any that may block adaptive coping
Defense mechanism: Rene talks about her sons death from cancer as being merciful and shows no signs of sadness or anger
Internationalization
Defense mechanism: Without realizing it Marie talks and acts similarly to her therapist, analyzing other pts
Introjection
Goal of Interpersonal model
Learn effective interpersonal skills using pt/nurse relationship to analyze interpersonal processes and test new skills
Interpersonal model
Learning effective interpersonal skills by using the nurse/pt relationship as a vehicle for analyzing interpersonal processes and testing new skills "Lets talk about what kind of tings make you nervous in your relationship with your father"
Nurse states, "You seem really upset today."
Making observations
What is the psychologist responsible for?
Meds
When reviewing pts chart she notices client was admitted involuntarily. What nursing intervention is priority?
Monitor closely for harm to self and others
Presenting reality (therapeutic communication)
Offering a view of what is real and what is not without arguing without the pt
Suggesting (therapeutic communication)
Offering help to solve problems
States, "I'll stay with you for a while."
Offering self
A client experiencing disturbed thought processes beliefs his food is poisoned. Which communication technique should the nurse use to encourage the client to eat?
Open ended questions and silence
Questioning (therapeutic communication)
Open ended questions to achieve relevance and depth in discussion
Therapeutic relationship phases
Orientation: -beginning of partnership between nurse/pt -nurse informs pt about role, completes assessment, agrees on goals/expectations Working: -works to achieve goals Termination: -goals have been met -sharing feelings related to ending of therapeutic relationship
Level 5 Anxiety
Panic -requires supervision -perceptions greatly disorganized -control of self is lost
Active listener (therapeutic communication)
Paying close attention to verbal and nonverbal communications
How long do panic attacks last?
Peak: 10 min Up to: 30 min
Which part of brain responsible for personality?
Prefrontal cortex in the frontal lobe
Nurse states, "I know the things you are seeing are real to you; however, I don't see them."
Presenting reality
Defense mechanism: Connie blames her husband for the fight last night, unable to recognize that she started it
Projection
Examples of SSRIs
Prozac Zoloft Luvox Paxil
Recovery model
Pt centered treatment method by empowering pt/family to define and manage treatment options "What are your treatment goals?"
Wyatt vs. Stickney
Pts have right for adequate treatment and cannot be treated like slaves
Rogers vs. Achen
Pts have right to refuse and cannot be forced to take meds against will
Focusing (therapeutic communication)
Pursuing a topic until meaning/importance is more clear
Nurse is assessing a client and states, "Tell me about your relationship with your husband."
Questioning
Defense mechanism: John tells his mom that he bit his sister because she pushed him first
Rationalization
Defense mechanism: Wren, whos parents are divorcing, tells her mother she doesnt want to spend time with her dad (so her mother doesnt get mad) even though she really misses him
Reaction formation
Empathy (therapeutic communication)
Recognizing/acknowledging pts feelings
Defense mechanism: 5 year old has been wetting his bed since the birth of his baby sister
Regression
Restating (therapeutic communication)
Repeating pt to remind them and let them know they are heard
Defense mechanism: Anna, a victim of incest, has limited memory of her childhood
Repression
Nurse states, "You say that you are an only child."
Restating
Summarizing (therapeutic communication)
Reviewing main points and conclusions
Best meds for treatment of OCD
SSRIS or clomipramine
What is the first line treatment for anxiety?
SSRIs/buspar
Side effects of Ativan
Sedation, dizziness
Level 4 Anxiety
Severe -fight/flight -disorganized -increase motor activity
Pt. states, "I am having trouble with my marriage. My husband doesn't understand me. He comes home from work and sits on the couch. I have to do everything around the house." Nurse sits quietly and listens to patient
Silence
A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing? 1. Agoraphobia 2. Social phobia 3. Claustrophobia 4. Hypochondriasis
Social phobia
What is the chaplain responsible for?
Spiritual concerns
Therapeutic Milieu
Stable, structured, and safe emotional and physical environment that provides ongoing therapy of various types for a psychiatric patient.
The client is experiencing a panic attack. He states "I'm losing control. I feel like I'm going crazy". Which nursing intervention takes priority?
Stay with client and offer support
Defense mechanism: Guy, a former heroin addict, starts a local narcotic anon meeting
Sublimation
Goal of cognitive behavioral model
Substitute rational beliefs for irrational ones
Cognitive-behavioral model
Substituting rational beliefs for irrational ones to reduce nonproductive behaviors "Lets make a list of advantages and disadvantages of thinking and acting that way"
Nurse asks, "Have you ever considered going for a massage?"
Suggesting
Nurse states, "So far you have said that..."
Summarizing
Defense mechanism: Aaron states to the nurse that his recent divorce is not a big deal
Suppression
T/F: Always ask for permission before hugging pt.
T
What is the most important skill a psych nurse can possess?
Therapeutic communication
What is the nurse responsible for?
Therapeutic communication
If a person requires a higher dose after an amount of time to receive the safe effect, what is that?
Tolerance
Defense mechanism: After accidently eating another pts cookies, Don apologizes to his peer, cleans the fridge, and labels everyone's snacks with their names.
Undoing
When to seclude patient
When they are at risk of harming self or others
Treatment for phobias
Xanax, ativan (short acting) SSRIs, SNRIs, clonidine, propranolol
Conversion disorder
a disorder in which a person experiences very specific genuine physical symptoms for which no physiological basis can be found
Reaction formation
conscious behavior that is the exact opposite of an unconscious feeling
Suppression
conscious exclusion from awareness anxiety-producing feelings, ideas, or situations
Identification
conscious or unconscious attempt to model oneself after a respected person
Compensation
consciously covering up for a weakness by overemphasizing or making up a desirable trait
Undoing
consciously doing something to counteract or make up for a transgression or wrongdoing
Sublimation
consciously or unconsciously channeling instinctual drives into acceptable activities
A client admitted to a medical nursing unit with a dx of acute blindness after being involved in hit and run. When dx testing cannot identify any reason why the client cannot see, a mh consult is prescribed. The nurse plans care based on which condition?
conversion disorder
Mileu
environment
Pyrophobia
fear of fire
Agoraphobia
fear of public spaces where it might be hard to escape quickly
Arachnophobia
fear of spiders
A culturally competent psychiatric nurse does what?
knowledge about the process of cultural competence but also incorporates cultural competence into interactions with peers, students, patients, families, and communities
Offering self (therapeutic communication)
making oneself available and showing interest/concern
Level 2 Anxiety
mild -can be healthy
Barriers to culturally competent care
miscommunication, failure to assess for a cultural perspective, and differences in worldview.
Level 3 Anxiety
moderate -learning can still take place but may need assistance
Are SSRIs effective for PTSD?
no
Level 1 Anxiety
none/little anxiety -helpful/motivating
Social phobia
overwhelming fears of social situations
Co-occurring inpatient units
pts with both mental health disorder and substance abuse
Utmost concern in psych?
safety
Nursing interventions related to spiritual needs
take a spiritual hx, show support and respect to pts beliefs, can pray with pt if nurse is comfortable and if pt requests, provide spiritual care by being kind, gentle, sensitive, and compassionate, refer to pastoral care
Repression
unconscious and involuntary forgetting of painful ideas, events, and conflicts
Conversion
unconscious expression of intrapsychic conflict symbolically through physical symptoms
Denial
unconscious refusal to admit an unacceptable idea or behavior
Regression
unconscious return to an earlier and more comfortable developmental level
Disassociation
unconscious separation of painful feelings and emotions from an unacceptable idea, situation, or object
Displacement
unconsciously discharging pent-up feelings to a less threatening object
Introjection
unconsciously incorporating values and attitudes of others as is they were your own
Projection
unconsciously or consciously attributing one's own repressed thoughts to someone else
How long do SSRIs take to work?
up to 10-12 weeks usually 4-6 weeks
Therapeutic Communication
verbal and nonverbal exchange which enhances trusting nurse pt relationship to client centered, goal specific, and theory based
