Mental Health 2 Study Guide

A nurse is reinforcing teaching to a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching?

"Cognitive reframing will help me change my irrational thoughts to something positive" - this helps the client looks at irrational cognitions (thoughts) in a more realistic light and to restrictive those thoughts in a more positive way

A nurse is reinforcing teaching about free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique?

"I should say the first thing that comes to my mind." - Free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind

A nurse is collecting data from a client who lost his job and who states he is "under a lot of stress right now." The nurse should recognize that which of the following statements by the client indicates the presence of a protective factor against stress?

"I spend some time praying every day" - Practicing spiritual or religious beliefs, such as meditating or praying, is a protective factor against stress

A nurse is caring for the parents of a child who has demonstrated recent changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son's condition, which of the following responses should the nurse make?

"I understand you're concerned. Let's discuss what concerns you specifically" - the therapeutic response reflects upon, and accepts, the mother's feelings, and it allows her to clarify what she is feeling

A nurse is reinforcing teaching with a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding?

"I will receive a muscle relaxant to protect me from injury during ECT." - A muscle relaxant, such as succinylcholine, is administered to reduce the risk for injury during induced seizure activity

A nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

"I will schedule the client for daily TMS treatments for the first several weeks" - TMS is a commonly prescribed daily for 4 to 6 weeks

A nurse is talking with a client who is at risk for suicide following the death of his partner. Which of the following statements should the nurse make?

"Losing someone close to you must be very upsetting." - This statement is an empathetic responses that attempts to understand the client's feelings

A nurse is reinforcing teaching with a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy?

"The therapist will focus on my past relationships during our sessions" - Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. He expects me to finish his work because he's too lazy!" When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding?

"When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities." - This response demonstrates assertive communication, which allows the client to state his feelings about the behavior, and then promote a change

Intrapersonal Communication

"self-talk" takes place with oneself Conversations with self when solving problems, making plans, react emotionally Adaptive when helping us cope or focus energies in 1 direction

Inpatient Client Types - Crisis

1 to 2 day treatment settings for interventions to establish balance = getting client out of crisis mode Intensive counseling; medications adjustments Stress management techniques taught Goal: help to cope with crisis Referrals or resources

4 steps for Caring

1. Become aware of your client as an individual 2. Learn to respect the uniqueness and individuality of each person 3. Increase your knowledge of the client's needs 4. Develop mutual sharing

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify the which of the following clients requires a temporary emergency admission?

A client who has borderline personality disorder and assaulted a homeless man with a metal rod - client who is a danger to self or others is a temporary emergency admission

The nurse is assisting with the care of a group of clients. Which of the following clients should a nurse consider for referral to a Program Assertive Community Treatment (PACT) group?

A client who lives at home and says he keeps forgetting to come in for his monthly antipsychotic injection for schizophrenia - A PACT group works with clients who are non adherent with traditional therapy, such as the client in a home setting who keeps "forgetting" his injection

A nurse is assisting with the care of several clients who are attending community-based mental health programs. Which of the following clients should the nurse plant to visit first?

A client who says he is hearing a voice that tells him he is not worthy of living anymore - the client's report of an auditory hallucination indicates that this client is at greatest risk for self-harm

Codependency

A relationship becomes unhealthy when it beings to fulfill the caregiver's needs Therapeutic effectiveness is lost resulting in unresolved feelings and unmet goals - client/caregiver may withdraw

Develop mutual trust - Empathy

A very powerful therapeutic tool When we recognize and show emotions to an individual that is going through a situation that we have not experienced but do have concern

Autonomy

Ability to direct and control one's activities and destiny Do not give our own opinion Include client in all decision making processes when appropriate Do not foster a dependent relationship by making all decisions for your client

Sensorium and Cognition - Calculation

Ability to do simple math

Sensorium and Cognition - Concentration

Ability to pay attention and answer questions

Sensorium and Cognition - Memory

Ability to recall past events, experiences and perception

Empathy

Ability to walk in another person's shoes Can develop through active listening-no specific directions for developing empathy Focus on the client

Mentally health adult

Able to cope and adapt to changes in their lives (functional in society) Basically content with who and where they are in life (ability to love, express love freely, have a good relationship with others) Flexible-willing to try something new and eager to learn

Principles of therapeutic communication

Acceptance Interest Respect Honesty Concreteness Assistance Permission Protection

Unpleasurable Responses (Dyshphoric)

Aggression: anger, hostility, or range that is out keeping with situation Agitation: motor restlessness, often seen with anxiety Ambivalence: having both positive and negative feelings about the same subject Anxiety: vague, uneasy feeling, often from unknown cause Depression: sadness, hopelessness, loss that is present over time Fear: reaction to recognized danger

What does DSM-IV-TR do?

Aids in diagnosing and help guide clinical practice Assessed and classified according to 5 categories or axes

Types of delusions Preoccupations

All experiences and actions are connected to central thought that is usually emotional in nature

Silence - Effective communication skills and techniques

Allows time for meaningful reflection

Intrapersonal dysfunction

Altered states of functioning (Ex:hallucinations)

When self-talk is dysfunctional?

Altered states of functioning - Ex: hallucinations

Non-therapeutic Communications - Being defensive

An attempt to protect something or someone; prevents clients from communicating

Communication

An essential part of survival and interaction between 2 or more people If we could not communicate some way, we could not make it on our own, we have to someway to communicate and exchange information

Nonverbal communication

Appearance, posture, gait, facial expressions, eye contact, gestures, sounds, territoriality, personal space, silence

Environmental Factors Evaluation

Are the basic needs being met before the patient is feeling any kind of self-worth

Therapeutic Self - Questions about Nursing Interventions

Are we attending to their needs? Are we encouraging the client? Are we monitoring verbal and nonverbal messages? Is our energy focused on the client? Are we acting as successful role models for our clients?

Therapeutic Communication Technique - Sharing Perceptions

Asking client to verify caregiver's understanding of client's message

Barriers to effective communication

Asking irrelevant personal questions Offering personal opinions Giving advice Giving false reassurance Minimizing feelings Changing the topic Asking "why" questions Offering value judgments Excessive questioning Responding approvingly or disapprovingly

A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict-resolution techniques. The nurse is correct in implementing this form of group leadership when she demonstrates which of the following actions?

Asks for group suggestions of techniques and then supports discussion - Democratic leadership supports group interaction and decision-making to solve problems

Mental Status Exam Purpose

Assess pt's current state of mind Allows observation and describe behavior in an objective, non-judgemental way Tool to assess mental dysfunctions and identifies causes of client's problems

A community mental health nurse is assisting with a plan of care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse recommend as a method of tertiary prevention?

Assisting in establishing rehabilitation programs to decrease the effects of depression - Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness

Therapeutic Communication Technique - Clarification

Attempting to put into words vague ideas or unclear thoughts of client; asking client to explain what he/she means

A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow-up care?

Attending a partial hospitalization program

A nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol. This method is an example of which of the following types of treatment?

Aversion therapy - This therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior

Ways that can build trust with your client

Be realistic - when talking to the client and giving an explanation Follow through on verbal statements Be honest - includes things the client may not want to hear like rules Explanations needs to be at client's level

Think in terms of therapeutic communication

Being a skilled listener Effectively understand and communicate with patients Positive outcome from the exchange

A nurse is attending a peer group discussion about the indications for ECT. Which of the following disorders should the nurse expect to include?

Bipolar disorder with rapid cycling - ECT is indicated for the treatment of bipolar disorder with rapid cycling

Mental Status Exam Speech Patterns Assoc with psych problems

Blocking: loses train of thought, stops speaking because of unconscious block Circumstantiality: describes in too much detail, cannot be selective Echolalia: repeats last word heard Flight of ideas: shifts rapidly between unrelated topics Loose Association: speaks constantly, shifting between loosely related topics Mutism: able to speak but remains silent Neulogism: coings new words and definitions Perseveration: repeated single activity, cannot shift from one topic to another Pressured speech: speech becomes fast, loud, rushed and emphatic Verbigeration: repeat words, phrases, and sentences several times over

Maslow's Hierarchy of Needs

Bottom tier - psychological needs: food, water, warmth, rest (basic needs) Safety needs - security, safety (basic needs) Love and belonging - intimate relationships, friends (psychological needs) Esteem - prestige and feeling of accomplishment (psychological needs) Top tier - self actualization: achieving ones full potential, including creative activities (self-fulfillment needs)

A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role?

Bragging about accomplishments - An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals

Inpatient Client Type - Acute mental or emotional problems

Cannot function sufficiently to satisfy needs Feel weakened and hopeless May be an involuntary admission - dehumanization Most successful treated with vigorous and well coordinated interventions Some progress to chronic maladaptive responses and cycles of repeated admissions (some individuals cannot handle treatment and it leads to chronic illness)

MILIEU

Certain settings or environments designed to help replace inappropriate behaviors with more effective personal and psychosocial skills (hospital, home, acute care units, long term care units, community settings)

Orientation Phase

Client and caregiver become acquainted, agree to work together, and establish a purpose for the relationship Establish a working agreement Discuss expectations and goals Patients are going to be trying, make sure you are supporting facility policies

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? Select all that apply

Client was offered 8oz water every hr - how much water was offered and how often it was - objective data Client should obscenities at assistive personnel - A description of the client's verbal communication - objective data Client received chlorpromazine 15mg by mouth at 1000 - The dosage and time of medication administration is objective data

Transference

Client's emotional response based on earlier relationships to the caregiver Past feelings, conflicts or attitudes go onto the present relationship, present circumstance, and present situation disrupting the therapeutic relationship Client's may become hostile and possible have no intentions of continuing the therapeutic relationship

Characteristics essential to therapeutic communication?

Client-centered: not social or reciprocal Purposeful, planned, and goal-directed Building rapport Trust Respect Genuineness Empathy

What is Axes 5?

Codes the level of function that the individual has attained at the time assessment and in some cases is used to indicate the highest level of function in the past year - Based on a level 0-100 the physician uses the GAF scale

Transpersonal communication

Communication that addresses an individual's spiritual needs and provides interventions to meet those needs, the nurse uses this when they assist the client with meditation as a means of relaxation

Small-group communication

Communication that occurs between two or more people in a small group, which allows the nurse to discuss a change in client's behavior with the health care team or discuss concerns during a group therapy session

Intrapersonal communication

Communication that occurs within an individual, also identified as "self-talk." Solve problems, make plans, react emotionally. Adaptive when helps us cope or focus energies in 1 direction

Public communication

Communication that occurs within large groups of people, this commonly occurs during educational endeavors where the nurse is instructing a large group of individuals = Ex: nurse informing a school assembly

Vital elements of health care

Compassion Empathy Acceptance

Therapeutic Listening Skills

Concentrate on the speaker and the message Keep distractions and interruptions to a minimum Change the setting (environment) if necessary Assess nonverbal communications Listen objectively and without judgement Discover which words trigger emotional responses in you Use eye contact and body language that is culturally appropriate Do not interrupt. Let the speaker finish delivering the message Jot down notes if needed Do not assume that you have understood another person's thoughts Clarify any messages about which you are unsure

Non-therapeutic Communications - Parroting

Continuous repeating of client's words

Behavior components

Core beliefs that turns into a thought, that turns into a feeling, based on the feeling an action occurs - but all actions have positive or negative consequences

Preparation Phase

Data gathering phase; caregiver is preparing for the relationship Time to find out as much as you can about the new client Preparing yourself for the relationship and plan of care Do not accept labels as facts - remain open-mined but prepared

Professional boundaries

Define the needs of the caregiver as distinctly different from the needs of the client Focus of professional aspect of caregivers life is the client - up to the professional to hold themselves accountable to these boundaries

A nurse is assisting in planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase?

Define the purpose of the group - During the initial phase, the nurse should identify the purpose of the group Discuss termination of the group - During the initial phase the nurse should discuss termination of the group Establish an expectation of confidentiality within the group - During the initial phase the nurse should set the tone of the group, including an expectation of confidentiality

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing, because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanism?

Denial - pretending the truth is not reality to manage the anxiety of acknowledging what is real

A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify an. an acute stress response?

Depressed immune system Increased blood pressure Unhappiness - all an indicator of acute stress

Effective Interviewing

Develop a skill set and talk to pts to get the info you need to help them Personal values must not cloud professional judgements (do not react, this can negatively impact the pt, just gather the info needed) Discover what each event means to the client (do not make assumptions about how you think the client feels or should feel!) Consider cultural values and beliefs (find out their thoughts and what they are thinking) Pay attention to nonverbal communication What subjects are avoided or quickly passed over or neglect during the interview - investigate and tell the physician/social worker what the didn't talk about Observe methods of self-expression (unspoken signals that the pt communicates) Have clearly set goals in mind (know the intent of the interview/conversation, what the purpose is and what we are trying to accomplish and try to stay on task) Monitor own reactions during the interview/conversation - have self awareness, know what kind of nonverbals we are using (do I look bored, what are my eyes doing)

What does DSM-IV-TR stand for?

Diagnostic and Statistical Manual of Mental Health Disorders IV-Text Revision

Therapeutic Communication Technique - Reflection

Directing back client's ideas, feelings, questions, and content

Therapeutic Communication Technique - Humor

Discharge of energy through comic enjoyment

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to reinforce necessary information with the client?

Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others

Principles of Mental Health Care

Do not harm Accept each client as a whole person Develop mutual trust Explore behaviors (perception, thought, feeling, actions) and emotions Encourage responsibility Encourage effective adaption Provide consistency

Non therapeutic communication-Failure to explore client's point of view

Does not ask client to describe abstract words such as "pain", "angry", or "sick"

Non-therapeutic Communications - Giving inadequate answers

Does not collect enough data to answer client's question accurately

Non-therapeutic Communications - Eliciting vague descriptions

Does not encourage client to explain or expand on message

Non-therapeutic Communications - Failure to probe

Does not seek clarification or validation from client

A newly licensed nurse is applying for a nursing job in a community mental health center. When working in this type of setting, the nurse should be prepared to assist with which of the following services?

Educational groups Medication dispensing programs Individual counseling programs Family therapy

Nurse's duties with therapeutic communication?

Elicit and attend to the client's thoughts, feelings, concerns and needs Express empathy and genuine concern for the client's and family's issues Obtain information and give feedback about the client's condition Intervene to promote functional behavior and effective interpersonal relationships Evaluate the client's progress toward goals and outcomes

Develop mutual trust - Advocacy

Empowerment - Imply cooperation, support, willingness, nurse/client working together through education, being patient and showing the patient

Therapeutic Communication Technique - Broad Openings

Encouraging client to select topics for discussion

Therapeutic Relationships

Energy is focused on client Not a friendship Consciously directed (goal is in mind) Purpose is to establish a connection with client to help them cope with their particular life demands

Pleasurable Responses

Euphoria: excessive feelings of well-being (feeling to good) Exaltation: intense happiness, often with feelings of grandeur

Sensorium and Cognition - Judgement

Evaluate choices and makes appropriate decisions - often have very clouded judgement

Principles of MILIEU treatment

Every interaction within the client's environment has a therapeutic potential All therapeutic environments needs limit settings or controls to maintain that therapeutic environment

Delicate balance

Exists between knowing when to and when not to help a client Keep the focus and maintain professional boundaries to help the client establish therapeutic goals and work towards those goals Fine line between compassion and over involvement

Presupposition questions

Explores the client's life goals or motivations by presenting a hypothetical situation in which the client no longer has the mental health disorder

Open-ended questions

Facilitates spontaneous responses and interactive discussion

Environmental Factors - Sound

Facilities can be very noisy

A nurse places a client in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts?

False Imprisonment - a civil wrong that violates a client's civil rights is a tort - confining a client to a seclusion room for convenience of the staff

Experiences - Illusions

False perceptions in response to an external object that other people can also see one way but the pt perceives it as something else - very real to pt and not to be discounted for that individual

Who can we as nurses prevent Recidivism?

Find adequate community resources and making them available for the client

Explore behaviors and emotions (perception, thought, feeling, actions)

Find out what is the route cause of someone's behavior Why did pt do what they did? Explaining to pt what our perception is their behavior and asking if it matches what the pt thinks Consider context and setting that occur (sometimes behaviors can be appropriate in one area but not in another) To truly understand the pt-you have to ask the pt on their interpretation (not our interpretation)

Environmental Factors - Lighting

Flickering lights can cause over stimulating or agitation Too bright or too dark can affect moods

Working Phase

Focused on achieving goals that were discussed in the orientation phase Time of solving problems and trying out new behaviors If relationship is moving forward and goals are met, the client's behavior will change so frequent evaluations are done to see if goals were achieved and if not reevaluate/reassess Very important to set limits during this phase We need to keep on track and keep everyone safe After goals met move on to next phase

What is a Physical Assessment?

Gathering, verifying, and communicating relevant information about the pt Holistic assessment: physical, intellectual, social, spiritual, and cultural factors that influence pts health Mental assessment: what influences the pts behavior Discover physical problems but treat medical problems first Rule out hormonal issues, exposure to toxins, severe pain Routine blood and urine tests usually obtained at admission to reassure that nothing physical is causing these problems (Ex: blood sugar issues) After results are obtained, decision made if further testing needs to be done

Mental Status Exam

General description-readily observable physical characteristics (things we can see) Appearance - dress, grooming, facial expressions, posture and gait Motor activity - fidgeting Speech - manner of response, choice of words, speech disorder Behavior at the time of the interaction Physical reactions

What is the GAF scale?

Global Assessment of Functioning Scale During initial assessment the physician is looking at client's social, occupational, and psychological functioning Baseline of where the pt is at on a functioning initially Assessing their mental status

A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy?

Gradually expose the client to an elevator while practicing relaxation techniques - Systemic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxation techniques suppress the anxiety response

Purposes of Mental Health Treatment Plan

Guide for planning and implementing care Monitor client's progress (vehicle from point A to point B)-check boxes if pt is progressing or mastered Document appropriately Assess the effectiveness of the interventions Communicate and coordinate care Provides a focus for all therapeutic activities Prevents costly duplication of services

Closed-ended questions

Helpful if used sparingly during the initial interaction to obtain specific data. The nurse should avoid using repeated closed-ended questions which can block further communication

A nurse working on an acute mental health unit assists with a client group focusing on self-management of medications. At each of the meetings, two of the members use the oppurtunity to discuss their common interest in gambling on sports. This an example of which of the following concepts?

Hidden agenda - when some group members have a different goal than the stated group goals. The hidden agenda is often disruptive to the effective functioning of the group

Accept each client as a whole person

Holistic nursing/healthcare Look at individual's work life, home life, family life, social patterns Acting as advocates and helping to educate Work with the pt to help overcome the social stigma or feelings that they have in relation to social ideals that impact their abilities or desire to seek healthcare

Thought processes

How a person thinks, how they analyze the world and connect/organize information

Risk with boundaries of becoming over involved

IF YOU SHOW A SIGNIFICANTLY GREATER LEVEL OF CONCERN FOR ONE CLIENT THAN FOR THE OTHERS

Disorders of thought processes - Amnesia

Inability to remember past events

Countertransference

Inappropriate emotional response identifying with someone from the past (caregiver's emotion response identifying with inappropriate on the part of the caregiver who identifies someone from the past) to prevent we have to focus on client's needs

Common reactions with Countertransference

Intense feelings of care Overinvolvement Disgust Hostility Anxiety

Non-therapeutic Communication - Definition

Interactions that slow or halt the development of a helping relationship Includes barriers that arise in the environment (bed alarms, lighting, distractions in hallway), the caregiver, or the client and the responses

A nurse is assisting in conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication?

Intonation - a component of verbal communication; the tone of one's voice can communicate a variety of feelings

Non-therapeutic Communications - Challenging

Inviting or daring client to explain, act, or compete

Hope

Involves the future for those with mental illness What do you think about their future? They don't think they have a future Instill the right attitude into the patient

A nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include?

It is goal-directed - a therapeutic nurse-client relationship Behavioral change is encouraged - a therapeutic nurse-client relationship encourages positive behavioral change A termination date is established - a therapeutic nurse-client relationship has an established termination date

Timing/relevance

Knowing when to communicate allows the receiver to be more attentive to the message, communicating with a client in pain or distracted will make it difficult for the nurse to convey the message

Inappropriate Response

Labile: rapid, dramatic changes in emotion Inconsistent: affect and mood do not agree Flat: unresponsive emotions

Reasons for Noncompliance

Lack of knowledge/education Medication side effects Caregiver/client relationship

Problems Encountered with Therapeutic Relationships - Environmental

Lack of privacy Inappropriate meeting place with uncomfortable furniture, lighting and temperature Noise and frequent interruptions Make appropriate arrangements

Therapeutic Communication Technique - Silence

Lack of verbal communication for therapeutic reason

What is Axes 4?

List major psychosocial stressors that the individual has faced recently (divorce, lost job, death of spouse, homeless)

What is Axes 3?

List medical or neurological disorders that may be relevant to current and/or past psychiatric problems (probably will see generic medical diagnosis)

What is Axes 2?

Lists any personality disorder that may be shaping/contributing to the current response to Axes 1 problem (may also indicate and developmental problems or disorders-mental retardation or learning disability)

A nurse is assisting with a family therapy group session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he's the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following?

Manipulation - this is the dysfunctional behavior of using dishonesty to support an individual agenda

Non-therapeutic Communications - Being judgmental, giving approval or disapproval, agreeing disagreeing

Many responses that tell the clients that they must think as you do

Inpatient Client Types - Chronically Mentally Ill

May have periods of relative comfort and east of functioning but rapidly fall into acute psychiatric states Some able to figure out when decompensating and voluntarily admit self May have no insight or judgment Some paranoid (not seek help or refuse it, and many think we are trying to hurt/kill them)

A nurse is reinforcing teaching for a client who is to begin ECT treatments. Which of the following assessments should the nurse instruct the client to expect following the procedure?

Measurement of the bp for hypertension - following ECT, the client's bp is expected to be elevated. The nurse should tell the client to expect bp measurements following ECT Questions to determine the presence of memory loss and confusion - the client is at risk for memory loss following ECT. the nurse should tell the client to expect to be questioned about her short-term memory following the procedure

Sensorium and Cognition - Recent

Memory of past 2 weeks

Sensorium and Cognition - Remote

Memory of the past

A nurse is providing preoperative teaching for client who was just informed that she requires emergency surgery. The client has a respiratory rate 30/min and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety?

Moderate anxiety - decreases problem-solving and can hamper the client's ability to understand information. Vital signs can increase somewhat, and the client is visibly anxious

Inpatient Client Type - Stress Management Techniques

Modifying stressful behaviors Cognitive thoughts Behavioral therapy Relaxation behaviors

Mental Status Exam - Emotional State

Mood: client's overall feelings (subjective factor-can only be explained by the person experiencing the mood) Affect: clients emotional display of mood being experienced; can be described as appropriate, inappropriate, pleasurable, unpleasurable

Therapeutic Listening

Most important communication tool

Therapeutic Self

Most therapeutic tool Focus energies on client Act as successful role models Feel good about yourself - important! Work to be aware of own feelings and attitudes Develop an awareness of how actions, gestures and expressions affect other people Therapeutic listening #1 skill

The key to Mental Health Treatment Plan?

Multidisciplinary approach Learn about patients Utilize critical thinking skills/assessment (go hand and hand) Obtain information

Hospitalization

Multidisciplinary team - many healthcare providers Manage environment Implement therapeutic intervention Coordinate and integrate multidisciplinary care Evaluate outcomes of treatment

Feelings/emotions

Non-intellectual reaction to stimuli based upon the individual's perception

Do not harm

Nonmaleficence Responsible to protect patients A guide for all therapeutic actions

Attending behaviors/Active listening

Nonverbal means of conveying interest in another Eye contact typically conveys interest and respect but varies by situation and culture Body language and posture can demonstrate level of comfort and ease Vocal quality enhances rapport and emphasizes particular topics or issues Verbal tracking provides feedback by restating or summarizing a client's statements

Environmental Factors - Cleanliness

OCD patients can be triggered by clutter

Mental Illness

Occurs when things happen in someone's life Unable to cope and they start to develop maladaptive behaviors (overwehlming) Difficulty in carrying out ADL's Cannot function independently

A nurse is communicating with a client who was just admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication?

Offering advice - this is a client barrier to therapeutic communication that the nurse should avoid using. Advice tends to interfere with the client's ability to make personal decisions and choices

Denotative/connotative meaning

Participants must share meanings, words have multiple meanings that can cause miscommunication if they are interpreted differently

Secondary Resistance

Patient is motivated by drives other than the need to regain mental health

Primary Resistance

Patient is unwilling to change even when aware

Resistance - defined by Freud

Patients attempt to avoid recognizing or exploring anxiety provoking material

What are the 4 behavior components?

Perception, Thought, Feelings, Actions

Experiences - Hallucinations

Perceptions having no external stimulus - taste, touch, illusions, sounds, or smell (ask the pt to explain what they are hearing, seeing, smelling, do they recognize the voice) very real to pt and not to be discounted for that individual

Types of delusions Persecution

Persecution, grandeur, obsessives, phobias, preoccupations

Problems Encountered with Therapeutic Relationships - Care Providers

Personal difficulties Personal health - try to do our best to take care of ourselves to be able to take care of client's Attitude - open minded; don't let our personal beliefs affect the way we take care of the client Over involvement - we are not there to rescue the client (boundaries)

Inpatient Client Types-Chronically Mentally Ill Therapeutic environmental provides:

Physical necessities (shelter, food, water) Protection Attention Emotional support

Non therapeutic communication-Failure to listen

Placing own thoughts about client not being involved in communication

Disorders of thought processes - Loose associations

Poorly organized or connected thoughts

What are the four phases of Therapeutic Relationship? P-O-W-T

Preparation phase Orientation phase Working phase Termination phase

Therapeutic Communication Technique - Suggesting

Presenting alternative ideas for client's consideration relative to problem solving

What is Axes 1?

Principle disorder that needs immediate attention or clinical disorder - usually, thought not always, what brings the person though the door (increased sxs of why they are here)

A nurse is assisting with planning cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse include in the plan of care?

Priority restructing Monitoring thoughts Journal keeping - These are all cognitive reframing techniques

Vital elements of health are are balanced by?

Professionalism Judgement Therapeutic Actions

Health care team members responsibilities for Milieu therapy

Promote independence for self-care and individual growth Treat clients as individuals Allow choices for clients within the daily routine and within individual treatment plans Model good social behavior for clients, such as respect for the right of others Apply rules of fair treatment of all clients Work cooperatively as a team to provide care Maintain boundaries with clients Maintain a professional appearance and demeanor Promote safe and satisfying peer interactions among the clients Practice open communication techniques with health team members and clients Promote feelings of self-worth and hope for the future

Therapeutic Environment Goals

Protection-protecting pt and others during periods of maladaptive behavior(safety is the number one concern upon admission) Develop self-worth and confidence Teach more effective coping skills and appropriate behaviors Return to community ASAP but make sure they have community resources available

Personal boundaries

Provide order and security as they help establish limits of one's behaviors Focus of the caregivers personal life is themselves (key)

Develop mutual trust.-Caring

Providing care to someone

Encourage effective adaptation

Pt having the ability perform ADLs; take small steps or simple instructions and repeat ADLs - if they won't take a shower maybe have them brush their teeth

Therapeutic Communication Technique - Focusing

Questions or statements that help clients expand topic

Disorders of thought processes - Flight of ideas

Rapid changes from one thought to another related thought

Non-therapeutic Communications - Rejecting

Refusal to discuss feelings or areas of concern

Therapeutic Communication Technique - Restating

Repairing main thought expressed by client

Inpatient Client Types-Chronically Mentally Ill Recidivism

Repeated inpatient admissions (revolving door syndrome) Seen a lot in schizophrenia patinets Frustrating for both client and caregiver Client and caregiver may feel like a failure (look at what we are doing on the outside to make things work for the client)

Disorders of thought processes - Perseverations

Repeating same work in response to different questions

Sensorium and Cognition - Immediate recall

Repeating something of 15 minutes ago

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, because he is threatening me." Which of the following actions should the nurse take?

Report the client's statement to the health care team - this information is a serious safety issue that must be reported to the health care team

Clients Problems - Defense Mechanisms

Resistance - client's stall or block the therapeutic actions

A nurse in an acute mental health facility is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating?

Restating - allows the nurse to repeat the main idea expressed

Clarifying techniques

Restating-uses the client's exact words Reflecting-directs the focus back to the client in order for the client to examine his feelings Paraphrasing-restates the client's feelings and thoughts for the client to confirm what has been communicated Exploring-allows the nurse to gather more information regarding important topics mentioned by the client

Termination Phase - Regression

Return to previous maladaptive behaviors - may be late to group or not come at all

Trust

Risk taking process-an individual's situation depends on the future behavior of another person Caregiver is trying to instill a trusting attitude to give the client what they need so they can participate in the therapeutic relationship

Situations Needing Hospitalization

Safety - becomes a threat to self or others Others cannot or will not continue supporting the mentally troubled person Perceive themselves as unable to cope or maintain behavior control

Provide consistency (the key)

Same message every time (within limits and focus on positive changes) Reward when positive behavior is accomplished (a task that has been difficult for them) All nurses and staff should give the same message

Sensorium and Cognition

Sensorium - part of consciousness that we perceive, sort and combine information; clear sensorium = A & O X 3 time, place, person Memory, Immediate recall, Recent, Remote, Concentration, Calculation, General knowledge, Reading ability, Abstract thinking, Judgment, Insight

Milieu therapy

Settings or environments designed to help replace inappropriate behaviors with more effective personal psychosocial skills Hospital, home, community settings Help satisfy needs and assist with problems

Termination Phase - Withdrawal

Shows a superficial interaction with the caregiver Demand we stop the relationship, the may quit coming to group

Therapeutic Communication Technique - Informing

Skill of informing giving

Pacing

Speaking rapidly can communicate the impression that the nurse is in a rush and does not have time for the client

Termination Phase

Steps reviewed to reaching goals Look at affective behaviors and how they can apply to other things to become more of a norm for the client Clients get nervous closer to discharge because they do not feel secure and safe so they have setbacks

Types of delusions Phobias

Strong fears of certain things, places, or situations

Sensorium and Cognition - Abstract thinking

Take things and sayings very literally

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?

Tell the nurse to stop discussing the behavior - The greatest risk to this client is an invasion of privacy sharing of confidential information a public place

Non-therapeutic Communications - Giving advice

Telling clients what to do; gives message that they are inferior and not able to make good decisions

Termination Phase - VITAl

That the nurse reinforces with client to use new behavior and how they can apply it to other situations Feel a sense of pride and that the client made new accomplishments

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior?

The client accuses the nurse of telling him what to do just like his ex-girlfriend - When a client views the nurse as having characteristics of another person who has been significant to his personal life, such as his ex-girlfriend this indicates transference

Caring

The foundation for all nursing aspects Clients can tell when you are truly concerned regarding their well being

What are Milieu therapy principles of treatment based on?

The idea that all environments are therapeutic

A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication?

The nurse asks the client about her body image perception - the nurse's one-on-one communication with the client is an example of interpersonal communication

Experiences - Perceptions

The ways or how the pt experiences the world (determines if they're living in a realistic or fantasy world)

Therapeutic communication

Then purposeful use of communication to build and maintain helping relationships with clients, families, and significant others

Types of delusions Obsession

Thought, action, or emotion that is unwelcome and difficult to resist

Disorders of thought processes - Blocking

Thoughts stop suddenly for no apparent reason

Therapeutic Communication

To communicate effectively with mentally and emotionally troubled clients, recognize that every interaction is part of the total therapeutic process Be careful how you behave, what you say and interact Make sure you have trust and respect Demonstrate patience, persistent, be consistent

MILIEU goals

To help satisfy needs and assist with problems

Secondary Resistance - Secondary gain

To profit or avoid unpleasant situations by remaining ill and remaining ill outweighs recovery

Intonation

Tone of voice can communicate a variety of feelings, nurse can communicate acceptance, judgement, and dislike through tone of voice

Environmental Factors - Temperature

Too hot or too cold? Can affect your mood!

5 Components fo a Therapeutic Relationship T-E-A-C-H

Trust Empathy Autonomy Caring Hope

Develop mutual trust

Trust is the basic concept of anything we do, assured reliance and hope that you give/have on an individual Erikson's stages are the core task of infancy of childhood Implies cooperation, support, willingness of the nurse and client working together The foundation of all therapeutic relationships

Social Relationships

Two way energy exchange Based on sharing personal opinions, attitudes, beliefs, and tastes Fun, supporting relationships that include good and bad

Therapeutic Communication Technique - Theme Identification

Underlying client issues or problems that emerge repeatedly during caregiver-client relationship

Techniques for Improving Compliance

Understand unwillingness reasons (Tell me more about why you don't want to take your meds) Perform complete assessment (hx, ADLs, attitudes) Challenge their expectations (help remove the limits they have set for themselves) They feel like they cannot accomplish anything Offer positive outlook and redirect negative behaviors Offer genuine concern (establish trust when talking to them, actively listen!)

Sensorium and Cognition - Insight

Understanding of their situation - May ask them "why do you think you have increased anxiety" Their answer may provide a good idea of their insight

Characteristics of Milieu therapy?

Unit should be clean and orderly Comfortable seating placed so that it promotes interaction Solitary spaces for reading and thinking alone Comfortable places conducive to meals Quiet areas for sleeping

A client says she is experiencing increased stress because, "My significant other is pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation?

Use assertiveness techniques - Assertive communication allows the client to assert her feelings and then make a change in the situation

Projective questions

Uses "what if" or similar questions to assist clients in exploring feelings and to gain greater understanding of problems and possible solutions

Perceptions

Using 5 senses to give information on what is going on around us Closely related to attitude-your attitude highly influences you perception Process in which we are gaining, interpreting, organizing a sensation to a particular situation or stimuli It can be distorted from what is really taking place-occurs a lot in mental illness Receptiveness to stimuli is highly selective - influenced by belief, attitude, motivation and personality

Non-therapeutic Communications - Following standard forms too closely

Using a question - and - answer format to elicit specific information

Non-therapeutic Communications - Using stereotyped responses

Using cliches, popular sayings, or trite expressions

Disorders of thought processes - Confabulation

Using untrue statements to fill in gaps of memory loss

Interpersonal communication

Verbal and Nonverbal messages between 1 or more persons, these messages can be sent and received during every interaction - symbols, language, culture. We need to have clarity to increase the chance of successful interaction. When the nurse obtains a psychosocial hx from client

Interpersonal Communication

Verbal and nonverbal interactions between 1 or more persons sent and received during every interaction Symbols, language, culture, behavior have an impact on most people We need to have clarity to increase the chance of successful interaction More complex and sophisticated

A nurse is contributing to the plan of care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects?

Voice changes - this is a common adverse effect of VNS due to the proximity of the implanted lead on the vagus nerve to the larynx and pharynx Dysphagia - this is a potential adverse effect of VNS. This usually subsides with time Neck pain - this is a potential adverse effect of VNS. This usually subsides with time

Environmental Factors - Aesthetics

Warm, comfortable environment

Encourage responsibility

We want pt to exercise capability and accountability Encourage acceptable behavior, then the pt will start feeling better about themselves and increase self worth-not blame their actions on someone else Responsibility - Maslow's hierarchy get to a point of self-actualization Should be learned at an early age that can be learned from everyone/anyone-church, family, friends, society

Thinking Content

What an individual is thinking Delusions: fixed, false beliefs that are contrary to reality

Why is therapeutic communication essential?

When caring for a client with a mental disorder because of emotional as well as the physical effects of the disorder on the client

Termination Phase - Continuation

When pt wants to continue the relationship and comes up with new problems They start to be helpless again and want caregiver to fix their problem

Therapeutic Communication Technique - Listening

active process of receiving information and examining reactions to messages received

Assessing actions

think about the steps involved of the situation and assess if action was appropriate or not for the situation