Mental Health Final Exam
What is the difference in nursing interventions between mild to moderate levels of anxiety and severe to panic levels of anxiety?
Mild-Moderate: help the patient identify anxiety, anticipate anxiety provoking situations, use nonverbal language to demonstrate interest, encourage patient to talk about feelings and concerns, avoid closing off parts of communication/focus on patient's concerns, ask questions to clarify what is being said, help patient identify thoughts or feelings before onset of anxiety, encourage problem solving, help the patient identify alternative solutions, explore behaviors that have helped in the past, and provide outlets for working off excess energy. Severe-Panic: maintain a calm manner, always remain with the person is experiencing an acute/severe/panic level of anxiety, minimize environmental stimuli, use clear and simple statements and repetition, speak slowly and use a low pitched voice, reenforce reality if delusions occur, listen for themes in communication, attend to safety needs when necessary, provide opportunities for exercise, assess needs for medication or seclusion.
What is the difference between mild, moderate, and severe anxiety?
Mild:occurs in the normal experience of everyday living and allows an individual to perceive reality in sharp focus Moderate:sees, hears, and grasps less information and may demonstrate selective inattention, where only certain things in the environment are seen or heard unless they are pointed out. Severe: may focus on one particular detail or on many scattered details and have difficulty noticing what is going on in the environment, even when another person points it out.
What is the difference between transference and countertransference?
-Transference refers to unconscious feelings that the patient has toward a healthcare worker that were originally felt in childhood for a significant other. Ex: the patient says "You remind me of my sister" -Countertransference refers to unconscious feelings that the healthcare worker has toward the patient. Ex: if a patient reminds you of someone you do not like, then you might treat them like you do not like them
What are the parts of a mental status exam? (box 7.4 chap 7)
Appearance: hygiene, grooming, pupils, facial expressions, height, weight, nutritional status, piercings/tattoos/scars, relationship between age and appearance Behavior: excessive/reduced/peculiar/abnormal movements, level of eye contact Speech: Rate, volume, disturbances Mood: affect (bland, flat,ect), mood (sad, euphoric, ect) Disordered thinking: thought process, thought content Perceptual disturbances: hallucinations, illusions Cognition: LOC, orientation, memory, knowledge, attention, abstraction, insight, judgement Ideas of harming others/themselves: history of suicidal/homicidal thoughts, means/opportunity to carry out plan
How are obsessions defined by the DSM 5?
Compulsions are defined by repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
What are the interview guidelines for suspected abuse? (box 28.2 chap 28)
DO: conduct the interview in private, be direct/honest/professional, use language the patient understands, ask patient to clarify words not understood, be understanding/attentive, inform the patient if you must make a referral to protective services, assess safety. DO NOT: try to "prove" abuse, display horror/anger/shock/disapproval of the perpetrator or situation, place blame, mae judgements, allow the patient to feel "at fault/in trouble", probe or press for answers, conduct the interview with a group of interviewers.
What are the common presenting problems for victims of abuse? (box 28.3 chap 28)
ED: bleeding injuries especially to head and face, internal injuries, concussion, perforated ear drum, abdominal injuries, severe bruising, strangulation marks on neck, back injuries, broken bones, burns, psychological trauma, miscarriage. Ambulatory care: perforated ear drum, twisted/stiff neck and shoulders, headache, depression, stress, talking about having problems with spouse, repeated visits, bruises in specific shapes. Any setting: signs of stress due to family violence, injuries in a pregnant woman, recurrent visits for being "accident prone".
What is an adverse childhood experience (ACE)?
Early exposure to stressful events including Any form of psychological, physical, and sexual abuse, Violence against a parent, particularly the mother, Living with people who have substance use disorders, have mental illness, or were ever incarcerated.
What is the difference between empathy and sympathy?
Empathy is when we understand a patient's feelings and sympathy is when we feel pity for others.
What is the mental status exam (MSE) and what is its purpose?
Evaluates the patient's current cognitive process. The purpose of this exam is to collect and organize objective data.
What is EDMR and how may it help with trauma or PTSD?
Eye Movement Desensitization and Reprocessing This is a psychotherapy that can help the client process upsetting memories, thoughts, and feelings related to the trauma.
What are the goals of the therapeutic nurse-patient relationship?
Facilitating communication of distressing thoughts and feelings, assisting with problem solving to help facilitate activities of daily living, examining self-defeating thoughts and behaviors and testing alternatives, promoting self care and independence, providing education about disorders/meds/symptom management
What are the characteristics of active learning?
Focusing, responding, and remembering what was said verbally and non verbally
What are the assessment guidelines for anger and aggression?
General risk identification: a history of violence, patient who is delusional/hyperactive/impulsive/predisposed to irritability, aggression happens most often in a limited-setting, history of poor coping skills. Questions for assessment: does the patient have a wish/intent to harm, does the patient have a plan, does the patient have the means available to carry out a plan, Does the patient have demographic risk factors (male gender, aged 14 to 24 years, low socioeconomic status, inadequate support system, and prison time)?
What are the risk factors for suicide?
Genetics, low serotonin levels, cognitive factors (rigid all-or-nothing thinking, inability to see different options, and perfectionism), previous suicide attempts, family history of suicide, exposure to suicidal behavior, substance use, mood disorders, access to lethal means, losses/other events, history of trauma/abuse, chronic illness/pain
What are some specific questions to ask about suicidal ideation ?
Have you ever felt that life was not worth living?, Have you been thinking about death recently?, Do you ever think about suicide?, Have you ever attempted suicide?, Do you have a plan for ending your life?, If so, what is your plan for suicide?
What does it mean for a nurse to suspend value judgments?
Help the patient explore the feelings surrounding certain behaviors without letting their own beliefs cloud the conversation
What purpose does a safety plan serve for those at risk for suicide?
Identifies warning signs, internal coping strategies, social setting, and people who provide distraction. Includes who to ask for help, professionals/agencies for crisis, how to make a safe environment.
Exactly how do benzodiazepines work in the body to help with anxiety?
Increase the effects of GABA in the patient's brain and body to help the patient feel relaxed. These meds have a fast onset
Does pregnancy result in an increased or decreased risk for intimate partner violence (IPV)?
Increased
What is the definition of non-suicidal self injury?
Intentional damage to one's own body without suicidal intent (causing pain without wanting to die)
What characterizes somatic symptom disorder (SSD)?
Is characterized by a focus on somatic (physical) symptoms, such as pain or fatigue, to the point of excessive concern, preoccupation, and fear
How should the lethality of a suicide plan be evaluated?
Is there a specific plan with details, how lethal is the proposed method, is there access to the planned method, people who have definite plans for the time, place, and means are at the highest risk.
What is the WHO's definition of mental health?
"A state of well being in which individuals reach their own potential, cope with the normal stresses of life, work productively, and contribute to the community."
Where does suicide fall in the overall causes of death in our country?
10th leading cause of death
How may silence during a therapeutic interaction prove beneficial?
can provide meaningful moments of reflection for both parties
Is a loss due to suicide a risk factor for suicide?
yes they are 4 times more likely
What is the difference between open ended and closed ended questions ?
Open-ended questions encourage patients to share information about experiences, perceptions, or responses to a situation EX: "How would you describe your relationship with your wife?" Closed-ended questions gives us specific and needed information EX: "When did you start hearing voices?
What is the difference between overt statements and covert statements?
Overt statements: "I can't take it anymore," "life isn't worth living anymore," "I wish I were dead," "everyone would be better off if I was dead" Covert statements: "soon everything will be fine," "it was never going to work out", "I won't be a problem much longer," "how can I give my body to medical science."
How may paraphrasing and reflecting be used to clarify understanding?
Paraphrasing is used to clarify what the patient is saying while also making them feel heard and providing a greater focus. Reflecting assists patients to better understand their own thoughts and feelings.
Which patient conditions are contraindicated for seclusion and restraints?
People who have an extremely unstable medical or psychiatric condition. Ex: COPD, pregnancy, spinal injury, seizure disorders.
What are the risk factors for DID?
People who have experienced sexual or physical abuse in childhood, or can develop in response to a traumatic event like combat.
What is primary, secondary, and tertiary care as it relates to mental health?
Primary: occurs before any problem manifests and seeks to reduce the incidence or rate of new cases. Secondary: aimed at reducing the prevalence of psychiatric disorders. Tertiary: the treatment of disease with a focus on preventing the progression to a severe course, disability, or even death.
When formulating a psychiatric nursing care plan, what should always be prioritized?
Problem: unmet need probable cause: What needs to be addressed supporting data: signs and symptoms.
What is the phenomena of concern for psychiatric mental health nurses? (box 1.3) chap 1
Promotion of optimal mental and physical health and well-being, Prevention of mental and behavioral distress and illness, Promotion of social inclusion of mentally and behaviorally fragile individuals, Co-occurring mental health and substance use disorders, Co-occurring mental health and physical disorders, Alterations in thinking, perceiving, communicating, and functioning related to psychological and physiological distress, Psychological and physiological distress resulting from physical, interpersonal, and/or environmental trauma or neglect, Psychogenesis and individual vulnerability, Psychogenesis and individual vulnerability, Alterations in self-concept related to loss of physical organs and/or limbs, psychic trauma, developmental conflicts, or injury, Individual, family, or group isolation and difficulty with interpersonal relations, Self-harm and self-destructive behaviors, including mutilation and suicide, Violent behavior, including physical abuse, sexual abuse, and bullying, Low health literacy rates contributing to treatment nonadherence.
What is the meaning of impaired coping and reduced anxiety? (table 15.8 chap 15)
Reduced anxiety: Monitors intensity of anxiety, uses relaxation techniques, decreases environmental stimuli as needed, controls anxiety response, maintains role performance Improved coping: Identifies ineffective coping patterns, asks for assistance, seeks information about illness and treatment, identifies multiple coping strategies, modifies lifestyle as needed
What drug class is evidenced based for use in PTSD symptoms?
SSRIs
What is the definitions of seclusion and restraints and which is more restrictive?
Seclusion: involuntary confinement of a patient alone in a room, or area from which the patient is physically prevented from leaving. Restraint: any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. RESTRAINTS ARE MORE RESTRICTIVE
What is the first pharmacological line of defense for anxiety and OCD disorders?
Selective serotonin reuptake inhibitors (SSRIs) are considered a first line of defense in most anxiety-related disorders
What are the signs and symptoms of lithium toxicity?
Signs of toxicity: (<1.5) N/V, diarrhea, thirst, polyuria, lethargy, sedation, and fine hand tremor, renal toxicity, goiter, and hypothyroidism. Early signs of toxicity: (1.5-2.0) GI upset, coarse hand tremor, confusion, hyperirritability of muscles, electroencephalographic changes, sedation, incoordination. Advanced signs of toxicity: (2.0-2.5) ataxia, giddiness, serious electroencephalographic changes, blurred vision, clonic movements, large output of dilute urine, seizures, stupor, severe hypotension, coma. Severe toxicity: (>2.5) convulsions, oliguria, and death
What are some therapeutic communication techniques? (table 9.2 chap 9)
Silence, accepting, giving recognition, offering self/general leads, giving broad openings, placing events in order, making observations, encouraging description of perception, encouraging comparison, restating, reflecting, focusing, exploring, giving information, seeking clarification, presenting reality, voicing doubt, seeking consensual validation, verbalizing the implied, encouraging evaluation, attempting to translate into feelings, suggesting collaboration, summarizing, and encouraging a plan of action.
What is the definition of somatization and what purpose manifesting symptoms physically, may serve for the patient?
Somatization: Is the psychological and emotional expression of stress through physical symptoms instead of feeling anxiety, depression or irritability, some individuals experience pain, paralysis, unexplained skin rashes, and other symptoms, manifestations of psychological and emotional distress
What are the three stages in the cycle of violence
Tension building: Abuser has minor explosions and victim feels like they are walking on eggshells. Serious battering phase: serious incident, victim may try to provoke it to get it over with/cover up injuries. Honeymoon phase:Abuser shows loving behaviors and victim is trusting and wants change.
What is the definition of resilience ?
The ability to and capacity for people to secure the resources they need to support their well being. Ex: managing strong emotions and impulses.
What is the definition of stigma?
The belief that the overall person is flawed, is characterized by social shunning, disgrace, and shame. Ex: "it's all in your head."
What is derealization?
The focus is on the outside world. It is the recurring feeling that one's surroundings are unreal or distant.
How long would obsessions or compulsions occur and/or what must they interfere with in order to meet the diagnostic criteria of DSM 5?
The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
What are the warning factors and protective factors for suicide?
Warning Factors: often talking/writing about death/dying/suicide, comments of being hopeless/helpless/worthless, expressions of having no reason for living; no sense of purpose in life; saying things like "It would be better if I wasn't here" or "I want out", increased alcohol/drug use, withdrawing from friends/family, reckless behavior, dramatic mood changes, talking about feeling trapped/being a burden. Protective factors: effective mental health care, strong connections to self and other people, marriage, having children, problem solving/conflict resolution skills, contact with providers.
What are the guidelines for when seclusion or restraints may be used?
When the patient creates a risk of harm to self or to others and no other restrictive alternative is available
What are two common ways that boundaries are blurred in a nurse-patient therapeutic relationship?
When the relationship slips into personal context and when the nurses' needs are met at the expense of the patient's needs
What is a neurotransmitter?
a chemical substance that functions as a neuromessenger.
What is a dissociative fugue?
a temporary state where a person has memory loss (amnesia) and ends up in an unexpected place
What is the definition of genuineness?
ability to be open, honest, and authentic in interactions with patients
What is depersonalization?
an extremely uncomfortable feeling of being an observer of one's own body or mental processes.
From the DSM 5 criteria for GAD, how long must anxiety and worry be present and how frequently, before diagnostic criteria are met?
anxiety and worry must occur more days than not for at least 6 months about a number of events or activities
What are defense mechanisms and how may they be beneficial or harmful?
automatic coping styles that protect people from anxiety and enable them to maintain their self-image by blocking feelings, conflicts, and memories. They can be beneficial because they can help lower anxiety, and help patients achieve goals in acceptable ways, however it could be harmful because they could be immature or used in excess.
In the DSM-5 Criteria, what provides evidence of persistent avoidance of stimuli?
avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events -avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, feelings about or closely associated with the traumatic events
What is trauma informed care?
based on the notion that disruptive patients often have histories that include violence and victimization
Why would "risk for suicide" be a highest priority nursing diagnosis?
because they could act on their plan
Why are benzodiazepines not recommended for the elderly?
because they increase the risk for delirium, falls, and fractures
How do we believe most psychotropic medications act?
by either increasing or decreasing the activity of certain neurotransmitter-receptor systems
What characterizes social anxiety disorder?
characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that could be evaluated negatively by others.
What are the safety considerations for individuals working in an in-patient psychiatric setting?
check all personal property and clothing to prevent any potentially harmful items.
What type of disturbance occurs in almost every psychiatric disorder and may be used as a gauge for recovery?
difficulties in interpersonal relationships
In the DSM-5 Criteria, what intrusive symptoms may be associated with traumatic events?
directly experiencing the traumatic event, witnessing, in person, the event as it occurred, learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or close friend, events must have been violent or accidental, experiencing repeated or extreme exposure to aversive details of the traumatic event (first responders collecting human remains, police officers exposed to child abuse)
What is the definition of anxiety?
feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat
What is the definition of general anxiety disorder (GAD)?
generalized anxiety disorder or excessive worry
What are three vital components of establishing a therapeutic relationship?
genuineness, empathy, and positive regard from the nurse
What are two of the biggest predictors of violence?
history of violence and brain injury
What is the old name for illness anxiety disorder (IAD)?
hypochondriasis
In the DSM-5 Criteria what negative alterations may be seen in mood and cognition associated with the traumatic event(s)?
irritable behavior and angry outburst (with little to no provocation) typically expressed as verbal or physical aggression toward people or objects, reckless or self-destructive behavior, hyper vigilance, exaggerated startle response, problems with concentration, sleep disturbance
What is a specific phobia and what does the patient with this disorder experience?
is a persistent irrational fear of a specific object, activity, or situation that leads to a desire for avoidance or actual avoidance of the object, activity, or situation.
What is an elopement?
leaving before being discharged
What are examples of deescalation techniques?
maintain patient's self esteem and dignity, maintain calmness, assess the patient and situation, identify stressors and stress indicators, respond as early as possible, use a calm clear voice, invest time, remain honest, determine what the patient considers to be needed, identify goals, avoid invading personal space, avoid arguing, give several clear options, use genuineness and empathy, be assertive, do not take chances.
What is the major target of drugs that are used to treat psychiatric disorders?
neurotransmitters and receptors
Is proof required to report abuse?
no
Why should we avoid "why" questions?
non therapeutic. Results in the patient not knowing which question to answer and possibly being confused about what is being asked
What is required for seclusion or restraints to be used?
order from a licensed provider
What is a therapeutic milieu?
overall environment and interactions within that environment
What are some common SSRIs?
paroxetine (Paxil), fluoxetine (Prozac), escitalopram (Lexapro), and sertraline (Zoloft)
What needs to happen before reintegration occurs?
patient must follow commands and control behaviors
What are the considerations for staff safety?
pharmacological intervention, seclusion, or restraints may be used
What are the basic level interventions for dissociative disorders? (table 16.2 chapter 16)
provide an undemanding/simple routine, Ensure patient safety by providing safe, protected environment and frequent observation, Confirm the identity of patient and orientation to time and place, Encourage patient to do things for self and make decisions about routine tasks, Assist with major decision making until memory returns, Support patient during the exploration of feelings surrounding the stressful event, Do not flood patient with data regarding past events, Allow patient to progress at own pace as memory is recovered, Allow patient to progress at own pace as memory is recovered, Teach patient grounding techniques, Accept patient's expression of negative feelings, Teach stress-reduction methods, If patient does not remember significant others, work with involved parties to reestablish relationships.
What is postvention?
providing mental health care and support to survivors
What is agoraphobia?
refers to intense excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or where help might not be available.
What is the definition of positive regard?
respecting a person and viewing another person as being worthy of caring about and as someone who has strengths and achievement potential.
Which two drugs within the above class are FDA approved specifically to treat PTSD?
sertraline (Zoloft) and paroxetine (Paxil)
What are the possible symptoms of a panic attack?
sudden onset of extreme apprehension or fear, usually associated with feelings of impending doom.
What are nurses legally mandated to report?
suspected/actual cases of abuse
Why is it so important to medically assess someone presenting with a possible depression or anxiety diagnosis?
symptoms like depression, anxiety, and psychosis are often associated with certain physical conditions
What is psychiatric/ mental health nursing?
the nursing specialty that is dedicated to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the life span
What should be the focus of a therapeutic relationship?
the patient's problems and concerns
In the DSM 5 criteria box for SSD, how do symptoms impact a patient's life?
they are distressing or result in significant disruption of daily life
Why might a sudden brightening in mood with a depressed patient be a cause for concern?
they might have enough energy to act on their suicide plan
What are suicidal ideations?
thinking about death, including the wish to be dead, considering methods of accomplishing death, and formulating plans to carry the act out.
What information must always be shared with professionals and parents?
threats of suicide, homicide, sexual abuse, or behaviors that put the patient or others at risk for harm
What are the primary goals of emergency psychiatric care?
to perform triage and stabilization
What are the patient's rights while being treated? (box 4.2 chap 4)
treated with dignity, be involved with treatment plan, refuse treatment, to request to leave the hospital, protected against harming one self or others, timely evaluation, legal counsel, vote, communicate privately by telephone or in person, informed consent, confidentiality, to have or refuse visitors, to the least restrictive means of treatment, send and receive mail and to be present during any inspection of packages received, to keep belongings if not dangerous, lodge a complaint, participate in a religious worship.
What is a key aspect of panic disorder?
unpredictability
What is cognitive behavior therapy?
used to treat a variety of psychiatric disorders, such as depression, anxiety, phobias, and pain. It is based on the underlying theoretical principle that feelings and behaviors are largely determined by the way people think about the world and their place in it