MENTAL HEALTH UNIT EXAM 1

Personality disorders: Nursing Care: Cluster A *7*

*Odd/eccentric* -Objective, matter of fact -Clear, consistent verbal-non-verbal -*Structure for ADL's* (what they lack!) -Maintain focus on reality -Help identify feelings -Assist with problem solving -Gradually involve in group situations

Personality disorders: DSM-IV-TR CRITERIA: *CLUSTER A:*

*Behaviors that are described as odd or eccentric:* 1. *Paranoid:* constantly on guard, untrusting, increased imaginary sensitivity -trauma 2. *Schizoid:* defect in forming personal relationships; cold illuf, indifferent; shy,anxious, avoid people(hermit) 3. *Schizotypical:* like schizoid, but more severe

NMS PNEUMONIC:

*FALTER* Fever AMS Leukocytosis Tremors Elevated CPK Rigidity

Antipsychotic agents: IRREVERSIBLE/DANGEROUS ADVERSE EFFECT: Neuroleptic malignant syndrome

*MEDICAL EMERGENCY* -life threatening reaction to antipsychotic medications within the 1-4 weeks of beginning regimen with symptoms of: fever severe muscular rigidity and stiffness *elevated CPK* sweating difficulty swallowing labile BP changes in state of consciousness

Antipsychotic agents: IRREVERSIBLE/DANGEROUS ADVERSE EFFECT: Tardive dyskinesia

*Tardive Dyskinesia* -usually occurs after years of taking drug -permanent and only *partially controlled*

Personality disorders: Nursing Care: Cluster C *7*

*anxious/fearful* -Caring consistent approach -Clear expectations for behavior -Expect patient to make decisions -Teach assertiveness -Encourage to identify (+) attributes -Provide (+) feedback for increased interactions in social situations -Teach stress management and relaxation techniques

Personality disorders: Nursing Care: Cluster B *10*

*dramatic/erratic* -Prevent self-harm -No-harm contract -Set limits on inappropriate or manipulative behavior -Assist in examining consequences of beh. -Consistent approach by staff -Do not rescue or reject -Give (+) feedback for goal acheivement -Explore feelings -Teach problem solving to change behavior -Encourage follow up treatment

Efficacy

- ability medication to produce response

Anxiolytics: Nursing interventions

-Safety measures -Change positions slowly -Increase fluids -Food-medication interactions; alcohol interactions -Monitor serum levels -Monitor serotonin syndrome - mental status changes (hallucinations, agitation, coma), autonomic instability (tachycardia, hyperthermia, changes in blood pressure), neuromuscular problems (hyperreflexia, incoordination), gastrointestinal disturbances (nausea, vomiting, diarrhea)

Personality disorders: Nursing Care

-Usually not admitted for P.D. -*Axis I psychiatric diagnosis needed for admitting disorder + P.D.* -Realistic goals - behavior will probably not change significantly

Potency

- dose medication required produce specific effect

Tolerance

- gradual decrease in action of medication at given dose or concentration

What is most important regarding the care of clients who are taking lithium? Take the medication only for 5 weeks Do not have diabetes mellitus Have serum Lithium levels evaluated Not eat any salt at all

Have serum Lithium levels evaluated

Crisis intervention: Planning and outcome identification

1. Assist the client in setting realistic goals to return to the pre-crisis level of functioning 2. Establish desired outcome criteria for the client using the problem solving approach.

Typical Antipsychotics agents:

1. Classification *Low potency—Thorazine* Medium Potency—Loxatine *High Potency—Haldol* 2. Mechanism of action *Block receptors of dopamine, acetylcholine, histamine, norepinephrine* 3. ADVERSE EFFECTS: *Neuroleptic malignant syndrome* *Extrapyramidal symptoms (EPS)* (COMMON) -Acute dystonia -Parkinsonism -Akathisia -Tardive dyskinesia *Anticholinergic effects* *Orthostatic hypotension* 4. Targeted symptoms: *(dopamine antagonists)* target the positive symptoms of schizophrenia (hallucinations, delusions, disordered thinking, and paranoia).

Third Generation Antipsychotics agents:

1. Classification Abilify (aripiprazole) 2. Action: dopamine/serotonin system stabilization 3. Side effects: nausea, dyspepsia, vomiting, constipation, somnolence, anxiety, and akathisia

Atypical Antipsychotic Agents

1. Classification: Clozapine 2. Action: -Blocks dopamine and serotonin -Fewer EPS symptoms 3. Adverse effects Agranulocytosis Orthostatic hypotension Anticholinergic effect Levodopa-induced psychosis 4. Target symptoms: *(serotonin-dopamine antagonists)* can diminish the negative symptoms as well (deficits in social interaction, blunted or inappropriate emotional expression, and lack of motivation).

Care of the manipulative client:

Help patient identify manipulative behaviors Set clear, consistent, enforceable limits Consistent team approach Be clear with consequences Follow through with consequences Avoid power struggles with client

Mood stabilizers: Lithium

1. Action: uncertain, crosses cell membranes, altering sodium transport, not protein-bound USE: -Psychiatic: manic episodes (bipolar), prevention of bipolar symptoms, and other psychotic disorders Medical -Seizure disorders, migraine prevention, pain manegment, and peripheral neuropathy 2. Side effects: thirst, metallic taste, increased frequency of urination, fine head and hand tremor, drowsiness, and mild diarrhea 3. Interventions: Blood levels: *monitor for lithium toxicity* (severe diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination; withhold in the event of these symptoms) -Monitor creatinine concentrations, thyroid hormones, and CBC every 6 months *(therapeutic range approx.: 0.5-1.5 mEq/L).*

EPS reactions: TREATMENT

1. Administer anticholinergic drugs as R(X) -Congentin, Benadryl, Artane, Akineton 2. Physician may discontinue; Nurse should notify physician 3. May switch to Atypical antipsychotic *(fewer side effects)*

Which of the following are appropriately planned, given a crisis intervention approach? Select all that apply (there are 3 correct answers). 1. The length of time the nurse sees Nell will be flexible 2. Reflective, non-directive responses will be used in responding to Nell's statements 3. Active responses, designed to keep Nell focused on her current situation and problem resolution, will be used 4. An in-depth exploration of Nell's childhood and personality development will be initiated 5. Active involvement of Nell's family in her treatment will be encouraged

1. The length of time the nurse sees Nell will be flexible 3. Active responses, designed to keep Nell focused on her current situation and problem resolution, will be used 5. Active involvement of Nell's family in her treatment will be encouraged

What are Two major groups of anti-psychotic agents?

1. Typical/traditional antipsychotics *(First generation)* *ACTION:* Block dopamine receptors 2. Atypical antipsychotics *(Second generation)* *ACTION:* Moderate blockade of dopamine receptors

Mental status exam: 5. Sensorium and Mental Capacity

1. Orientation: place, time, person. 2. Memory: -Remote: dates of service, marriage, jobs. -Recent: account of past 24 hours; three words after five minutes. -Immediate: numbers, name objects, digits forward and backward. 3. Symbolization and Proverb: abstract words' "rolling stone"/"glass houses" proverb interpretation. 4. Grasp of General Information: 5 presidents, governor, wars, recent newspaper reports. 5. Calculations: arithmetic tests, serial seven's subtraction. 6. Attention and Concentration: digit repetitions; serial seven's subtraction; story repition

Crisis Intervention Assessment

1. Perception of event: -What happened that prompted you to seek help?; -How are you feeling now?; etc. 2. Coping mechanisms: -Suicidal?; Homicidal?; Plans?; -What helps you feel better?; etc. 3. Support systems: -With whom do you live with?; Who is available to help you?; Who is most helpful?; etc 4. Mental status, previous history 5. Identify client's strengths 6. Self-assessment: Nurses' feelings

Crisis intervention: Nursing Diagnosis

1. Risk self directed violence 2. Chronic low self esteem 3. Hopelessness 4. Powerlessness 5. Severe/Panic levels of anxiety 6. Disturbed thought process 7. Sleep deprivation

A client with major depression has been prescribed fluoxetine (Prozac). What dosing regimen would be appropriate? 20 mg every morning 40 mg three times/day 50 mg at bedtime 100 mg four times/day

50 mg at bedtime

Personality traits

A characteristic mode of behavior or any mannerism that distinguishes one individual from another. Example shy, outspoken, etc Exhibited in a wide range of important social and personal contexts

A 44-year-old single woman loses her job and has been unable to find a job for 8 months. She has exhausted her savings and is overwhelmed. She comes to the crisis intervention center because she is despondent and feels hopeless. What type of crisis does the nurse identify? 1 Subjective 2 Situational 3 Adventitious 4 Maturational

Situational

Anxiolytics: Classes

Barbiturates Benzodiazepines Nonbenzodiazepines Sedative-hypnotics

A client with an obsessive-compulsive disorder continually walks up and down the hall, touching every other chair. When unable to do this, the client becomes upset. What should the nurse do? 1 Distract the client, which will help the client forget about touching the chairs 2 Encourage the client to continue touching the chairs as long as the client wants until fatigue sets in 3 Remove chairs from the hall, thereby relieving the client of the necessity of touching every other one 4 Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed

Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed -It is important to set limits on the behavior, but it is also important to involve the client in the decision-making. Distracting the client, which will help the client forget about touching the chairs, is nontherapeutic; rarely can a client be distracted from a ritual when anxiety is high. Encouraging the client to continue touching the chairs for as long he desires until fatigue sets in is a nontherapeutic approach; some limits must be set by the client and nurse together. Removing chairs from the hall, thereby relieving the client of the necessity of touching every other one, will increase the client's anxiety because the client uses the ritual as a defense against anxiety.

When a nurse is working with a client with psychiatric problems, a primary goal is the establishment of a therapeutic nurse-client relationship. What is the major purpose of this relationship? 1 Increasing nonverbal communication 2 Presenting an outlet for suppressed hostile feelings 3 Assisting the client in acquiring more effective behavior 4 Providing the client with someone who can make decisions

Assisting the client in acquiring more effective behavior

he nurse is caring for a newly admitted male client with the diagnosis of bipolar disorder who has a history of hyperactivity and combativeness. Later in the evening, a commotion is heard and the new client is found beating another client. What is the legal interpretation of this situation? 1 The client should have been placed in restraints on admission. 2 A client who is known to have been combative should have been kept sedated. 3 A client with bipolar disorder who is in contact with reality does not require supervision. 4 Because it was known that the client was frequently combative, close observation by the nursing staff was indicated.

Because it was known that the client was frequently combative, close observation by the nursing staff was indicated.

A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client? 1 Increased libido 2 Phobic behavior 3 Boundary violations 4 Excessive aggression

Boundary violations

A nurse is on the crisis hotline with a client and has assessed identifying data. The client says, "Don't try to help me anymore. This is it. I've had enough and I have a gun in front of me now." Without another word, the client disconnects the call. What is the nurse's best course of action? 1 Call the local clergyman and request an immediate visit. 2 Call the client back and try to persuade a change of mind. 3 Call the emergency hotline and inform the responder of the situation. 4 Call the client's neighbors and ask them to go to the house immediately.

Call the emergency hotline and inform the responder of the situation.

A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client? 1 Seclusion room 2 Four-point restraints 3 Constant one-on-one supervision 4 Removal of unsafe objects from the environment

Constant one-on-one supervision -A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed. Seclusion and four-point restraints are overly restrictive.

CRISIS INTERVENTIONBALANCING FACTORS

Crisis- good outcome Perception of event realistic Situational support adequate Coping mechanism adequate *No crisis* Crisis- development Perception of event distorted Situational support inadequate Coping mechanisms inadequate *Crisis*

CRISIS INTERVENTION GENERAL OVERVIEW

Crisis.... -May occur to everyone -Not necessarily pathological, may encourage growth and change -Time limited to a brief period, 4-6 weeks except death -A person's perception determines the crisis

A client has had repeated hospitalizations for aggressive, violent behavior. While on the mental health service, the client becomes very angry, starts screaming at the nurse, and pounds the table. What is the priority nursing assessment at this time? 1 Range of expressed anger 2 Extent of orientation to reality 3 Degree of control over the behavior 4 Determination of whether the anger is justified

Degree of control over the behavior -Degree of control over the behavior is the most important assessment because it will influence the nurse's intervention. Depending on the extent of the client's control, the nurse may or may not need assistance. It is not the degree of anger but instead the behavior it precipitates that is important to assess. The extent of orientation to reality may or may not influence the ability to control behavior. Anger is always justifiable to the person; the determination of whether the anger is justified will not help the nurse address the client's behavior.

Cholinergics: Acetylcholine: Mental illness

Depression Alzheimer

Monoamines: Norepinephrine: mental illness

Depression *(decreased levels)* Mania, anxiety states, schizophrenia *(ijncreased levels)*

One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. The nurse identifies the defense mechanism that the client is using as what? 1 Projection 2 Dissociation 3 Displacement 4 Intellectualization

Displacement

Mental status exam: 3. Emotional State (Mood and Affect):

Elated, euphoric, calm, placid, depressed, perplexed, anxious, apathetic, flattened, labile, inappropriate.

Suicide risk: Interventions

Enlist help from others Safety in the home: remove any type of weapon/medications Rapport and trusting relationship Support groups Anti-depressants

A client arrives at the clinic and tells the nurse about various aches and pains since her spouse's death 3 months ago. The client appears depressed and tense. What is the initial nursing intervention? 1 Facilitating a discussion of the spouse's death 2 Focusing on teaching the client relaxation exercises 3 Asking the practitioner for a psychiatric consultation 4 Helping the client recognize ambivalence toward the spouse

Facilitating a discussion of the spouse's death -Facilitating a discussion of the spouse's death will encourage the client to speak about the spouse and begin moving toward resolving the loss. Although relaxation exercises may be beneficial, the focus should be on the expression of feelings. A psychiatric consultation is not indicated by the data at this time. The data do not indicate ambivalence toward the spouse.

What should the nurse consider when caring for clients who are at risk for suicide? 1 A client who fails in a suicide attempt will probably not try again. 2 Formal suicide plans increase the likelihood that a client will attempt suicide. 3 It is best not to talk to clients about suicide, because it may give them the idea. 4 Clients who talk about suicide are not planning it; they are using the threat to gain attention.

Formal suicide plans increase the likelihood that a client will attempt suicide. -A formal plan demonstrates determination, concentration, and effort, with conclusions already thought out. Failure to successfully complete the suicidal act can add to feelings of worthlessness and stimulate further acts. Verbalizing feelings may help reduce the client's need to act out. Many clients verbalize their suicidal thoughts as they are working on their decision and plan of action; a suicide attempt is not necessarily just to receive attention.

A mother whose child has been killed in a school bus accident tells the nurse that her child was just getting over the chickenpox and did not want to go to school but she insisted that the child go. The mother cries bitterly and says that her child's death is her fault. The nurse understands that perceiving a death as preventable most often will influence the grieving process in that it may do what? 1 Grow in intensity and duration 2 Progress to a psychiatric illness 3 Be easier to understand and to accept 4 Cause the mourner to experience a pathological grief reaction

Grow in intensity and duration -Deaths that are perceived as preventable cause more guilt for the mourners and therefore increase the intensity and duration of the grieving process. Perceiving a death as preventable will not necessarily result in a pathological reaction, but it will usually make it harder to understand and accept the death.

A nurse is preparing to care for a client who engages in ritualistic behavior. What is the most appropriate intervention to include in the plan of care? 1 Redirecting the client's energy into activities to help others 2 Teaching the client that the behavior is not serving a realistic purpose 3 Administering antianxiety medications that block out the memory of internal fears 4 Helping the client understand that the behavior is caused by maladaptive coping with increased anxiety

Helping the client understand that the behavior is caused by maladaptive coping with increased anxiety -Helping clients understand that a behavior is being used to control anxiety usually makes them more amenable to psychotherapy. Treatment includes activities to help the client, not others. The client usually understands already that the behavior is not serving a realistic purpose. Administering antianxiety medications that block out the memory of internal fears will only mask symptoms and will not get at the root of what is bothering the client.

A nurse in the mental health clinic concludes that a client is using confabulation when the client does what? 1 The flow of thoughts is interrupted. Correct2 Imagination is used to fill in memory gaps. Incorrect3 Speech flits from one topic to another with no apparent meaning. 4

Imagination is used to fill in memory gaps. -Connections between statements are so loose that only the speaker understands them. Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits. Interruption of the flow of thoughts is the definition of thought blocking. Flitting of speech from one topic to another with no apparent meaning is the definition of flight of ideas. The definition of associative looseness is connections between statements so loose that only the speaker understands them.

Which suicide method is the least lethal? 1 Hanging 2 Ingesting pills 3 Jumping from a tall bridge 4 Poisoning with carbon monoxide

Ingesting pills -Ingesting pills is considered the least lethal of these suicide methods, because it is considered slower. Hanging, jumping, and carbon monoxide poisoning are all quicker and therefore more lethal methods.

An older retired client is visiting the clinic for a regularly scheduled checkup. The client tells the nurse about the great life he has lived and the activities that he enjoys at the senior center. According to Erikson, what developmental conflict has been resolved by this client? 1 Trust versus mistrust 2 Integrity versus despair 3 Generativity versus self-absorption 4 Autonomy versus shame and doubt

Integrity versus despair

A client in the mental health clinic who has been seeing a therapist for more than 6 months begins to talk and act like a therapist who is analyzing coworkers. What defense mechanism does the nurse identify? 1 Undoing 2 Projection 3 Introjection 4 Intellectualizatio

Introjection

Personality disorders: common behaviors

Manipulation Self-Centeredness Power Struggles Rigidity Inflexibility Poor ability to self-regulate

Anxiolytics: Sedative-Hypnotics

Medication - zaleplon (Sonata) *Use* short-term sleep aid, usually few days to 2 weeks *Side effects:* Hallucinations, abnormal behavior, severe confusion, suicidal thoughts, daytime drowsiness, dizziness, ataxia, double vision/other vision problems, agitation, vivid or abnormal dreams -Habit-forming -Withdrawal effects

Antidepressant Agents: Selective Serotonin Reuptake Inhibitors (SSRIs)

Medication: *Prozac (fluoxetine)*, citalopram (Celexa), escitalopram oxalate (Lexapro), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox) *Action* Inhibit reuptake of serotonin by blocking its transport into presynaptic neuron; increase concentration synaptic serotonin *Side effects:* Headache, anxiety, insomnia, transient nausea, vomiting, diarrhea, sedation , sexual dysfunction, diastolic hypertension, increased perspiration

Antidepressant Agents: Tricyclic antidepressants (TCAs)

Medication: Elavil (amitriptyline) *Action* Act on neurotransmitter systems including norepinephrine & serotonin reuptake systems -As effective as SSRIs, with more serious side effects & higher lethal potential -Most can be given once-daily single dose; *cause sedation, give at bedtime* *Most common side effects:* Sedation, orthostatic hypotension, anticholinergic side effects , tremors, restlessness, insomnia, nausea & vomiting, confusion, pedal edema, headache, seizures, blood dyscrasias

Anxiolytics: Benzodiazepines

Medications - alprazolam (Xanax), lorazepam (Ativan), diazepam (Valium), chlordiazepoxide (Librium), flurazepam (Dalmane), triazolam (Halcion), oxazepam (Serax) *Use* short-term relief anxiety or anxiety with depression *Side effects:* Drowsiness, intellectual impairment, memory impairment, ataxia, reduced motor coordination, sedation, "hangover" effects -Tolerance develops -Alcohol potentiates the CNS depression -*Tolerance & psychological dependence are common* *Abrupt discontinuation* - rebound insomnia or anxiety

Anxiolytics: Non-benzodiazepines

Medications - buspirone (BuSpar), zolpidem (Ambien) *Use* Treating anxiety disorders with less CNS depressant effects or potential for abuse & withdrawal syndromes *Side effects:* Dizziness Drowsiness Nausea Excitement Headache

Stimulants

Medications - methylphenidate (Ritalin), pemoline (Cylert): used for hyperactivity & attention deficit disorders; modafinil (Provigil): for narcolepsy *Use* Adjunct therapy depression/other mood disorders, decrease fatigue *Action* Stimulate sympathetic nervous system, produce alertness, wakefulness, vasoconstriction, suppressed appetite & hypothermia *Side effects:* Appetite suppression, insomnia, irritability, nausea, H/A, blurred vision, dry mouth, constipation, tremors, dizziness, blood pressure changes(hyper/hypotension), palpitations, tachycardia, irregular heart rate -Tolerance develops; caution history substance abuse

Antidepressant Agents: Norepinephrine-Dopamine Reuptake Inhibitor *(NDRI)*

Medications: bupropion (Wellbutrin, Zyban) *Action* Inhibits norepinephrine, serotonin, and dopamine *Side effects:* agitation or anxiety , insomnia, appetite suppression, psychosis

Antidepressant Agents: Serotonin-Norepinephrine Reuptake Inhibitors *(SNRIs)*

Medications: venlafaxine (Effexor), nefazodone (Serzone), duloxetine (Cymbalta), desipramine (Norpramin) *Action* Prevent reuptake of serotonin & norepinephrine at presynaptic site *Side effects:* Similar to the SSRIs Risk for increase in blood pressure

EPS reactions: Pseudoparkinsonism

Parkinson type symptoms

Monoamines: Dopamine: mental illness

Parkinson's disease and depression *(decreased levels) Mania and Schizophrenia *(increased levels)*

Because a severely depressed client has not responded to any of the antidepressant medications, the primary healthcare provider decides to try electroconvulsive therapy (ECT). What should the nurse do before the treatment? 1 Have the client speak with other clients undergoing ECT. 2 Give a detailed explanation of what to expect after the procedure. 3 Limit the client's intake to a light breakfast on the days of the treatment. 4 Provide emotional support while presenting a simple explanation of the ECT procedure.

Provide emotional support while presenting a simple explanation of the ECT procedure.

A maturational crisis is typically precipitated by a developmental change or event (internal source). Among older people like Nell, which of the following often precipitates a maturational crisis? Parenthood Grandparenting Retirement Death of a spouse

Retirement

Monoamines: Serotonin: mental illness

Schizophrenia and anxiety *(increased levels)* Depression *(decreased levels)*

In addition to hallucinating, a client yells and curses throughout the day. What should the nurse do? 1 Ignore the client's behavior. 2 Isolate the client until the behavior stops. 3 Explain the meaning of the behavior to the client. 4 Seek to understand what the behavior means to the client.

Seek to understand what the behavior means to the client. -All behavior has meaning; before planning intervention, the nurse must try to understand what the behavior means to the client. Ignoring behavior does little to alter it and may even cause further acting out. Isolation may increase anxiety and precipitate more acting-out behavior. The nurse cannot explain the meaning of the client's behavior; only the client can

A client with major depression has been prescribed fluoxetine (Prozac). What nursing diagnosis would be most appropriate? Social isolation Impaired physical mobility Impaired urinary elimination Disturbed sensory perception

Social isolation

A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior supports this diagnosis? 1 Making huge efforts to avoid "any kind of bug or spider" 2 Experiencing flashbacks to an event that involved a sexual attack 3 Spending hours each day worrying about something "bad happening" 4 Becoming suddenly tachycardic and diaphoretic for no apparent reason

Spending hours each day worrying about something "bad happening" -Using worrying as a coping mechanism is a behavior characteristic of GAD. Experiencing an accelerated heart rate and perfuse sweating for no apparent reason is consistent with a panic attack. Avoiding bugs and spiders would indicate a phobia. Flashbacks to traumatic events are characteristic of posttraumatic stress disorder (PTSD).

A nurse is working with a child who was physically abused by a parent. What is the most important goal for this family? 1 The child will live in a safe environment. 2 The parents will use verbal discipline effectively. 3 The family will feel comfortable in its relationship with the counselor. 4 The parents will gain an understanding of their abusive behavior patterns.

The child will live in a safe environment.

A disturbed client who has been out of touch with reality has been hospitalized for several weeks. One day the nurse notes that the client's hair is dirty and asks whether the client wants to wash it. The client answers, "Yes, and I'd like to shower and change my clothes, too." What can the nurse conclude about the client in relation to this response? 1 The client has some feelings of self-worth. 2 The client is open to suggestions from others. 3 The client may be entering a hyperactive phase. 4 The client has a need for social reassurance from others

The client has some feelings of self-worth. -When individuals express interest in physical appearance, it demonstrates a rebuilding of the self-image and the return of feelings of worth and concern for how others see them. The client's response goes further than the nurse's suggestion to wash the hair. The client has identified the need to shower and change clothes. The client's response is well within the expected range; it does not indicate the beginning of a hyperactive phase. The information provided does not demonstrate a need for social reassurance or approval.

Which are the most important assessment data for a nurse to gather from the client in crisis? 1 The client's work habits 2 Any significant physical health data 3 A history of emotional problems in the family 4 The client's perception of the circumstances surrounding the crisis

The client's perception of the circumstances surrounding the crisis

What is the most important tool a nurse brings to the therapeutic nurse-client relationship? 1 The self and a desire to help 2 Knowledge of psychopathology 3 Advanced communication skills 4 Years of experience in psychiatric nursing

The self and a desire to help

Psychobiology

The study of the biological foundations of cognitive, emotional, and behavioral processes.

Antidepressant Agents: Classes

Tricyclic antidepressants (TCAs) Monoamine Oxidase Inhibitors (MAOIs) Selective Serotonin Reuptake Inhibitors (SSRIS Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Norepinephrine-Dopamine Reuptake Inhibitor (NDRI) 2 Antagonist (NaSSA) Serotonin-2 Antagonist/Reuptake Inhibitor (SARI)

Mental status exam: 2. Speech:

Volume, rate, latency, push or pressure, loquacious, retarded, mute, increased or decreased.

A nurse is caring for a client with an antisocial personality disorder. What consistent approach should the nurse use with this client? 1 Warm and firm without being punitive 2 Indifferent and detached but nonjudgmental 3 Conditionally acquiescent to client demands 4 Clearly communicative of personal disapproval

Warm and firm without being punitive -The client needs positive relationships with other adults, but clear, consistent limits must be presented to minimize attempts at manipulation. Acting indifferent and detached but nonjudgmental is not a therapeutic approach. Being indifferent and detached gives the impression that the nurse does not care. Being conditionally acquiescent to client demands is not a therapeutic approach because clear, consistent limits are necessary to prevent manipulation. Being clearly communicative of personal disapproval is a judgmental attitude that should be avoided.

The nurse should first discuss terminating the nurse-client relationship with a client during which phase? 1 Working phase, when the client initiates it 2 Orientation phase, when a contract is established 3 Working phase, when the client shows some progress 4 Termination phase, when discharge plans are being made

Working phase, when the client shows some progress

A male college student who is smaller than average and unable to participate in sports becomes the life of the party and a stylish dresser. What defense mechanism does the nurse determine that the client is using? 1 Introjection 2 Sublimation 3 Compensation 4 Reaction formation

compensation By developing skills in one area, the individual compensates for a real or imagined deficiency in another, thereby maintaining a positive self-image. Had the student incorporated the qualities of the college athlete, that would be introjection. Sublimation is related to unacceptable impulses that may pose a threat. This person is trying to make amends not for unacceptable feelings (reaction formation), but rather for a believed deficiency and an inadequate self-image.

A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. What does the nurse's behavior reflect? 1 Affiliation 2 Displacement 3 Compensation 4 Countertransference

countertransference

EPS reactions: Dystonias

involuntary movements

Personality disorders: DSM-IV-TR CRITERIA

*Axis II disorder* -Enduring pattern of inner experience and behavior that deviates markedly from an individual's culture manifesting in two or more of the following areas: 1. Cognition 2. Affect 3. Interpersonal functioning 4. Impulse control

Personality disorders: DSM-IV-TR CRITERIA: *CLUSTER C:*

*Behaviors that are described as anxious or fearful:* 1. *Avoidant:* sensitive to rejection, "everything is personal", secluded 2. *Dependent:* lack self confidence, wangt everyone to do everything, "needy" 3. *Obsessive compulsive:* over disciplined, perfecting, inflexible, lack spontaneity, rigid "only way way"

Personality disorders: DSM-IV-TR CRITERIA: *CLUSTER B:*

*Behaviors that are described as dramatic, emotional, or erratic:* 1. *Antisocial:* "your psychopath"; general disregard for others; difficulty in relationship/employment 2. *Borderline:* more female than male; intense, chaotic relationships; impulsive, self destructive; manipulate: likely to split staff 3. *Histrionic:* dramatic, extroverted, flirtatious 4. *Narcissistic:* self-centered; EX: "HOUSE"

Crisis: definition

- is an overwhelming reaction to a threatening situation in which a person's usual problem solving strategies fail to resolve the situation. -Unanticipated/part of life/universal experience/creates disequilibrium/individually perceived -Results in personality disorganization or growth

Toxicity

- point at which concentrations of medication in bloodstream become harmful or poisonous to body

Desensitization

- rapid decrease in medication effects; may develop within minutes of exposure

Therapeutic index

- ratio of the maximum non-toxic dose to minimum effective dose

Mental status exam: 1. General Appearance, Attitude & Behavior:

-*Clothes:* tidy, slovenly, neat, careless, dirty, decorative, mourning. -*Facies:* smiling, crying, blank, scared, sad, mask-like. -*Attitude:* cooperative, resistive, sociable, reserved, seclusive, belligerent, negativistic, suspicious, apathetic, fearful, confident, over-confident, sarcastic, superior. -*Motor Activity:* hyperactive, bizarre gestures, mannerisms, posture, tics, gait, paralysis, tremors.

Adventitious Crisis

-*are not part of everyday life.* They are unplanned and accidental resulting in traumatic experiences. Such as... 1. Natural disasters.. hurricanes, flood, fire, earthquake, etc... 2. National disasters.. war, riots, etc... 3. Crime of violence.. Child abuse, rape, assault, bombing in crowded areas, etc...

Situational Crisis

-*occurs in response to a sudden unexpected event in a person's life from an external source.* The critical life events involves a loss or a change that threatens the person's self esteem. -For example job loss, divorce, abortion, death of a love one, severe physical or mental illness, etc.

Developmental (Maturational) Crisis

-*predicted times of stress in everyone's life* which occurs in response to a transition from one stage to another in the life cycle. -Example- Erikson's stages... going from Industry to Identity (passage from school age child to adolescence)

Personality disorders: DSM-IV-TR CRITERIA: Enduring pattern is..

-Inflexible/pervasive -personal/social situations -Significant distress in social, occupational, other areas of functioning -Of stable and long duration -Not due to physiological effects of substance or medical condition

EPS reactions: Akathesia

-Jitteriness, patient in constant motion, cannot sit still -Non-stop foot tapping or other repetitive movement -inability to sleep

Personality disorders:

-Occur when traits become *inflexible and maladaptive but stable over time.* -Cause either significant functional impairment or subjective distress. However they stay in the main stream of society. -Present with symptoms more subtle than other disorders. -Onset in adolescence or early adulthood

Personality: def

-Personality is a consistent way of thinking and feeling which results from the interaction of a person's *genetic make-up, his level of education and past experiences.* -Largely unconscious -Cannot be changed easily

During a group therapy session some members accuse another client of intellectualizing to avoid discussing feelings. The client asks whether the nurse agrees with the others. What is the best response by the nurse? 1 "It seems that way to me, too." 2 "What's your perception of my behavior?" 3 "Are you uncomfortable with what you were told?" 4 "I'd rather not give my personal opinion at this time."

"Are you uncomfortable with what you were told?" -Asking the confronted client whether he or she is uncomfortable with what he or she is being told will help the client identify behaviors and feelings in a nonthreatening manner. Agreeing with the confronting group members indicates a lack of acceptance of the client. The nurse's behavior is not the issue; the situation should be turned back to the client's behavior. Evasion and refusal to answer will have the psychological effect of removing the nurse from the group.

What response to Nell would be appropriate when she says, "It's been a burden on me not to be able to tell her how I feel"? "I imagine that this burden helped contribute to your crisis." "How would you feel about telling Sara about your feelings and their reasons now?" "It probably would be a good idea if you and Sara talked about it." "Would you like me to help you with some role playing so that you could practice telling Sara how you feel?" "Since Sara is here, why don't we call her in so that you can tell her?"

"How would you feel about telling Sara about your feelings and their reasons now?" -This response would suggest a course of action that Nell could accept or reject. It would encourage her to think through whether or not she is ready to talk with Sara.

The nurse realizes more medication teaching is necessary when the 30-year-old female client taking lorazepam (Ativan) states: "I must stop drinking coffee and colas." "I can stop this medicine after 3 weeks if I feel better." "I must stop drinking alcoholic beverages completely." "I should not become pregnant while taking this medicine."

"I can stop this medicine after 3 weeks if I feel better."

Monoamines: Norepinephrine: Functions:

may have a role in the regulation of mood, in cognition and perception, in cardiovascular functioning, and in sleep and arousal.

Monoamines: Serotonin: function

play a role in sleep and arousal, libido, appetite, mood, aggression, and pain perception

What statement by a male client during a yearly physical examination indicates to a nurse that the client may have a sexual arousal disorder? 1 "I have no interest in sex." 2 "I don't get hard during sex anymore." 3 "I climax almost before we even get started." 4 "It takes forever before I finally have an orgasm."

"I don't get hard during sex anymore."

A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? Select all that apply. 1 "I cry all the time; I'm just so sad." 2 "Since I retired I've been so depressed." 3 "I'd like to end it all with sleeping pills." 4 "The voices say I should kill all prostitutes." 5 "My boss makes me so angry—he's always picking on me."

"I'd like to end it all with sleeping pills." "The voices say I should kill all prostitutes." -The statement about ending it all is a suicide threat; it is a direct expression of intent without action. Likewise, the threat to harm others must be heeded. Confiding feelings of sadness or depression does not indicate that the client plans to self-harm or harm others. The statement about the boss reflects the client's feelings of anger and the cause but does not indicate a threat to self or others.

A nursing team holds a conference to develop goals for the care of a withdrawn, shy male client with low self-esteem who is afraid to talk to members of the opposite sex. Which objective should be given priority and documented in the client's plan of care? 1 "The client will increase his self-esteem." 2 "The client will understand his sexual disorder." 3 "The client will examine his feelings toward women." 4 "The client will increase his knowledge of sexual function."

"The client will increase his self-esteem." -If the goal to increase the client's self-esteem is met, the client's relationship with others should improve in all aspects, including sexual. Increasing insight may be helpful but should not receive priority. The client may or may not have a sexual disorder. Examining his feelings toward women is not appropriate at this time; examining these feelings is nonproductive until the client's self-esteem improves. Increasing the client's knowledge of sexual function may be done, but improvement of self-esteem should receive priority.

On the day after admission a suicidal client asks a nurse, "Why am I being watched around the clock, and why can't I walk around the whole unit?" Which reply is most appropriate? 1 "Why do you think we're observing you?" 2 "What makes you think we're observing you?" 3 "We're concerned that you might try to harm yourself." 4 "We're following your primary healthcare provider's instructions, so there must be a reason."

"We're concerned that you might try to harm yourself."

During a phone conversation to a crisis hotline a client states, "I'm falling apart and can't put myself together. This goes on and on." What is the most therapeutic response by the nurse? 1 "Is there anyone there with you?" 2 "What do you think this means?" 3 "How do you usually handle this type of situation?" 4 "What's happening right now that prompted you to call?"

"What's happening right now that prompted you to call?" -Getting the client's perception of what has prompted the call is essential to determining whether the client is in danger. The client has chosen to call the crisis line as a help-seeking behavior; asking whether someone else is there does not focus on the client's reaching out. "What do you think this means?" is a question that can be asked later to assist the client in gaining insight into the present situation. "How do you usually handle this type of situation?" is a question that may follow assessment of the situation.

A client who experiences auditory hallucinations agrees to discuss alternative coping strategies with a nurse. For the next 3 days when the nurse attempts to focus on alternative strategies, the client gets up and leaves the interaction. What is the most therapeutic response by the nurse? 1 "Come back; you agreed that you would discuss other ways to cope." 2 "You seem very uncomfortable every time I bring up a new way to cope." 3 "Did you agree to talk about other ways to cope because you thought that was what I wanted?" 4 "You walk out each time I start to discuss the hallucinations; does that mean you've changed your mind?"

"You seem very uncomfortable every time I bring up a new way to cope." -"You seem very uncomfortable every time I bring up a new way to cope" focuses on a feeling that the client may be experiencing and provides an opportunity to validate the nurse's statement. "Come back; you agreed that you would discuss other ways to cope" demands that the client stay in an uncomfortable situation without offering any support. "Did you agree to talk about other ways to cope because you thought that was what I wanted?" fails to recognize the part anxiety plays in changing behavior. "You walk out each time I start to discuss the hallucinations; does that mean you've changed your mind?" seems like an attack on the client; also, although it offers an explanation for the behavior, it fails to convey an understanding that changing behavior is anxiety-producing.

Crisis intervention: Implementation

1. *Assess for any suicidal/ homicidal thoughts or plans.* 2. Take initial steps to make the client feel safe and lower anxiety. 3. *Safety*- intervene to prevent violence- suicide/ angry, aggressive client. 4. *Listen attentively* and encourage the client to discuss the crisis situation. -*Facilitate the verbalization of thoughts and feelings.* 5. Creative and directive approach needed. -Initially nurse may make phone calls (arrange baby-sitters, find shelters, contact social workers, etc.) 6. *Use problem solving approach.* 7. Identify needed social support (with patient's input) and mobilize the most needed first. 8. *Identify and work to increase needed coping skills* (problem solving, relaxation, assertiveness, job training, newborn care, self-esteem). 9. *Plan with patient interventions that are acceptable to both.* 10. Evaluate plan and instruct patient with alternative plan if needed.

Mood stabilizers: Lithium: Patient education

1. Take with plenty of water and AFTER meals to minimize GI upset 2. Educate importance of having regular blood work done to to monitor drug levels; lithium toxicity occus with slight elevation 3. do not abruptly stop taking med 4. Instruct to report s/s of weakness, lethargy, loss of appetite or vomiting, as this could lead to more serious side effects

Antipsychotic agents: Patient education

1. Teach pt to get up slowly (prevent OH) 2. Drowsiness that occurs in the beginning of med regimen may go away after a few weeks 3. Sunscreen; sunburn is more severe (photosensitivity) 4. Drink extra fluids during hot weather 5 *target symptoms will reoccur if pt stops taking med* 6. medication compliance is extremely important and to see doctor after discharge

Types of psychiatric medications:

Antipsychotic medications Mood stabilizers Anti-depressants Antianxiety and sedative-hypnotic Stimulants

Suicide: Nursing considerations

Any hint take seriously No secrets Good listener Express concern Suicide hotlines Non judgmental Evaluation is on going

A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request? 1 Justice 2 Veracity 3 Autonomy 4 Beneficence

Autonomy

A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention? 1 Encouraging the client to try to walk 2 Explaining to the client that there is nothing wrong 3 Avoiding focusing on the client's physical symptoms 4 Helping the client follow through with the physical therapy plan

Avoiding focusing on the client's physical symptoms -The physical symptoms are not the client's major problem and therefore should not be the focus of care. This is a psychological problem, and the focus should be in this domain. Encouraging the client to try to walk is focusing on the physical symptom of the conflict; the client is not ready to give up the symptom. The disorder operates on an unconscious level but is very real to the client; saying there is nothing wrong denies feelings. Psychotherapy, not physical therapy, is needed at this time.

What should a nurse consider about the past experiences of clients who have immigrated to this country? 1 It affects all of their inherited traits. 2 There will be little impact on their lives today. 3 It is important that their values be assessed first. 4 How they will interact is permanently established.

It is important that their values be assessed first. -Past experiences are important and must be recognized because they help set the individual's values throughout life. Past experiences will not affect inherited traits. Past experiences play an important role in an individual's life. Nothing establishes how an individual responds forever; new experiences continue to influence future responses.

How can a nurse minimize agitation in a disturbed client? 1 By ensuring constant staff contact 2 By increasing environmental sensory stimulation 3 By limiting unnecessary interactions with the client 4 By discussing the reasons for the client's suspicions

By limiting unnecessary interactions with the client -Limiting unnecessary interactions will decrease stimulation and therefore agitation. Constant client and staff contact increases stimulation and agitation. Increasing environmental sensory stimulation bombards the client's sensorium and increases agitation. Not all disturbed clients are suspicious. This client is unlikely to benefit from this discussion at this time.

A nurse is preparing to teach a mental health course at a community health center. What information should the nurse include as one of the most effective ways to limit the occurrence of mental illness in the community? Correct1 Developing multiple coping strategies 2 Reporting strange behaviors by others 3 Correcting myths about mentally ill people 4 Addressing genetic issues related to mental illness

Developing multiple coping strategies A variety of strategies gives people options when they are attempting to cope with stress. Different strategies work better in different situations. Reporting strange behaviors by others is too vague; the definition of "strange" may vary, depending on the individual. Although correcting myths about mentally ill people is useful, it will not limit the occurrence of mental illness. Although some mental disorders may have familial tendencies and may have a genetic link, this information is too limited. Topics

The nurse is explaining behavior to a nursing assistant. Which characteristic of a behavior usually results in that behavior being viewed and accepted as normal? 1 Fitting within standards accepted by one's society 2 Helping the person reduce the need for coping skills 3 Expressing the individual's feelings and thoughts accurately 4 Allowing achievement of short-term and long-term goals by the individual

Fitting within standards accepted by one's society

A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing feelings of what? 1 Guilt 2 Grandeur 3 Worthlessness 4 Self-deprecation

Grandeur -During a manic episode a client has an inflated self-esteem that replaces feelings with which the client cannot cope. Feelings of guilt, worthlessness, and self-deprecation are not associated with bipolar disorder, manic episode.

Active listening: SOLER

S - Sit squarely facing the client. O - Observe an open posture. L - Lean forward toward the client. E - Establish eye contact. R - Relax.

A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child? 1 Keeping the child from inflicting any self-injury 2 Helping the child improve communication skills 3 Helping the child formulate realistic ego boundaries 4 Providing the child with opportunities to discharge energy

Keeping the child from inflicting any self-injury -All nursing care should be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills, formulation of realistic ego boundaries, and opportunities to discharge energy are all important, prevention of injury is the priority.

Mental status exam: 4. Thought Processes (Form vs. Content):

Logical, circumstantial, loose associations, flight of ideas, clang associations, loss of goal, preoccupations, areas of concern, imaginations, suicidal/homicidal ideation in thought content, delusions, hallucinations, anxiety, phobia, compulsions, obsessions.

A client with the diagnosis of dementia of the Alzheimer type, stage 1, is living at home with an adult child. To best address the functional and behavioral changes associated with this stage, what should the nurse encourage the daughter to do? 1 Place the client in a long-term care facility. 2 Provide for the client's basic physical needs. 3 Post a schedule of the client's daily activities. 4 Perform care so the client does not need to make decisions

Post a schedule of the client's daily activities. -In stage 1 of Alzheimer-type dementia [1] [2], clients have mild cognitive impairment with short-term memory loss; establishing a daily routine, posting it, and adhering to it provides a concrete, structured approach. Placing the client in a long-term care facility may be required during stage 3 or the end of stage 2 if the child is unable to cope with the client's functional and behavioral changes. In stage 1, clients can provide for their own basic activities of daily living such as bathing, dressing, and eating. Clients can make simple decisions in stage 1, and they have the right to make choices; an authoritarian approach may promote regression, anxiety, depression, or anger.

A young female client admitted to the trauma center after being sexually assaulted continues to talk about the rape. Toward what goal should the primary nursing intervention be directed? 1 Getting her involved with a rape therapy group 2 Remaining available and supportive to limit destructive anger 3 Exploring her feelings about men to promote future relationships 4 Providing a safe environment that permits the ventilation of feelings

Providing a safe environment that permits the ventilation of feelings

Personality disorders: etiology

Psychoanalytical/Developmental Theories Biological Theories, e.g. genetic Socio-Cultural Theories Behavioral Theories

Monoamines: Dopamine: funstion

is involved in the regulation of movements and coordination, emotions, voluntary decision-making ability, and because of its influence on the pituitary gland, it inhibits the release of prolactin

A client in the mental health clinic who has concerns about getting married says to the nurse, "I guess I'd better get married. All the plans are made and paid for, and the invitations have all been mailed." What defense mechanism is the client using? 1 Introjection 2 Identification 3 Compensation 4 Rationalization

Rationalization In rationalization, seemingly logical reasons are used to justify behaviors or feelings that are unacceptable or painful. This is not introjection because the client has not assumed the feelings of another. This is not identification because the client has not attempted to emulate another person. This is not compensation because the client is not counterbalancing deficiencies in one area by excelling in another area.

Mental status exam: 6. Insight and Judgment:

Realization and recognition of degree and nature of illness; ability to make reasonable and practical plans; goals and ethics.

A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. What defense mechanism does the nurse know is being utilized by this woman? 1 Projection 2 Regression 3 Repression 4 Displacement

Repression -

After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client? 1 Projection 2 Repression 3 Suppression 4 Rationalization

Repression Repression is coping with overwhelming emotions by blocking awareness or memory of the stressful event. Projection is attributing one's own unacceptable feelings and thoughts to others. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Rationalization is the attempt to mask unacceptable feelings or behaviors by providing excuses and explanations.

A female client's stream of consciousness is occupied exclusively with thoughts of her mother's death. The nurse plans to help the client through this stage of grieving, which is known as what? 1 Resolving the loss 2 Shock and disbelief 3 Developing awareness 4 Restitution and recovery

Resolving the loss -Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features, emerges. The shock-and-disbelief stage is usually dominated by a refusal to accept or comprehend the fact that a loved one has died. The reality of the death and its meaning as a loss, plus anger, dominate this stage. The various rituals of the funeral help to initiate the recovery or restitution stage.

A 17-year-old client is found to have anorexia nervosa. The psychiatrist, in conjunction with the client and the parents, decides to institute a behavior modification program. What does the nurse recall is a major component of behavior modification? 1 Rewarding positive behavior 2 Reducing necessary restrictions 3 Deconditioning fear of weight gain 4 Reducing anxiety-producing situations

Rewarding positive behavior -In behavior modification [1] [2] [3], positive behavior is reinforced, and negative behavior is not reinforced or punished. Reducing the number or complexity of necessary restrictions, deconditioning the fear of weight gain, and reducing the number of anxiety-producing situations may all be part of the program, but none is a major component.

A nurse is conducting the Mini-Mental Status examination on an older client. What should the nurse ask the client to do when testing short-term memory? 1 Subtract serial sevens from 100. 2 Copy one simple geometric figure. 3 State three random words mentioned earlier in the exam. 4 Name two common objects when the nurse points to them.

State three random words mentioned earlier in the exam. -Stating three random words mentioned earlier in the examination is a test of the client's ability to recall from short-term memory. Subtracting serial sevens from 100 is a test of the ability to calculate and pay attention. Copying one simple geometric figure is a test of visual comprehension. Naming two common objects when the nurse points to them is a test of verbal skills to identify aphasia.

A client with the diagnosis of schizophrenia refuses to get out of bed and becomes upset. What is the nurse's initial therapeutic response? 1 Requiring the client to get out of bed at once 2 Allowing the client to stay in bed for a while 3 Staying at the bedside until the client calms down 4 Giving the prescribed as-needed tranquilizer to the client

Staying at the bedside until the client calms down provides support and security without rejecting the client or placing value judgments on behavior. Eventually limits will have to be set, but this is not the immediate nursing action. Allowing the client to stay in bed for the time being ignores the problem, and isolation may imply punishment. Although medication will calm the client, it does not address the problem.

An executive busy at work receives a phone call from a friend relating bad news. The executive makes a conscious effort to put this information out of mind and continues to work at the task at hand. The next day executive remembers that the friend telephoned but is unable to recall the message. Which defense mechanism does this behavior represent? 1 Regression 2 Suppression 3 Reaction formation 4 Passive aggression

Suppression -Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations. In regression, a person returns to an earlier and more comfortable developmental level. Passive aggression is the use of behaviors such as passivity, procrastination, and inefficiency that negatively affect others. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.

A client whose spouse died 2 years ago is brought to the psychiatric unit by a family member, who states that the widowed spouse has no interests, is neglecting personal hygiene, and has become totally isolated. The nurse completes a history and physical examination that verifies the family member's concerns. What is most important for the nurse to explore with the client at this time? 1 Feelings about the spouse's death 2 The real cause of the depressed behavior 3 The relationship with the deceased spouse 4 Whether suicide has been considered recently

The client is depressed; it is important to know whether the client is considering suicide so the nurse can provide a safe environment and related therapeutic care. Concern for the client's safety takes priority at this time over the client's feelings, the underlying cause of the behavior, or the dynamics of the marital relationship.

Cholinergics: Acetylcholine: location

major effector chemical within the autonomic nervous system (ANS), producing activity at all sympathetic and parasympathetic presynaptic nerve terminals and all parasympathetic postsynaptic nerve terminals

Monoamines: Dopamine: def/location

is derived from the amino acid tyrosine and may play a role in physical activation of the body Dopamine pathways arise from the midbrain and hypothalamus and terminate in the frontal cortex, limbic system, basal ganglia, and thalamus.

Monoamines: Serotonin: def/location

is derived from the dietary amino acid tryptophan. Serotonin pathways originate from cell bodies located in the pons and medulla and project to areas including the hypothalamus, thalamus, limbic system, cerebral cortex, cerebellum, and spinal cord

Monoamines: Norepinephrine: Location

is found in the ANS at the sympathetic postsynaptic nerve terminals.

Cholinergics: Acetylcholine: function

is implicated in sleep, arousal, pain perception, the modulation and coordination of movement, and memory acquisition and retention.

A decrease in Nell's anxiety would be evidenced by: 1. a decreased level of anxiety 2. statements by Nell indicating that she no longer feels overwhelmed 3. improved self-perception 4. statements by Nell indicating that she can take care of herself

statements by Nell indicating that she no longer feels overwhelmed -Outcome criteria should be *specific, measurable, and directly related to a goal (Nell will experience less anxiety).* Statements by Nell indicating that she no longer feels overwhelmed would validate a decrease in anxiety. In addition, a decrease in problematic physical symptoms (difficulty sleeping, pounding heart, sweating etc.) would validate a decrease in anxiety.