PTSD Mental Health Exam #4

When planning care for a client with a history of violent behavior toward others, the nurse should include which interventions? Select all that apply.

- Admitting the client to a room near the nurses' station -Arranging for a security officer to be nearby and available but out of the client's sight

Examples of child maltreatment include-

- Calling the child stupid for climbing on a fence and getting injured. - Spanking an infant who won't stop crying. - Watching pornographic movies in a child's presence. - Withholding meals as punishment for disobedience.

Warning signs of relationship violence-

- Emotionally abuses you (insults, makes belittling comments, or acts sulky or angry when you initiate an idea or activity) - Tells you with whom you may be friends or how you should dress, or tries to control other elements of your life - Talks negatively about women in general - Gets jealous for no reason - Drinks heavily, uses drugs, or tries to get you drunk - Acts in an intimidating way by invading your personal space such as standing too close or touching you when you don't want him to - Cannot handle sexual or emotional frustration without becoming angry - Does not view you as an equal: sees himself as smarter or socially superior - Guards his masculinity by acting tough - Is angry or threatening to the point that you have changed your life or yourself so you won't anger him - Goes through extreme highs and lows: is kind one minute, cruel the next - Berates you for not getting drunk or high, or not wanting to have sex with him - Is physically aggressive, grabbing and holding you, or pushing and shoving

Which behavior would the nurse anticipate a client diagnosed with Nyctophobia to demonstrate?

- always turns on the overhead light before entering a darkened room

PTSD - EMDR-

- eye moment, desensitization, and reprocessing is used to treat PTSD.

Several nurses are engaged in an assignment report when a client with a history of aggressive behavior approaches the nurses' station. The client becomes very loud and offensive, and demands to be seen by the health care provider (HCP) immediately. Which intervention will address the needs of both the client and the milieu?

- offer to assist the client to an examination room until the HCP is notified.

The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid speech. The nurse should determine that which action is the priority of care at this time?

- providing a safe place for the client to pace that is away from the other clients.

Characteristics of violent families-

- social isolation - abuse of power and control - alcohol and other drug abuse - intergenerational transmission process

Risk factors r/t crisis management-

-Accumulation of unresolved losses -Current life stressors -Concurrent mental&physical health issues -Excessive fatigue or pain -Age&developmental stage

The nurse should assess clients' risks for anger or aggression in the care of clients with which of the following psychiatric diagnoses?

-Alzheimers dementia -Schizophrenia -Alcohol intoxication

What a culture considers acceptable strongly influences the expression of anger. Which culture-bound syndrome is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects?

-Amok

Panic related to anxiety symptoms include-

-Characterized by markedly disturbed behavior -The client is not able to process what is occurring in the environment and can lose touch w/ reality -The client experiences extreme fright & horror. -The client experiences severe hyperactivity. -Other characteristics include dysfunction in speech, dilated pupils, severe shakiness, severe withdrawal, inability to sleep, delusions, hallucinations, the client may bold and run or be mute and immobile, dilated pupils, increased b/p and pulse, and may be suicidal.

Coping mechanisms for stress

-Compensation is excelling in one area to counterbalance deficiencies in another area. -Displacement- is the discharge of pent-up feelings onto something or someone else less threatening than the original source of the feelings. -Fantasy- is the gratification of frustrated desires, achievement, and relationships by substituting them with daydreams and imagery. -Regression- in which a client returns to an earlier, less threatening level of adaptation (development).

Atypical antipsychotics-

-Current meds of choice for psych disorders, and the generally treat both positive&negative. symptoms -Risperidone -Olanzapine -Quetiapine -Ziprasidone -Clozapine -To minimize weight gain, advise the client to follow a healthy, low cal diet, engage in regular exercise and monitor weight -Adverse effects of agitation, dizziness, sedation and sleep disruption can occur... instruct client to report these manifestations b/c the provider might need to change the med-Inform the client of the need for blood tests to monitor for agranulocytosis.

In the psychiatric setting, what is the most effective intervention in preventing the hostile client's behavior from escalating to physical aggression?

-Engaging the hostile person in dialogue.

Common characteristics of crisis-

-Experiencing a sudden event w/ little or no time to prepare -Perception of the event as overwhelming or life threatening -Loss or decrease in comm w/ significant others-Sense of displacement from the familiar-An acute or perceived loss

A client with PTSD may exhibit with-

-Flashbacks -Nightmares (very vivid) -Sleep disturbances -Depression -Denial/emotional numbness -Anger -Guilt, or remorse -Low self esteem -Seperation anxiety -Irritability -Inability to concentrate, to show love or empathy, or experience pleasure. -Difficulty in relationships; often leading to divorce. -Abuse in relationships. -Substance abuse -Physical symptoms.

What is the major difference between posttraumatic stress disorder (PTSD) and acute stress disorder?

-In PTSD, the symptoms occur 3 months or more after the trauma.

In the alarm stage of the GAS, what are the effects of the sympathetic nervous system on each of the following: heart, brain, glycogen stores, and skeletal muscle?

-In the GAS alarm stage, the sympathetic nervous system produces a fight-or-flight response that: -Increases heart rate and strength of contractions, increasing cardiac output -Increases mental alertness -Causes the release of glycogen stores and increases in blood glucose levels -Increases muscle strength (ability to contract)

Treatment for PTSD includes-

-Individual and group therapies. -Self help groups. -EMDR (eye movement desensitization and reprocessing). -Prolonged exposure therapy; combined with relaxation techniques. -Hypnotherapy -Biofeedback -Medications such as SSRI's/SNRI's-Venlafaxine, or Risperidone.

Screening tools used for PTSD include-

-Life events checklist -DSM-5 PTSD -Substance abuse screening -BPRS (brief psychiatric rating scale)

Behavioral Techniques-

-Meditation techniques includes formal techniques, as well as prayer for those who believe in a higher power. GUIDED IMAGERY: The client is guided through a series of images to promote relaxation, images vary depending on the person... for example, one client might imagine walking on a beach, while another client might imagine himself in a position of success. BREATHING EXERCISES: Used to decrease rapid breathing and promote relaxation. PROGRESSIVE MUSCLE RELAXATION: A person trained in this method can help a client attain complete relaxation w/in a few mins. PHYSICAL EXERCISE: Causes release of endorphins that lower anxiety, promote relaxation, and have antidepressant effects -Use nursing judgement to determine the approp of relaxation techniques for clients who are experiencing acute manifestation of a psychotic disorder.

The four levels of anxiety are-

-Mild- helps individuals learn grow and change. -Moderate- increases focus on the alarm; learning is still possible. -Severe- greatly decreases cognitive function, increases preparation for physical responses, and increases space needs. -Panic- fight or flight or freeze response; no learning is possible; the is attempting to free themselves from the discomfort of this high stage of anxiety.

When should the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior?

-No aggressive behavior has been observed for 1 hour after the release of two of the extremity restraints.

Severe anxiety symptoms include-

-Perceptual field is greatly reduced w/ distorted perceptions -Learning and problem solving do not occur -Functioning is ineffective -Other characteristics include confusion, feelings of impending doom, hyperventilation, tachycardia, withdrawal, severe headache, N/V/D, trembling, rigid stance, vertigo, pale, tachycardia, chest pain, and ritualistic or aimless activity. -The client is usually not able to take direction from others.

Which of the following might the nurse recognize when dealing with a client, as longer-term responses to trauma and stress?

-Posttraumatic stress disorder -Adjustment disorder -Reactive attachment disorder -Dissociative disorder

The client is experiencing night terrors. Which of the following would the nurse know are the major elements of posttraumatic stress disorder (PTSD)?

-Re-experiencing the trauma through dreams or recurrent and intrusive thoughts. -Emotional numbing such as feeling detached from others. -Being on guard, irritable, or experiencing hyper-arousal.

Warning signs of abused or neglected person's-

-Serious injuries such as fractures, burns, lacerations, with no reported history of trauma. -delay in seeking treatment for significant injury. -Child or parent giving a history inconsistent w/with severity of injury, such as a baby w/injuries to the brain (due to excessive shaking) and the parents state the child just rolled off of the sofa. -Inconsistencies or changes in the child's history during the evaluation by either the child or the adult. -Unusual injuries for the child's age and level of development, such as a fractured femur in a 2 month old, or a dislocated shoulder in a 2 year old. -High incidence of urinary tract infections, bruising, red, or swollen genitalia, tears or bruising of rectum or vagina. -Evidence of old injuries not reported such as scars, fractures not yet treated, and multiple bruising in various stages of healing that the parent cannot explain.

What is the appropriate nursing intervention for a client diagnosed with posttraumatic stress disorder and paranoid tendencies who begins to pace and fidget?

-Share the observation with the client so the behavior can be recognized.

Crisis management client education-

-Support system -Prior experience w/ stress/crisis -Identify&coordinate w/ support agencies&other resources -Plan and provide for followup care. **Admin anti-anxiety and/or antidepressant med as prescribed.

Hyper-arousal is defined as-

-Symptoms that arise from high levels of anxiety, including insomnia, irritability, anger outbursts, watchfulness, suspiciousness, and distrustfulness. **due to excess activation of the fight or flight response.

A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior?

-The client will employ new coping methods that will resolve the problem.

Which client on the mental health unit should be assessed as being at highest risk for directing violent behavior toward others?

-a client who has paranoid delusions and believes is being followed by members of the mafia.

Which is the best therapeutic approach for the nurse to use in crisis counseling?

-active w/focus on the current situation.

A nurse is teaching staff which factors to include in an abuse assessment of a client. Which of the following factors should the nurse include in the teaching?

-alcohol use -support system -coping strategies -suicide risk

A female client comes to an urgent care clinic and says, I've just been raped. What should the nurse do?

-allow the client to express whatever she wants. -ask the client if staff can call a friend or family member for her. -stay with the client until someone else arrives to be with her.

Which is the primary goal of crisis intervention therapy?

-assist the client in returning to the level of precrisis functioning.

An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. The most appropriate action by the nurse would be which of the following?

-call for an emergency response from trained personnel.

When interacting with a client in the day room, the nurse determines that a violent outburst is imminent. Which of the following should the nurse do first?

-call for assistance.

Which of the following is the best action for the nurse to take when assessing a child who might be abused?

-consult with a professional member of the health team about making a report.

A nurse is caring for a child who has Autism spectrum disorder. Which of the following findings should the nurse expect?

-delayed language development -spinning a toy repeatedly -ritualistic behavior

A man is discovered wandering the street, looking confused and stepping out into traffic. When emergency responders approach the man, he cannot recall his name or where he lives. The responders transport the man to the mental health crisis unit for further evaluation. Which of the following is the man potentially suffering from?

-depersonalization disorder -dissociative identity disorder -dissociative amnesia.

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

-determining if the client is having psychotic thinking. Rationale-Clients experiencing a situational crisis are at greatest risk for injury to themselves or others; therefore, determining if psychotic thinking is present is the highest priority.

A client tells a nurse about recent episodes of strange behavior that the client cannot recall, but has discussed with family. The client reports being told of going out late at night dressed, but not in the usual wardrobe. Upon return, the client cannot recall any of the event. The nurse suspects the client is dealing with which personality disorder?

-dissociative identity disorder.

The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs?

-flashbacks.

Women in battering relationships often remain in those relationships as a result of faulty or incorrect beliefs. Which of the following beliefs is valid?

-if she tried to leave, she would be at increased risk for violence.

Which of the following assessment findings might indicate elder self neglect?

-inability to manage personal finances.

The traumatized client has suddenly changed demeanor and voice pitch. Which of the following is true about the use of touch with a client with dissociative identity disorder?

-it is best not to touch the client without asking his or her permission.

Nursing interventions for Panic disorder-

-provide a safe environment and ensure privacy during the attack. -remain with the client during a panic attack to ensure safety. -help the client to focus on deep breathing. -talk to the client in a calm reassuring voice. -engage with the client to explore how to decrease stressors and anxiety provoking situations. -encourage regular exercise. -discuss time management techniques such as creating a to do list w/realistic estimated deadlines for each activity, crossing off completed items for sense of accomplishment, and letting the client know its ok to say "NO."

Which of the following is true about domestic violence between same sex partners?

-rates of violence are about the same as between heterosexual partners.

Help promote the clients self esteem by-

-referring to the client as a survivor and not a victim. Rationale- defining themselves as survivors allows them to see themselves as strong enough to survive their ordeal. -help establish social support w/in the community. -make a list of people of activities in the community for the client to contact when he or she needs help.

A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?

-set behavioral limits Rationale- the nurse should first set behavioral limits for the client to stop harming others.

Which of the following statements regarding the individual responses to trauma and stressors is a positive outcome?

-some individuals may develop enhanced coping as a result of dealing with the stressors.

Exhaustion stage of GAS can lead to

-stress-induced illness, burnout, or death.

A client is clenching his fists and yelling at another client on the unit. He appears to be close to losing control of his anger. Which of the following actions by the nurse is appropriate at this time?

-tell the client to stop and take a time out.

Resistance stage of GAS has the following effects on the body-

-the body attempts to stabilize by using physiological and psychological coping mechanisms, and the body systems (e.g., heart, lungs, and immune response) return to normal. -Normalizes heart rate, blood pressure, cardiac output, respiratory function, and hormone levels -Stimulates insulin secretion, increasing glucose uptake by cells

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. Which is the most appropriate interpretation of the client's behavior?

-the client is displaying typical behaviors. RAtionale- In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors that can be disturbing to the nurse. Typical behaviors include return of symptoms, anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal feeling during the termination phase and does not necessarily indicate the need for hospitalization or treatment.

What is an appropriate short-term outcome for a client grieving the recent loss of a spouse?

-the client verbalizes stages of grief and plans to attend a community grief group.

Which of the following outcomes would take priority for a client who has survived trauma or abuse?

-the client will be physically safe -the client will distinguish between ideas of self-harm and taking actions on those ideas.

Which of the following interventions would be most effective for friends and family members to implement in order to boost the self-esteem of a person who has just experienced trauma or abuse?

-to help them refocus their view of themselves from being survivors and not victims.

Kubler-Ross stages of Grief are-

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

Do's of working w/ Victims of Partner Abuse-

1. believe the victim 2. ensure & maintain confidentiality 3. listen, affirm, & say "I'm sorry you've been hurt" 4. express concern for safety 5. tell the victim, "you have a right to be safe & respected" 6. say, "the abuse is not your fault" 7. recommend a support group or individual counseling 8. identify community resources & encourage client to develop a safety plan 9. offer to help client contact a shelter, police 10. accept & respect victim's decision 11. help the client develop a safety plan.

Phases of Crisis response are-

1. vulnerable state 2. precipitating event 3. acute crisis 4. reorganization

Most victims of elder abuse are-

75 years and older w/ a greater percentage being women. Abuse is more likely when the elder has multiple chronic mental and physical health problems and when they are dependent on others for food, medical care, and various ADL's.

*TCAs* Tricyclic Antidepressants Prototype = *Amitriptyline (Elavil)* Imipramine (Tofranil)

AMITRIPTYLINE -Advise the client to change positions slowly to minimize dizziness from orthostatic hypotension. -To minimize anticholinergic effects, advise, the client to chew sugraless gum, eat foods high in fiber&increase fluid intake to 2-3 L/day from food&beverage sources

Panic disorders are treated with-

CBT, deep breathing exercises, relaxation techniques, and medications such as SSRI's, benzodiazepines, TCA's, and antihypertensives such as Clonidine, or Propranolol.

SSRIs (selective serotonin reuptake inhibitors)-

CITALOPRAM, FLUOXETINE, SERTRALINE** LEADING TREATMENT FOR DEPRESSION** -Advise he client that adverse effects can include nausea, headache, and central nervous system simulation (agitation, insomnia, anxiety) -Instruct the client that sexual dysfunction can occur&to notify the provider if effects are intolerable -Advise the client to observe for manifestations of serotonin syndrome, if nay occur, instruct the client to w/hold the med&notify the provider -Instruct the client to avoid concurrent use of St Johns wort which can increase the risk of serotonin syndrome -Instruct the client to follow a healthy diet& exercise regimen b/c weight gain can occur w/ long term use.

A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?

Crisis stage

The nurse in the psychiatric unit is aware the atmosphere can change at any time. At which point in the stages of aggressive incidents is intervention least likely to be effective in preventing physically aggressive behavior?

Crisis stage.

Don't's of working w/ with Victims of Partner Abuse-

DONT: 1. Tell the victim what to do 2. Express disgust, disbelief, or anger 3. Disclose client communications without consent 4. Preach, moralize, or imply doubt 5. Minimize the impact of violence 6. Express outrage with the perp 7. Imply that the client is responsible for the abuse 8. Recommend couples counseling 9. Direct the client to leave the relationship 10. Take charge and do everything for the client

Nursing care r/t Crisis management-

Designed to help provide rapid assistance for people or groups who have an urgent need-The initial task of the nurse is to promote a sense of safety by assessing the clients potential for suicide/homocide INITIAL INTERVENTIONS: -Identifying the current problem&directing interventions for resolution-Taking an active, directive role w/ the client -Helping the client to set realistic, attainable goals -Critical incident stress debriefing is a group approach that can be used w/ a group of people who have been exposed to a crisis situation PROVIDE FOR CLIENT SAFETY: -Initiate hospitalization to protect clients who have suicidal or homicidal thoughts -Prioritize interventions to address the clients physical needs first USES STRATS TO DECREASE ANXIETY: -Develop a therapeutic nurse -client relationship-Remain w/ the client-Listen&observe -Make eye contact-Ask questions related to client's feelings and the event -Demonstrate genuineness and caring-Communicate clearly and, if needed, with clear directives -Avoid false reassurance and other non-therapeutic responses -Teach relaxation techniques-Identify and teach coping skills (assertiveness training&parenting skills) ASSIST THE CLIENT W/ THE DEVELOPMENT OF THE FOLLOWING TYPE OF ACTION PLAN: -Short term, no longer then 24-72 hrs -Focused on the crisis-Realistic&manageable

Which type of child abuse is the most difficult to identify?

Emotional

Hans Selye's General Adaptation Syndrome (GAS)-

General responses to a stressful events -A IS FOR ALARM -R IS FOR RESISTANCE -E IS FOR EXHAUSTION

A nurse on a crisis hotline is speaking to a client who says I just took an entire bottle of amitriptyline. Which of the following responses should the nurse make?

Im glad you called, and I want to send an ambulance to help you. Rationale- Amitriptyline, a tricyclic antidepressant, is used to treat depression. This therapeutic statement shows the nurse's concern for the client's safety and responds to the client's priority need. Maslow's hierarchy of needs states that the client's physical and safety needs come first. Therefore, the client needs to be evaluated immediately.

Expected findings for Crisis management-

Nursing hx should include: -Presence of SI/HI requiring hospitalization -The clients perception of the precipitating event -Cultural of religious needs for the client-Support system -Present coping skills

Mild anxiety symptoms include-

Occurs in the normal experience of everyday living. -Increases ones ability to perceive reality -There is an identifiable cause of the anxiety -Other characteristics include a vague feeling of imld discomfort, restlessness, irritability, impatience and apprehension -The client can exhibit behaviors such as finger or foot tapping, wringing of hands, fidgeting or lip chewing as mild tension relieving behaviors. -Restlessness, irritability, GI related butterflies, difficulty sleeping, hypersensitive to noise.

Moderate Anxiety symptoms include-

Occurs when mild anxiety escalates -Slightly reduced perception & processing of information occurs, and selective inattention can occur. -Ability to think clearly is hampered, but learning & problem solving can still occur. -decreased attention span. -poor impulse control. -Other characteristics include concentration difficulty, cannot connect thoughts or events independently, tiredness, pacing, voice tremors, shakiness, and increased RR. -The client can report somatic headaches, backache, urinary urgency/frequency and insomnia, muscle tension, excessive sweating, rapid pulse, dry mouth, high pitch voice, rapid pace speech, and frequent urination. -The client who has this type of anxiety usually benefits from the direction of others.

Phases of Crisis management-

PHASE 1: Escalating anxiety from a threat activates increased defense responses PHASE 2: Anxiety continues escalating as defense responses fail, functioning becomes disorganized, & the client resorts to trail-and-error attempts to resolve anxiety PHASE 3: Trail-and-error methods of resolution fail, and the clients anxiety escalates to severe or panic levels, leading to flight or withdrawal behaviors PHASE 4: The client experiences overwhelming anxiety that can lead to anguish&apprehension, feelings of powerlessness&being overwhelmed, dissociative symptoms (depersonalization, detachment from reality), depression, confusion and/or violence against others or self

MAOIs (monoamine oxidase inhibitors)-

PHENELZINE (NARDIL) -Due to the risk for HTN crisis, advise the client to avoid foods w/ tyramine (ripe avacados or figs, fermented/smoked meats, liver, dried or cured fish, most cheeses, some beer&wine, and protein dietary supplements) -Due to the risk of med interactions, instruct the client to avoid all meds, including OTC, w/out first discussing them w/ the provider.

Possible indicators of elder abuse include-

PHYSICAL ABUSE INDICATORS -frequent unexplained injuries accompanied by a habit of seeking medical assistance from various locations. -reluctance to seek medical treatment for injuries or denial of their existance. -disorientation or grogginess indicating misuse of medications. -fear or edginess in the presence of family member or caregiver. PSYCHOLOGICAL ABUSE INDICATORS -change in elder's general mood or usual behavior. -isolated from previous friends or family. -sudden lack of contact from other people outside the elder's home. -helplessness. -hesitance to speak openly. -anger or agitation. -withdrawal or depression. MATERIAL ABUSE INDICATORS -unpaid bills. -standards of living below the elder's means. -sudden sale or disposal of the elder's property/possessions. -unusual or inappropriate activity in bank accounts. -signatures on checks that differ from the elders. -recent changes in will or power of attorney when the elder is not capable of making those decisions. -missing valuable belongings the are not just misplaced. -lack of television, clothes, or personal items that are easily affordable. -unusual concern by the care giver over the expense of the clients treatment when it is not the caregivers money being spent. NEGLECT INDICATORS -poor personal hygiene. -lack of needed medications or therapies. -dirt, fecal, or urine smell, or other health hazards in the clients living environment. -rashes, sores, or lice on the client. -untreated medical conditions or is malnourished, dehydrated. INDICATORS OF SELF NEGLECT -inability to manage personal finances such as hoarding, squandering, or giving away money while not paying bills. -inability to manage ADL's, such as shopping, personal care, or housework. -wandering, refusing needs medical attention, isolation, and substance abuse. -failure to keep needed medical appointments. -confusion, memory loss, and unresponsiveness. -lack of toiling facilities, or living quarters infested w/animal or vermin. WARNING INDICATORS FROM CAREGIVER -the elder is not given the opportunity to speak for self, to have visitors, or to see anyone without the presence of the caregiver. -attitudes of indifference or anger towards the elder. -blaming the elder for his or her illness, or limitations. -defensiveness -conflicting accounts of elder's abilities, problems, and so forth. -previous history of abuse or problems with alcohol, or drugs.

Crisis management psychotherapeutic interventions-

PRIMARY CARE: -Collab w/ client to identify potential problems, instruct on coping mechanisms and assist in lifestyle changes SECONDARY CARE: -Collab w/ client to identify interventions while in an acute crisis that promote safety TERTIARY CARE: -Collab w/ client to provide support during recovery from a severe crisis that include outpatient clinics, rehab centers and workshops

Nursing interventions r/t severe and panic anxiety-

PROVIDE AN ENVIRONMENT THAT MEETS THE PHYSICAL & SAFETY NEEDS OF THE CLIENT, REMAIN W/ CLIENT: -Minimizes the risk to the client, who might be unaware of the need for basic things, such as fluids, food and sleep. PROVIDE A QUIET ENVIRONMENT W/ MINIMAL STIMULATION: -Helps to prevent intensification of the current level of anxiety. USE MEDS&RESTRAINTS, BUT ONLY AFTER LESS RESTRICTIVE INTERVENTIONS HAVE FAILED TO DECREASE ANXIETY TO SAFER LEVELS: -Meds and/or restraints might be necessary to prevent harm to the client ,other clients or provider. ENCOURAGE GROSS MOTOR ACTIVITIES, SUCH AS WALKING AND OTHER FORMS OF EXERCISE: -Provides an outlet for pent up tension, promotes endorphin release, and improves mental well being. SET LIMITS BY USING FIRM, SHORT AND SIMPLE STATEMENTS.. REPETITION MAY BE NECESSARY: -Can minimize the risk to the client&providers, clear, simple comm facilitates understanding DIRECT THE CLIENT TO ACKNOWLEDGE REALITY&FOCUS ON WHAT IS PRESENT IN THE ENVIRONMENT:-Focusing on reality assists w/ reducing the clients anxiety level.

Types of Crisis-

SITUATIONAL/EXTERNAL:Often unanticipated loss or change experienced in everyday, often unanticipated, life events MATURATIONAL/INTERNAL: Achieving new developmental stages, which requires learning additional coping mechanisms ADVENTITIOUS: The occurrence of natural disasters, crimes or national disasters, people in communities w/ large scale psychological trauma caused by natural disasters

SAFE questions to ask r/t victims of abuse-

Stress/Safety: What stress do you experience in your relationships? Do you feel safe in your relationships? Should I be concerned for your safety? Afraid/Abused: Have there been situations in your relationships where you have felt afraid? Has your partner ever threatened or abused you or your children? Have you ever been physically hurt or threatened by your partner? Are you in a relationship like that now? Has your partner ever forced you to engage in sexual intercourse that you did not want? People in relationships/marriages often fight; what happens when you and your partner disagree? Friends/Family: Are your friends aware that you have been hurt? Do your parents or siblings know about this abuse? Do you think you could tell them, and would they be able to give you support? Emergency plan: Do you have a safe place to go and the resources you (and your children) need in an emergency? If you are in danger now, would you like help in locating a shelter? Would you like to talk to a social worker/a counselor/me to develop an emergency plan?

Nursing interventions r/t mild/moderate anxiety-

USE ACTIVE LISTENING TO DEMONSTRATE WILLINGNESS TO HELP, AND USE SPECIFIC COMMUNICATION TECHNIQUES. -Encourage the client to express feelings, develop trust, and identify the source of the anxiety PROVIDE A CALM PRESENCE, RECOGNIZING THE CLIENTS DISTRESS: -Assist the client to focus and to begin to problem solve. EVAL PAST COPNG MECHS: -Assists the client to identify & adaptive/maladaptive coping mechs. EXPLORE ALTERNATIVES TO PROBLEM SOLVING -Offers options for problem solving ENCOURAGE PARTICIPATION IN ACTIVITIES THAT CAN TEMPORARILY RELIEVE FEELINGS OF INNER TENSION: -provides an outlet for pent up tension, this will promote endorphin release, and improves mental well being.

Mood stabilizers-

Used to treat anxiety often found in clients who have psych disorders, as well as some of the positive&negative symptoms -Valporate -Lamotrigine -Lorazepam -Inform clients of sedative effects -Use these meds w/ caution in older adults

SNRIs (serotonin-norepinephrine reuptake inhibitors)-

VENLAFAXINE DULOXTETINE -Adverse effects include nausea, insomnia, weight gain, diaphoresis and sexual dysfunction -Caution in admin to clients who have a hx of HTN

Generalized Anxiety Disorder (GAD) is defined as-

a disorder characterized by chronic excessive worry (for > than 6months) accompanied by three or more of the following symptoms: restlessness, fatigue, concentration problems, irritability, muscle tension, and sleep disturbance. **SSRI, SNRI, and Buspar are the most effect medications used to treat this disorder.

PTSD (Post Traumatic Stress Disorder) is defined as-

a disturbing pattern of behavior demonstrated by someone who has experienced, has witnessed, or has been confronted with a traumatic event such as, a natural disaster, combat, or an assault. **Autism spectrum disorder can be a precursor to PTSD.

Grounding techniques are helpful to use when working with-

a person who is dissociating or experiencing a flash back. **this technique reminds the person that they are in the present, as an adult and are safe. Use a calm reassuring tone using statements such as "I know this is frightening, but you are safe now."

Help the client to see that mild anxiety can be-

a positive catalyst for change and does not need to be avoided. Rationale- the client may feel that all anxiety is bad and not useful.

Be consistent with the client; convey-

acceptance of them as a person while setting and maintaining limits regarding behavior. Rationale- the client may test limits of the therapeutic relationship. Problems w/ acceptance, trust, or authority often occur with PTSD related behavior.

Reactive Attachment Disorder (RAD) takes place prior to-

age 5 years in response to child abuse or neglect. **The child shows disturbed social relatedness, and rather than seeking comfort from a trusted caregiver; the child exhibits resistance to social contact with extreme watchfulness and hyper-arousal.

Cognitive behavior techniques used to treat clients with-

anxiety disorders include positive reframing, A, thought stopping, and distraction.

Automatisms are geared toward-

anxiety relief and increase in frequency and intensity with the clients anxiety level. ** examples include- key jingling, finger tapping, or twisting of hair.

Nurses in various settings can uncover abuse by-

asking women about their safety in relationships. Many hospitals and clinics now ask women about safety issues as an integral part of the intake interview or health history.

The memory of the panic attack coupled with the fear of having more can lead to-

avoidance behavior.

Flooding is a form of rapid desensitization in which a-

behavioral therapist confronts the client with the known phobic object (a picture of or an actual object) until it no longer produces anxiety. Rationale- the clients worst fear has been realized and the client did not die so therefore there is little reason to continue to fear the situation.

Avoid asking or forcing the-

client to make choices. Rationale- the client is unable to make sound decisions, or problem solve while in an anxious state.

In the Resistance stage the-

digestive system reduces function to shunt blood to areas needed for defense. The lungs take in more air, and the heart beats faster and harder so it can circulate this highly oxygenated and highly nourished blood to the muscles in order to defend the body by fight, flight, or freeze behaviors. **If the person adapts to the stress, the body responses relax, and the gland, organ, and systemic responses abate.

In PTSD the symptoms occur 3 months or more after the trauma, which-

distinguishes PTSD from acute stress disorder.

Elder abuse is the maltreatment of older adults by-

family members, or others in a caregiver role. It may include physical, sexual, psychological abuse, neglect, self-neglect, financial exploitation, and denial of medical treatment.

Agoraphobia is defined as-

fear or avoidance of situations, such as crowds or wide open places, where one has felt loss of control and panic. **they usually don't leave their homes.

Validate the clients feelings of-

fear, but try to increase contact with reality. **use supportive touch if the client responds well to it.

During Dissociative experiences or-

flashbacks, help the client change body position, do not grab or force the client to stand up or move. **teach relaxation or deep breathing techniques. Rationale- often during flashbacks or dissociative episodes the client curls up into a fetal position (defensive posture) getting the client to stand and walk around helps dispel the episode. At this time the client can focus on their feet touching the floor or swinging movements of their arms. This reorients them to reality along with the nurse calling the client by name, introducing the nurse by name and role, reminding them where they are at and stating the day and date including the year. **Ask the client to open their eyes (if they are closed) and to look around the room. When the client is able to move their eyes back and forth this helps them avoid being in a locked daze where flashbacks are more likely to occur.

PTSD occurs in countries around the world. People who-

flee from their native countries for asylum benefit from remaining connected to their culture.

Help the client arrange for-

follow up therapy as needed. Rationale- recovering from trauma may be a long term process. Therapy can offer continued support in the clients recovery.

The nurse can help the client to minimize dissociative episodes or flashbacks through-

grounding techniques, and reality orientation.

PRN medications may be indicated for-

high levels of anxiety, delusions, or disorganized thoughts. (always use PRN meds before physical restraints). Rationale- medication may be needed to decrease anxiety to a level where the client can feel safe.

Victims of Rape have one of the-

highest rates of PTSD; approx. 70%.

Encourage the client to pursue past relationships, personal interests, or-

hobbies that were positive in the past or that may appeal to the client. Rationale- these activities can serve as a structure for the client to build social interactions as well as provide enjoyment.

Feelings associated with PTSD are-

intense fear, helplessness, or terror. **this can occur through dreams, recurrent thoughts, showing emotional numbness, detachment from others, being on guard, irritability, or experiencing hyper arousal.

Characteristics of violent families include-

inter-generational transmission process, social isolation, power and control, and the use of drugs and alcohol.

Adjustment disorder is defined as-

is a reaction to a stressful event that causes problems for the individual. The person has more than the expected difficulty coping with the event. **financial, relationship, and work related stressors are the most common.

Talk with the client about employment-

job related stress and refer to vocational services if necessary. Rationale- problems with employment frequently occur in clients w/PTSD.

Remain with the client at all times when-

levels of anxiety are high (severe or panic stage). **the clients safety is our highest priority.

Women and children are the most-

likely victims of abuse and violence.

When you initially approach the client be-

non threatening and professional. Remain aware of your own feelings and care for the client in a nonjudgemental way. **give the client positive feedback for sharing feelings and sharing experiences. Rationale- the client may feel like they are burdening others with their problems. It is important not to reinforce the clients internalized blame.

Remove the client to a quiet area with minimal-

or decreased stimuli such as a small room. Rationale- in a large room the client can feel lost and panicky, but a smaller room can enhance security.

Primary gain is the relief achieved by-

performing the specific anxiety driven behavior such as staying in the house to avoid the anxiety of leaving a safe place.

Use distraction techniques such as participating in-

physical exercise, listening to music, talking with others, or engaging in an enjoyable activity or hobby. **help keep a list of activities and keep materials on hand to engage the client when feelings are intense.

Elder abuse may include-

physical, sexual, psychological abuse, and neglect, exploitation, and medical abuse.

Important nursing interventions for survivors of abuse and trauma include-

protecting the clients safety, helping the client to manage stress and emotions, and working with the client to build a network of community support.

Dissociation is a defense mechanism that-

protects the emotional self form the full reality of abusive or traumatic events. **this disorder interrupts function of consciousness, memory, identity, and environmental perceptions.

Encourage the client to identify and-

pursue relationships, personal interests, hobbies, or recreational activities. Rationale- the clients anxiety may have prevented them from engaging is such activities in the past, but these can be helpful in building confidence and allowing the client to focus on something other than anxiety.

Acute Stress Disorder (ASD) occurs after a traumatic event and is characterized by-

re experiencing, avoidance, and hyper-arousal that take place from 2 days to 4 weeks following a trauma. This can lead to PTSD. **CBT, exposure therapy, and anxiety management can help prevent the progression to PTSD.

Secondary gain is the attention-

received from others as a result of these behaviors.

If the client has a religious or spiritual orientation-

referral to a member of the clergy, or chaplain may be appropriate. Rationale- guilt and forgiveness often are religious or spiritual issues for the client.

Encourage the clients participation in-

relaxation exercises such as deep breathing, progressive muscle relaxation, meditation, and imagining being in a quiet, peaceful place. Rationale- these techniques are effective, non chemical ways to reduce anxiety. Using these techniques independently once the client is ready helps the them feel confident in being able to better control anxiety.

Sexual abuse involves-

sexual acts performed by an adult on a child younger than 18 years of age.

Remain calm in your approach with the client; in addition to-

short, simple, and clear statement r/t communication. Rationale- the client will feel more secure if you are calm and if the client feels that you are in control of the situation. The client ability to think abstractly is impaired.

Family violence is encompasses-

spouse battering, neglect and physical, emotional, or sexual abuse of children, elder abuse and marital rape.

Help the client learn and practice-

stress management and relaxation techniques, assertiveness, or self defense training. Rationale- this will result in the client experiencing greater self confidence/self esteem.

Be aware of the clients use or abuse of-

substances. Set limits and consequences for this behavior. Rationale-substance use undermines therapy and may endanger the clients health. Allowing input from the client regarding this issue helps avoid power struggles.

Often clients who have experienced a trauma feel-

survivors guilt; that they survived when others did not, or guilt r/t the behavior they undertook in order to survive (killing in combat, enduring a rape, or not being able to save others).

Encourage the client to express their feelings through-

talking, writing, crying, or in other ways that the client is comfortable with. Especially encourage the expression of anger, guilt, and rage. Rationale- retelling the experience can help the client to identify the reality of what happened and to help work through related feelings. **Identification and expression of feelings are central to the grieving process.

In the Alarm reaction stage stress stimulates-

the fight or flight network which generates the involuntary activities of the body that are involved in self preservation. **when the danger has passed this process is reversed and the body returns to normal operating conditions.

The Exhaustion phase occurs when-

the person has responded negatively to an anxiety or stress; body stores become depleted; or the emotional components are not resolved, resulting in continual arousal of the psychological responses and little reserve capacity.

In the initial phase of treatment assign-

the same staff members to the client if possible; and respect the clients fears and feelings. Rationale- limiting the number of staff members will facilitate familiarity and trust. The client may have strong feelings of fear from past encounters when dealing with professionals that have similar characteristics and this may interfere with the therapeutic success.

Stress is defined as-

the wear and tear that life causes on the body. It occurs when a person has difficulty dealing with life situations, problems and related goals.

In order to promote client safety discuss with the client-

thoughts of self harm; help the client develop a plan for going to a safe place when having destructive thoughts or impulses. **counseling offered immediately after a traumatic event can help individuals process the event and possibly avoid PTSD.

Perseveration is the tendency to-

use repetition of phrases or behavior and is most often exhibited in clients under stress.

Systematic desensitization (Serial) is-

when a therapist progressively exposes the client to the threatening object in a safe setting until the clients anxiety decreases. During each exposure the intensity of exposure gradually increases, but the clients level of anxiety decreases.

Neglect is malicious or ignorant-

withholding of physical, emotional, or educational necessities for the child's/or person's well being.

The symptoms r/t adjustment disorder develop-

within a month; lasting no longer than 6 months. **outpatient counseling or therapy is the most common and successful treatment.