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Study guide for Nurses. Pls. don't reproduce. Property of NCSBN and other rightful owner.
Results for Psychosocial Adaptation Questions are numbered by the order in which they appeared in the test. * Represents the correct answer. Question 1 Which of the following assessments made by the Answers Correct C admitting nurse suggests that the client is experiencing a Student's C manic episode? A) Expresses suicidal thoughts B) Concerned about persecution * C) Shares grandiose ideas D) Suspicious of others Review Information: The correct answer is: C) Shares grandiose ideas. Grandiosity is characteristic of a manic episode. Potter, P. & Perry, A. (2000). Fundamentals of nursing: Concepts, process and practice. St. Louis: Mosby. Thompson, J., McFarland, G., Hirsch, J., & Tucker, S. (1993). Mosby''s clinical nursing (3rd ed). St. Louis: Mosby. Question 2 A client was admitted to the unit because of severe Answers Correct B depression and suicidal threats and was placed on suicidal Student's B precautions. The nurse should be aware that the danger of the client committing suicide is GREATEST A) During the night shift When the client’s mood improves and energy level * B) increases C) At the time of the client’s greatest despair D) Following a visit from the client’s estranged spouse Review Information: The correct answer is: B) When the client’s mood improves and energy level increases. Suicide potential is often increased when there is an improvement in mood and energy level (ambivalence is decreased and a decision is reached to commit suicide). Fortinash & Holoday-Worret (‘95) p 264 Antai-Otong (‘95) p346 Antai-Otong (‘95) p346 Question 3 A client has many delusions. As the nurse is assisting the Answers Correct D client to prepare for breakfast the client comments "Don’t Student's D waste good food on me. I’m dying from this disease I have." The nurse’s BEST response would be "You need some nutritious food to help you regain A) your weight." "None of the laboratory reports show that you have B) any physical disease." "Try to eat a little bit, breakfast is the most C) important meal of the day." "I know you believe that you have an incurable * D) disease." Review Information: The correct answer is: D) "I know you believe that you have an incurable disease.". This response does not challenge the client’s delusional system and thus forms an alliance by providing reassurance of desire to help the client. Fortinash, K. & Holoday-Worret, P. (1995) Psychiatric Nursing Care Plan. St. Louis: C.V. Mosby p. 83-87 Antai-Otong, B. (1995) Psychiatric Nursing: Biological & Behavioral Concepts Philadelphia: W.B. Saunders. p 242-247 Question 4 When planning the therapeutic milieu, it is MOST Answers Correct C important to select group activities which Student's C A) Match the clients’ preferences B) Are consistent with clients’ skills * C) Achieve clients’ therapeutic goals D) Build skills of group participation Review Information: The correct answer is: C) Achieve clients’ therapeutic goals. Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, e.g., to minimize withdrawal and regression, to develop self care skills, etc. Keltner, N & Folks, D. (1997) Psychotropic Drugs. St. Louis: C.V. Mosby, p. 314 Johnson, B.S. (1993)>br> Psychiatric- Adaptation & Growth: Mental Health Nursing. Philadelphia: Lippincott, p. 185 Question 5 A nurse in the Emergency Department suspects domestic Answers Correct B violence as the etiology of a client's injuries. What action Student's B should the nurse take FIRST? A) Ask client if there are any old injuries also present * B) Interview the client alone C) Gain client's trust D) Photograph bruises and wounds Review Information: The correct answer is: B) Interview the client alone. It is critical to separate the client from their spouse or significant other. Nurses should consider the potential for abuse when completing client assessments just as they consider potential respiratory and circulatory problems. Davey, PA and Davey, DB. (1997). Domestic Violence: Assessment and Intervention. In KS Martin, BJ Larson, LA Gorski, and DM Hayko (Eds.), Mosby''s Home Health Client Teaching Guides: Rx for Teaching, III H 1-8. St. Louis: Mosby. Question 6 The nurse is assessing a client for suspected domestic Answers Correct D violence. Which statement by the client is MOST Student's B indicative that this individual is in an abusive relationship? A) "I am determined to leave my house in a week." "No one else in the family has been treated like B) this." C) "I have only been married for two months." * D) "I have tried leaving, but have always gone back." Review Information: The correct answer is: D) "I have tried leaving, but have always gone back.". Victims develop a high tolerance for abuse; they blame themselves for being victimized. All members in the family suffer from the effects of abuse, even if they are not the actual victims. For these reasons, victims often have an extensive history of abuse and struggle for a long time before they can leave permanently. Davey, PA and Davey, DB. (1997). Domestic Violence: Assessment and Intervention. In KS Martin, BJ Larson, LA Gorski, and DM Hayko (Eds.), Mosby''s Home Health Client Teaching Guides: Rx for Teaching, III H 1-8. St. Louis: Mosby. Question 7 A client was admitted to the psychiatric unit for severe Answers Correct D depression. After several days, the client continues to Student's D withdraw from other clients. Which of the following would be the MOST appropriate statement by the nurse to promote interaction with other clients? "Your doctor thinks its good for you to spend time A) with others." "It is important for you to participate in group B) activities." C) "Painting this picture will help you feel better." * D) "Come play Chinese Checkers with Gloria and me." Review Information: The correct answer is: D) "Come play Chinese Checkers with Gloria and me.". This gradually engages the client in interactions with others and uses positive behavioral expectation. Fortinash, K. & Holoday-Worret, P. (1995) Psychiatric Nursing Care Plan. St. Louis: C.V. Mosby p. 56 Antai-Otong, B. (1995) Psychiatric Nursing: Biological & Behavioral Concepts Philadelphia: W.B. Saunders. p. 183-84 Question 8 The nurse can BEST ensure the safety of a demented Answers Correct D client who wanders from the room by Student's D A) Repeatedly reminding the client of time and place B) Explaining the risks of becoming lost C) Using soft restraints Attaching a wander-guard sensor band to the * D) client's wrist Review Information: The correct answer is: D) Attaching a wander-guard sensor band to the client''s wrist. This type of identification band easily tracks the client's movements and ensures safety while wandering on the unit. Potter, P. & Perry, A. (2000). Fundamentals of nursing: Concepts, process and practice. St. Louis: Mosby. Thompson, J., McFarland, G., Hirsch, J., & Tucker, S. (1993). Mosby''s clinical nursing (3rd ed). St. Louis: Mosby. Question 9 A client is brought to the ER by police after receiving Answers Correct D several complaints from the neighbors . The client is Student's D unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice. Which of the following is an appropriate nursing intervention for this client? Allow the client to randomly move about in ER to A) decrease anxiety Engage the client in an activity that requires her to B) focus Isolate the client in a secure room until she regains C) control Locate a room for the nurse and client with minimal * D) stimulation Review Information: The correct answer is: D) Locate a room for the nurse and client with minimal stimulation. This intervention allows the client with moderate anxiety to have human contact in an environment with minimal simulation. Varacolis, EM. (1994) Foundations of Psychiatric-Mental Health Nursing. Philadelphia: W. B.Saunders p. 208 Arnold, E & Boggs, K. (1995) Interpersonal Relationships Professional Communication Skills for Nurses. Philadelphia: W B Saunders. Question 10 A client with paranoid thoughts refuses to eat because he Answers Correct C believes the food is poisoned. The MOST appropriate Student's A initial action is to A) Taste the food in the client’s presence B) Suggest that food be brought from home * C) Simply state the food is not poisoned Inform the client he will be tube fed if he does not D) eat Review Information: The correct answer is: C) Simply state the food is not poisoned. This actions presents reality. Johnson, B.S. (1993) Psychiatric- Adaptation & Growth: Mental Health Nursing. Philadelphia: Lippincott. p. 477 Keltner, N., Schwecke, L. & Bostrom, E. (1998) Psychiatric Nursing St. Louis: Mosby. P. 375 Question 11 A client who is hospitalized with anorexia nervosa states Answers Correct A after eating lunch, "I shouldn’t have eaten all of that Student's A sandwich, I don’t know why I ate it, I wasn’t hungry." The client’s comments indicate that the client is likely experiencing * A) Guilt B) Bloating C) Immediate weight gain D) Fear Review Information: The correct answer is: A) Guilt. If people with anorexia lose control and eat more than they believe to be appropriate, they experience guilt. Fontaine, K. & Fletcher, J. (1998) Essentials of Mental Health Nursing. Menlo Park, CA.: Addison- Wesley. P. 193 Varacolis, EM. (1994) Foundations of Psychiatric-Mental Health Nursing. Philadelphia: W. B.Saunders p. 724 Question 12 A teenage female is admitted with the diagnosis of Answers Correct C anorexia nervosa. Upon admission, the nurse finds a bottle Student's D of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for her stomach pains. The BEST response by the nurse would be A) "These pills aren’t antacids." B) "Some teenagers use pills to lose weight." * C) "Tell me about yourself." D) "Are you taking pills to lose weight?" Review Information: The correct answer is: C) "Tell me about yourself.". This is an open-ended question which is nonthreatening and allows for further discussion. Murray, R. & Huelskoetter, M. (1993). Psychiatric/Mental Health Nursing. Norwalk, CT: Appleton & Lang. Stuart, G. & Sundeen, S. (1997) Principles and Practice of Psychiatric Nursing. St. Louis: Mosby. Question 13 The nurse is caring for a severely depressed client who Answers Correct D has just been admitted to the in-client psychiatric unit. Student's D Which of the following is a PRIORITY of care? A) Nutrition B) Elimination C) Rest * D) Safety Review Information: The correct answer is: D) Safety. Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan. Potter, P. & Perry, A. (2000). Fundamentals of nursing: Concepts, process and practice. St. Louis: Mosby. Thompson, J., McFarland, G., Hirsch, J., & Tucker, S. (1993). Mosby''s clinical nursing (3rd ed). St. Louis: Mosby. Question 14 A client is admitted to the hospital with a history of Answers Correct D confusion. The client has difficulty remembering recent Student's D events and becomes lost when she leaves her home. Which of the following statements would provide the BEST reality orientation for this client? A) "Good morning. Do you remember where you are?" "Hello. My name is Elaine Jones and I am your B) nurse for today." "How are you today? Remember, you're in the C) hospital." "Good morning. You’re in the hospital. I am your * D) nurse Elaine Jones." Review Information: The correct answer is: D) "Good morning. You’re in the hospital. I am your nurse Elaine Jones.". This response establishes time, location and the caregivers name. This response uses five or fewer words per sentence as recommended. Fortinash, K. & Holoday-Worret, P. (1995) Psychiatric Nursing Care Plan. St. Louis: C.V. Mosby p. 175-176 Antai-Otong, B. (1995) Psychiatric Nursing: Biological & Behavioral Concepts Philadelphia: W.B. Saunders. p. 264 Question 15 A client says, "It's raining outside and it's raining in my Answers Correct D heart. Did you know that St. Patrick drove the snakes out Student's D of Ireland ? I've never been to Ireland." The nurse assesses that this client is experiencing a speech pattern commonly seen in manic episodes called A) Perseveration B) Circumstantiality C) Neologisms * D) Flight of ideas Review Information: The correct answer is: D) Flight of ideas. Flight of ideas is characterized by over productivity of talk and verbal skipping from one idea to another. Shives, L. (1998). Basic Concepts of Psychiatric-Mental Health Nursing. Philadelphia: J.B. Lippincott Co. Varcarolis, E.(1998). Foundations of Psychiatric Mental Health Nursing. Philadelphia: W.B. Saunders. pp. 600. PSYCHOSOCIAL ADAPTATION I. Schizophrenia A. Definition: a multifaceted psychosis with early onset; criteria from DSM IV as follows: 1. When disease is in active phase, client shows psychotic behaviors. (Psychosis is severe ego dysfunction. Psychosis is also part of other DSM-IV diagnoses of dysfunctions of thought and sensorium.) 2. Symptoms involve many psychological processes 3. Previously, client had functioned at a higher level 4. Schizophrenia normally sets in before 30 years of age 5. Symptoms last 6 months or more 6. Not caused by affective or organic mental disorder 7. Involves hallucinations and/or delusions B. General characteristics of schizophrenia - six losses: S-S-O-B-E-R 1. Self-care often fails 2. Social adjustment is impaired 3. Orientation to the environment is lost 4. Boundaries between self/others dissolve 5. External/internal stimuli are confused (delusions/hallucinations) 6. Reality testing fails C. Etiologies of Schizophrenia 1. Biogenetic (possible hereditary factor) 2. Biochemical a. Dopamine hydrochloride - too much neurotransmitter for neural activity b. Research has suggested abnormalities of neurotransmitters norepinephrine, serotonin, acetylcholine and GABA (gamma aminobutyric acid). psychosis A term formerly applied to any mental disorder but now generally restricted to those disturbances of such magnitude that there is personality disintegration and loss of contact with reality. TYPES OF SCHIZOPHRENIA 1. Paranoid a. Dominant: hallucinations and delusions. b. No disorganized speech 2. Disorganized a. Dominant: disorganized speech and behavior and inappropriate affect 3. Catatonic a. Motor immobility b. Excessive, purposeless motor activity 4. Residual a. No longer has active phase symptoms b. Negative symptoms 5. Undifferentiated a. Has active phase symptoms b. No one clinical presentation dominates Contributing Factors a. Poor relationships with primary caretaker b. Dysfunctional family systems c. Double-bind communication d. Stressful life events e. Decreased socio-economic status (SES) E. Signs and symptoms of schizophrenia 1. Positive Symptoms a. Hallucinations b. Delusions c. Looseness of associations d. Agitated or bizarre behaviors 2.Negative Symptoms c. Apathy d. Poverty of speech or content of speech e. Poor social functioning f. Anhedonia g. Social withdrawal D. Positive Symptoms 1. Acute onset 2. Normal premorbid functioning 3. Normal social functioning during remission 4. Normal CT Scan 5. Normal neuropsychological test results 6. Favorable response to antipsychotic meds 7. Appear early in illness 8. Often precipitate hospitalization 9. Alterations in thinking, perceiving and behavior E. Negative Symptoms 1. Insidious onset 2. Premorbid history of emotional problems 3. Chronic deterioration 4. Demonstration of atrophy on CT scan 5. Abnormalities on neuro-psychological testing 6. Poor response to antipsychotic meds 7. Interferes with person's ability to: a. Initiate and maintain relationships b. Initiate and maintain conversations c. Hold a job d. Make decisions e. Maintain adequate hygiene and grooming F. Alterations in thinking 1. Types of delusions a. Ideas of reference b. Persecution c. Grandeur d. Somatic delusions e. Jealousy f. Control/being controlled g. Thought-broadcasting h. Thought insertion i. Thought withdrawal 2. Associative looseness 3. Neologisms 4. Concrete thinking 5. Echolalia 6. Clang association 7. Word salad G. Alterations in Perceiving 1. Hallucinations a. Auditory b. Visual c. Olfactory d. Gustatory e. Tactile 2. Loss of ego boundaries H. Alterations in Behavior 1. Bizarre behavior a. Extreme motor agitation b. Stereotyped behaviors c. Automatic obedience d. Waxy flexibility 2. Stupor 3. Negativism 4. Agitated behavior F. Associated Symptoms 0. Depression/suicide 1. Water intoxication 2. Substance abuse 3. Violent behavior K. Treatments in Schizophrenia 1. Psychopharmacology a. Antipsychotic agents and neuroleptics 1. Decrease psychotic symptoms 2. Decrease agitation 3. Less effective with negative symptoms 4. Decrease dopamine - dependent neural activity in the brain and other parts of the body (causing extrapyramidal symptoms) b. Antiparkinsonian agents: used to counteract these extrapyramidal symptoms 2. Individual psychotherapy a. Long-term therapy b. Difficult because schizophrenia impairs interpersonal functioning c. Focused, supportive problem-solving is most useful 3. Group therapy in schizophrenia a. Oriented toward providing support, an environment in which the client can develop social skills, and a format that allows friendships to begin b. Some success with long-term work c. Less success if client actively delusional and/or psychotic 4. Social skills training a. Role play to simulate anticipated interactions b. Teach eye contact, interpersonal skills, voice, posture 5. Vocational/Rehabilitation often succeeds a. Long-term treatment b. Includes job training c. Promotes semi-independent daily activities d. Raises self esteem 6. Family therapy a. To help families cope with psychotic and residual symptoms of schizophrenia b. To help reduce relapse rate G. Nursing Care in Schizophrenia 1. Protect client and others from harm, including suicide precautions as indicated 2. Administer medications as ordered 3. Monitor for extrapyramidal symptoms 4. Establish trust, decrease anxiety 5. Encourage or reinforce: a. Client's sense of control b. Reality orientation c. Self-care 6. Help client set realistic goals 7. Provide safe and successful experiences 8. Assist with hygiene and/or feeding as indicated 9. Teach client a. Importance of medication compliance b. Medications and side effects Get a Clue In major mental illnesses, the nursing care clusters around four goals: protection, medication, reality, and hygiene. (Popcorn Makes Rick Happy.) Protection: Protect client and others from harm, including Suicide Precautions; Establish trust Medication: Give meds, Teach about meds and compliance; Monitor for extrapyramidal symptoms ANTIPSYCHOTICS / NEUROLEPTICS 1. Types A. Phenothiazines B. Thioxanthenes C. Butyrophenones D. Dibenzoxazepines E. Dibenzodiazepines F. Indolenes 2. Physiology: Blocks postsynaptic dopamine hydrochloride receptors in the brain that cause psychotic symptoms: hallucinations, delusions, disorganized thought patterns and paranoia 3. Used for schizophrenia, paranoia, mania 4. Side effects: extrapyramidal symptoms 5. Contraindications: liver damage, severe hypertension, coronary disease, arteriosclerosis , dyscrasias , Parkinson's disease , narrow-angle glaucoma , severe depression 6. May cause orthostatic hypotension and drowsiness 7. Advise client to rise slowly from sitting or lying position 8. To prevent hypotension, teach client to avoid hot baths, showers, hot tubs 9. Teach client the hazards of driving and operating machinery while taking antipsychotics or neuroleptics II. Mood Disorders (Affective Disorders) A. Definition: 1. Elevated or depressed mood, with disturbances in behavioral response 2. Divided into bipolar and depressive disorders B. Bipolar Disorders: mood disorders that include one or more manic or hypomanic episodes and usually one or more depressive episodes C. Mania: 1. Person's elevated mood described as euphoric 2. Inflated self-esteem 3. Impaired judgement 4. Constant physical activity 5. Pressured speech 6. Racing thought patterns 7. Requires hospitalization D. Hypomania: 1. Symptoms less severe 2. Does not impair social, occupational or interpersonal functioning 3. Treated in outpatient setting E. The Seven (7) Traits Typical of Mood Disorders 1. Impair job functioning 2. Impair social activities 3. Impair relationships 4. Necessitate hospitalization (in most cases) 5. No time longer than 2 weeks has client had delusions or hallucinations without the mood disturbance 6. Symptoms are not superimposed on a. Schizophrenia b. Delusional disorder c. Psychotic disorder 7. Symptoms are not caused by organic disease F. Etiology - unknown; possible genetic, biochemical predisposition 1. Psychosocial theories of depression a. Freud: anger internalized and directed against ego b. Seligman: Depression results from learned helplessness: individual who fails over time learns to expect poor outcomes and eventually gives up c. Beck: Cognitive theory: over time, cognition is altered, resulting in negative attitudes; events can trigger depression 2. Biological cycles affect mood (via Circadian rhythm) a. Light affects mood by increasing melatonin b. Melatonin is a mood modulator which decreases in depression c. Seasonal Affective Disorder (SAD) 3. Biochemical theories of Mood Disorders a. Mania 1. Probably a genetic factor 2. Biochemical influences a. Possible deficiency of neurotransmitter GABA (gamma aminobutyric acid) b. Possible excess of norepinephrine and dopamine hydrochloride c. Possible increase in electrolytes: sodium and calcium b. Depression 1. Possible deficit of serotonin, dopamine, norepinephrine 2. Possible deficit of TSH (thyroid-stimulating hormone) and/or other neuroendocrine disturbances 3. Depression is more common in viral infections (AIDS, mononucleosis, hepatitis) 4. Possible deficit in vitamin intake or metabolism: (vitamin B complex, folic acid) 5. Genetics may be involved H. Types of Mood Disorders: Mania, Bipolar, Depression 1.Mania - DSM IV Criteria for mania a. Period of abnormally/persistently elevated mood or irritability b. At least three of these six signs 1. Grandiosity 2. Decreased sleep 3. Hypertalkative, with pressured speech and flight of ideas or racing thoughts 4. Highly goal-directed activity (sexual, work) 5. Highly distractible 6. Pursues pleasure, but overestimates own skill and luck bipolar disorder A disorder marked by manic or manic and depressive episodes. 2. Bipolar Disorders Onset usually before age 30 a. Bipolar disorder, mixed: both manic and depressive episodes present 1. Bipolar I a. Consists of one or more periods of major depression plus one or more periods of clear-cut mania b. Symptoms as in Definition of Mood Disorder (on page 6) c. No marked drop in social and job functioning d. Manic episode requires hospitalization 2. Bipolar II a. Consists of one or more periods of major depression plus periods of hypomania b. Includes all symptoms in Definition of Mood Disorder (on page 6) and does not require hospitalization b. Bipolar disorder, manic: fulfills criteria for manic episode (see Signs and symptoms below) c. Bipolar disorder, depressed: major depressive episode and at least one manic episode, current or past d. Cyclothymic mood disorder: 1. Many milder symptoms of mania and depression 2. Periods of normal mood are short 3. Usually does not require hospitalization 3. Depression a. Includes all 7 Typical Traits of Mood Disorders b. Specific criteria for Depression (see Signs and Symptoms below) I. Signs and symptoms 2. Mania a. Elation, euphoria; inappropriate laughter; very talkative b. Irritable, hostile, aggressive c. Flight of ideas, delusions of grandeur, exhibitionism, sexual acting-out d. Reduced sleep e. Unlimited energy; no time for food or drink f. Impulsive, easily distracted g. Manipulative behavior 2. Depression a. Melancholia, crying, absence of pleasure; slumped posture b. Apathy; loss of desire for food and/or sex c. Slower reactions d. Low self-confidence; inhibition, introversion e. Ruminating, decreased communication, social isolation f. Fatigue and/or insomnia g. Decreased concentration h. Poor hygiene i. Hopelessness, pessimism j. Self-destructiveness J. Treatments 2. Treatments for Mania a. Pharmacologic 1. Lithium carbonate (Lithane), carbamazapine (Carbatrol), valproic acid (Depakene) 2. Antipsychotics: chlorpromazine (Thorazine), haloperidol (Haldol) b. Occupational therapy c. Recreational therapy occupational therapy Therapeutic use of work, self-care, and play activities to increase independent function, enhance development, and prevent disability; it may include adaptation of task or environment to achieve maximum independence and to enhance quality of life. 2. Treatments for Depression a. Pharmacologic Antidepressants 1. Tricyclic antidepressants - amitriptyline HCl (Elavil), doxepin (Sinequan), imipramine (Tofranil) 2. Monoamine oxidase inhibitors - phenelzine (Nardil), tranylcypromine (Parnate) 3. Selective serotonin reuptake inhibitors (SSRI) - fluoxetine (Prozac), sertraline (Zoloft) b. ECT: electroconvulsive therapy c. Psychotherapy d. Occupational therapy e. Recreational therapy f. Cognitive therapy K. Nursing Care in Mood Disorders Mania a. Protect client and others from harm b. Provide quiet environment with few stimuli c. Give medications as ordered; be sure client swallows meds d. Establish trust relationship e. Do not argue with client or provoke hostility f. Redirect client to task at hand g. Set firm, consistent limits; explain them simply h. Allow client to express anger in positive ways i. Offer finger foods j. Increase client's fluid intake to at least 1000cc/day k. Allow client to pace l. Teach client 1. Acceptable ways to release anger 2. Medications and side effects 3. Importance of taking medication Be Prepared Don't pay attention to how quickly other nursing candidates complete their examination. The time taken by a candidate to complete the examination is not a predictor of passing or failing. ANTI DEPRESSANTS 1. Types A. Tricyclics and tetracyclic antidepressants 1. Prevent nerve endings from taking up norepinephrine and serotonin 2. Increase the action of norepinephrine and serotonin in nerve cells B. MAO Inhibitors (Monoamine oxidase inhibitors) 1. Lower the production of monoamine oxidase 2. Thus the central nervous system stores more endogenous epinephrine, norepinephrine, serotonin, and dopamine 2. Contraindications: convulsive disorders, prostatic hypertrophy, severe renal, cardiac or hepatic disease 3. Administer with food to prevent GI disturbance 4. Therapeutic effect may take up to three weeks 5. Teach client about potential for drowsiness or dizziness 6. Teach client to avoid drinking alcohol 7. Do not stop taking antidepressants suddenly 2. Depression a. Monitor suicidal thoughts b. Take suicide precautions as indicated and observe for suicide warning signs c. Build trust with client d. Speak slowly and clearly in simple sentences e. Administer medications as ordered f. Encourage client to ventilate g. Provide relaxation exercises h. Help with hygiene and feeding as indicated i. Help client assess negative thoughts more objectively j. Divert client from morose thoughts k. Encourage client to focus on positive attributes l. Teach client 1. Medications and side effects 2. Importance of taking medication 3. Problem-solving techniques Get a Clue Remember Popcorn Makes Rick Happy: the four goals of nursing care in major mental illnesses: Protection Medication and Monitoring Reality: In mood disorders, "reality" is relaxation, ventilation, and diverting or assessing negative thoughts. Hygiene SUICIDE PRECAUTIONS 1. Remove all harmful objects from the environment 2. One to one monitoring of the client day and night, having the client in view at all times even during toileting, gradually progress to 15 minute and then hourly checks 3. Ask client exactly how she/he would commit suicide. Assess how lethal the attempt would be, and how quickly it could be carried out. 4. Keep client within one arm's length distance or less at all times 5. Use plastic utensils 6. Keep electrical cords to a minimum length 7. Take all potentially harmful gifts from visitors 8. Keep all windows locked and if possible keep client in room with unbreakable glass in windows 9. Do not assign a private room WARNING OF SUICIDAL THOUGHTS OR PLANS 1. Previous suicide attempt 2. Threatening to commit suicide 3. Giving away prized possessions 4. Collecting and discussing information on suicide methods 5. Expressing hopelessness, helplessness, and anger at self or world 6. Death or depression in talk, writing, or artwork 7. Client states or suggests he/she would not be missed 8. Client expresses no hope for the future 9. Self-mutilation 10. Recent loss of friend or family member through natural death, accident or suicide; other major loss such as job or divorce 11. Acute personality changes such as unusual withdrawal or aggressiveness, moodiness, or taking risks 12. Sudden change in academic performance, truancy, or running away 13. Physical symptoms such as insomnia or excessive sleeping, headaches, stomach aches 14. Use or increased use of potentially addictive substances 15. Low self esteem; feeling worthless, ashamed, guilty, self-hating III. Anxiety Disorder A. Definition: Group of disorders in which anxiety is predominant symptom Degrees range from mild anxiety to severe (panic attack) 1. Seven Types a. GAD: generalized anxiety disorder b. Phobic disorders c. Panic disorder d. Dissociative disorder e. Somatoform disorder f. Obsessive-compulsive disorder (OCD) g. PTSD: Post-traumatic stress disorder B. Etiology 1. Found equally in men and women 2. Hereditary predisposition 3. Biochemical factors: neurotransmitters may play a role 4. Psychologic and interpersonal factors a. early psychic trauma, b. pathogenic parent-child relationship, c. pathogenic family patterns d. loss of social supports C. Signs and symptoms 1. Fear, dread, or apprehension 2. Feeling powerless 3. Crying 4. Irritability 5. Scattered thoughts, inability to concentrate or solve problems 6. Preoccupation with self 7. Rapid speech, hyperventilation, tachycardia 8. Palpitations, chest pains, jittery behavior 9. Diaphoresis 10. Insomnia 11. Diarrhea and/or urinary urgency and frequency generalized anxiety disorder Excessive anxiety and worry predominating for at least 6 mo. dissociative disorder SEE TABERS ONLINE Nursing Diagnoses Appendix. Dissociative reaction. A sudden, temporary alteration in the normal functions of consciousness, identity, or motor behavior. panic disorder An anxiety disorder characterized by panic attacks (e.g., agoraphobia with panic attacks). somatoform disorder A mental disorder in which the physical symptoms suggest a general medical condition and are not explained by another condition such as a medication or another mental disorder. obsessive-compulsive disorder A disorder characterized by recurrent obsessions or compulsions that are severe enough to be time consuming or cause marked distress or significant impairment post-traumatic stress disorder The development of characteristic symptoms after a psychologically traumatic event that is generally outside the range of usual human experience. D. Treatments for Anxiety Disorders 1. Pharmacologic: Anxiolytics (antianxiety drugs) such as alprazolam (Xanax) and diazepam (Valium) 2. Psychotherapy 3. Occupational therapy 4. Recreational therapy E. Nursing Care 1. Provide a nondemanding environment; stay with client if indicated 2. Acknowledge client's feelings of fear, worry, helplessness 3. Do not force contact with feared item or situation 4. If client demonstrates compulsive behavior, allow the compulsion but set reasonable limits 5. Provide distracting activities 6. Allow temporary dependence 7. Speak calmly, slowly and clearly 8. Assist client in ADL as indicated 9. Encourage relaxation techniques and regular physical exercise 10. Administer medications as ordered 11. Limit caffeine intake 12. Teach client a. Medications and side effects b. Relaxation techniques IV. Borderline Personality Disorder A. Definition 1. Client shows personality traits that are long-lasting, inflexible and maladaptive. 2. Client may appear to function normally until stressed 3. Generally begins in childhood or adolescence 4. More common in women B. Etiology 1. Impaired development of object relations; separation- individuation process is arrested 2. Issues of dependence, independence, and control are mixed with fear of abandonment, loss of love, or engulfment by mother C. Signs and symptoms 1. Personal relationships are unstable; lonely; emotions shallow 2. Images of self and others are primarily bad; feels inadequate 3. Anger, Hostility 4. Projection of hostility onto others 5. Acts out and denies responsibility for actions 6. Poor judgment 7. Impaired problem solving 8. Very "Black or White" thinking 9. Regression 10. Marked mood swings 11. Demanding 12. Sarcastic 13. Manipulative 14. Behaves self-destructively 15. Splitting D. Treatment 1. Pharmacologic a. Antianxiety agents: oxazepam (Serax) b. Antidepressants: carbamazapine (Carbatrol) 2. Psychotherapy object relations Emotional attachment for other persons or objects. Splitting Alternating between idealizing and devaluation; failure to integrate the positive and negative qualities of self or others E. Nursing Care in Borderline Personality Disorder 1. Protect client and others from harm 2. Administer medications as ordered 3. Establish a trusting relationship 4. Set limits, and provide a structured environment 5. Use a calm, controlled approach; see that other staff stay consistent 6. Do not argue with client 7. Encourage client to evaluate consequences of actions 8. Divert anger, or let client ventilate it in positive ways 9. Set limits on manipulative behaviors by communicating expected behaviors 10. Teach client a. Medications and their side effects b. Anger-control strategies c. Relaxation strategies Get a Clue Remember Popcorn Makes Rick Happy (Protection, Medication, Reality, and Hygiene). In Borderline Personality Disorders, the client will probably care for hygiene. Nursing tasks cluster around PMR: Protection, Medication, and Reality (in this case, real consequences of actions and ventilation or control of anger). V. Suicide Intervention A. Definitions: 1. Suicide is a self-harming act intended to produce death 2. Degrees a. Completed suicide: Life ends b. Attempted suicide: Failed self-destructive act c. Suicide ideation: Thoughts of ending one's life B. Epidemiology 1. Women attempt more than men 2. Men are more often successful 3. Second leading cause of death in adolescence 4. Black males have higher incidence C. Etiology 1. Depression 2. Delusions/hallucinations in psychotic clients 3. Hopelessness 4. Environmental factors: work or school performance, loss of job, death of loved one, unsatisfying interpersonal relationships D. Signs and symptoms 1. Statements about suicide 2. Anger, sadness, hopelessness, negative view of future 3. Recent loss of job, loved one 4. Perceived lack of support system 5. Self-mutilation E. Treatment for Suicidal Condition 1. Objective: to treat the condition that underlies the suicidal thoughts 2. Medications: amitriptyline (Elavil), chlorpromazine (Thorazine) 3. Suicide precautions F. Nursing Care 1. Administer medications as ordered 2. Institute suicide precautions 3. Encourage relaxation strategies VI. Crisis Intervention A. Definition - Crisis: Temporary personality disorganization with an acute emotional state. Crisis is a normal response to threatening environment. B. Types and Phases of Crisis Response 1. Panic state: acute crisis where client temporarily loses control a. Emotional reactions are overwhelming b. Decision making and problem solving abilities are inoperative c. Thinking is scattered d. Social isolation e. Immobilization (unable to act) 2. Exhaustion crisis a. Under emergency conditions b. Person has lost effective coping c. Cannot continue to function 3. Shock crisis a. Sudden external change b. Causes release of emotions c. Overwhelms client 4. Four Phases of Crisis (average crisis 4-6 weeks but may vary widely) a. Vulnerable state b. Precipitating event 1. Developmental change (maturational crisis) 2. A life change (situational crisis) 3. Loss of loved one or job (situational crisis) 4. Environmental disaster or war (adventitious crisis) c. Acute crisis d. Reorganization C. Signs and Symptoms of Crisis 1. Mild to severe anxiety 2. Anger 3. Crying, social isolation, helplessness 4. Impaired cognitive processes; inability to concentrate; confusion 5. Insomnia 6. Regression 7. Nausea and vomiting D. Treatment: Crisis Intervention 1. Objective: to help the client through the current crisis 2. Brief supportive interventions focused on the phase of crisis 3. Allow free discharge of emotions 4. Enhance client's cognitive processes 5. Pharmacologic: trazodone (Desyrel), alprazolam (Xanax) 6. Occupational therapy 7. Recreational therapy E. Nursing Care in Crisis 1. Provide a quiet, restful environment 2. Help the client solve problems 3. Let the client ventilate 4. Correct any misperceptions about the crisis that the client may have 5. Help the client to identify support systems, alternative solutions 6. Help the client to deal with long term impact of crisis 7. Encourage relaxation strategies 8. Assist the client in the development of new coping skills 9. Give medications as ordered VII. Substance Abuse A. Definitions 1. Maladaptive behaviors resulting from the regular intake of large amounts of addictive chemicals 2. Addictive chemicals include alcohol, stimulants, depressants, hallucinogens, narcotics. 3. Levels of Substance Abuse a. Abuse is pathologic use of mood-altering chemicals that continues for at least 1 month, which impairs social or occupational functioning b. Dependence is a more severe level of abuse that involves impaired ability to control use of substance and results in withdrawal (adverse consequences) when substance is discontinued or reduced. There are three types of dependence 1. Psychologic dependence: pleasure that intensifies craving for substance; often begins in teens and twenties. 2. Physiologic dependence: After repeated use, physiology changes; and after substance is reduced or removed, withdrawal symptoms appear 3. Tolerance: Drug dosage must keep increasing to achieve same effect Relax Mentally rehearse how you will take the examination and your success. B. Alcohol Although alcohol is a legal substance, problem drinking has detrimental physiologic and social effects. 1. Dependence a. daily intake of large quantities, or b. excessive drinking limited to weekends; or c. periods of abstinence with binges lasting for weeks or longer 2. Etiology unknown a. Stress has been implicated b. Some research suggests a familial tendency 3. Produces withdrawal symptoms 4. Signs of Chronic Alcohol Use a. Anemia b. Hypertension c. Tachycardia d. Hepatomegaly e. Ascites f. Cirrhosis g. Gastritis h. Esophagitis i. Malabsorption syndrome j. Fatigue k. Depression l. Impaired judgment; cognitive impairment m. Tremors n. Wernicke-Korsakoff syndrome 5. Treatment of Alcohol Dependence a. Antianxiety agents: chlordiazepoxide (Librium) b. Vitamin and nutritional therapy c. Disulfiram (Antabuse) - alcohol abuse deterrent d. Support groups (Alcoholics Anonymous) WITHDRAWAL EFFECTS OF ABUSED SUBSTANCES 1. Narcotics a. Runny nose, watery eyes b. Severe anxiety to panic; irritability c. Gooseflesh; tremors d. Loss of appetite; nausea and vomiting e. Muscle cramps f. Tachycardia; Hypertension g. Increased respirations h. Increased temperature i. Insomnia 2. Alcohol a. Acute withdrawal symptoms 1. Tremors, Agitation, Tachycardia 2. Nausea and vomiting; abdominal cramps 3. Diaphoresis 4. Visual or tactile hallucinations b. Severe Withdrawal - delirium tremens (DTs) 0. Confusion, Disorientation 1. Visual, tactile hallucinations 2. Diaphoresis, Fever 3. Tachycardia 4. Grand mal seizures 3. Sedatives/Hypnotics . Weakness, Nausea and vomiting a. Hypertension, Tachycardia, Orthostatic hypotension b. Gross tremors c. Agitation , Anxiety d. Disorientation e. Hallucinations, Delirium f. Convulsions g. 4. Stimulants . Fatigue a. Depression b. Disturbed sleep c. Apathy d. Cravings 5. Hallucinogens - No withdrawal symptoms reported but flashbacks can occur episodically after use 6. Marijuana . Irritability a. Insomnia b. Loss of appetite c. Tremors d. Perspiration e. Nausea 6. Nursing Care in Alcohol Dependence a. During acute withdrawal 1. Stay with client 2. Provide quiet environment 3. Administer medications as ordered 4. Protect the client from harm 5. Institute seizure precautions as indicated 6. Maintain adequate fluid intake b. During abstinence 1. Provide emotional support 2. Provide nutritious diet 3. Encourage the development of new coping skills 4. Provide relaxation exercises 5. Inform client about support groups and rehab programs C. Use of Psychoactive Drugs (prescription or "street"): Stimulants, Depressants, Hallucinogens, and Narcotics 1. Stimulants a. Include cocaine, crack, amphetamines b. Effects of Abuse of Stimulants 1. Psychomotor agitation 2. Mood swings 3. Tachycardia 4. Hypertension 5. Dilated pupils 6. Perspiration and chills 7. Insomnia 8. Impaired cognitive function 9. Seizures 10. If discontinued, withdrawal follows c. Overdose may cause lethal cardiac or respiratory arrest d. Emergency care of overdose on stimulants: Cardiopulmonary support 2. Depressants a. Include barbiturates, tranquilizers, sedatives and hypnotics b. Signs and symptoms of depressant use 1. Slurred speech 2. Impaired cognitive function; confusion 3. Emotional lability 4. Lack of coordination 5. Cold and clammy skin 6. Produce withdrawal symptoms c. Overdose can lead to respiratory depression, coma d. Emergency care of overdose 1. Respiratory support 2. Keep client awake and moving 3. Narcotics a. Include: heroin, morphine, meperidine, codeine, methadone b. Signs and Symptoms 1. Euphoria 2. Tranquility 3. Drowsiness 4. Constricted pupils 5. Clouded sensorium c. Overdose threatens life: depresses respiratory function and alters level of consciousness d. Emergency care includes cardiopulmonary support (illustration 1 illustration 2 illustration 3 ) 4. Hallucinogens a. Include: LSD, PCP, marijuana, mescaline, psilocybin b. Signs 1. tachycardia 2. hypertension 3. dilated pupils 4. hallucinations 5. nausea 6. impaired attention and judgment 7. aggressive behavior c. Potentially life threatening d. Potentially psychotic long-term effects E. Treatment: Drug rehabilitation E. Nursing Care in Substance Abuse 1. Protect the client and others from harm 2. Help client through drug rehabilitation as indicated 3. Provide emotional support 4. Help the client develop a support system 5. Provide emergency care for overdose VIII. Autism A. Definition: Syndrome in which child does not relate to people 1. May become attached to objects 2. Develops before age three B. Etiology unknown C. Signs and symptoms 1. Does not respond to human touch 2. Lack of eye contact 3. Talks poorly or not at all 4. Ritualistic behavior 5. Cannot deal with change 6. Emotional lability 7. May be self destructive (head-banging, hair pulling, finger/hand biting) 8. Failure to develop friendships or play with other children 9. Posture or gait abnormalities: poor coordination, tiptoe walking, peculiar hand movements (flapping, clapping) D. Treatment 1. Special education 2. May need full time care (institution) E. Nursing Care 1. Support parents emotionally 2. Protect the child from self harm 3. Help child with hygiene and feeding as indicated 4. Maintain consistency in schedule 5. Allow ritualistic behavior IX. Abuse Syndromes A. Definition - Abuse may be physical, sexual, psychological or physiological 1. Victims powerless to stop abuse 2. May be directed toward a child, a spouse, the elderly 3. Rape is a violent sexual abuse 4. Abusers a. Often blame victim b. Demonstrate poor impulse control c. Have frequently been victims of abuse themselves B. Signs and symptoms 1. Physical abuse a. Broken bones and/or dislocations b. Welts, and/or bruises 2. Sexual abuse a. Bruising or bleeding in genital or anal area, b. Pain or itching in genital area, c. Rape, evidence of sexual intercourse, d. Genitourinary infections 3. General neglect a. Malnutrition b. Habitual behaviors: rocking, head banging c. Learning disorders d. Social isolation e. Aggressive behavior C. Treatment 1. In general, cases of abuse must be reported (refer to state statutes for variations) 2. Removal of victim from source of abuse 3. Protective services 4. Directing abuser to help or therapy D. Nursing Care 1. Provide emotional support 2. Document all signs of abuse 3. File appropriate reports (Report of suspected abuse is mandatory in most states) 4. Assist in placement for protection 5. Assist abuser in obtaining appropriate counseling X. Eating Disorders A. A subcategory of disorders that includes multiple types of eating behavior disturbances B. Types of Eating Disorders 1. Anorexia Nervosa a. Weight loss through restriction of food intake leading to emaciation b. May involve purging behaviors c. Tend to reject mature-appearing body d. Tendency to asceticism 2. Bulimia Nervosa a. Eating binges alternate with dieting or purging b. Purging behaviors may include self-induced vomiting, misuse of emetics and cathartics or laxatives c. More likely than those with anorexia to show impulsive or chaotic behavior d. Usually near normal weight e. Tend to be outgoing and sensitive to others f. Major issue: control self/environment through eating behaviors g. Drive for thinness h. Population at Risk 1. Adolescents and young adults 2. In industrialized countries 3. Models, dancers and gymnasts at higher risk i. Potentially life threatening C. Etiology 1. Psychoanalytic theory a. Conflicts stem from oral phase of development b. Clients often have anxious, compulsive mothers c. Obsessive-compulsive control of body and life, via food d. Controlling bodily functions is critical to client's attempt at self-control 2. Interpersonal theory a. Results from dysfunctional family relationships b. Parents avoid their own conflicts by controlling child c. Child's self-identity becomes blurred d. During adolescence parents become overcontrolling and demanding e. Demands thwart client's attempts at autonomy f. Adolescent attempts to control self through controlling food intake. 3. Cognitive theory a. Eating-disorder behaviors are learned b. Society glorifies thinness c. For the adolescent or young adult, thinness equates with self-worth. D. Signs and Symptoms of Eating Disorder 1. Personal relationships become superficial and distant 2. Social contact avoided especially if food is involved 3. Preoccupation with food, meal planning, caloric intake and methods to avoid eating 4. Eats in private 5. Mood irritable and defiant 6. Exercises excessively 7. Physical symptoms a. Weight falls below 85% of normal b. Bradycardia c. Anemia d. Amenorrhea e. Decreased renal function f. Dental problems g. Fluid and electrolyte imbalances h. Delayed skeletal maturation E. Treatment of Eating Disorders 1. Objective: to correct underlying cause and prevent complications of weight loss 2. Client may require hospital care 3. Nutritional planning 4. Psychotherapy: Individual and/or family 5. Group therapy 6. Occupational therapy 7. Recreational therapy 8. If underlying depression, treat with antidepressants F. Nursing Care 1. Monitor weight as prescribed 2. Monitor client's eating/record intake and output 3. Administer nasogastric feedings if ordered 4. Encourage oral hygiene 5. Set limits on eating including time allotted for meals 6. Stay with client during meals 7. Accompany client to bathroom after meals to prevent self-induced vomiting 8. Encourage client to express feelings 9. Encourage socialization 10. Monitor for signs and symptoms of electrolyte imbalance or dehydration 11. Assist client to identify strengths 12. Teach client a. Relaxation techniques b. Alternative coping methods c. Assertiveness skills Schizophrenia is the most common psychotic disorder. It originates from complex genetic, biological, and psychosocial factors. Extrapyramidal side effects of antipsychotic medications must be treated. Depression can be mild, moderate, or severe. Mild depression is often undiagnosed. Antidepressants take 2-3 weeks to take effect. Many people have fleeting thoughts of killing themselves at some point in their lives. Cognitive Triad of Depression - negative view of self, negative view of the world, negative view of the future. Anorexia nervosa and bulimia are conditions that primarily occur among adolescent and young women. The three phases of a therapeutic relationship are: (1) initial phase, (2) working phase and (3) termination phase. catharsis The Freudian method of freeing the mind by recalling from the patient's memory the events or experiences that were the original causes of a psychoneurosis. neologism A mental condition in which the patient coins new words that are meaningless or words to which he or she gives special significance without being aware of their normal significance. ng from the patient's memory the events or experiences that were the original causes of a psychoneurosis. neologism A mental condition in which the patient coins new words that are meaningless or words to which he or she gives special significance without being aware of their normal significance.
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