Mental Health-Psychiatric Care: Abuse and Negelect, ADD/ADHD, Alcohol & Drug Abuse, Anxiety, Ausism,

Abuse & Neglect

Mental Health "Psychiatric Care"

Elder Elder neglect is a form of abuse that happens when the caregiver fails to provide for the needs of the elderly client either emotionally, physically, or socially.

Caregiver Role Strain (CRS)

Key signs Poor eye contact

NCLEX TIP

“Client breaks eye contact when talking with a caregiver”

Broken assistive devices Glasses, hearing aids

Assess stressors & NCLEX TIP Unmet needs Ask about the nature & requirements of providing daily care

Expired medication Physical Weight loss, dehydration & malnutrition Pressure ulcers

HESI Question A 79-year old … weighs 93 lbs, and is wearing old, dirty clothes … diagnosed with pneumonia.

Which comment by this patient suggests a significant risk for abuse?

KEY WORD What is the nature & requirements of providing daily care?

Our family is poor, so my daughter gets my monthly retirement and Social Security checks

Poor Hygiene: orally, soiled clothing

Intimate Partner Violence Intimate partner violence is domestic violence or abusive behavior inflicted by one partner against the other - be it physically, emotionally, verbally, sexually, or economically.

Abusive partner: extreme jealousy & possessiveness NCLEX TIP Abuse gets more intense during pregnancy Victim stays: Financial, Fear of harm, Child custody, Religion, etc.,

HESI Question ... expect the abuse to worsen?

When the victim moves toward independence from the abuser Please, i need help!

Interventions

Victim

Affirm that the patient did not HESI deserve or cause the abuse Developing a plan to assure safety: Local shelter

Psychotherapy (Talk Therapy) Identity triggers Recognize destructive patterns of behavior & learn alternative responses

The clinic nurse notes bruises in various stages of healing... What questions must the nurse include?

Select all that apply.

Is anyone hurting you?

When you and your spouse disagree, what happens to you?

Has your spouse ever threatened you verbally or with violence?

ATI Question Which of the following ... should the nurse implement … client in a domestic violence situation?

Select all that apply.

Priority Action: Have partner leave the room to speak with & examine client in private

Treatment

HESI Question

Assure the victim that he/she is not alone Preserve any physical evidence, if applicable Convey an attitude of concern and respect for the client

HESI Question … injuries associated with intimate partner violence.

The patient plans to return home. Which action by the nurse has priority?

Provide the patient with contact information for the local shelter.

ATI Question … coping strategies … clients who are experiencing intimate partner violence...understanding of the teaching?

“I should try to identify issues that increased my partner’s stress level.”

Local shelter

ADD/ADHD

Mental Health "Psychiatric Care"

Pathophysiology

Management

ADD - Attention Deficit Disorder ADHD - Attention Deficit Hyperactivity Disorder The brain has low levels of the neurotransmitters dopamine & norepinephrine which help the brain focus on reward vs. risk and control impulsivity & mood, making client with ADHD more likely to have anxiety & substance abuse problems.

Give a written schedule of daily activities NCLEX TIP

Increased risk for injury

ATI Question 9 year old hospitalized client on bedrest who has attention deficit disorder…

Which of the following should the nurse prioritize?

Norepinephrine

Signs & Symptoms

T W TH F SA S

Aggressive behavior: distract the child & ask them to blow up a balloon

Always think calm with ADHD

Dopamine

M

● Provide the child with a daily schedule that is typed or written

HESI Question

1. Hyperactivity “restless” 2. Inattention “reduced ability to focus” 3. Impulsiveness “excessive talking” 4. Low self-esteem & impaired social skills NCLEX TIP

A nursing diagnosis that should be considered for a child with attention deficit hyperactivity disorder is ● Risk for injury

ATI Question … new diagnosis of ADHD… which of the following statements should the nurse include in the teaching? ● Your child is at an increased risk for injury

Communication

1. Eye contact first (before speaking) 2. Simple language 3. Child repeats back what was said 4. Offer praise upon task completion

ATI Question 6 year old client with … ADHD. What techniques should the nurse use to communicate most effectively with the client when asking the client to complete a task?

Select all that apply. ● Obtain eye contact before speaking ● Use simple language ● Have him repeat what was said ● Praise him if he completes a task

Kaplan Question ... child with attention deficit disorder. Which statement by the nurse is most appropriate? ● “Hug your child after a task is completely performed.”

Causes & Risk Factors

Classroom Strategies

• Head trauma: TBI (traumatic brain injury) Children who have had a serious head injury are more likely to develop ADHD later on in age.

ATI Question

ATI Question … classroom strategies for children who have ADHD. Which of the following information should the nurse plan to discuss with the teachers?

Select all that apply. ● Allow for regular breaks

Risk factors of ADHD… Which of the following should the nurse include in the teaching?

● Combine verbal instruction with visual cues

● History of head trauma

● Decrease the amount of homework assigned

● Establish consistent classroom rules

CLASSROOM RULES

Alcohol & Drug Abuse Mental Health "Psychiatric Care"

6 Key Definitions

Enabling & Codependence

1. Tolerance: decreased response to a drug / alcohol

3 NCLEX TIPS

2. Withdrawal: symptoms that develop after abruptly stopping drugs / alcohol

“It is my fault that my spouse drinks so much”

3. Dependance: the body’s physical addiction to a drug / alcohol

“I will take care of the children so that my spouse can drink”

4. Relapse: the recurrence of drug/ alcohol use after remission

“I have lied to my spouse’s boss about why he missed work”

5. Denial & projection

ATI …client who abuses alcohol & illicit drugs... spouse tells the nurse: “have lied to his boss, his children, and his friends and I just don’t think I can do this anymore.” Which of the following best describes this behavior?

Enabling

HESI Patient with chronic pain... A regular dose of analgesic medication is ineffective in reducing the patient’s pain?

The patient is showing signs of tolerance

6. Enabling & codependence

Cocaine & Meth. Or Methamphetamines are both stimulants that act on the brain to increase the heart rate & blood pressure.

NORMAL

LOW

Q1: ... significant dental problems. The nurse expects that this patient abuses which substance?

Meth = dental problems

Methamphetamines Q2: The nurse finds that a patient who is a drug addict has nasal damage. Which substance does the nurse suspect?

Cocaine

Cocaine = nasal damage Nursing Interventions

A nurse is learning how to manage patients with substance abuse disorders. Which step should the nurse apply as a first-line intervention in such cases?

Providing safety and sleep

KAPLAN The client is agitated and fights against the nurse ... positive for cocaine... priority intervention?

Provide a calm atmosphere and monitor respiratory and cardiac status

1st

Opioids Signs & Symptoms

HESI

HESI

Symptoms

HESI Which vital sign would be most concerning to the nurse?

Respirations 10 breaths/min

aaa...

bbb...

ooo...

Slurred incoherent speech

KAPLAN

Decreased respiratory rate (norm: 12 - 20)

aaa...

bbb...

A client uses heroin several times a day.

Which signs and symptoms does the nurse expect to observe? Select all that apply.

Narrowed “constricted” pupils

ooo...

Constricted pupils Depressed respirations Drowsiness or sedation Slurred incoherent speech

Sedation & coma

Opioids Withdrawal

ATI

Treatment

Signs & Symptoms Runny nose Diaphoresis (sweating) Insomnia Dilated pupils

HIGH

Cocaine Methamphetamines

Opioid

Naltrexone = Prevents relapse by reducing cravings

STOP

Clonidine = Lowers BP Methadone = Low dose opioid (wean off addiction) NCLEX TIP

Treatment for opioid dependence... which of the following medications is used for treatment of opiate withdrawal?

Select all that apply Clonidine Methadone

HESI ... teaching a patient with a new prescription for naltrexone?

It helps prevent relapse by reducing your drug cravings

Alcohol & Drug Abuse II Mental Health "Psychiatric Care"

Alcohol Abuse Alcohol is a toxin that causes central nervous system depression, making the vitals signs low & slow, causing coordination & balance problems.

Big Key Point

Hypoglycemia

<70

PRIORITY

Alcohol intoxication & Diabetic Monitor blood glucose levels at night NCLEX TIP Psychosocial Assessments

KAPLAN Identify triggers

Q1: The nurse prepares to lead a group session for ... dependence on alcohol. The nurse knows that a client with a diagnosis of alcoholism drinks because of which reason?

Select all that apply

Escape from problems Cover up depression & anxiety

Escape from problems

Primary goal of counseling: identify triggers

Cover up depression or anxiety Q2: The nurse provides care for a client diagnosed with alcohol abuse ... Which is the primary goal of counseling?

Assist the client to identify factors that trigger alcohol use

Recovery Teaching After detox the primary goal of recovery is total abstinence meaning NO alcohol forever!

HESI

3 NCLEX TIPS

... patient with alcohol misuse. What intervention does the nurse plan for rehabilitation of this patient?

Develop motivation and self-help skills

Expressed accountability: taking responsibility & acknowledging 2. Coping skills 3. Setting Goals: develop motivation & self help skills

24 hours: anxiety, insomnia, palpitations 48 hours: Seizures & unstable vitals 48 - 72 hours: Delirium Tremens NCLEX TIP 1. HYPERreflexia “Hand Tremors” 2. Diaphoresis (sweating) 3. Hallucinations Increased Vitals: Tachycardia (HR over 100 BPM) Hypertension Fever Mood: Agitation & Anxiety Mental: Confused & restless Seizures!

KAPLAN

Anxiety Tachycardia

Q1: The client reports drinking socially ... states, “I am anxious and shaking inside.” ... vital signs are Temp. 100 F (38 C), HR 120 bpm, RR 24/min, BP 130/90 mm Hg. Which conclusion does the nurse make?

>100.30F

120 bpm

24/min

130/90 mmHG NORMAL

HIGH

Alcohol, Benzodiazepines, Barbiturates

HESI Signs of alcohol withdrawal. What assessments will the nurse include when providing care to this client?

Select all that apply

LOW

Alcohol Withdrawal & DT

The client has early signs of alcohol withdrawal

Irritability Tremors

ATI ... result of sudden withdrawal from barbiturate use?

Q2: The nurse admits a client for possible appendicitis... client states, “Most days I drink about one pint of vodka.”... alcohol withdrawal delirium time frame?

48-72 hours after last consumption

Seizures

Nursing Care Implement seizure precautions

Kaplan The nurse admits a client who has a diagnosis of alcoholism and admits to drinking a pint of vodka a day.... which intervention is appropriate?

Ensure seizure precautions are in place

STOP

Anxiety Disorders

Mental Health "Psychiatric Care"

HESI Question

TYPES GAD: General Anxiety Disorder SAD: Social Anxiety Disorder Panic disorder Separation Anxiety Phobias

NCLEX

Client states... “every time I need to leave the house for work ... Mom becomes extremely anxious and cries that something terrible is going to happen to me.” ... supports which psychiatric diagnosis?

EXAMS

OCD: Obsessive Compulsive Disorder

Separation anxiety disorder

● Separation anxiety disorder

PTSD: Post-traumatic Stress Disorder

ATI Question

Pathophysiology During severe anxiety the mind goes into a state of panic & so the body goes into fight or flight mode turning on the SNS - sympathetic nervous system.

The SNS tells the body to shunt blood flow away from the extremities & toward the core of the body for the vital organs & to increase the vital signs.

Which of the following are physiological signs of anxiety?

Select all that apply ● Increased pulse rate ● Hyperglycemia ● Dilated pupils ● Dilated bronchioles

MEMORY TRICK

● Peripheral vasoconstriction

SNS - Sssspeeds Up the Vital Signs Increasing the HR, BP, RR, sugar levels, & dilating the pupils!

120

Classifications

Small Mild Anxiety

Medium Moderate Anxiety

Large Severe Anxiety

EXTRA Large Panic Attacks!

Signs & Symptoms

ATI Question Mild Anxiety Restless, irritability

Moderate Anxiety Increased RR & HR Pacing back & forth Slightly reduced perception

Severe Anxiety Increased RR & HR “hyperventilation” Pacing back & forth Feeling of “Impending Doom” Perception is GREATLY reduced: Can NOT respond to directions

...clinical manifestations ... expected in a client with severe anxiety?

The client is pacing the hallway and tells the nurse he has a feeling of impending doom

HESI Question Q1: ... a patient tells the nurse, “I feel like I am going to die.” Based on the statement the patient made, what level of anxiety is the patient experiencing? � Severe Q2: A male patient is running ... and keeps repeating, “They are coming!” ... neither follows staff directions nor responds to verbal efforts to calm him. The level of anxiety can be assessed as: � Severe

Anxiety Disorders II

Mental Health "Psychiatric Care"

Signs & Symptoms

HESI Questions

Panic Attack

Q1: A symptom associated with panic attacks is:

Fear of death “Impending doom”

Panic disorder

� Fear of impending doom

Feeling detachment “Hallucinations”

Q2: A patient who has to undergo surgery ... complains of chest pain, feelings of choking, and hot flashes. What appropriate diagnosis does the nurse make from the patient’s symptoms?

Physical s/s: • Chest Pain & heart palpitations • Trembling & Numbness • Hyperventilation • Sweating & Hot flashes • Nausea & choking sensations

� The patient has panic disorder

Interventions

Severe Anxiety & Panic Attacks 1. REMAIN with the client #1 Priority NCLEX TIP 2. Place client in a quiet room “Sit with client” “remain at bedside” 3. Speaking calmly with simple clear words

Pharmacology

HESI Questions Q1: Client ... becoming increasingly anxious. What initial actions should the nurse take for this client?

Select all that apply. � Stay by the client’s side � Escort the client to a quiet place � Use a comforting tone of voice when speaking to the client Q2: ... new client ... spontaneous onset of hyperventilation, trembling, and an inability to concentrate. What is the nurse’s priority action? � Stay with the new client

ATI Questions

Kaplan Questions

Q1: ... a client with a severe level of anxiety is rocking back and forth … stating, “Something bad is going to happen.” Which action should the nurse take? � Sit in a chair next the client’s bed Q2: ... client who has generalized anxiety disorder and is trembling and pacing during a group activity... Which of the following statements should the nurse make to the client?

Q1: Client with anxiety disorder… begins to sweat profusely and breathe rapidly.. & states “I feel like I am having a panic attack.” Which response by the nurse is best? � “I’m going to help you back to your room.”

Q2: … client reporting dizziness and a ‘racing heart’.... extremely anxious. Which response by the nurse is best?

� Come with me to an area where we can talk without interruption

� “When did you first notice that you were feeling anxious?”

Effective Coping

3 NCLEX TIPS

Beta blockers “-lol” • Atenolol Antidepressants • SSRI: Sertraline & Paroxetine • TCA: Amitriptyline & Imipramine • MAOI: Phenelzine & Isocarboxazid Anxiolytics MOST TESTED • Benzodiazepines • Barbiturates • Buspirone

1. Increased comfort while exposed to the phobia 2. Verbalizing feelings & insight about anxiety (self observation) 3. Self distraction: focusing on something other than the phobia

NCLEX TIP Resilience: Practicing stress reduction techniques daily

Top Missed NCLEX Questions A client with social anxiety disorder has been struggling with his new job when coworkers invite him to lunch. Which of the following statements indicates the client is improving in coping mechanisms?

Select all that apply 1. I went to a restaurant with a few coworkers & focused on our conversation rather than my phobia.

2. I planned to go out of town rather than attend our company’s christmas party.

Benzodiazepines

Buspirone

3. I must admit that I am still very nervous about eating in front of my coworkers, but I am working through it.

4. I went to a coffee shop by myself and sat to watch people.

5. I will make excuses to avoid going to eat with my boss.

Cognitive Behavior Therapy (CBT) CBT is a type of talk therapy that helps clients reframe their thought processes to prevent negative thought patterns in order to adapt to stress & anxiety.

Autism Spectrum Disorder Mental Health "Psychiatric Care"

Risk Factors

Pathophysiology ASD is a developmental disorder that impairs a child’s ability to communicate and interact. Cause of autism is unknown.

?

?

MOST tested

Highest risk factor = sibling with autism

C T U C B A

HESI

?

C T U C B A

Delayed developmental milestones

?

ATI Autism can usually be diagnosed when the child is approximately: 2 years of age

For example - while performing a developmental screening on 2 siblings. If the older sibling has autism then the younger sibling is at highest risk for having it too.

Don’t let NCLEX trick you Highest risk factors are NOT having early vaccinations & NOT having parents of older age - this is according to the NCLEX.

Signs & Symptoms C T U C B A

Does NOT Maintain eye contact NCLEX TIP Interact with gestures Like being cuddled & plays alone Education

Does NOT Respond to questions NCLEX TIP Display nonverbal behavior Delay in language development

Routines & Consistency

Are you hungry?

Give a schedule of daily activities A

Repetitive

NCLEX TIP

Maintain daily routines when possible HESI

C B A

C B A

Avoid making acute changes in their environment

Actions “Ritualistic behavior” Words (echolalia)

ASD - Autism Spectrum Disorder

HESI

HESI

HESI Child who plays alone, does not maintain eye contact, repeatedly twists fingers, has inadequate speech, and does not interact with gestures?

Q1: Child with autism spectrum disorder (ASD).

The parents say, “We are going to move our child to a different bedroom in our home.”

Select the nurse’s therapeutic response.

“Children with autism spectrum disorder usually prefer for things to stay the same.”

Autism spectrum disorder (ASD) C T U C B A

Q2: Child with autism spectrum disorder. Which statements by the parents indicate … that they understand the teaching?

Select all that apply.

C B A

C B A

Repetitive movements are common Non-verbal communication is limited Maintain a daily routine whenever possible

Kaplan Child with autism is admitted to the pediatric unit ... Which response by the nurse is best?

“The inability to maintain eye contact is a characteristic of autism.”

Prevent Overstimulation Limit number of visitors & choices Private room away from the nurse’s station NCLEX TIP

ATI 1... 2... 3...

4... 5... 6...

A A A

Which of the following manifestations … are indications of autism spectrum disorder?

Select all that apply.

Nonverbal behavior Repetitive counting Spins a toy repetitively Delayed language development Exhibits ritualistic behavior

Limit

I

W B

A

C B A

ATI What is the most important intervention when admitting a child with autism spectrum disorder?

Placement in a private room down the corridor from the nurses’ station

Bipolar Disorder Mental Health "Psychiatric Care" Pathophysiology Bipolar is a mood disorder with cycling periods of lows with Depression followed by highs with Acute Mania.

During depression: clients have low mood, low energy, & motivation & high risk for suicide.

During acute mania: high energy, hyperactivity, elevated mood, & even aggression with violence.

HESI Question Depression

Acute Mania

MEMORY TRICK

Four or more mood episodes in a 12-month period, the patient is said to be

Depression Declined mood

Mania

More energy + Maniac

Rapid cycling

ATI Question Five acute manic episodes in one year Rapid cycling

Types of Bipolar Disorders

Bipolar 1 - 1 episode of mania that lasts over 1 week or need for hospitalization Bipolar 2 - 2 episodes of milder high hypomania, which can last longer Cyclothymia - milder lows & milder highs cycling over a period of 2 years Rapid Cycling - 4 episodes of depression & mania within a 12 month period Causes & Risk Factors

The cause is unknown but what does play a big part is: • Genetics - having a family member with bipolar, clients are 10x more likely to have it.

• SSRIs (antidepressants) can trigger a manic episode SSRIs can trigger a manic episode

Genetics

SSRI 10x

Signs & Symptoms

M

More energy & Mood Swings

A

Agitation

N I A

Euphoric energy, impulsive, grandiosity Hallucinations & delusions of grandeur

Set limits & structured environment

Non-stop talking & Flight of ideas Colorful bizarre clothing choices

Insomnia

Cannot sleep for days

Attention span POOR

Easily distracted = reduce stimuli

ATI Question symptoms with manic behavior?

• More talkative than usual • Easily distracted • Intense need for activity

HESI Question

manic phase?

Select all that apply.

• The client is quickly angered • Flight of ideas • Going rapidly from one activity to another • Colorful & outlandish clothing

Kaplan Question Q1: Acute manic phase: Which symptom does the nurse expect?

• Hyperactivity & irritable Q2: “I just bought myself a home computer and a large screen TV for the family.” Which interpretation is most accurate?

• Mood disturbance and judgement that is poor at this time

Saunders Assessment finding that requires immediate intervention?

• Nonstop physical activity and poor nutritional intake • Constant delusions

Bipolar Disorder II Mental Health "Psychiatric Care"

Interventions

Acute Manic Episode

Acute Manic Episode

1. Reduce Stimulation: Quiet, calm environment “Private Room near the nurses station” NCLEX TIP

2. Physical exercise

- Alternating aerobic exercise with scheduled periods of rest ATI - Assist the client with sweeping the floor of the unit HESI

- Manic episode? A single room near the nurses’ station HESI - Manic phase of bipolar disorder? A private room across from the nurses’ station ATI

- Take the client to a quiet area with low stimulation ATI

3. Set structure & limits on aggression “Choose clothes for the client” NCLEX TIP Set limits & be consistent with consequences

Limit group contact: NO dining room NO group activities (1-on-1 activity)

Acute Manic Episode 4. Diet: HIGH calories & protein HIGH FLUID intake Foods “on the go”: NCLEX TIP Hamburgers, Sandwiches, Burritos Milkshake, protein shake Hand held: fruits & veggies

- “If you throw that lamp, you will need to stay in your room for 1 hour” HESI - “Swearing & profanity are unacceptable here” ATI

Provide the client with a chicken leg and carrot sticks HESI

NO caffeine (coffee, tea, soda)

Top Missed NCLEX Questions Interventions for a client with bipolar disorder who is admitted to the hospital for an acute manic episode? Select all the apply 1. Encourage physical exercise with staff 2. Private room near the nurses station 3. Pick out clothing for the client 4. Avoid group activities 5. Eat meals in the dining area with other patients

Pharmacology

Mania Anxiolytics: Clonazepam Alprazolam

Depression Antidepressants Mood Stabilizers: - Carbamazepine - Valproic acid - Lithium

VaLproic acid

Liver Toxic

Valporic Acid

Lithium

ATI Question

HESI Question

Valproic acid… monitor: Liver function

HESI Question Valproic acid…. Which laboratory finding is most important?

Liver function test results

Q1: What action should the nurse take ... lithium level is 1.8 mEq/L • Withhold medication and notify the healthcare provider (HCP) Q2: Taken lithium for 1 year … nurse’s priority attention?

• “I’ve had very bad diarrhea for 3 days.”

L I T H

Kaplan Question Lithium carbonate …

The nurse understands which other medication is contraindicated?

• Diuretic

ATI Question Q1: Scheduled to begin lithium therapy… priority to report to the provider?

• I am currently taking furosemide for congestive heart failure

Levels OVER 1.5 mEq/L = TOXIC! Increase FLUID & Sodium (Na+) HIGH RISK Toxicity = Dehydration & Hyponatremia < 135 mEq/L Do NOT limit sodium or water intake TOXIC Signs to REPORT: Excessive urination and extreme thirst!

Vomiting & diarrhea

HOLD NSAIDS – (Ibuprofen, Naproxen) NSAIDS decrease renal blood flow = toxicity risk

Q2: Manifestations of lithium toxicity?

• Nausea & vomiting • Diarrhea • Polyuria • Muscle weakness Q3: Lithium for treatment of bipolar disorder… teaching: • Aspirin is better to use than ibuprofen • Report excessive thirst & increased urination • Avoid exercising outdoors on hot days • Regular laboratory tests to monitor lithium level

CBT - Cognitive Behavior Therapy Mental Health "Psychiatric Care" Pathophysiology CBT is a common type of psychotherapy (talk therapy). It helps clients reframe their thought processes in order to slowly cope with stress & anxiety, helping to treat many disorders from PTSD & OCD, to eating disorders like anorexia & bulimia, and even depressive disorders.

Kaplan Question A client states ... “I travel only by train because I am terrified of flying.” ... the phobic client is most likely to respond to which intervention?

• Systematic desensitization

5 CBT Strategies NCLEX TIP 1. Learn about the disorder

Systematic desensitization

HESI Question

2. Exposure: Desensitization to situations & events (behavioral strategies)

Q1: A nurse teaches ... examining negative thoughts and restating them in positive ways. The technique is call:

3. Self-observation & monitor

• Cognitive reframing

4. Relaxation techniques 5. Teaching new coping skills & Techniques to reframe thinking (Cognitive restructuring) Systematic desensitization

Gradual exposure to a phobia or traumatic event which helps to desensitize the client to the major stress & anxiety & at the same time administer relaxation techniques.

Q2: The nurse is teaching cognitive reframing ... to counteract depression.

Which response by the patient indicates effective teaching by the nurse?

• “I have many friends who love me and care for me.”

Guided Imagery

Biofeedback

Guided imagery is a mind-body intervention where clients concentrate on mental images to help reduce stress, anxiety, & improve concentration.

Biofeedback is just like guided imagery, but the key difference is that machines are used to help the mind focus, sort of like virtual reality

ATI Question

ATI Question

Q1: Which of the following have been

shown to be advantages of using guided imagery?

Select all that apply.

• Finding relaxation and inner peace • Solving complicated problems • Improving concentration

A nurse is providing education to student nurses about non-pharmacological modalities of pain control.

Which best describes biofeedback?

Q2: Which of the following information should the nurse include about guided imagery?

• Teaching the body to respond differently to stress of other stimuli

• It concentrates on descriptive mental pictures to treat pathological conditions

Therapeutic Milieu

Group Therapy

This provides a safe & secure environment for clients that are in therapy. It’s basically the goal of every behavioral health or psych unit in the clinical setting. Clients are encouraged to freely roam around in the social environment.

Kaplan Question

Psychiatric inpatient setting: which description is the best for milieu therapy?

• Providing a therapeutic physical and social environment

HESI Question Primary goal of milieu therapy for patients diagnosed with personality disorders?

• Managing the effect of the behavior on the entire group

ATI Question

... how to establish a therapeutic milieu on the unit?

• Orient new clients to their environments, rights, and responsibilities

Goal

Reduce isolation & Communicate acceptance

Problem?

• Allow the group to handle it • Silent member: encourage interaction, then divide groups into pairs • Aggressive member: address the anger & separate in another room

KAPLAN Question Q1: The nurse understands which is the primary benefit of group therapy?

• Groups reduce isolation in structured, controlled environments Q2: The client with depression joins an ongoing therapy group. Which is the goal of group therapy?

• To communicate acceptance to the client

HESI Question ... one participant ... interrupts others when they are talking. What is the best action ... to take in this situation?

• Allow the group to handle the problem

ATI Question Q1: Group therapy: Which of the following is the primary focus of group therapy?

• Personal feelings that affect behavior Q2: Group therapy: Which response should the nurse make to a client’s aggressive statement?

• “You seem very upset.”

Crisis Management Mental Health "Psychiatric Care"

ATI Question

4 Phases

… which of the following best describes what should be in the first box? ● The triggering event

1. Trigger event: anxiety in response to threat 2. Escalation: increasing anxiety & agitation 3. CRISIS: outburst, violence, or shouting

Escalation

Crisis

Disorganization

The client states, “I feel like I can barely get out of bed in the morning.” The nurse recognizes the client is in which stage of crisis?

4. Post Crisis Disorganization & Depression

Interventions

The triggering event

Kaplan Question

● Disorganization & depression

1st

...

2nd

3rd

...

Communication 1. Explain all activities of care clearly & calmly NCLEX TIP 2. Eliminate the trigger 3. Low-stimulation environment - NOT near nurses station 4. Determine the source of anger

HESI Question

The patient becomes agitated and threatens to harm a staff person. Which nursing intervention is appropriate? ● Address the patient with simple directions and a calming voice

Kaplan Question When intervening with a violent client, the nurse takes which action? ● Identifies the nurse to the client and remains calm

ATI Question Q1: A client becomes agitated and threatens to punch the other client. What is the priority action by the nurse? ● Eliminate the trigger using nursing measures and interventions Q2: … yelling and screaming at the staff… which actions should the nurse take? ● Determine the true source of the client’s anger Q3: angry and throws a chair in the dayroom.

Which of the following interventions should the nurse perform first? ● Acknowledge the client’s emotions

HESI Question Q1: A client … bursts out in a verbal tirade in the dayroom. The client has a history of poor impulse control. What is the nurse’s priority action? ● Remove any other clients from the day room Q2: When approaching an angry patient, which safety considerations should be taken? ● Have other staff as backup, and stand far enough away to avoid injury

I'm Lily and I'm here to help I see you are upset

5. Acknowledge the client's emotions

Pharmacology

Anxiolytics Benzos: “-pam” “-lam” Lorazepam (brand: Ativan) Antipsychotics: Haloperidol (brand: Haldol) Ziprasidone (brand: Geodon)

Physical Restraints 1. Get an order for restraints (Renewed every 4 hours Adults) 2. Must be assessed by HCP within 1 hour of order 3. Document every 15 minutes 4. Monitor & meet physical needs

HESI Question

A client who is displaying violent behavior.

Which of the following medications should the nurse expect the provider to prescribe? Select all that apply. ● Lorazepam ● Haloperidol ● Ziprasidone

HESI Question Physical restraints are placed on the client, and then the client is put into a seclusion room. Which actions must the nurse take in the next hour? ● Meet the physical needs of the client ● Obtain a prescription for the restraints ● Objectively document the client’s behavior

LORAZEPAM

HALOPERIDOL

Ziprasidone hydrochloride Geodon

Death & Dying Mental Health "Psychiatric Care" 5 Stages of Grief

1. Denial

Bowlby’s 4 Stages of Grief

KAPLAN Q1: The client appears angry and demanding following a below-the-knee amputation.

Numbness or protest

The client is having difficulty accepting the new body image

2. Anger

Q2: After being told the feet will need to be amputated, the client states, “I’m sure if I start taking my medication my feet will heal.”... example of which behavior?

Disequilibrium

?

?

3. Bargaining 4. Depression

?

?

Denial

ATI … acute grief process. Which of the following statements made by the client indicates understanding of feelings?

Select all that apply

Disorganization and despair

I might experience feelings of resentment

5. Acceptance

I might have some guilt over how my partner died I might have angry feelings that I should express

Defense Mechanisms 1. Disaplacement NCLEX TIP shifting of anger or impulses from an outside situation toward another person.

2. Repression

Reorganization

Type of Loss

HESI

Perceived loss

A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism?

The type of loss that is felt by the person, but is intangible to others. For example loss of financial independence or a valued personal item.

Situational Loss

Unexpected loss caused by an external event, like cancer in a family member.

Choosing to hide or ignore painful memories instead of facing them in hopes of forgetting.

Maturational Loss

Loss that is expected with normal life transitions, like graduating from high school & leaving your friends behind.

3. Compensation Overachieving in one area to compensate for failures in another.

ATI

4. Undoing A person tries to cancel out an unhealthy memory, by doing good acts.

5. Sublimation

A person channels unacceptable desires into an activity that is appropriate & safe.

… best describes an instance when displacement is used as a defense mechanism?

A man who loses his job goes home and yells at his wife

HESI

6. Projection Taking unacceptable qualities or feelings & pinning them on other people.

7. Rationalization

A 20 year old was sexually molested at age 10, but can no longer remember the incident... defense mechanism used:

Identification

HESI .. an adolescent with a history of violence ... sublimation?

Joined a competitive boxing team

KAPLAN The client is told ... she cannot have children.... forms a close attachment to the niece and nephew … example of which defense mechanism?

Sublimation

ATI … a client who was bullied about his interest in chemistry now tutors students having difficulty with science. Which of the following defense mechanisms?

Sublimation

Repression

Justify illogical or irrational ideas & feelings

KAPLAN

8. Identification A person adopts the behavior of a person who is perceived to be more powerful

IDENTIFICATION

… a client with alcoholism… states, “I need a drink or two to relax after a busy day at work. I have an incredibly high stress job.” ...which defense mechanism?

Rationalization

Interventions - Pediatric

Interventions - Adult

1. Play therapy

I feel sad

2. Honestly answer questions

• Therapeutic communication • Sit with the client • Support Groups • Focus on good memories

3. Therapeutic touch

ATI

Saunders

KAPLAN

HESI

The parent of the younger child asks the nurse why the child is involved in play therapy. Which statement is best?

A nurse is caring for a client who just delivered a stillborn fetus at 36 weeks of gestation. Which of the following statements should the nurse make?

A 6 year old learns about the death of a grandparent… What will the nurse include in the parent’s teaching plan?

Select all that apply.

… an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping?

Select all that apply.

“Young children have difficulty verbalizing emotions.”

Young children have difficulty verbalizing emotions

Promote activities that the child enjoys Encourage the child to express feeling through coloring Answer the child’s questions honestly Hold and cuddle the child to rein force closeness

You may hold your baby as long as you want NCLEX TIP

Looking at old snapshots of the family Participating in a senior citizens program Visiting the spouse’s grave once a month

NCLEX You may hold your baby as long as you want

Decorating a wall with the spouse’s pictures and awards

Depression Mental Health "Psychiatric Care" Pathophysiology Major Depressive Disorder (MDD) also called clinical depression is when a client experiences a severe depressed mood, loss of enjoyment in life, low energy & few other critical signs and symptoms. Everything is low & slow, it is thought to be from low levels of neurotransmitters within the brain.

O

Serotonin

Neurotransmitters

O

Low Serotonin

O

Dopamine

Low Dopamine

Blah...

Low Norepinephrine

Risk Factors

N

KAPLAN Question recently become unemployed and the client reports feeling depressed. The nurse understands which statement to be true?

Females Substance abuse disorders

unemployment is a significant potential stressor

Signs & Symptoms

HESI Question Q1: “Life just doesn’t have any joy in it anymore. Things I once did for pleasure aren’t fun.”

Diagnosis: 5 or more symptoms

Anhedonia

Diagnosis

2. Anhedonia HESI & ATI (loss of joy/ interest in life)

3. Weight loss (anorexia) or Wt. Gain

5/9 symptoms

MDD?

4. Psychomotor retardation NCLEX TIP

or hypersomnia (sleeping too much)

6. Fatigue (Anergia)

Side Note Pediatrics: Adolescents 10 - 19 years NCLEX TIP Angry, aggressive outbursts & vandalism / skipping class Weight loss or gain “suddenly” “rapidly”

I wake up about 4 am and cannot go back to sleep. I feel tired all the time

A nurse is assessing an adolescent who has depression. Which of the following findings should the nurse expect?

Select all that apply.

5. Insomnia

7. Feelings of worthlessness or Guilt 8. Difficulty concentration 9. Suicidal thoughts (Recurrent)

Q2: Which complaint regarding sleep would the nurse expect from a patient diagnosed with major depression?

ATI Question

Slower speech, response time, & Decreased movement

Low self-esteem (withdrawal)

N

a risk factor for depression?

Stressful life events

Genetics: Family history

Napping during day

N

ATI Question

Stressful life event Chronic illness

(hopeless, empty)

O

N

Norepinephrine

1. Depressed mood

O

N

Irritability Anergia

Anhedonia Appetite changes

TOP Missed NCLEX QUESTION Which of the following pediatric clients should the nurse screen for depression?

Select all that apply.

4 weeks

10 year old taking frequent naps during class time 16 year old quit the chess team despite being the team captain 14 year old sent home from school due to angry outbursts & skipping class 17 year old suddenly lost 15 lbs (6.8 kg) in 4 weeks

48.2

kg

Depression II Mental Health "Psychiatric Care" Treatment

Types

3 Phases

Dysthymia Mild symptoms

1. Acute Phase

Seasonal affective disorder

2. Continuation Phase

Use of light therapy

3. Maintenance phase

Pre & Postpartum baby blues

HESI Question … seasonal affective disorder.

What appropriate action...?

Instruct the patient to be exposed to a light source for 30 to 45 minutes daily

Nursing Care

Priority: Suicide Risk

ATI Question

Assessment: Calmer or MORE Energetic = INCREASED suicide risk Sudden, abrupt, rapid change in energy Giving away possessions (cherished / valued) Statements: “I can’t go on” “I do not want to live” “I won’t be a problem much longer” HESI “This will all be over soon” Kaplan Questions: Suicide risk assessment “Have you had any thoughts of hurting yourself?”

NCLEX TIP

“Do you have a plan to kill yourself?”

... major depression and suicidal ideation who is suddenly calmer and more energetic. Which of the following should the nurse consider?

The client is suicidal

Saunder’s Question Q1: … a depressed client ... suddenly begins

smiling and reporting that the crisis is over.

The client says to the nurse, “I’m finally cured.” Intervention?

Increasing the level of suicide precautions

HESI Question A man tells the nurse … he has no reason to continue living. What should the nurse ask him first?

Q2: Which behavior ... indicates an

adolescent client may be suicidal?

Gives away a DVD and a cherished autographed picture of their favorite performer

Do you have any plans to end your life right now?

“Do you want to die?

NCLEX TIPS 1. Continuous one-to-one observation 2. Semi-private room (near nurses’ station) Remove harmful objects from room Supervise during meals Reassess: changes in suicidal thoughts Clear plans of the future involving personal goals, family, & friends NCLEX TIP

Kaplan Question ... client states, “I don’t want to live anymore.

I’ll find something else to kill myself with.”

Which nursing intervention is important to perform next?

Provide direct one-to-one observation to the client at all times

ATI Question Q1: … newly admitted client who has severe depression.

Interventions Encourage & Invite client to participate Assist with ADLs Help the client get ready NCLEX TIP

Sit with the client and offer simple, direct information Q2: … client seems more withdrawn and depressed than usual.

Say to the client, “I would like to spend some time with you.”

Communication with simple & direct language Reevaluation

Q1: A client .. admits to a plan for suicide ..

What is the nurse’s priority action?

Provide one on one supervision Q2: One week ago, a patient attempted suicide…. which comment by the nurse is most therapeutic?

“I’d like to hear about how you are feeling now”

Kaplan Question Q1: Client diagnosed with depression … Which approach by the nurse is best?

Invite the client to join in group activities Q2: … crying alone in the room. The client has refused to eat breakfast or have morning care.

Which intervention by the nurse is best?

Offer to sit with the client and help the client get dressed

Spend time with client “Sit with the client”

HESI Question

HESI Question Which comment … shows improvement in depression?

“I talked with my family about ways we can celebrate holidays together.”

Saunder’s Question ...diagnosis of depression … plan of care that includes which intervention?

A structured program of activities in which the client can participate

Depression III Mental Health "Psychiatric Care" Diet Remember a big symptom of depression is rapid weight loss or weight gain, typically weight loss is the most tested, since it is more common. Clients lose appetite & refuse to eat.

Poor nutritional intake

HESI Question

1. Small “frequent” meals 2. High calorie foods & fluids

Saunder’s Question

... imbalanced nutrition, less than body

Client with depression ... poor nutritional intake.

requirements … with severe depression. The

… which interventions in the plan of care?

most reliable evaluation of outcomes?

Select all that apply.

Assist the client in selecting foods from

Weekly weights

the food menu Offer high-calorie fluids throughout

3. Stay with client during meals

the day and evening Offer small high-calorie, high-protein

4. Weekly weights

snacks during the day and evening g

30 k

Procedures

MOST tested

MOST TESTED

Vagus nerve stimulator

1. ECT - Electroconvulsive therapy 2. TMS - Transcranial magnetic stimulation 3. Vagus nerve stimulation

ECT

TMS

ECT - Electroconvulsive Therapy

BEFORE 1. Screen for Medical History & Report to HCP Recent myocardial infarction Saunder’s Cerebral neoplasm ATI 2. Assess Concerns: What are your concerns about ECT? NCLEX TIP 3. NPO x 6 - 8 hours NCLEX TIP 4. NO anticonvulsant meds NCLEX TIP Valproic Acid, Carbamazepine 5. Remove: dentures & contacts 6. Side Effect: Memory loss ATI & Kaplan Equipment: Cardiac monitor Oxygen Crash cart Suction Informed Consent signed

AFTER NO driving (during course of ECT treatment) NCLEX TIP Temporary confusion & memory loss common after

ECT induces electrical activity on the scalp to create a generalized seizure. Think of this as jump starting the brain like jump starting a car or doing a hard reset on your iphone. Each seizure lasts around 15 - 20 seconds, done 2-3 times a week for 6-12 treatments total.

ATI Question Which of the following is a side effect of ECT? Memory loss

Kaplan Question after ECT… It is most important for the nurse to take which action?

Remind the client that memory loss is temporary

Temporary

HESI Question … electroconvulsive therapy (ECT), which equipment should the nurse make sure is available?

Select all that apply.

Oxygen Suction equipment Crash cart

Saunder’s Question ECT ... interventions before procedure?

Select all that apply.

Have the client void Obtain an informed consent Remove dentures and contact lenses Withhold food and fluids for 6 hours

REMOVE

Dissociative Identity Disorder Mental Health "Psychiatric Care"

Pathophysiology Dissociative identity disorder occurs when 2 or more identities rotate control over the client’s behavior.

Clients will typically have amnesia or lack of memory, not aware that the alternate identities exist, & often confused by the big gaps in their memory.

How does this happen? Ususally originated by a traumatic event like abuse or rape, the various identities & memory gaps serve as protective mechanisms helping to shield the client from the traumatic memories.

Naturally, stress & anxiety that remind the client can trigger the identities into play.

HESI Question Dissociative episode: Select all that apply.

.....

.....

Dissociation is a method for coping with severe stress Dissociative symptoms are not under the person’s conscious control The existence of two or more subpersonalities, each with its own patterns of thinking

Treatment The goal of care is to help the client merge the various identities into 1 personality by integrating past events.

5 NCLEX TIPS 1. Grounding techniques: Deep breathing, counting coins, holding an ice cube

HESI Question grounding techniques... to alleviate symptoms?

Hold an ice cube in your hand

Which factor would indicate successful treatment?

The patient has integrated past events

2. Journal about feelings & triggers 3. Trust: Develop a trusting relationship with each identity

HESI Question

Remember?

4. Self-harm: Monitor & listen for expressions of self-harm 5. NEVER ask the client to recall memories

Notes

Anorexia Nervosa

Mental Health "Psychiatric Care"

Pathophysiology Anorexia nervosa is an eating disorder causing clients to obsess about their weight & what they eat.

Distorted body image & fear of being overweight

Risk Factors: - Adolescent females are the most affected - Anorexia also has the highest death rate of all mental disorders due to suicide

KAPLAN ATI

1st

Which statements are true regarding anorexia nervosa?

Select all that apply.

Anorexia nervosa: The client has an unrealistic fear of obesity

Clients see themselves as overweight Adolescent females are most affected Anorexia nervosa has the highest mortality rate of all mental disorders

Signs & Symptoms

Starvation → Malnutrition Vigorous Exercise

SEVERE

HESI

6 NCLEX TIPS

Q1: adolescent female with anorexia nervosa. Which physical findings support the diagnosis?

Select all that apply Lanugo Irregular heart rate Pulse rate 48 bpm

1. Extreme weight loss Less than 75% of expected weight “25% below normal weight” NCLEX TIP 2. Fluid & electrolyte imbalance

Hypokalemia: potassium below 3.5 (cardiac dysrhythmias)

3. Lanugo (thin hair) 4. Amenorrhea (no menstruation)

Q2: ... which assessment finding meets the criteria for hospitalization?

Serum potassium level 2.6 mEq/L

5. Cold intolerance 6. Low Vitals: Low temp., Low BP, Low HR (below 60)

Treatment Typically done in an outpatient clinic (outside the hospital), but hospitalization may be needed if the client's body weight is below 75% ideal.

Priority short-term goal 2 NCLEX TIPS 1. Increase caloric intake for gradual weight gain 2. One-on-one supervision during feedings

HESI Q1: What is the focus for the acute phase of treatment for anorexia nervosa?

Weight restoration

Q2: … anorexia nervosa presents with severe dehydration and rapid weight loss in the last week: Suggest hospital admission

Admitted for Malnutrition

5 NCLEX TIPS

1. Strict record: protein & calorie intake 2. Stay with the client during each meal & 1 hour after 3. Morning weights prior to oral intake 4. Help the client identify triggers 5. NO exercise!

Communication Encourage & reinforce: NCLEX TIP “Progress toward healthy weight” 35 kg

HESI What is a subjective symptom ... with anorexia nervosa?

Fear of gaining weight

Saunder’s … cognitive behavioral approach ● Help the client to examine dysfunctional thoughts and beliefs

Let sort out your emotions together

Bulimia

Mental Health "Psychiatric Care"

Pathophysiology Bulimia is an eating disorder that involves 2 cycles: 1. Episodes of uncontrolled binge eating in secret (eating a lot of food at once) 2. Followed by self-induced vomiting or purging. Also the use of laxatives, diuretics, and fasting to prevent weight gain, along with even excessive exercise.

Clients have a distorted view of body image & an obsessive desire to lose weight.

Signs & Symptoms

HESI … assessment finding with bulimia nervosa?

Binge eating

Dental erosion Patients with bulimia often appear to have a normal weight

then compensatory behavior: purging, exercise, fasting, laxatives Tooth & gum deterioration Scaly skin Normal body weight

70 kg

Interventions HESI 1 - 2 hours after each meal NCLEX TIP

ATI

Q1: A nurse is teaching a patient with bulimia nervosa about scheduling healthy, balanced meals:

One-on-one supervision during meals Monitor for fluid & electrolyte imbalances

To avoid binge-purge cycles

hypokalemia: potassium below 3.5 (cardiac dysrhythmias)

NCLEX TIP

Q2: A patient with bulimia nervosa uses ememas and laxatives to purge ... which imbalance should the nurse assess?

Check for hidden binging or purging “Hidden or trashed food wrappers” “Laxative boxes in the trash” Food diary during hospitalization

Mg

Na Ca

… a client with bulimia nervosa… states that at times she feels helpless... The most appropriate short-term goal: Verbalizing the desire to increase control over stressful situations

K

I want to control myself...

Let me help you!

Disrupted fluid and electrolyte balance

Pharmacology HESI Bupropion Wellbutrin

Not recommended

Bupropion

Bupropion Wellbutrin

NOT recommended for purge bulimia

The nurse is caring for a patient with bulimia nervosa who overuses laxatives but does not purge. Which drug is known to be effective to treat the patient?

Bupropion

Notes

OCD Mental Health "Psychiatric Care"

Pathophysiology

ATI Question Client with OCD ... constantly reorganizing

Obsessions = Excessive thoughts & impulses

books ... the client uses this behavior to do which of the following?

You should take a break.

Compulsions = Repetitive “ritualistic behaviors”

1 2 3 4

Decrease anxiety to a tolerable level

Kaplan Question .. client with OCD must wash, rinse, and dry

Key term

door handles before entering or leaving a room. Which action by the nurse is best?

Give a reminder that it’s time to take a break, since the client has been cleaning for hours.

Provide time for the client to complete the ritual

Treatment

You should spend only 5 minutes on this.

HESI Question

Initial Plan of Care

5 NCLEX TIPS

... priority nursing action 3 days after the admission of a client diagnosed with OCD?

1. Decrease ritual time slowly NEVER “suddenly” deny ritualistic activity (initially) Gradually limit the time of the activity

2. Identify triggers that increase anxiety

TOP Missed NCLEX QUESTION

3. CBT: thought stopping techniques

While evaluating a client with obsessive-compulsive disorder, the nurse knows which of the following indicates an improvement in effective coping?

4. Relaxation / Redirection Deep-breathing Exercise (take a short walk)

CBT

My mom helps disinfect my house everyday when I am at work, so I can have peace of mind everything is clean.

NEVER say judgemental comments about OCD habits

My boss gave me a large project which has increased my stress, but I will use deep-breathing to decrease my anxiety.

Give positive feedback during group activities & non ritualistic behavior

I used to wash door handles 10 times before opening, but for 2 weeks now I can open doors without washing them.

OCPD - Obsessive Compulsive Personality Disorder

Clients will have their whole day planned out NCLEX TIP MEMORY TRICK

Pharmacology

Antidepressants SSRI: Sertraline & Paroxetine SNRI: Duloxetine Anxiolytics Benzodiazepines Barbiturates Buspirone

OCPD

Punctual NCLEX TIP Perfectionism

I don’t want change!

In the morning when I feel anxiety building, I have been able to attend an exercise class to decompress.

Completing rituals of handwashing effectively helps me cope with my anxiety and ensures that I am clean.

5. Communication

I have to do this way.

This time try to spend only 4 minutes.

gradually decrease the compulsive behaviors

ATI Question … client with obsessive-compulsive personality disorder (OCPD)... information about the diagnosis.

Select all that apply.

Perfectionism and overemphasis on tasks This disorder typically involves inflexibility and a need to be in control

SERTRALINE

PAROXETINE

Personality Disorders Mental Health "Psychiatric Care"

HESI Which behaviors are demonstrated characteristically by a patient diagnosed with narcissism?

Grandiose, exploitive, and rage-filled behavior Exploitation of others

Narcissistic Personality Disorder Believes they are perfect Acts entitled, arrogant, & grandiose

ATI

Relies on constant reinforcement & need for admiration = attempt to maintain self-esteem NCLEX TIP

Narcissistic personality disorder: Which of the following manifestations should the nurse expect?

Lack of empathy Feelings of entitlement

HESI Which behavior indicates... that a client with paranoid ideas is improving?

Discusses his feelings of anxiety with the nurse

Paranoid Personality Disorder

ATI

Distrust & suspicion of others

A client with a paranoid personality disorder sees some clients laughing … asks the nurse, “Why are they laughing at me? I bet they are making fun of me.” Which of the following responses… is most appropriate?

Intense need to control the environment NCLEX TIP

“They are laughing at a joke another client told.

They are not laughing at you.”

HESI

Histrionic Personality Disorder

… a patient behaves in a melodramatic way and acts flirtatiously. What possible personality disorder does the patient have?

Histrionic personality disorder

4 NCLEX TIPS 1. Center of attention 2. Exaggerated or shallow emotional expression

ATI

3. Little tolerance for frustration & demands gratification

Histrionic personality disorder: Which of the following findings should the nurse expect?

Lack of insight

4. Overly friendly & flirtatious

Dependent Personality Disorder

ATI

Extreme dependency in a relationship & fear separation.

Dependent personality disorder: Which of the following actions should the nurse plan to take?

PROGRESS

2 NCLEX TIPS

Give positive feedback when the client is assertive with staff or clients

1. “My sister could not drive me here, so I took the bus.”

2. “I am planning which plants I wish to cultivate this spring”

HESI Q1: Priority nursing intervention... borderline personality disorder: Assess for suicidal and self-mutilating behaviors

Borderline Personality Disorder

Q2: Primary coping style of persons with borderline personality disorder?

“Last night the nurse let me go outside and smoke. I can’t believe you aren’t letting me. I used to think you were the best nurse here”

Fear of being abandoned & uses manipulative behavior 1. Cling to 1 favorite staff 2. Self-harm to draw attention = HIGH risk for suicide

ATI

Priority action: 2 NCLEX TIPS

Q1: Client with borderline personality disorder … makes numerous minor requests & spends a lot of time near the nurses station. How should the nurse interpret these behaviors?

Fear of abandonment and attention-seeking

1. Assign different staff members to the client each day 2. Assess immediately: any self-harm behavior “superficial cuts”

Q2: Client at greatest risk for suicide?

Personality disorder

Antisocial Personality Disorder

I'm not guilty!

Impulsive, manipulates others for personal gain & lacks empathy

Q2: Which statement best indicates improvement in the client’s condition?

“I get into trouble because I don’t think before I act.”

HESI ... antisocial personality may present with which characteristic?

Lack of remorse

KAPLAN Q1: The client shoves another client out of the way …Which action should the nurse take?

Calmly confront the behavior and remind the client of consequences for negative behavior

1 2 8 4 8

ATI … demonstrating manipulative behavior. Which of the following actions should the nurse take?

Institute consequences for manipulative behavior

Schizotypal Personality Disorder Withdrawn & alone “Special powers” & Magical thinking

HESI A patient is withdrawn and suspicious ... prefers to be alone… patient describes themself as having “special powers” and states, “I believe we can all read each other’s thoughts at times.” … which personality disorder?

Schizotypal (STPD)

Phobias

Mental Health "Psychiatric Care"

Pathophysiology

HESI Question

Phobias are excessive fear of an object or situation.

The inability to leave one’s home because of severe anxiety • Panic attacks with agoraphobia

Phobias disorder Arachnophobia: fear of spiders Zoophobia: fear of animals Claustrophobia: fear of being closed in

ATI Question Q1: “I am terrified of being outside alone.” The nurse should identify that the client is experiencing which of the following phobias?

• Agoraphobia

Agoraphobia: NCLEX TIP Fear of leaving a safe place “riding on trains or buses”

Q2: Phobias can be manifestations of PTSD

Therapeutic Communication You always want to assess first, & reinforce the facts, simply state what the client has just stated, for example:

You feel like your fear does not make sense, but it is very real to you

KAPLAN Question Q1: Phobic disorder: “I am so terrified of heights that the thought of going up my stairs makes me feel like I am going to hyperventilate. I know it sounds ridiculous.” Which response is best?

• “You feel like your fear does not make sense, but it is very real to you.”

Effective Coping This is demonstrated as clients increase their comfort levels little by little when exposed to their phobias.

This is done via systematic desensitization: meaning the clients gradually get exposed to their phobia little by little - to decrease the anxiety over all.

Systematic desensitization

KAPLAN Question “I travel only by train because I am terrified of flying.” … phobic client is most likely to respond to which intervention?

• Systematic desensitization

3 NCLEX TIPS 1. Increased comfort while exposed to the phobia 2. Verbalizing feelings & insight about anxiety (self observation) 3. Self distraction: focusing on something other than the phobia

PTSD & Acute Stress Disorder Mental Health "Psychiatric Care"

Pathophysiology

PTSD - Post Traumatic Stress Disorder

Acute stress disorder ASD is a mental disorder that can occur within the first month following a traumatic event - typically a near death experience like war, sexual assault, a car accident, physical abuse, & others, it becomes PTSD - Post Traumatic Stress Disorder if symptoms persist over 1 month.

1st month

Signs & Symptoms

NCLEX TIPS Increased anxiety • Sweating, pounding heart • Persistent anger • Hypervigilance & restless Flashbacks & Reliving the event Feeling detached from others Sleep disturbance: • Insomnia • Recurring nightmares AVOIDing reminders of trauma

Assessments

HESI Question

1. Self-harm: thoughts or plans 2. Substance abuse (drugs & alcohol) 3. Relationships with family & friends 4. Explain that difficult symptoms after the trauma are normal

You could not have anticipated rape & you did not deserve it

5. Rape Victim: Assess for guilt & shame NCLEX TIP • Reinforce the client could not have anticipated rape & did NOT deserve it

Interventions

1. Priority Action: NCLEX TIP Encourage the client to talk about the traumatic experience at their own pace 2. Exposure therapy 3. Group therapy 4. CBT: thought stopping techniques

Q1: … “The war was years ago, but I still remember my friends who were killed. I don’t know why I lived and they died.” What is the nurse’s priority response?

• Are you having any thoughts of harming yourself?

Q2: PTSD … first stage of the treatment?

• Stopping self-destructive behavior of the patient

HESI Question Q1: war veteran … says, “Sometimes I still hear explosions but I know I am safe in my home.” What is the nurse’s best response?

• You are experiencing flashbacks. I’d like to arrange for you to talk more about your feelings and reactions Q2: Which actions will the nurse include in the war veteran’s plan of care?

• With each session, explore each traumatic experience more deeply

Kaplan Question victim of bank robbery …. reports daily flashbacks … Which action is best?

• Offer assurance of safety, & tell the client these feelings are normal

Pharmacology

Antidepressants SSRI: Sertraline & Paroxetine TCA: Amitriptyline & Imipramine

Anxiolytics

• Benzodiazepines • Barbiturates • Buspirone

SERTRALINE

PAROXETINE

Schizophrenia Mental Health "Psychiatric Care"

Pathophysiology

Memory trick S - Schizophrenia

Abnormal scattered pattern of thinking for about 6 months or more.

It often starts to affect relationships as well as school & work flow as clients cannot concentrate.

S - Scattered pattern of thinking S - Suicide Risk HIGH

Causes & Risk Factors Children are more likely to have schizophrenia when parents have the condition. It is thought to be caused by a decrease in dopamine within the brain.

Genetics Signs & Symptoms

Positive Symptoms = Psychotic

?

Hallucinations Delusions Thought Disturbance

? ?

Negative Symptoms = Negative State Cognitive Symptoms = Capacity of Memory

Positive Symptoms

Hallucinations

Delusions Delusions of Reference: NCLEX TIP

Tactile Hallucination:

P

P

Positive Symptom

Psychotic Symptoms

“This song has a secret message just for me”

sensation of being touched

Delusions of Control:

Auditory Hallucination:

“I do not go online, that's how the FBI controls you”

hearing voices & sounds not there

Delusions of Grandeur: ”I have a very important meeting with the Queen today”

Best action: Provide earphones

Persecutory (paranoid) delusions:

& music NCLEX TIP

“The hospital food is trying to poison me”

HESI

HESI

Hearing voices that tell him or her to stay home: Positive symptoms of schizophrenia

Schizophrenia: positive symptom?

Delusions

Memory trick

This song has a secret message just for me

P - Positive Symptoms P - Psychotic Symptoms

Disorganized Speech & Thought 1. Loose associations “flight of ideas”: rapid shift of thought with no logical connection

NCLEX TIP “The universe is like a raisin, but the the moon is a home & I rode my bike” “Glass breaks if you throw stones .. My cousin shoots guns. I live in glass houses Saunders

2. Neologisms: made up imaginary words

3. Clang associations: listing rhyming words together that make no sense

5. Concrete thinking: taking a statement literally.

“Grass is greener on the other side” or “don't put all

“Lets go to the bay, hit the hay, what do you say, we can go today”

4. Word Salad: mixing words together that have no meaning except to the client “Here is the chair, moon, orange, drank too much”

“I have to get away. The vomers are coming to

7. Echolalia: repetition of words they hear from someone else NCLEX TIP

your eggs in one basket”

Nurse says “we will take your vitals”

Thinking there is actual grass & eggs.

Client repeats this phrase over & over

6. Tangentiality: speaking of unrelated topics that do not correlate to the main discussion.

8. Perseveration: repeating the same words / phrases when answering different questions

Nurse asks “how was your sleep?”

Nurse says “how do you feel today?”

Client says “When I was five, my cat was killed,

Client says “Absolutely splendid”

I love dogs”

Nurse says “do you know today's date?”

execute me.” HESI

Client says “Absolutely splendid”

@#% LCENA

MO

NO

?

Grass is greener on the other side

Don't put all your eggs in one basket

We will take your vitals

Vitals

We will take your vitals

Vitals

Schizophrenia II Mental Health "Psychiatric Care"

Negative Symptoms

Saunders negative symptoms associated with schizophrenia? Select all that apply.

Verbal communication is almost nonexistent

The 5 A’s A - Affect Flat

The client needs frequent redirection

(expressionless, blank look) Saunders

because of short attention span

A - Anhedonia

(inability to experience pleasure) client mood turned off like a light switch

ATI

I wanna be alone

aaa...

negative symptoms?

Anhedonia

bbb...

A - Apathy & Avolition

ooo...

Blunt affect

(lack of interest or motivation)

HESI

A - Alogia

NOT a positive symptom of schizophrenia?

(poor speech)

Affective flattening

A - Anxiety & Avoids social interaction NCLEX TIP

Cognitive Symptoms

Top Missed NCLEX Question Client with schizophrenia leaves the room as soon as the nurse enters & asks about the client’s day. Best action?

Let the client leave & sit quietly

C

C

Cognitive symptoms

Capacity to remember

?

Affects memory, learning, & understanding Memory trick

C - Cognitive symptoms C - Capacity to remember

ATI

NCLEX Key Points

… catatonia with catalepsy. Which of the following findings should the nurse expect?

Cataonic Schizophrenia

Muscle rigidity

+ 2 more features: Immobility Bizarre postures “muscle rigidity”

Prodromal withdrawn socially

Active

S

U FOC NOT

extreme symptoms

Mute (no speech)

HESI

Severe Negativism

“I understand that the voices are very real

NCLEX TIPS

Staring

Priority:

1. Focus on reality & reinforce it verbally

Fluid & nutritional intake NCLEX TIP

Paranoid schizophrenia Residual cognitive symptoms

“Persecutory Delusions”

2. Acknowledge client’s

Plan of care: NCLEX TIP 1. Focus on reality & reinforce it verbally 2. Acknowledge client’s feelings

feelings

to you, but I do not hear them.”

KAPLAN “That must be an unpleasant experience for you. Have you had these feelings before?”

Saunders Facilitate awareness that hallucination is not the reality of the world.

Therapeutic Communication

HESI

Assessment: (open-ended questions) What are the voices saying? What do you see? NCLEX Tell me what you are feeling at this moment HESI Describe what you are seeing now HESI How does it feel to think you are being watched? Kaplan What activities did you enjoy in the past? ATI

KAPLAN “Do you see those cameras in the ceiling? I am being watched all the time.” Which response by the nurse is most appropriate?

“Those are sprinklers in the ceiling that come on if there is a fire. How does it feel to think you are being watched?”

What do you see?

What are the voices saying?

State the Facts: I see you are frightened, let's go to your room & talk about this NCLEX It might be frightening to think that others want to hurt you Saunders I don’t hear any voices, but I know they are scary for you Kaplan I understand the voices are real to you, but I do not hear them HESI You see yourself as the savior I see you as my client HESI

… paranoid schizophrenia refuses food, stating the voices are saying the food is contaminated and deadly. A therapeutic response for the nurse would be: “I understand that the voices are very real to you, but I do not hear them.”

KAPLAN “There are really strange people in the corner of my room laughing at me and saying horrible things.”Which response by the nurse is best?

“I don’t hear any voices, but I know this is frightening for you.”

I don’t hear any voices, but I know this is frightening for you.

Schizophrenia III Mental Health "Psychiatric Care"

Interventions • Provide safe & structured environment and promote trust • Decrease environmental stimuli • Always MONITOR for suicide risk

Delusions & hallucinations Never label voices or argue Always present reality Pharmacology

Antipsychotics: Haloperidol (brand: Haldol)

HALOPERIDOL CLOZAPINE

Clozapine Risperidone

RISPERIDONE

Ziprasidone (brand: Geodon)

Ziprasidone hydrochloride Geodon

Life-threatening reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and dizziness.

Clozapine Adverse Reactions

NCLEX Question Clozapine: Priority to monitor?

PRIORITY

Complete blood count & absolute neutrophil count

ATI Q1: ... a client prescribed multiple antipsychotic medications... has rigid extremities, hypertension, hyperpyrexia, and diaphoresis.

Neuroleptic malignant syndrome NMS Q2: Antipsychotic meds further teaching is necessary?

“I should not be concerned about fever and muscle stiffness.”

Key terms

HIGH

LOW

NORMAL

Somatic System Disorders Mental Health "Psychiatric Care"

Pathophysiology SDD is a psychological disorder where clients have unexplained physical symptoms like abdominal pain, weakness, chest pain, shortness of breath, & others. The key point is that there is NO medical cause of the physical symptoms!

All diagnostic tests come back negative. These physical symptoms are real & clients are not making them up or faking it.

Unexplained physical symptoms

NO medical cause

?

IVE

NEGAT

Causes Clients will often obsessively focus their time & energy on the symptoms, often going to many different doctors & practitioners in order to get a medical diagnosis that does not exist. All the pain in the body is typically caused by stress.

FIRED

Interventions

Limiting focus on being sick Limit time discussing NCLEX TIP physical symptoms Promote insight Identify stressors that intensify symptoms Coping mechanisms (Stress reducing techniques) Deep-breathing Meditation Exercise

FIRED

Don’t let THE EXAMS TRICK YOU - DO NOT reinforce negative exam results when the client wants pain meds.

- NEVER debunk or dispute the clients symptoms saying they are not real!

- DO NOT advocate for more diagnostic tests or a new diet plan, since it is a psychological disorder.

Therapeutic Communication Mental Health "Psychiatric Care"

Open-ended questions

I don’t hear any voices, but I know this is frightening for you.

These are NOT simply “Yes” or “No” questions, rather it requires an in depth response.

HESI Open-ended questions?

Select all that apply.

“How do you cope with anxiety? ” “What event in your life has been the most stressful?”

Closed-ended comments

“Can you please tell me more about what was happening to you that led you to be hospitalized here?”

Stating facts used portray empathy, builds trust & assess further.

Top Missed NCLEX Question

Build TRUST 2 NCLEX TIPS

Elderly client losing their spouse to pancreatic cancer. Choose the most therapeutic response.

Select All That Apply

AVOID

1. Ask & Assess Emotions “Tell me when you started noticing ...”

1. Leave the room to allow the client to grieve in private.

“Non-Therapeutic” Communication

“Tell me what concerns you have ...”

“What are you feeling right now?”

“How are you feeling about your baby?”

2. State Facts “We have the vital signs under control” “You must be very upset after experiencing this” “I understand you are worried” “You sound very discouraged & scared.”

“You sound angry. Anger is a normal feeling associated with loss.”

NEVER: Offer opinions, advice, or personal experiences

2. “I recently lost my grandfather to cancer, so I understand what you are going through.”

3. “I know this is a difficult time for you. Tell me how you have been coping with this loss.”

NEVER: Minimize client’s feelings

4. “What are your feelings & thoughts about attending a support group.”

NEVER: Leave the room!

5. “It takes time to deal with & come to terms with a lost spouse, but it will be ok”

NEVER: Give false reassurance NCLEX TIP

6. “Why do you feel sad when you are alone?”

“Everything is going to be alright” “I’m sure you will do the correct thing” NEVER: Ask “WHY?” NCLEX TIP

Combo:

“This experience has been overwhelming for you. What are you feeling right now?”

“Client’s with cancer experience fear of dying, tell me about your concerns.”

Ask Questions Exploring emotions: gather more information Restating: repeating patient words to confirm what you understand Reflecting: return focus on client

Stating Facts Voicing doubt & presenting reality: refutes misconceptions or delusions Suggesting resources or strategies: helps offer guidance

Why do you feel sad when you are alone?

“WHY do you feel angry when…”

“WHY do you act this way?”

“WHY did you leave your child alone”

Practice Questions HESI Q1: What is the most helpful nursing response to a patient who reports thinking of dropping out of college because it is too stressful?

“School is stressful. What do you find most stressful?”

Q2: Which statements will the nurse indicate as therapeutic? Select all that apply.

“Am I correct in restating that you are feeling less anxious today?”

“In looking back at what you said, you stated you are feeling better.”

“Help me understand what you are feeling today?”

Q3: A man was killed during a robbery 10 days ago. His widow… cries spontaneously when talking to the nurse.

What is the nurse’s most therapeutic response?

ATI Q1: “I am really concerned about my mom.” Which of the following responses should the nurse make?

Select all that apply.

“Tell me what is troubling you.”

“Tell me about what you are feeling right now.

What is upsetting you?”

“It seems that you feel responsible for what happened to your mother.”

Q2: Client who has cancer is scheduled to receive chemotherapy ... she wants to try homeopathic treatments first. Which of the following responses should the nurse make?

“Tell me more about your concerns about taking chemotherapy.”

Q3: A parent who recently lost her child … states she cries frequently and can't bear the loss … therapeutic statements should the nurse make?

“You are feeling great pain at the loss of your child.”

“The sudden death of your husband is hard to accept.

Tell me about how you are feeling?”

KAPLAN Q1: Client with ... end stage heart failure, says “Why can’t this just end? I’m no good to anyone anymore.” Which response is best?

“This must be difficult. Please tell me about your feelings?”

Q2: The nurse finds the client crying … & says, “What do you want? Go away, you can’t help me. I hate you and I hate myself.” Which response by the nurse is best?

“You seem to be in pain; I’ll stay with you for a while.”

Q3: Client’s spouse has been unemployed for more than six months, and is afraid of not being able to pay the rent.

Which response is most appropriate?

“You’re worried that you won’t be able to pay the rent?”

SAUNDERS Q1: … “I can’t believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house.” … therapeutic nurse response?

“It must be hard to accept that she has passed away” Q2: ... “This condition is just another nail in my coffin.”

Which response by the nurse is therapeutic?

“You seem very distressed over learning you have asthma.”

Q3: A client diagnosed with terminal cancer says to the nurse, “I wish my family would stop hoping for a cure! I get so angry when they carry on like this.” Which response by the nurse is most therapeutic?

“You’re feeling angry that your family continues to hope for you to be cured?”