Mental Health PN ATI A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. What should the nurse do first? - ✅ Tell the nurse to stop discussing the behavior, sharing private information about the client in a pubic place is an invasion of privacy A nurse in a outpatient mental health clinic is preparing to assist with an initial client interview, what action should the nurse take as a priority? - ✅ Identify the client's perception of her mental health status. A nurse in an acute mental health facility is communicating with a client, The client states, "I can't sleep. I stay up all night." The nurse responds, You are having difficulty sleeping?" Which type of therapeutic communication technique is the nurse using? - ✅ Restating A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that this client needs a temporary emergency admission? - ✅ A client who has borderline personality disorder and assaulted a homeless man with a metal rod, this client is a danger to self and others A nurse is assisting in conducting a class on therapeutic communication to a group of newly licensed nurses. What aspect of communication should the nurse identify as a component of verbal communication? - ✅ Intonation, the tone of ones voice A nurse is assisting with a peer group discussion about the DSM-5. What information should the nurse include in the discussion? - ✅ - The DSM-5 establishes diagnostic criteria for individual mental health disorders. - The DSM-5 assists nurses in planning care for client's who have mental health disorders. - The DSM-5 indicates expected findings of mental health disorders A nurse is assisting with the plan of care for a client who has a mental disorder. What actions should the nurse recommend as a psychobiological intervention? - ✅ Monitor for adverse effects of medications A nurse is caring for a client who has anorexia nervosa. What is an example of the nurse demonstrating interpersonal communication? - ✅ The nurse asks the client about her body image perception. This is one on one communication with the client A nurse is caring for a client who is experiencing moderate anxiety. What actions should the nurse take when trying to reinforce necessary information with the client? - ✅ Discuss prior use of coping mechanisms with the client
demonstrate a calm manner while using simple and clear directions A nurse is caring for a client who is in mechanical restraints, What should the nurse include in the documentation? - ✅ - client was offered 8 oz of water every hour - client shouted obscenities at assistive personnel - Client received chlorpromazine 15 mg PO at 1000 A nurse is caring for a client who smokes and has lung cancer. The client reports, I'm coughing because i have a cold. The nurse should identify that the client is using which defense mechanism? - ✅ Denial A nurse is caring for the parents of a child who has demonstrated recent changes in mood and behavior. When a mother asks the nurse for reassurance about her son's condition, what should the nurses response be? - ✅ I understand your concerned. Let's discuss what concerns you specifically, this response reflects the mothers feelings and it allows her to clarify what she's feeling A nurse is communicating with a client who was just admitted for treatment of a substance use disorder. What communication technique should the nurse identify as a barrier to therapeutic communication? - ✅ Offering advise, advise tends to interfere with the client's ability to make personal decisions and choices A nurse is discussing mental health status examinations with a newly licensed nurse. What statements by the new nurse indicate an understanding of the teaching? - ✅ -To check cognitive ability, I should ask the client to count backwards by sevens. -To check affect, I should observe the client's facial expression -To check language ability I should instruct the client to write a sentence A nurse is providing preoperative teaching to a client who was just informed that she needs emergency surgery. The client has a respiratory rate of 30/min, and states, "this is difficult to comprehend, I feel shaky and nervous. Which level of anxiety is the client experiencing? - ✅ Moderate, vital signs can increase somewhat A nurse is told during shift change that a client is stuporous. When evaluating the client, what should the nurse find? - ✅ The client arouses briefly in response to sternal rub A nurse places a client in seclusion overnight because the unit is very short staffed and the client frequently fights with other clients. The nurse's actions are and example of which tort? - ✅ False imprisonment, for convenience of the staff. This is a big NO! acute anxiety - ✅ this level of anxiety is precipitated by an imminent loss or change that threatens one's sense of security Affect - ✅ an objective expression of mood, such as flat affect or lack of facial expression.
Alert - ✅ client is responsive and able to fully respond by opening her eyes and attending to a normal tone of voice and speech. She answers questions spontaneously and appropriately altruism - ✅ Dealing with anxiety by reaching out to others Autonomy - ✅ the client's right to make decisions, but the client must accept the consequences of those decisions. The client must also respect the decisions of others. Rather than giving advice to the client who has difficulty making decisions, a nurse helps the client explore all alternatives and arrive at a choice Beneficence - ✅ doing good , can be described as charity A nurse helps a newly admitted client who has a psychotic disorder to feel safe in the environment of the mental facility Characteristics essential to therapeutic communication - ✅ client- centered, not social or reciprocal purposeful, planned, and goal directed building rapport trust respect genuineness empathy chronic anxiety - ✅ This level of anxiety is one that usually develops over time, often starting in childhood. The adult who experiences chronic anxiety might display that anxiety in physical manifestations, such as fatigue and frequent headaches. clarity and brevity - ✅ the shortest, simplest communication is usually most effective closed-ended questions - ✅ helpful if used sparingly during the initial interaction to obtain specific data. The nurse should used this sparingly as it can block further communication Collaborative Care - ✅ assisting with the coordination of holistic care to include medical, mental health, and social services Comatose - ✅ the client is unconscious and does not respond to painful stimuli compensation - ✅ emphasizing personal strengths in one area to shift focus from failure in another area Confabulation - ✅ the act of filling in memory gaps
Conversion - ✅ Responding to stress through the unconscious development of physical manifestations not caused by a physical illness Counseling - ✅ - using therapeutic communication skills - assisting with problem solving - crisis intervention - stress management decerebrate rigidity - ✅ neck and elbow extension, with wrists and fingers flexed decorticate rigidity - ✅ flexion and internal rotation of upper extremity joints and legs Denial - ✅ pretending the truth is not reality to manage the anxiety of acknowledging what is real denotative/connotative meaning - ✅ when communicating, participants must share meanings. Words that have more than one meaning Displacement - ✅ shifting feelings related to an object, person, or situation to another less threatening object, person, or situation Dissociation - ✅ creating a temporary compartmentalization or lack of connection between the person's identity, memory, or how they perceive the environment Documentation related to violent or other unusual behavior - ✅ Client behavior- state in clear and objective manner, note exactly what was said and done Staff response- exactly what was done time the nurse notified the provider- and also any prescriptions received Examples of Torts - ✅ False imprisonment, assault and battery fidelety - ✅ loyalty and faithfulness to the client A client asks a nurse to be present when he talks to his mother for the first time in a year. The nurse remains with the client during this interaction Focusing - ✅ This technique helps the client to concentrate on what is important Giving information - ✅ This technique provides details that the client might need for decision making. Glasgow Coma Scale - ✅ This examination is used to obtain baseline data of a client's level of consciousness and for ongoing evaluation. Eye, verbal, and motor response is checked and a number value based on response is assigned. Highest possible value is
15, indicates awake and responsive, a score of 8 or less indicates that the client is in a coma Health education - ✅ reinforcing teaching about social and coping skills Health promotion and health maintenance - ✅ assisting the client with cessation of smoking, monitoring other health conditions How do you show a client you can be trusted? - ✅ Demonstrate reliability without doubt or question How is silence from the nurse effective in therapeutic communication? - ✅ It allows time for meaningful reflection how to show honesty to a client - ✅ be open, direct, truthful, and sincere identification - ✅ conscious or unconscious assumption of the characteristics of another individual or group immediate memory - ✅ the ability to hold something in mind for just a few seconds Intarpersonal communication - ✅ self talk, thinking thoughts and not outwardly verbalizing them Intellectualization - ✅ separation of emotions and logical facts when analyzing or coping with a situation or event interpersonl communication - ✅ communication occurs one-on-one with another individual intonation - ✅ The rise and fall of the voice in speaking., Tone can communicate feelings from the nurse such as judgement, or dislike Involuntary admission - ✅ Admission to a psychiatric facility without the patient's consent. 2 physicians are needed to certify that the client's condition requires commitment, varies by state limited to 60 days Justice - ✅ fairness and equal treatment for all lethargic - ✅ the client is able to open her eyes and respond but is drowsy and falls asleep readily.
Long-term involuntary admission - ✅ Used for extended care and treatment of those with mental illness. Commitments are obtained through medical certification, judicial hearings, or administrative action. 60 to 180 days, but sometimes there is no set release date Mentally healthy children and adolescence.... - ✅ trust others, view the world as safe, accurately interpret their environments. master development tasks, and use appropriate coping skills mild anxiety - ✅ Occurs in normal experience of everyday life, and promotes a sharp focus of reality milieu therapy - ✅ -orienting the client to the physical setting -identifying rules and boundaries of the setting -ensuring a safe environment for the client -assisting the client to participate in appropriate activities moderate anxiety - ✅ -occurs when mild anxiety escalates. -slightly reduced perception and processing of information occurs, and selective inattention can occur. -ability to think clearly is hampered, but learning and problem-solving can still occur. -other characteristics include concentration difficulties, tiredness, pacing, change in voice pitch, voice tremors, shakiness, and increased heart rate and respiratory rate. -the client can report somatic manifestations including headaches, backache, urinary urgency and frequency, and insomnia. -the client who has this type of anxiety usually benefits from the direction of others Mood - ✅ provides information about the emotion that a client is feeling. Nonmaleficence - ✅ duty to do no harm. example: A client refuses medication and the nurse must decide how to maintain client safety while not medicating the client normal anxiety - ✅ An appropriate response to an event being faced. nursing interventions for mild to moderate anxiety - ✅ use active listening provide a calm presence evaluate past coping mechanisms explore alternatives to problem situations encourage participation in activities, such as exercise that can temporarily relieve feelings of inner tension Nursing interventions for severe to panic level anxiety - ✅ provide an environment that meets the physical and safety needs of the client, remain with the client
provide a quiet environment with minimal stimulation use medications and restraints, only after less restrictive interventions have failed encourage gross motor activities, such as walking and other forms of exercise set limits by using firm, short, and simple statements direct the client to acknowledge reality and focus on what is in the present Nursing Liability - ✅ malpractice and negligence Offering general leads, broad opening statements - ✅ This encourages the client to determine where the communication can start and to continue talking. Offering self - ✅ demonstrates a willingness to spend time with patient open-ended questions - ✅ facilitates spontaneous responses and interactive discussion Pacing - ✅ the rate of speech can communicate a meaning to the receiver, speaking rapidly can communicate the impression that the nurse is in a rush and doesn't have time for the client Panic level of anxiety - ✅ characterized by markedly disturbed behavior; client is not able to process what is occurring in the environment and may lose touch with reality; extreme fright and horror; dysfunction in speech, inability to sleep, delusions, and hallucinations Presenting reality - ✅ helping the client to differentiate the real from the unreal projection - ✅ Attributing one's own unacceptable thoughts, feelings, or motives to another. promotion of self-care activities - ✅ Offering assistance with self-care tasks Allowing time for the client to complete self-care tasks Setting incentives to promote client self-care Psychobiological interventions - ✅ -administering prescribed medications, -providing teaching to the client/family about medications, -monitoring for adverse effects and effectiveness of pharmacological therapy public communication - ✅ transmission of a message from one person who speaks to a number of individuals who listen Rationalization - ✅ creating reasonable and acceptable explanations for unacceptable behavior
reaction formation - ✅ Overcompensating or demonstrating the opposite behavior of what is felt recent memory - ✅ -The ability to recall events of the past few days Regression - ✅ psychoanalytic defense mechanism in which an individual faced with anxiety retreats to a more infantile psychosexual stage, where some psychic energy remains fixated remote memory - ✅ very long-term recall, such as birth date, mother's maiden name Repression - ✅ unconsciously pushing unwanted memories out of awareness Seclusion and Restraint guidelines: - ✅ - Patient's can request seclusion if too much stimulation. (temporarily) - Restraint can be physical or chemical - Seclusion must never be used for convenience of staff, punishment of client, patients who are extremely physically or mentally unstable, cannot tolerate decreased stimulation. - must be prescribed by physician in writting and for the shortest time possible severe anxiety - ✅ Perception field greatly reduce, focuses on one detail or many scattered details, has difficulty noticing environmental details, learning & problem solving is not possible at this level, sense of impending doom or dead. Showing acceptance and recognition - ✅ this technique acknowledges the nurse's interest and nonjudgmental attitude small group communication - ✅ communication occurring within small groups of two or more people some barriers that happen within the communication process - ✅ asking irrelevant personal questions offering personal opinions giving advise giving false reassurance minimizing feelings asking why questions offering value judgements excessive questioning responding approvingly or disapprovingly Splitting - ✅ demonstrating an inability to reconcile negative and positive attributes of self or others
Stuporous - ✅ The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. She might not be able to respond verbally. Sublimation - ✅ dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression Summarizing - ✅ this technique emphasizes the important points and reviews what has been discussed Suppression - ✅ Consciously and intentionally pushing unpleasant feelings out of one's mind Temporary emergency admission - ✅ The client is admitted for emergent mental health care due to the inability to make decisions regarding care. The medical healthcare provider may initiate the admission which is then evaluated by a mental healthcare provider. The length of the temporary admission varies by the client's need and state laws but often is not to exceed 15 days. The client tells the nurse, "Dont tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, because he is threatening me." What should the nurse do? - ✅ Report the client's statement to the health care team, this is a serious safety isssue the client's right to privacy is protected by... - ✅ HIPPA of 2003 The nurse can only use restraints without first obtaining a written prescription if... - ✅ it is an emergency situation. The nurse must obtain the written prescription within a specified period of time, usually with in 15-30 mins Therapeutic communication - ✅ Verbal and nonverbal communication techniques that encourage patients to express their feelings and to achieve a positive relationship. Things to look for when using the HEADSSS psychosocial interview to evaluate risk factors in an adolescent. - ✅ Home environment, (what are the relationships like at home) education/employment, (how is their performance in school or work) activities, (does the client participate in sports or other activities?) drug and substance use, sexuality, suicide/depression, (is the client at risk for self harm?) savagery (is the client exposed to abuse in the home or violence in his neigborhood?)
timing/relevance - ✅ knowing when to communicate allows the receiver to be more attentive to the message Torts - ✅ wrongful acts for which an injured party has the right to sue touch - ✅ if appropriate, therapeutic touch communicates caring and can provide comfort to the client. Trasnpersonal communication - ✅ communication that addresses an individual's spiritual needs. In nursing, transpersonal communication is used when the nurse assists the client with meditation as a means of relaxation Types of nonverbal communication - ✅ appearance, posture, gait, facial expressions, eye contact, gestures, sounds, territoriality, personal space, silence Undoing - ✅ Performing an act to make up for prior behavior veracity - ✅ honesty when dealing with a client voluntary admission - ✅ client admits himself or herself to an institution for treatment and retains civil rights What are cognitive and behavioral therapies? - ✅ modeling operant conditioning systematic desensitization What are presupposition questions? - ✅ they explore the client's life goals or motivations by presenting a hypothetical situation in which the client no longer has the mental health disorder What are projective questions? - ✅ the use "what if" or similar questions to assist clients in exploring feelings and to gain greater understanding of problems and possible solutions What are some clarifying techniques? - ✅ restating reflecting paraphrasing exploring These techniques are used to make sure the nurse accurately received the message What are the levels of anxiety? - ✅ mild, moderate, severe, panic
What do nurses use the DSM-5 for? - ✅ identify diagnosis and diagnosis criteria to guide data collection, to identify nursing diagnoses, and to assist in the planning, implementation, and evaluation of care. What does MMSE stand for? - ✅ mini mental status exam What is the DSM-5 used for? - ✅ diagnostic tool used to identify mental health diagnosis What is the DSM-5? - ✅ Diagnostic and Statistical Manual of Mental Disorders, 5th edition What rights do clients who are receiving acute care for a mental disorder have? - ✅ The right to humane treatment and care the right to vote the rights related to granting, forfeiture, or denial of drivers licence the right to due process of law, including the right to press legal charges against another person the right to informed consent and refusal of treatment confidentiality a written plan of care that includes discharge follow ups, as well as participation in the care plan and review of care plan communication with people outside the facility