2900 Exam Four Flashcards
what are four main purposes in doing a behavioral health assessment?
to develop goals for treatment
to identify risk factors
to develop a nursing plan of care
to establish rapport with a patient
what are some key elements of a mental health nursing assessment?
physical assessment
psychosocial history
mental status examination
use of standardized screening tools
what is included in a mental status examination?
assessment of: level of consciousness physical appearance behavior cognitive and intellectual abilities
what are some standardized screening tools used in mental health assessment?
MMSE (mini mental state examination)
pain assessment
hamilton anxiety rating scale
what is the difference between sympathy and empathy?
empathy is understanding and awareness of the feelings of others, and trying to envision what it’s like in their position.
sympathy is actually feeling what the other person feels
is sympathy or empathy more therapeutic in nursing communication?
empathy
what is considered the basis of all psychiatric mental health nursing treatment?
the nurse-patient relationship
what are some barriers to effective communication?
irrelevant questions offering personal opinions giving advice or false reassurance minimizing feelings changing the topic asking why giving approval or disapproval
what is mileu therapy?
creating an environment that is supportive, therapeutic, and safe
what is the goal of mileu therapy?
the client learning to cope adaptively, interact effectively/appropriately, and strengthen relationship skills
what is the purpose of the therapeutic nurse-patient relationship?
identifying the clients needs or problems and then focus on meeting those needs or solving those issues
what is transferrence?
when the client views the nurse or a member of the healthcare team as having characteristics of someone else significant in their life
what is countertransferrence?
when a healthcare team member displaces characteristics of someone from their past onto their client
what are the three phases of the therapeutic relationship?
orientation
working phase
terminiation
what happens in the orientation phase of the therapeutic relationship?
introductions are made
goals for treatment, including termination time, are talked about and agreed upon
trust is built and boundaries are established
begin exploring the clients thoughts and ideas
what happens in the working phase of the therapeutic relationship?
relationship is maintained according to the contract
ongoing assessment
facilitate client expressing needs and issues
promote client self esteem and behavioral change explore and deal with resistance and defense mechanisms
support adaptive coping and try out new behaviors
what happens in the termination phase of the therapeutic relationship?
let client discuss thoughts and feelings about termination and loss, including previous experiences with it
discuss clients feeling about work accomplished in therapeutic relationship
summarize goals and achievements
express feelings (nurse) to validate clients experiences
help client figure out how to integrate what they learned into their life
maintain agreed limits of relationship termination
what is schizophrenia?
psychotic thinking/behavior are present for at least six months and hinder functioning, work, self care, and/or relationships
what is schizophreniform disorder?
client has manifestations of schizophrenia but they only last for 1-6 months
what is schizoaffective disorder?
disorder meets the criteria for both schizophrenia and depressive or bipolar disorder
what are some comorbid conditions often seen with schizophrenia?
depression
anxiety
bipolar
substance abuse
what are positive symptoms in schizophrenia? give examples
manifestations of things that are not normally present, such as: hallucinations delusions alterations in speech bizarre behaviors
what are negative symptoms in schizophrenia? give examples
absence of things that are normally present, such as: flat affect anhedonia anergia avolition (lack of motivation) alogia
what are cognitive findings in schizophrenia?
problems with thinking, like disordered thinking, inability to make decisions, poor problem solving, and memory deficits
what are affective findings in schizophrenia?
manifestations involving emotions, like hopelessness, suicidal ideation, unstable or rapidly changing mood
associative looseness
unconscious inability to concentrate on a single thought
clang association
meaningless rhyming of words
word salad
words jumbled together with little meaning or significance
neologisms
made up words that only have meaning to the client
echolalia
client repeating words spoken to them
religiosity (in schizophrenia)
obsession with religious beliefs
magical thinking
belief that actions or thoughts are able to control a situation or affect others
flight of ideas
switching between many unrelated topics in a very short period of time
depersonalization (in schizophrenia)
nonspecific feeling that the client has lost their identity, feeling that self is different or unreal
derealization
perception that the environment has changed
what are sensory perceptions that do not have any apparent external stimulus?
hallucinations
what are command hallucinations?
auditory hallucinations that command the person to perform an action (usually to hurt self or others)
what are some examples of first generation antipsychotics for treating schizophrenia?
chlorpromazine and haloperidol
what are some side effects of first generation antipsychotics?
anticholinergic effects extrapyramidal symptoms neuroleptic malignant syndrome orthostatic hypotension sedation seizures dysrhythmias sexual dysfunction weight gain liver impairment
what is neuroleptic malignant syndrome?
a life threatening emergency that can happen with antipsychotic medications
will manifest as sudden high fever, blood pressure fluctuations, diaphoresis, tachycardia, muscle rigidity, decreased LOC, and coma
what symptoms fall in the category of extrapyramidal symptoms?
acute dystonia
akathisia
tardive dyskinesia
pseudoparkinsonism
acute distonia
severe spasm of the tongue, neck, face, and back, this is a crisis that requires immediate intervention
what is the treatment for acute distonia?
antiparkinsonian agent like benztropine or anticholinergic med like diphenhydramine
akathisia
inability to sit or stand still, continual pacing or movement
what is the treatment for akathisia?
benzodiazapines like alprazolam or antiparkinsonian meds
what is pseudoparkinsonism?
parkinson’s disease-like manifestations, such as bradykinesia, rigidity, shuffling gait, drooling, and tremors
what is the treatment for pseudoparkinsonism?
antiparkinsonian agent like benztropine
tardive dyskinesia
late EPS that develop after months or years of medication therapy. will manifest as involuntary movement of the tongue and face, as well as of the arms, legs, and trunk
what is the treatment for tardive dyskinesia?
there is not one, and symptoms rarely decrease even when medication is discontinued
what are some examples of second generation antipsychotics?
risperidone
clozapine
lurasidone
what is an example of a third generation antipsychotic?
aripiprazole
what is the most commonly used assessment scale for alcoholism and withdrawal?
CIWA scale
in general, how does the CIWA scale work?
nurse rates the patient with a number from 0-7 in eight categories (N/V, tremors, anxiety, agitation, sweating, orientation, tactile/visual/auditory disturbances, headache)
what is the standard treatment for alcohol withdrawal in the acute setting?
benzodiazapines (often on a sliding scale based on CIWA score)
after giving benzos for alcohol withdrawal, what should the nurse do?
reassess in 30 minutes using CIWA, and give more benzos if needed. do this 3 times, and if patient is still not better, they may need to go to ICU and get benzo drip
what is chlamydia?
common bacterial STD that affects men and women equally
what are complications of chlamydia (usually affects women)?
infertility or fatal ectopic pregnancy
how can chlamydia spread?
any form of sex or from mother to baby during childbirth
can you get chlamydia more than once?
yes
what symptoms will women with chlamydia notice?
often none, but possibly vaginal discharge or burning sensation while urinating
what symptoms will men with chlamydia notice?
often none, but possible discharge from penis, burning sensation while urinating, or pain/swelling in one or both testicles
how is a chlamydia diagnosis confirmed?
urine sample or by cotton swabbing affected area
what are treatment options for chlamydia?
single dose of azithromycin or seven day course of doxycycline
what education should be given to a patient diagnosed with chlamydia?
finish entire course of antibiotic treatment
don’t have sex again until patient and partner have completed treatment
how is a crisis defined?
an event that is acute and time limiting, and one in which people don’t have the coping skills to handle whatever happened
how is mental health nursing different from other forms of nursing?
medical nursing is more focused on giving specific directions and education, while mental health nursing is a lot more listening/questioning/letting patients arrive at their own conclusions about the situation, as well as helping patients develop new ways of coping
what is the nurses first priority during a crisis?
safety
what are other nursing goals during a crisis or in a mental health setting?
setting realistic goals with the patient
listening and decreasing patient anxiety
assessing patient potential for self-harm
what is a Critical Incident Stress Debriefing?
a group approach used to help people involved in a serious crisis or incident. It gives them a way to talk through and process what happened
what are signs and symptoms of escalating behavior?
agitation
increased volume and gesturing
poor eye contact
what are risk factors for suicide?
being male (for a successful attempt) family history chronic illness older adults psychosocial issues trauma history lack of support system unemployment native american and alaskan native
what does the SAD PERSONS scale assess for and what specifically does it look at?
risk for suicide attempt, each category is worth one point
Sex (male) Age (between 25 and 44 or above 65) Depression Previous attempt Ethanol abuse Rational thinking loss Social support lacking Organized plan No spouse Sickness (chronic)
what should nurse ask about in regards to suicide?
if they have a plan
details of the plan
if they have access to what they need to carry out plan
what is “suicide mood lift”?
when patient suddenly gets more cheerful because they’ve decided to follow through with their plan
what is included in suicide precautions?
one to one supervision searching belongings before admission plastic utensils hands always being visible no private rooms ensuring meds are being taken and not hoarded daily environment checks restrictions on certain visitors
how often must the nurse document typically in a one to one setting?
every 15 minutes
what are pharmacological interventions for depression/suicidal ideation?
antidepressants
benzodiazapines
mood stabilizers
what is a “no suicide contract”?
a pact the patient makes to not harm self, often done before patient leaves hospital for a weekend pass. is not legally binding but can be effective
