ATI #3 Flashcards
Asses the client’s memory
Immediate
Ask the client repeat series of number or list of object
Asses the client’s memory
Recent
Ask to recall recent events or the purpose of the current mental health appointment or admission
Asses the client’s memory
Remote
Ask to state a fact from their past that is verifiable (their birthday etc)
Asses client’s ability think abstractly
Cliche
A bird in the hand is worth two in the bush?
A nurse is planning care for a client who has a mental health order.
Which action should the nurse include psychobiological intervention?
a) Assist the pt systemic desensitization therapy.
b) Teach the pt appropriate coping mechanisms.
c) Assess the pt for comorbid health conditions.
d) Monitor the pt for ARDs of medications
psychobiological =Behavioral neuroscience
d
a) cognitive
b) counseling or health teaching
c) health promotion
Level of consciousness
Lethargic
Able to open their eyes and respond. but is drowsy and falls asleep readily.
Level of consciousness
Stuporous
Requires vigorous or painful stimuli to elicit a brief response
What is informal admission?
Least restrictive
doesn’t pose a threat to self or others
Pt free to leave the hospital at any time
What voluntary admission?
The client or the client’s guardian chooses admission
What temporary emergency admission?
due to the inability to make decisions regarding care.
not more than 15 days
What is involuntary admission?
against their will
Risk of harm to self or others
Limited to 60 days
Restraint
a) The provider must prescribe the
restraint order in ??
Time limits for restraints
b) Age 18 and older?
c) Age 9 to 17 hears
d) Age 8 to younger
a) writing
b) 4hr
c) 2hr
d) 1hr
Confining a client to a specific area physically, verbally, or using a chemical restraint when it is not part of the treatment is called?
False imprisonment
Making a threat to a client’s person
Assault
Touching a client in a harmful or offensive way called?
Battery
A type of professional negligence called?
Malpractice
A nurse is caring for a client who is in mechanical restraints.
Which of the following should nurses to includes documentation?
a) Ate most of breakfast
b) Offered 8 oz of water every hr
c) Shouted obscenities at assistive personnel
d) received chlorpromazine 15mg PO at 1000
e) Acted out after lunch
B,C, D
Documentation= objective data
e) behavior is medical record
acted out= 怒りを身ぶりで表わす
Trauma
Acute stress disorder
Exposer to traumatic events causes anxiety
at least 3 days but not more than 1 month
Trauma
Posttraumatic stress disorder (PTSD)
Event for longer than 1 month
Can be last for years
Trauma
Adjustment disorder
A stressor triggers a reaction
Change in mood and or dysfunction in performing usual activities
Less severe than with ASD or PTSD
No celling effect= effect never ends till die
A nurse is communication with a pt who was adminitted for treatment of a substance use disorder;
Which one is the nurse should identify as a barrier t therapeutic communication?
a) Offering advice
b) Reflecting
c) Listening attentively
d) Giving information
a
Advice tends to interfere with the pt ability to make personal decisions and choices.
c) active listening
attentively 注意深く
Defense mechanisms
A) A nurse who lost a family member in a fire is a volunteer firefighter.
M)N/A
Altruism
Dealing with anxiety by reaching out to others
giving your lunch away is altruistic because it helps someone who is hungry,
Defense mechanisms
A) A person who has feelings of anger and hostility toward their work supervisor sublimates those feeling by working out vigorously at the gym during their lunch period
M) N/A
Sublimation
Dealing with unacceptable feeling or impulses by unconsciously substituting acceptable forms of expression
Defense mechanisms
A) A student outs off thinking about fight they had with a friend so they can focus on a test.
M) A person who jabs lost their job states they will worry about paying bills next week
Suppression
Voluntarily denying unpleasant thought and feelings
Defense mechanisms
A) A person preparing to give speech unconsciously forgets about the time when they were young and kids laughed at them while on stage.
M) A person who has a fear of the dentist continually forget to go to their dental appointments.
Repression 抑圧
unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness
Defense mechanisms
A) A young child temporarily wets the bed when they learn that their pet died.
M) A person who has disagreement with a co-worker begins throwing things at their office.
Regression 前の悪い状態に戻る
Sudden use of childlike or primitive behaviors that do not correlate with the person’s current developmental level
Defense mechanisms
A) An adolescent angrily punches a punching bag after losing a game.
M) A person who is angry about losing their job destroys their child’s favorite toy
Displacement
Shifting feeling related to an object, person, or situation to another less threatening object, person, situation
Defense mechanisms
A) A person who is trying to quit smoking repeatedly talks to adolescents about the danger of nicotine.
M) A person who resents having to care for an aging parent becomes overprotective and restricts their freedom.
Reaction formation
Unacceptable feelings or behaviors are controlled or kept out of awareness by overcompensating or demonstrating.
Defense mechanisms
A) An adolescent completes their chores without being promoted after having an argument with their parents.
M) An individual buys their significant other flowers and gifts after incident of partner abuse.
Undoing
Performing an act to make up for prior behavior(most commonly in child)
Defense mechanisms
A) An adolescent says “They must already have a boyfriends” when rejected by another adolescent.
M) A young adult explains they had to drive home from a party after drinking alcohol because they had feed the dog.
Rationalization 合理化
Creatine reasonable and acceptable explanation for unacceptable behavior
Defense mechanisms
A) A parent blocks out the distracting noise of their children in order to focus while driving in traffic.
M) A person forgets who they are following a sexual assault.
Dissociation
Disconnection and lack of continuity between thoughts, memories, surroundings, actions, and identity.
Defense mechanisms
A) A person initially says “ NO, that cannot ne true” when told they have cancer.
M) A parent who is informed that their child was killed in combat tells everyone months later that the child is coming home for the holiday.
Daniel
Pretending the truth is not reality to manage unpleasant, anxiety-causing thoughts or feelings
Defense mechanisms
A) An adolescents who is physically unable to play contact sports excels in academic competitions.優れる
M) A person who is shy learners computer skills to avoid socialization.
Compensation 代償
Emphasizing strengths to make up for weaknesses
Defense mechanisms
A) A child who had a chronic illness pretends to be a nurse for their dolls
m) A child who observes their parent be abusive toward the other parent becomes a bully at school.
Identification
Conscious or unconscious assumption of the characteristics of another individual or group
Defense mechanisms
A) A law enforcement officer blocks out the emotion aspect of a crime so they can objectively focus on the investigation.
M) A person who learns they have a terminal illness focuses on creating a will and financial matters rather than acknowledging their grief.
Intellectualization 知的化
Separation of emotion and logical facts when analyzing or coping with a situation or event
reasoning is used to block emotional stress
Defense mechanisms
A) N/A
M) A person experiences deafness after their partner tells them that they want to a divorce
難聴
Conversion 変換
Resending to stress through the unconscious development of physical manifestations not cause by physical illness
Defense mechanisms
A) N/A
M) A client tells a nurse that the nurse is the only one who cares about them, yet the following day, the clients refuses to talk to that nurse.
Splitting
Demonstrating an inability to reconcile negative and positive attributes of self or others into a cohesive image
A nurse planning care for a client who has bipolar, maniac episode.
Which following interventions should the nurse include?
a) Provide flexible client behavior expectations.
b) offer concise explanations.
c) Establish consistent limits.
d) Disregard client concerns
E) use a firm approach with communication
b,c,e
A nurse caring for a client who has bipolar. Which one is the priority nursing action?
a) Set consistent limits for expected client behavior.
b) Administer prescribed meds as schedule
c) Provide the client with step-by-step instructions hygiene
d) Monitor the clients for escalating behavior
d
This is client’s priority need for safety
A nurse is discussing relapse prevention with bipolar patient.
Which following will you teach?
a) use caffeine in moderation to prevent relapse.
b) Difficulty sleeping can indicate a relapse.
c) Being taking your medications as soon as relapse begins
d) Participating in psychotherapy can help prevent a relapse
e) Anhedonia is a clinical manifestation of depressive relapse.
b,d,e
Anhedonia
-inability to feel pleasure
Acute schizophrenia, what to plan?
Non-competitive physical activities Walking is good.
Avoid stimulation, competition, and dangerous objects.
Oppositional defiant disorder?
Pt will ignore or frequently break rules.
Pts disregard those in position of authority.
They have negative emptions such as anger or irritability.
They enjoy obtaining rewards which can help motivate positive behavior, but they don’t care about penalties or punishment after negative behaviors.
Oppositional defiant disorder, effective approach?
Use POSITIVE REINFORCEMENT for oppositional defiant disorder.
Bulimia nervosa
can cause calluses on the knuckles (Russell’s sign), hair loss, ecchymosis, and petechiae
Binge eating
Usually obese and can have HTN and diabetes
Opioid wothderaw symptoms
Oppositional defiant disorder, effective approach
Use POSITIVE REINFORCEMENT for oppositional defiant disorder.
Opioids withdraw symptoms
Rhinorrhea(runny nose)
Flu like symptoms
What is important for pt who alcohol use disorder?
Take charge of personal responsibility
“I am not taking charge of my partner’s work responsibility”
Pt has bipolar and experiencing mania. What nurse should include in plan?
Offer the pt high-calorie finger food frequently
Because they cannot sit down to eat or drink
Pt has bipolar and experiencing mania. What we should NOT do?
environment
encourage the pt to participate in group therapy
should maintain a low-stimuli, dim the lights, decrease noise limit the number of people around the pt
Pt has bipolar and experiencing mania. What we should NOT do?
daily life
Instruct the pt to avoind napping dring the day
The nurse should encourage them to take frequent rest. They are at risk of exhausting that can be life threatening
onset
delirium?
dementia?
acute
slow
PTSD
What is findings?
Experiences feelings of isolation
the nurse should expect pt who has PTSD to feel estranged and detached from others
Tourette’s syndrome
A condition of the nervous system. TS causes people to have “tics”
Fear of abandonment
separation anxiety disorder
Delirium patient nurse should permit is?
Perform daily rituals to decrease anxiety
Conduct disorder
An ongoing pattern of aggression toward others
Serious violations of rules and social norms at home, in school, and with peers.
Bipolar meal?
Chicken nuggets, crackers with cheeses stick and cookie
High calories and finger food
Dementia findings
Impairment judgment
