Ch 1-6 Flashcards
Stupor
Client responds to painful or vigorous stimuli to elicit a brief response may or may not be able to respond verbally
Coma
No response from repeated painful stimuli
What are the abnormal posturing in a client who is comatose
Decorticate rigidity- flexion and internal rotation of UPPER EXTREMITY JOINTS AND LEGS
Decerbrate rigidity- neck and elbow extension, wrist and finger flexion
What is the mini mental state examination
Is used to objectively assess a clients cognitive status by evaluating the following:
Orientation to time and place
Attention span and ability to count backward by 7
Registration and recalling of objects
Language, including naming of objects, following of commands, and ability to write
Glasgow coma scale
Examination used to obtain baseline assessment of a clients level of consciousness and for ongoing assessment. Eye, verbal and motor response is evaluated and a number value is assigned based on that response. The highest possible score is 15 a score of 7 indicates the client is in a coma.
If a client is stuporous, what does this mean
The client arouses briefly in response to a sternal rub
In caring for a client with a mental health disorder, what is appropriate to include as a psychobiological intervention
Monitor client for adverse effects of medications.
What is a tort
A wrongful act or injury committed by an entity or person against another person or another persons property.
Beneficence
Relates to the quality of doing good
Autonomy
Refers to the clients right to make her own decisions. The client must also accept the consequences of those decisions
Justice
Fair and equal treatment for all
Fidelity
Loyalty and faithfulness to the client and to ones duty
Veracity
Being honest
What must be present for a nurse to apply restraints on her own
An emergency situation. If this treatment is initiated, the nurse must obtain a written order within 15-30 min
What are the 4 primary levels of basic communication
Intra personal
Interpersonal
Public communication
Transpersonal communication
Intra personal
Communication that occurs within an individual also identified as self talk
Interpersonal
Communication that occurs between 2or more ppl in a small group
Public communication
Communication that occurs within large groups of people
Transpersonal communication
Communication that addresses a persons spiritual needs and provides interventions to meet those needs
Clarity/ brevity
The shortest,simplest communication is usually most effective
What defense mechanisms are healthy
Altruism and sublimation
Altruism
Dealing with anxiety by reaching out to others
Sublimation
Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression
Give a example of sublimation
A person angry at his boss, works out vigorously during his lunch hour
Give a example of Displacement
A person who is angry he lost his job smashes his sons toy
Dissociation
Temporarily blocking memories from consciousness
Splitting
Inability to reconcile negative and positive attributed to self and others
Give and example of splitting
A client likes a nurse one day and refuses to speak to her the next
Projection
Blaming others for unacceptable thoughts and feelings
Example of projection
A kid blames his substance use disorder in his parents
Mild anxiety
Normal experience of everyday living
Moderate anxiety
Slightly reduced perception and processing of information, selective inattention may occur
Ability to think clearly is hampered, learning and problem solving may still occur.
Client may report somatic complaints .
This type of anxiety usually benefits from direction of others
Severe anxiety
Perceptual field is greatly reduced with distorted perceptions
Learning and problem solving do not occur
Functioning is in effective
Confusion, feeling of impending doom, hyperventilation,tachycardia, withdrawal, Loud and rapid speech.
Panic level anxiety
Dysfunction in speech. Dilated pupils, immobility can occur, not able to process reality, inability to sleep, hallucinations
Nursing intervention for the client with mild to moderate anxiety
Use actively listening to demonstrate willingness to help.
Provide a calm presence, evaluate past coping mechanisms, explore alternatives to situation, encourage participation in activities
Nursing interventions for the client with severe to panic levels of 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 restraint, but only after less restrictive interventions have failed. Encourage walking and exercise, set limits by using short, firm, simple statements.
Direct the client to acknowledge reality and focus on what is present in the environment.
Transference
Views someone on the healthcare team, as having the characteristics of someone they know.
Give an example of transference
A client sees a nurse as being just like his mother
Give an example of counter transference
A nurse may feel a certain way towards a client because they remind her of someone from her past.
Primary prevention
Promotes health and prevents mental health problems from occurring
Ex. A nurse leads a group promoting healthy development
Secondary prevention
Focuses on early detection of mental illness
Ex. A nurse screens parents of children who have developmental disorders
Tertiary prevention
Focuses on rehabilitation and prevention of further problems in clients previously diagnosed.
Ex. A nurse leads a support group for ppl who have completed a substance use disorder program.
Partial hospitalization programs
These programs provide intense short term treatment for clients who are well enough to go home every night and have a responsible person at home.
Assertive community treatment ACT
Includes non traditional case management and treatment by an interprofessional team for client who have severe mental illness and are non compliant with traditional treatment
Community mental health centers
Provide a variety of services for wide range of community Client s including educational groups, medication dispensing programs, individual counseling services.
Phychosocial rehabilitation programs
Includes a structured range of programs for clients in the mental health setting including residential services, day programs for older adults.
Lethargy
The client is able to open her eyes and respond but is drowsy and falls asleep readily
To assess remote memory what should u have the client do
Repeat a list of objects
What is a psychobiological intervention
Monitor for adverse effects of medications
If a client is stuporous, how will they appear
They will arouse briefly in response to a sternal rub
Reaction formation
Over compensating or demonstrating the opposite behavior of what is felt.
Give an example of reaction formation
A person who dislikes her sisters daughter offers to baby sit
Undoing
Performing a act to make up for a prior behavior
What is an example of undoing
A child completed his chores without being prompted to do so after being in trouble
Primary prevention
Promotes health and prevents mental health problems from occurring
Secondary prevention
Focuses on early detection of mental illness
Tertiary prevention
Focuses on rehabilitation and prevention of further problems in clients previously diagnosed.
Partial hospitalization programs
Provides intense short term tx for clients who r well enough to go home every nite, have a responsible person at home and is safe from harm to self or others
Assertive community treatment ( ACT)
For clients who have severe mental illness and are noncompliant with traditional treatment
Where is crisis intervention offered
In an assertive community treatment program (ACT)
Where are detox programs offered
In partial hospitalization programs
