Chapters 21, 23, 30,31 Flashcards
A major long term mental illness marked by significant functional impairments.
serious mental illness (SMI)
Serious mental illness (SMI) effects multiple areas such as:
ADL’s, poverty, social interaction, employment, relationships, and ability to maintain home
Have a severe mental illness and a substance abuse problem
Dual Diagnosis
Legislation that resulted in the mass movement of severely mentally ill persons from state hospitals to outpatient care.
deinstitutionalization
What two groups can SMIs be seperated into
- ) Those old enough to have experienced long-term institutionalization
- ) those young enough to have been hospitalized only for acute care during exacerbations of their disorder
Focuses on managing patients deficits and helping them learn to live with their illnesses, dominated psychiatric care.
Rehabilitation
Focuses on achieving goals of patients’ choosing, and leading a increasingly productive and meaningful life.
Recovery
What is the recovery model supported by? It is the leading mental health consumer advocacy organization. Helps people become more aware of disease and also helps educates families on disease.
National Alliance on Mental Illness (NAMI)
Issue Confronting those with SMI?
It is difficult for the person to establish goals and find meaning in life
People with SMIs commonly have what comorbid conditions?
Substance abuse (60%) Physical disorders (HTN, CVD, DM, Obesity) Depression/Suicide
View of a certain group of persons, assigning them with negative traits.
Stigma
Common stigma with people with SMIs is?
All persons with mental health issues are violent (usually the opposite MH person is victim)
Most common coping mechanism with SMIs is….
Denial
The inability to recognize one’s deficits due to one’s illness.
Anosognosia
Those that do not improve completely or consistently with treatment.
Residual symptoms
Residual symptoms will eventually lead to….
hopelessness and helplessness, pt may discontinue treatment in response, worsening the illness
Coordinate services and help with accessing them. Goal is to make sure the patients needs are met.
Case management
Multidisciplinary team provides comprehensive services to the patient in their own home environments.
Assertive Community Treatment (ACT)
Focus on helping patient gain ability to cope during overwhelming stressful situations
Crisis Intervention Services
Includes couseling and therapy based on a variety of models, usually provided by independently licensed mental health professional.
Group and individual psychotherapy
Include supervised or unsupervised group homes, “board and care” homes.
Housing services
Goals of SMI patients
stabilization and independence
The appointment of a person to make decisions for the consumer during times when judgement is impaired
Guardianship
Focused on homeless persons to help them get needed services (hot meals, clothing, transportation)
Community outreach programs
Includes medical and psychosocial assessment, detox, medication such as methadone (synthetic narcotic) if applicable. Family tx.
Substance abuse treatment
Principle that compromised neurological functions can be assumed by healthier areas of the brain
cognitive enhancement therapy
What is one of the strongest predictors of recovery
Family support and partnership
Focuses on teaching a wide variety of social and ADL skills. work on this in group home.
Social skills training
Instead of focusing on change, it stresses coping and anxiety reduction at their present stage of illness.
Supportive psychotherapy
Can include vocational training, financial support for attaining employment, or supported-employment services.
vocation rehab and related services
Consumers run their own business, such as a coffee shop or housekeeping service, they teach all members to perform a job in order to run the business.
clubhouse model
Mandated by the court when the patient leaves the hospital or prison for persons unlikely to continue treatment and then become a danger to self or society
Mandatory outpatient treatment
Shifting a person from one kind of institution to another (state hospital to jails, prisons, nursing homes or shelters)
Trans-institutionalization
The focus of the clubhouse model of treatment is….
providing socialization and building independence
One of the roles of a case manager working with severely and persistently mentally ill clients who are homeless is to
coordinate needed services and provide outreach.
The mother of a client with severe, persistent schizophrenia tells the nurse, “My son has slipped so far away from me over the past few years. We really don’t have a relationship anymore. I miss him.” The nursing diagnosis that best describes the mother’s feelings is
Grieving
After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This patient now requires persistent direction to accomplish activities of daily living and expects others to provide meals and do laundry. The nurse assesses this behavior as the probable result of……..
dependency caused by institutionalization
An adult diagnosed with a serious mental illness says, “I do not need help with money management. I have excellent ideas about investments.” This patient usually does not have money to buy groceries by the middle of the month. The nurse assesses the patient as demonstrating:
anosognosia
Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with serious mental illness?
Assertive Community Therapy
A family discusses the impact of a seriously mental ill member. Insurance partially covered treatment expenses, but the family spent much of their savings for care. The patient’s sibling says, “My parents have no time for me.” The parents are concerned that when they are older, there will be no one to care for the patient. Which response by the nurse would be most helpful?
a. Acknowledge their concerns and consult with the treatment team about ways to bring the patient’s symptoms under better control.
b. Give them names of financial advisors that could help them save or borrow sufficient funds to leave a trust fund to care for their loved one.
c. Refer them to crisis intervention services to learn ways to manage caregiver stress and provide titles of some helpful books for families.
d. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the patient become more independent.
D. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the patient become more independent.
The sibling of a patient who was diagnosed with a serious mental illness asks why a case manager has been assigned. The nurse’s reply should cite the major advantage of the use of case management as:
Case managers coordinate services and help with accessing them, making sure the patient’s needs are met
Which nursing diagnosis is likely to apply to an individual diagnosed with a serious mental illness who is homeless?
a. Insomnia
b. Substance abuse
c. Chronic low self-esteem
d. Impaired environmental interpretation syndrome
C. Chronic low self esteem
A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, “You cause too much trouble.” What problem is the patient experiencing?
Stigma
Select all that apply.
The nurse manager of a mental health center wants to improve medication adherence among the seriously mentally ill persons treated there. Which interventions are likely to help achieve this goal?
a. Maintain stable and consistent staff.
b. Increase the length of medication education groups.
c. Stress that without treatment, illnesses will worsen.
d. Prescribe drugs in smaller but more frequent dosages.
e. Make it easier to access prescribers and pay for drugs.
f. Require adherence in order to participate in programming.
A, E
Select all that apply.
A person diagnosed with serious mental illness has frequent relapses, usually precipitated by situational stressors such as running out of money or the absence of key staff at the mental health center. Which interventions would the nurse suggest to reduce the risk of stressors to cause relapse?
a. Discourage potentially stressful activities such as groups or volunteer work.
b. Develop written plans that will help the patient remember what to do in a crisis.
c. Help the patient identify and anticipate events that are likely to be overwhelming.
d. Encourage health-promoting activities such as exercise and getting adequate rest.
e. Accompany the patient to a National Alliance on Mental Illness support group.
B,C,D,E
Select all that apply. An adult patient tells the case manager, "I don't have bipolar disorder anymore, so I don't need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends." Where should the nurse refer the patient? a. Psychoeducational classes b. Vocational rehabilitation c. Social skills training d. A homeless shelter e. Crisis intervention
A, B, C
Select all that apply.
Which statements most clearly indicate the speaker views mental illness with stigma?
a. “We are all a little bit crazy.”
b. “If people with mental illness would go to church, their problems would be solved.”
c. “Many mental illnesses are genetically transmitted. It’s no one’s fault that the illness occurs.”
d. “Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people.”
e. “People with mental illness are lazy. They get government disability checks instead of working.”
A, B, E
A repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. Primarily a child disorder
oppositional defiant disorder
How long does it take to diagnose a kid with oppositional defiant disorder?
6 months
Repetitive pattern of outburst. Inability to control aggressive impulses in adults 18 years or older.
Intermittent Explosive Disorder
Stages of Intermittent Explosive Disorder:
- Tension & arousal
- Explosive behavior & aggression
- Sense of relief and release
- Feelings of remorse, regret and embarrassment
Persistent pattern of behavior in which the rights of others are violated and societal norms or rules are disregarded. Abnormally aggressive..
Conduct disorder
Occurs prior to age 10 and if found mainly in males who are physically aggressive, have poor peer relationships, show little concern for others and lack feelings of guilt or remorse.Often misperceive others’ intentions as hostile and believe their aggressive responses are justified.
Childhood-onset conduct disorder
What may be a predictor of future antisocial personality disorder for adolescents or kids with conduct disorders?
Callousness (lack of emotion/empathy)
Repeated failure to resist urges to steal objects not needed for personal use or monetary value.
Kleptomania
Psychological factors of conduct disorders?
immature coping and problem solving
The number one predictor of suicidal risk is a……
past suicide attempt
Medications for intermittent explosive disorder might include…..
SSRI: fluoxetine (Prozac)
mood stabalizer: Lithium
anticonvulsent agents
Antipsychotics clozapine (Clozaril) haloperidol (Haldol)
Medications for Conduct disorders might include……
2nd gen. anti-psychotic: Risperdal, Zyprexa, Seroquel, Geodon
3rd gen anti-psychotic: Abilify
Underlying feelings and motivations and explores conscious and unconscious thought process
Psychodynamic Psychotherapy
Focus on impulse control. Skills taught include mindfulness, emotional regulation, distress, tolerance, and personal effectiveness
Dialectical Behavioral Therapy (DBT)
A procedure in which an individual is required or expected to correct the adverse environmental or relational effects of his or her misbehavior by restoring the environment to its prior state, making a plan to correct his or her actions with the nurse and implementing the plan
Simple restitution
What is the last resort to managing disruptive behavior
physical restraints
Advanced practice nurses sit behind one-way mirrors and coach parents through an ear audio device while they interact with their children.
parent-child interaction therapy (PCIT)
Is for children aged 2-14 with mild to severe behavioral problems. Targets the parents rather than the child and focuses attention on reinforcement of positive prosocial behavior, and on brief, negative consequences of bad behaviors.
Parent Management Training (PMT)
Is the most extensive. An intensive family and community-based program that takes into consideration all of the environments of violent juvenile offenders. The go to where the child is
Multisystemic Therapy (MST)
A nursing diagnosis that should be considered for a child diagnosed with conduct disorder who shows no capacity for empathy would be
impaired social interaction
When treating impulse control disorders, psychodynamic psychotherapy is directed toward
identifying the triggers of the rage
A 16-year-old diagnosed with a conduct disorder has been in a residential program for 3 months. Which outcome should occur before discharge?
a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences.
b. The adolescent identifies friends in the home community who are a positive influence.
c. Temporary placement is arranged with a foster family until the parents complete a parenting skills class.
d. The adolescent experiences no anger and frustration for 1 week.
A.
A child known as the neighborhood bully says, “Nobody can tell me what to do.” After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher’s computer. These behaviors support a diagnosis of:
a. conduct disorder.
b. oppositional defiant disorder.
c. intermittent explosive disorder.
d. attention deficit hyperactivity disorder.
B. Opposition defiant disorderw
An adolescent diagnosed with a conduct disorder stole and wrecked a neighbor’s motorcycle. Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescent’s reaction?
Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy.
A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patient’s history support the suspected diagnosis? Select all that apply.
a. Family history of mental illness
b. Allergies to multiple antibiotics
c. Long history of severe facial acne
d. Father with history of alcohol abuse
e. History of an abusive relationship with one parent
A, D, E
Represents a fundamental human feature that distinguishes living from existing.
Cognition
Cognitive function involves what domains?
attention(ability to focus/respond appropriately to env.)
short/long term memory
3 main neurocognitive syndromes are
Delirium
Mild cognitive disorder
Major cognitive Disorder
An acute cognitive disturbance and often-reversible condition that is common in hospitalized patients, especially older patients. Is short term.
Delirium
4 cardinal features of delirium
- ) Acute onset and fluctuating course
- ) Reduced ability to direct, focus, shift, and sustain attention
- ) Disorganized thinking
- ) Disturbance of consciousness
Errors in perception of sensory stimuli. Real object in environment and is features as a something threatening
Illusion
A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, “Bugs are crawling on my legs. Get them off!” Which problem is the patient experiencing?
Tactile Hallucination
Prime culprit of delirium.
Anesthesia
Nursing intervention for delirium management
Acknowledge patient’s fears and feelings
Broad term used to describe progressive deterioration of cognitive function and global impairment of intellect with no change in consciousness.
Dementia
Most common type of dementia
Alzheimer’s disease (AD)
Characterized by symptoms that place individuals in a zone between normal cognition and noticeably significant cognitive deterioration.
Mild neurocognitive disorder
Characterized by substantial cognitive decline that results in curtailed independence and function among affected individuals.
Major neurocognitive disorder
Loss of language ability. Initially the person has difficulty finding the correct words, then is reduced to a few words, and finally is reduced to babbling or mutism.
Aphasia
Loss of purposeful movement in the absence of motor or sensory impairment.
Apraxia
Loss of sensory ability to recognize objects.
Agnosia
Catastrophic reactions, lability of mood, aggressive behaviors, and nocturnal delirium and increased confusion and agitation at night.
sundowning
Nursing Interventions for Dementia managment
Give one simple direction at a time in a respectful tone of voice
What medications slow disease progression of Alzheimer’s disease?
Tacrine (Cognex)
Donepezil (Aricept)
What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
Careful observation and supervision
Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington’s disease. Which term unifies these problems?
Dementia
Which medication prescribed to patients diagnosed with Alzheimer’s disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase?
Memantine
An older adult was stopped by police for driving through a red light. When asked for a driver’s license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?
Agnosia
An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer’s disease is evident?
Moderately severe AD
A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment?
Assist the patient to perform simple tasks by giving step-by-step directions.
An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful?
Using the patient’s glasses and hearing aids
During morning care, a nurse asks a patient diagnosed with dementia, “How was your night?” The patient replies, “It was lovely. I went out to dinner and a movie with my friend.” Which term applies to the patient’s response?
Confabulation
An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient’s family?
Label the bathroom door
What is the priority need for a patient with late-stage dementia?
Maintenance of nutrition and hydration
A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer’s disease. Which problem common to that stage should the nurse address?
Communication deficit
Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply
Impaired level of consciousness
Disorientation to place and time
Wandering attention
Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer’s disease? Select all that apply.
Urinary incontinence
Disturbed sleep pattern
Risk for caregiver role strain
Which event would a client with early stage 4 Alzheimer’s disease have greatest difficulty remembering?
What he or she ate for breakfast
Used to evaluate the presence and severity of pain in patients with advanced dementia who no longer have the ability to communicate verbally.
Pain Assessment in Advanced Dementia (PAINAD)
5 domains of PAINAD
breathing, negative vocalization, facial expression, body language, and consolability
What type of medication can help with pain control
Antidepressants
A bias against older people based on advanced age.
Ageism
Requiring that health care facilities provide clearly written information for every patient regarding his or her legal rights to make health care decisions, including right to accept or refuse treatment.
Patient Self Determination Act (PSDA)
Those with serious mental illness can designate a health care agent to make treatment decisions during an illness relapse.
psychiatric advance directive
Happens when drug-induced symptoms are treated with another drug.
prescribing cascades
A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include?
Pain assessment techniques for older adults
Which information is most important to obtain during assessment of an older adult diagnosed with a mental disorder?
Functional ability and emotional status
An advance directive gives legally binding direction for health care interventions when a patient:
is unable to make decisions for self because of illness.
When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
Medications the patient has recently taken
A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization?
Remotivation
Discharge planning begins for an elderly patient hospitalized for 2 weeks diagnosed with major depression. The patient needs ongoing assessment and socialization opportunities as well as education about medication and relapse prevention. The patient lives with a daughter, who works during the week. Select the best referral for this patient.
Partial hospitalization
An elderly patient brings a bag of medications to the clinic. The nurse finds a bottle labeled “Ativan” and one labeled “lorazepam,” both of which are to be taken BID. There are also bottles labeled “hydrochlorothiazide,” “Inderal,” and “rofecoxib,” each to be taken once daily. Which conclusion is accurate?
Lorazepam and Ativan are the same drug, so the dose is excessive.
A nurse leads a staff development session about ageism among health care workers. What information should the nurse include about the consequences of ageism? Select all that apply.
a. Failure of the elderly to receive necessary medical information
b. Development of public policy that discriminates against the elderly
c. Staff shortages because caregivers prefer working with younger adults
d. The perception that elderly consume a smaller share of medical resources
e. More ancillary than professional personnel discriminate with regard to age
a,b,c
Which beliefs by a nurse facilitate provision of safe, effective care for older adult patients? Select all that apply.
a. Sexual interest declines with aging.
b. Older adults are able to learn new tasks.
c. Aging results in a decline in restorative sleep.
d. Older adults are prone to become crime victims.
e. Older adults are usually lonely and socially isolated.
B, C, D
A terminally ill, elderly client wants to ensure that his wishes about end-of-life care are followed. To best guarantee this, the client should
execute a durable power of attorney for health care.
