Exam 1 Study Guide: Q Flashcards
which diagnosis is written correctly?
- risk for social isolation related to low self-esteem evidence by staying in room during the day
- low self-esteem related to MDD evidenced by childhood abuse
- imbalanced nutrition less than body requirements related to suspiciousness evidenced by 20-lb weight loss
- conduct disorder related to childhood sexual abuse evidence by hostile and aggressive abuse
imbalanced nutrition:
less than body requirements related to suspiciousness evidenced by 20 lbs. weight loss is a correctly written nursing diagnosis
evidence of a nutritional problem is documented and the cause of the problem, suspiciousness, is identified
which indicates to the nurse a client is at risk for developing a mental disorder?
- express thoughts, feelings, and behaviors included among diagnostics mental disorder criteria
- demonstrates impaired daily functioning and maladaptive responses to stress
- communicate significant distress that has not interfered with important activities
- employs various defense mechanism to protect the ego from anxiety
demonstrated impaired daily functioning and maladaptive response to stress
a new nurse states “that clients use of defense mechanisms should be eliminated”.
Which is a correct evaluation of the nurse’s statement?
- defense mechanisms are a self-protective response to stress and do not need to be eliminated
- defense mechanisms are maladaptive attempts of the ego to manage anxiety and should always be eliminated
- defense mechanisms are used by individuals with weak ego integrity and should not be eliminated
- defense mechanisms cause disintegration of the ego and should be fostered and encouraged
defense mechanisms are self-protective response to stress and do not need to be eliminated
a client made a decision to leave her alcoholic husband and reports feeling depressed.
which non-therapeutic statement represents sympathy?
- you are depressed. I felt the same way when I decided to leave my husband
- I can understand you are feeling depressed, it was a difficult decision, i’ll sit with you
- you seem depressed, it was a difficult decision. would you like to talk about it
- i know this is a difficult time, would you like medication
you are depressed. I felt the same way when i decided to leave my husband.
- sharing things about yourself/personal information is sympathy not empathy
a nurse in a long-term care setting enters the room and the client begins berating the nurse stating that “he looks like my ex-husband”,
this behavior is best descried as:
- transference
- conversion
- counter transference
- regression
transference
what is the nurses best action when a client demonstrates transference?
help client clarify meaning of current nurse client relationship
a client who was discharged 2 weeks ago sends a thank you card to a psychiatric nurse. the nurse finds season tickets to a football team in the card.
which of the following must the nurse consider when deciding whether or not to keep the tickets?
- material boundaries
- personal boundaries
- social boundaries
- professional boundaries
professional boundaries
a hungry homeless client with schizophrenia refuses to participate in the admission interview. The nurse postpones the interview, verbally assures safety, and provides the client with a meal.
which of the following does the nurse’s actions demonstrate?
- sympathy
- trust
- veracity
- manipulation
trust
a nurse is interviewing a newly admitted psychiatric client.
which nursing statement is an example of offering a general lead?
- do you know why you are here?
- are you feeling depressed or anxious?
- yes, I see, go on
- can you chronologically order the events that led to your admission?
yes, I see, go on
a nurse is assessing a client with schizophrenia for hallucinations.
which therapeutic communication exemplifies making an observation?
- you appear to be talking to someone i don’t see
- please describe what you are seeing
- why do you continually look in the corner of the room?
if you hum a tune, the voices may not be so distracting
you appear to be talking to someone i don’t see
a client diagnosed with dependent personality disorder states, “do you think i should move out from my parents’ house and get a job?”
which response by the nurse is most appropriate?
- it would be best to do that to increase independence
- why would you want to leave a secure home?
- lets discuss and explore all of your options
- im afraid you would feel very guilty leaving your parents
lets discuss and explore all of your options
a client tells the nurse “i feel bad because my mom doesn’t want me to return home after i leave the hospital.”
which response is an example of therapeutic communication?
- its quite common for patients to feel that way after a lengthy hospitalization
- why don’t you talk to your mom, you may find she doesn’t feel that way
- your mother seems like an understanding person, i’ll help you approach her
- you feel that your mom does not want you to com back home?
you feel that your mom does not want you to come back home?
a client in an inpatient psych unit tells the nurse “i should have died because i am worthless.”
to encourage the client to continue talking about their feelings, which should be the nurse’s initial response?
- how would your family feel if you died?
- you feel worthless now but that can change with time
- you’ve been feeling sad and alone for some time now
- it is great that you have come in for help
you’ve been feeling sad and alone for some time now
a nurse says to newly admitted client “tell me more about what led up to your hospitalization.”
what is the purpose of this therapeutic communication technique?
- explore a subject, idea, experience, or relationship
- reframe clients’ thoughts about mental health treatment
- put the client at ease
- communicate that the nurse is listening to the conversation
explore a subject, idea, experience, or relationship
a nurse is caring for a client who tells the nurse he is feeling stressed and overwhelmed.
which of the following response should the nurse make?
- life is rough isn’t it
- im sorry, i know exactly how you are feeling
- dont worry, you will feel beter in no time
- lets talk more about the stress you’re feeling
let’s talk more about the stress you’re feeling
a nurse tells a client “things will look better tomorrow after a good night’s sleep.”
this is an example of which communication technique?
- giving advice
- defending
- presenting reality
- giving false reassurance
giving false reassurance
a student nurse tells her instructor “im concerned when clients ask for advice, i wont have a good solution.”
what would be the instructor’s best response?
- it’s scary to be put on the spot by a client, nurses don’t always have the answer
- remember clients, not nurses, are responsible for their own choices and decisions
- keep the client’s best interest in mind and do the best you can
- set a goal to continue to work on this aspect of your practice
remember, clients, not nurses are responsible for their own choices and decisions
group therapy is strongly encouraged but not mandatory in an inpatient psych unit. the manager’s policy is that clients can make a choice to attend group therapy?
which ethical principle is this?
- justice
- autonomy
- veracity
- justice
autonomy
a client diagnosed with schizophrenia refuses to take his medication citing the right of autonomy. under which circumstance would a nurse have the right to medicate a client against their will?
- makes inappropriate sexual statements to a staff member
- repeatedly demands constant attention from the nurse
- physically attacks another client during group therapy
- refuse to bathe or attend to personal hygiene
physically attacks another client during group therapy
which regulates the scope of practice for register nurses working in a mental health facility located in nurses state?
Nurse Practice Act
a nurse working in an inpatient treatment center receives a call asking if an individual has been a client there.
which response appropriately reflects legal and ethical obligations of the nurse?
- refuse to give information to caller and cite confidentiality laws
- refuse to give any information and hang up
- affirm only that the person has been seen there
- suggest caller contact the client’s psychiatrist
refuse to give information to caller and cite confidentiality laws
which statement should the nurse identify as correct regarding a client’s right to refuse treatment?
- client can refuse pharmacological but not psychological treatment
- professionals can override treatment refusal if a client is suicidal or homicidal
- client can refuse any type of treatment at any time
- the only treatment client can refuse is electroconvulsive therapy
professionals can override treatment refusal if a client is suicidal or homicidal
which client should the nurse identify as a potential candidate for involuntary commitment?
- client living under bridge in cardboard box
- client verbalizing intent to commit suicide
- homeless client refusing to bathe
- client eating waste out of a trash can
client verbalizing intent to commit suicide
a nurse is providing teaching to assistive personnel about clients with restraints
which statement by the assistive personnel indicates understanding?
- i will put all 4 side rails up if the client is confused
- restraints must be very tight to work properly
- i will tie the restraints to the portion of bed that does not move
- i will tie the restraints with the extremities flexed to ensure safe range of motion
i will tie the restraints to the portion of bed that does not move
a client is taking Ritalin for ADHD.
which of the following would be part of the patient education associated with administration of this medication?
- do not take with foods that contain tyramine
- always use sunblock when spending time outdoors
- report for blood tests once a month
- do not discontinue the medication abruptly
do not discontinue the medication abruptly
patients taking an alpha agonist should not discontinue therapy abruptly. to do so may result in symptoms of nervousness, agitation, headache, tremor, and a rapid rise in blood pressure. dosage should be tapered gradually under the supervision of the physician
what part of the brain is responsible for processing feelings or is also called the emotional brain?
- medulla
- limbic system
- pons
- autonomic nervous system
limbic system
the limbic system is the “emotional brain” and can help in stabilizing emotional behavior
the nurse identifies which symptom as typical of the fight-or-flight response?
- decreased heart rate
- decreased peristalsis
- increased salivation
- pupil constriction
decreased peristalsis
during the fight-or-flight response, the heart rate increases in response to the release of epinephrine. pupils dilate to enhance vision. salivation and peristalsis decrease as the body slows unessential functions
the nurse understands that psychotropic medications improve symptoms of mental disorders b acting on which of the following parts of nervous system?
- interneurons
- neural synapse
- the cerebral cortex
- the cerebellum
neural synapse
psychotropic medications improve symptoms of mental disorders by acting on the neural synapse
which part of the nervous system should the nurse identify as playing a major role during stressful situations?
- sympathetic nervous system
- somatic nervous system
- peripheral nervous system
- the cerebellum
sympathetic nervous system
sympathetic division of the nervous system is dominant in stressful situations
a patient was brought to the emergency room and was having an extreme anxiety attack.
what division in the brain would be dominant and responsible to react in this situation?
- sympathetic nervous system
- thalamus
- hypothalamus
- parasympathetic nervous system
sympathetic nervous system
sympathetic division of the nervous system is dominant in stressful situations
anxiety attack = stressful situation
which of the following regulates the scope of practice for a registered nurse working in a mental health facility located in the nurses’ state?
- american nurses’ association
- american psyciatric association
- nurse practice act
- national council of the state board of nursing
nurse practice act
which statement should then nurse identify as correct regarding a protocol/client’s right to refuse treatment?
- clients can refuse pharmacological but not psychological treatment
- clients can refuse any type of psychiatric treatment at any time
- the only treatment a client can refuse is electroconvulsive therapy (ECT)
- professionals can override treatment refusal if the client is actively suicidal or homicidal
professionals can override treatment refusal if the client is actively suicidal or homicidal
professionals can override treatment refusal if the client is actively suicidal or homicidal under a court ordered denial of rights as a petitioned by the interdisciplinary team lead by the psychiatrist
what are defense mechanisms?
behaviors people use to separate themselves from unpleasant events, actions, or thoughts
self-protective responses to stress and DO NOT NEED TO BE ELIMINATED or else anxiety will progress and may get worse
justify unacceptable feelings/behaviors
rationalization
refusing to acknowledge the existence of a real situation or the feelings associated
denial
preventing unacceptable or undesirable thoughts of behaviors from being expressed by exaggerating opposite thoughts or types of behaviors
reaction formation
transfer the feeling from one target to another that is less threatening
displacement
attributing feelings unacceptable to one’s self to another person
projection
the nurse is interviewing a client with a history of alcoholism. the client states, “i work hard to provide for my family. I don’t see why i can’t drink to relax.”
the nurse recognizes the client is using which defense mechanism?
- rathionalization
- regression
- reaction formation
- undoing
rationalization
the client is using rationalization, a common defense mechanism.
the client is attempting to make excuses and create logical reasons to justify unacceptable feelings or behaviors
due to COVID, the nursing unit director informed the unit manager that they need to eliminate the position or have him/her step down as a staff nurse due to budgeting reasons. the manager’s behavior represents the defense mechanism of displacement when he/she does which of the following actions?
- angrily criticizes a coworker
- confronts the nursing director
- cried at home
- eats lunch with the director
angrily criticizes a coworker
displacement refers to transferring feelings from one target to a neutral or less threatening target
a male student is attracted to the school’s female nurse. the male student tells his friend, “i know she has a crush on me.”
the friend recognizes that the student is using which defense mechanism?
- undoing
- projection
- regression
- rationalization
projection
projection refers to the attribution of one’s unacceptable feelings or impulses to another person. when the client “passes the blame” of the undesirable feelings, anxiety is reduced
a male student nurse teases a female classmate and makes jokes about her.
you identify this as what type of defense mechanism?
- reaction formation
- sublimation
- projection
- displacement
reaction formation
the male student nurse is using the defense mechanism of reaction formation. reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors
True or False:
a client demonstrating impaired daily functioning and maladaptive responses to stress indicates to the nurse that he/she is at risk for developing mental disorder
True
the nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental function to be diagnosed with a mental disorder
True or False:
a feeling of self-fulfillment and realization of full potential is the highest level of functioning according to maslow’s hierarchy of needs
true
what is DSM 5: diagnostic and statistical manual of mental disorders (purple book) used for?
USED BY CLINICIANS AND RESEARCHERS to diagnose and classify mental disorders
NOT USED BY NURSES
related to fight or flight syndrome and regulates sympathetic nervous system
norepinephrine
excess can lead to hallucinations and schizophrenia
dopamine
- used among antidepressants, regulates mood, happiness, and anxiety.
- excess will lead to what syndrome?
- serotonin
- serotonin syndrome
related to antianxiety medications, inhibits reduces neuronal activity, regulates behavior cognition and stress to help someone calm down
gaba
involved with alzheimer’s medications, deficiency can lead to cognitive decline, memory loss, and alzheimer disease
acetylcholine
where do psychotropic medications work?
in the neural synapse
the nurse knows an increase in dopamine activity might play a significant role in the development of which disorder?
- schizophrenia
- major depressive disorder
- body dysmorphic disorder
- parkinson’s disease
schizophrenia
an increase in dopamine activity might play a significant role in the development of schizophrenia.
dopamine functions include regulation of emotions, coordination, and voluntary decision-making ability.
the quality of doing good; can be described as charity
beneficence
the client’s right to make their own decisions. however, the client must accept the consequences of those decisions. the client must also respect the decision of others
autonomy
fair and equal treatment for all
justice
loyalty and faithfulness to the client and to one’s duy
fidelity
honesty when dealing with a client
veracity
what is L2K?
- 72 hour psychiatric hold for clients who are a danger to self or others
- state mandated law
- professionals can override treatment refusal if the client is actively suicidal/ homicidal/ severely psychotic = COURT ORDERED PETITION TO DENY PATIENT’S RIGHT
a psychiatrist working on an inpatient unit refuses to treat clients who do not have health insurance coverage and also prematurely discharges clients whose health insurance benefits have expired.
the nurse recognizes the psychiatrist is violating which ethical principle?
- autonomy
- justice
- non maleficence
- beneficence
justice
the psychiatrist has violated the ethical principle of justice, which requires individuals to be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious beliefs
True or False:
state law determines the length of time a psychiatric facility can hold a client
true
most states commonly cite that, in an emergency, a client who is dangerous to self or others may be involuntarily hospitalized
patient transfers feelings to the nurse
transference
nurse transfers their feelings to the patient
countertransference
True or False:
in a client demonstrating transference, the nurse should respond by assisting the client separate the past from the present and clarify the meaning of the nurse-client relationship, based on the current situation
true
transference occurs when the client unconsciously displaces feelings formed toward a person from the past toward the nurse.
do not immediately terminate or ignore the conversation as it does not promote client safety.
guide the clients toward independence by assisting the client to separate past from the present and clarify the situation.
client tells you, “you look just like my sister.”
the nurse should recognize this behavior as which of the following?
- transference
- conversion
- counter-transference
- regression
transference
this is transference, the client looks at the nurse and transfers feelings to this caregiver.
able to recall definitions of concepts in mental health nursing
what are the 4 phases of a nurse client relationship?
POWT:
Pre-Interaction: explore self-perceptions, obtain report
Orientation (introduction) - establish trust and develop goals
Working - promote change
Termination - evaluate goal attainment, ensure therapeutic closure
which outcome does the nurse expect during the working phase of the nurse-client relationship?
- the client gains insight and incorporates alternative behaviors
- the client and nurse establish rapport and mutually develop treatment goals
- explore self-perceptions
- establish trust and formulate a contract for intervention
the client gains insight and incorporates alternative behaviors
what are important points about tricyclic antidepressants?
- block reuptake of serotonin and norepinephrine
- less commonly used because there are more side effects
- it can take weeks before therapeutic effects are reached
what are goals with therapeutic communication?
- be empathetic, NOT sympathetic
- promote independence
-avoid WHY questions - judged or defensive - never argue
- get more info regarding patient
- collaborative with patient
- assess patient further
- stay neutral
- a lot of rewording/restating
- clarify if you are on the same page with patient
what are examples of therapeutic communication techniques?
- silence
- acceptance, “yes, i understand what you said”, eye contact, nodding
- restating
- reflecting
- exploring
- general leads
- making observations
patient: i cant study. my mind keeps wondering
nurse: you have trouble concentrating
restating
patient: she makes me upset
nurse: so you’re feeling angry at your boss?
reflecting
tell me more about that particular situation
exploring
yes, i see. go on
general leads
“you appear sad today” or “i notice you are pacing a lot”
making observations
what are examples of nontherapeutic communication?
- giving false reassurance
- disapproving
- belittling feeling
- interpreting
- making stereotypical comments
- giving advice
- nurse sharing personal experiences and relates it to patient’s
what were classes of psychotropic medications before 1950s?
sedatives and amphetamines
what were classes of psychotropic medications post 1950s?
psychotropic medications were expanded into antipsychotic, antidepressant, antianxiety, mood-stabilizer, sedative/hypnotics
what is the difference between the sympathetic and parasympathetic nervous system?
sympathetic:
- dominant in stressful situations
- fight or flight
parasympathetic:
- dominant in relaxed situation
- rest or digest
the nurse identifies which symptom as typical of the fight or flight response?
- decreased heart rate
- decreased peristalsis
- increased salivation
- pupil constriction
decreased peristalsis
what is limbic system?
- called the emotional brain
- includes thalamus and hypothalamus
- feeling of fear, anxiety, anger, rage, aggression, love, joy, home, sexuality, and social behavior
what is the nurse practice act and its ethic/legal implications?
- regulates scope of practice for RN working in mental health facility located in the nurse’s state
- ethical and legal implications
- must know implications associated with administration of psychotropic medications
- most states adhere to patient right to refuse treatment except in emergency situations
what are the 4 parts of the johari window?
- self awareness
- public self-known to yourself and others
- unknowing self - unknown to you but known to others
- private self - known to self, unknown to other
- unknown self - not known to anyone
a nurse uses the johari window to increase client self-awareness. which quadrant represents “things i do not know about myself, but is known to others?”
- the open self
- the blind/unknowing self
- the private/hidden self
- the unknown self
the blind/unknowing self
what are important points with lithium use?
- mood stabilizer
- lithium normal level = 0.4 - 1.2 mEq
- TOXICITY: NAUSEA, VOMITING, DIARRHEA, confusion, sedation, slurred speech, polyuria, tinnitus and ataxia
- must check serum levels
what is neuroleptic malignant syndrome?
- rare reaction to antipsychotic drugs that treat schizophrenia, bipolar disorder, and other mental health conditions.
- it affects the nervous system and causes symptoms like a high fever and muscle stiffness
- NMS symptoms usually last for 7 - 10 days. may include:
F = Fever
E = Encephalopathy
V = Vitals Unstable
E = elevated CK
R = Rigidity of Muscles - neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with a neuroleptic (antipsychotic) medication.
- it is characterized by dyspnea or tachypnea; tachycardia or irregular pulse rate; fever; blood pressure changes; increased sweating; loss of bladder control; and skeletal muscle rigidity
what is agranulocytosis?
- extremely low levels of white blood cells
- symptoms include sore throat, fever, and malaise
- this may be a side effect of long-term therapy with CLOZARIL/CLOZAPINE
- drugs that can cause agranulocytosis include: antipsychotics, such as clozapine (clozaril)
a client with schizophrenia has recently begun a new medication, clozapine.
about which signs and symptoms of a potentially fatal side effect will the nurse teach the client?
- blurring vision and muscular weakness
- sore throat, fever, and malaise
- tremor, shuffling gait, and rigidity
- fine tremor, tinnitus, and nausea
sore throat, fever, and malaise
the symptoms of infection indicate that the client has a low WBC count (below 3500/mm3), which indicates that the body’s ability to fight infection is significantly decreased.
agranulocytosis is a potentially fatal disorder in which the client’s WBC drops to extremely low levels, placing the client at great risk for infections.
the nurse notes that a client with paranoid schizophrenia and receiving an antipsychotic medication complains of muscle rigidity. on further assessment, the nurse finds the client is sweating, has a fever, tachycardia and an increased blood pressure.
the nurse suspects that the client is experiencing which medication complication?
- dystonia
- tardive dyskinesia
- hypertensive crisis
- neuroleptic malignant syndrome
neuroleptic malignant syndrome
is a potentially fatal syndrome that may occur at any time during therapy with a neuroleptic (antipsychotic) medication. it is characterized by dyspnea or tachypnea; tachycardia or irregular pulse rate, fever; blood pressure changes; increased sweating; loss of bladder control; and skeletal muscle rigidity
a geriatric client with schizophrenia takes an antipsychotic and a blood pressure medication. give the combined side effects of these drugs, which client teaching should the nurse provide?
- make sure you concentrate on taking slow, deep, cleansing breaths
- watch your diet and try to engage in some regular physical activity
- rise slowly when you change position from lying to sitting or sitting to standing
- wear sunscreen and try to avoid midday sun exposure
rise slowly when you change position from lying to sitting or sitting to standing
antihypertensive drugs and antipsychotic medication reduce blood pressure. due to the hypotensive properties of each, clients can develop orthostatic hypotension when combined
a patient is recently prescribed risperidone.
which of the following statements by the patient indicate successful teaching by the nurse?
- i will avoid foods like chocolate and aged cheese
- i might experience hallucinations with this medication
- this medication will help me with my depression
- i will report any flu-like symptoms
i will report any flu-like symptoms
mr. brown has been taking an anti-anxiety agent for the past 4 weeks. he is complaining that his new anxiety medication has not been working even though he took it 2 hours ago. mr. brown rates his anxiety as an 8 on a 1 - 10 scale.
based on this information, the nurse suspects that mr. brown is suffering from the effects of:
- tolerance
- non-compliance
- withdrawal
- maladaptive coping
tolerance
what are extrapyramidal symptoms?
- involuntary movements with antipsychotics
- pseudo parkinsonism, acute dystonia, akathisia, tardive dyskinesia (mostly mouth/lips)
what are important points with alzheimers drugs?
- cholinesterase inhibitors - slow rate of memory loss
- take weeks to be effective
what are important points with benzodiazepines?
- promotes GABA - causes calming effect
- anxiety, insomnia, seizure, alcohol withdrawal
- toxic - resp depression, extreme hypotension, arrest
- highly addictive - given PRNs
what are common symptoms with all 4 levels of anxiety?
- MILD: restlessness, irritability, fidgeting
- MODERATE: decreased ability to concentrate, increased perspiration, increased muscular tension
- SEVERE: unable to concentrate/problem solving, cannot effectively learn, palpitations
- PANIC: characterized by recurrent sudden onset panic attacks in which the person feels intense fear, apprehension or terror, cannot learn, dilated pupils, hallucinations, and delusions
a nursing student is taking a standardized exam for the first time in nursing school and begins to experience severe anxiety.
which of the following findings are expected in someone experiencing severe anxiety? SELECT ALL THAT APPLY
- hallucinations
- palpitations
- difficulty focusing
- dilated pupils
- motivation
- palpitations
- difficulty
a mental health nurse is assessing a client.
which behaviors indicate the client is experiencing moderate anxiety? SELECT ALL THAT APPLY
- fidgeting
- difficulty concentrating
- muscle tension
- increased perspiration
- extremely limited attention span
- difficulty concentrating
- muscle tension
- increased perspiration
a cab driver stuck in traffic is suddenly, out of nowhere, lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. an extensive work-up in an emergency department reveals no pathology.
which medical diagnosis and nursing diagnosis is expected?
- generalized anxiety disorder and a nursing diagnosis of fear
- altered sensory perception
- pain disorder and a nursing diagnosis of altered role performance
- panic disorder and a nursing diagnosis of panic anxiety
panic disorder and a nursing diagnosis of panic anxiety
what are important points of HIPAA?
- ensuring patient information is kept private is the priority
- nurses are legally and ethically obligated to withhold information from a caller and/or family member if they do have the patient’s permission and/or legal documents to support guardianship
you hear a group of nursing students in the cafeteria discussing about a medical code emergency that happened earlier in your unit. which of the following actions should the nurse take first?
tell the nursing students to stop discussing the incident
what are important points with restraints and seclusion?
- are nursing interventions to keep the patient from pulling at tubes, drains, and lines or to prevent the patient from ambulating when its unsafe to do so - in other words, to enhance patient care
- restraint or seclusion must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm
- eating, hydration, toileting, range of motion must be checked every 15 mins. 1:1
a nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints.
which of the following statements by the AP indicates an understanding of the teaching?
- i will put 4 side rails up if the client is confused
- the restraint must be very tight to work properly
- i will tie a restraint to the portion of the bed that does not move
- i will tie the client with the extremities flexed to ensure safe range of motion
i will tie a restraint to the portion of the bed that does not move
what is the ross grief cycle?
DABDA
D = Denial
A = Anger
B = Bargaining
D = Depression
A = Acceptance
- five stages of grief
- not all people go through cycle in the same way but each go through each stage
what is adaptive coping?
- positive - active coping, positive reframing, planning, acceptance, religion, emotional support, instrumental support, humor
what is maladaptive coping?
- negative - denial, self-distraction, substance abuse, behavioral disengagement, venting, self-blame
- manifests as loss of appetite, anorexia, sleep disturbances, headaches, and lack of energy (anergia)
boundaries that individuals define for themselves
personal boundaries
are established within a culture and define how individuals are expected to behave in social situations
social boundaries
physical property that can be seen, such as fences that border land
material boundaries
limit and outline expectations for appropriate professional relationships with clients; clients receiving care may feel indebted toward health-care providers and give a gift
professional boundaries
what is an appropriate response to a client who is demonstrating transference by the nurse?
- nursing consideration: assist the patient in clarifying the meaning of the current nurse-client relationship
- the nurse may remind the patient of someone in their life sibling, etc. and feelings toward that sibling-annoyed etc.
- occurs when the patient unconsciously displaces (or transfers) to the nurse feelings formed toward a person from his or her past. these feelings may be triggered by something about the nurse’s appearance or personality characteristics that remind the patient of another person.
- transference can interfere with therapeutic interaction when the feelings expressed include anger and hostility. anger toward the nurse can be manifested by uncooperativeness and resistance to therapy
what is tardive dyskinesia?
antipsychotics can cause extrapyramidal side effects (EPS) one of which is tardive dyskinesia
- protrusion and rolling of the tongue
- sucking and smacking movements of the lips
- chewing motion
- facial dyskinesia
- involuntary movement of the body and extremities
- minimal facial grimacing/lack of expression
what are the time limits for seculsion/restraints?
- time limit for seclusion or restraints until it needs to be re-evaluated if deemed necessary (remember 4-2-1)
18 years and older: 4 hours
9 - 17 years: 2 hours
8 years and younger: 1 hour
