exam 2

Question 1

what is MSE

Answer 1

assesses clients health IN THE MOMENT

Question 2

9 parts of MSE

Answer 2

appearance, behavior and activity, mood and affect, speech, thought processes, thought content, sensorium and intellectual processes, judgement and insight

Question 3

judgement vs insight

Answer 3

judgement- soundness of decision making and ability to plan course of action / insight = awareness of own needs and circumstances ability to draw rational conclusions

Question 4

6 client rights

Answer 4

prompt evaluation
dignitity
not a subject of experiental research
least restrictive enviornment
send and recieve mail

Question 5

when is someone hospitalized

Answer 5

presenting danger to self or others and cannot take care of themselves

Question 6

what is least restrictive enviornment

Answer 6

free of unecessary commitments and person not committed if they can find OP services

Question 7

5 restraint rules

Answer 7

Face-to-face evaluation by primary health care

provider must be obtained in 1 hour, every 8 hours (every 4 hours for children)

Physician’s order every 4 hours (every 2 hours for children)

Documented assessments by nurse every 1 to 2 hours

Close supervision of patient (face to face in VA)

Debriefing session with nurse and/or physician within 24 hours after release from seclusion or restraint

Question 8

6 criteria of duty to warn 3rd parties

Answer 8

• Is the client dangerous to others?
• Is the danger the result of serious mental illness?
• Is the danger serious?
• Are the means to carry out the threat available?
• Is the danger targeted at identifiable victims?
• Is the victim accessible?

Question 9

3 criteria for intentional tort

Answer 9

willful and voluntary
nurse intended to bring harm
act was a factor in the injury

Question 10

• Utilitarianism

Answer 10

theory that bases decisions on greatest good for greatest number

Question 11

• Deontology:

Answer 11

decisions based on whether action is morally right or wrong, with no regard for consequences

Question 12

veracity and fidelity

Answer 12

honesty/ doing what you said you would do

Question 13

• Anticipatory grieving:

Answer 13

persons facing an imminent loss begin to deal with very real possibility of loss or death in near future.

Question 14

6 tasks of grieving

Answer 14

recognize, react, recollect, relinquish, readjust, reinvest

Question 15

How do people respond to loss/grief cognitively?

Answer 15

By rethinking the meaning of life, faith, relationships; questioning and trying to make sense of the loss.

Question 16

disenfranchised grief

Answer 16

Loss of relationship between lovers, the loss of a nurturing parent for a child, the loss of a partner that may not be accepted or even recognized, the death of a pet, the loss of a patient that the nurse has worked closely with.

Question 17

complicated grieving

Answer 17

**When grief is complicated by unhelpful perspectives of the loss or ineffective coping strategies.

Question 18

ambivalent attachment

Answer 18

mixed feelings about relationship with the person before the person died

Question 19

dependent attachment

Answer 19

emotion and economic attachment prior to death

Question 20

insecure attachment

Answer 20

inability to rely on deceased before they died

Question 21

hostility is

Answer 21

verbal

Question 22

what med is contraindicated for dementia

Answer 22

benzos

Question 23

2 nursing diagnoses for aggressive clients

Answer 23

risk for other directed violence and ineffective coping

Question 24

best predictor for futrue agression

Answer 24

past agression

Question 25

4 factors that increase agression

Answer 25

unpredictable schedule, lack of staff, fewer groups, fewer activities

Question 26

triggering symptoms and intervention

Answer 26

restness, anxiety, pacing, loud voice, anger - approach client, express empathy, enourage verbalization of feelings

Question 27

escalation symptoms and interventions

Answer 27

pale face, yelling, swearing, clenched fists, hostility - provide directions, direct client to take a time out, offer meds

Question 28

crisis symptoms and interventions

Answer 28

loss of control, kicking, spitting, biting - take charge, seclusion or restraint, give PRN med

Question 29

recovery symptoms and interventions

Answer 29

lowering of voice, decreased tension - talk about triggers, relax

Question 30

postcrisis symptoms and interventions

Answer 30

remorse, apologies - remove client from restrain, discuss incident, give feedback

Question 31

workplace hostility example

Answer 31

passive = refusing to perform tasks

Question 32

4 characteristics regardless of type of abuse

Answer 32

social isolation, abuse of power, alcohol and drugs, intergenerational transmission

Question 33

cycle of partner violence

Answer 33

violence -honeymoon -tension-violence

Question 34

what does SAFE stand for

Answer 34

stress safety, afraid abused , friends family, emergency plan

Question 35

PTSD criteria

Answer 35

. Has to be exposed to an actual or threatened death, serious injury, or sexual violence.
2. Have one or more of the following intrusive symptoms:flashbacks, depersonalization, derealization
3. A persisting pattern of trying to avoid anything that may be associated with the trauma
4. Negative thoughts, thought difficulties, and emotions associated with the traumatic events
. Marked alterations in arousal and reactivity associated with the traumatic events.

Question 36

acute stress disorder vs ptsd

Answer 36

ASD: lasts 3 days to 1 month
PTSD: 3 months or more

Question 37

reactive attachment disorder

Answer 37

child under 5 in response to traume - child has disturbed social relatedness

Question 38

disinhibited social engagement disorder

Answer 38

unselective socialization - lack hesitation in taking to strangers

Question 39

2 health promotions for ptsd

Answer 39

daily routine and goals and sleep etc and dealing with trauma as soon as it occurs

Question 40

3 goals of therapy for ptsd

Answer 40

improve quality of life, improve functional abilities, decrease symptoms

Question 41

4 interventions for pt with ptsd

Answer 41

promoting safety
helping them cope
promote self esteem
social support

Question 42

what is anxiety

Answer 42

send of psychological distress

Question 43

3 dx for anxiety

Answer 43

• When the underlying cause is not addressed
• When the symptoms of anxiety are too intense to address an underlying cause or causes
• When a person’s stress response system malfunctions in some way.

Question 44

3 phases of anxiety

Answer 44

alarm rxn, resistance, exhaustion

Question 45

buspirone use

Answer 45

not an immediate acting anxiolytic so it is not effective in immediate treatment of severe anxiety or panic.

Question 46

BB use in anxiety

Answer 46

by blocking the effects of norepinephrine, which is involved in the fight-or-flight response.

Question 47

antihistamine med for anxiety

Answer 47

hydroxyzine