exam 2 Flashcards
what is MSE
assesses clients health IN THE MOMENT
9 parts of MSE
appearance, behavior and activity, mood and affect, speech, thought processes, thought content, sensorium and intellectual processes, judgement and insight
judgement vs insight
judgement- soundness of decision making and ability to plan course of action / insight = awareness of own needs and circumstances ability to draw rational conclusions
6 client rights
prompt evaluation
dignitity
not a subject of experiental research
least restrictive enviornment
send and recieve mail
when is someone hospitalized
presenting danger to self or others and cannot take care of themselves
what is least restrictive enviornment
free of unecessary commitments and person not committed if they can find OP services
5 restraint rules
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
6 criteria of duty to warn 3rd parties
- 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?
3 criteria for intentional tort
willful and voluntary
nurse intended to bring harm
act was a factor in the injury
- Utilitarianism
theory that bases decisions on greatest good for greatest number
- Deontology:
decisions based on whether action is morally right or wrong, with no regard for consequences
veracity and fidelity
honesty/ doing what you said you would do
- Anticipatory grieving:
persons facing an imminent loss begin to deal with very real possibility of loss or death in near future.
6 tasks of grieving
recognize, react, recollect, relinquish, readjust, reinvest
How do people respond to loss/grief cognitively?
By rethinking the meaning of life, faith, relationships; questioning and trying to make sense of the loss.
disenfranchised grief
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.
complicated grieving
**When grief is complicated by unhelpful perspectives of the loss or ineffective coping strategies.
ambivalent attachment
mixed feelings about relationship with the person before the person died
dependent attachment
emotion and economic attachment prior to death
insecure attachment
inability to rely on deceased before they died
hostility is
verbal
what med is contraindicated for dementia
benzos
2 nursing diagnoses for aggressive clients
risk for other directed violence and ineffective coping
best predictor for futrue agression
past agression
4 factors that increase agression
unpredictable schedule, lack of staff, fewer groups, fewer activities
triggering symptoms and intervention
restness, anxiety, pacing, loud voice, anger - approach client, express empathy, enourage verbalization of feelings
escalation symptoms and interventions
pale face, yelling, swearing, clenched fists, hostility - provide directions, direct client to take a time out, offer meds
crisis symptoms and interventions
loss of control, kicking, spitting, biting - take charge, seclusion or restraint, give PRN med
recovery symptoms and interventions
lowering of voice, decreased tension - talk about triggers, relax
postcrisis symptoms and interventions
remorse, apologies - remove client from restrain, discuss incident, give feedback
workplace hostility example
passive = refusing to perform tasks
4 characteristics regardless of type of abuse
social isolation, abuse of power, alcohol and drugs, intergenerational transmission
cycle of partner violence
violence -honeymoon -tension-violence
what does SAFE stand for
stress safety, afraid abused , friends family, emergency plan
PTSD criteria
. 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.
acute stress disorder vs ptsd
ASD: lasts 3 days to 1 month
PTSD: 3 months or more
reactive attachment disorder
child under 5 in response to traume - child has disturbed social relatedness
disinhibited social engagement disorder
unselective socialization - lack hesitation in taking to strangers
2 health promotions for ptsd
daily routine and goals and sleep etc and dealing with trauma as soon as it occurs
3 goals of therapy for ptsd
improve quality of life, improve functional abilities, decrease symptoms
4 interventions for pt with ptsd
promoting safety
helping them cope
promote self esteem
social support
what is anxiety
send of psychological distress
3 dx for anxiety
- 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.
3 phases of anxiety
alarm rxn, resistance, exhaustion
buspirone use
not an immediate acting anxiolytic so it is not effective in immediate treatment of severe anxiety or panic.
BB use in anxiety
by blocking the effects of norepinephrine, which is involved in the fight-or-flight response.
antihistamine med for anxiety
hydroxyzine
