Final

Question 1

Two most important mental health concepts

Answer 1

Clear boundaries and safety

Question 2

4 elements of nurse-patient relationship

Answer 2

1. Dignity and respect (clear boundaries)
2. Information sharing
3. Mutual participation (patient is full partner in care)
4. Collaboration

Question 3

What encompasses therapeutic use of self? (3)

Answer 3

• using personality consciously and with full awareness to promote healing
• attempting to establish relatedness
• structured nursing interventions

Question 4

6 goals of the nurse-patient relationship

Answer 4

1. Establish nurse as safe, confidential, reliable, consistent
2. Facilitate communication of distressing thoughts and feelings
3. Assist with problem solving and development of coping skills
4. Help patient examine self-defeating behaviors and test alternatives
5. Promote self-care, recovery, and independence
6. Provide education on condition and management

Question 5

3 types of relationships and what they look like

Answer 5

• Intimate (emotional commitment; not allowed in nurse-patient)
• Personal (mutual needs met; purpose of friendship)
• Therapeutic (nurse maximizes communication skills, understanding of human behavior, and personal strengths to enhance patient’s growth)

Question 6

Five steps to establish therapeutic relationship

Answer 6

1. Needs of patient identified and explored
2. Clear boundaries established
3. Problem-solving approaches taken
4. New coping skills developed
5. Behavioral change supported

Question 7

4 Do’s of setting boundaries

Answer 7

1. Ensure that the focus of the conversation remains on your patients
2. Set firm limits and boundaries on negative or inappropriate behavior
3. Disclose a small amount of personal information (if it will strengthen the therapeutic relationship)
4. Show genuine concern for patients

Question 8

7 Don’ts of setting boundaries

Answer 8

1. Behave meanly towards your patient
2. Become your patients’ friend
3. Allow your needs to be met at the expense of your patient
4. Accept cash or gifts for you personally (can blur boundaries)
5. Excessively touch patients
6. Try to influence patients’ beliefs
7. Probe patient about sensitive topics

Question 9

Transference and when it is intensified

Answer 9

The patient unconsciously and inappropriately displaces onto the nurse feelings and behaviors related to significant figures in patient’s past

Intensified in relationships of authority

Can be positive or negative

Question 10

Countertransference

What is it?
When can it happen?
How to recognize it?

Answer 10

• The nurse unconsciously displaces feelings related to people in his/her past onto patient
• Patient’s transference to nurse often results in countertransference in the nurse
• Common sign of countertransference in nurse is over-identification with the patient or strong emotions

Question 11

Peplau’s Four phases of therapeutic nurse-patient relationship

Answer 11

1. Preorientation phase
2. Orientation Phase
3. Working Phase
4. Termination Phase

Question 12

Pre-orientation Phase (3)

Answer 12

• Obtain information about the client from chart, significant others, or other health-team members
• Research client condition
• Examine one’s own feelings, fears, and anxieties about working with a particular client

Question 13

Orientation Phase (5)

Answer 13

• Introductions (name, purpose)
• Patient may discuss feelings, problems, goals
• Establishing rapport (understanding, harmony, empathy)
• Specifying a formal/informal contract (including terms of termination; this is with not for patient)
• Establish confidentiality

Question 14

Working Phase (6)

Answer 14

• Maintain trust & rapport
• Gather further data
• Promote patient’s problem-solving skills & self-esteem
• Promote symptom management
• Provide education on diagnosis & medication
• Evaluate progress

Question 15

Termination Phase (5)

Answer 15

• Summarize goals & objectives achieved
• Review items taught
• Discuss ways to incorporate new coping strategies
• Review situations of nurse-patient relationship
• Exchange memories to facilitate closure

Question 16

What is the greatest trigger for the development of a patient’s nurse- focused transference?

a. The similarity between the nurse and someone the patient already dislikes
b. The nature of the patient’s diagnosed mental illness
c. The history the patient has with the patient’s parents
d. The degree of authority the nurse has over the patient

Answer 16

D

Question 17

What should nurse do if patient interrupts during time with current patient?

Answer 17

• Let the patient know you will meet with them later, the time contracted for one patient is their time

Question 18

What should nurse do if the Patient threatens suicide? (3)

Answer 18

• Figure out is patient has plan and lethality
• Share with other staff
• Discuss patient feelings and circumstances that lead to this decision

Question 19

What should nurse do if the patient asks the nurse to keep a secret? (2)

Answer 19

• Nurse cannot make such a promise; info may be important to health and safety of others
• Nurse lets patient know then patient decides to share or not share

Question 20

What should nurse do if the patient asks the nurse a personal question? (2)

Answer 20

• Nurse can answer or not answer

- If nurse answers, be short then refocus on patient

Question 21

What should nurse do if patient cries? (3)

Answer 21

• Nurse stays with patient and reinforces that it is alright to cry
• May inquire about reason for crying
• Offer tissues when appropriate

Question 22

What should nurse do if the patient makes sexual advances? (4)

Answer 22

• Nurse sets clear boundaries
• Nurse frequently states nurse role to maintain boundaries
• Nurse leaves to give patient time to regain control
• Reassignment if behavior continues

Question 23

What should nurse do if patient leaves before session is over?

Answer 23

• Check back in with patient later; they may have needed a break

Question 24

What should nurse do if patient gives the nurse a present? (2)

Answer 24

• “If the gift is expensive or money, the only policy is to graciously refuse.
• If it is inexpensive, then (1) if it is given at the end of hospitalization when a relationship has developed, graciously accept; (2) if it is given at the beginning of the relationship, graciously refuse and explore the meaning behind the present

Question 25

What should nurse do if patient does not want to talk? (3)

Answer 25

- Spend short frequent periods with them - Let them know you do not half to talk, you will just spend time with them - Both of these establish nurse as reliable

Question 26

What does verbal Communication communicate? (2)

Answer 26

- Beliefs and values - Perceptions and meaning

Question 27

What does verbal Communication convey? (4)

Answer 27

- Interest and understanding - Insult and judgment - Clear or conflicting messages - Honest or distorted feelings

Question 28

Examples of Nonverbal communication (8)

Answer 28

- Tone of voice - Emphasis on certain words - Physical appearance - Facial expressions - Body posture and movement - Amount of eye contact - Touch - Hand gestures

Question 29

Double-bind messages

Answer 29

Mutually contradictory messages, usually given by a person in power; no-win

Question 30

How do verbal and nonverbal communication interact? (3)

Answer 30

- Messages can be conflicting or congruent - Nonverbal messages and behaviors are less obvious. - Verbal message = content; nonverbal behavior = process

Question 31

Autocratic leader

Answer 31

- Exerts control over the group and does not encourage much interaction - Production ↑, morale ↓

Question 32

Democratic leader

Answer 32

- Supports extensive group interaction in the process of problem solving - Production somewhat ↓ than with autocratic leadership, morale much ↑

Question 33

Laissez-faire Leader

Answer 33

- Allows the group members to behave in any way they choose and does not attempt to control the direction - goals are undefined - Productivity and morale ↓

Question 34

Milieu therapy (3)

Answer 34

- a psychiatric philosophy involving a secure environment to support recovery - uses naturally occurring events as learning opportunity for patients - involves consistency and structure (Structured aspects of the milieu include activities, rules, reality orientation practices, and environment)

Question 35

Peplau’s Therapeutic Milieu (2)

Answer 35

- recognizes the people (patients and staff), the setting, the structure, and the emotional climate as important to healing - offers patients a sense of security and promotes healing.

Question 36

4 steps of Milieu Therapy/Management

Answer 36

1. Orienting patients to rights and responsibilities 2. Providing culturally sensitive care 3. Selecting activities (individual & group) meet patients’ physical and mental health needs 4. Using the least restrictive environment (consistent and routine)

Question 37

Paraphrasing (2)

Answer 37

- when you restate the basic content of a patient’s message in different, usually fewer, words. - Using simple, precise, and culturally relevant terms, the nurse may confirm an interpretation of the patient’s message and patient confirms or denies

Question 38

Restating (3)

Answer 38

- Repeats the main idea expressed to give the patient an idea of what has been communicated. - If the message has been misunderstood, the patient can clarify it - avoid overuse

Question 39

Reflecting (4)

Answer 39

- Directs questions, feelings, and ideas back to the patient. - Encourages the patient to acknowledge and own personal ideas and inner feelings. - Encourages the patient to think of oneself as a capable person and acknowledges the patient’s right to have opinions and make decisions  - useful when patient asks for advice

Question 40

Exploring (2)

Answer 40

- Examines certain ideas, experiences, or relationships more fully by asking for more details - If the patient chooses not to elaborate by answering no, the nurse does not probe or pry.

Question 41

Using Silence (4)

Answer 41

- gives person time to collect thoughts or think through a point - some patients have slower thinking process - avoid with young people who may be uncomfortable with silence - allows patient to take control of the discussion if they desire

Question 42

Active Listening

Answer 42

-nurses focus, respond, and remember what patient says verbally and nonverbally

Question 43

Making Observations (4)

Answer 43

- Calls attention to the person’s behavior (i.e. trembling, nail-biting, restless mannerisms) - Encourages patient to notice the behavior and describe thoughts and feelings for mutual understanding. - Posture change, facial expressions, behavioral change, etc. → what happened? - Helpful with mute and withdrawn people

Question 44

Offering self

Answer 44

- offers presence, interest, desire to understand - not offered to get person to talk or behave in a specific way

Question 45

Offer General leads (2)

Answer 45

- allow patient to choose direction - indicates nurse is interested in what comes next

Question 46

Reflecting Examples (2)

Answer 46

Patient: “What should I do about my husband’s affair?” Nurse: “What do you think you should do?” OR Patient: “My brother spends all of my money and then has the nerve to ask for more.” Nurse: “You feel angry when this happens?”

Question 47

Making Observations Examples(3)

Answer 47

- “You appear tense.” - “I notice you’re biting your lips.” - “You seem nervous whenever John enters the room.”

Question 48

Open-ended questions (3)

Answer 48

- encourage patients to share information about experiences, perceptions, or responses to a situation. - not intrusive and do not put the patient on the defensive - useful in the beginning of an interview or when a patient is guarded or resistant to answering questions.

Question 49

Closed-ending questions (2)

Answer 49

- used sparingly, can give you specific and needed information. - most useful during an initial assessment, intake interview, or to determine specific results

Question 50

Projective questions

Answer 50

- usually start with a “what if” to help people articulate, explore, and identify thoughts and feelings.

Question 51

Miracle question

Answer 51

A goal-setting question that helps patients to see what the future would look like if a particular problem were to vanish

Question 52

Nontherapeutic communication (10)

Answer 52

- excessive questioning - Approval/disapproval- value judgement - giving advice or interpretations - probing on sensitive topics - force treatments - asking why - minimizing - false reassurance - changing subjects - participate in negative behavior

Question 53

4 Do’s in Client Interview (besides therapeutic communication)

Answer 53

- keep focus on facts and patient perceptions - pay attention to nonverbal communication - encourage patient to look at pros and cons of treatment - if patient makes serious accusations, explore with senior staff and clarify perceptions

Question 54

After introductions in the clinical interview, what should you do?

Answer 54

Turn conversation over to patient with an open-ended question

Question 55

Methadone Side effects (5)

Answer 55

- shallow or deep breathing - lightheadedness - chest pounding - hives and rashes - swelling of HEENT area

Question 56

Methadone (3 notes)

Answer 56

- synthetic slow acting agonist opioid (may have withdrawal symptoms), 1x a day - blocks euphoria, reduces cravings and prevents pure opioid withdrawal symptoms (lacrimation, rhinorrhea, pupillary dilation, yawning) - low dose = safest for pregnant women (neonatal withdrawal will be mild and managed w/ paregoric)

Question 57

6 Symptoms of Wernicke-Korsakoff Syndrome

Answer 57

* Altered gait * confusion * vestibular dysfunction * ocular motility abnormalities * sluggish reaction to light * anisocoria (unequal pupil size)

Question 58

Wernicke-Korsakoff Syndrome What is the cause? What is the treatment? What is the difference between the two?

Answer 58

- Wernicke’s encephalopathy: acute and reversible condition (responds rapidly to Thiamine over 1-2 weeks) - Korsakoff’s syndrome is severe and chronic version of Wernicke’s encephalopathy (treated w/ Thiamine but no full recovery) - Both due to thiamine deficiency from malnourishment (drinking over eating) or poor nutrition

Question 59

Normal anxiety

Answer 59

-Necessary for survival and provides energy to carry out tasks; constructive

Question 60

Mild Anxiety (3)

Answer 60

- Everyday problem-solving leverage to perceive reality in sharp focus - Grasps more information effectively - Coping mechanisms used

Question 61

Mild Anxiety symptoms (6)

Answer 61

- Slight discomfort - restlessness - attention-seeking behavior - easily startled - irritability/ impatience - mild tension-relieving behaviors (nail biting, fidgeting, finger taping)

Question 62

Moderate Anxiety (6)

Answer 62

- Selective inattention unless pointed out - Clear thinking hampered - Problem solving can happen, but not optimal - Defense mechanisms start here - can be constructive and indicate danger - SNS activation happens here

Question 63

Moderate Anxiety symptoms (6)

Answer 63

- muscle tension (and more tension relieving behaviors such as pacing, banging hands on table) - increase HR and RR - perspiration - mild somatic symptoms (gastric discomfort, headache, backache, urinary urgency, insomnia) - voice tremors and change in pitch - shakiness

Question 64

Severe level of Anxiety (4 notes)

Answer 64

- Perceptual field greatly reduced - Difficulty concentrating on environment even if pointed out - Dazed and Confused ; no problem solving or learning - all behavior is automatic and aimed at reducing anxiety

Question 65

Severe anxiety Physical Symptoms (5)

Answer 65

- more intense somatic (chest discomfort, nausea, dizziness, insomnia) - hyperventilation - trembling - pounding heart - diaphoretic

Question 66

Severe anxiety Psychological Symptoms (5)

Answer 66

* sense of impending doom and dread (purposelessness) * confusion * withdrawal * loud and rapid speech * threats and demands

Question 67

Panic level of Anxiety (4)

Answer 67

- Markedly dysregulated behavior and exhaustion - Unable to process reality and environment and may lose touch - life threatening - Automatic behaviors are used to reduce anxiety; may be ineffective*

Question 68

Panic level of Anxiety Symptoms (8)

Answer 68

* uncoordinated * erratic and impulsive ( including pacing, running, shouting, screaming) * severe withdrawal * hallucinations or delusions * terror * unintelligible communication (amplified or muffled speech) * somatic complaints increase (numbness, tingling, shortness of breath, dizziness, palpitations, overheating, chills, chest pain) * immobility or severe hyperactivity or flight

Question 69

How does anxiety level affect perceptual field?

Answer 69

Mild: heightened Moderate: narrowed, grasp less of what is going on Severe: greatly reduced and distorted Panic: unable to attend to environment

Question 70

How does anxiety level affect focus?

Answer 70

Mild: focus is flexible; aware of anxiety Moderate: focus on source of anxiety , less able to pay attention Severe: focuses on details or one specific detail, scattered attention Panic: focus is lost, may feel depersonalization or derealization

Question 71

How does anxiety level affect problem-solving ability?

Answer 71

Mild: ability to work effectively and examine alternatives Moderate: possible but not optimal Severe: feels impossible; unable to connect events and details Panic: completely unable to process what is happening; disorganized and irrational reasoning

Question 72

2 General Interventions for mild to moderate anxiety

Answer 72

- use therapeutic communication and calm presence techniques - closing off topics and bring up irrelevant details can increase anxiety

Question 73

3 general Interventions for severe to panic anxiety

Answer 73

- priority interventions are patient safety and meeting physical needs; seclusion and restraints may be necessary - they are unable to problem solve so therapeutic communication ineffective - focus on reinforcing environment and reality

Question 74

Antidepressants used for Anxiety disorders (8)

Answer 74

-1st line of defense and treat comorbid depression SSRIs - fluoxetine and sertraline are most activating - paroxetine is more calming - escitalopram - Fluvoxamine (for OCD) SNRIs Venlafaxine-for anxiety, depression, nerve pain Duloxetine (GAD) TCA (clomipramine for OCD)

Question 75

Usage of Benzodiazepines for Anxiety (4 notes) Ex: clonazepam, diazepam, lorazepam, chlordiazepoxide, Alprazolam (short term for PD and agoraphobia)

Answer 75

- antianxiety (treat somatic and psychological symptoms) - quick onset - dependence and paradoxical reactions - not recommended in pregnancy, older adults, comorbid SUD

Question 76

Usage of antihistamines for Anxiety

Answer 76

Hydroxyzine; safe non addictive alternative to benzodiazepines

Question 77

Usage of Buspirone for anxiety (5)

Answer 77

- antianxiety (treat somatic and psychological symptoms) - no dependence or CNS depressant - 2-4 weeks for full effect (effects start in 1-2 weeks) - not recommended for those with impaired hepatic, renal - safe for fetus

Question 78

Usage of anticonvulsants for Anxiety Ex. gabapentin, pregabalin

Answer 78

- for GAD and social anxiety

Question 79

Usage of antipsychotics for Anxiety

Answer 79

Only for more severe symptoms

Question 80

Usage of noradrenergic drugs for Anxiety (3)

Answer 80

- slow HR and BP - Propranolol-short-term relief social anxiety - Clonidine- PD and other anxiety

Question 81

Intervention for mild to moderate anxiety: Help the patient identify anxiety. “Are you comfortable right now?” What is the rationale:

Answer 81

Rationale: It is important to validate observations with the patient, name the anxiety, and start to work with the patient to lower anxiety.

Question 82

Intervention for mild to moderate anxiety: Use nonverbal language to demonstrate interest (e.g., lean forward, maintain eye contact, nod your head) What is the rationale:

Answer 82

Rationale: Verbal and nonverbal messages should be consistent. The presence of an interested person provides a stabilizing focus.

Question 83

Intervention for mild to moderate anxiety: Encourage the patient to talk about feelings and concerns. What is the rationale:

Answer 83

Rationale: When concerns are stated aloud, problems can be discussed and feelings of isolation decreased.

Question 84

Intervention for mild to moderate anxiety: Avoid closing off avenues of communication that are important to the patient. Focus on the patient’s concerns. What is the rationale:

Answer 84

Rationale: When staff anxiety increases, changing the topic or offering advice is common but leaves the person isolated.

Question 85

Intervention for mild to moderate anxiety: Help the patient to identify thoughts or feelings before the onset of anxiety. “What were you thinking right before you started to feel anxious?” What is the rationale:

Answer 85

Rationale: The patient is helped to identify thoughts and feelings, and problem solving is facilitated.

Question 86

Intervention for mild to moderate anxiety: Help the patient to develop alternative solutions to a problem through role-play or modeling behaviors. What is the rationale:

Answer 86

Rationale: Encouraging patients to explore alternatives increases their sense of control and decreases anxiety.

Question 87

Intervention for mild to moderate anxiety: Explore behaviors that have worked to relieve the patient’s anxiety in the past. What is the rationale:

Answer 87

Rationale: The patient is encouraged to mobilize successful coping mechanisms and strengths

Question 88

Intervention for mild to moderate anxiety: Provide outlets for working off excess energy (e.g., walking, playing ping-pong, dancing, exercising). What is the rationale:

Answer 88

Rationale: Physical activity can provide relief of built- up tension, increase muscle tone, and increase endorphin levels.

Question 89

Intervention for mild to moderate anxiety: Anticipate anxiety-provoking situations. What is the rationale:

Answer 89

Rationale: “Escalation of anxiety to a more disorganizing level is prevented.”

Question 90

Intervention for severe to panic anxiety: Use a low-pitched voice; speak slowly. What is the rationale:

Answer 90

Rationale: A high-pitched voice can convey anxiety. Low pitch can decrease anxiety.

Question 91

Intervention for severe to panic anxiety: Reinforce reality if distortions occur (e.g., seeing objects that are not there or hearing voices when no one is present). What is the rationale:

Answer 91

Rationale: Anxiety can be reduced by focusing on and validating what is going on in the environment.

Question 92

Intervention for severe to panic anxiety: Listen for themes in communication. What is the rationale:

Answer 92

Rationale: verbal communication themes may be the only indication of the patient’s thoughts or feelings.

Question 93

Intervention for severe to panic anxiety: Attend to physical and safety needs when necessary (e.g., need for warmth, fluids, elimination, pain relief, family contact) What is the rationale:

Answer 93

Rationale: High levels of anxiety may obscure the patient’s awareness of physical needs

Question 94

Intervention for severe to panic anxiety: Physical limits may have to be set. Speak in a firm, authoritative voice What is the rationale:

Answer 94

Rationale: A person who is out of control is often terrorized. Staff must offer the patient and others protection from destructive and self- destructive impulses.

Question 95

Intervention for severe to panic anxiety: Provide opportunities for exercise (e.g., walk with nurse, punching bag, ping- pong game). What is the rationale:

Answer 95

Rationale: Physical activity helps channel and dissipate tension and may temporarily lower anxiety.

Question 96

Intervention for severe to panic anxiety: When a person is constantly moving or pacing, offer high-calorie fluids. What is the rationale:

Answer 96

Rationale: Dehydration and exhaustion must be prevented.

Question 97

Intervention for severe to panic anxiety: Assess need for medication or seclusion after other interventions have been tried and have been unsuccessful. What is the rationale:

Answer 97

Rationale: Exhaustion and physical harm to self and others must be prevented.

Question 98

Obsessions

Answer 98

thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind -seem senseless and cause distress and anxiety

Question 99

Compulsions (3)

Answer 99

- Ritualistic behaviors an individual feels driven to perform - temporaily reduce anxiety or prevent imagined calamity - time-consuming and interfere with function

Question 100

Why should you not stop people doing compulsions? What should you do instead?

Answer 100

Do not stop people while doing obsessions and compulsions because they do it to relieve their anxiety. Stopping them will increase their anxiety. You should wait for them to finish Nurse should relieve anxiety, not control behavior

Question 101

Bipolar I disorder (3)

Answer 101

- most severe bipolar; shifts in mood, energy, and ability to function - at least one Mania episode followed by hypomanic or major depressive episode - chronic interpersonal or occupational difficulties exist even during remission

Question 102

Hypomania (3)

Answer 102

- low-level and less dramatic mania; euphoric and increases functioning for at least 4 days - psychosis is never present; hospitalization is rare - usually does not impact social or occupational functioning in a way noticeable to others

Question 103

How does mood look in bipolar disorder? (3)

Answer 103

- Unstable euphoria that could quickly change to irritation and anger - Boundless enthusiasm, friendliness, self-confidence - More time depressed vs manic

Question 104

How does behavior look in bipolar? (5)

Answer 104

o Big appetites for social, spending, activities, sex o Makes grand plans and stays busy all hours of day and night o Easily distracted o May manipulate and exploit vulnerabilities of others o May skip sleep for days -> worsens mania and physical exhaustion

Question 105

Pressured speech

Answer 105

fast (rapid to frenetic) with inappropriate sense of urgency; often loud and incoherent; individual may dominate conversation

Question 106

Circumstantial speech

Answer 106

addition of unnecessary details when communicating; person eventually gets to the point

Question 107

Tangential speech

Answer 107

similar to circumstantial speech, but they forget the point but often a common word connects sentences to each other (awareness of losing the point and less tangential speech indicate less thought disturbance)

Question 108

Name the Thought Process: Ex. I had to do my laundry that day because it was Saturday. On Saturday, I always watch Ninja Turtles on television. Have you seen those 60-inch televisions? Giants. I used to think of giants as I fell asleep, and I thought that sleep activated them.

Answer 108

Tangenital speech

Question 109

Loose associations

Answer 109

disordered way of processing information; thoughts are only loosely connected to each other in person’s conversation

Question 110

Name the thought process Ex. The sky’s the limit now that I have money. I took a flight, you know, from Kennedy. Drinking beer is a belly full of bags

Answer 110

Loose associations

Question 111

Flight of ideas (2)

Answer 111

continuous flow of rapid, verbose, circumstantial speech with abrupt changes from topic to topic Speech may be disorganized and incoherent; often uses associations, plays on words, jokes, teasing

Question 112

Name the thought process: How are you doing, kid, no kidding around, I’m going home … home sweet home … home is where the heart is, the heart of the matter is I want out and that ain’t hay … hey, Doc … get me out of this place.

Answer 112

Flight of ideas

Question 113

Clang associations (and when it happens)

Answer 113

stringing together of words because of their rhyming sounds, w/o regard to meaning may happen after flight of ideas as mania escalates

Question 114

Name the thought process: Cinema I and II, last row. Row, row, row your boat. Don’t be a cutthroat. Cut your throat. Get your goat. Go out and vote. And so I wrote.

Answer 114

Clang associations

Question 115

Grandiose delusions

Answer 115

highly inflated self-regard; apparent in both ideas expressed and person’s behavior (religious, science fiction, supernatural themes are common) ex. Brianna believes she is a famous playwriter | seen in schizophrenia and bipolar

Question 116

Persecutory delusions

Answer 116

common in bipolar and Schizo; Believing that one is being singled out for harm or prevented from making progress by others Ex. God or FBI is watching

Question 117

5 barriers to bipolar treatment

Answer 117

- individuals often ambivalent (avg. 10 yrs before getting treatment) - lack of adherence to mood stabilizers often leads to relapse. - self-medicating w/ alcohol complicates things and delays treatment - patients may minimize or deny consequences of their behavior - patient may be reluctant to give up the mania or hypomania

Question 118

When is hospitalization indicated for bipolar depressive episodes?

Answer 118

when suicidal ideation, psychosis, catatonia

Question 119

What is purpose of hospitalization in acute mania ? (3)

Answer 119

a. provide safety in BPD I mania via imposing external control and stabilizing with medication b. limits set in firm, nonthreatening, and neutral manner to prevent escalation of behavior and safe boundaries c. Ensure structure, clear expectations, needs are met (nutrition, sleep, hygiene, elimination)

Question 120

What is the rationale for the following intervention in bipolar ? Use firm and calm approach: “John, come with me. Eat this sandwich.”

Answer 120

Structure and control are provided for a patient who is out of control. Believing that someone is in control may improve feelings of security.

Question 121

What is the rationale for the following intervention in bipolar? Use short and concise explanations or statements.

Answer 121

Structure and control are provided for a patient who is out of control. Believing that someone is in control may improve feelings of security.

Question 122

What is the rationale for the following intervention in bipolar? Be consistent in approach and expectations.

Answer 122

Consistent limits and expectations minimize potential for patient’s manipulation of staff.

Question 123

What is the rationale for the following intervention in bipolar? Identify expectations in simple, concrete terms with consequences. Example: “John, do not yell at or hit Peter. If you cannot control yourself, we will help you.” Or “The seclusion room will help you feel less out of control and prevent harm to yourself and others.”

Answer 123

Clear expectations help the patient experience outside controls as well as understand reasons for medication, seclusion, or restraints (if he or she is not able to control behaviors).

Question 124

What is the rationale for the following intervention in bipolar? Hear and act on legitimate complaints.

Answer 124

Underlying feelings of helplessness are reduced, and acting-out behaviors are minimized.

Question 125

What is the rationale for the following intervention in bipolar ? Firmly redirect energy into more appropriate and constructive channels.

Answer 125

Distractibility is the most effective tool with the patient experiencing mania.

Question 126

What is the rationale for the following intervention in bipolar? Maintain low level of stimuli in patient’s environment (e.g., away from bright lights, loud noises, and people).

Answer 126

Escalation of anxiety can be decreased.

Question 127

What is the rationale for the following intervention in bipolar ? Provide structured solitary activities with nurse or aide.

Answer 127

Structure provides security and focus.

Question 128

What is the rationale for the following intervention in bipolar? Provide frequent high-calorie fluids.

Answer 128

Serious nutritional deficiencies and dehydration are addressed.

Question 129

What is the rationale for the following intervention in bipolar? Redirect aggressive behavior.

Answer 129

Physical exercise can decrease tension and provide focus.

Question 130

What is the rationale for the following intervention in bipolar? In acute mania, use as needed medication, seclusion, and/or restraint to minimize physical harm.

Answer 130

Exhaustion can result from dehydration, lack of sleep, and constant physical activity.

Question 131

What is the rationale for the following intervention in bipolar ? Encourage frequent rest periods during the day.

Answer 131

Lack of sleep can lead to exhaustion and increase mania.

Question 132

What is the rationale for the following intervention in Bipolar Disorder? Keep patient in areas of low stimulation.

Answer 132

Relaxation is promoted, and manic behavior is minimized.

Question 133

What to note about taking lithium? (4)

Answer 133

- Not addictive but taper dose to reduce relapse of mania though - maintain sodium and fluid levels( 1500–3000 mL/day or six 12-oz glasses of fluid) - take with meals to reduce stomach irritation) - narrow therapeutic range so check levels regularly

Question 134

Signs of <1.5 mEq/L Lithium toxicity (8)

Answer 134

- N/V/D - thirst - polyuria (producing too much urine) - lethargy, sedation - fine hand tremor - Renal toxicity - goiter - hypothyroidism

Question 135

Interventions of <1.5 mEq/L Lithium toxicity (2)

Answer 135

Doses should be kept low. assess Kidney function and thyroid levels before treatment and then on an annual basis.

Question 136

Interventions of 1.5-2.0 mEq/L early Lithium toxicity (3)

Answer 136

-hold medication -measure blood lithium levels -reevaluate dosage

Question 137

Signs of 1.5-2.0 mEq/L early Lithium toxicity (7)

Answer 137

- GI upset - coarse hand tremor - confusion - hyperirritability of muscles, - EEG changes - sedation - incoordination

Question 138

Signs 2.0–2.5 mEq/L advanced Lithium toxicity (8)

Answer 138

* Ataxia/ giddiness * serious EEG changes * blurred vision * clonic or seizure movements * large output of dilute urine * severe hypotension * coma/ stupor * Death is usually secondary to pulmonary complications.

Question 139

Interventions of 2.0–2.5 mEq/L advanced Lithium toxicity (3)

Answer 139

- hospitalization - hold drug and haste excretion - Whole bowel irrigation may be done to prevent further absorption

Question 140

Signs of >2.5 mEq/L severe Lithium toxicity (3)

Answer 140

convulsions, oliguria (none or small amount of urine), death

Question 141

Interventions of >2.5 mEq/L severe Lithium toxicity

Answer 141

-same as others plus hemodialysis

Question 142

5 precautions for lithium

Answer 142

avoid diuretics, NSAIDS, if N/V/D present

Question 143

When are anticonvulants used in bipolar? (5)

Answer 143

o continuously cycling patients o no family history of bipolar o to diminish impulsive and aggressive behavior in nonpsychotic pts o useful when alcohol or benzodiazepine withdrawal o useful to control mania (within 2 wks) and depression (within 3 wks)

Question 144

Valporate usage

Answer 144

- FDA approved anticonvulsant for acute mania and preventing future manic episodes; black box warning though for teratogenicity o Divalproex and valproic acid

Question 145

Verbal and nonverbal cues of suicide (2)

Answer 145

- Clues may be in overt/open or concealed/covert statements to someone patient trusts like nurse) - be wary of sudden bursts in energy, giving away possessions

Question 146

5 Hard methods of suicide

Answer 146

gun, hanging, poison, car crash, jumping

Question 147

3 soft methods of suicide

Answer 147

pills, gases, cutting wrists

Question 148

6 specific questions to ask about suicide

Answer 148

* Have you ever felt that life was not worth living? * Have you been thinking about death recently? * Do you ever think about suicide? * Have you ever attempted suicide? * Do you have a plan for ending your life? * If so, what is your plan for suicide?

Question 149

What are four suicide precautions in the hospital?

Answer 149

- One-to-one observation, 24hrs - Record mood, verbatim statements, behavior (esp hands) - Remove glass, silverware, "sharps", strangulation risks - Observe patient swallowing medication

Question 150

Persistent Depressive disorder (3)

Answer 150

- chronic low-level depression most of the day for the majority of days AND at least two of the following: increased/decreased appetite, insomnia/hypersomnia, low energy, poor self-esteem, difficulty thinking, hopelessness - feelings last 2 yrs in adults, 1 yr in children and adolescents; often early onset - not severe enough for hospitalization

Question 151

Major depressive disorder (3)

Answer 151

- persistent depression lasting a minimum of 2 weeks (may last 5-6 months or even > 2 yrs) - Primary symptoms: depressed mood, loss of interest/pleasure - Secondary symptoms: significant weight changes, insomnia or hypersomnia, psychomotor retardation or agitation, fatigue, feeling worthless, thinking problems, thoughts on death (suicidal ideation, hx of suicide, suicide plan)

Question 152

Appearance in depression (3)

Answer 152

neglected personal hygiene, grooming, dressing; lack of eye contact; slumped posture

Question 153

Behavior in depression (5)

Answer 153

* Anergia (abnormal lack of energy) * psychomotor retardation (fixed gaze, slow movements, lack of facial expressions, even incontinence) * some have psychomotor agitation (pacing, tension-relieving behaviors) * Vegetative signs of depression (alteration in physical life and growth activities) including appetite changes, bowel changes, sleep disturbance * low libido or impotence

Question 154

Feelings and Emotions in depression (5)

Answer 154

specific and can change quickly - worthlessness (inadequate to unrealistic negative self-eval), - guilt (ruminate over failures), - helplessness (inability to problem solve) - hopelessness (^ suicidality), - anger and irritability (active byproducts)

Question 155

Affect vs mood in depression

Answer 155

Mood is general emotional state (often depressed) Affect is outward emotional state; may be congruent or incongruent with mood (often constricted, blunt, or flat)

Question 156

Speech in depression

Answer 156

slow and softy; may also be monotone and lack spontaneity

Question 157

Thought Processes in depression

Answer 157

poverty of thought (slow thinking), responses slow or absent, may even be mute in severe depression

Question 158

Thought content and perceptions in depression

Answer 158

psychosis (delusions and hallucinations) may be present and ^ suicidality; psychosis may be mood congruent or incongruent

Question 159

Cognitive Changes and judgement in depression

Answer 159

impaired concentration ( attention, short-term and working memory, verbal and nonverbal learning) which may linger after treatment -poor judgment may lead to indecisiveness

Question 160

What may be used if someone acutely suicidal since antidepressants have slow onset?

Answer 160

Electroconvulsive therapy

Question 161

What do all antidepressants have in common? (5)

Answer 161

- All have similar efficacy( in improving self-concept, social withdrawal, vegetative signs, activity level) - May induce psychotic or manic episode in those with schizophrenia or bipolar disorder - All have delayed response (3 month trials)--1-3 wks for improvement to be seen, maintain for 6-9 months after remission of symptoms - discontinuation syndrome - black box warning for suicidal thoughts and behaviors

Question 162

4 things to note about SSRIs and depression

Answer 162

- 1st line of treatment for major depression (w/ anxiety and psychomotor agitation as well) - Some SSRIs activate and others sedate; choice depends on patient symptoms - Risk of lethal overdose minimized with SSRIs - low side-effect profile and no anticholinergic effects

Question 163

4 Patient teaching for MAOI

Answer 163

- give wallet card with MAOI regimen - avoid asian restaurants - go to ED immediately if severe headache - maintain dietary and drug restrictions for 14 days after MAOI stopped

Question 164

Symptoms of MAOI hypertensive crisis (5 early)

Answer 164

Early symptoms: irritability, anxiety, flushing, sweating, and a severe headache.

Question 165

Symptoms of MAOI hypertensive crisis (4 late)

Answer 165

Late symptoms: severe fever, seizures, cerebrovascular accident, intracranial hemorrhage

Question 166

4 Other foods with Tyramine

Answer 166

protein dietary supplements, soups with protein extract, shrimp paste, soy sauce

Question 167

Food with yeast with Tyramine

Answer 167

yeast extract (marmite, bovril)

Question 168

milk products with Tyramine

Answer 168

most cheeses except cottage cheese, cream cheese, yogurt, and milk

Question 169

Fish with Tyramine

Answer 169

Dried or cured fish; fermented, smoked, aged, or spoiled fish

Question 170

Sausages with tyramine

Answer 170

fermented (bologna, pepperoni, salami)

Question 171

Meats with Tyramine

Answer 171

fermented, smoked, aged, spoiled meats, and liver, unless very fresh

Question 172

Fruits with tyramine

Answer 172

figs, bananas in large amounts

Question 173

Vegetables with tyramine

Answer 173

avocados, fermented bean curd, soybean or soybean paste

Question 174

3 MAOIs used in depression

Answer 174

Isocarboxazid, Phenelzine, and Selegiline (patch w/o strict diet at lowest dose),

Question 175

What is the rationale for the following intervention with depression: When a patient is silent, use the technique of making observations: “There are many new pictures on the wall.” “You are wearing your new shoes.”

Answer 175

When a patient is not ready to talk, direct questions can raise the patient’s anxiety level and frustrate the nurse. Pointing to commonalities in the environment draws the patient into and reinforces reality.

Question 176

What is the rationale for the following intervention with depression: Avoid platitudes such as “Things will look up” or “Everyone gets down once in a while.”

Answer 176

Platitudes tend to minimize the patient’s feelings and can increase feelings of guilt and worthlessness because the patient cannot “look up” or “snap out of it.”

Question 177

What is the rationale for the following intervention with depression: Use simple, concrete words.

Answer 177

Slowed thinking and difficulty concentrating impair comprehension.

Question 178

What is the rationale for the following intervention with depression: Allow time for the patient to respond.

Answer 178

Slowed thinking necessitates time to formulate a response.

Question 179

What is the rationale for the following intervention with depression: Listen for covert messages, and ask about suicide plans.

Answer 179

People often experience relief and decrease in feelings of isolation when they share thoughts of suicide.

Question 180

What is the rationale for the following intervention with depression: Encourage formation of supportive relationships, such as individual therapy, support groups, and peer support.

Answer 180

Such relationships reduce social isolation and enable the patient to work on personal goals and relationship needs.

Question 181

What is the rationale for the following intervention with depression: Provide information referrals, when needed, for religious or spiritual support

Answer 181

Spiritual and existential issues may ^ during episodes; people find strength, support, and comfort in spirituality or religion

Question 182

What should you know about furosemide?

Answer 182

It is a diuretic which can promote sodium loss and thereby increase the risk for lithium toxicity Toxicity can occur because in the presence of low sodium, renal excretion of lithium is reduced, causing lithium levels to rise

Question 183

What is the rationale for the following intervention with depression: Work with the patient to identify cognitive distortions that result in a negative self-perception. For example: 1. Overgeneralizations 2. Self-blame 3. Mind reading 4. Discounting of positive attributes

Answer 183

Cognitive distortions reinforce a negative inaccurate perception of self and world. 1. Taking one fact or event and making a general rule out of it (“He always…”; “I never…”). 2. Consistently blaming self. 3. Despite a lack of evidence, assumes that others don’t like him or her. 4. Focusing on the negative

Question 184

Delusions

Answer 184

false beliefs that are held despite a lack of evidence to support them

Question 185

Referential delusion and example

Answer 185

A belief that events or circumstances that have no connection to you are somehow related to you Ex. Sarah believes that songs on the radio are chosen to send her a message.

Question 186

Somatic delusion and example

Answer 186

Believing that the body is changing in unusual ways Ex. Chris says that her heart is dead and rotting away.

Question 187

Control delusion and example

Answer 187

Believing that another person, group, or external force controls your feelings, impulses, or behavior Ex. Brian covered his apartment walls with aluminum foil to block aliens’ efforts to control his thoughts

Question 188

Nihilistic delusion and example

Answer 188

The conviction that a major catastrophe will occur Ex. Deepesh is giving away all his belongings since they won’t be of any use when the comet hits.

Question 189

Word Salad and example

Answer 189

Extreme associative looseness; jumble of words which are meaningless to listener Ex: agents want strength of policy on a boat reigning supreme

Question 190

Echolalia

Answer 190

pathological repetition of another’s words, may be due to patient’s thought processes being so impaired that they are unable to generate speech of their own.

Question 191

Neologism

Answer 191

Words that have meaning for patient but a different or nonexistent meaning of others Ex. His mannerologies are poor

Question 192

Paranoia

Answer 192

An irrational fear, ranging from mild (being suspicious, wary, guarded) to profound (believing irrationally that another person intends to kill you)

Question 193

Why is paranoia dangerous in the schizophrenic?

Answer 193

may result in dangerous defensive actions such as harming another person before that person can harm the patient”

Question 194

Hallucinations

Answer 194

perception of sensory experience for which no external source exists

Question 195

4 ways to recognize person is experiencing an auditory hallucination

Answer 195

1. tracking motions (turning one’s head in the direction of the perceived sound) 2. lips moving silently 3. talking as if to another when no one is present 4. otherwise unexplained changes in affect (e.g., suddenly laughing with no apparent reason).

Question 196

Why are command hallucinations particularly concerning?

Answer 196

particularly concerning because person is directed to take action and may be warning of a psychiatric emergency

Question 197

Three things to assess in a patient whom you feel is experiencing command hallucinations?

Answer 197

1. Assess what patient hears 2. the source it is attributed to 3. patient’s ability to recognize the hallucination as not real and resist commands

Question 198

Catatonia (definition, most common, persistent impact)

Answer 198

pronounced increase or decrease in the rate and amount of movement. Most common form is when the person moves little or not at all Persistent catatonia may contribute to rigidity/catalepsy, exhaustion, pneumonia, blood clotting, malnutrition, or dehydration -in schizophrenia

Question 199

Motor retardation or agitation

Answer 199

Pronounced slowing of movement or excited behavior in response to internal or external stimuli. -in schizophrenia

Question 200

Stereotyped behaviors

Answer 200

Repetitive behaviors that do not serve a logical purpose -in schizophrenia

Question 201

Echopraxia

Answer 201

The mimicking of movements of another -in schizophrenia

Question 202

Impaired impulse control

Answer 202

A reduced ability to resist one’s impulses. Ex: interrupting others or throwing unwanted food on the floor; increases risk of assault. -in schizophrenia, ADHD, borderline

Question 203

Boundary impairment

Answer 203

An impaired ability to sense where one’s body or influence ends and another’s begins -in schizophrenia

Question 204

5 negative symptoms of schizophrenia

Answer 204

Anhedonia (lack of pleasure) Avolition (lack of goal-directed behavior or motivation) Asociality (decreased desire for social interaction) Apathy (decreased interest in activities) Alogia (reduction in speech)

Question 205

5 affects seen in schizophrenia

Answer 205

i. Flat: Immobile or blank facial expression ii. Blunted: Reduced or minimal emotional response iii. Constricted: Reduced in range or intensity (e.g., shows sadness or anger but no other moods) iv. Inappropriate: Incongruent with the actual emotional state or situation (e.g., laughing in response to a tragedy) v. Bizarre: Odd, illogical, inappropriate, or unfounded; includes grimacing

Question 206

Concrete thinking in Schizophrenia

Answer 206

impaired ability to think abstractly and respond or understand things like humor, love, sarcasm or recognize social cues

Question 207

4 Interventions for managing delusions

Answer 207

1. Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner. 2. Avoid questioning the delusion itself 3. Focus on the feelings or themes within the delusion. (Ex. If a patient believes that he is a famous leader, comment: “It would feel good to be more powerful.” If the patient believes that others intend to hurt him, comment: “It must feel frightening to believe others want to hurt you.) 4. Focus on helping patient feel safe and identify triggers

Question 208

Why should you not question delusions? What should you do instead?

Answer 208

Trying to prove the delusion is incorrect can intensify the delusion and cause patient to view staff as people who cannot be trusted You can clarify misinterpretations of the environment and gently suggest more reality-based perspective

Question 209

Treatment for Tardive Dyskinesia

Answer 209

valbenazine and deutetrabenazine which reduce the severity of abnormal movements in tardive dyskinesia but tardive does not go away completely Adverse effects: sleepiness and QT prolongation.

Question 210

What can you do if Tardive dyskinesia develops?

Answer 210

Switch to a SGA OR reduce or (paradoxically) increase FGA dosage can help too

Question 211

Tardive Dyskinesia

Answer 211

persistent EPS involving involuntary rhythmic movements usually after prolonged treatment and persists after the medication has been discontinued

Question 212

5 points on Tardive Dyskinesia

Answer 212

- More common with FGAs - Increased risk with smoking, alcohol, stimulant use - Usually begins in oral and facial muscles and progresses to include the fingers, toes, neck, trunk, or pelvis. - More common in women - varies from mild to severe, and can be disfiguring or incapacitating

Question 213

Clozapine 5 problems

Answer 213

severe neutropenia myocarditis new onset diabetes life-threatening bowel emergencies ketoacidosis

Question 214

What is the impact of SUD on some psychiatric medications? (2 notes)

Answer 214

- Substance use disorders affect the majority of people with schizophrenia and can intensify symptoms and cause relapse. - SUD can decrease effectiveness of some psychiatric meds

Question 215

Severe neutropenia Symptoms (3)

Answer 215

reduced neutrophil counts (<500), increased frequency and severity of infections, Any symptoms suggesting infection (e.g., sore throat, fever, malaise, body aches) should be carefully evaluated.

Question 216

3 things to note about severe neutropenia

Answer 216

-more common with Clozapine -Left untreated, this life-threatening condition leads to death, most commonly through bacterial infection of the blood, or septicemia. -some groups naturally have low ANC levels and this does not make them more susceptible

Question 217

4 notes on Somatic Symptom Disorder

Answer 217

-often have high level of help seeking but rarely eases concerns -often multiple symptoms and one is severe (usually pain is primary symptom and subjective) -suffering is real and patient often has high functional impairement -often these individuals are hard on themselves and have limited self-compassion

Question 218

Somatic Symptom Disorder

Answer 218

focus on somatic/physical symptoms to point of excessive concern, preoccupation, and fear; used to be hypochondriasis

Question 219

4 treatments for Somatic Symptom Disorder

Answer 219

-hypnotherapy with strong, supportive approach useful -avoid repetitive and unnecessary testing -CBT and medication helpful -TCA (amitriptyline) and SSRI (fluoxetine)

Question 220

5 common somatic symptoms

Answer 220

a. head pain b. back pain c. chest pain d. paralysis e. unexplained skin rashes

Question 221

5 notes on Illness Anxiety Disorder

Answer 221

- frequent self-scanning for signs of illness (extreme fear and worry about possibility of having a disease) - chronic and relapsing esp w/ stress, depression, and loneliness - actual symptoms and complaints of symptoms are mild or absent - thoughts about illness are intrusive and hard to dismiss even when patient realizes their fears are unrealistic - may be reassurance seekers or care avoiders

Question 222

3 guidelines for Nursing Care with Illness Anxiety Disorder

Answer 222

- allow time to discuss illness concerns, but limit amount of time in favor of other topics - emphasize and reassure patient that psychiatric care will supplement medical care; not replace it - encourage socialization due to loneliness relation

Question 223

3 treatments for Illness Anxiety Disorder

Answer 223

- symptomatic pain relief with NSAIDs, laxatives, complementary medicine - SSRIs may treat anxiety - ECT and CBT useful as well

Question 224

Conversion Disorder (3)

Answer 224

- functional neurological disorder; neurological symptoms in absence of a neurological diagnosis - deficits in voluntary motor or sensory functions (paralysis, blindness, movement, gait disorder, numbness, paresthesia) - emotional conflicts or stressors manifest in physical symptoms

Question 225

La belle Indifference

Answer 225

in Conversion disorder; aspect where patients show lack of emotional concern about often dramatic symptoms; despite this providers should assume organic cause of symptoms until ruled out

Question 226

2 Guidelines for Nursing Care of Conversion Disorder

Answer 226

- avoid direct confrontation of the conversion symptom - provide reassurance and support for the patient’s feelings and beliefs

Question 227

4 Treatments for Conversion Disorder

Answer 227

- hypnosis-> rapid resolution - Narcoanalysis with amobarbital -> immediate cessation of symptoms - body-oriented psychological therapy (use nonverbal expressive behavior to expression of emotions with change) - PT for motor symptoms

Question 228

6 general recommendations for Somatic Symptom Disorder

Answer 228

1. Provide continuity of care. 2. Avoid unnecessary tests and procedures. 3. Provide frequent, brief, and regular office visits. 4. Always conduct a physical examination. 5. Avoid making disparaging comments such as “Your symptoms are all in your head.” 6. Set reasonable therapeutic goals such as maintaining function despite ongoing pain.”

Question 229

Treatment of Factitious Disorder (2)

Answer 229

- CBT - no benefit from various medical interventions such as antidepressants and antipsychotics

Question 230

Factitious Disorder

Answer 230

consciously controlled and compulsive; pretend to be ill (physical or psychiatric) to have their emotional needs met and achieve status of patient

Question 231

3 notes on Factitious disorder

Answer 231

-dramatic fabrication or self-infliction of violence with goal of assuming sick role; unusually proper medical terminology -often conceals true nature of their alleged illness through deception -may be imposed on self or on another

Question 232

What is the rationale for the following Intervention in Somatic Symptom Disorder: Offer explanations and support during diagnostic testing.

Answer 232

Reduces anxiety while ruling out organic illness

Question 233

What is the rationale for the following Intervention in Somatic Symptom Disorder: After physical complaints have been investigated, avoid further reinforcement (e.g., do not take vital signs each time patient complains of palpitations).

Answer 233

Directs focus away from physical symptoms

Question 234

What is the rationale for the following Intervention in Somatic Symptom Disorder: Observe and record frequency and intensity of somatic symptoms. (Patient or family can give information.)

Answer 234

Establishes a baseline and later enables evaluation of effectiveness of interventions

Question 235

What is the rationale for the following Intervention in Somatic Symptom Disorder: Spend time with patient at times other than when patient summons nurse to voice physical complaint.

Answer 235

Rewards non-illness-related behaviors and encourages repetition of desired behavior

Question 236

What is the rationale for the following Intervention in Somatic Symptom Disorder: Do not imply that symptoms are not real.

Answer 236

Acknowledges that symptoms are real to the patient

Question 237

What is the rationale for the following Intervention in Somatic Symptom Disorder: Use matter-of-fact approach to patient exhibiting resistance or covert anger.

Answer 237

Avoids power struggles; demonstrates acceptance of anger and permits discussion of angry feelings

Question 238

What is the rationale for the following Intervention in Somatic Symptom Disorder: Shift focus from somatic complaints to feelings or to neutral topics.

Answer 238

Conveys interest in patient as a person rather than in patient’s symptoms; reduces need to gain attention via symptoms

Question 239

What is the rationale for the following Intervention in Somatic Symptom Disorder: Have patient direct all requests to case manager.

Answer 239

Reduces manipulation

Question 240

What is the rationale for the following Intervention in Somatic Symptom Disorder: Help patient look at effect of illness behavior on others.

Answer 240

Encourages insight; can help improve intrafamily relationships

Question 241

What is the rationale for the following Intervention in Somatic Symptom Disorder: Teach assertive communication.

Answer 241

Provides patient with a positive means of getting needs met; reduces feelings of helplessness and need for manipulation

Question 242

What is the rationale for the following Intervention in Somatic Symptom Disorder: Show concern for patient while avoiding fostering dependency needs.

Answer 242

Shows respect for patient’s feelings while minimizing secondary gains from “illness”

Question 243

What is the rationale for the following Intervention in Somatic Symptom Disorder: Reinforce patient’s strengths and problem-solving abilities.

Answer 243

Contributes to positive self-esteem; helps patient realize that needs can be met without resorting to somatic symptoms

Question 244

1. Depression and anxiety are common comorbidities associated with somatic symptom disorders. Which of the following medications would the nurse anticipate the provider to prescribe for a patient diagnosed with a somatic symptom disorder and comorbid anxiety? a. Paroxetine b. Lithium c. Risperidone d. Buspirone e. Phenelzine f. Lorazepam

Answer 244

a. Paroxetine d. Buspirone

Question 245

PTSD (definition and 3 notes)

Answer 245

- persistent re-experiencing of a highly traumatic event (actual or threatened death or serious injury to self or others) - can occur after any traumatic event outside range of usual experiences (includes diagnosis with life-threatening illness or treatment for serious illness) - symptoms appear anywhere from 1 month to years after exposure - person often does not know where symptoms are coming from, so patient attributes them to present circumstances and past becomes present

Question 246

5 major features of PTSD

Answer 246

1. Re-experiencing the trauma through recurrent intrusive recollections of the event (flashbacks) or dreams about the event. 2. Avoidance of stimuli associated with the trauma (activities, people, or places) --avoidance is accompanied by feelings of detachment, emptiness, and numbing. 3. Persistent symptoms of increased arousal, as evidenced by irritability, difficulty sleeping, difficulty concentrating, hypervigilance, or exaggerated startle response. 4. Alterations in mood, such as chronic depression, negative appraisals, and lack of interest in previously pleasurable activities 5. Numbness

Question 247

General Treatment for PTSD

Answer 247

Primary is psychotherapy -antidepressants used for depression, anxiety, sleep problems and concentration (SSRIs-sertraline, paroxetine)

Question 248

A client with a dementia diagnosis is throwing their dentures, screaming at staff, and trying to climb out the window. Which intervention is most appropriate for this patient? A. Medicate the client with risperdal by mouth B. Call the house supervisor for a sitter C. Medicate the client with prn lorazepam by injection D. Apply four-point restraints

Answer 248

C. Medicate the client with prn lorazepam by injection

Question 249

Symptoms of PTSD and ASD

Answer 249

Display 8 of 14 symptoms: - A subjective sense of numbing - Derealization (a sense of unreality related to the environment) - Inability to remember at least one important aspect of the event - Intrusive distressing memories - Recurrent distressing dreams - Feeling as if the event is recurring - Intense prolonged distress - Avoidance of thoughts about the event - Sleep disturbances - Hypervigilance - Irritable, angry, or aggressive behavior - Exaggerated startle response - Agitation or restlessness

Question 250

Acute Stress Disorder (2)

Answer 250

- after exposure to highly traumatic event - diagnosed 3 days to 1 month after the traumatic event (after 1 month resolves or becomes PTSD)

Question 251

3 treatments of Adjustment Disorder

Answer 251

- psychotherapy to encourage verbalization of emotions - depressive symptoms treated with antidepressants - anxiety symptoms treated with benzodiazepines

Question 252

Adjustment Disorder (definition, time frame, symptoms)

Answer 252

- milder, less specific version of ASD and PTSD precipitated by stressful event but not as severe i.e retirement, chronic illness, breakup - diagnosed immediately or within 3 months - Symptoms: all forms of distress and physical complaints; role performance deficits

Question 253

Dissociation

Answer 253

unconscious defense mechanism which protects individual against overwhelming anxiety through an emotional separation which results in memory, perception, and identity disturbances -may serve protective function to decrease immediate distress of trauma (seen in children who cling to abusive caregivers

Question 254

Positive and negative symptoms of Dissociative Disorders

Answer 254

-Positive symptoms: unwanted additions of mental activity; flashbacks -Negative symptoms: memory problems; inability to sense or control different parts of the body

Question 255

Treatments of Dissociative Disorders (2)

Answer 255

- no specific but medications prescribed for hyperarousal and intrusive symptoms (includes antidepressants, anxiolytics, antipsychotics) - SUD and suicide risk are common so careful selection needed

Question 256

What is the rationale for the following Intervention for Dissociative Disorders: Provide an undemanding, simple routine.

Answer 256

Reduces anxiety

Question 257

What is the rationale for the following Intervention for Dissociative Identity Disorders: Ensure patient safety by providing safe, protected environment and frequent observation

Answer 257

Sense of bewilderment may lead to inattention to safety needs; some alters may be thrill-seeking, violent, or careless

Question 258

What is the rationale for the following Intervention for Dissociative Disorders: Confirm the identity of patient and orientation to time and place.

Answer 258

Supports reality and promotes ego integrity

Question 259

What is the rationale for the following Intervention for Dissociative Disorders : If patient does not remember significant others, work with involved parties to reestablish relationships.

Answer 259

Helps patient experience satisfaction and relieves sense of isolation

Question 260

Dissociative Identity Disorder (definition and 3 notes)

Answer 260

presence of two or more distinct personality states that recurrently take control of behavior which take shifts ranging from minutes to months (usually short) - Transitions may happen dramatically or be barely noticeable; often during times of stress - Often misdiagnosed as schizophrenic due to infrequency of episodes (minutes to months but shorter shifts common) - Extremely high suicide risk and difficult to assess due to presence of multiple personalities

Question 261

What is the rationale for the following Intervention for Dissociative Disorders: Encourage patient to do things for self and make decisions about routine tasks.

Answer 261

Enhances self-esteem by reducing sense of powerlessness and reduces secondary gain associated with dependence

Question 262

What is the rationale for the following Intervention for Dissociative Disorders: Assist with major decision making until memory returns.

Answer 262

Lowers stress and prevents patient from having to live with the consequences of unwise decisions

Question 263

What is the rationale for the following Intervention: for Dissociative Disorders Accept patient’s expression of negative feelings.

Answer 263

Conveys permission to have negative or unacceptable feelings

Question 264

What is the rationale for the following Intervention for Dissociative Disorders: Teach patient grounding techniques, such as taking a shower, deep breathing, touching fabric on chair, exercising, or stomping feet.

Answer 264

Helps to keep the person in the present and decrease dissociation

Question 265

What is the rationale for the following Intervention for Dissociative Disorders : Support patient during the exploration of feelings surrounding the stressful event.

Answer 265

Helps lower the defense of dissociation used by patient to block awareness of the stressful event

Question 266

What is the rationale for the following Intervention for Dissociative Disorders: Do not flood patient with data regarding past events.

Answer 266

Memory loss serves the purpose of preventing severe to panic levels of anxiety from overtaking and disorganizing the individual

Question 267

Alter vs primary personality in Dissociative Identity Disorder

Answer 267

o Alternate personality (alter) fixated on trauma but has its own pattern of perception, relations, and thinking of self and environment (may behave as different sex, race, religion, intelligence, EEG changes); often believe they are separate and unaffected by other’s actions (cognitive distortion) o Primary is usually moralistic, pleasure seeking, nonconforming and not aware of alters so confused by lost time and unexplained events; blocks assess to traumatic memories

Question 268

What is the rationale for the following Intervention for Dissociative Disorders: Provide support through empathetic listening during disclosure of painful experiences.

Answer 268

Can be healing, while minimizing feelings of isolation

Question 269

3 notes on Depersonalization/Derealization Disorder Treatment

Answer 269

- usually go away without treatment - comorbidities treated with antianxiety, antidepressants - repetitive transcranial magnetic stimulation has been used to treat successfully

Question 270

Depersonalization/Derealization Disorder (definition and two notes

Answer 270

persistent or recurrent episodes of depersonalization and derealization -mostly transient episodes; but may be constant -severe stress and illegal drug use precipitate an episode

Question 271

Depersonalization vs derealization

Answer 271

- Depersonalization: an extremely uncomfortable feeling of being an observer of one’s own body or mental processes.; feelings of unreality, detachment, or unfamiliarity - Derealization: recurring feeling that one’s surroundings are unreal or distant. o Visual ( blurriness, changes in the visual field, object sizes) and Auditory distortions(muting or heightening of sound)

Question 272

Autonomy

Answer 272

Respecting the rights of others to make their own decisions (e.g., acknowledging the patient’s right to refuse medication supports autonomy).

Question 273

Beneficence

Answer 273

The duty to act to benefit or promote the health and well-being of others (e.g., spending extra time to help calm an anxious patient).

Question 274

Justice

Answer 274

The duty to distribute resources or care equally, regardless of personal attributes (e.g., an intensive care unit [ICU] nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain aneurysm).

Question 275

Fidelity

Answer 275

Maintaining loyalty and commitment to the patient and doing no wrong to the patient (e.g., maintaining expertise in nursing skill through continuing nurse education).

Question 276

Veracity

Answer 276

The duty to communicate truthfully (e.g., describing the purpose and side effects of psychotropic medications in a truthful and non-misleading way)

Question 277

4 fundamental guidelines for MH Hospitalization

Answer 277

o Neither voluntary nor involuntary determines patient’s ability to make informed decisions about personal healthcare. o Mental illness present o The illness and its symptoms will result in an immediate crisis situation and other less-restrictive alternatives (i.e., outpatient care) are inadequate or unavailable. o There is a reasonable expectation that the hospitalization and treatment will improve the presenting problems

Question 278

Nonmaleficence

Answer 278

Doing no harm to the patient (e.g., protecting confidential information about a patient)

Question 279

Voluntary Admissions How to be admitted? How to be released?

Answer 279

-apply in writing for admission -individual can leave AMA (reevaluation can be done and make admission involuntary though)

Question 280

Involuntary Admissions 4 criteria

Answer 280

- Diagnosed with mental illness - Danger to self or others - Gravely disabled (unable to provide for basic necessities) - In need of treatment and mental illness itself prevents voluntary help-seeking

Question 281

Two arguments patients can make to be released from involuntary commitment

Answer 281

i. Writ of habeas corpus: “formal written order” to “free the person; the procedural mechanism used to challenge unlawful detention by the government; hospital immediately submits to court and court decides ii. Least restrictive alternative doctrine: mandates that care take the least drastic action to achieve a specific purpose i.e outpatient less restrictive than inpatient

Question 282

Emergency Commitment Who is it used for? (2) What is the primary purpose? Length?

Answer 282

o Used for people who 1) are so confused they cannot make decisions on their own or (2) are so ill they need emergency admission Primary purpose: observation, diagnosis, and treatment of patients who have mental illness or pose a danger to themselves or others Length: 24 to 96 hours depending on the state. A court hearing is held and a decision is made for discharge, voluntary admission, or involuntary commitment.

Question 283

Unconditional release for Voluntary admission What is it? What if provider disagrees?

Answer 283

termination of legal patient-institution relationship by patient or provider If provider disagrees, patient may be held 72 hours for involuntary admission or released AMA (against medical advice)

Question 284

Conditional release What does it require? What 3 things are evaluated during the time? How does it differ for voluntary vs involuntary admitted?

Answer 284

requires outpatient for specified period of time During time, individual evaluated for follow-through on medication regimen, ability to meet basic needs, and ability to reintegrate into community o Voluntary admitted who are conditionally released cannot be readmitted without involuntary commitment process o Involuntarily admitted who are conditionally released can be readmitted involuntarily based on original order

Question 285

Assisted outpatient treatment What is it? Who is it used for? (4) How does it work? Result of nonadherence?

Answer 285

court-ordered outpatient treatment; may occur post-discharge or straight from community to reduce or prevent relapse - Used for those with hx of repeated hospitalizations, arrested for treatment nonadherence, Unlikely to participate in outpatient treatment and need treatment to prevent relapse; threat to self or others if relapse happens - It is usually tied toward receipt of social welfare goods (disability benefits and housing) to improve adherence - Nonadherence may lead to inpatient admission

Question 286

6 patient rights in MH setting

Answer 286

1. Right to treatment (most fundamental; right to quality care) 2. Right to refuse treatment (even if involuntarily committed) 3. Right to Informed Consent 4. Rights of Psychiatric Advance Directives 5. Rights on Restraints and Seclusion 6. Right to Confidentiality

Question 287

AMA discharge When done? What must patient do? Why is it an ethical dilemma?

Answer 287

AMA release is if treatment seems beneficial but there is no compelling reason to seek an involuntary continuance of stay Patient must sign a form indicating that they are leaving AMA. This form becomes part of the patient’s permanent record. AMA is ethical dilemma because patient autonomy and right to refuse treatment clash with beneficence to protect patient

Question 288

5 rights under right to treatment

Answer 288

i. The right to be free from excessive or unnecessary medication ii. The right to privacy and dignity iii. The right to the least restrictive environment iv. The right to an attorney, clergy, and private care providers v. The right to not be subjected to lobotomies, electroconvulsive treatments, and other treatments without fully informed consent

Question 289

Right to refuse Psychopharmacological drugs How does it work in emergencies? How does it work in nonemergencies? (5 criteria)

Answer 289

i. In an emergency where harm to self or others may occur, institution can medicate person without a court order ii. In nonemergencies, after a court hearing, person can be medicated if all the following are met: 1.Patient has serious mental illness 2. The person’s functioning is deteriorating and if the person is suffering or exhibiting threatening behavior 3. The benefits of treatment outweigh the harm 4. The person lacks the capacity to make a reasoned decision about the treatment 5. Less-restrictive services have been found inadequate

Question 290

Informed Consent What is it? What does it require of the patient? When is it needed? What is nurse's role?

Answer 290

it is when person has been provided basic info on problem, purpose of treatment, risks, benefits, alternatives to treatment; likelihood of success before accepting to do a procedure - Requires patient to have capacity and competence to voluntarily accept - Generally needed for surgery, ECT, and use of experimental drugs or procedures; may be required for all medications in some facilities (the more intrusive or risky the procedure; the greater need for informed consent) - Nurse role is to provide education and witness signature; provider gets consent

Question 291

Capacity What is it? When does it change? Who decides if person has capacity?

Answer 291

Capacity: person’s ability to make an informed decision - Fluid and can change rapidly - Mental health providers may provide opinions about capacity.

Question 292

Competency What is it? When does it change? Who decides if person has competency? If someone is incompetent, who makes their decisions?

Answer 292

Competency: legal term related to the degree of mental soundness a person has to make decisions or to carry out specific acts a. Competent until they have been declared incompetent b. If found incompetent through formal legal proceeding, patient may be appointed a legal guardian or representative who is responsible for giving or refusing consent for the patient while always considering the patient’s wishes. i. Order of selection usually (1) spouse or partner, (2) adult children or grandchildren, (3) parents, (4) adult siblings, and (5) adult nieces and nephews -> court-appointed person if no one available

Question 293

Restraints Definition What to assess before restraints?

Answer 293

any mechanical or physical device that reduces movement of patient including side rails and holding -assess for physical origins of violence such as drug interactions and side effects; temp elevation, hypoglycemia, hypoxia, electrolyte imbalances which can all cause behavioral disturbances

Question 294

Seclusion What is it? What does it not include? Who is it for?

Answer 294

confinement alone or in an area and preventing from leaving including if unlocked door but make threats about what happens if they leave 1. Physical restraint in public room is not seclusion 2. Reserved for violent, self-destructive

Question 295

Chemical Restraints (and how do they compare to mechanical restraints)

Answer 295

medications or doses of medication not used for patient's condition Less restrictive than physical or mechanical but can impact patient’s ability to relate to environment

Question 296

Restraints and least restrictive doctrine 5 less restrictive alternatives What does CMS say about restraints in emergencies

Answer 296

i. In emergencies, CNS says less restrictive do not have to be used but need to be considered ineffective ii. Least restrictive alternatives 1. Verbal intervention 2. Reducing stimulation 3. Actively listening 4. Providing diversion 5. Offering PRN medications

Question 297

Documentation for Restraints and Seclusion (3 things included)

Answer 297

a. specific behaviors and mental state leading to restraint or seclusion b. time the patient is placed in and released from restraint c. 15–30-minute assessments for physical needs, safety (including protection from harm), and comfort

Question 298

Orders for restraints and seclusion (4 notes)

Answer 298

- no PRN or standing orders for restraints - renew every 4 hours (adults) for total of 24 hour (2 hours for children over 9-17; 1 hour for children under 9) - After 24 hours, provider personally assesses the patient - Restraint or seclusion is discontinued as soon as safer and calmer behavior begins and new order is required to reinstitute the intervention.

Question 299

Confidentiality and Nurse-patient (3 tidbits)

Answer 299

- only patient can waive confidentiality (even in death) - avoid conversations about patients in public places - nurse does not have patient-nurse confidentiality like psychiatrists and attorneys (nurses must answer to the court)

Question 300

4 exceptions to patient confidentiality (and what does failure to report lead to ?)

Answer 300

- Duty to warn (obligation to warn 3rd parties if they may be in danger from patient) - Duty to protect (required to call and warn intended victim, victim family, or police to take necessary steps under the circumstances)- must assess and predict patient's level of danger and identify who they are threatening - Child Abuse (all nurses are mandatory reporters; some states allow anonymous reporting) - Older Adult and Dependent/Disabled Adult Abuse (required by most states to report) Failure to report suspected abuse, neglect, or exploitation may result in misdemeanor

Question 301

7 interventions for seclusions and restraints

Answer 301

o Staff in constant attendance (do not leave patient alone) o Monitor vital signs o Assess range of movement o Observe blood flow in hands/feet o Observe that restraint is not rubbing o Provide for nutrition, hydration, and elimination o Continuously assess the need seclusion or restraint

Question 302

Negligence

Answer 302

most common unintentional tort involving failure to use ordinary care in any professional or personal situation when there is duty to do so

Question 303

5 elements to prove malpractice (and what each entails)

Answer 303

- Duty of care established (nurse represents self as capable of caring for psychiatric patient and accepts employment) - Breach of duty (nursing performance below standard of care which exposes patient to unreasonable risk of harm; can be commission or omission) - Cause in Fact (Actual cause aka if nurse did not do what they did, would injury have occurred?) - Proximate cause (Legal cause aka determined by whether event was foreseeable; If average reasonable nurse could foresee injury that would result from action or inaction, injury was foreseeable) - Damages (Pain and suffering; Actual damages (loss of earning, medical expenses, property damage); Incidental damage (deprivation of benefits like normal relationships)

Question 304

Delirium What is it? 6 cardinal symptoms

Answer 304

progressive and reversible acute cognitive disturbance with an underlying physiological cause that impairs lower-level cognition and can lead to permanent cognitive decline if not addressed - impaired attention (inability to direct, focus, sustain, or shift) - abrupt onset with fluctuating periods of lucidity and disorganized thinking - disorientation (to time and place; not usually person) - anxiety, agitation - poor memory - altered perceptions (visual hallucinations and illusions; delusions)

Question 305

Delirium Onset Causes/ Contributing Factors Cognition (4) Activity level (4) Emotional state Speech and language (4) Prognosis

Answer 305

Onset: sudden and fluctuates throughout day Causes/ Contributing Factors: underlying medical condition (UTI, substances, medications) Cognition: impaired attention, memory deficit, disorientation, perceptual disturbances Activity level: increased or decreased; restless; sundowning; reversed sleep-wake cycle Emotional state: rapid swings (fearful, anxious, suspicious, aggressive; hallucinate or delusions) Speech and language: rapid, inappropriate, incoherent, rambling Prognosis: reversible with proper treatment

Question 306

Dementia Onset Causes/ Contributing Factors (5) Cognition (6)

Answer 306

Onset: slowly over months and years Causes/ Contributing Factors: Alzheimer's; vascular disease; HIV, chronic alcoholism; head trauma Cognition: impaired memory, judgment, calculations, attention, abstract thinking, agnosia (inability to recognize things)

Question 307

Dementia Activity level (2) Emotional state (2) Speech and language (5) Prognosis

Answer 307

Activity level: not altered; may have sundowning Emotional state: flat (unresponsive in severe); agitation Speech and language: incoherent, slow (difficulty finding the right word), inappropriate, rambling, repititious Prognosis: not reversible; progressive

Question 308

Mild Alzheimer's 8 hallmark symptoms

Answer 308

* Difficulties retrieving correct words or names * Trouble remembering recent conversations, material just read (family may notice memory lapses) * Challenges in performing tasks in social or work settings (still able to work) * Losing or misplacing a valuable object * Increasing trouble with planning or organizing * Apathy * Depression * Personality is intact

Question 309

Moderate Alzheimer's 8 hallmark symptoms

Answer 309

* Forget events or their personal history i.e be unable to recall their own address or telephone number or the high school/college from which they graduated * Agnosia * Behavior changes i.e become moody or withdrawn, especially in socially or mentally challenging situations * Disorientation (confused about place and time) * Need for help choosing proper clothing for the season or the occasion * Wandering * Change sleep patterns (may sleep during the day and becoming restless at night * Paranoiac, agitated, and delusional or compulsive, for example, repetitive behavior like hand wringing

Question 310

Severe Alzheimer's 6 hallmark symptoms

Answer 310

* Require full-time, around-the-clock assistance with daily activities and personal care * Lose awareness of recent experiences and of their surrounding * Apraxia so they need repeated instructions and directions for simple tasks * Experience changes in physical abilities, including urinary incontinence ability to walk, sit, and eventually swallow, * Have increasing difficulty communicating and speaking (difficulty responding to environment) * Become vulnerable to infections, especially pneumonia

Question 311

Alzheimer's and Symptoms Confabulation (2) Preservation Agraphia

Answer 311

Confabulation: unconscious mechanism to protect ego involves creation of stories or answers in place of actual memories to maintain self-esteem; not lying b-c it is unconscious Preservation: persistent repetition of word, phrase or gesture that continues after the original stimulus has stopped i.e repeatedly saying hello Agraphia: early AD; diminished ability and eventual inability to read or write

Question 312

Alzheimer's and Symptoms Aphasia Apraxia Agnosia

Answer 312

Aphasia: the loss of language ability; from difficulty finding right word to few words to babbling or mutism Apraxia: loss of purposeful movement in the absence of motor or sensory impairment which results in the inability to perform familiar and purposeful tasks. -For example, in apraxia of dressing, the person is unable to put clothes on properly (e.g., putting arms in trousers). Agnosia: loss of sensory ability to recognize familiar objects, sounds, sights (can be auditory, visual or tactile)

Question 313

Alzheimer's and Symptoms Hyperorality Sundowning, or sundown syndrome Memory impairment

Answer 313

Hyperorality: the tendency to put everything in the mouth and to taste and chew. Sundowning, or sundown syndrome: tendency for an individual’s mood to deteriorate and agitation increase in the later part of the day, with the fading of light, or at night. Memory impairment: initial difficulty remembering recent events -> deterioration of recent and remote memory.

Question 314

9 Interventions around comfort and anxiety for Delirium

Answer 314

* Provide optimistic but realistic reassurance. * Provide patient with information about what is happening and what can be expected. * Accept patient’s perceptions or interpretation of reality and respond to the theme or feeling tone. * Approach patient slowly and from the front and address patient by name. * Always introduce self to patient when approaching. * Communicate with simple, direct, and descriptive statements. * Limit decision making if aggravates delirium * Encourage significant others to remain with patient. * Provide a consistent physical environment, daily routine, and caregivers.

Question 315

5 Interventions around safety for Delirium

Answer 315

* Administer prn (as needed) medications for anxiety or agitation with caution. * Physical restraints may increase symptoms and should be avoided if possible. * Never leave a patient in acute delirium alone (family can watch) * Maintain a well-lit, hazard-free, low-stimulation environment * Encourage use of aids that increase sensory input (e.g., eyeglasses, hearing aids, and dentures).

Question 316

3 Interventions around Orientation for Delirium

Answer 316

* Monitor neurological status on an ongoing basis * Avoid frustrating the patient by quizzing with orientation questions that cannot be answered. * Use environmental cues (e.g., signs, pictures, clocks, calendars, and color coding of environment) to stimulate memory, reorient, and promote appropriate behavior.

Question 317

4 basic Interventions for Alzheimer's Disease

Answer 317

- Provide emotional support to patient and family: Ascertain what is important to these patients, their values and beliefs, as well as their life histories. (unconditional positive regard is key) - support caregivers: Include family members in planning, providing, and evaluating care - assess and facilitate self - care: Identify usual patterns of behavior for such activities as sleep (provide rest periods), medication use, elimination, food intake, self-care - Provide finger foods to maintain nutrition for patient who will not sit and eat.

Question 318

7 interventions for comfort care and anxiety management in Alzheimer's

Answer 318

- Introduce self and address patient by name when initiating interaction and speak slowly. - Give one simple direction at a time in a respectful tone of voice. - Use distraction, rather than confrontation, to manage behavior. - Provide consistent caregivers, physical environment, and daily routine. (Limit number of choices patient must make so as not to cause anxiety.) - Select television or radio programs based on cognitive processing abilities and interests. - Place patient’s name in large block letters in room and on clothing, as needed. - Use symbols, rather than written signs, to assist patient in locating room, bathroom, or other area.

Question 319

What is the rationale for the following intervention for Dementia? Gradually restrict use of motor vehicles

Answer 319

As judgment becomes impaired, the person may be dangerous to self and others.

Question 320

What is the rationale for the following intervention for Dementia? Minimize sensory stimulation.

Answer 320

Decreases sensory overload, which can increase anxiety and confusion.

Question 321

What is the rationale for the following intervention for Dementia ? If the person becomes verbally upset, listen and be supportive, allowing the person to be upset. Gradually try to redirect and change the topic.

Answer 321

Goal is to prevent escalation of anger. When attention span is short, the person can be distracted to more productive topics and activities.

Question 322

What is the rationale for the following intervention for Dementia? Label all rooms and drawers. Label often-used objects (e.g., hairbrushes and toothbrushes)

Answer 322

May keep the person from wandering into other people’s rooms. Increases environmental clues to familiar objects.

Question 323

What is the rationale for the following intervention for Dementia? Have the person wear medical alert bracelet that cannot be removed (with name, address, and telephone number). Provide police department with recent pictures.

Answer 323

The person can easily be identified by police, neighbors, or hospital personnel.

Question 324

What is the rationale for the following intervention for Dementia? If the person wanders during the night, put mattress on the floor.

Answer 324

Prevents falls when the person is confused.

Question 325

What is the rationale for the following intervention for Dementia? If the person is in the hospital, have the person wear brightly colored vest with name, unit, and phone number printed on back.

Answer 325

Makes the person easily identifiable.

Question 326

What is the rationale for the following intervention for Dementia? Put complex locks on top of door and use sensor devices.

Answer 326

Reduces opportunity to wander.In moderate and late Alzheimer-type dementia, ability to look up and reach upward is lost. Sensor devices provide warning if person wanders

Question 327

What is the rationale for the following intervention for Dementia? Encourage physical activity during the day.

Answer 327

Physical activity may decrease wandering at night

Question 328

What to know about use of psychotropic drugs and Alzheimer's? (4)

Answer 328

- they increase risk of mortality from cardiovascular and infectious causes - Antipsychotics, antidepressants, antianxiety, anticonvulsants are not FDA approved and are used off label - Try to avoid but If used, start low, go slow, use smallest dose for shortest duration and discontinue if not effective - Use as last resort to manage behavior

Question 329

Donepezil Mechanism of action Use Therapeutic Effect Drug interaction

Answer 329

Mechanism of action: Inhibit acetylcholinesterase from breaking down Ach Use: all stages of AD including severe Therapeutic Effect: small and short-lived improvements in cognitive function after 1 year but do not slow disease progression Drug interactions: NSAIDs increase potential for GI bleeds and ulceration

Question 330

8 adverse effects of Donepezil

Answer 330

temporary GI disturbances (Nausea, vomiting, diarrhea) Insomnia muscle cramps fatigue anorexia urinary incontinence rare is bradycardia or syncope

Question 331

1. Which statement made by the primary caregiver of a person with dementia demonstrates an accurate understanding of providing the person with a safe environment? a. “The local police know that he has wandered off before.” b. “I keep the noise level low in the house.” c. “We’ve installed locks on all the outside doors.” d. “Our telephone number is always attached to the inside of his shirt pocket.”

Answer 331

c. “We’ve installed locks on all the outside doors.”

Question 332

2. Which statement made by a family member tends to support a diagnosis of delirium rather than dementia? a. “She was fine last night but this morning she was confused.” b. “Dad doesn’t seem to recognize us anymore.” c. “She’s convinced that snakes come into her room at night.” d. “He can’t remember when to take his pills or whether he’s bathed.”

Answer 332

a. “She was fine last night but this morning she was confused.”

Question 333

3. In terms of the pathophysiology responsible for both delirium and dementia, which intervention would be appropriate for delirium specifically? a. Assisting with needs related to nutrition, elimination, hydration, and personal hygiene b. Monitoring neurological status on an ongoing basis c. Placing an identification bracelet on patient d. Giving one simple direction at a time in a respectful tone of voice

Answer 333

b. Monitoring neurological status on an ongoing basis

Question 334

4. What side effects should the nurse monitor for while caring for a patient taking donepezil (Aricept)? Select all that apply. a. Insomnia b. Constipation c. Bradycardia d. Signs of dizziness e. Reports of headache

Answer 334

a. Insomnia c. Bradycardia d. Signs of dizziness e. Reports of headache

Question 335

5. What is the rationale for providing a patient diagnosed with dementia easily accessible finger foods thorough the day? a. It increases input throughout the day b. The person may be anorexic c. It helps with the monitoring of food intake d. It helps to prevent constipation

Answer 335

a. It increases input throughout the day

Question 336

6. Ophelia, a 69-year-old retired nurse, attends a reunion of her former coworkers. Ophelia is concerned because she usually knows everyone, and she cannot recognize faces today. A registered nurse colleague recognizes Ophelia’s distress and “introduces” Ophelia to those attending. The nurse practitioner understands that Ophelia seems to have a deficit in her a. Lower-level cognitive domain b. Delirium threshold c. Executive function d. Social cognition ability

Answer 336

d. Social cognition ability

Question 337

7. After talking with her 85-year-old mother, Nancy became concerned enough to drive to her home and check on her. Her mother’s appearance was disheveled, her words were nonsensical, she smelled strongly of urine, and there was a stain on her dressing gown. Because she is a nurse, Nancy recognizes that her mother’s condition is likely due to a. Early-onset dementia b. A mild cognitive disorder c. A urinary tract infection d. Having skipped breakfast

Answer 337

c. A urinary tract infection

Question 338

8. Lucia, 70 years old, recently underwent a major orthopedic surgical procedure. On postoperative day 3, she responds to the nurse who has been caring for her with affection. At other times, however, she tells the nurse to leave because she does not recognize her and asks to have another nurse care for her, specifically naming the nurse as the “nice one.” The most likely reason for Lucia’s behavior is that she is a. Attention-seeking and manipulative b. Showing signs of early dementia c. Experiencing an acute delirium d. Playing one staff member off against another

Answer 338

c. Experiencing an acute delirium

Question 339

What is the rationale for the following intervention for Dementia? Provide picture magazines and children’s books when the person’s reading ability diminishes.

Answer 339

Allows continuation of usual activities that the person can still enjoy; provides focus.

Question 340

What is the rationale for the following intervention for Dementia? Provide simple activities that allow exercise of large muscles.

Answer 340

Exercise groups, dance groups, and walking provide socialization, as well as increased circulation and maintenance of muscle tone.

Question 341

What is the rationale for the following intervention for Dementia? Encourage group activities that are familiar and simple to perform.

Answer 341

Activities such as group singing, dancing, reminiscing, and working with clay and paint all help increase socialization

Question 342

9. Since his wife’s death 2 months earlier, Aaron, 90 years of age and in good health, has begun to pay less attention to his hygiene and seems less alert to his surroundings. He complains of difficulty concentrating, disrupted sleep, and lacks energy. His family has to remind and encourage him to shower, take his medications, and eat, all of which he then does. Which of the following responses would be most appropriate? a. Reorient Mr. Smith by pointing out the day and date each time you have occasion to interact with him. b. Meet with the family and support them to accept, anticipate, and prepare for the progression of his stage 2 dementia. c. Avoid touch and proximity. These are likely to be uncomfortable for Mr. Smith and may provoke aggression when he is disoriented. d. Arrange for an appointment with a mental health professional for the evaluation and treatment of suspected major depressive disorder.

Answer 342

d. Arrange for an appointment with a mental health professional for the evaluation and treatment of suspected major depressive disorder.

Question 343

10. Nurses caring for patients who have neurocognitive disorders are exposed to stress on many levels. Specialized skills training and continuing education are helpful to diffuse stress, as well as which of the following? Select all that apply. a. Expressing emotions by journaling b. Describing stressful events on Facebook c. Engaging in exercise and relaxation activities d. Having realistic patient expectations e. Participating in a happy hour after work to blow off steam

Answer 343

a. Expressing emotions by journaling c. Engaging in exercise and relaxation activities d. Having realistic patient expectations

Question 344

Atttempted vs completed rape

Answer 344

Attempted rape: threats of rape or intention to rape that is unsuccessful Completed rape: penetration, no matter how slight, of the vagina or anus with anybody part or object, or oral penetration by a sex organ of another person, without the consent of the victim

Question 345

Clinical Picture of survivors of abuse (6)

Answer 345

- comorbid PTSD/ASD, MDD, anxiety, suicide - impaired daily functioning - low self-esteem - sexual dysfunction - somatic complaints - recurrent and intrusive memories, dreams, flashbacks, and distress from cues that remind them of the assault.

Question 346

Most effective counseling approach in ED for sexual assault (5)

Answer 346

- Provide nonjudgmental care and optimal emotional support - Convey confidential nature of visit - Listen and let patient talk (a patient who feels listened to and understood no longer feels alone and can feel in control of situation) - Separate vulnerability from blame (survivor may try to rationalize or blame their behavior for the incidence) - Social support is key (Fewer somatic symptoms of stress if survivor is able to confide comfortably in at least one person, especially immediately after the assault)

Question 347

8 do's of IPV interview

Answer 347

* Conduct the interview in private. * Develop trust to make patient comfortable enough to self-disclose * Be direct, honest, and professional * Use language the patient understands. (ask about ways they solve disagreements or discipline methods rather than abuse or violence) * Ask the patient to clarify words not understood. * Be attentive but relaxed * Inform the patient if you must make a referral to Children’s or Adult Protective Services, and explain the process. * Use open-ended question that requiring descriptive response (also they are less threatening)

Question 348

7 Don'ts of IPV interview

Answer 348

* Try to “prove” abuse by accusations or demands. * Display horror, anger, shock, or disapproval of the perpetrator or situation. * Place blame or make judgments. * Allow the patient to feel “at fault” or “in trouble.” * Probe or press for answers the patient is not willing to give. * Conduct the interview with a group of interviewers. * Interrupt the patient

Question 349

7 signs of physical abuse in child

Answer 349

- minor complaints (headaches, back pain, dizziness, accidents) - overt signs (bruises, scars, burns, or wounds in various stages of healing in body parts that are usually covered or arms)--Any bruise on infant <6 months needs to be explored - Shaken baby syndrome: leading cause of death from physical abuse in children under 2; signs include respiratory problems, bulging fontanels, retinal hemorrhage, CNS damage (seizures, vomiting, coma). - In utero (Fetal alcohol spectrum disorders (brain damage and growth problems) & Neonatal abstinence syndrome (lasts days to weeks; includes irritability, difficulty soothing; long term hearing, vision, and learning difficulties) - inconsistent explanations for injuries - vague explanations - minimization of seriousness

Question 350

4 Signs of Sexual abuse

Answer 350

- Sexualized behavior (acting out) in young children - Sexual promiscuity or knowledge in older children - PTSD symptoms (nightmares, somatic complaints, feelings of guilt) - Adults sexually abused as child mainly report depression (other symptoms also reported)

Question 351

5 Signs of emotional abuse

Answer 351

*less obvious and more difficult to assess than other abuse* - low self-esteem and feeling of inadequacy - anxiety - withdrawal - learning difficulties - poor impulse control

Question 352

3 signs of neglect

Answer 352

- Undernourished - Dirty and poorly clothed - Inadequate medical care (lack of immunizations and untreated medical or dental conditions)

Question 353

What is economic abuse? 2 signs

Answer 353

Failure to provide for the needs of the victim when adequate funds are available -leaving bills unpaid -preventing spouse from seeking job or education to promote dependency

Question 354

Cycle of Violence: Tension building phase (3)

Answer 354

- begins with minor incidents, such as pushing, shoving, and verbal abuse. - victim often ignores or accepts the behavior due to fear of escalation - As the tension builds, both participants may try to reduce it (abuser via substance use, victim through minimization of tension)

Question 355

Cycle of Violence: Acute battering phase (4)

Answer 355

- when the tension peaks and becomes unbearable - It is usually triggered by an external event, abuser’s emotional state; or victim provokes it to move on - Victim may seek help or cover up abuse - Abuse may be worsened by pregnancy or move toward independence

Question 356

Cycle of Violence: Honeymoon phase (3)

Answer 356

- period of calm after the abuse occurs - Abuser usually demonstrates kindness and loving behaviors and makes promises to change - The victim usually feels needed, loved, and hopes for change (often cancels plans to leave which were made during acute phase)

Question 357

Cycle of Violence 3 stages How it changes over time? Impact on victim

Answer 357

3 stages: tension building, acute battering, honeymoon - Cycle repeats itself and honeymoon becomes briefer and other stages more intense - cycle erodes victim’s self-esteem leading to depression, hopelessness, immobilization, and self-deprecation

Question 358

6 Interventions for PTSD or post-sexual assault

Answer 358

1. reduce anxiety with use of relaxation techniques and sleep 2. encourage help-seeking 3. reduce arousal and regulate emotions 4. encourage patient to develop narrative of event and the meaning of the event to them 5. gently suggest that person was not responsible for what happened 6. reassure that reactions to trauma do not indicate personal failure or weakness

Question 359

3 Signs of abuse or neglect

Answer 359

-hesitant to talk -fearful in presence of perpetrator -tearful

Question 360

4 guidelines for personality disorders

Answer 360

- acknowledge the patient's feelings but set limits on bad behavior - do not make empty threats. Set clear and realistic expectations - setting firm limits and boundaries is very important. - Know the facts before you act.

Question 361

How does intervention differ for “Sometimes, I just wish I could die” vs “I am going to kill myself.”

Answer 361

With the former, you would ask the patient to talk more about their feelings. With the latter, you would immediately place them on 1:1 observation.

Question 362

Two treatment goals for personality disorders

Answer 362

- decrease the behaviors associated with the various disorders that affect function and interpersonal relationships. - reduce the inflexibility that interferes with functioning and relationships

Question 363

Cluster A personality disorders What are they? Which personalities are included?

Answer 363

-odd or eccentric - Paranoid, Schizotypal, Schizoid

Question 364

Cluster C personality Disorders What are they? Which personalities are included?

Answer 364

- anxious or fearful - Avoidant, OCD personality disorder

Question 365

Cluster B personality Disorders What are they? Which personalities are included?

Answer 365

- dramatic, emotional, or erratic - histrionic, narcissistic, borderline, antisocial

Question 366

Paranoid Personality Disorder: Characteristics (8)

Answer 366

* Longstanding distrust and suspiciousness of others * believe that others want to exploit, harm, or deceive the person so anticipate hostility * Relationship difficulties due to jealousy, controlling behaviors, and envious behaviors * unwilling to forgive. * Hypervigilant, oversensitive, guarded * Provoke hostile responses by initiating a counterattack * Exhibits self-destructive behaviors * Projection is the dominant defense mechanism

Question 367

Paranoid Personality Disorder: Guidelines to Nursing Care (5)

Answer 367

* Strictly adhere to promises, appointments, and schedules due considering the degree of mistrust * Being too nice or friendly may be met with suspicion. * Give clear and straightforward explanations of tests and procedures beforehand. * Use simple language and project a neutral but kind affect. * Limit setting is essential when threatening behaviors are present.

Question 368

Schizoid Personality Disorder: Characteristics (8)

Answer 368

* Social withdrawal (Do not seek out or enjoy close relationships) * Expressionless with restricted range of emotional expression (cold and indifferent) * loners and poor academic performance * inappropriate seriousness * lack of spontaneity * Approval nor rejection by others has an effect * May have many imaginary friends or fantasies (aloof) * depersonalized and detached

Question 369

Schizoid Personality Disorder: Guidelines to Nursing Care (5)

Answer 369

* avoid being too “nice” or “friendly.” * Do not try to increase socialization * Patients may be open to discussing topics such as coping and anxiety. * Conduct a thorough assessment to identify symptoms that the patient is reluctant to discuss. * Protect against ridicule from group members because of the patient’s distinctive interests or ideas.

Question 370

Schizotypal Personality Disorder: Characteristics (8)

Answer 370

* Extreme anxiety in social settings * Do not blend with the crowd (lengthy, abstract, overly detailed contributions to conversations) * Magical thinking (belief they can do acts of god) * Odd beliefs (overly superstitious) * Strange speech patterns (rambling) * Inappropriate affect * Paranoia (overly suspicious and anxious of others; blame others for their social isolation) * Hallucinations and delusions (less than in schizophrenia and brief)

Question 371

Schizotypal Personality Disorder: Guidelines to Nursing Care (4)

Answer 371

* Respect the patient’s need for social isolation. * Be aware of the patient’s suspiciousness and use appropriate interventions. * Help identify cognitive distortions * Be aware that strange beliefs and activities, such as strange religious practices or peculiar thoughts, may be part of the patient’s life.

Question 372

Histrionic Personality Disorder: Characteristics (6)

Answer 372

* Excitable and dramatic yet high functioning * Drama queens (Extroversion, flamboyance, colorful personalities) * Limited ability to develop meaningful relationships due to partner smothering or insensitivity of histrionic * attention-seeking behavior (self-centeredness, low frustration, tolerance, excess emotionality) * Impulsive, flirtatious, provocative * Difficulty regulating their feelings

Question 373

Histrionic Personality Disorder: Guidelines for Nursing Care (5)

Answer 373

* Know seductive behavior is a response to distress. * Communication and interactions should always be kept professional; ignore flirtations * Encourage and model the use of concrete and descriptive rather than vague and impressionistic language. * Help patients to clarify their own feelings, as they often have difficulty identifying them. * Teach and role model assertiveness.

Question 374

Histrionic Personality Disorder: Treatment (6 notes)

Answer 374

* Often do not believe they need psychiatric help * Psychotherapy to help promote feelings clarification and expression (treatment of choice) * group therapy can be helpful but they may dominate the conversation * Antidepressants for somatic or depressive symptoms * Antianxiety for anxiety * Antipsychotics for derealization or delusions

Question 375

Narcissistic Personality Disorder: Main trait 6 other Characteristics

Answer 375

Main trait: antagonism via grandiosity and attention-seeking behaviors (Blame others for issues) * Feelings of entitlement * Lacks empathy and exploits others * Exaggerated belief of one’s own importance(arrogance) * Suffer from weak self-esteem * hypersensitivity to criticism and rejection * Feel intense shame and fear of abandonment

Question 376

Narcissistic Personality Disorder: Guidelines for Nursing Care (5)

Answer 376

* Nurses should remain neutral and recognize the source of narcissistic behavior—shame and fear of abandonment. * Help identify goals and to develop a stronger self-identity. * Role model empathy and practice how to engage in meaningful interaction. * Avoid engaging in power struggles or becoming defensive in response to the patient’s disparaging remarks. * Do not directly challenge grandiose statements.

Question 377

Narcissistic Personality Disorder: Treatment (4 notes)

Answer 377

* Less impairment in functioning and quality of life than other personality-based disorders * Often difficult b/c pt must confront problem (often do not seek treatment) * CBT for deconstructing faulty thinking * Lithium for mood swings

Question 378

Borderline Personality Disorder 4 main features Primary defense mechanism 3 other symptoms

Answer 378

Main features: emotional dysregulation, emotional lability, impulsivity, self-image distortions Primary defense mechanism: splitting (inability to view both positive and negative aspects of others as part of a whole; people are either wonderful or horrible) Others - Self-destructive behaviors include ineffective self-soothing habits; chronic suicidal ideation - Feelings of antagonism seen as hostility, anger, irritability-> physical violence or property damage - May be psychotic during stress

Question 379

Borderline Personality Disorder Areas to Assess (8)

Answer 379

- Feelings of emptiness - risky behaviors, such as reckless driving, unsafe sex, substance use, binge eating, gambling, or overspending - Intense feelings of abandonment that result in paranoia or feeling spaced out - Idealization of others and becoming close quickly - tendency toward anger, sarcasm, and bitterness - Self-mutilation and self-harm - Sudden shifts in self-evaluation that result in changing goals, values, and career focus - Intense, unstable romantic relationships

Question 380

Borderline Personality Disorder: Guidelines to Nursing Care (6)

Answer 380

* Nurse understands complaints originate from feeling of being threatened * Be aware of manipulative behaviors such as flattery, seductiveness, instilling guilt * Provide clear and consistent boundaries and limits * Use straightforward and calm communication * Be neutral and respond matter-of-factly * Instruct patient to write down sequence of events leading to injuries and consequences before staff discusses the event

Question 381

Borderline Personality Disorder: Pharmacotherapy Treatment Goals of pharmacotherapy (3) 5 categories of drugs and when are they used

Answer 381

- Geared toward maintenance of cognitive function, symptom relief, improved quality of life - SSRIS, anticonvulsants, lithium for mood and emotional dysregulation - Naltrexone, opioid antagonist, can reduce self-injurious behaviors - SGAs control anger and brief episodes of psychosis

Question 382

CBT and Borderline Personality disorder (2)

Answer 382

- helps individuals identify and change inaccurate core perceptions of themselves and relationship problems - reduces mood and anxiety symptoms including self-harm

Question 383

Dialectical Behavioral Therapy (DBT) and Borderline Personality disorder What is it? What is the goal? What is its progression?

Answer 383

- evidence-based to treat chronically suicidal which combines CBT with mindfulness Goal to increase pt’s ability to manage distress and improve interpersonal effectiveness skills to emphasize awareness of one’s thoughts and actively shape them Begins with identification and interventions for suicidal behavior and progress to disruption of destructive behaviors

Question 384

Schema-focused therapy and Borderline Personality disorder

Answer 384

combines CBT with other therapies to focus on ways individuals view themselves; reframing schemas to fix dysfunctional self-image

Question 385

Antisocial Personality Disorder: Main trait 6 other Characteristics

Answer 385

Primary: antagonistic behaviors such as deceitfulness, manipulative, hostile (sociopaths) for personal gain * Callousness (profound lack of empathy) results in lack of concern about feelings of others, absence of remorse or guilt except in face of punishment ( Pattern of disregard for rights of others and their frequent violation) * Disinhibited behaviors (criminal misconduct and substance misuse are common; inability to delay gratification) * Little to no capacity for intimacy and exploit others (Adept at pretending to care or show concern if these behaviors help them manipulate and exploit others) * Shallow, unexpressive, superficial affect * intimidating and argumentative * restless and easily bored

Question 386

Antisocial Personality Disorder: Guidelines to Nursing Care (5)

Answer 386

- Provide consistency, support, boundaries, limits and realistic choices - Prevent or reduce untoward effects of manipulation (flattery, seduction, instillation of guilt of others) - Assist patients in recognizing their feelings of anger, source, and identification of options to handle anger - Listening and showing empathy can defuse an aggressive situation - Help reduce anger and anxiety through physical outlets and therapeutic activities

Question 387

Antisocial Personality Disorder: Addressing Manipulation(2)

Answer 387

- Direct discussion of your concerns is best ( For example, nurse can say: “People enjoy hearing positive comments made by others about themselves. However, in the context of a nurse-patient relationship, these comments are not acceptable.”) - For severe manipulation, address openly and include consequences in the form of rewards or penalties

Question 388

Antisocial Personality Disorder: Pharmacotherapy treatment (4 types and when used)

Answer 388

*no FDA approved* - Mood stabilizers i.e lithium or valproic acid for aggression, depression, impulsivity - SSRIs i.e fluoxetine and sertraline for irritability, anxiety, depression - Benzodiazepines for anxiety w/ caution due to addiction - Methylphenidate if comorbid ADHD

Question 389

Antisocial Personality Disorder: Psychological treatment (4 types and why helpful)

Answer 389

- CBT helpful b-c bond with psychotherapists - Mentalization behavioral therapy: long-term treatment that supports individuals’ ability to recognize and understand their own and other people’s mental states - Dialectical behavior therapy (DBT): regulating emotions and being mindful - Group therapy helps to feel camaraderie

Question 390

Avoidant Personality Disorder: Main trait 5 other characteristics

Answer 390

Main trait: low self-esteem related to poor functioning in social situations; feelings of inferiority compared with peers; Reluctance to engage in unfamiliar activities * Extremely sensitive to rejection * Feel inadequate * Socially inhibited * Failure of support system may lead to depression, anxiety, anger * preoccupation with rejection, failure, and humiliation

Question 391

Avoidant Personality Disorder: Guidelines to Nursing Care (4)

Answer 391

* use a friendly, accepting, and reassuring approach. * Being pushed into social situations can cause severe anxiety for these patients. (accept patient fears) * Provide the patient with exercises to enhance new social skills but use these with caution because any failure can increase the patient’s feelings of poor self-worth. * assertiveness training

Question 392

Obsessive-Compulsive Personality Disorder: Main trait Defense mechanism 5 other Characteristics

Answer 392

Main: rigidity and inflexible standards for self and others Defense mechanism: reaction formation * Limited emotional expression * Stubbornness, perseverance, and indecisiveness * Preoccupation with orderliness, perfectionism, and control * Constant goal-seeking behavior (self-defeating and goal-defeating because strict standards interfere with project completion) * Solicitous, ingratiating with superiors; pompous, self-righteous with subordinates

Question 393

Obsessive-Compulsive Personality Disorder: Guidelines to Nursing Care (3)

Answer 393

* Guard against power struggles with these patients, as their need for control is very high. * It is helpful to provide structure yet allow patients extra time to complete habitual behavior (patients have difficulty dealing with unexpected change) * Help patients to identify ineffective coping and to develop better coping techniques.

Question 394

Difference between OCD and Obsessive-compulsive personality disorder

Answer 394

OCD has obsessive thoughts and repetition or adherence to rituals. People are aware that these thoughts and actions are unreasonable. Obsessive-compulsive personality disorder has an unhealthy focus on perfectionism. Such people “know” that their actions are right and feel comfortable with their self-imposed systems of rules.

Question 395

Difference between Schizophrenia and Schizotypal Personality Disorder

Answer 395

People with schizotypal personality disorder can be made aware of their suspiciousness, magical thinking, and odd beliefs. Schizophrenia is characterized by far stronger delusions.

Question 396

5 areas to assess for all personality disorders

Answer 396

1. Assess for suicidal or homicidal thoughts 2. Determine whether the patient has a medical disorder or another psychiatric disorder that may be responsible for the symptoms (especially a substance use disorder). 3. Take into account the person's ethnic, cultural, and social background. 4. Ascertain whether the patient experienced a recent important loss. (Personality disorders are often exacerbated after the loss of significant supporting people or in a disruptive social situation.) 5. Evaluate for a change in personality in middle adulthood or later, which signals the need for a thorough medical workup or assessment for unrecognized SUD

Question 397

1. A man is being abused by his wife whom he loves very much. He initially decided to leave his wife but ultimately changed his mind after she agreed to go to marriage counseling. What is the best response by the nurse? A. You are making the right decision. If you need help, our facility is here to assist you. B. I hope you have made the right decision. If you need help, our facility is here to assist you. C. You should be careful when you return. If you need help, our facility is here to assist you. D. Why are you returning to this dangerous situation? If you need help, our facility is here to assist you.

Answer 397

B. I hope you have made the right decision. If you need help, our facility is here to assist you.

Question 398

Borderline personality disorder What is emotional dysregulation? What is emotional liability? What is impulsivity?

Answer 398

- Emotional dysregulation: poorly modulated mood; mood swings and difficulty managing painful emotions - Emotional lability: rapidly moving from one emotional extreme to another (Includes out of proportion emotional responses; fear of separation; intense sensitivity to personal rejection) - Impulsivity: act quick in response to emotions; may lead to damaged relationships or suicide

Question 399

4 Symptoms of Autism: Deficits in social relatedness

Answer 399

- Abnormal social approach: failure of normal back-and-forth conversation; reduced sharing of interests, emotions, or affect - Disturbances in developing, maintaining, and understanding peer or parental relationships - Deficits or abnormal nonverbal communication (eye contact, body language, gestures, facial expressions) - Inability to engage in play or make believe

Question 400

Symptoms of Autism Spectrum Disorder: Repetitive or restrictive patterns of behavior (6)

Answer 400

- Lack of spontaneous enjoyment - Stereotypical repetitive speech - Obsessive focus on specific objects or interests - Savant syndrome: low IQ but brilliant in specific areas i.e. music, visual-spatial, photographic memory recall; complex math calculations - Over adherence to routines or rituals; insistence on sameness and resistant to change - Hyperreactivity or hyporeactivity to sensory input (Sensitivity to loud noises)

Question 401

3 things that determine severity of Autism

Answer 401

o Degree of responsiveness or interest to others o Presence of associated behavioral problems (head banging) o Ability to bond with peers

Question 402

6 components of Autism Assessment

Answer 402

1. Assess for developmental delays, uneven development, or loss of acquired abilities (Use baby books and diaries, photographs, videotapes, or anecdotal reports from nonfamily caregivers.) 2. Assess the child’s communication skills (verbal and nonverbal), sensory, social, and behavioral skills (including presence of any aggressive or self-injurious behaviors). 3. Assess the parent-child relationship for evidence of bonding, anxiety, tension, and fit of temperaments. 4. Assess for physical and emotional signs of possible abuse. 5. Ensure that screening for comorbid intellectual disability has been completed. 6. Assess the need for community programs with support services for parents and children, including parent education, counseling, and after-school programs

Question 403

5 notes on interventions/treatment of Autism

Answer 403

- Early intervention programs (usually around 2-3 years) is key to improve potential for full, productive life - Reward system - Teaching caregivers to provide structure, rewards, consistency, expectations to modify and foster developmentally appropriate skills - PT, SLP, OT, ABA, EIBI - Pharmacotherapy (to improve relatedness, decrease anxiety, compulsive behaviors, and agitation)

Question 404

What is Early intensive behavioral intervention?

Answer 404

combines operant conditioning (reinforcement and negative consequences) and ABA in long-term, intensive program to improve language and cognitive skills; most effective for Autism

Question 405

3 drugs used off-label for Autism

Answer 405

- SSRIs: improve mood and reduce anxiety to improve tolerance of new situations and social interaction (Ex. Citalopram, Fluoxetine, Paroxetine, Sertraline) - Stimulants (methylphenidate, amphetamine compound, Lisdexamfetamine): for hyperactivity, impulsivity, or inattention - Naltrexone: reduce disability repetitive and self-injurious behaviors

Question 406

Usage of SGAs (risperidone and aripiprazole) in Autism (2 notes)

Answer 406

- reduce irritability and agitation that is expressed in severe temper tantrums, aggression, and compulsive behavior - Improve relatedness by decreasing agitation, anxiety and compulsive behavior Side effects: EPS, somnolence, weight gain, gynecomastia

Question 407

Attention-deficit/hyperactivity-Disorder Definition 4 notes

Answer 407

inappropriate degree of inattention, impulsiveness, and hyperactivity that interferes with social, academic or occupational functioning - child can be inattentive yet not hyperactive - Symptoms must be present in at least two settings and occur before age 12 for at least 6 months (nowadays adults are diagnosed too) - Symptoms not due to schizophrenia or better explained by another disorder - ADHD is chronic and unremitting and often persists into adulthood

Question 407

Symptoms of ADHD: Inattentive (7)

Answer 407

- Lacks close attention to detail and makes careless mistakes - Does not listen when spoke to - High distractibility - Disorganization - Unable to complete challenging or tedious tasks OR avoids or dislikes them - Easily bored (disruptive, noisy) - Require frequent prompts to complete tasks (lost or forgotten homework)

Question 408

Symptoms of ADHD: Hyperactivity and impulsivity (6)

Answer 408

- Fidgeting, tapping, squirming - Unable to remain seated when expected - Runs or climbs in inappropriate situations (always on the go; inappropriate social norms for their age) - Unable to engage in leisure activities quietly - Talks excessively or when inappropriate - Difficulty waiting their turn and may interrupt others-

Question 409

5 components of ADHD assessment

Answer 409

1. Gather data from parents, caregivers, teachers, or other adults involved with the child. (Ask about level of physical activity, span, talkativeness, frustration tolerance, impulse control, and the ability to follow directions and complete tasks) 2. Monitor eating and sleeping patterns 3. Assess through observations and note any developmental variance in these behaviors. 4. Assess social skills, friendship history, problem-solving skills, and school performance. 5. Assess for comorbidities such as anxiety and depression; learning disorders, autism spectrum disorder, or intellectual disabilities

Question 410

9 Interventions for ADHD

Answer 410

- Focus on recognizing ineffective coping mechanisms and safety (may have difficulty assessing risks of danger) - Hospitalization if imminent danger due to aggressive or disruptive behaviors - Teach parents about behavior modifying techniques - provide consistent, structured, and nurturing home environment to promote achievement of normal developmental milestones - positive attention and additional affection - Effective instructions - Consistent rewards and consequences (limited) - Split tasks up - Use therapeutic and creative play

Question 411

Behavior therapy/CBT and ADHD (3 notes)

Answer 411

- teaches parents skills and strategies to help child with conflict resolution, problem solving, empathy, and social skills - Younger than 6, first line of treatment is parent training in behavior therapy - Over 6, parent training in behavior therapy plus medication

Question 412

4 drug classes used for ADHD aggression

Answer 412

- Stimulants- dose dependent; low doses stimulate aggression but moderate to high doses suppress aggression - Mood stabilizers (Lithium and anticonvulsants)- recommended for impulsivity, explosive temper, and mood lability - Alpha-adrenergic agonists (Clonidine and guanfacine)- reduce agitation, rage, and increase frustration tolerance due to side effects of fatigue and somnolence - Antipsychotics- reduce violent behavior, hyperactivity, and social unresponsiveness (only for severely aggressive behavior due to tardive dyskinesia and metabolic problems)

Question 413

Usage of SNRI (Atomexetine) in ADHD (3 notes)

Answer 413

o Slow responses (up to 6 weeks for full improvement) o Preferred when individual’s anxiety is increased with stimulants OR comorbid anxiety, active SUD, or tics o May cause suicidal ideation in those with comorbid depression

Question 414

Side effects of Atomexetine (6-ish)

Answer 414

- GI disturbances - urinary retention - dizziness - fatigue - insomnia Rare: livery injury, small increase in BP and HR, serious allergic reactions

Question 415

Patient education for Stimulants and ADHD (3) Ex. Methylphenidate, mixed amphetamine salts, lisdexamfetamine

Answer 415

- Minimum dose and no later than 4pm or lower dose later in day - Extended-release formulation to improve dosing and scheduling and decrease insomnia - ALWAYS eat before stimulant use (and have finger foods available)

Question 416

Common side effects of stimulants (6) Ex. Methylphenidate, mixed amphetamine salts, lisdexamfetamine

Answer 416

- insomnia - appetite suppression (weight loss so take prior to meal) - headache - abdominal pain - lethargy - dry mouth

Question 417

Stimulants and ADHD (3 notes) Ex. Methylphenidate, mixed amphetamine salts, lisdexamfetamine

Answer 417

- paradoxical increase in attention and task-directed behavior while reducing impulsivity, restlessness, and distractibility - main drug/ drug of choice - Relatively safe and simple to use