Final (Nursing Interventions & Action) Flashcards

Question

Role of the Nurse in Cognitive Therapy

Answer 1

Cognitive therapy requires an understanding of educational principles and the ability to use problem- solving skills to guide clients’ thinking through a reframing process

Answer 2

Avoid “always” and “never” Accept that change is constant Appreciate differences Current treatment for borderline personality disorder

Answer 3

These are tools for your tool box when you go to clinical. The core philosophy is to build on what is strong and positive with your client. Work with your client to recognize their strengths, gifts, and positive coping skills.

Answer 4

``` Well being therapy Healing therapies Positive Psychotherapy Identify signature strength Gratitude Visit Gratitude Therapy Daily Affirmations Build strengths to foster hope ```

Answer 5

Impaired personal functioning | Impaired relationships

Answer 6

Unable to meet role expectations | Deterioration in appearance

Answer 7

Intrusive | Isolate

Answer 8

``` Risk for violence (self or other) *Disturbed thought processes *Disturbed sensory perceptions Impaired verbal communication Self-care deficits Social isolation Ineffective health/home maintenance Disabled family coping ```

Answer 9

``` Remains safe Communicates with others Completes ADLs Interacts satisfactorily with others Reports control over hallucinations Perceives environment realistically Verbalizes logical thought processes ```

Answer 10

Reassure patients they are safe Protect from physical harm as they respond to the altered perceptions Encourage verbalization of fears Contract for safety Intervene at early sign of anxiety, agitation

Answer 11

Validate belief of patient, but that you do not share belief Avoid arguing with patient or deny the false belief Present reality

Answer 12

``` Consistent staff Keep promises Avoid physical contact Monitor communication with others Food, medication Avoid competitive activities ```

Answer 13

``` Observe for and determine type Develop trusting relationship Calming techniques One-to-one interactions Do not reinforce perception, orient to reality Use distraction techniques Active involvement in activity Correlation of anxiety to hallucinations ```

Answer 14

``` Promote verbal communication Pay close attention and monitor for “themes” to understand the message Seek clarification Teach assertive communication Promote social interaction and activity Group therapy Promote social skills ```

Answer 15

``` Explore adaptive coping strategies Enhance self esteem Encourage self care activities Acknowledge achievements Positively reinforce independence Prevent relapse Educate regarding relapse triggers (physical, personal, and community stressors) ```

Answer 16

Promote medication adherence Involve the patient in medication-based treatment decisions Teach patient how to report and manage side effects Discuss patient’s expectation of the medications Provide hope Involve the family/caregiver

Answer 17

Loss of ego boundaries leads to bizarre and inappropriate behaviors. Protect the patient from retaliation Reintegrate the patient into the Milieu

Answer 18

Discuss basic nature of disorder Help families identify their initial response to the diagnosis Acknowledge families for supporting treatment of the ill family member Encourage family participation in psycho- educational programs Provide contact information for NAMI

Answer 19

``` Risk for self-directed violence Complicated grieving Low self-esteem Hopelessness Self-care deficit Imbalanced nutrition Disturbed sleep pattern Social isolation or Impaired social interaction ```

Answer 20

``` Observe frequently/Close Observations Evaluate level of suicide intent Remove sharp/dangerous objects from Intervene at first sign of increased agitation Remain calm; Spend time with patient Have sufficient staff on hand Encourage verbalization of feelings including anger Contract for safety ```

Answer 21

``` Develop trust Encourage expression of anger Teach positive coping strategies to release anger Teach about normal grief Assess spiritual needs Encourage use of support groups ```

Answer 22

Identify and focus on strengths Encourage independence Teach assertiveness skills Teach use of “I” statements Encourage involvement in activities they can be successful Recognize and praise small accomplishments

Answer 23

``` Assess calorie needs and food preferences Provide high protein, high calorie finger foods & drinks Record I & O - Assess Weight Assess activity level Monitor sleep patterns Promote adequate sleep Teach relaxation techniques Encourage daily hygiene ```

Answer 24

Make brief but frequent interactions Spend time with patient, in silence if necessary Attend activities with patient at first Reinforce social skills and self-confidence

Answer 25

Keep environmental stimuli to a minimum Set limits on inappropriate behavior Do not argue, bargain or try to reason Provide positive reinforcement for expected behavior Help patient identify positive aspects of self Help patient accept consequences of behavior

Answer 26

Signs of relapse

Answer 27

Medications - side effects, lab work, compliance Assertiveness techniques Anger management Coping Strategies

Answer 28

Complications of Medication Non-Compliance Alcohol and/or drug abuse may be used as a strategy to “self-medicate.” Personal relationships, work, and finances may suffer as a result of mood swings. Suicidal thoughts and behaviors are very real complications.

Answer 29

``` NAMI Crisis hotline Support groups Legal/financial assistance Suicide hotline ```

Answer 30

Safety Establish trust Acceptance of child separate from behavior Immediate positive feedback for acceptable behavior Redirect violent behaviors into positive outlets Role play Behavioral reinforcement Structured activities - starting with lower expectations and progressing Identification of feelings Limit setting Consistent discipline

Answer 31

No physical harm to self or others Appropriate interactions with others Positive self concept Follows rules without becoming defensive Fewer demanding behaviors Cooperation and completion of tasks Demonstrates self- control by managing tics Able to accept directions without becoming defensive Decreased anxiety upon separation from caregiver

Answer 32

Nurses must begin relationship development with an individual who abuses substances by examining own attitudes and personal experiences with substances

Answer 33

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) Michigan Alcoholism Screening Tool (MAST) CAGE

Answer 34

``` Denial Ineffective CopingAlternate Strategies Nutrition - Less than Body Requires Infection Low Self Esteem Deficient Knowledge Injury Suicide ```

Answer 35

Provide safe and supportive environment | Administer substitution therapy

Answer 36

Provide explanations of physical symptoms Promote understanding and identify causes of substance dependency Help patient accept use of substance as a problem Provide education and assistance to patient and family

Answer 37

Encourage continued participation in long- term treatment Promote participation in outpatient support system. Assist patient to identify alternative sources of satisfaction Provide support for health promotion and maintenance.

Answer 38

Ways in Which Use of Substance Affects Life | Effects (of Substance) on the Body

Answer 39

``` Activities to substitute for (substance) in times of stress Relaxation techniques: – Progressive relaxation – Tense and relax – Deep breathing Problem-solving skills Essentials of good nutrition ```

Answer 40

``` Rape-trauma syndrome Powerlessness Delayed growth & development Fear Low self esteem Acute Confusion Ineffective Coping Risk for self directed violence Disturbed sleep pattern ```

Answer 41

Reassure client they are in a safe place Display empathy that this has happened Instill that they are not to blame for abuse Provide privacy during interview and physical exam Explain all procedures (photography) Treat injuries/diseases Listen to them, support open communication Maintain a non-judgmental attitude Establish trust Encourage expression of feelings : fear, loss of control, powerlessness, grief Assure client of confidentiality Assist with decision making Avoid ‘rescuing’ the client Provide information for available resources Help them contact support systems Promote self esteem and self worth Review coping strategies

Answer 42

``` Protect from harm Provide safe, secure, structured environment Maintain calm, quiet environment Low level stimuli Consistency of staff Maintain routines Engage in social and leisure activities Reorient to time place situation Label objects Ask one part questions Give simple explanations Speak slowly and distinctly Hearing aids/glasses Assist with ADLs as needed ```

Answer 43

Stay with client, reassure client they are safe Provide caring, non judgmental environment Unconditional positive regard Low stimuli environment Calm, quiet, clear communication Review sign and symptoms of escalating anxiety Identify/teach adapt coping strategies Thought stopping, relaxation, exercise

Answer 44

Identify events/situations that trigger increase in anxiety and initiate ritualistic behaviors Acknowledge relationship of anxiety to behaviors. Initially, meet client’s dependency needs, then encourage independence. Initially, allow plenty of time for ritual. Then gradually limit amount of time. Use positive reinforcement for non- ritualistic behaviors

Answer 45

Assess client’s perception of body Help client see that body image is distorted or out of proportion in relation to significance of actual anomaly Involve client in activities that reinforce a positive sense of self not based on appearance

Answer 46

``` Reassurance of safety Encourage expression feelings Integration of the trauma into persona Progress through the grief process Develop a sense of optimism and hope for the future ```

Answer 47

Nature of illness Management of illness - Medication, Stress Relaxation techniques Support services

Answer 48

Non judgmental approach Assist with self care as need Review medical testing and assessment with client Limit time discussing physical complaints/deficits Gradually withdraw attention from physical complaints Identify gains by client

Answer 49

Nursing care for the patient with a dissociative disorder is aimed at restoring normal thought processes. Assistance is provided to the patient in an effort to determine strategies for coping with stress by means other than dissociation from the environment.

Answer 50

Symptoms of eating disorders Causes of eating disorders Effects of the illness or condition on the body

Answer 51

``` Principles of nutrition Ways patient may feel in control of life Importance of expressing fears and feelings, rather than holding them inside Alternative coping strategies Relaxation techniques Problem-solving skills ```

Answer 52

Coping with emotional issues adaptively Reaching ideal body weight and maintaining Behavioral change are made by the patient and family members.