Mental Health Exam #1 Flashcards

Question

What rights do patients have to REFUSE treatment?

Answer 1

Right to withhold consent Right to withdraw consent at any time Right to retract consent; must be honored, whether verbal or written The right of a patient who is mentally ill to refuse treatment with psychotropic drugs has been debated in the courts A patient can refuse meds - UNLESS two doctors approve of “forced meds”

Answer 2

Canterbury v. Spence (1972): right to self-determination | An adult with sound mind has a right to determine what shall be done with his or her own body

Answer 3

If the clinician approached the patient with medication in hand and the patient indicates a willingness to receive the medication, then implied consent ha occurred. State psychiatric hospitals generally require informed consent for every medication given General rule to follow: the more intrusive or risky the procedure, the higher the likelihood informed consent must be obtained

Answer 4

The Dead Man’s Statue Legal privilege of confidentiality exists after death in some states (ex: nurse-patient, physician-patient, attorney-patient) Duty to report: you may be required to divulge private information shared by the patient (ex: murder trial) Different states have varying laws

Answer 5

Some states mandate health care providers to warn spouse if a partner tests positive for HIV Nurses must understand the laws in their jurisdiction regarding privileged communications and warnings of infectious disease exposures

Answer 6

Release of information to a patient’s employer about a patient’s condition without the patient’s consent is a(n) Breach of confidentiality Invasion of privacy Violation of HIPAA

Answer 7

Duty to Warn Tarasoff v. Regents of University of California (1974): California supreme court case Ruled that a psychotherapist has the duty to warn a patient’s potential victim -University student in counseling at a -California university becomes despondent over a rejection by Tatiana Tarasoff -Psychologist notifies police verbally and in writing that the young man may be dangerous to Tarasoff -Police question the student, find him to be rational, and secure a promise to stay away from Tarasoff -The student kills Tarasoff 2 months later

Answer 8

Duty to Protect Third Parties California supreme court issued a second ruling in the Tarasoff case (1976) It now includes the duty to protect Duty to protect usually includes the following: -Assessing and predicting a patient’s danger of violence toward another -Identifying specific individual(s) being threatened -Identifying appropriate actions to protect victim(s)

Answer 9

Nursing implications In jurisdictions that have adopted the Tarasoff doctrine… Duty to warn third parties is applied to advance practice registered nurses (APRNs) and psychiatric mental health nurses Staff nurses and members of the mental health team should report threats of harm Failure to communication and record relevant information from police and relatives may result in patient’s old records being deemed as negligent

Answer 10

- Original order may be extended after a review and reauthorization (typically conducted every 24 hours) - Must specify the type of restraint - In an emergency, the nurse may place the patient in seclusion and/or restraints, but must first obtain a written or verbal order - A telephone order is acceptable, but must be followed by a written order in the chart with a physician follow-up and physician signature (this must happen within 24 hours) - For emergency restraints, the situation must have immediate risk of harm to the patient or others (Exception: patient may request seclusion) - Patient must be protected from harm - Must be documented (behavior leading to restraint, time patient is placed in and released from restraint or seclusion)

Answer 11

Patient must be: - Assessed at regular and frequent intervals for physical needs (ex: food, hydration, toileting), safety, and comfort every 15-30 minutes - Removed from restraint when safer and quieter behavior is observed - Observations must be documented every 15-30 minutes

Answer 12

Child Abuse Reporting Statues Established in all 50 states and Washington, DC. Statutes differ from state-to-state Most statutes include civil penalties for the failure to report Many states require nurses to report cases of suspected abuse

Answer 13

When health care professionals discover child abuse or neglect during a suspected abuser’s alcohol and drug treatment Federal laws govern confidentiality apply to most providers of drug abuse and alcohol treatment Prohibit any disclosure without a court order Federal law supersedes state laws, although compliance with state law may be maintained under the following If a court order is obtained pursuant to the regulations If a report can be made without identifying the abuser as a patient in an alcohol and drug treatment program If the report is made anonymously (though some states do not allow anonymous reporting)

Answer 14

Elder Abuse Reporting Statutes Apply to older adults – 65 years of age and older Many states require RNs to report abuse Federally funded agencies (Medicare, Medicaid) have strict guidelines for reporting and preventing elder abuse

Answer 15

Start with a what if question to help people articulate, explore, and identify thoughts and feelings. Examples: If you had three wishes, what would you wish for? What if you could go back and change how you acted in [X situation] or [significant life event]? What would you do differently now? What would you do if you were given $1 million, no strings attached? Projective questions can help people imagine thoughts, feelings, and behaviors they might have in certain situations.

Answer 16

Suppose you woke up in the morning and a miracle happened, and this problem had gone away: What would be different? How would it change your life? These two questions can reveal a lot about a person, which can be used in identifying goals that the patient might be motivated to work on. These questions often get to the crux of what might be among the most important issues in a person’s thinking and life.

Answer 17

Using silence Accepting Giving recognition Offering self Offering general leads (“I read you came here because…”) Giving broad openings (“How are you feeling today?”) Placing the events in time and sequence Making observations (“I noticed you didn’t come to group.”) Encouraging description of perception Encouraging comparison Restating Reflecting Exploring Giving information (patient education, resources) Seeking clarification Presenting reality (correcting altered perceptions) Voicing doubt (“I don’t think they hate you are much as you seem to think.”) Seeking consensual validation Verbalizing the implied (“It seems you’re upset with…”) Encouraging evaluation Attempting to translate into feelings Suggesting collaboration Summarizing Encouraging formulation of plan Focusing (bringing them back to the topic at hand)

Answer 18

``` Asking excessive questions Giving approval (agreeing) Disapproving (disagreeing) Giving premature advice *ASKING “WHY” QUESTIONS Minimizing feelings Being falsely reassuring Making value judgements Changing the subject ```

Answer 19

Therapeutic relationship Facilitating (therapeutic communication) Assisting patient in: alternative problem solving, new coping skills Helping Promoting independence Focusing on patient’s problems Encouraging behavioral changes ``` Nontherapeutic relationship Blocking (nontherapeutic communication) Does not assist patient in: alternative problem solving, coping skills Controlling Promoting dependence Focusing on nurse’s needs Enabling negative behaviors ```

Answer 20

Transference Person unconsciously and inappropriately displaces (transfers) those emotional reactions that originated from significant figures in childhood onto another individual Example: “You remind me of _____.” Countertransference Tendency of the nurse to displace feelings related to people in his or her past onto a patient Frequently, the patient’s transference to the nurse evokes countertransference feelings in the nurse Example: shown as favoritism on the nurse’s part Although the boundaries of the nurse-patient relationship are generally clearly defined, they can become blurred. This burring can be insidious and may occur at an unconscious level. Usually, the transference and countertransference phenomena are operating when boundaries are blurred.

Answer 21

``` Anxiety Diazepam (Valium) Clonazepam (Klonopin) Alprazolam (Xanax) Lorazepam (Ativan) ``` Lorazepam and alprazolam reduce anxiety without being as soporific (sleep-producing) at lower therapeutic doses Insomnia Flurazepam (Dalmane) Triazolam (Halcion)

Answer 22

Stress: our responses to it are central to psychiatric disorders and the provision of mental health care Eustress “good stress” (graduation, wedding day, etc.) Distress “bad stress” (death in the family, failing a test, etc.)

Answer 23

``` Troubles with eating or sleeping (either too much or too little) Experience headache or back pain Lose interest in favorite activities Feel tense and become irritable Feel powerless ```

Answer 24

PTSD = Posttraumatic Stress Disorder Usually occurs after a traumatic event outside the range of usual human experience HPA system is abnormal (Hypothalamic-pituitary-adrenal axis) Major depression frequently occurs If left untreated or undertreated, painful repercussion can result

Answer 25

Childhood physical abuse, kidnapping, sexual assault Natural disasters, human disasters Crime-related events (terror attack, muggings, taken hostage) Diagnosis of a life-threatening illness

Answer 26

Flashbacks Avoidance of stimuli associated with trauma Persistent negative alterations in mood and cognition; guilt, detachment Persistent symptoms of increased arousal (angry outbursts, self-destructive behavior, startling, sleep difficulties)

Answer 27

Acute Stress Disorder occurs as a result of Witnessing a violent or gruesome death or experience Repeated exposure to aversive details of the event Example: first responders who collect body parts, police officers exposed to details of child abuse, etc. If acute stress disorder continues after 30 days, it becomes PTSD.

Answer 28

Intrusive symptoms: experience keeps coming into mind, interrupts daily life Dissociative symptoms: ignores situation that could be triggering (tries to distract self by putting mind elsewhere) Avoidance symptoms: avoiding situations that could be triggering altogether Arousal symptoms: hyperactive, anxiety By definition, acute stress disorder should resolve in about a month.

Answer 29

Anxiety is the most basic emotion; it is a universal human experience Dysfunctional behavior is often a defense against anxiety When behavior is recognized as dysfunctional, interventions can be initiated by the nurse to reduce anxiety As anxiety decreases, dysfunctional behavior will frequently decrease

Answer 30

Anxiety and fear are indistinguishable, except for the cause FEAR = a reaction to a specific danger ANXIETY = a feeling of apprehension, uneasiness, uncertainty, or dread, resulting from a real or perceived threat whose actual source is unknown or unrecognized

Answer 31

Normal anxiety: healthy life force necessary for survival Acute anxiety: precipitated by imminent loss or threat Pathological anxiety: differs from normal anxiety in terms of duration, intensity, and disturbance of a person’s ability to function (ex: dysfunction behaviors or extreme withdrawal) Chronic anxiety: long-term; thought to be associated with increased risk for cardiovascular morbidity, usually begins at a young age

Answer 32

Mild (normal “worry”) Moderate (more stressed than usual) Severe (debilitating; interferes with ability to function) Panic (lost all touch with all reality, not able to think straight)

Answer 33

Perceptual fields become narrowed Ability to learn impaired Physical characteristics sympathetic NS (chest pain, heart attack symptoms, trouble breathing, etc.)

Answer 34

``` Defense mechanisms are Major means of managing conflict Relatively unconscious Discrete from one another Hallmarks of major psychiatric syndromes, which are reversible (if finding new ways of coping) Adaptive, as well as pathologic ```

Answer 35

Attribute feelings/thoughts onto someone else | Ex: I don't like a boy named Mike, and I say "I know that dude hates me, I know it."

Answer 36

Return to earlier stage of development | Ex: "My 7 year old is wetting the bed again, since he found out he's going to have a little sister."

Answer 37

The action of "reaction formation". Acting out the reverse of unacceptable behavior. Ex: Pyromaniac putting out fire

Answer 38

Using an unacceptable impulse for good. | Ex: Pyromaniac starts working for a special effects company.

Answer 39

``` Highly co-occurring Substance abuse Major depressive disorder (MDD) Frequently co-occurring Eating disorders Bipolar disorder Dysrhythmias Co-occurring medical conditions Cancer, heart disease, HTN, IBS, renal/liver dysfunction, reduced immunity Chronic anxiety Associated with increased risk for cardiovascular morbidity and mortality ```

Answer 40

Panic Disorders (PD) Panic attack Sudden onset of extreme apprehension or fear, usually with a feeling of doom (not necessarily in response to a stressor) Terror so severe that normal function is suspended Signs similar to a heart attack Severely limited perceptual field Increased rate of suicidal and suicide attempts Physical manifestations: chest pain, diaphoresis, muscle tension, urinary frequency, hyperventilation, breathing difficulties, nausea, chills, hot flashes, GI symptoms Panic Disorder with Agoraphobia Agoraphobia An intense and excessive level of anxiety; fever of being in places and situation from which escape is impossible (open spaces, large crowds, airplanes, etc.) Feared places are avoided to control anxiety Avoidance behaviors can be debilitating

Answer 41

Phobia Persistent, irrational fear of something Usually specific objects of situations (dogs, spiders, heights, storms, blood, closed spaces, open spaces) Are common, but usually do not cause much difficulty Social anxiety disorder (SADs) Severe anxiety produced by exposure to a social or performance situation Fear of saying something foolish, not be able to answer questions in a classroom, eating in the presence of others, performing onstage Fear of public speaking is most common

Answer 42

General Anxiety Disorder (GAD) Severe distress with pervasive cognitive dysfunction and impaired functioning No specific triggers

Answer 43

Obsessions (thoughts) – unwanted and persistent, ideas, thoughts, or impulses that cause significant anxiety Compulsions (behaviors) – unwanted and ritualistic behavior the individual feels driven to perform (in order to reduce anxiety)

Answer 44

Obsessive Compulsive Disorder (OCD) OCD behavior exists along a continuum “Normal” individuals may experience mild obsessive-compulsive behaviors Mild compulsions can even be valued traits in U.S. society More severe symptoms: center around dirtiness, contamination, and germs (occur with corresponding compulsions, such as cleaning or hand-washing) Most severe symptoms: include persistent thoughts of sexuality, violence, illness, and death

Answer 45

Body Dysmorphic Disorder (BDD) Preoccupation with an imagined “defective body part” Obsessional thinking about the body Impairment of normal social activities, related to academic or occupational functioning Compulsive Hoarding Excessive collection of items considered worthless Individual is ashamed of failure to discard items Extreme life disruption and distress Social isolation Unsafe living conditions

Answer 46

Modeling – mimicking appropriate behaviors in situations Systematic desensitization – gradually exposing a person to a feared object or situation until the person is free of incapacitating anxiety Response prevention – starts with the therapist preventing the compulsion, such as handwashing, and gradually helps the patient limit the time between rituals, until the urge dissipates Thought stopping – snapping a rubber band on wrist to stop an obsession or negative thought

Answer 47

Somatic Symptom Disorders Characterized by the presence of multiple, real, and/or physical symptoms for which no evidence of medical illness is revealed Accompanied by abnormal thoughts, feelings, and reactions to symptoms Associated with increased health care use, functional impairment, provider dissatisfaction, psychiatric co-morbidity, and failure treatment responses May be exacerbated by other physical disorders Symptoms: impaired functioning, obsession with health concerns, actively seeks medical relief; pain is predominant symptoms (cause not always identifiable) Persistent (>6 months) – can be mild, moderate, or severe

Answer 48

Illness Anxiety Disorder (aka, hypochondria) Illness preoccupation, with or without mild symptoms Persistent (>6 months) Symptoms: high anxiety over health, alarmed by body sensations, may or may not seek help

Answer 49

Conversion Disorder Presents with impaired motor or sensory function compliant Findings inconsistent with known neurologic conditions Symptoms are not voluntarily controlled or created Exhibits either la belle indifference (lack of concern) OR high distress over symptoms Current theories: dispute purely psychologic origin; think patients may have smaller hippocampal volume Co-morbidities: childhood abuse, depression, anxiety, personality disorder

Answer 50

Factitious disorder Imposed on self (Munchausen) Deliberate symptom fabrication or self-injury without obvious potential reward (attention presume to be possible motivation) Patient identifies self as ill Single or recurrent episodes Different from malingering (faking injuring for obvious, often monetary, gain) Imposed on another (Munchausen by-proxy) Offender is usually parent or caregiver, motivation is attention or nurturing for self at expense of a dependent victim

Answer 51

Nursing assessment History and course of past symptoms Current physical/mental status No voluntary control over symptoms (with exception of factitious disorders) Assess for secondary gains (benefits derived from symptoms) Cognitive style Misinterpretation of physical stimuli Reality distortion regarding symptoms Ability to communicate emotional needs Dependence on medications patients often seek prescription renewal, and seek treatment from many physicians (go “doctor shopping”); nurse must evaluate the importance of each med Anxiolytics, such as benzos (rebound anxiety occurs on withdrawal), pain meds, and sleep meds

Answer 52

Disturbance in a normally well-integrated continuum of consciousness, memory, identity, and perception Dissociation = the unconscious defense mechanisms to protect an individual against overwhelming anxiety Intact reality testing (is not delusional or hallucinating) Includes amnesiac states

Answer 53

Depersonalization/Derealization Disorder Recurrent periods of feeling unreal, detached, outside the body, dreamlike, numb, or with a distorted sense of time or perception Reality testing remains intact Symptoms are not related to medical conditions or substance use Dissociative Amnesia Psychologically induced memory loss and inability to recall important personal information after a severe stressor Dissociative Amnesia with Fugue Sudden, unexpected travel from a customary location, and the inability to recall one’s identity after a traumatic event Dissociative Identity Disorder (DID) – very rare Formerly known as “Multiple Personality Disorder” Presence of two or more personality states that control behavior Each alternate personality (alter) has its own pattern of perceiving, affect, cognition, behavior, and memories Severe sexual, physical, psychologic trauma in childhood predisposes an individual to DID

Answer 54

``` Patient history Recent injuries, seizure history, early trauma, memory/identity questions, history of similar episodes Mood Depressed, anxious, unconcerned, suicidal Frequent shifts in mood Erratic behavior Use of alcohol or other drugs Effect on patient and family ```