Mental health test 2 Flashcards
Includes all willful, self-inflicted, life-threatening attempts that have not led to death.
suicide attempt
Occurs when a client is having thoughts about committing suicide.
suicidal ideation
The intentional act of ending one’s own life.
suicide or completed suicide
A person contemplating suicide believes that the act is the
end to his/her problems
true or false: In the U.S. in 2017, white males accounted for almost 70% of suicide deaths, with the rate of suicide highest in middle-age white men.
true
what are considered protective factors for suicide?
feelings of responsibility toward children or pets, religious and cultural beliefs, positive self esteem, and sense of hope
risk factors for suicide for youth
Contagion, substance use, impulsive/aggressive personality disorders, stressful life events, family factors.
risk factors for suicide for older adults
Major changes in social roles; fear of burdening family members; substance use; death of loved ones
risk factors for suicide for middle-age
Relationship, legal or financial problems; substance use; job stress
Occurs when sexual contact takes place without consent, whether the vulnerable person is able or unable to give that consent
sexual violence
Includes failure to provide any of the following: physical care, such as feeding; emotional care, such as interacting with a child, or stimulation necessary for a child to develop normally; education, such as enrolling a young child in school; necessary health or dental care
neglect
Occurs when physical pain or harm is directed toward an infant or child, an intimate partner, or a vulnerable adult in the home.
physical violence
Includes behavior that minimizes an individual’s feelings of self-worth or humiliates, threatens or intimidates a family member
emotional violence
Failure to provide for the needs of a vulnerable person when adequate funds are available
economic maltreatment
true or false: In relation to child abuse, any bruising on an infant before age 6 months is considered suspicious.
true
phase in the cycle of violence in which the abuse has minor episodes of anger, can be verbally abusive and responsible for some minor physical violence. The vulnerable person is tense during this stage and tends to accept the blame for what is happening.
tension building phase
phase in the cycle of violence in which The tension becomes too much to bear and serious abuse takes place. The vulnerable person can try to cover up the injury or try to get help
acute battering phase
phase in the cycle of violence in which The situation is diffused for a while after the violent episode. The abuser becomes loving, promises to change, and is sorry for the behavior. The vulnerable person wants to believe this and hopes for a change.
honeymoon phase
somatic reaction that can occur later after a rape in which the client can have a variety of physical manifestations
gonorrhea
True or False: The majority of perpetrators of sexual violence are known to their victims.
true
Displacement
Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation
Reaction formation
Overcompensating or demonstrating the opposite behavior of what is felt
Undoing
Performing an act to make up for prior behavior
Suppression
Voluntarily denying unpleasant thoughts and feelings
Repression
Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness
Regression
Sudden use of childlike or primitive behaviors that do not correlate with the person’s current developmental level
Altruism
Dealing with anxiety by reaching out to others
Sublimation
Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression
Rationalization
Creating reasonable and acceptable explanations for unacceptable behavior
Dissociation
Creating a temporary compartmentalization or lack of connection between the person’s identity, memory, or how they perceive the environment
Denial
Pretending the truth is not reality to manage the anxiety of acknowledging what is real
Compensation
Emphasizing strengths to make up for weaknesses
Identification
Conscious or unconscious assumption of the characteristics of another individual or group
Intellectualization
Separation of emotions and logical facts when analyzing or coping with a situation or event
Conversion
Responding to stress through the unconscious development of physical manifestations not caused by a physical illness
Splitting
Demonstrating an inability to reconcile negative and positive attributes of self or others
Projection
Attributing one’s unacceptable thoughts and feelings onto another who does not have them
stress
the body’s nonspecific response to any demand made upon it
Eustress
Beneficial stress
Motivates people to develop the skills they need to solve problems and meet personal goals
Distress
Causes problems both mentally and physically
May trigger depression, cause confusion, instill helplessness/ hopelessness, cause fatigue, etc.
three stages stages in the human response to stressors
alarm reaction stage, resistance stage, and exhaustion stage
Alarm reaction stage
Individual becomes aware of the stress or stressor and the sympathetic nervous system springs into a fight-or-flight reaction
Resistance stage
Body attempts to adapt to the stress response, and in many instances adaptation occurs
Exhaustion stage
If homeostasis is not restored, exhaustion results
Normal anxiety
Healthy life force necessary for survival; motivates people to take action
Acute anxiety
Precipitated by an imminent loss or change that threatens an individual’s sense of security
Acute anxiety is a normal and expected response to stress
Chronic anxiety
Usually develops over time, often starting in childhood
might display that anxiety in physical manifestations, such as fatigue and frequent headaches
Mild Anxiety
Occurs in the normal experience of everyday living Wide perceptual field Sharpened senses Increased motivation Effective problem solving Increased learning ability Irritability
Moderate Anxiety
As anxiety escalates, the patient’s perceptual field narrows and some details are excluded from observation
Selectively attentive
Cannot connect thoughts or events independently
Increased use of automatisms
Severe Anxiety
The perceptual field of a person experiencing severe anxiety is greatly reduced
Cannot complete tasks
Cannot solve problems or learn effectively
Behavior geared toward anxiety relief and is usually ineffective
Doesn’t respond to redirection
Feels awe, dread, or horror
Cries
Ritualistic behavior
Panic Level of Anxiety
Most extreme form and results in markedly disturbed behavior
May bolt and run or Totally immobile and mute
Dilated pupils
Nursing Interventions: Mild to moderate anxiety
active listening, Evaluate past coping mechanisms, Encourage participation in activities
Nursing Interventions:Severe to panic-level anxiety
Provide an environment that meets the physical and safety needs of the client. Remain with the client, Set limits by using firm, short, and simple statements, Encourage gross motor activities, such as walking and other forms of exercise
A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client has a respiratory rate of 30/min. and says “This is difficult to comprehend. I feel shaky and nervous.” The nurse should identify that the client is experiencing which of the following levels of anxiety?
moderate
A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following information should the nurse include in the discussion?
Excessive stressors cause the client to experience distress.
4 Cs of addiction
Craving, Control, Compulsion, and Consequences
risk factors for substance use disorder
chronic stress, history of trauma, low self esteem, few life successes
socioculture factors for substance use disorder
childhood trauma, culture, peer pressure, older adults
older adults who use substances
especially prone to falls and other injuries, memory loss, somatic reports (headaches), and changes in sleep patterns
screening for substance abuse
MAST, DAST, CAGE, AUDIT, CIWA, and withdrawal scale
CAGE- AID
C-Have you ever felt you ought to Cut down on your drinking (or drug use)?
A—Have people Annoyed you by criticizing your drinking (drug use)?
G—Have you ever felt bad or Guilty about your drinking (drug use)?
E—Have you ever had a drink (used drugs) first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
AID—Adapted to Include Drugs
Death could occur from acute toxicity from alcohol in levels greater than
0.4%
alcohol intoxication effects
Slurred speech, nystagmus, memory impairment, altered judgment, decreased motor skills
alcohol withdrawal effects
Abdominal cramping; vomiting; tremors; restlessness and insomnia; increased heart rate, blood pressure, respiratory rate, and temperature
Alcohol withdrawal delirium (Delirium tremens or DTs)
Sedatives/hypnotics/anxiolytics Effects of Intoxication
Increased drowsiness and sedation, agitation, slurred speech Respiratory depression and decreased level of consciousness
Sedatives/hypnotics/anxiolytics Effects of withdrawal
Anxiety, insomnia, diaphoresis, hypertension, possible psychotic reactions, hand tremors
cocaine Effects of Intoxication
Mild toxicity:
Dizziness, irritability, tremor, blurred vision
Severe effects:
Hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, possible cardiovascular collapse and death
cocaine Withdrawal manifestations
Depression, fatigue, craving, excess sleeping or insomnia, dramatic unpleasant dreams, psychomotor retardation, agitation
Not life threatening, but possible occurrence of suicidal ideation
Amphetamines Effects of Intoxication
Impaired judgment, psychomotor agitation, hypervigilance, extreme irritability
Acute cardiovascular effects (tachycardia, elevated blood pressure) which could cause death
Amphetamines Withdrawal manifestations
Craving, depression, fatigue, sleeping
Not life-threatening
opioids Effects of intoxication
Slurred speech, impaired memory, pupillary changes
Decreased respirations and level of consciousness, which can cause death
opioids Withdrawal manifestations
Occur within hours to several days after cessation of opioid use
Common findings include agitation, insomnia, flu-like manifestations, muscle aches, abdominal cramps, rhinorrhea, yawning, sweating, and diarrhea
treatment for alcohol withdrawal
benzodiazepines such as chlordiazepoxide and diazepam
adjunct med - carbamazepine and clonidine
nursing consideration for benzodiazepines
Monitor vital signs and neurological status on an ongoing basis
Provide for seizure precautions
Composed of discrete episodes of panic attacks, that is, 15 to 30 minutes of rapid, intense, escalating anxiety in which the person experiences great emotional fear as well as physiologic discomfort.
panic disorder
Client exhibits uncontrollable, excessive worry for at least 6 months.
generalized anxiety disorder
Extreme fear of certain places (such as the outdoors or being on a bridge where the client feels vulnerable or unsafe).
agoraphobia
Irrational fear of a certain object or situation.
specific phobias
Excessive fear or anxiety when separated from an individual to which the client is emotionally attached.
separation anxiety
A client with anxiety is beginning treatment with lorazepam (Ativan). It is most important for the nurse to assess the client’s:
use of alcohol
A nurse observes a client who has OCD repeatedly applying, removing, and the reapplying makeup. the nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?
reduce anxiety
A type of dissociative amnesia in which the client travels to a new area and is unable to remember one’s own identify and at least some of one’s past. Can last weeks to months and usually follows a traumatic event.
dissociative fugue
Characterized by persistent or recurrent episodes of depersonalization, derealization, or both in response to overwhelming stress
depersonalized/derealization disorder
Charaterized by (1) the existence of two or more distinct personality states and (2) recurrent episodes of amnesia
dissociative identity disorder
Characterized by the inability to recall important personal information, usually of a traumatic nature
dissociative amnesia disorder
A nurse is collecting an admission history or a client who has acute stress disorder (ASD). Which of the following information should the nurse expect to collect?
The client expresses a sense of unreality about the traumatic incident.
A client diagnosed with postraumatic stress disorder (PTSD) is close to discharge. Which client statement would indicate that teaching about the psychosocial cause of PTSD was effective?
“My experience, how I deal with it, and my support system all affect my disease process.”
A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (select all that apply)
Difficulty concentrating on tasks, Negative self-image, Recurring nightmares
adjustment disorder
Characterized by marked emotional distress resulting form an identifiable stressful life event (e.g. marital breakup, persistent painful illness, job loss, natural disaster)
acute stress disorder
Exposure to traumatic events causes anxiety, detachment and other manifestations about the event for at least 3 days, but for not more than 1 month following the event.
PTSD
Exposure to traumatic events causes anxiety, detachment, and other manifestations about the event for longer than 1 month following the event. Manifestations can last for years.
A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider?
The client had a motor vehicle crash last year and sustained a head injury.
The greatest risk to the client is the development of seizures. Bupropion can lower the seizure threshold and should be avoided by clients who have a history of a head injury. This information is the highest priority to report to the provider.
Which of the following are examples of anticholinergic side effects from tricyclic antidepressants? (Please select all that apply):
Urinary hesitancy, Constipation, Blurred vision, Dry mouth
A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? (Please select all that apply):
History of chronic bronchitis, Family history of depression, Personal history of panic disorder, Recent death in a client’s family
A nurse is interviewing a 25-year-old client who has a new diagnosis of Persistent Depressive Disorder (PDD). Which one of the following findings should the nurse expect?
Presence of manifestations for at least 2 years
A client is admitted to an in-patient mental health unit with a diagnosis of Major Depressive Disorder (MDD). Which of the following data would the nurse expect to assess? (Please select all that apply):
Loss of interest in almost all activities and anhedonia., A significant change in appetite or weight. Psychomotor retardation or agitation. Insomnia or hypersomnia
A noninvasive therapy that uses magnetic pulsations to stimulate the cerebral cortex of the brain.
transcranial magnet stimulation
Provides electrical stimulation through the vagus nerve to the brain through a device that is surgically implanted under the skin on the client’s chest.
vagus nerve stimulation
Uses electrical current to induce brief seizure activity while the client is anesthetized
electroconvulsive therapy (ECT)
Which of the following client education/nursing considerations apply to SSRIs (Selective Serotonin Reuptake Inhibitors)? (Please select all that apply):
take with food to minimize GI disturbances, Avoid concurrent use of St. John’s Wort, which can increase risk of serotonin syndrome, Observe for manifestations of serotonin syndrome; if any occur, stop the medication and notify provider
