Test 7 MH

Question 1

1. Name the first step in the Nursing Process and when it begins.

Answer 1

• Assessment is the first step in the nursing process.
• Begins at the time of the client’s arrival to the unit

Question 2

3. Name the steps of the Nursing Process.

Answer 2

• Step 1: Assessing the patient’s mental health.
• Step 2: Nursing Diagnosis; defining patient problems.
• Step 3: Planning (short- and long-term goals)
• Step 4: Implementations/ Interventions
• Step 5: Evaluating Interventions

Question 3

8. When does discharge teaching begin?

Answer 3

• Beings at admissions

Question 4

9. How does a discharge differ from a transfer?

Question 5

10. What are Defense Mechanisms? List them.

Answer 5

• Denial
• Repression
• Dissociation
• Rationalization
• Compensation
• Reaction Formation
• Regression
• Sublimation
• Projection
• Displacement
• Restitution (Undoing)
• Isolation
• Conversion Reaction
• Avoidance
• Scapegoating

Question 6

11. Define Denial and give an example of it.

Answer 6

• Usually, the first defense learned and used.
- The alcoholic states, “I can quit any time I want to.”
• Unconscious refusal to see reality.
- Is not consciously lying.

Question 7

12. Define Dissociation and give an example of it.

Answer 7

• Painful events or situations are separated or dissociated from the conscious mind.
- Patient who had been sexually abused as a child describes the situation as if it happened to a friend or sibling.
• Could be described as an out-of-body experience.
- Police visit parent to inform parent of death of child in car accident. Parent tells police, “That’s impossible. My child is upstairs asleep. You must have the wrong house.”

Question 8

13. Define Compensation.

Answer 8

• Making up for something a person perceives as an inadequacy by developing some other desirable trait.

Question 9

14. Define Regression and give an example of it.

Answer 9

• Emotionally returning to an earlier time in life when there was far less stress.
- Children who are toilet trained beginning to wet themselves.
• Commonly seen in patients while hospitalized. Note: People do not regress to the same developmental age. This is highly individualized.
- During serious illness, a patient exhibits behavior more appropriate for a younger developmental age, such as excessive dependency.

Question 10

15. Define Projection and give an example of it.

Answer 10

• Attributing feelings or impulses unacceptable to oneself to others.
- Wife tells patient’s nurse, “My husband is worried about going home.” (Wife is the one who is worried.)
- Young soldier is fearful of upcoming deployment and says, “Those other guys are a bunch of cowards.”

Question 11

15. Define Scapegoating and give an example of it.

Answer 11

• Blaming others
- “I didn’t get the promotion because you don’t like me.”

Question 12

16. Define Displacement and give an example of it.

Answer 12

• The “kick-the-dog syndrome.”
• Transferring anger and hostility to another person or object that is perceived to be less powerful.
- Parent loses job without notice; goes home and verbally abuses spouse, who unjustly punishes child, who slaps the dog.

Question 13

3. Describe the 4 different extrapyramidal side-effects.

Answer 13

Dystonia: muscle rigidity, torticollis (neck turned in awkward angle)

Pseudoparkinsonism or dyskinesia: stiffness, tremors, shuffling gait

Akathisia: restlessness, inability to sit still

Oculogyric crisis: uncontrolled rolling back of the eyes

Tardive dyskinesia: late onset movement disorder that includes lip smacking, grimacing, tongue protrusion

Question 14

4. Name the antipsychotic medication best used with pts who are non-compliant.

Answer 14

• Prolixin Decanoate

Question 15

5. Which side effect of antianxiety agents is very concerning?

Answer 15

• Dependency

Question 16

8. Pts taking MAOIs must avoid what? What foods contain this and should be avoided?

Answer 16

Avoid foods containing the amino acid tyramine.
• Aged cheese (cheddar, Swiss, provolone, blue cheese, parmesan)
• Avocados (guacamole)
• Yogurt, sour cream
• Chicken and beef livers, pickled herring, corned beef
• Bean pods
• Bananas, raisins, and figs
• Smoked and processed meat (salami, pepperoni, and bologna)
• Yeast supplements
• Chocolate
• Meat tenderizers (MSG), soy sauce
• Beer, red wines, and caffeine

Question 17

9. What is Lithium used to treat and what should be part of the pts teaching?

Answer 17

• Lithium is used for the manic phase of bipolar disorder and sometimes for other depressive or schizoaffective disorders.

• Keep all Appt for blood work and evaluation of drug effectiveness
- Monitor for signs toxicity ( severe diarrhea, persistent nausea and vomiting, muscle weakness, tremors, blurred vision, slurred speech, and seizures)
- Not safe for pregnancy (ask provider if want to become pregnant)
- Dehydration and fever can cause increase risk of toxicity
- Adequate fluid and sodium intake are essential.
• To inform the physician immediately if they are ill.
• Hard, sugarless candy can be helpful to decrease dry mouth and thirst but consult your health-care provider

Question 18

13. Describe ECT and what its used for.

Answer 18

• ECT delivers a small electrical charge to the brain that creates a change in nerve impulses.
• ECT is an alternative treatment for certain mental disorders when nothing else works.

Question 19

14. Who is at risk to commit suicide? Who should the nurse be most concerned about?

Answer 19

• A person in crisis is at risk for physical and emotional harm inflicted by self or by others.

Question 20

18. Describe the difference between Alternative Medicine and Complementary Medicine.

Answer 20

• Complementary and alternative medicine (CAM) present additional options in health promotion. In general, alternative medicines replace those of conventional/Western medicine, whereas complementary medicine methods are used together with conventional treatments.

Question 21

19. Describe Biofeedback, include how it’s done, and for what purpose.

Answer 21

• Biofeedback is a training program designed to develop one’s ability to control the autonomic nervous system.
• The patient is taught to obtain a deep level of relaxation as a means to control a light, buzzer, image, or a video game, to which he or she is attached by electrodes and cables. The machine is then gradually adjusted to greater sensitivity, and the patient learns improved control.
• The primary purpose of biofeedback training is to teach patients to be aware of tension within the body and to respond with relaxation.

Question 22

20. What is Aromatherapy, and how does it work?

Answer 22

• Aromatherapy may well be one of the oldest methods used to treat illness in human beings. Related to herbal therapy, aromatherapy provides treatment by both the direct pharmacological effects of aromatic plant substances and the indirect effects of certain smells on mood and affect.

Question 23

22. Describe the following touch or massage techniques:
    - Shiatsu
    -Rolfing
    -Reiki

Answer 23

Shiatsu: Shiatsu is a Japanese form of acupressure that uses pressure from the fingers to free energy flow

Rolfing: Rolfing is a therapy designed to realign the body with gravity through fascial manipulation, a vigorous form of bodywork that is finding increasing acceptance.

Reiki: Reiki is representative of methods of touch healing that are often associated with massage.

Question 24

23. What does the term “Reiki” mean? What does it refer to?

Answer 24

• Reiki is a term that means “universal life energy” and refers to the process whereby this energy is drawn along the body’s meridians.