Week 12 - Mental Health

Question 1

mental health

Answer 1

finding balance in all aspects of life; can vary over time across a continuum

Question 2

mental disorder

Answer 2

constellations of so-occurring symptoms involving alterations in thought, experience, and emotion

Question 3

mental health nursing assessment

Answer 3

methods:
observation
interview
examination
physical assessment
collaboration with others`

Question 4

components of the health history interview

Answer 4

identification/biographical information
reason for seeking care
past health
- illness, injury, hospitalization; chronic illness
current health/review of systems

Question 5

functional assessment

Answer 5

self-concept, self-esteem
interpersonal relationships and resources
coping and stress management

Question 6

Nurse-patient relationship influenced by

Answer 6

-personal, socioeconomic and political factors.
-gender, age, sexual orientation, economic factors, cultural, historical and geographic elements
-poverty, income, education and neocolonial policies and practices

Question 7

mental status examination

Answer 7

emotional and cognitive functioning
Domains A B C T
Appearance
Behavior
- mood and affect, speech
Cognition
- consciousness, orientation, memory, attention and concentration, comprehension and abstract reasoning
Thinking
- perception, content, process, insight, judgement

Question 8

Appearance

Answer 8

posture
body movements
dress
grooming and hygiene

Question 9

behavior

Answer 9

LOC
- Alert, oriented, drowsy, obtunded, stupor, coma, delirium
Facial expression
- smiling, frowning, fear, anger, surprise, disgust
Speech
- raised or muffled, fast, slow, articulation
Mood and affect
- flat, depressed, elated, euphoric, anxiety, fear, irritability, rage, ambivalences, inappropriate

Question 10

cognitive functions

Answer 10

orientation
attention span
- do something that has three or more steps
immediate memory
- recall a statement you just made
recent memory
- 24-hour diet recall
remote memory
- ask a verifiable historic event
new learning
- four words e.g., apple, table, cow and penny

Question 11

thought processes, content, and perceptions

Answer 11

Thought process:
1) Does this person make sense?
2) Logical – Goal directed, coherent, and relevant
Thought content:
-What person says should be consistent and logical ie. “Do you perform specific actions to reduce certain thoughts?”
Perceptions:
-Is the person aware of reality ie. Delusions- “Do you have any thoughts that other persons think are strange?”

Question 12

objective data

Answer 12

sudden behavior changes
includes LOC
Aphasia
Suicide risk

Question 13

risk assessment

Answer 13

Screen for suicidal thoughts
Screen for Assault or Homicidal Ideation
Screen for Elopement Risk
ASK:
Have you ever felt so blue that you thought of hurting yourself?
Do you have thoughts of hurting others?
Do you understand why you need to be in the hospital at this time?

Question 14

abnormal findings

Answer 14

abnormalities of mood and affect
Flat affect (blunted affect)
Depression
Depersonalization
Elation
Euphoria
Anxiety
Fear
Irritability
Rage
Ambivalence
Lability
Inappropriate affect

Question 15

knowledge of substance use applied in health assessment

Answer 15

health promotion
take patient’s and population’s context into account
trauma- and violence-informed care
minimize harm

Question 16

relevant terms and documentation

Answer 16

Substance use / abuse:
American Psychiatric Association prefers the term “substance use disorder” in DSM-5
Substance use:
Preferred term over addiction, dependence, disorder, misuse

Confusing or Problematic Terms:
Addiction:
Generally refers to compulsion and dependence; disagreement over usefulness of term.
Dependence:
Used as a label for compulsive, out of control substance use.

Include
- type of substance used
- amount(s)
- route
- result of health history and physical assessment

Question 17

screening tools - TWEAK

Answer 17

tolerance
worry
eyeopener
amnesia
Kcut Down
Used to identify WOMEN who are at risk for alcohol use problems

Question 19

CAGE questionnaire

Answer 19

Cutdown
Annoyed
Guilty
Eye-opener
Quick test for alcohol abuse and dependence
Four straightforward questions with yes/no responses
Does not distinguish past problem drinking from active present drinking
Useful to initiate conversation about alcohol use

(Please note: This test will only be scored correctly if you answer each one of the questions.
Please check the one response to each item that best describes how you have felt and behaved over your whole life.)

Have you ever felt you should cut down on your drinking? __Yes __No
Have people annoyed you by criticizing your drinking? __Yes __No
Have you ever felt bad or guilty about your drinking? __Yes __No
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? __Yes __No

If client answers 2 or more “yes” responses, consider at risk for alcohol withdrawal.

Question 20

assessing for withdrawal

Answer 20

Alcohol:
- insomnia, sweating, racing heart, tremors, nausea and vomiting, psychomotor agitation, anxiety, seizures (rarely hallucinations and perceptual disturbances). Can be life-threatening if not treated (cardiovascular collapse)
Sedatives
- anxiety, orthostatic hypotension, tremors of the hands, tongue and eyelids,
Nicotine
- vasodilation, headaches, irritability and nervousness,
Cannabis
- irritability, nervousness, sleep difficulty, decreased appetite, restlessness, depressed mood and physical symptoms such as discomfort.
Cocaine
- dysphoric mood, agitation, insomnia, or hypersomnia
Amphetamines
- as above
Opiates
- as above

Question 21

5 A’s for integrating knowledge of substance use in health assessment

Answer 21

Acquire knowledge; replace erroneous assumptions
Anticipate harm that may be caused by your practices, reactions, judgements
Analyze organizational practices (e.g., clinical assessment tools) and resources
Avoid social judgement about substance use, such as seeing a person as “bad,” deviant, or morally weak
Approach patients respectfully

Question 22

interpersonal violence

Answer 22

-always an abuse of power
-involves physical/sexual violence, psychological violence, or financial abuse within current/former intimate, marital or common-law relationships, and same-sex spousal relationships
-may include physical/sexual assault, verbal abuse, imprisonment, humiliation, stalking, denial of access to financial resources, shelter, or services
-can involve denial of access to children, family members

Question 23

structural violence

Answer 23

refers to the harmful ways in which society is organized (the ways power is distributed) so that people are put at risk, such as through systemic discrimination based on:
- race/ethnicity, class ability, gender, and other social constructions,
- poverty sustained by economic arrangements and policies
- other policies that create vulnerabilities for some people

Question 24

ecological model

Answer 24

helps nurses understand IPV in the wider context of society

Question 25

effects of violence on health

Answer 25

Direct effects of physical injury (bruises, fractures)
Chronic health problems
- Chronic pain
- Neurological
- GI, GU
- Chronic pelvic pain
- Unintended pregnancy
- STIs, including HIV
- Urinary tract infections
Mental health problems
- Depression
- Suicidal thoughts/attempts
- Symptoms of PTSD
- Substance abuse

Question 26

assessing intimate partner violence

Answer 26

spousal abuse:
physical/sexual violence, psychological violence, or financial abuse within current/former marital or common-law relationships, including same-sex spousal relationships

LISTEN, INQUIRE, VALIDATE, ENHANCE SAFETY, SUPPORT

Question 27

trauma-and-violence-informed care

Answer 27

Definition:
-creation of an environment that is safe for people who have previously or currently faced violence
-focuses on creating a safe environment, NOT focused on forcing a disclosure of the patient’s circumstances or victimization
-assumes all patients have a history of some form of abuse, there is likely current abuse, power underlies all abuse, and all forms of abuse must be considered in the assessment.

A relational approach includes:
-listening in a non-judgmental and accepting manner
-being alert for “red flags” and inquiring directly about abuse when people present with direct injuries consistent with abuse, chronic health problem associated with abuse, mental health problems consistent with abuse, or factors known to increase vulnerability
-assessing and intervening collaboratively

Question 28

abuse and neglect

Answer 28

Reports or suspicion of physical, emotional, psychological, or financial abuse requires nursing intervention

Question 29

assessing for child maltreatment

Answer 29

Greater vulnerability of children.
Evaluate any physical injury within the context of a child’s developmental age and stage.
Avoid leading/suggestive questions.
Be aware of race and class stereotypes.
Maintain relationship with parents.

Question 30

elder abuse and neglect

Answer 30

Physical abuse or neglect, failure to provide basic services, psychological abuse or neglect (failure to provide stimulation), financial abuse or neglect
Inflicted by any persons in a situation of power or trust
In home or institutions
Older women at higher risk than older men

Question 31

assessing for elder abuse

Answer 31

Possible signs of elder abuse:
- Caregiver reluctance to leave older person alone
- Patient defers excessively to caregiver
- Delay in seeking treatment
- Inconsistency with reported mechanism of injury
- Lack of hygiene, appropriate clothing

Question 32

physical examination

Answer 32

Complete head-to-toe exam
Multiple factors can contribute to bruises in older adults
- Medications and abnormal blood values
- Underlying hematological disorders
- Accidental bruising (on extremities)
Health evaluation for known or suspected elder abuse and neglect should include baseline laboratory tests
Check History for
- Prior abuse
- History of traumatic injuries
- Mental health exam

Question 33

documentation

Answer 33

Detailed, objective, unbiased notes
- Include “exceptionally poignant” statements that specify the perpetrator and the threat
- Do not sanitize language, either used by the patient or quoted by the patient and attributed to the perpetrator
- With children, use the words of the child
Use of injury maps
Photographic documentation requires consent