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76 Cards in this Set
- Front
- Back
during mini mental status exam-- test ...?
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during mini mental status exam-- test ability to think in the abstract
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pt changes topic very quickly...?
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pt changes topic very quickly---flight of ideas
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Nurse assess client's ability and their judgment--
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Nurse assess client's ability and their judgment--discuss hypothetical
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If have to determine flat affect--
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If have to determine flat affect--EMOTIONLESS TONE AND NO FACIAL EXPRESSION
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axis 1-5?
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axis 1-5
Axis I - All mental health diagnoses except those found in Axis II Axis II - Any personality disorder diagnoses and mental retardation Axis III - Any general medical diagnoses (asthma, DM) Axis IV - Pertinent psychosocial problems and problems concerning the client’s living conditions Axis V - Global assessment of functioning (GAF) rates the client’s level of functioning, present and past year, in the areas of work performance, social abilities and psychological ability on a scale of 1-100 - 80-100 normal or near normal function - 60-80 moderate problems - 40 and below serious mental disability and/or functioning impairments |
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pt voluntarily at facility and wants to leave nurse neglecting to let go-
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pt voluntarily at facility and wants to leave nurse neglecting to let go--false imprisonment
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how to tell if pt is oriented, what ask?
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how to tell if pt is oriented, what ask?
- name date where they live time of day season, situation, where they are |
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Nurse talking about delivery of baby on elevator, conversation overheard----
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Nurse talking about delivery of baby on elevator, conversation overheard----breach of confidentiality
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client in restraints (four way, full) how often check circulation?
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client in restraints (four way, full) how often check circulation- EVERY 10-15 MINUTES
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Mental health laws on restraints- when used?
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Mental health laws on restraints- when used? when pt is in an emergency--a danger to self or others (imminent danger)
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Decide whether pt meets criteria for emergency involuntary commitment---
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Decide whether pt meets criteria for emergency involuntary commitment---person threatening to harm self or others
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Defense mechanisms?
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Defense mechanisms? pt trying to suppress anxiety of situation-trying stabilize self---RELIEF BEHAVIOR
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using silence in therapeutic manner what demonstrate to client?
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using silence in therapeutic manner what demonstrate to client? pt can express feelings, validation, build trust, (select all that apply)
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Don't give advice allow client to develop own thoughts, give pt opportunity to think....
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don't give advice allow client to develop own thoughts, give pt opportunity to think. help pt reflect
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Dysfunctional family, lack of positive role models, what do you see?
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Dysfunctional family, lack of positive role models, what do you see? abuse and neglect
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Restraints, if you're the nurse must check that they are on correctly---
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Restraints, if you're the nurse must check that they are on correctly---check circulation, check pulses below restraints, how attached at bed, FIRST INTERVENTION check CIRCULATION
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Compensation:
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Compensation:
- Making up for deficits in one area by excelling in another area in order to raise or maintain self esteem - “Short man becomes assertively verbal and excels in business” |
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Conversion
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Conversion
- The unconscious transfer of anxiety to a physical symptom that has no organic cause - “Student is unable to take a final exam because of a terrible headache” |
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Denial
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Denial
- Escaping of unpleasant realities by ignoring their existence - “Man reacts to news of the death of a loved one: “No, I don’t believe you, the doctor said he was fine” |
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Displacement
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Displacement
- Transfer of emotions association with a particular person, object, or situation to another person, object, or situation that is nonthreatening - “The person who has a bad day at work and comes home and yells” |
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Dissociation
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Dissociation
- Technique of putting threatening thoughts or feelings out of conscious awareness before they are able to trigger overwhelming and intolerable anxiety (splits threatening event from awareness) - “A young mother who watches her son get run over by a car is taken to the neighbors, when the police come says “I really don’t remember what happened” |
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Identification:
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Identification:
- Unconsciously taking on the thoughts, mannerism, or behaviors of a person or group, in order to decrease anxiety - “A teenager who dresses like a favorite rock singer” |
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Introjection
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Introjection
- Process by which a person incorporates or takes into his or her own personality qualities or values of another person or group with whom or with which intense emotional ties exist - “After his wife’s death, husband has transient complaints of chest pain and difficulty breathing; the symptoms his wife had before she died” |
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Projection:
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Projection
- The unconscious attributing of one’s own intolerable wishes, emotional feelings, or motivation to another - “A student who does poorly blames the teacher for not presenting the material correctly” |
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Rationalization
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Rationalization
- Justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener - “I didn’t get the raise because the boss hates me” |
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Reaction Formation (overcompensation)
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Reaction Formation (overcompensation)
- The process of keeping unacceptable feelings or behavior out of awareness by developing the opposite emotion or behavior - “Recovering alcoholic constantly preaches about the evils of alcohol” |
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Regression:
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Regression:
- In the face of overwhelming anxiety, the ego returns to an earlier, more comforting (although less mature) way of behaving - “An 8 year old who wets the bed when hospitalized” |
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Repression
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Repression
- The exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness; thought of as the first line of psychological defense - “Man who forgets wife’s birthday after marital fight” |
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Sublimation
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Sublimation
- The unconscious process of substituting constructive and socially acceptable activities for strong impulses that are not acceptable in their original forms, such as strong aggressive or sexual drives - “The teenager fights constantly with his siblings who engages in multiple group sports” |
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Suppression
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Suppression
- The conscious putting off of awareness of disturbing situations or feelings; the only defense mechanism that operates on a conscious level - “A student who deliberately fails to keep an appointment for academic counseling” |
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Fantasy
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Fantasy
- Gratification by imaginary achievements and wishful thinking |
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Fixation
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Fixation
- Never advancing to the next level of emotional development and organization; the persistence in later life of interests and behavior patterns appropriate to an earlier age |
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Insulation
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Insulation
- Withdrawing into passivity and becoming inaccessible in order to avoid further threatening situations |
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Intellectualization
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Intellectualization
- Excessive reasoning to avoid feelings; the thinking is disconnected from feelings, and situations are dealt with at a cognitive level - “Lincoln, going through a messy divorce, refuses to become emotional about the situation. He continually philosophizes about the meaning of relationships and love, saying things like “Nothing lasts forever.” |
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Isolation
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Isolation
- Response in which a person blocks feelings associated with an unpleasant experience |
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Substitution
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Substitution
- The replacement of a valued unacceptable object with an object that is more acceptable to the ego |
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Symbolization:
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Symbolization:
- The conscious use of an idea or object to represent another actual event or object; many times the meaning is not clear because the symbol may be representative of something unconscious |
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Undoing
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Undoing
- Engaging in behavior that is considered to be opposite of a previous unacceptable behavior, thought, or feeling |
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admission of pt- which cardiovascular effect would sympathetic nervous system produce?
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admission of pt- which cardiovascular effect would sympathetic nervous system produce? speeds up
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client has severe anxiety, what would they have?
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client has severe anxiety, what would they have? DECREASED PERCEPTUAL FEEL
heightened concentration-- no decreased resp rate-no decreased perceptual feel?--yes |
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nursing intervention panic attack-----
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nursing intervention panic attack-----STAY WITH PT
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nonpharmacological intervention pt having hard time sleeping and has PTSD----
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nonpharmacological intervention pt having hard time sleeping and has PTSD----encourage warm milk, tea, massage, relaxation exercise, relaxing music, reading for a little while
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pt anxious---nurse says...
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pt anxious---nurse says let's talk about what is bothering you---let person tell you about it
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person who is in hospital as charge nurse of psychiatric unit, have responsibility for prioritizaion and delegation--what assign to UAP?
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person who is in hospital as charge nurse of psychiatric unit, have responsibility for prioritizaion and delegation--what assign to UAP?
-assist in ADL's, eating, monitor for sharp objects or contraband, activities, monitor in one-to-one if trained, cannot assess, empty jackson pratt drain, place tube feeding,` SAFETY SAFETY SAFETY |
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how describe therapeutic communication?
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how describe therapeutic communication?
- Communication is a complex process of sending, receiving, and comprehending messages between 2 or more people - Therapeutic communication helps the client to feel understood, explore interpersonal problems, discover healthy ways to cope, and experience a satisfying interpersonal relationship - The nurse must recognize and respond to both verbal and nonverbal communication |
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therapeutic nurse pt relationship begins with ...
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therapeutic nurse pt relationship begins with nurse assessing self before reaching out and helping pt
the nurse brings to the situation ability to communicate with the pt in therapeutic way and build trust and rapport |
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from beginning set the tone by explaining to the client that ....
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from beginning set the tone by explaining to the client that you'll be meeting with them for x amount of time and that this relationship will end
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prevention--how contribute to primary prevention in mental health field, how do this? (select all that apply)
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prevention--how contribute to primary prevention in mental health field, how do this? (select all that apply)
SEXUAL EDUCATION to ADOLESCENTS HANDWASHING TO CHILDREN |
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interview with client, no eye contact, is this an indication of a lack of communication or cultural situation?
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interview with client, no eye contact, is this an indication of a lack of communication or cultural situation?
determine what their culture is |
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can nurse ask about cultural background and religious preferences?
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can nurse ask about cultural background and religious preferences?
Yes |
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during mini mental status exam...one thing that u go into is proverbs..and u ask client to explain a proverb to assess what?
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during mini mental status exam...one thing that u go into is proverbs..and u ask client to explain a proverb to assess what?
abstract thinking |
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pt changes topic quickly?
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pt changes topic quickly?
flight of ideas |
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how do u assessment judgement?
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how do u assessment judgement?
hypothetical ?s |
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u need to determine flat affect?
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u need to determine flat affect?
person has emotionless tone |
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pt is there voluntarily and wants to leave, another nurse takes clothing and wont let them leave...whats that called?
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pt is there voluntarily and wants to leave, another nurse takes clothing and wont let them leave...whats that called?
false imprisonment |
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how to tell if pt is orientated?
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how to tell if pt is orientated?
name, date, time, season, where r u, why r u here |
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staff is discussing the delivery of a baby in an elevator, what is that?
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staff is discussing the delivery of a baby in an elevator, what is that?
Breach of confidentiality |
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pt in full restraints, how often do u check circulation?
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pt in full restraints, how often do u check circulation?
every 10-15 min |
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u can use restraints under which condition?
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u can use restraints under which condition?
eminent danger of hurting themselves or others |
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how do u decide if person meets criteria for an emergency invulontary commitment?
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how do u decide if person meets criteria for an emergency invulontary commitment?
threatening to kill themselves or someone else |
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what is going on when pt uses defense mechanisms?
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what is going on when pt uses defense mechanisms?
supress the anxiety, re establish personal emotional equilibrium...relief behaviors |
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why use silence on client?
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why use silence on client?
allow them to think/ respond validating them build trust show acceptance |
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dysfunctional family, lack of positive role models, what might u see?
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dysfunctional family, lack of positive role models, what might u see?
abuse and neglect |
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restraints: what do u need to automatically do?
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restraints: what do u need to automatically do?
MAKE SURE THEY ARE APPLIED CORRECTLY check circulation and pulses look at how they are attached to bed |
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u r doing an admission, which cardio effect would be produced by sympathetic nervous system?
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u r doing an admission, which cardio effect would be produced by sympathetic nervous system?
speeds up |
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pt has severe anxiety?
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pt has severe anxiety?
decreased perception to touch ***** |
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nursing intervention for pt with panic attack?
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nursing intervention for pt with panic attack?
stay with them |
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pt has panic disorder and has trouble sleeping, what can u teach them about non pharmacological?
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pt has panic disorder and has trouble sleeping, what can u teach them about non pharmacological?
music, snack (warm milk), masage, reading, relaxation |
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pt is anxious, what should u say to them?
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pt is anxious, what should u say to them?
lets talk about whats bothering u |
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charge nurse over psych unit, what can u assign UAP?
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charge nurse over psych unit, what can u assign UAP?
ADLS Eating Monitored for safety entertaining pts vitals/i and o NO assessment No tube feeding |
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how would u describe therapeutic communication?
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how would u describe therapeutic communication?
strong therapeutic nurse pt relationship begins with the nurse understanding herself |
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what is one of the things that the nurse brings miliu??? to the situation?
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what is one of the things that the nurse brings miliu??? to the situation?
person pt will bond with and trust |
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how can u contribute to primary prevention in the mental health field?
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how can u contribute to primary prevention in the mental health field?
education...sexual education for adolescents, teaching hand washing, immunization, etc |
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if u r working w a pt from a diff cultural background...how do u deal with this?
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if u r working w a pt from a diff cultural background...how do u deal with this?
- The goal of the culturally competent nurse is to adapt mental health nursing care to the client’s needs and preferences |
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pt wont make eye contact, how could u determine if this was cultural or not?
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pt wont make eye contact, how could u determine if this was cultural or not?
observe how they interact with visitors, how do they interact with others, what culture are they? |
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if u r admitting a pt, are u expected to ask about religion and culture?
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if u r admitting a pt, are u expected to ask about religion and culture?
- Yes |