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76 Cards in this Set
- Front
- Back
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What is the purpose of the DSM-IV-TR Multiaxial system?
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Used to identify medical diagnoses for clients with mental health disorders using a multiaxial system.
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Axis I
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all mental health diagnoses except those found in Axis II
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Axis II
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any personality disorder diagnoses and mental retardation
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Axis III
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any general medical diagnoses (asthma, DM)
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Axis IV
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pertinent psychosocial problems and problems concerning the client’s living conditions
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Axis V
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– 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 psychosocial ability on a scale of 1-100
o 80-100 – normal or near normal function o 60-80 – moderate problems o 40 and below – serious mental disability and/or functioning impairments |
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What are some strategies you can use to assess a patients orientation?
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Ask the patient: name, city, state, residence, president, time, year, etc.
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A patient that is in the hospital voluntarily is trying to leave. The nurse is holding on to his personal belongings in an attempt to keep him from leaving. What is this an example of?
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False imprisonment
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Two nurses are discussing a patient in the elevator. Legally, what is this called?
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Breach of confidentiality
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The nurse is documenting that a women described her situation in a very emotional tone. How would she note this as?
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Affect
-Affect: objective expression of mood, such as flat affect (lack of facial expression) |
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What is the difference between “insight” and “judgment”?
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Insight – objective assessment of the client’s perception of the illness. Judgment – based on the client’s answer to a hypothetical question.
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During the mental status examination, what is something you could ask or discuss to assess the patients cognitive and intellectual abilities?
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Discuss hypothetical ethical situations
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What is the purpose of evaluating a patient by using proverbs?
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Assess their ability to think abstractly
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What does “flight of ideas” mean?
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Flight of ideas – a rapid change of topic. It is a thought process.
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Does a man that is threatening to kill his wife meet the criteria for an emergency commitment?
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Yes. Emergency commitment – A type of involuntary commitment in which the client is hospitalized to prevent harm to self or others.
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How long are restraints or seclusion usually ordered for?
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The shortest duration necessary and only if less restrictive measures are insufficient.
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What should seclusion and/or restraints never be used for?
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Should never be used for staff convenience, client punishment, for clients who are physically or mentally unstable, and for clients who can’t tolerate the decreased stimulation of a seclusion room.
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What are some things that must be done for a patient in restraints or seclusion?
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Check circulation every 15 mins, remove restrain every 2 hours. Must be ordered by the PCP in writing and specify duration of the treatment, the order must be rewritten every 24 hours. A client can be placed in seclusion or restrain in an emergency but an order must be obtained within a specific period of time.
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What is an important factor for the nurse to help develop a therapeutic relationship with the patient?
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The nurses self awareness of own thought/feelings. You have to know yourself.
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What is the purpose of “silence” communication?
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Serves a function, such as time for meaningful reflection
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What are some examples of blocking effective communication with a patient?
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Giving advice about the patient’s decisions, anything that implies judgment or moralizing, close ended questions, and “why” questions, false reassurances.
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What is anxiety?
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A feeling of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat.
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What are signs and symptoms of severe anxiety?
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: Perceptual field is greatly reduced with distorted perceptions; learning and problem solving not possible; confusion, feelings of impending doom; aimless activity; not able to take direction from others, tachycardia, tachypnea
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What are some nursing interventions for patients with anxiety?
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Actively listen to patient; provide a calm presence; explore alternatives to problem situations; encourage participation in activities that may temporarily relieve feelings of inner tension; encourage gross motor activities; set limits by using firm, short, simple statements
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What should the nurse do if the patient is in a panic state?
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Stay with the patient
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Your patient has panic disorder with insomnia. What should the nurse suggest for this?
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Encourage the patient to do relaxation exercises.
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How can the nurse prevent a patient from harming them self or others?
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Don’t allow access to sharp or otherwise harmful objects.
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Your patient has heightened anxiety. How would you try to decrease this?
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Talk about what’s causing this with the patient
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When should the end of the nurse-client relationship be introduced?
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During the orientation phase
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A patient is not making eye contact with his nurse. The nurse suspects this is culturally based. What should the nurse do?
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Observe how the patient, friends, and family interact.
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Your patient is from a different cultural background. What nursing actions are appropriate?
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o Respect the religious/spiritual practices of the patient
o death rituals vary among cultures, the nurse must be prepared to facilitate such practices whenever possible o recognize the way a client reacts to and displays pain o Use an alternative to the pain scale, it may not appropriately reflect pain evaluation for all cultures o explore religious beliefs that may influence pain o provide food choices that are consistent with cultural beliefs o improve nurse client communication when cultural variations exist o use interpreters when the communication barrier is great enough to impact the exchange of information between the nurse and the client o cautiously use nonverbal communication, it may have different meanings for the client and the nurse o Include and communicate with the person who has the authority to make the decisions in the family o Assist families as they mark rituals that symbolize cultural values. Common cultural rituals: puberty, pregnancy, childbirth, postpartum period, dying and death |
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What are some tasks the nurse can delegate to UAP or CNA?
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Feedings; empty foley caths; do an inventory of patients personal belonging; look for contraband; check for sharp objects, check visitors for sharp objects
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What does the nurse want to establish with the patient with a mental disorder?
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Rapport
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A patient has multiple stressors and is using defense mechanisms as what?
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Using as relief behaviors
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What is the purpose of defense mechanisms?
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Is a coping mechanism used in an effort to protect the individual from feelings of anxiety. Reestablish personal emotional equilibrium.
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What is a possible reason for someone having issues with unhealthy personal boundaries?
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Could be a result of abuse
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What is the difference between “assault” and “battery”?
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Assault is making a threat, approaching in a threatening manner. Battery is touching in a harmful way such as threatening the client with a syringe and then giving an injection.
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What is a resource used for solving ethical client issues?
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Patient Care Partnership (formerly the Patients’ Bill of Rights)
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Does an involuntary commitment patient have the right to refuse treatment?
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Yes. Still considered to be competent and have the right to refuse treatment unless they have gone through a legal competency hearing and have been judged incompetent.
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What is a therapeutic nurse-client relationship?
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Purposeful and goal directed; well-defined with clear boundaries; structures to meet client needs; characterized by an interpersonal process that is safe, confidential, reliable, and consistent.
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What are the phases of the therapeutic nurse-client relationship?
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1. Orientation
2. Working, 3. Termination |
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What must be established in order to maintain a safe and professional nurse-client relationship?
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Boundaries. The nurse must work to maintain a consistent level of involvement with the client, to reflect on boundary issues frequently, and to maintain an awareness of how behaviors are perceived.
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What do open ended questions facilitate?
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Spontaneous responses and interactive discussion.
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What does paraphrasing, restating, reflecting, and exploring do when communicating with your patient?
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Clarification and validation of the client’s messages to promote mutual understanding.
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What does management of the milieu mean?
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Manipulating the total environment of the mental health unit in order to provide the least amount of stress while promoting the greatest benefit for all the clients.
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What criteria needs to be met to admit a person into an acute mental health care facility?
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Admission criteria: danger to self or others, failure of community based treatment, dangerous decomposition of a client undergoing long term treatment, medical need in addition to mental illness.
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Sorrow
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A feeling of deep distress caused by loss, disappointment, or other misfortune suffered by oneself or others.
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False imprisonment
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confining a client to a specific area, such as seclusion when the reason is for staff convenience.
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Milieu therapy
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orienting the client to the physical setting, identifying rules and boundaries of the setting, ensuring a safe environment for the client, selecting activities for the client that meet physical and mental health needs.
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Counseling
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– using therapeutic communication skills, assisting with problem solving, crisis intervention, stress management
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Ethical issues
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are philosophical ideas regarding right and wrong
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Transference
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– Occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the clients personal life. Ex: the client may see the nurse as being his mother and demonstrate some of the behaviors with the nurse as he did with his mother.
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Countertransference
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– occurs when the healthcare team member displaces characteristics of people in her past onto the client. The nurse may feel defensive and angry with a client for no apparent reason id the client reminds her of a friend who often elicited those feelings
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What are the 3 levels of prevention are utilized by nurses when implementing community care interventions and teaching?
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o Primary prevention – promotes health and prevents mental health problems from occurring.
o Secondary prevention – focuses on early detection of mental illness o Tertiary prevention – focuses on rehabilitation and prevention of further problems in clients previously diagnosed |
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Intellectualization
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Excessive reasoning to avoid feelings; the thinking is disconnected from feelings, and situations are dealt with at a cognitive level. Example: A woman’s husband recently passed away. She is only focusing on the details of the funeral as opposed to the sadness and the grief.
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Denial
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Disowning consciously intolerable thoughts and impulses. Example: A client is denying that his physician’s diagnoses of cancer is correct and is seeking a second opinion.
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Regression
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Returning to an earlier developmental stage to express an impulse to deal with reality. Example: 2 roommates have gotten into an argument. One of them stomp off into another room and pouts; An 8 year old who wets the bed when hospitalized.
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Repression
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An unconscious process in which the client blocks undesirable and unacceptable thoughts from conscious expression. Example: A person’s father has passed away, but this person forgets the father’s funeral; Woman is unable to enjoy sex after having pushed out of awareness a traumatic sexual incident from childhood.
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Displacement
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Feelings toward one person are directed to another who is less threatening, thereby satisfying an impulse with a substitute object; transfer of emotions associated with a particular person, object, or situation to another person, object, or situation that is nonthreatening. Example: A male client becomes belligerent toward the nurse after speaking with his mother on the phone; the person who has a bad day at work and comes home and yells.
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Somatization
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The process by which psychological distress is expressed as physical symptoms. It is an unconscious process. In somatization, the mental experiences or states are “converted” to bodily symptoms. Example: A tension headache: tension is converted to a headache.
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Rationalization
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– An attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior. Example: A person is stating that she was fired because she didn’t kiss up to the boss, when the real reason was her poor performance.
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Suppression
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The conscious, deliberate forgetting of unacceptable or painful thoughts ideas, and feelings. Example: A woman feels a breast lump before vacation, but waits to see the doctor until after she returns from vacation.
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Introjection
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A type of identification in which the individual incorporates the traits or values of another into self. Example: After his wife’s death, husband has transient complaints of chest pains and difficulty breathing; the same symptoms his wife had before she died.
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Projection
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Transferring one’s internal feelings, thoughts, and unacceptable ideas and traits to someone else; the unconscious attributing of one’s own intolerable wishes, emotional feelings, or motivation to another. Example: A student who does poorly blames the teacher for not presenting the material correctly.
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Sublimation
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Replacement of an unacceptable need, attitude, or emotion with one more socially acceptable; the unconscious process of substituting constructive and socially acceptable activities for strong impulses that are not acceptable in their original forms. Example: A person is having strong sexual impulses that they do not want to act upon. This person instead focuses on rigorous exercise.
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Compensation
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Making up for deficits in one area by excelling in another area in order to raise or maintain self esteem. Example: A boy who is small in stature places his emphasis on academics rather than attempting to do sports.
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Acting out
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Performing an extreme behavior in order to express thoughts or feelings the person feels incapable of otherwise expressing. Example: Self-injury may be a form of acting-out, expressing in physical pain what one cannot stand to feel emotionally.
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Conversion
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The unconscious transfer of anxiety to a physical symptom that has no organic cause; the expression of emotional conflicts through physical symptoms. Example: Student is unable to take a final exam because of a terrible headache.
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Dissociation
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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; the blocking off of an anxiety-provoking event or period of time from the conscious mind. Example: A victim retells her situation while smiling and laughing about it.
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Fixation
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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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Identification
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Unconsciously taking on the thoughts, mannerisms, or behaviors of a person or group, in order to decrease anxiety. Example: A 5 year old girl dresses in her mother’s shoes and meets daddy at the door.
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Insulation
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Withdrawing into passivity and becoming inaccessible in order to avoid further threatening situations.
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Isolation
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Response in which a person blocks feelings associated with an unpleasant experience. Example: A medical student dissects a cadaver without being disturbed by death.
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Reaction formation
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Developing conscious attitudes and behaviors and acting out behaviors opposite to what one really feels. Example: Person is excessively polite to someone they dislike.
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Symbolization
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the conscious use of an idea or object to represent another actual event or objects; many times the meaning is not clear because the symbol may be representative of something unconscious. Example: A soldier, when asked why he volunteered, says, “to defend the flag.” He rejects as irrelevant a question about the purpose of the war.
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Undoing
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Engaging in behavior that is considered to be opposite of a previous unacceptable behavior, thought, or feeling. Example: A man has just insulted his significant other unintentionally. He now spends the next hour praising her beauty, charm, and intellect.
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