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182 Cards in this Set
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theraputic nursing
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# This is the primary intervention in psychiatric nursing.
# The nurse needs to be aware of both the patient’s verbal and nonverbal messages. # The patient must feel safe and respected to allow therapeutic communication to occur # Therapeutic relationship allows the patient to feel understood and able to discuss problems and feelings. |
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inattentive listening
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by listening to the patient intently to the patient, allows the nurse hear and analyze what the patient say.
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Rephrasing of key ideas: by succinct rephrasing of the patient thoughts allows the patient to confirm the nurse’s interpretation
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Example: “It sounds like you are hurt by the way your family treats you.”
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Use broad open-ended and general statements: encourage conversations the patient to discuss any subject that comes to mind.
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* Example: “Is there anything you would like to talk about?”
* Clarifying patient ideas: by clarifying a confusing or vague statement demonstrates the nurse’s desire to understand the patient |
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silence
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Silence: this technique can be very useful; allowing patient to gather thoughts and nurse to gather more information, however, must be used carefully to prevent the impression of judgment or disinterest.
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Focusing: allows the nurse to refocus the patients thought toward a specific interest.
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Example: “Let’s go back to what you were saying about your mother.”
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Collaboration: this allows the patient to explore the pros and cons of an approach. The nurse must be very careful to avoid directing the patient.
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Example: “How would you feel about meeting with your husband to discuss this?”
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sharing impressions
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he nurse describes the patient’s feelings and then asks for clarification and confirmation of nurse’s interpretation.
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mini mental status exam
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# Orientation
# Registration # Recall # Calculation # Language # Motor skills |
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individual therapy
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# Individual therapy: this requires the usage of a structured therapeutic relationship between the nurse and patient in an attempt to achieve goals and changes in the patient’s behaviors. There are three phases to the therapeutic relationship:
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orentation phase
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in this phase, the nurse establishes a rapport and a sense of trust with the patient
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working phase
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Working phase: in this phase the patient becomes increasingly involved in self-exposure
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termination phase
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Termination phase: in this phase the patient and the nurse determine the closure of the relationship is appropriate
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Milieu therapy
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Milieu therapy: this is the usage of all aspects of the hospital environment in a therapeutic manor
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You are caring for a 40 year old man who says, "I never argue with people, I like everyone." Which of the following would be the most appropriate response?
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"How do you deal with your anger?
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Your patient tells you that his son's nagging about his drinking is very annoying, he asks you if you can speak to him in the next family therapy session. The most appropriate response to this would be?
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"I can help you think about the best way to approach the subject.
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Your patient is diagnosed with conversion disorder and is unable to walk. There are no physiological abnormalities detectable. The patient states, "you think I can walk don't you?" The most appropriate reponse would be?
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"I am sure that you can't walk now, for whatever reason."
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The patient you are caring for is a 52 years old woman who is uncontrollably crying and very anxious. Her husband of 17 years is asking for a divorce. The most appropriate response would be?
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"I see you are upset, why don't we find a place to talk?
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Your patient is complaining of sleeplessness, extreme apprehension and a sense of impending doom. What would be the most appropriate response?
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Has anything happened recently that upset you
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Question #6 : You are the nurse in an emergency room, where a 32 year old female was brought in by the police because she was walking around outside without shoes on,on a snowy night. Which of the following actions should be your priority?
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Assess vital signs and treat them appropriately
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The purpose of the Mini-Mental status exam is to do which of the following?
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Assess orientation status
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The optimal number of patients in a group therapy session is?
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6-8
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The nurse is aware that the therapeutic relationships begins with:
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The nurse's self-awareness and understanding
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You are the nurse caring for a patient who is channeling his anger on you by responding in an anger tone, Which of the following would be the most appropriate response?
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I feel very angry when I hear speech in such a tone
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beneficence
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duty to act
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autonomy
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right to make owns own decsions
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justice
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treating fairly with equality
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fedlity
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nonmalfience maintaning loyalty and commitment
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veracity
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ones duty to always tell the truth
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writ of habeas corpus
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to challenge unlawful detention
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voluntary admission
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have right to demand and optain release
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civil commentment
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involuntary temporary for observation dx and tx
last 60-180 days |
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restraned clients
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check every 15-30 for physical needs and document q 15 - 30
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tort
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civil wrong which money damages may be collected
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defemation of charecter
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written or oral
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supervisory liablity
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deligating to undertrained staff
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intentional tort
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voluntary act performed with intent to bring physical damages
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duty
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measured by the standard of care
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schizophrenia: epidemiology
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Prevalence - 0.5-1.5%
Urban Born > Risk than Rural Risk 10X Greater in First Degree Relatives Women - Later Age Onset Men = Earlier 10% + Commit Suicide |
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Cognitive Disorders: Schizophrenia: Cognitive Impairment
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pathy
Memory Loss Decreased Concentration Decreased Attention Decreased Insight (During Heightened Illness) Working Memory Executive Functioning Perception & Processing of Sensory Stimuli Sensorimotor Gating, Selective Attention Slowed Reaction Times Cognitive Differentiation Social Perception/Social Cognition: foresightedness and reflectiveness Verbal Communication Memory Executive Functioning Social cognition = perspective taking, interpersonal problem solving, relationship maintenance, moral judgment communication skills Sustain Vigilance with Competing Stimuli Shifting Focused Alertness Short Term Spatial and Verbal Memory Limited |
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Schizophrenia: Neurological Impairment
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Dorsolateral prefrontal cortex - Broca’s area
Superior Temporal Cortex and Inferior Parietal Cortex Thalamus Third Ventricles Limbic Region |
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axsis 1
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SM-IV-TR Multiaxial System:
Refers to teh collection of signs and symptoms that together constitue a particular disorder |
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axsis 2
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SM-IV-TR Multiaxial System:
Personality disorders and mental retardation; long term disturbance |
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axis 3
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General medical conditions believed to be relevant to the mental disorder in question
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axsis 4
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SM-IV-TR Multiaxial System:
Psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of the mental disorder |
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axsis 5
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Lobal assessment of functioning; gives an indicaiton fo the person's best level of psychological, social and occupational functioing during the preceding year; rated from 1-100 Axis V
DSM-IV-TR Multiaxial System: |
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gaf 10
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DSM-IV-TR Multiaxial System:
Persistent dange |
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gaf 100
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Superior functioning
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gaf 50
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Serious symptoms or impairment
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transference
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When client experiences feelings toward the nurse or therapist that were originally held toward significant others in his life
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Haloperidol
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Pharmacogenetics:
This causes 50% higher plasma concentrations in Asian clients with schizophrenia than in white clients |
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Clozapine
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This causes agranulocytosis in Ashkenazi Jews than in other ethnic groups
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Beneficence
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duty to act so as to benefit or promote good of others
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Fidelity
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Maintaining loyalty and commitment to the client and doing no wrong to the client
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Varacity
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omes duty to always tell the truth
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Voluntary admission
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Sought by the client or the client's guardian through a written application to the facility; right to demand and obtain release
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Writ of habeas corpus
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Meaning to "free the person"; procedural mechanism used to challenge unlawful detention by the government
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emergency involuntary hospitalization
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1-10 days long; used in order to prevent dangerous behavior that is likely to cause harm to self or
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Observational or temporary involuntary hosp
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The primary purpose of this type of hospitalization is ovservation, diagnosis and treatment; application may be made by family memeber, physician, public health officers; also need medical certification by two or more physicians and judicial review
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Genuineness
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Self-awareness of one's feelings as they arise within the relationship and the ability to communicate them when appropriate; key ingredient in building trust
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Haldol
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Typical Antipsychotics: High incident of EPSE; high potency
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Aripiprazole (Abilify)
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This drug is an Atypical; new class of AAP
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Acute dystonic reaction
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EPS:
Acute contraction of tongue, face, nech and back with opisthotonos (hightening of entire body) and oculogyric crisis (eyes upward) |
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Benadryl
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Acute dystonic reaction nursing measures
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Akathisia
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EPS:
restlessness |
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Akathisia nursing measures
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/c med; adm inderal (beta blocker), ativan or valium
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Tardive dyskinesia
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Facial protruding and rolling tongue; limbs flailing; truck movements
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Agranulocytosis
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Toxic effects of typical: symptoms include sore throat, fever,malaise and mouth sores; FLULIKE symtoms
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propranolol (Inderal)
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This med decrease akathisia, useful for HA
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Atypical Antipsychotics
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These medications produce little EPSE/ TD; treat both positive and neg symptoms; decrease suicidal bx
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Traditional or Typical Antipsychotics
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These medications have have potential for EPSE, TD and NMS
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SE for Depakote and theraputic range
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hair loss; sexual dysfunction; wbc changes; liver and pancreas problems
50-125 mcg/ml |
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aiprasidone (Geodon)
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This drug is an Atypical; ECG changes like QT prolongation
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Clozapine (Clorazil)
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his drug is a Atypical; major concern is agranulocytosis, weight gain and seizure
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What are manifestations of CATATONIC schizophrenia?
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Non movement (motor immobility)
Excessive motor activity Extreme negativism Peculiar movements Echolalia (repeating speech) or echopraxia (repeating movements |
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negative symptoms
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Social withdrawal
Apathy Lack of motivation Emotional unresponsiveness |
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positive symptoms
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delusions
Hallucinations Disordered thinking and speech |
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interventions for schizophrenic patients
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Understanding the meaning of client’s words and behavior
Reinforcing reality Promoting clarification Intervening in hallucinations Recognizing and accepting affect Role modeling Tolerance Social/Behavioral interventions Trust Approaching the client Encouraging independence Dealing with hostilty |
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ions can a nurse perform to manage delusions?
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Empathize with patient
Assess triggers (stress)and remove ones that exacerbate schizophrenia Respond to feelings Provide Diversional activities |
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Dystonic reactions
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brupt onset of frightening muscle spasms in head and neck
Oculogyric crisis – eyes roll up in head Laryngospasm – spastic closure of larynx |
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Akathasia
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Syndrome characterized by unpleasant sensations of "inner" restlessness that manifests itself with an inability to sit still or remain motionless
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Parkinsonism
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Having Parkinson's like symptoms
-pill rolling -shuffled walk |
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What are some major side effects of Neuroleptic Malignant Syndrome?
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High fever
Respiratory depression Increased heart rate Confused Delirious |
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Tardrive Dyskinesia
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Movements of the tongue, mouth, face and jaw
Puckering Chewing movements Involuntary movements |
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side effects with antipsychotic drugs
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Photosensitivity
Weight gain Interference with sexual function |
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ANTICHOLINERGIC side effects from antipsychotics
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Dry mouth
Constipation Urinary retention Blurry vision Memory difficulties Confusion |
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What are the DISADVANTAGES of antipsychotic drugs?
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Dry mouth
Blurred vision Dizziness Movement disorders (some have high incidence) Little effect on negative symptoms |
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Clozapine DISADVANTAGES (Side effects)
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granulocytosis (in at least 1% of patients)
- Problem with clozaril is that it can cause agranularcytosis causing low white blood cell count, thus increasing chances of infection, fever, etc. Drowsiness, dizziness, drooling Seizures (in 1-5% of patients) Muscle weakness Weight gain Diabetes Rapid withdrawal may lead to psychosis |
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Risperidone DISADVANTAGES (Side effects)
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Dizziness
Drowsiness Dry mouth Rapid heartbeat Some movement disorders at high doses Weight gain Diabetes |
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zyprexia Olanzapine DISADVANTAGES
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Drowsiness
Dry mouth Substantial weight gain Diabetes |
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Quetiapine (Seroquel) ADVANTAGES
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milar to Risperidone and Olanzapine, but little risk of dry mouth or dizziness
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geodon Ziprasidone DISADVANTAGES (Side effects)
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eadaches
Nausea Drowsiness Dizziness Rash Can slow electrical conduction through the heart |
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Loose associations
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isorganized thinking
Absence of the normal connectedness of thoughts, ideas, and topics; Sudden shifts withough apparent relationship to preceding topic |
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Flight of ideas
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The topic of conversation changes repeatedly and rapidly, generally after just one sentence or phrase
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Word salad
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String of words that are not connected in any way
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Autistic thinking
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Restricts thinking to the literal and immediate so that the individual have private rules of logic and reasoning that make no sense to anyone else
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Clang association
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isorganized thinking
Repitition of words of phrases that are similar in sound but in no other way e.g.:Right, sight, light, might |
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Negative symptoms of Schizophrenia
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ifficult expressing emotion
Laugh, cry, and get angry less than often Flat affect Ambivalence Inability to complete simple activities of daily living (dressing, combing hair) Anhedonia Cause individuals to withdraw and suffer feelings of severe isolation |
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Extrapyramidal side effects
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Movement disorders caused by some antipsychotics
Related to the blockade of dopamine Include dystonia, pseudoparkinsonism, and akathisia Managed by restoring balance between acetylcholine and dopamine (use or anticholinergic drug or reducing dosage of antipsychotic) |
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Dystonia
or Dystonic reactions |
EPS
Develops rapidly and dramatically More common in yound men Characterized by tense muscles and body contortions Patients first report thick tongue, tight jaw, or stiff neck Oculogyric crisis, Torticollis, Retrocollis, Oropharyngeal-pharyngeal hypertonus |
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alogia
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Term used to describe poverty of content or lack of any real meaning or substance in what is said by client.
Example: Nurse: "How have you been sleeping lately?" Client: "Well, I guess, I don't know, hard to tell." |
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propranolol (Inderal)
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Assess for palpitations, dizziness, cold hands and feet
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diphenhydramine (Benadryl)
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Use ice chips or hard candy for dry mouth; observe for sedation
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amantadine (Symmetre
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Use ice chips or hard candy for dry mouth; assess for worsening psychosis (an occasional side effect)
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benztropine (Cogentin)
trihexyphenidyl (Artane) biperiden (Akineton) procyclidine (Kemadrin) |
Increase fluid and fiber intake to avoid constipation; use ice chips or hard candy for dry mouth; assess for memory impairment (another side effect)
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Intervening with delusions
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Do not argue with false belief
Focus on the reality based aspects of their communication Protect them from acting on their delusions Difference between delusion & personal preference Suggest options to cope with delusional thoughts: concrete tasks, caretaking activities, redirection |
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Intervening with hallucinations
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Determine kind of hallucination
Managed with current coping? Better coping: distraction, resisting, calming, medication |
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a client that is aggitated and placed on isolation should have
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a staff member make frequent contact with pt
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steps for a client who is angry include
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discuss alternative solutions, decide on one, evaluate its effectivness and continue repeating the process
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anectine
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for ect skeletal muscle paralysis
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haldol
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watch for parkinson sx
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clozaril
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monitor for seziures
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values
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abstract satandards the represent an ideal good or bad
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anger how staff keeps safe in preassultive stage.
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analyze the client and the situation. observe, gather info, encourge the pt to move some where quite and safeis a good first suggestion. Tell the pt your concerned and want to listen. " I expect you will stay in control."
Use verbal techniques of deescalation// you are calm, controlled, and caring. Relaxed posture maintain pt personal space Interact with the pt//speak in a low calm voice, open ended questions. Pay attention to the environment choose a quite space but one that is visable by staff. Assure safety. |
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projection
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most common defense mechanism for the paranoid. Example when a paranoid pt feels self critical they experence others as being harshly critical
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milieu for schizo
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group therapy targets symptoms. group therapy includes drawing pics, music, reading poetry to increase self esteem .
Saftey number 1 |
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tangential speech
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loose associations a responce that does not answer the question or a question or comment not related to the current topic
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termination stage
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begins at orientation phase and should be clear from the begining
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duty to warn
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to protect a third party
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abilify
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sedation, wt gain, hyperglycemia new onset type 2 dm
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civil rights
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right to vote, right to drivers lisence, write to make purchases, write to contractual relationships, right to press charges against another client or staff. right to humane care and tx, right to religus freedom, right to social interactions, right to excercise and right for recreational oppertunites.
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positive schizo sx
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reflect an excess or distoriton of normal fnx.
Delusions/hallucinations/disorganzed thinking,speech/disorganized behavior |
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negative symptoms 4 a's
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affective flattening/alogia/avolition, apathy/ anhedonia
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nms
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hyperthermia associated with haldol which includes hypertension, tachycardia, urinary. call 911
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td
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(TD). Tardive dyskinesia is a syndrome of involuntary movements that may appear in patients treated with neuroleptic drugs. Although prevalence of TD appears highest among the elderly, especially women, it is impossible to predict which patients are likely to develop the syndrome. Both the risk of developing TD and the likelihood that it will become irreversible are increased with higher doses and longer periods of treatment. The syndrome can develop after short treatment periods at low doses. Anticholinergic agents may worsen these effects. Clozapine has occasionally been useful in controlling the TD caused by other antipsychotic drugs.
protuding tunge, blowing, smacking, licking, facial disortion, smacking movements. Discontunue drug no know txcheck pt a t least q3months. |
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acute dystonic rxn
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acute contractions of tongue face and neck . give Benadryl relief occurs in minutes
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pseudoparkinsonism
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give artane or cogentin
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akathesia
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acathisia, is a syndrome characterized by unpleasant sensations of "inner" restlessness that manifests itself with an inability to sit still or remain motionless
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depakote nl lab value
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50-120
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autonomy
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right to make ones own decsions
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beneficence
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duty to act as to benifit the good of others
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justice
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treating others fairly
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fedelity nonmleficence
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maintaing loyalty and commitment doing no wrong to the client
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veracity
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ones duty to tell the truth
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thought broadcasting
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thoughts can be heard by others
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thought insertion
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thoughts of othrers are being inserted into ones mind
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thought withdrawl
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thoughts have been removed by ones mind by outside agency
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delusions of being controlled
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ones body or mind is controlled by an outdside agency
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concrete thinking
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overemphasis on specific details and imparment in the ablity to use abstract concepts
example what brought you to the hospital? A cab. |
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developing trust
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by demonstarting genuineness and empathy, developing positive regard, offering assistance.
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orientation phase
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address; parameters of the relationship, formal and informal contract, confidentiality and termination.
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clozaril
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Clozapine (Clozaril) - Requires weekly to biweekly CBC (FBC) because of risk of agranulocytosis (a severe decrease of white blood cells).
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Olanzapine (Zyprexa)
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Olanzapine (Zyprexa) - Used to treat psychotic disorders including schizophrenia, acute manic episodes, and maintenance of bipolar disorder. Dosing 2.5 to 20 mg per day. Comes in aform that quickly dissolves in the mouth (Zyprexa Zydis). May cause appetite increase, weight gain, and altered glucose metabolism leading to an increased risk of diabetes mellitus.
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Ziprasidone (Geodon)
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Ziprasidone (Geodon) - Now (2006) approved to treat bipolar disorder. Dosing 20 mg twice daily initially up to 80 mg twice daily. Prolonged QT interval a concern; watch closely withpatients that have heart disease; when used with other drugs that prolong QT interval potentially life-threatening.
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Aripiprazole (Abilify)
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Aripiprazole (Abilify) - Dosing 1 mg up to maximum of 30 mg has been used. Mechanism of action is thought to reduce susceptibility to metabolic symptoms seen in some otheratypical antipsychotics.
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dopamine
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All antipsychotic drugs tend to block D2 receptors in the dopamine pathways of the brain. This means that dopamine released in these pathways has less effect. Excess release of dopamine in the mesolimbic pathway has been linked to psychotic experiences. It is the blockade of dopamine receptors in this pathway that is thought to control psychotic experiences.
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abstract thinking example
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people in glass houses
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delusions of persecution
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false belief that one is being singled out for harm
Believing the secret service is out to kill you |
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interventions for hallucinations
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Ask pt " are you hearing voices, what are they telling you?"
watch pt for clues there hallucinating avoid reacting to hallucinations like they are real do not negate the clients experence but offer your own perspective. " I don't see the devil but I can understand how that could upset you!" Focus on reality based interventions "Try not to listen to the voices now,I'll sit with you for a while." Be alert for signs of anxiety. |
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interventions for delusions
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Be honest, open and relible to reduce suspiciousness
respond in matter of fact calm manner "Who is trying to hurt you?" avoid arguing "It most be frightening to think there is a conspiracy against you." focus on reality based topics. Set firm limits on times alotted to talk about delusions. observe events that trigger delusions. valadate " yes, there was a man at the nurses station, but I did not hear him talk to you/ |
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dealing with isolative withdrawn client
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physical needs tak priority
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haldol s/e
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nms
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clozoril
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agranulocytosis increase r/f seizures
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client with residual schizophrenia is uninterested in community activities. He lacks initiative, demonstrates both poverty of content of speech and poverty of speech, and seems unable to follow the schedule for taking his antipsychotic medication. The case manager continues to direct his care with the knowledge that his behavior is most likely prompted by
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neural dysfunction
Schizophrenia is considered a neurobiological disorder. The course of schizophrenia involves recurrences. With each relapse further deterioration is noted. Residual schizophrenia refers to the disorder when active phase symptoms are no longer present and the individual is left with two or more of the following symptoms: lack of initiative, social withdrawal, impaired role function, marked speech deficits, and odd beliefs. |
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A client with paranoid schizophrenia refuses food. He states the voices are telling him the food is contaminated and will change him from a male to a female. A therapeutic response for the nurse would be
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"I understand that the voices are very real to you, but I do not hear them."
This reply acknowledges the client's reality but offers the nurse's perception that he or she is not experiencing the same thing. |
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A client with disorganized schizophrenia would have greatest difficulty with the nurse
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giving multistep directions.
The thought processes of the client with disorganized schizophrenia are severely disordered and severe perceptual problems are present, making it extremely difficult for the client to understand what others are saying. All communication should be simple and concrete and may need to be repeated several times. |
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A nursing intervention designed to help a schizophrenic client manage relapse is to
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teach the client and family about behaviors associated with relapse.
By knowing what behaviors signal impending relapse, interventions can be quickly invoked when the behaviors occur. The earlier the intervention, the greater the likelihood that a recurrence can be averted |
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When a client with paranoid schizophrenia tells the nurse "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be
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"It must be frightening to think something is going to harm you."
This response focuses on the client's feelings and neither directly supports the delusion nor denies the client's experience. |
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A desired outcome for a client with schizophrenia who has a nursing diagnosis of Disturbed sensory perception: auditory hallucinations related to neurobiological dysfunction would be that the client will
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ask for validation of reality.
Beginning to question his or her own altered perceptions by seeking input from staff is highly desirable. |
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A client has reached the stable plateau phase of schizophrenia. An appropriate clinical focus for planning would be
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social, vocational, and self-care skills.
During the stable plateau phase of schizophrenia, planning is geared toward client and family education and skills training that will help maintain the optimal functioning of schizophrenic individuals in the community. |
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A client has been receiving antipsychotic medication for 6 weeks. At her clinic appointment she tells the nurse that her hallucinations are nearly gone and that she can concentrate fairly well. She states her only problem is "the flu" that she's had for 2 days. She mentions having a fever and a very sore throat. The nurse should
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arrange for the client to have blood drawn for a white blood cell count.
Antipsychotic medications may cause agranulocytosis, the first manifestation of which may be a sore throat and flulike symptoms. |
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The purpose for a nurse periodically performing the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has schizophrenia is early detection of
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tardive dyskinesia.
An AIMS assessment should be performed periodically on clients who are being treated with antipsychotic medication known to cause tardive dyskinesia. |
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Which principle of bioethics is adequately represented
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A nurse who values autonomy will respect a client's right to make decisions.
Autonomy refers to self-determination. Self-determination can be exercised when one makes his or her own decisions without interference from others. |
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Which statement about right to treatment in public hospitals is accurate?
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Hospitalization without treatment violates the client's rights
Many years ago psychiatric clients were warehoused in large mental institutions, given custodial care, and rarely released into the community. As enlightenment occurred, it was determined that each client who is hospitalized has the right to receive treatment. |
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What ethical principle is supported when a physician obtains informed consent for electroconvulsive therapy from a depressed client?
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Autonomy
Autonomy refers to self-determination. One way to exercise self-determination is to make decisions about one's care. |
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A psychiatric technician comes to the charge nurse saying she has been told by a client that he is going to sue her for negligence because she intervened to prevent him from striking another client. The charge nurse should tell the psychiatric technician that she will not be liable for negligence because negligence
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is an act or failure to act in a way that a wise employee would act.
Behaving as a wise and prudent person would act under the same circumstances is one way of judging whether the standard of care has been violated. Employers typically hope that staff will prevent clients from striking each other. |
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The use of seclusion or restraint to control the behavior of a client who is at risk of harming self or others gives rise to conflict between the ethical principles of
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autonomy and beneficence.
Autonomy refers to self-determination and beneficence refers to doing good. When a client is restrained or secluded, the need to do good and prevent harm outweighs the client's autonomy. |
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What assumption can be made about the client who has been admitted on an involuntary basis?
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At the time of admission, the client was considered to be a danger to self or others or unable to meet basic needs.
Involuntary admission implies that the client did not consent to the admission. The usual reasons for admitting a client over his or her objection is if the client presents a clear danger to self or others or is unable to meet even basic needs independently. |
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n the admitting department of a psychiatric hospital a client fills out a standard admission form and agrees to receive treatment and abide by hospital rules. When the nurse reads the medical record, he or she can make the assessment that the client is hospitalized under the type of admission known as
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voluntary.Voluntary admission occurs when the client is willing to be admitted and agrees to comply with hospital and unit rules.
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A client is released from involuntary commitment by the judge, who orders that a caseworker supervise him for the next 6 months. This is an example of
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conditional discharge
An unconditional discharge gives the client complete freedom to choose or reject follow-up care. A conditional discharge imposes a legal requirement for the client to submit to follow-up supervision. |
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A client who is to be discharged the next day tells the nurse that once he's released he will make sure his wife will never again be able to have him committed to a psychiatric hospital. Although he makes no direct threat, his words sound ominous to the nurse. What action should the nurse take?
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Report the incident to the client's therapist and document
The Tarasoff ruling makes it necessary for nurses to report client statements that imply the client may harm another person or persons. The nurse reports to the treatment team, and the mandated reporter (usually the professional leader of the team) is responsible for notifying the person against whom the threat was made. |
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If a client is placed in seclusion and held there for 24 hours without a written order or examination by a physician, the client would have the right to bring suit against the hospital for
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. false imprisonment
False imprisonment is the arbitrary holding of a client against his or her will. When seclusion is ordered, it is not invoked arbitrarily, but after other less restrictive measures have failed. If the client is secluded without the medical order, the measure cannot be proven as instituted for medically sound reasons. |
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Which client on the mental health unit is at highest risk for violence directed at others?
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Mr. C, who has delusions of persecution and has assaulted his brother\A prior episode of assault is predictive. In addition, Mr. C. perceives others to be against him and may lash out if he feels threatened.
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A client is experiencing manic hyperactivity. In the dining room she stands up and shouts "This food is garbage! I'll fight anyone who says it's not! I can fight all of you at one time and win with one hand tied behind my back!" She is flushed, her fists are clenched, and she glares challengingly at clients and staff. The nurse can assess that the client
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has a high potential for other-directed violence.
The client's offers to fight are suggestive of a high potential for violence. Clients may have coping skills that are adequate for day-to-day events in their lives but are overwhelmed by the stresses of illness or hospitalization. Other clients may have a pattern of maladaptive coping, which is marginally effective and consists of a set of coping strategies that have been developed to meet unusual or extraordinary situations. |
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An adolescent male is swearing and shouting at his physician, who refused to give him a pass to leave the unit. This behavior
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is a major indicator that the client may become physically aggressive.
Physical aggression is preceded by anger, which may be expressed by swearing and shouting, pacing, and other menacing behaviors. |
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The clinic waiting room is crowded and hot. The doctor seeing clients was late because of an emergency surgery and is quite behind schedule. A client is pacing and looking tense. The nurse estimates that he has at least a 45-minute wait. The nurse should |
explain to the client what caused the back-up and suggest that he has time to go to the coffee shop.
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An angry client has made a suicide attempt by shooting himself in the chest. He has a complicated dressing that is changed twice daily. He frequently loses patience with the nurses and shouts at them while they perform the dressing change. Which plan could they create to intervene effectively in this behavior?
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Wordlessly finish the dressing and leave when the shouting starts. Return in 20 minutes.
The nurse is using behavioral techniques to reinforce desirable behavior (spending time with the client when he is calm) and limit reinforcement of undesirable behavior (leaving when he is acting out anger). |
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to intervene verbally when an angry client threatens to throw a chair. The client turns his wrath from the original unmet need to the nurse and begins to shout at her. Several staff gather behind the nurse. In response to the direction to try to calm down, the client shouts "I will calm down when that bitch isn't in my face." The nurse should
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move to the rear of the staff group.
There is no need for the nurse to stand her ground to save face. The goal is to deescalate the situation. When the client makes a request that can be met without compromising safety, granting the request is acceptable. |
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A short-term goal for a client who has demonstrated aggression while an inpatient would be that the client will
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identify situations that precipitate hostility.
The identification of situations that create hostile feelings must occur if the client is to develop new coping strategies. |
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A client has been placed in seclusion to control aggressive behavior. Care while the client is secluded should include
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providing for nutrition and hydration.
Clients must be given meals on schedule and frequently offered cold liquids in paper cups (at least every 2 hours, hourly if the client is highly hyperactive). |
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During a therapeutic session, a client tries to shift the focus of discussion from himself to the nurse by asking questions about the nurse's personal life and social activities. The nurse can be most therapeutic by saying
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"The time we spend together is meant for you to use to discuss your concerns."This reply restates a concept that is fundamental to the nurse-client relationship. Clients occasionally need reminders of the parameters of the therapeutic relationship.
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uring a therapeutic encounter the nurse remarks to a client "I noticed anger in your voice when you spoke of your father. Tell me about that." What communication techniques is the nurse using?
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Reflecting and exploringReflecting conveys the nurse's observations of the client when a sensitive issue is being discussed. Exploring seeks to examine a certain idea more fully.
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