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Psych Review (Final Exam)
Concepts Of Psychiatric-Mental Health Nursing (NUR 4250)
Nova Southeastern University
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75 questions, no math, comprehensive
⇒Test taking Tip!
o “Priority in psych is SAFETY!!! This is usually the correct answer choice” o “If answer choice turns anything back to the nurse, that is not usually the answer “well, what I do...” ▪ “Make sure the answer choice keeps the focus on the patient”
Therapeutic response by a nurse
- Stay calm with patient
- Use open-ended questions and anything that will make the patient talk more o NEVER ASK WHY!!
Activity for patient with GAD
Per her recording: physical exercise Behavior therapy - Systematic desensitization→ gradual exposure to the phobic stimulus (slowly introduce them to their stressors) - Implosion therapy→ imagine or participate in real-life situations the person finds extremely frightening (describe detail by detail)
Medications: alprazolam, diazepam, buspirone, lorazepam:
indications, abruptly stopping meds, assessment when administering
meds
Alprazolam (Xanax)→ benzo, antianxiety
Diazepam (Valium)→ benzo, antianxiety
Lorazepam (Ativan)→ benzo, antianxiety
- Do not stop abruptly, can cause SEIZURE, withdrawal symptoms
- Do not take with other antidepressants
- Short-term use, not to be taken for more than 6 weeks
- DO NOT TAKE WITH ALCOHOL
- SSRI’s are long term treatment
Buspirone (Buspar)→ antianxiety
- Do not stop abruptly
- DO NOT TAKE WITH ALCOHOL
- Assess neuro before administration, BP especially
- If groggy or bradycardic, HOLD medication
Effectiveness of treatment for patient with phobia
- Per her recording be able to recognize provoking factors for phobia
- Recognizing what is causing the anxiety, what triggers my anxiety (Anxiety, eating disorders)
- Using positive talk (cognitive therapy)
Treatment of bipolar disorder
- Carbamazepine (Tegretol)(3) for bipolar disorder
- Per her recording: if Lithium (1) doesn’t work→ Valproic acid (2)
Treatment for anxiety disorder
- Per her recording: Benzo (short-term use)
- SE of Benzo and Buspirone: mental confusion, hallucinations, skin rash, trouble sleeping, irritability, headache, involuntary movement of the neck and head, blurred vision, constipation, diarrhea, N/V, and difficulty urinating
- SSRI’s for long term use
Interventions for Alzheimer’s
- Improving memory deficit, safety
- Reorient patient
- Monitor for safety (if rugs are not place properly)
- Priority nursing diagnosis:
- Be able to identify based on presentation of scenario
- Delirium vs. Dementia (major differences)
- Delirium is acute and can be relieved
- If underlying issue is treated, the confusion or change in mental status will go back to normal
- Dementia is chronic and progressive.
- Can’t be relieved
Symptoms, nursing interventions, and treatment for patients with
Anorexia nervosa (chapter 31, p. 654)
Anorexia nervosa is characterized by a morbid fear of obesity. Symptoms -Family Hx- strict and perfectionism and controlling parents -Purging after a meal acts as a way to decrease anxiety for a patient with anorexia nervosa - Gross distortion of body image - Preoccupation with food and refusal to eat
- Staff and client agree about→ goals, and system of rewards
Individual therapy → when underlying psychological problems are contributing
to the maladaptive behaviors
Family therapy→ involves educating the family about the disorder; assess the
family’s impact on maintaining the disorder; and assist in methods to promote adaptive functioning by the client
Psychopharmacology→ no medications are specifically indicated for eating
disorders. These medications have been tried with some success:
- Fluoxetine (Prozac)
- Clomipramine (Anafranil)
- Cyproheptadine (Periactin)
- Chlorpromazine (Thorazine)
- Olanzapine (Zyprexa)
Symptoms, nursing intervention, and treatment for patient with
Bulimia
- Same as Anorexia Nervosa.
- Psychopharmacology→ no medications are specifically indicated for eating disorders. These medications have been tried with some success: - Fluoxetine (Prozac) - Imipramine (Tofranil) - Desipramine (Norpramine) - Amitriptyline (Elavil) - Nortriptyline (Aventyl) - Phenelzine (Nardil)
- Causes for eating disorder, home environment for anorexic
- Family Hx- strict and perfectionism and controlling parents
- Biological: genetics, physiological, lifestyle, and psychosocial factors
- Nursing interventions and treatment for morbidly obese patients
- Food journal-keep track of what they are eating to develop better coping skills
- Help client develop a realistic perception of body image and relationship with food
- Discuss feelings and emotions associated with eating
- Formulate eating plan with input from client
- Identify realistic goals for weekly weight loss (1-2 lbs/wk)
- Plan progressive exercise program
- Identify appropriate nursing diagnosis
Imbalanced nutrition: < body requirements
Deficient fluid volume
Ineffective denial
Imbalanced nutrition: more than body requirements
Disturbed body image/low self esteem
Anxiety (moderate to severe)
Therapeutic communications (chapter 8, p. 140)
o Encourage pt to speak more→ open-ended questions, welcoming, and facilitate
communication
o Using silence→ gives the client the opportunity to collect and organize thoughts, to
think through a point, or to consider introducing a topic of greater concern than the one being discussed
o Accepting→ conveys an attitude or reception and regard
o Giving recognition→ acknowledging and indicating awareness; better than
complimenting, which reflects the nurse’s judgment o Offering self-making oneself available on an unconditional basis, increasing client’s feelings of self-worth
o Giving broad openings→ allows the client to take the initiative in introducing the
topic; emphasizes the importance of the client’s role in the interaction
o Offering general leads → offers the client encouragement to continue
o Placing the event in time or sequence→ clarifies the relationship of events in time so
that the nurse and client can view them in perspective
o Making observations→ verbalizing what is observed or perceived.
o Encouraging description of perceptions→ asking the client what is perceived
o Encourage comparison→ compare and contrast similarities and differences
o Restating→ repeating the main idea of what the client has said
o Reflecting→ questions and feelings are referred back to the client so that they may
recognized and accepted
o Focusing→ taking notice of a single idea or even a single word
o Exploring→ Delving further into a subject, idea, experience, or relationship
o Seeking clarification and validation → Striving to explain that which is vague or
incomprehensible and searching for mutual understanding ▪ Clarifying the meaning of what has been said facilitates and increases understanding for both client and nurse
o Presenting reality→ client has a misperception of environment; the nurse defines
reality or indicates his/her perception of situation of the client
o Voicing doubt→ expressing uncertainty as to the reality of the client’s perception
o Verbalized the implied→putting into words what the client has only implied or said
indirectly
o Attempting to translate words into feelings→ when feelings are expressed indirectly,
the nurse tries to desymbolize what has been said
o Formulate a plan of action→ when a client has a plan in mind for dealing with what is
considered to be a stressful situation, it may serve to prevent anger or anxiety from escalating to an unmanageable level
Sympathy vs. Empathy (chapter 7, p. 128)
Empathy
- Transference: client→ nurse unconsciously o Can take the form of overwhelming affection for the nurse or excessive dependency on the nurse o Occurs when the client unconsciously displaces to the nurse feelings formed toward a person from the past o Ex. You remind me of Uncle Johnny Find out why they are identifying you with that person or else client will continue with the transference.
- Countertransference: refers to the nurses behavioral and emotional response to the client o May be related unresolved feelings toward significant others from the nurse’s past or generated from transference feeling on the part of the client
Mental status exam
Per her recording: assess appearance, affect, and speech Affect
Defense mechanisms: sublimation, displacement, reaction-formation,
regression
o Sublimation- (Conscious) Rechanneling of drives and impulses that are personally or socially unacceptable into activities that are constructive ▪ A mother whose son was killed in a drunk driving accident channels her energy into being the president of a local chapter- Mothers Against Drunk Driving ▪ Teenage boy with strong competitive and aggressive drives becomes star football player ▪ Young unmarried women with a strong desire for marriage and family achieve satisfaction and success by opening a child day care center o Displacement- (Conscious) transferring of feeling from one target to another that is considered less threatening of that is neutral ▪ Client who is angry with physician, does not express it, but becomes abusive with his nurse ▪ A man is passed up on a promotion and doesn’t say anything to his boss but later belittles his son for not making the basketball team ▪ A boy who is teased at school, doesn’t say anything, but instead comes home and kicks his dog o Reaction formation- (Conscious) Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors ▪ Jane hates nursing. She attended nursing school to please her parents, during career day, she speaks to prospective students about the excellence of nursing as a career ▪ A young soldier who has extreme fear of participating in military combat volunteers in dangerous military front line duty o Regression- (Conscious/ Unconscious) retreating in response to stress to an earlier level of development and the comfort measures associated with that level of
functioning ▪ When 2 y/o is hospitalized for tonsillitis he will drink only from a bottle, even though mother says he’s been drinking from cup for 6 months ▪ New baby comes home, older sibling, who has been toilet trained begins wetting his pant, crying to be held, and sucks his thumb
Levels of anxiety: symptoms
Mild- seldom a problem, sharpens senses Moderate- perceptual field diminishes attention span and concentration decreases Severe- perceptual field is no diminished that concentration centers on one detail only or on many extraneous details: difficulty completing a simple task Panic- most intense state and can’t focus on one detail and misperception is common Prolonged panic anxiety can lead to physical and emotional exhaustion and can be life- threatening situation
Crisis: assessing a patient, overall goals, nursing assessment
Assessment
- Gather info regarding precipitating stressors and resulting crisis that prompted the individual to seek professional help
- Ask individual to describe event that precipitated the crisis
- Determine if it occurred
- Assess physical and mental status
- Has client experienced this stressor before, what method of coping was used
- Assess suicide or homicidal potential, plan, and means
- Assess adequacy of support system
- Any use of substances
- Ineffective coping
- Anxiety
- Disturbed thought process Overall goals
- Calm patient down, redirect them, support them, restore functioning and, at most, to enhance personal growth. Bring them to pre-crisis level or better
- The minimum therapeutic goal of crisis intervention is psychological resolution of the individual’s immediate crisis and restoration to at least the level of functioning that existed before the crisis period. A maximum goal is improvement in functioning above the precrisis level. The therapist’s role is direct, supportive, and that of an active participant. Nurses ay be called on to function as crisis helpers in virtually any setting committed to the practice of nursing (assessment, planning of therapeutic intervention, intervention, and evaluation of crisis resolution and anticipatory planning).
Schizophrenia: intervention for paranoid patient, patient experiencing
delusions, command hallucinations, negative and positive symptoms
⮚ Somatic delusions→ individual has a false idea about the function of his or her
body (Ex. I’m 70 years old and I will be the oldest person ever to give birth)
⮚ Nihilistic delusions→ client has a false idea that the self, a part of self, others, or
the world in nonexistent (Ex. The world no longer exists, I have no heart) o Religiosity
o Paranoia→ extreme suspicious of others and of their actions or perceived intentions (ex.
I won’t eat this food. I know it’s been poisoned.) o Magical thinking
o Clang association→ rhyming
o Word salad→ group of words put together randomly, without any logical connection,
makes no sense
o Hallucinations→ false sensory perceptions not associated with real external stimuli
⮚ Auditory→ false perceptions of sound, usually voices
⮚ Visual→ false visual perceptions
⮚ Tactile→ false perceptions of sense of touch, something under the skin
⮚ Gustatory→ false perception to taste
⮚ Olfactory→ false perception to smell
o Echolalia→ repeating words that she/he hears
o Echopraxia→ may purposely imitate moves made by others
Negatives
o Inappropriate affect o Bland or flat affect o Apathy
o Volition→ inability to initiate goal-directed activity
o Disoriented appearance→ personal grooming and self-care activities are neglected
o Impaired social interaction o Social isolation
o Anergia→ lack of energy
o Waxy flexibility→ body parts placed in bizarre or uncontrollable positions
o Anhedonia→ inability to experience pleasure
o Regression
Neurotransmitters in brain responsible for which disorder (chapter 4,
p. 57)
Norepinephrine
Low levels→ depression
High levels→ mania, anxiety states, and schizophrenia
Dopamine
Low levels→ Parkinson’s disease and depression
High levels→ mania and schizophrenia
Serotonin
Low levels→ depression
High levels→ anxiety states
GABA
Low levels→ Huntington’s disease, anxiety disorders, schizophrenia, and various
forms of epilepsy Acetylcholine
High levels→ depression
Low levels: Alzheimer’s disease, Huntington’s disease, and Parkinson’s disease
- Recognizing EPS, treatment (chapter 24, p. 447) Symptoms - Pseudoparkinsonism→ tremor, shuffling gait, drooling, rigidity. Symptoms may appear 1 to 5 days following initiation of antipsychotic medication; occurs most often in women, the elderly, and dehydrated clients - Akinesia→ muscular weakness - Akathisia→ continuous restlessness and fidgeting. Motor restlessness. This occurs most frequently in women; symptoms may occur 50 to 60 days following initiation of therapy - Dystonia→ involuntary muscular movements or spams of face, arms, legs, and neck. This occurs most often in men and in people younger than 25 years of age - Oculogyric crisis→ uncontrolled rolling back of the eyes - Tardive dyskinesia→ bizarre facial and tongue movement, stiff neck, and difficulty swallowing. The symptoms are potentially irreversible. The drug should be withdrawn at the first sign - Neuroleptic malignant syndrome (NMS)→ it is rare but fatal, complication of treatment with antipsychotic drugs. Routine assessments should include temperature, and observation for parkinsonian symptoms
Treatment
Diphenhydramine (Benadryl) Benztropine mesylate (Cogentin)
- If clients aren’t treated for EPS, they can develop tardive dyskinesia
ECT: indications, symptoms post treatment, medications used in the
treatment (chapter 20, p. 311)
Indication - Last 15-25 seconds, administered every other day, 3/week; most clients need 6- 12 treatments - Indicated effective Tx of severe depression→ TREATMENT RESISTANT DEPRESSION - Use as a last resort, if nothing else has worked - May also be used in Tx of acute manic episodes of bipolar affective disorder Symptoms post treatment - Temporary memory loss (short term memory loss) - Confusion
- Ask patient if they thought of harming themselves
- Create safe environment→ SAFETY
- Formulate a short-term verbal or written contract
- Maintain close observation of client
- Maintain special care in admin of meds
- Make frequent rounds, irregular intervals to prevent predictability
- Encourage client to express feelings
- Identify stressors
- Determine coping behaviors previously used
- Provide expressions of hope to client
- Encourage client to explore and verbalize feelings and
- Perceptions
- Expressions of hope, positive
- Help client identify areas of life situation that are under own control
- Identify sources that client may use after discharge when crises occur (suicide hotline)
- Establish rapport and do not leave patient alone, nonjudgmental Treatment outcomes
- No physical harm to self
- Sets realistic goals
- Expresses some optimism and hope for the future Nursing diagnosis
- Risk for suicide
- Hopelessness
Substance abuse: alcoholism withdrawal considerations-time,
withdrawal, delirium, treatment, medications
- Find out the last drink client had to know when withdrawal symptoms will occur
Concerns for alcohol withdrawal - 4-12 hr. after cessation of reduction in heavy or prolonged alcohol consumption o Coarse tremors of hands, tongue, and eyelids o Nausea or vomiting o Malaise or weakness o Tachycardia o Sweating o High blood pressure o Anxiety o Depressed mood o Irritability o Transient hallucination or illusions o Headache o Insomnia
Complicated alcohol withdrawal delirium → delirium tremens (hallucinations, seizures)
S/S
- Shaking
- Vomiting
- Increased pulse rate
- Increase BP
- Increase temp
- Sweating
TX for Delirium tremens
Benzodiazepines→ Chlordiazepoxide- Librium (alcohol withdrawal)
If Librium is not available client can take another benzo
Anticonvulsants used for management of delirium tremens
Onset of delirium: 2 or 3 days after cessation
Childhood disorders: ADHD, side effects of medications; ODD;
Autism
ADHD
- Methylphenidate→ tx for ADHD
▪ SE→ decrease growth and development, decrease appetite, and
psychosis
- Oppositional defiant disorder
Therapeutic interventions
- Behavior therapy→ rewards given for appropriate behaviors
- Family therapy→parents should be involved is designing and implementing the Tx plan for child
- Group therapy→ opportunity to interact within an association of their peers
- Psychopharmacology→ used in combination with psychosocial therapy
- Positive reinforcement
- Give rest periods (do homework for 15 min and then child can take a break)
- Give them time to run and use up all their energy
- Encourage dividing tasks into smaller, attainable steps and reward successful completion
- SAFETY! Free from injury
- Encourage appropriate interactions with others
- Increasing feeling of self-worth
- Fostering motivation for compliance with task
- Therapy includes music, art, crafts, play, and psychoeducation
Patient/family teaching
▪ Treatment - Atypical antipsychotic o Dosage based on the weight of the child o Side effects ▪ GI distress ▪ Weight gain (metabolic syndrome) - EDUCATE about healthy eating habits
Plan of care
Risk for self-mutilation
Impaired social interaction
Impaired verbal communication
Disturbed personal identity Nursing Interventions
Protection of child from self-harm
Improvement in social functioning
Improvement in verbal communication
Enhancement of personal identity Family support
Provide encouragement
Teach family about Autism, S/S, how to manage child
Strategies and resources for raising child with Autism
ODD
- Persistent pattern of angry mood and defiant behavior
- Usually occurs around 8 y/o and no later than early adolescents
Predisposing factors - Biological influences - Family influences Assessment - Passive-aggressive behavior (stubbornness, procrastination, disobedience, carelessness, negativism, testing limits, resistance to directions, deliberately ignoring communication of others, and unwillingness to compromise - Children do not see themselves as being oppositional but view the problem as arising from others whom they believe are making unreasonable demands
Nursing dx→ noncompliance with therapy r/t neg temperament, denial of
problems, underlying hostility
Nursing dx→ defensive coping r/t retarded ego development, low self-esteem,
unsatisfactory parent/ child relationship
Nursing dx→ low self-esteem r/t lack of positive feedback, retarded ego
development
Nursing dx→ impaired social interaction r/t neg temperament, underlying
hostility, manipulation of others Outcomes
Complies with Tx by participating in therapies without negativism
Accepts responsibility for problem
Does not manipulate people
Verbalizes positive aspects about self
Interacts with others in approp. Manner Nursing interventions
Structured plan
Minimum → increase expectations
Systems of rewards
Convey acceptance
Help client recog. feeling of inadequacy
Feedback for accepting and passive-aggressive behavior
o Intellectual development disorder (no longer called mental retardation)
▪ Look at physical and emotional functioning ▪ Look at strengths and difficulties for this patient ▪ Prior to age 18 ▪ Genetic factors=5% ▪ Disruptions in embryonic development=30% - Ex.) pregnant women, fetal alcohol syndrome, crack baby, etc. ▪ Can happen due to trauma or complication during delivery that deprive the infant of oxygen, fetal malnutrition, or viral infection during pregnancy= 10%
▪ (Laing personal Story): Placenta separated from fetus→ Emergency C-Section
▪ Predisposing Factors - Sociocultural and other Mental Disorders (15-20%) ▪ Assessment - Four Levels o Mild (50-70), moderate, severe, Profound (below 20) - Assess Strengths as well as limitations - Include family members in care - Encourage to be self-independent during care ▪ Application of the Nursing Process: Intellectual Disability - Risk for injury r/t altered physical mobility or aggressive behavior - Self-care Deficit r/t altered physical mobility or lack of maturity - Impairment in social interaction (AUTISM) r/t speech deficiencies or difficulty adhering to convenient social behavior - Impairment in communication r/t developmental alteration
Personality disorders; antisocial, borderline-nursing interventions,
treatment
Antisocial personality disorder→ they don’t give a dam (from lecture)
Nursing Interventions - In milieu they need structure and need to follow the rules, they can’t just do whatever they want
- If warranted by high acuity of the situation, staff may need to be assigned on a one-to-one basis
Tx for borderline→ interpersonal psychotherapy, psychoanalytical therapy, milieu or group
therapy, cognitive/behavioral therapy, dialectical behavior therapy, psychopharmacology
Students should be able to integrate following concepts:
- Abusive relationships:
a. why women stay?
i. fear of retaliation
1. fear of her life and/or the lives of their children
a. compounded with low self-esteem and sense of
powerlessness→ woman sees no way out
ii. fear for children
1. fear losing custody
iii. financial reasons
1. no financial resources, access to resources or job skills
iv. lack of support networks
1. may be under pressure to stay in marriage and try to work
things out
v. religious reasons
1. religion against divorce
a. must save marriage at all costs
vi. hopefulness
1. remembers good times and love in relationship and has hope
that her partner will change his behavior and they can have
good times again
b. Assessment
i. Victim
1. Low self-esteem
2. Inadequate support system
3. Grew up in an abusive home
ii. Victimizer
1. Low self-esteem
2. Pathologically jealous
3. “dual personality”
a. Limited coping ability
4. Severe stress reactions
5. Views spouse as a personal possession
c. Cycle of battering
i. Battering
1. Pattern of behavior used to establish power and control over
another person with whom an intimate relationship is had,
through intimidation and fear
a. Including threat and violence
b. Happens when one person believes they are entitled to
control another
ii. 3 phases:
1. Phase 1
a. Tension-building phase
2. Phase 2
a. Acute battering incident
3. Phase 3
a. Calm, loving respite (honeymoon) phase
d. Child abuse
i. Physical
ii. Emotional
1. Causes serious impairment of child’s social, emotional or
intellectual functioning
2. Signs:
a. Extremes of behavior
b. Delayed physical or emotional development
c. Lack of attachment to parent
iii. Physical neglect
1. Refusal to seek healthcare
2. Abandonment, expulsion from home
e. Sexual abuse of a child
i. Signs:
1. Difficulty walking
2. Refuses to change for gym or participate in physical activities
3. Reports nightmares or bedwetting
4. Sudden change in appetite
5. Bizarre, sophisticated, unusual sexual knowledge
f. Socioeconomic facts
i. the poor are more likely to be abusers
g. Nurses’ legal responsibility
i. if you ever suspect child abuse need to report the suspicion to the
Department of Health and Human services
h. Elderly patients
i. elder abuse
1. abuser is often a relative and/or the assigned caregiver
a. under economic stress, substance abuser, themselves
victims of abuse, and exhausted and frustrated by the
caregiver role
2. physical
3. psychological
4. financial
Psych Review (Final Exam)
Course: Concepts Of Psychiatric-Mental Health Nursing (NUR 4250)
University: Nova Southeastern University
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