NR 326 Exam 1

NR 326 Exam 1 What is needed for involuntary admission to a psychiatric inpatient unit? 1. Petition needed. 2. The RN will assess the pt for lethality; assess the inability of client to care for self; assess judgment and thought. 3. At first, clinical certification is needed from a clinical eval done by physician or psychologist. 4. A second clinical cert from a clinical eval by a psychiatrist is needed within 24 hrs after initial cert. Examples of non-therapeutic communication techniques -Offering false reassurance -Giving opinions -Asking "why" questions -Asking too many questions without first establishing rapport or allowing pt to verbalize judgement; interrupting -Focusing on the person's character weaknesses vs. strengths, opportunities for improvement, and behavioral motivation Therapeutic communication techniques -Active listening skills -Redirecting patient to healthy ways of coping and interacting -Providing dignity and respect -Observing and relating the person's strengths to 1:1 and group interactions -Identify and focus on the person's strengths, motivations What are active listening techniques? Clarifying, reflecting, summarizing, emotional labeling, silence, offering self, exploring (possible options and previous coping that has worked) Nursing interventions for a pt exhibiting threatening behavior and violence -Have staff nearby -One person talks to the pt with a calm, non-threatening voice -De-escalation skills -Redirect pt (let's walk, I have time to listen, let's solve this together) What are your priority actions during a situational crisis? -Determine if the client has psychotic thinking (Clients experiencing a situational crisis are at greatest risk for injury to themselves or others) What do you do for a pt exhibiting panic level anxiety? Remain with the pt for awhile (the nurse should not leave a pt who has severe anxiety alone. The nurse's priority is to use the least restrictive intervention, such as staying with the pt and calmly encouraging them to express their feelings) Repression A patient who just got assaulted and can't remember circumstances of the event Denial A nurse manager expects the nurse abusing alcohol to demonstrate the defense mechanism of denial. Denial is the most common defense mechanism, especially used by people dealing with the problems and missed responsibilities associated with substance abuse behavior. Rationalization A pt states they have to drink a bottle of alcohol daily to relax due to a veery high stress job. Rationalization is when a person creates reasonable and acceptable explanations for unacceptable behavior. Somatization A pt indicates they keep feelings nauseated and sick to their stomach, chest pains, and a headache, every time they are asked to go to art therapy and be with other people (Somatization is developing physical symptoms in place of anxiety) Reaction formation A pt dislikes his roommate and speaks ill of him to everyone who will listen; but, when the roommate returns, he offers the roommate a cookie and a snack (Reaction formation is overcompensating or demonstrating the opposite behavior of what the person feels) Displacement A pt kicks a chair after emotionally yelling and screaming at a psychiatrist for prescribing a med (displacement is shifting feelings r/t an object, person, or situation to another less threatening object, person, or situation) Regression A pt is describing what he does to cope with things not working out the way he expects (Regression is reverting to an earlier, more primitive and child-like pattern of behavior) What does a crisis situation contain? A crisis situation contains the potential for psychological growth or deterioration What may be prescribed for a pt experiencing anxiety? Paroxetine and Lorazepam (benzo) Nursing interventions for a pt experiencing a crisis r/t anxiety -Establish rapport with the pt -Identify the cause of the anxiety -Validate the client's feelings What are usual findings for panic level anxiety? Increased pulse rate, respirations, and blood pressure. *Elevated temp and decreased CO2 are not usual findings What does a nurse do if a pt verbalizes that they are better off dead than alive? The nurse needs to do a lethality assessment. "Do you have a plan to harm yourself?" (When a pt expresses suicidal intent, it is the nurse's priority to determine the seriousness of the content and the lethality of the means. What is the nurse's priority if the pt has hallucinations, is responding to internal stimuli, and is delusional and/or paranoid? The nurse's priority is to place the pt on suicide precautions, monitoring within line of sight, or 1:1 supervision/monitoring *Assess TMAPI: thoughts, means, ability, plan, and intent Nursing interventions for pts who have a history of panic level anxiety Provide continuity of care by assigning the same staff (consistent interactions are important in any care setting, but especially in mental health. This will help pts establish trust and a sense of seecurity) What should the nurse do if a pt gets angry and throws a chair?