ATI Mental Health UAMS 2022 Exam 2- COMBINED SETS ANSWERED.

ATI Mental Health UAMS 2022 Exam 2-COMBINED SETS ANSWERED. ACE's study - Adverse Childhood Experience Questionnaire What has the ACE's study demonstrated? - The study has demonstrated an association of adverse childhood experiences (ACEs) (aka childhood trauma) with health and social problems across the lifespan. Events that are screened on the ACE's screening tool: - Did parents swear, insult, humiliate you Did parents act in a way that made you afraid of physical harm Did parents push, grab, slap, throw you Did parents touch, fondle, or attempt sex Did you feel unloved, unimportant, unspecial Did your family look out for each other Did you often feel like you didn't have food, clean clothes, protection Were your parents often too drunk or high Were your parents separated or divorced Was your mother pushed, grabbed, slapped, thrown, kicked, bitten, etc. Did you live with an alcoholic Was anyone in the household mentally ill, depressed, suicidal Did anyone in the household go to prison What is the importance of ACE's - it will shape the future of healthcare because of the correlation to future health problems. More attention must be paid to the health of nurses to positively influence - the quality of patient care and patient safety (and to control costs). Common problems nurses experience - musculoskeletal pain, depression, burn out, etc Five Steps to Nurse Self Care: - Do a self-care assessment Diagnose self-care deficit Plan a course of action Implement the plan Evaluate your progress Three Important suggestions for self-care: - Eating a nutritious diet Exercise regularly Practice stress reduction CDC recommends a weekly exercise regimen that includes - 2.5 hours of moderate aerobic activity, 1.25 hours of vigorous intensity aerobic exercise, or some combination of the two. You also need 2 or more days of strength activities. Other self-care includes - socializing/solitude, gratitude practice Homeostasis - a relatively stable state of equilibrium or a tendency toward such a state between different interdependent elements or groups of elements. Maintaining homeostasis is necessary to - maintain life The autonomic nervous system and the endocrine system link the brain with - cardiac muscles, smooth muscles, and glands of our internal organs Central nervous system contains the - brain and spinal cord Parasympathetic NS - "rest and digest" state. Constricts pupils, stimulates saliva, slows heartbeat, constricts airways, stimulates stomach activity, inhibits release of glucose, stimulates gallbladder, peristalsis, contracts bladder, promotes erections, etc. Sympathetic NS - "fight or flight" state. Dilates pupils, inhibits saliva, increases heartbeat, relaxes airway, inhibits stomach activity, stimulates release of glucose, inhibits gallbladder, inhibits peristalsis, secretes epinephrine and norepinephrine, relaxes bladder, and promotes ejaculation and vaginal contraction Hypothalamic-Pituitary -Adrenal Axis (HPTA) - Hypothalamus releases CRH which stimulates pituitary gland to release ACTH which stimulates adrenal glands to secrete cortisol. Pituitary and Adrenal glands are important to mental health functioning. Changes in biological drives that indicate psychiatric conditions - Over or Under eating, Sexual disinterest or over interest, sleep cycles, etc. Brainstem - Connects to spinal cord and controls primitive function like heart rate, breathing, digestion, sleeping. Limbic System - Complex system of nerves in brain that controls instinct, mood, emotions (like fear, pleasure, & anger), & drives (like hunger sex, dominance, care of offspring). Hypothalamus - Controls body temp, thirst, hunger, and other homeostatic systems involves with sleep and emotional activity. Cerebellum - receives information from sensory systems and regulates voluntary motor movements, balance and equilibrium. Cerebrum - large part of brain that distinguishes humans and is responsible for mental activities, conscious perception, memory, & language. 3 physiological actions for neuro-nerve cells in brain - Responding to stimuli, conducting electrical impulses, releasing chemical neurotransmitters. Parts of Neuron - Dendrites (receives messages from other cells), Axon (passes message), Terminal branches of axon (form junctions with other cells/release neurotransmitter). How do neurons communicate - chemically and electrically Can neurons release more than one chemical at the same time - yes What happens to chemical neurotransmitters that don't bind to receptors - they stay in the synapse until an enzyme breaks them down or they are reabsorbed back into the neuron. This is known as reuptake. Important brain imaging techniques: - EEG - Electrical CT - Structural MRI - Structural Functional MRI (fMRI) - Functional Positron-emission tomography (PET) - Functional Single photon emission computed tomography (SPECT) - Function List of Neurotransmitters to know: p. 41 in textbook - Acetylcholine - Alzheimer's disease Dopamine - depression, schizophrenia (high) Serotonin - depression Gamma-amniobutyric Acid (GABA) - anxiety Glutamate - Alzheimer's disease (high) Norepinephrine - depression, ADHD Histamine - inflammatory response Substance P - pain signal Somatostatin - cell proliferation Neurotensin - works in intestines Pharmacodynamics - what drugs do to the body and how they do it (mechanism of action, drug response) Pharmacokinetics - How drug moves through the body (absorption, distribution, metabolism, excretion). Pharacogenetics - Genetic variation (enzymes, messengers, receptors) leading to clinical differences in drug response for individuals or ethnic groups. Leading to more personalized healthcare/medicine. Enzyme that breaks down most psychotropic drugs - CYP450 Persons that are fast metabolizers will experience - less of a therapeutic response Most psychotropic drugs act by either increases or decreasing - the activity of neurotransmitter receptor systems Antipsychotic Drugs: - First Gen Antipsychotic - known as typical/traditional. Works on the neurotransmitter dopamine. Examples include Chlorpromazine & Haloperidol. Second Gen Antipsychotic - known as atypical/nontraditional. Works on dopamine and serotonin. Preferred gen. Examples include Risperidone, Clozapine. Can cause metabolic changes increasing risk of DM2, Obesity, Gynecomastia. Third Gen Antipsychotic - known as Abilify. Dopamine stabilizer. Adverse Effects - Anticholinergic effects, orthostatic hypotension, extrapyramidal symptoms, Neuroleptic Malignant Syndrome, Bone marrow suppression Neuroleptic Malignant Syndrome - Sudden high fever, Muscle rigidity, Diaphoresis, Fluctuating level of consciousness, extrapyramidal symptoms, delirium, blood pressure issues. Antidepressant Drugs: - MAOI's - Phenelzine, TCA's - Amitriptyline SSRI's - Fluoxetine SNRI's - Duloxetine, Venlafaxine Atypicals - Bupropion Antianxiety Drugs: - Benzodiazepines - fast acting. works on GABA. Examples include Alprazolam. BuSpar - slow acting, like most antidepressants. Mood Stabilizers: - Lithium - narrow therapeutic window (keep below 1.5). Acute mania treated with with levels between 0.8-1.4. Maintenance level 0.4-1.0. Watch lithium level, thyroid function, and kidney function. Anticonvulsants - Examples include Valprate, Carbamazepine, Lamotrigine, Gabapentin, Topiramate. Valproic acid and carbamazepine require serum drug levels. Lamotrigine does not require drug level monitoring. Alzheimer's Treatment: - Cholinesterase inhibitors - Aricept. Works on acetylcholine. N-Methyl-D-aspartic acid antagonist (NMDA) - Namenda. Works on glutamate. Ventral tegmental are (VTA) - pleasure center of the brain. Pathway activated by dopamine and glutamate. Psychoactive substances can release 10x the usual amount of dopamine. Process/Behavioral Addiction - behaviors recognized as addiction (internet gaming, gambling, sex, social media, shopping). Tolerance - need increasing amounts to receive original effect from drug Withdrawal - physiological symptoms occur as concentration of chemical decreases in blood stream Addiction - primary, chronic, disease of the brain's reward, motivation, memory, and related circuits. Intoxication - excess use of a substance Abuse - obligations not met, hazardous living, legal problems, interpersonal problems, but continue to use... Dependence - tolerance to drug/withdrawal, desire to control use, time involved in drug use increases, use regardless of consequences. Only behavioral addiction in current DSM - gambling Substance Use Disorder (SUD) - DSM requires at least 2 of the following: impaired control (use longer/more than intended, can't quite, etc.), social impairment (can't meet obligations), risky use (even though they know), pharmacological criteria (tolerance/dependence) DSM groups substance related disorders into two groups - - substance use disorder (SUD) Substance induced disorder (alcohol induces psychotic disorder) Substance abuse disorder often presents with - comorbidities (especially psychiatric). Twice as likely to have SUD if you have hx of mood, anxiety, conduct disorders. Most people with psychiatric disorders also have medical comorbidities such as - HIV, DM, Hep C, CV disease, Pulmonary disease, Hepatic disease, etc. CAGE screening for alcoholism - Cut down, Annoyed by criticism, Guilty feelings, Eye opening experience Nursing assessment on patient with SUD should always include - individual's willingness to change Codependence - unhealthy dependence on relationships, avoid abandonment at all costs, defines self-worth by caring for others to the exclusion of own needs. Overly responsible for others, overlap of love and pity, do more than fair share "martyr", extreme need to approval, difficulty identifying feelings and making decisions. Alcohol: - CVS depressant, loss of coordination, lowered inhibitions, emotional volatility Alcohol poisoning - difficult to arouse, cool clammy skin, resp <10, cyanosis, emesis while unconscious Alcohol withdrawal - early signs within a few hours, peaks 24-48 hours (may progress to delirium), anxiety, insomnia, anorexia. Withdrawal is severe and may be fatal. Alcohol withdrawal delirium - medical emergency (can cause death). Anxiety, insomnia, anorexia. Hyperactivity, sensory/perceptual disturbances (hallucinations), fluctuations in level of consciousness, delusions, fever. Can cause Wernick's encephalopathy (acute, ataxia, eye dysfunction, confusion, coma, death) or Korsakoff's syndrome (chronic, confusion, memory loss). Alcohol Treatment: - Withdrawal phase—SEIZURE PREVENTION: Anticonvulsants - Carbamazepine Benzodiazepines - Diazepam Maintenance phase: Disulfiram Pt. can decide not to take and drink instead Educate about hidden sources of alcohol (mouthwash) Pt must be abstinent from alcohol for > 12 hours Naltrexone Blocks high Interacts with opioids (ask about use) Available as long-acting IM Stimulants: - Increased HR, BP, body temp, increased risk for stroke, seizure, CV events Increased energy, metabolism, weight loss, Anxiety, tremors, irritability, panic, paranoia, psychosis Nasal damage (associated with cocaine) & tooth damage (associated with meth) Long term issues of anxiety, psychosis, depression, paranoia, & ideas of reference that may last for months/years. Smoking is highly associated with people that have - schizophrenia or bipolar disorder Opioids: - Treatment for overdose is Narcan (naloxone). Don't confuse with Naltrexone which aids in abstinence. Intoxication is CNS depression (low HR, BP, RR, temp, movement). Sedation, calm, euphoria, Pinpoint pupils (meiosis). Withdrawal is CNS stimulation (high HR, BP, RR, temp, movement). Increased sweating, yawning, runny nose, muscle spasms, abdominal cramps, N&V, bone/muscle pain, anxiety, and enlarged pupils (mydriasis). Opioid Treatment: - Withdrawal phase: Clonidine - treats withdrawal symptoms and hypertension Suboxone (buprenorphine/naloxone)- blocks withdrawal effects by acting like opioid; and suppresses "high" with naloxone Methadone- blocks the craving Maintenance phase: Buprenorphine - decreases cravings and suppresses "high" with naloxone (narcan) Methadone- blocks the craving. Approved for pregnant women. Naltrexone Blocks high Available as long-acting IM Naltrexone is used for recovery in - both alcohol and opioids. Blocks opiate receptors to prevent cravings and block high. Inhalants: - Volatile Solvents - ether, chloroform, alcohol, acetates. Often what kids huff. Volatile Nitrates - video head cleaner, nail polish remover, room odorizers. Enhance sexual pleasure, profound hypotension. Anesthetics - nitrous oxide. Euphoria, giggling, chronic use neuropathy. Intoxication is similar to alcohol. Long term effects to liver, kidney, heart, bone marrow, nerves, and brain. Adverse effects of MDMA - hyperthermia, cardiac, kidney failure What is Dual Diagnosis - mental disorder coexisting with substance use disorder What to do about dual diagnosis - expect it (both substance use disorder and psychiatric disorders are primary and need simultaneous treatment). Have empathy and hope. Know that recovery happens in stages and not all at once. The key to intervention in substance use disorder is - the individuals readiness to change Psychotherapy challenges include - the first 6 months have physical changes, emotional responses (no longer diluted by drug), dealing with triggers, new coping skills. Relapse - is very common, plan for it, lengthen time between relapses. Three concepts for all 12 step programs - people are powerless over addiction, life is unmanageable, not responsible for disease but responsible for recovery, must face addiction, can't blame others. Which withdrawal has highest morbidity and mortality rate - alcohol Worden Four Tasks of Mourning: - Task 1 - accepting the reality of loss; Task 2 - Processing the pain and grief via coping mechanism ; Task 3 - Adjusting to the world; Task 4 - finding an enduring connection with the lost entity while developing new life Types of abuse - Physical Sexual Emotional Neglect Economic What is the most prevalent type of abuse - Neglect Secondary effect of violence against women - Physical Negative behaviors-drinking, drugs, smoking, self-harm; sexual risk Psychosomatic-chronic pain, IBS, etc Reproductive issues: STDs, PIDs, unwanted pregnancy, Psychological- PTSD, panic disorder, etc Components of abuse - Perpetrator Vulnerable party Crisis situation- perceived or actual Characteristics of perpetrators - poor social/coping skills, pathological jealousy, extreme disciplinarian that believes in physical punishment, poor impulse control, low self-esteem, violent outbursts, substance abuse, likely abused as a child, views personal needs as most important, has intimate relationship with victim (codependency). Characteristics of vulnerable party - low self-esteem, feelings of hopelessness, helplessness, guilt, shame, denial of seriousness of situation, protects perpetrator and accepts responsibility of abuse. Abuse may increase with - marriage, pregnancy, acts of independence Greatest risk is put on vulnerable party if - they have attempted to leave Children are at higher risk for abuse if - younger than 3 yo, have congenital abnormalities, chronic disease, correlation with a disliked person, or were unwanted. Older adults are at higher risk for abuse if - they have poor mental or physical health, disruptive behavior like dementia, are highly dependent on others, or if they use to be the perpetrator. Do all crises lead to violence - no. effective impulse control, problem solving skills, and support systems can prevent violence. Examples of crises triggers include job loss, financial strain, pregnancy, and onset of illness. Cycle of violence: - Tension building stage verbal abuse and minor acts of aggression (pushing/shoving), unhealthy attempts by both partners to reduce tension. The perpetrator may use alcohol, drugs, and rationalizations. The victim may minimize, and accept fate. ; Battering stage - Severe violence. Results in injury.; Honeymoon stage - Apologies, promises of change, kindness and loving behavior. Nursing self-assessment when dealing with situations of violence - anger/blame towards perpetrator, family, society, fear of perpetrator, anguish (history of victimization), blame the victim mentality, save the victim mentality. Victims often have physical issues such as - bleeding injuries in head or face, internal injuries, bizarre injuries (cigarette, chemical, appliance burns), miscarriage, broken bones (x-rays show old fractures), repeated visits with new complaints. Victims often have behaviors such as - reporting injuries as accidents, labeling of accident prone or clumsy, fear of partner or caretaker, lack of crying in presence of perpetrator and instead shows a flat affect, poor eye contact, minimal interaction, may not speak until perpetrator is out of room. Main question to ask yourself when victims present is - does the story match the injury? Always interview client - alone. Ask questions like tell me what happened to you, who takes care of you, what happens if you do something wrong, how do you resolve disagreements, do you feel safe at home, are you afraid of anything or anyone at home, what can I do to help you Mandated reporter - you are required to report suspected or actual abuse of children or elders. Adults (over 18) must make the decision to report. You cannot report for adults without consent! #1 priority for client to ensure and maintain their safety. - Provide phone numbers, shelters, support group. Victim safety plan for leaving should include - identified behaviors and triggers, an escape route, phone numbers to call, people to tell, places to go, extra money, car keys, clothes, phone, documents, knowledge of legal options. NEVER do the following with the client - try to convince victim to leave (you cannot save them, they must rescue themselves). Never judge, accuse, display doubt, shock, outrage, force anyone to complete physical exam, take charge and try to do everything for the client. Sexual Assault - - sex acts completed or attempted against a victim's will or when a victim is unable to consent due to age, illness, disability, or influence of alcohol or other drugs. Can involve actual or threatened physical force, use of weapons, coercion, intimidation, or pressure. Sexual assault stats - most are perpetrated by someone the victim knows, most are never reported, 1/3 happen inside the home, most of the time weapons are not involved, ¼ of college females admit to being a victim, males make up 10% of reported rapes. Mental Health and Sexual Assault Survivors - 25-50% seek treatment for depression, PTSD, anxiety, suicide, chemical dependency, self mutilation, etc. Rape Trauma Syndrome - not a DSM-5 diagnosis, but type of PTSD. 1/3 of victims meet criteria but few are diagnosed. ; Acute Phase - occurs immediately after assault, may last a few weeks, lifestyle is disorganized and dysfunctional, somatic symptoms are common (pain from trauma, headache, sleep trouble, etc.). Disruptions in cognition, affect, mood (fear, denial, anxiety, shock, humiliation, etc.). ; Acute Phase coping Styles - controlled (confusion, calm, subdued, difficulty making decisions, shock, numbness), and expressed (overt emotions and behaviors, crying, yelling, tenseness). ; Long-term Reorganization Phase - intrusive thoughts (flashbacks, dreams, insomnia, similar to PTSD), increased activity (moving, vacations, changing phone numbers), increased emotional liability (anxiety, mood swings, crying spells, depression, possible suicidal thoughts or self-harm). Assessing a Sexual Assault Survivor - victim's body is a crime scene, obtain consent, patient has right to refuse! Sexual Assault Nurse Examiner (SANE) called and everything is collected (clothing, hair, body fluid, swabs). Nursing interventions for sexual assault survivor - assure client it is not their fault, allow client to feel in control and support their decisions, allow and encourage grief, anger, working through fear, provide resources, promote self-care and education, prophylaxis meds (for pregnancy, STD), provide WRITTEN info for follow-up including medications and labs. Anger - normal emotional response to frustration. Can be positive when it rights wrongs. Can be negative when it is denied, suppressed, or expressed inappropriately. Can be physical with BP elevation, headaches, gastric ulcers, coronary artery disease. Can also manifest psychologically as depression, stress, low self-esteem. Aggression - a manifestation of anger that is goal directed with intent to harm. Can be directed toward self or others. Can be associated with feelings of inadequacy, insecurity, guilt, fear, rejection. Comorbidities with anger include - depression, PTSD, Alzheimer's, personality disorders, and psychotic disorders. Categories of assault: - Pre assaultive - becomes angry and exhibits increasing anxiety, hyperactivity, verbal abuse; Assaultive - client commits act of violence; Post assaultive - staff reviews incident with client during this stage Battery vs. Assault - a person can only be charged with battery if they cause real physical harm to someone, while a person can be charged with assault with the mere threat of harm. Seclusion & Restraints - are always last resort. Use according to legal guidelines after all other options have been tried. Don't usually lead to positive behavior changes, but can keep persons safe during outbursts. Risk factors for anger/aggression - past history of aggression, poor impulse control, violence, poor coping, limited support, comorbid condition, paranoia, command hallucinations, cognitive disorders, living in a violent environment. Behaviors of anger/aggression - hyperactivity, pacing, defensive response when criticized, easily offended, intense eye contact, no eye contact, facial expressions of frowning or grimacing, body language like clenched fists, arms waving, rapid breathing, aggressive posturing, appearing tense, yelling, loud rapid talking, drug or alcohol use. How to set limits for clients - tell them calmly and clearly what they must do, use physical activity to deescalate anger, inform client of consequences of behavior, use pharmacological interventions if needed, have a show a of force if appropriate. After an aggressive episode - What should you do? - discuss incident, ways to cope in the future, encourage client to talk about triggers, debrief with staff, document entire incident completely (behavior leading up to incident, during incident, nursing interventions implemented & client response). Serotonin Syndrome - results from increased levels of serotonin (due to SSRIs [fluoxetine], TCA's [amitriptyline], & MAOI's [phenelzine]). Fever, agitation, confusion, anxiety, hallucinations, etc. Starts 2-72 hours after taking medication. MAOI generated hypertensive crisis - Caused by interaction with tyramine (no aged cheese, pepperoni, salami, smoked fish, avocado, figs, bananas, soy sauce, red wine, beer. Headache, N&V, sweating, severe anxiety, nose bleed, chest pain, rapid heartbeat, change in vision, shortness of breath. SSRI's - 1st line to treat depression. Prototype is Fluoxetine (Prozac). Increase serotonin. Have early side effects (nausea, tremors, sweating, fatigue) and late side effects (sexual dysfunction, weight gain, hyponatremia). Can cause bruxism (treated with buspirone). What teaching is important for the client that is starting an SSRI in regards to suicidal ideations - - All antidepressants can cause suicidal ideation. Need to report immediately. SSRIs take 1-3 weeks to start working and 2-3 months to reach full effect. Don't suddenly stop. Lithium - a mood stabilizer used to treat bipolar disorder. Has narrow therapeutic level meaning patient will have to adhere to strict lab appointments, and will have to increase fluid intake to prevent toxic levels. Normal lithium level - - - 0.4 - 1.0. anything below 1.5 is not toxic. Normal side effects include fine hand tremors, weight gain, polyuria, hypothyroidism, weakness, nausea. Toxic lithium level - 1.5 - 2.0 is toxic with coarse tremors, N&V, diarrhea, confusion. Tx with dose modification. 2.0-2.5 is severely toxic with extreme polyuria, tinnitus, blurred vision, ataxia, seizure. Tx with gastric lavage. Anything above 2.5 will result in rapid progression of symptoms and death. Tx with hemodialysis. Possible complications involving the kidneys and thyroid of being on lithium long term - lithium causes polyuria and renal toxicity (why they need to increase fluids). Lithium causes hypothyroidism which can result in a goiter. Hypothyroidism also causes slowed metabolism and weight gain. What are the common myths about suicide? - People who talk about suicide DO NOT attempt suicide People who talk about suicide are only trying to get attention Telling someone to cheer up is helpful- If you mention the word suicide, you might plant the idea into someone's mind If someone survives a suicide attempt-they weren't serious about ending their life Levels of Lethality - Definition- those who have a definite plan for time and a place and have the means are the MOST at RISK! Plan of suicide - how detailed can they describe it exactly? Lethal of suicide - how quickly would a person die by the method elected to attempt suicide** Hard Methods of Lethality of suicide - gun, jumping from the bridge, hanging, CARBON dioxide, staging car crash! Soft methods of suicide - Slashing wrists, ingesting pills , inhaling natural gas Access? Is there access to the suicide? - Do they have access to the proposed items? Practice Question: Four different patient's responses "what is your suicide plan?" Prioritize HIGHEST to LOWEST? - I would get my dad's gun and go out into the woods behind my house-MOST Lethal I looked at the bridge on I30 this morning. I know the jump is high enough to get the job done-NEXT I would take a bunch of pills-NEXT I don't know-I guess I would cut my wrists or something.LEAST Completed suicide - attempt at suicide that results in DEATH Copycat suicide - suicide attempt that follows a highly publicized suicide of a public figure, an idol/peer in the community Parasuicide - attempt at suicide that is considered more of a gesture such as non-lethal dose of medication is ingested.-this is considered a risk factor of suicide Suicidal ideation - thinking about suicide, usually with some serious emotional and intellectual or cognitive overtones; considering methods of accomplishing death, and formulating plans to carry the act out Suicide - the 10th leading cause of death! Risk factors of suicide - Gender, age, race marital status, profession, physical illness, trauma hx, family hx, previous attempt Mental illness linked to suicide - mood disorders, schizophrenia, borderline personality disorder, substance abuse disorder Risk Factors continued for suicide-NOTES section - •Gender-males take their own lives at nearly four times that rate of females and represent almost 78% of all US suicides. Women attempt suicide 2-3 times more often than men •Age-In 2013-17% of high school students reported that they had seriously considered attempting suicide during the 12 months preceding the survey-~ 8% of students reports that they had actually attempted suicide on or more times during the same period. •Suicide is the 3rd leading cause of death among 10-14 year olds and second-leading cause of death among 15-34 year olds •Suicide rates among American Indian/Alaskan Native adolescents are 1.5 times than the national average for the same age group •Hispanic students in grade 9-12 had significantly more suicide attempts than black or white students •85-90% of completed suicides are by Caucasians •Religion is associated with decreased rates of suicide-Protestants and Jews have higher rates of suicide than Roman Catholics •Divorced men are more likely to commit suicide than divorced women •Professionals are generally considered at higher risk for suicide-particularly with loss of status-physicians, dentists, vets, and chiropractors-also included law enforcement, sales, mechanics, insurance agents and lawyers •This with a physical illness are at increased risk-loss of mobility, disfigurement and chronic pain are especially at risk What is the feeling most associated with suicidal ideations? - Suicidal ideation occurs when a client is having thoughts about committing suicide. Clients have feelings of Hopelessness, helplessness, and inner pain Warning factors of suicide - talking or writing about death, dying, or suicide Making comments about being hopeless, helpless, or worthless, Expressions of having no reason for living or no sense of purpose INCREASED ETOH or drug misuse Reckless behavior Dramatic mood changes Talking about feeling trapped or being a burden to others Protective factors-less likely to commit suicide - access to healthcare satisfaction with life strong connections to individuals-marriage, kids, friends Pregnant- Religion and beliefs effective coping and problem solving skills Nursing Process for Suicide- ASSESSMENT! - Assess for verbal AND nonverbal clues: Overt- I can't take it anymore; I wish I were dead COVERT- I won't be a problem much longer; It's okay now. Soon everything will be fine **NOTES** •People who contemplate suicide, attempt suicide, and even those who regret the failure of their attempt, are often extremely receptive to talking about their suicide crisis •"Have you ever felt that life was not worth living"? •"Have you been thinking about death recently"? •"Did you ever think about suicide"? Don't be afraid to ASK- leads to DECREASED isolation Always remember- Nurse Self-Assessment is important! Nursing Assessment Tools- - Assessment Tools for suicide: SAD-Persons scale- 10 major risk factors of personal comfort, lack of professional confidence, and time constraints- Score of 3-4 NEEDS HELP and follow-up C-SSRS SAFE-T Suicide Nursing Assessment Continued- - Use follow up question if first answer is negative Establish rapport Limit amount of time patient spends alone Involve significant others in plan Carry out treatments for patient with comorbid disorders ATI Example of follow-up Question - •ATI example: "I'm feeling completely hopeless". "Are you thinking of suicide"? "No I'm just sad." "Are you thinking about hurting yourself"? •If they bring it up, chances are they want to talk •Involve significant others, if they feel hopeless or alone, involving their family may lessen this. Also provides support system Nursing Assessment- Nonverbal behaviors - Sudden brightness in mood Giving away possessions Organizing finances ESTABLISH THERAPEUTIC RAPPORT LEVEL OF LETHALITY Nursing Process-Diagnosis - Use the Risk for suicide, self-care deficit, sleep pattern, altered nutrition, and Anxiety PLANNING-based on risk and protective factors Nursing IMPLEMENTATION FOR SUICIDE - IMPLEMENTATION-nursing interventions 3 different levels •Primary- teaching about suicide!!! You don't have it..only PREVENTION- Teaching, Immunizations Provide support and information/education-prevent •Secondary- screening for depression/suicidal ideation-you go the disease but we don't know yet. SCREENING.. Treatment of actual suicide crisis •Tertiary-you got the disease-but what are we doing to not allow it to get WORSE!! Learn how to recognize..THERAPY, Rehab-teaching a group in a rehab TERTIARY.. No-suicide plan/contract - Contracts you make with someone who has had suicidal ideation and ask them to commit to not do it for 24 hours and then talk again after the 24 hours Suicide precautions- - Milieu management: plastic utensils, no private rooms, jump/hang proof, cord lengths, unbreakable glass, searches, etc.; inventory room, room checks, Survivors may experience - guilt/shame; increased risk for suicidal ideation; difficulty discussing the situation; anniversary date may be particularly hard-recommend support groups! be listeners! Medications in regards to suicide: - SAFEST-antipsychotics SSRI*** vs. TCA vs. MAOI..? Most DANGEROUS- mood stabilizers, lithium-NARROW therapeutic range! ECT for refractory depression-nothing we can do helps with the depression=refractory! A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following statements as an OVERT comment about suicide? Select ALL That apply! - A. My family will be better off when I am dead C. I wish my life was over E. If I kill myself then my problems will go away A nurse is caring for a client who states, I plan to commit suicide. Which of the following assessments should the nurse identify as the PRIORITY? - B. Lethality of the method and availability of means! A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as PRIMARY interventions? Select ALL THAT APPLY! - A. Conducting a suicide risk screening on all new clients. C. Educating high school teens about suicide prevention E. Teaching middle-school educators about warning indicators of suicide. A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care. - D. Ensure that the client swallows the medicine! A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? - D. A no suicide contract decreases the client's risk for suicide. What is a crisis? - defined as a pro-found disruption of a person's normal psychological homeostasis NOT pathological-it is disequilibrium CRISIS=disequilibrium Primary cause of crisis? - actual traumatic event; 2 other conditions are included: 1. individual perceives event as significantly distressing 2. Individual is unable to resolve problem using previously successful coping mechanisms Acute crisis - time limited 4-6 weeks Overwhelming emotional reaction to perception of: stressful situation, developmental, societal, cultural event Remember a person's perception of a crisis - is THEIR reality! Crisis intervention - Short-term therapeutic process that focuses on the rapid resolution of an immediate crisis or emergency using available personnel, family, and/or environmental resources. How can a crisis be viewed? - BOTH: Opportunity for personality growth DANGER- to personality organization Crisis outcome depends on: - perception of the event; coping mechanisms; availability of outside resources; Crisis comorbidities - number of stresses presence of other unresolved losses concurrent psychiatric disorders excessive fatigue/pain quality/quantity of a person's coping skills Risk factors Types of Crisis: Maturational - Maturational/Internal new stage of maturation; former coping styles no longer work-retirement, marriage, birth of a child Types of Crisis: Situational - Situational- arises from external sources; often unanticipated but part of everyday life: loss of job, divorce, physical illness Types of Crisis: Adventitious - Adventitious- not part of everyday life; unanticipated! ex. natural: flood, fire, earthquake crime-rape, assault, incest, murder National- acts of terroism, riots, school shootings Phases of a crisis: - Phase 1: Person confronted by conflict that threatens self-concept responds with increased anxiety. Phase 2: If the usual defensive response fails and if threat persists, then anxiety escalates. Trial-and-error begins. Phase 3: If the trial-and-error attempts fail, then anxiety can escalate to severe and panic levels. -fight or flight Phase 4: If the problem is not solved and new coping skills are ineffective, then anxiety can overwhelm the person and lead to serious illness; assess for suicidal thoughts. Violence against others or self! Goal of Crisis resolution - to return to the person to pre-crisis levels of functioning ability to a HIGHER LEVEL!!! Nursing Process of Crisis: Assessment - to clearly define the problem! : Clients perception of the precipitating event Coping skills Situational support Religious/beliefs Does client's situation warrant hospitalization? Priority concern during initial crisis - safety of patient- assess for potential suicide/homicide then follow up with physical needs Physical needs: red cross-treatment, of any wounds/ life threatening situations, food, shelter, clothing, medicines Therapeutic interventions have 2 goals: - Patient safety- suicide/homicide risk, physical needs, and anxiety reduction Crisis-Intervention Patient Centered Care: - provide rapid assistance for individuals or groups who have an urgent need Initial task-Patient safety- suicide/homicide risk, physical needs, and anxiety reduction Primary- promote mental health to decrease incidence of crisis Secondary- during an acute crisis, promote safety, help develop coping skills Tertiary- AFTER crisis, provide support and recovery When providing intervention with overwhelmed client - be active and direct=offer encouragement and support. Set realistic goals, Plan interventions on CURRENT situation! Action plan - Short-term, no longer than 24-72 hours Focused on the CRISIS Realistic and manageable CRISIS INTERVENTIONS IN RED- from notes - •PRIMARY - Promote mental health to decrease incidence of crisis; Teach prevention before crisis •SECONDARY - During acute crisis; promote safety, help develop coping and problem-solving skills •TERTIARY - After crisis, provide support for those who are recovering-this includes outpatient clinics, rehabilitation centers, and workshops Common problems with nurse/client relationships in crisis: - •Needs to be needed •(patient becomes dependent on nurse) •Sets unrealistic goals •(expectations not met, nurse feels defeated/frustrated) •Difficulty dealing with suicidal patient •(patient unable to share feelings, remains suicidal) •Difficulty terminating relationship with patient after crisis (nurse becomes dependent on patient, practices outside of scope) Outcomes and Goals for Evaluation of Crisis - Coping= client reports DECREASE in stress Client uses available social support DECISION-Making=client identifies relevant information Client weighs alternatives before making decisions Roles and Stress level Performance of crisis - ROLES client performs family role behaviors client performs work role behaviors Stresses: demonstrates DECREASE in BP and pulse demonstrates NO emotional outbursts! A category 5 hurricane destroys homes and businesses in a community. How would this crisis be classified? A.Disequilibrium B.Adventitious C.Maturational D.Situational - B- Adventitious! -unexpected!! Role of the nurse in a crisis - you are asking the client/patient to change their behavior-this is CHALLENGING! What are the diagnostic PET Scans, EEG, MRI- FMRI; Structural..etc. - What are the diagnostic PET Scans, EEG, MRI- FMRI; Structural..etc. - EEG- electrical - a recording of electrical signals from the brain made by hooking up electrodes to the subject's scale Uses- can show the state a person is in asleep, awake, anesthetized, bc the characterized patterns of current differ for each of these states CT-STRUCTURAL - a series of x-ray images is taken of the brain and a computer analysis produces slices providing precise 3d reconstruction- USES- can detect: lesions, abrasions, areas of infarction, aneurysm MRI (structural imaging) - a magnetic field is applied to the brain; nuclei of Hydrogen atoms absorb and emit radio waves that are analyzed by computer; 3D visual of the brain Uses- brain edema, ischemia, infection, neoplasm, trauma fMRI (functional magnetic resonance imaging) - A technique for revealing indirect blood flow and, therefore, brain activity by comparing successive MRI scans. fMRI scans show brain function. USES- brain edema, ischemia, infection, neoplasm, trauma SPECT Function - radio nucleus that emits gamma radiation (photons) measures various aspects of brain functioning and provides images of multiple layers of CNS USES-Circulation of cerebrospinal fluid; similar to PET scan PET - a visual display of brain activity that detects where a radioactive form of glucose goes while the brain performs a given task BRIGHT red spots on the scan 3D images for the CNS USES- oxygen utilization, glucose metabolism blood flow neurotransmitter-receptor interaction What is grief? - inner emotional response to loss Bereavement - Period of loss that includes both grief and mourning Mourning- the outward display of loss The widow had many visitors during her berevement Desolation - state of intense grief, as after the loss of a loved one, Deprivation - loss by force: the hurricane left a trail of bereavement of ordinary people. Client Grief: - The client experiences grief over their own pending death family and caregivers experience grief over their loved ones death or pending death Healthcare providers experience grife secondarily by nature of our relationship with those that have loss or are experience death/grief Types of Loss-ATI pg. 161 - Necessary- part of the circle of life- anticpated can still be intensely felt Actual- any loss of a valued person/item Perceived- any loss defined by a client that is NOT obvious to others Maturational- losses normally expected due to the developmental processing of life-very similar to necessary Situational- unanticipated loss caused by an external event Kubler-Ross stages of grief - 1. Denial- difficulty believing 2. Anger-anger can be directed toward self, others, objects 3. Bargaining- negotiates for more time or different outcomes 4. Depression-mourns-directly confronts feelings related to loss 5. Acceptance-accepts what is happening and plans for the future Bowlbly- 4 stages of grief- identifies behaviors observed in clients who are grieving. These stages are present in clients as YOUNG as 6 months old - 1. Numbness or protest- in denial over reality of the loss and experiences shock 2. Disequilibrium- focuses on the loss and has an intense desire to regain what is lost 3. Disorganization and despair- feels hopelessness which impacts the clients ability to carry out tasks of daily living 4. Reorganization- reaches acceptance of the loss Factors that influence the experience - Developmental Stage Social Support Type/significance of loss Culture/ethnicity Spiritual-religious beliefs and practices Hx of previous loss Socioeconomic factors Types of Grief - Normal, anticipatory, maladaptive, Normal Grief - •Uncomplicated •Emotions: anger, resentment, withdrawal, hopelessness, and guilt-these change to acceptance over time •Client should achieve some acceptance by 6 months after the loss •Somatic manifestations can include chest pain, palpitations, headaches, nausea, changes in sleep patterns or fatigue •Nurse assess for normal vs maladaptive grief response Anticipatory Grief - Implies Letting go prior to the loss Get an opportunity to grieve before the actual loss occurs. It may be helpful because you get the time to process.. Maladpative Grief - Client who experience maladaptive grief commonly experience a loss of self-esteem and a sense of worthlessness not associated with normal grief •Delayed or inhibited grief No demonstration of normal grieving behaviors Can be influenced by cultural norms Client can end up stuck in denial stage for extended period of time Due to clients inability to progress a subsequent minor loss (even years later) can trigger the grief response •Chronic or prolonged grief-Maladaptive Can be hard to identify-we all work through things at varying rates Can remain in denial-remain unable to accept loss Can end up unable to perform adl's Risk factors for Maladaptive Grief - •Being dependent on the deceased •Unexpected death •Young age •Violence or socially unacceptable manner •Inadequate or unhealthy coping skills •Lack of social supports •Pre-existing mental illness-depression or SUD Nursing Interventions for Grief: - Facilitate Mourning: •Allow time •Educate on the stages, mourning, normalcy of grieving and associated emotions. •Use therapeutic communication- "tell me about her" •Avoid barriers to T.C- "she is in a better place now" •Assist with acceptance of the reality of the loss •Support your clients efforts whatever their stage •Encourage client to go to resourceful events-grief sharing etc. •Ask about spiritual supports that you may contact- "do you have a pastor or spiritual leader i can call?" Nursing Interventions for Grief - Psychosocial Use an Interprofessional approach-social work, Chaplin, etc. •Care for client and family •Discuss specific concerns- finances, role changes •Maintain nurse-client relationship-professional relationship •Facilitate communication between client, family, provider •Encourage good coping mechanisms •Assist with facilitating decision making Nursing Interventions of Grief - Protection against abandonment/Isolation: •Decrease fear of dying alone •Make presence known-answer call lights •Keep client informed-routine, procedures, etc. •Facilitate family presence •May need to move client's room nearer nurses station or if at home move it to a more central location Nursing Interventions for Grief - Support the family •Support family presence while still allowing for client rest/needs •If applicable make sure family is informed of treatment plans-within hipaa context •Allow family to participate in as much care as desired and appropriate •Provide for privacy for family and client •Educate family on physical changes to expect as the client moves closer to death 1. A nurse is caring for a client following the loss of her partner due to a terminal illness. Identify the sequence of Engel's five stages of grief that the nurse should expect the client to experience. (Select the stages of grief in order of occurrence. all steps must be used.) A. Developing awareness B. restitution C. shock and disbelief D. recovery E. resolution of the loss - Step 1: C. shock and disbelief is the first stage in Engel's five stages of grief. In this stage the client experiences a sense of numbness and denial over the loss.Step 2: A. Developing awareness is the second stage in Engel's five stages of grief. In this stage the client becomes aware of the reality of the loss resulting in intense feelings of grief. This begins within hours of the loss.Step 3: B. restitution is the third stage in Engel's five stages of grief. In this stage the client carries out cultural/religious rituals, such as a funeral, following the loss.Step 4: E. resolution of the loss is the fourth stage in Engel's five stages of grief. In this stage the client is preoccupied with the loss. This preoccupation gradually decreases over about a 12 month time period.Step 5: D. recovery is the fifth and final stage in Engel's five stages of grief. In this stage the client moves past the preoccupation with the loss and moves forward with life. A charge nurse is reviewing Kübler‑ross: five stages of grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply.) A. Disequilibrium B. Denial C. Bargaining D. Anger E. Depression - A. Disequilibrium is the second stage of Bowlby's four stages of grief. B. CORRECT: the denial stage is when the client has difficulty believing a terminal diagnosis or loss. This is one of Kübler‑ross five stages of grief. C. CORRECT: The bargaining stage is when the client negotiates for more time or a cure. This is one of Kübler‑ross five stages of grief. D. CORRECT: the anger stage is when the client directs anger toward self, others, or objects. This is one of Kübler‑ross five stages of grief. E. CORRECT: the depression stage is when the client mourns and directly confronts feelings related to the loss. This is one of Kübler‑ross five stages of grief. A nurse is working with a client who has recently lost his mother. The nurse recognizes that which of the following factors influence a client's grief and coping ability? (Select all that apply.) A. interpersonal relationships B. Culture C. Birth order D. religious beliefs E. Prior experience with loss - A. CORRECT: the client's interpersonal relationships are factors which influence the client's reaction to grief and ability to cope. B. CORRECT: the client's culture is a factor that influences the client's reaction to grief and ability to cope. C. Birth order is not a factor that influences grief and ability to cope. D. CORRECT: the client's religious beliefs are factors that influence the client's reaction to grief and ability to cope. E. CORRECT: the client's prior experience with loss is a factor that influences the client's reaction to grief and ability to cope. A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply.) A. "I may experience feelings of resentment." B. "I will probably withdraw from others." C. "I can expect to experience changes in sleep." D. "It is possible that I will experience suicidal thoughts." E. "It is expected that I will have a loss of self‑esteem." - A. CORRECT: resentment is an emotion that can be associated with normal grief. B. CORRECT: Withdrawal is an emotion that can be seen with normal grief. C. CORRECT: somatic manifestations such as changes in sleep patterns can be associated with normal grief. D. Suicidal ideations are associated with maladaptive grieving. The client who is experiencing a distorted or exaggerated grief response can direct anger towards himself. The nurse should assess and monitor the client for thoughts of suicide or self‑injury .E. A client who is experiencing a maladaptive grief response commonly experiences a loss of self‑esteem and a sense of worthlessness. these findings are not associated with normal grief A nurse is caring for a client who lost his mother to cancer last month. The client states, "I'd still have my mother if the doctor would have diagnosed her sooner." Which of the following responses should the nurse make? A. "You sound angry. Anger is a normal feeling associated with loss." B. "I think you would feel better if you talked about your feelings with a support group." C. "I understand just how you feel. I felt the same when my mother died." D. "Do other members of your family also feel this way?" - A. CORRECT: this is a therapeutic response for the nurse to make. This response acknowledges the client's emotion and provides education on the normal grief response. B. This response offers advice, which is a nontherapeutic communication technique. C. This response minimizes the client's feelings and takes the focus away from the client, which are nontherapeutic communication techniques. D. This response takes the focus away from the client, which is a nontherapeutic communication technique. What is somatic? - dealing with the body! Somatization - the expression of psychological distress through physical symptoms Types of somatic disorders - somatic symptom disorder illness anxiety disorder conversion disorder factitious disorder Somatic Symptoms include: - cause distress Lead to long-term use of health care systems Often are vague or exaggerated Course of disease complain can be acute but is often chronic Periods of remission and exacerbation are common Clients with somatic symptom disorders typically - Spend a significant amount of time worrying about their physical manifestations-it assumes a central role in the clients life and relationships Often reject a psychological diagnosis as the cause for physical manifestations Often seek care from multiple service providers which increases medical costs Most often are first seen in primary or medical care rather than mental health care setting Risk factors for somatic disorders include: - Those with a 1st degree relative with it Those with decreased levels of serotonin and endorphins Depressive disorder, personality disorder or anxiety disorder Childhood trauma, abuse or neglect Learned helplessness Female gender (especially 16-25 y/o) What are the expected signs of somatic disorders you would see? - Somatic symptoms that disrupt the clients daily life Excessive preoccupation with somatic symptoms Increased level of anxiety about somatic symptoms Symptoms present longer than 6 months-though can vary Remissions and exacerbations of symptoms Probable alcohol or other substance use Over medication with analgesics and antianxiety medications How do you screen for a somatic disorder> - PHQ-15 Used to identify the presence of the 15 most commonly reported somatic symptoms What should the nurse do if you determine the patient has somatic symptoms? - If no cause can be found for client complaints and client is considered stable-vs stable, etc. Then... Accept somatic symptoms as being real to the client Assess for suicidal ideation and thoughts of self-harm Identify the cultural impact on the client's view of health and illness Identify secondary gains from somatic symptoms (attention, distraction from problems/obligations) Report new physical manifestations to provider Limit the amount of time focused on somatic symptoms Make follow-up appointments 4-6 weeks Why are follow-up appointments 4-6 weeks important? - This sets up scheduled appointments and decreases the clients need for unscheduled health care, as well as medical costs associated with laboratory and diagnostic tests if the client seeks treatment from other providers. Treatment for somatic illness - Reattribution treatment Medications-analgesics, antidepressants, anxiolytics Client Education: Encourage client to participate in individual and group therapy Assist with a follow up every 4-6 weeks Reattribution treatment- 4 Stages! - Assists client to see the link between physical manifestations and psychological factors While at the same time promoting a sense of caring and understanding. Four stages Stage 1- feeling understood Stage 2- Broadening the agenda-acknowledge client and give feedback Stage 3- Making the link: ◦Acknowledge the lack of a physical cause for the manifestations while allowing the client to maintain self-esteem Stage 4- Work with provider and client to develop a treatment plan that allows for regular follow-up visits. Illness anxiety disorder - The client misinterprets physical manifestations as evidence of a serious disease process Was previously known as hypochondriasis Leads to obsessive thoughts and fears about illness Clients with illness anxiety disorder will: - Are overly aware of bodily sensations and attribute them to a serious illness. Actual physical manifestations can be minimal or absent-but the client still has a preoccupation about having an undiagnosed, serious illness Research their suspected disease excessively and examine themselves repeatedly May seek numerous medical opinions or avoid seeking health care so as not to increase their anxiety Continue to have anxiety despite negative diagnostic tests and reassurance from the provider Risk factors for illness anxiety disorder: - 1st degree relative with illness anxiety disorder Previous loss or disappointments resulting in feelings of anger, guilt, or hostility Childhood trauma, abuse, or neglect Depressive disorder or anxiety disorder Major life stressor Low self-esteem Findings for illness anxiety disorder: - Excessive anxiety that they have or will get a serious illness-for more than 6 months-though the illness can change during that time Preoccupied with performing health related behaviors-daily breast self-exam due to fear of breast cancer Can be health-seeking type-wants to see provider and have tests done over and over Care-avoidant type-avoids all contact due to increased anxiety Treating illness anxiety disorder - Build rapport and trust with client Encourage independence in self-care Encourage verbalization of feelings Educate on alternative coping mechanisms Educate on stress management techniques Medications may include antidepressants and anxiolytics Patient Education: Encourage participation in individual and group therapy Refer clients to community support groups Educate on medications Collaborate with provider for client to receive brief, frequent office visits What is conversion disorder? - Also known as functional neurological disorder Results when a client exhibits neurologic manifestations in the absence of a neurological diagnosis Clients transmit emotional and psychological stressors into physical manifestation These can cause extreme anxiety and distress to some clients while others are blasé Neurological manifestations cause a significant impairment in multiple aspects of clients life These clients have deficits in voluntary motor and sensory functions Risk factors and expected findings for Conversion Disorder - Risk Factors: 1st degree relative who has conversion disorder Childhood Physical or Sexual Abuse Comorbid Mental Illness Comorbid medical or neurological condition Recent acute stressful event Female Gender Adolescent or young adult Expectant Findings: Manifestations of an alteration in voluntary motor or sensory function Motor: Paralysis, movement/gait disorders, seizure-like movements Sensory: Blindness, loss of speech (aphonia) loss of smell (anosmia), numbness, deafness, tingling or burning sensations Clients who have an extreme desire to become Pregnant can manifest a false pregnancy (pseudocyesis) Factitious Disorder - Previously known as Munchhausen syndrome or when imposed on another Munchausen syndrome by proxy Is the conscious decision by the client to report physical or psychological manifestations. Factitious disorder is a mental disorder in which a person acts as if he or she has a physical or mental illness when, in fact, he or she has consciously created the symptoms. These people are willing to undergo painful or risky tests to get sympathy and special attention. Done in the absence of personal gain by the client other then possible fulfillment of an emotional need for attention. In some cases clients inflict self-injury. factitious disorder by proxy - when the client deliberately causes injury or illness to a vulnerable person-emotional need for attention or relief of responsibility may be a possible motivating factor. Clients with factitious disease often: - Clients-often have average or above average intelligence Is dramatic in the description of illness Uses proper medical terminology Often hesitant for the provider to speak to family members or prior providers Client often reports new manifestations following negative test results Different from malingering. Factitious disorder is a considered a mental illness Malingering is not considered a mental illness-Malingering is motivated and driven by personal gain-disability benefits, evading military service, etc. Risk factors for factitious disorders - History of emotional or physical distress, child abuse, or frequent/chronic childhood illnesses requiring hospitalizations Impaired neurological ability for information processing Dependent personality disorder Borderline personality disorder Nursing care for factitious disorder clients - perform a self-assessment FIRST! Avoid confrontation communicate openly any concerns you may have of factitious disorder with healthcare team A nurse is discussing the risk factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply.) A. Age older than 65 years B. Anxiety disorder C. Female gender D. Coronary artery disease E. Obesity - A. Age 16 to 25 years is a risk factor for somatic symptom disorder. B. CORRECT: Anxiety disorder is a risk factor for somatic symptom disorder. C. CORRECT: Female gender is a risk factor for somatic symptom disorder. D. Coronary artery disease is not a risk factor for somatic symptom disorder. E. Obesity is not a risk factor for somatic symptom disorder. A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder? A. Death of a child 2 months ago B. Recent weight loss of 30 lb C. Retirement 1 year ago D. History of migraine headaches - A. CORRECT: The death of a child 2 months ago is an acute stressor that places the client at risk for conversion disorder. B. A recent weight loss of 30 lb does not place the client at risk for conversion disorder. C. Retiring 1 year ago does not place the client at risk for conversion disorder. D. A history of migraine headaches does not place the client at risk for conversion disorder. A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Obsessive thoughts about disease B. History of childhood abuse C. Avoidance of health care providers D. Depressive disorder E. Narcissistic personality - .A CORRECT: Obsessive thoughts about disease is an expected finding in a client who has illness anxiety disorder. B. CORRECT: A history of childhood abuse is an expected finding in a client who has illness anxiety disorder. C. CORRECT: Avoidance of health care providers is an expected finding in clients who have illness anxiety disorder of the care‐avoidant type. D. CORRECT: A depressive disorder is an expected finding in a client who has illness anxiety disorder. E. Low self‐esteem is an expected finding in a client who has illness anxiety disorder A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? A. Encourage the client to spend time alone in his room. B. Monitor the client for self‐harm once per day. C. Allow the client unlimited time to discuss physical manifestations. D. Discuss alternative coping strategies with the client. - A. The nurse should encourage the client to communicate with others and participate in group therapy and support groups. B. The nurse should continuously monitor the client for risk of self‐harm. C. The nurse should establish a time limit for discussion of physical manifestations. .D. CORRECT: The nurse should discuss alternative coping strategies with the client A nurse is counseling several clients. Which of the following client statements should the nurse identify as expected for factitious disorder imposed on another? A. "I had to pretend I was injured in order to get disability benefits." B. "I know that my abdominal pain is caused by a malignant tumor." C."I needed to make my son sick so that someone else would take care of him for a while." D."I became deaf when I heard that my husband was having an affair with my best friend." - A. INCORRECT: A client's falsification of an illness or injury for the purpose of personal gain is malingering, rather than factitious disorder. B. INCORRECT: Although clients who have factitious disorder often use proper medical terminology, a client's fear of a serious illness is expected with illness anxiety disorder rather than factitious disorder imposed on another. C. CORRECT: A client who has factitious disorder imposed on another often consciously injures another person or causes them to be sick due to a personal need for attention or relief of responsibility .D. Developing a sensory impairment due to an acute stressor is an expected finding of conversion disorder, rather