NR548 EXAM 2

NR548 EXAM 2 Psychiatric interview - CORRECT ANSWER-the process by which psychiatric assessment is conducted -primary tasks • building a therapeutic alliance between the PMHNP & client • obtaining a database of psychiatric info about the client • establishing a dx • negotiating a tx plan Therapeutic Alliance - CORRECT ANSWER-a feeling that you should create over the course of the diagnostic interview, a sense of rapport, trust, and warmth -most important goal of the interview process -the cooperative working relationship between the therapist and client • begins during the initial or opening phase of the interview -fundamental component of successful therapy • Without trust, adherence to treatment recommendations may be compromised • interview may not elicit the information needed to formulate an appropriate dx & plan of care without rapport & trust Creating rapport: tips - CORRECT ANSWER--Be Yourself -Be Warm, Courteous, and Emotionally Sensitive -Actively Defuse the Strangeness of the Clinical Situation -Give Your Patient the Opening Word -Gain Your Patient's Trust by Projecting Competence How to approach threatening topics (sensitive/embarrassing material) - CORRECT ANSWER--Normalization -Symptom Expectation -Symptom Exaggeration -Reduction of Guilt -Use Familiar Language When Asking about Behaviors Normalization - CORRECT ANSWER-Introducing Q with some type of normalizing statement -two principal ways to do this: 1. start the question by implying that the behavior is a normal or understandable response to a mood or situation • ex: Sometimes when people are very depressed, they think of hurting themselves. Has this been true for you? 2. Begin by describing another patient (or patients) who has engaged in the behavior, showing your patient that she is not alone • ex: I've talked to several patients who've said that their depression causes them to have strange experiences, like hearing voices or thinking that strangers are laughing at them. Has that been happening to you? Symptom Expectation - CORRECT ANSWER-communicate that a behavior is in some way normal or expected -Phrase your Q's to imply that you already assume the patient has engaged in some behavior and that you will not be offended by a positive response -high index of suspicion of some self-destructive activity -Ex: patient is profoundly depressed and has expressed feelings of hopelessness. You suspect suicidality, but you sense that the patient may be too ashamed to admit it. Rather than gingerly asking "Have you had any thoughts that you'd be better off dead?" you might decide to use symptom expectation. "What kinds of ways to hurt yourself have you thought about?" *reserve this technique for situations in which it seems appropriate Symptom Exaggeration - CORRECT ANSWER-suggesting a frequency of a problematic behavior that is higher than your expectation, so that the patient feels that their actual, lower frequency of the behavior will not be perceived by you as being "bad." -helpful in clarifying the severity of symptoms *reserve this technique for situations in which it seems appropriate Reduction of guilt - CORRECT ANSWER-seeks to directly reduce a patient's guilt about a specific behavior in order to discover what they have been doing -useful in obtaining a hx of domestic violence & other antisocial behavior Domestic Violence -"Have you ever been in situations where fights occurred and you were affected?" • If patient answers "yes," you can flesh out whether role was being a witness, victim, or perpetrator According to Peplau's Theory of Interpersonal Relations, establishing early rapport allows the role of the nurse to evolve from stranger to: - CORRECT ANSWER-resource person, teacher, leader, surrogate, technical expert, and counselor Establishing the Relationship - CORRECT ANSWER--Trust is essential for a therapeutic alliance -First impressions are important -PMHNP should take time to make introductions and ensure the client is comfortable -Ask general questions to arrive at an empathic understanding of how the client feels -Listen carefully and communicate an appreciation for the client's concerns -Building a trusting relationship based on respect, kindness, and acceptance will break down barriers and allow for client needs to be the center of the plan of care -Being present and openly engaged will enhance the communication experience three phases of the psychiatric interview - CORRECT ANSWER-1. Opening phase 2. Body of the Interview 3. Closing the Interview Opening phase - CORRECT ANSWER--first 5-10 minutes -establish rapport & therapeutic alliance -often most important phase • establishes the foundation -begins with PMHNP asking "what brought you in to see me today?" Body of the Interview - CORRECT ANSWER--30-40 minutes -Chief Complaint Established • additional Q's asked to elicit info r/t the complaint -ask about HPI, family hx, social/developmental hx, medical hx, psychiatric ROS -basis for dx and tx formulation Closing the Interview - CORRECT ANSWER--5-10 minutes, final phase Should include 2 components: discussion of your assessment using patient education techniques & negotiated agreement about tx or f/u plans -wrap-up statement and inquiry about missing info that may be of value -Patient education regarding working dx & recommended plan of tx • education about meds if recommended -Homework may be assigned • especially in CBT -Return visit agreed upon Four Tasks of the Diagnostic Interview - CORRECT ANSWER-1. Build a therapeutic alliance 2. Obtain the psychiatric database 3. Interview for diagnosis 4. Negotiate a tx plan with your patient Obtain the Psychiatric Database - CORRECT ANSWER-Also known as the psychiatric history -includes historical information relevant to the current clinical presentation • history of present illness, psychiatric history, medical history, family psychiatric history, and aspects of the social and developmental history Tricks for Improving Patient Recall - CORRECT ANSWER--Anchor Questions to Memorable Events • major transitions (graduations and birthdays), holidays, accidents or illnesses, major purchases (a house or a car), seasonal events ("hurricane Katrina"), or public events (such as 9/11 or President Obama's election) -Tag Questions with Specific Examples • similar to posing multiple-choice questions, specifically for areas in which your patient is having trouble with recall -Define Technical Terms • patient's vague recall may be a lack of understanding of terms How to Change Topics with Style - CORRECT ANSWER--Smooth Transition • cue off something the patient just said to introduce a new topic -Referred Transition • refer to something the patient said earlier in the interview to move to a new topic -Introduced Transition • introduce the next topic or series of topics before actually launching into it Techniques for the Reluctant Patient - CORRECT ANSWER--Open-Ended Questions and Commands • increase the flow of information -Continuation Techniques, keep the flow coming: • Go on. • Uh huh. • Continue with what you were saying about... • Really? • Wow -Neutral Ground • changing the subject to something nonpsychiatric, with the intention of sidling back into your territory once you've gained the patient's trust. -Second Interview • When all else fails *must feel comfortable that the patient is not at imminent risk of suicide or other dangerous behaviors Techniques for the Overly Talkative Patient - CORRECT ANSWER--Closed-ended and multiple-choice questions -Redirecting questions to another topic • The Art of the Gentle Interruption • redirecting statement • empathic interruption, you add an empathic statement to soften the blow • educating interruption incorporates a structuring statement in which you educate the patient about the sorts of questions you have yet to ask and the time constraints you're both working under -Structuring statements regarding information required and/or clinical procedures -brisk, highly controlling style therapeutic or nontherapeutic communication & communication technique it represents: Why are you so anxious? - CORRECT ANSWER-Nontherapeutic communication technique: Asking for Explanations therapeutic or nontherapeutic communication & communication technique it represents: Why don't you and John get married? - CORRECT ANSWER-Nontherapeutic communication technique: Asking Personal Questions therapeutic or nontherapeutic communication & communication technique it represents: What would you like to talk about today? - CORRECT ANSWER-Therapeutic communication technique: Broad Openings therapeutic or nontherapeutic communication & communication technique it represents: What do you think you should do about it? - CORRECT ANSWER-Therapeutic communication technique: Reflecting therapeutic or nontherapeutic communication: Older adults are always confused. - CORRECT ANSWER-Nontherapeutic therapeutic or nontherapeutic communication & communication technique it represents: I don't see anyone else in the room. - CORRECT ANSWER-Therapeutic communication technique: Presenting Reality therapeutic or nontherapeutic communication & communication technique it represents: If I was you, I'd take a break from school. - CORRECT ANSWER-Nontherapeutic communication technique: Giving Advice therapeutic or nontherapeutic communication & communication technique it represents: I'm so sorry about your mastectomy; it must be terrible to lose a breast. - CORRECT ANSWER-Therapeutic communication technique: Sympathy therapeutic or nontherapeutic communication & communication technique it represents: Today we have talked about a plan for you to manage feelings of anger. - CORRECT ANSWER-Therapeutic communication technique: Summarizing therapeutic or nontherapeutic communication & communication technique it represents: You shouldn't even think about assisted suicide; it's not right. - CORRECT ANSWERNontherapeutic communication technique: Disapproval