NUR 2459 MENTAL HEALTH EXAM FULL NEW VERSION EXAM WITH
WELL DETAILED RATIONALES
Explain the two breeches of HIPAA that can occur in psych nursing - ANS- duty to warn
others that a patient is dangerous to others, child abuse or elder abuse that should be
immediately reported to authorities
explain what a voluntary admission is - ANS-The client or client's guardian chooses
admission to a mental facility.
A voluntarily admitted client may request release at any time.
explain what a temporary emergency admission is - ANS-The client is admitted for
emergent mental health care due to the inability to make decisions regarding care. After the
admission is initiated by a healthcare provider, the client is evaluated by another
healthcare provider.
This temporary admission varies by client's needs and state laws.
explain what a involuntary admission is - ANS-The client enters against her/his will for an
indefinite period time.
This is based on the client's need for psychiatric treatment, the risk of harm to self or
others, and the inability to provide self-care.
Physicians(generally) certify the client's condition meets the above criteria. The client can
request a legal review.
explain competent/incompetent client in regards to involuntary admissions - ANS-can be
competent or incompetent.if competent- the client can make decisions regarding refusal
of treatment/meds. if incompetent- by the court, someone will sign the consent for the
client.
,how long is an involuntary admission lasting? - ANS-60 days
least restrictive restraint measures include: - ANS--verbal intervention
-diversion or redirection
-providing a calm, quiet environment
-offering medication (chemical restraint is less restrictive than mechanical restraint)
we should never use restraints or seclusion for: - ANS--punishment
-convenience of staff
-clients who are physically or mentally unstable
if a restraint or seclusion is used, we should do the following: - ANS-have the provider
prescribe it in writing, see the patient face to face, have a order rewritten every 24 hrs,
assess frequently every 30 mins safety, behavior, food, fluids, toiling, vitals, pain, skin
assessment.
how long should restraints be applied to someone 18 years or older? - ANS-4
hrs
how long should restraints be applied to someone 9-17 years old ? - ANS-2 hrs
how long should restraints be applied to someone 8 years or younger? - ANS-1 hr
,explain what a crisis is - ANS-psychological disequilibrium in a person who experiences a
situation that constitutes a problem that cannot be escaped or solved with usual problem
solving techniques.
what does the client need while they are in a crisis that the nurse can help with? - ANS- In
this type situation, guidance and support must be provided to help mobilize resources
needed to resolve the crisis and restore equilibrium.
phase 1 of the crisis development stage is: - ANS-The individual is exposed to a
precipitating stressor.
phase 2 of the crisis development stage is: - ANS-When previous techniques to handle the
stressor are not effective,the individual begins to feel a great deal of discomfort.
phase 3 of the crisis development stage is: - ANS-Resources, both internal and external are
called upon to resolve the problem but fail,and the individual becomes more anxious.
phase 4 of the crisis development stage is: - ANS-Anxiety reaches a panic level. Cognitive
functions are disordered, emotions are labile and behavior may reflect unrealistic thoughts
and actions.
what can we do if there is a emergency and a patient needs restraints or seclusion quickly?
- ANS-In an emergency, the nurse can use seclusion or restraint without first obtaining an
order, but must obtain the written order within a certain amount of time.
*The nurse must be aware of state, federal, and facility policies that govern the use of
seclusion and restraints.
explain the purpose of crisis intervention - ANS-is designed to provide rapid assistance to
the client
, what is the initial intervention when giving interventions to one in a crisis situation? - ANS-
assess the client's potential for suicide or homicide.
what are some of the other interventions we can do for a client needing crisis
interventions? - ANS--Identify the problem and direct intervention for resolution
-Take an active, directive role with the client
-Help the client set realistic goals
-Provide for client safety
-Attend to physical needs first Use reality-oriented approach
-Remain with the individual
-Show unconditional acceptance
-Practice active listening
-Discourage lengthy explanations
-Set firm limits
-Clarify the problem with the individual through a problem-solving process
-Discuss alternative strategies
-Identify external support
what is the role of the nurse when a disaster occurs? - ANS-an event that overwhelms local
resources and threatens the function and safety of the community. Can cause destruction
and leave victims with a sense of anxiety and damaged sense of safety.
The nurse can provide interventions that not only help the patient but help the community
to address needs.
what are protective factors for a client in crisis? - ANS-Resilient temperament Social
competency
WELL DETAILED RATIONALES
Explain the two breeches of HIPAA that can occur in psych nursing - ANS- duty to warn
others that a patient is dangerous to others, child abuse or elder abuse that should be
immediately reported to authorities
explain what a voluntary admission is - ANS-The client or client's guardian chooses
admission to a mental facility.
A voluntarily admitted client may request release at any time.
explain what a temporary emergency admission is - ANS-The client is admitted for
emergent mental health care due to the inability to make decisions regarding care. After the
admission is initiated by a healthcare provider, the client is evaluated by another
healthcare provider.
This temporary admission varies by client's needs and state laws.
explain what a involuntary admission is - ANS-The client enters against her/his will for an
indefinite period time.
This is based on the client's need for psychiatric treatment, the risk of harm to self or
others, and the inability to provide self-care.
Physicians(generally) certify the client's condition meets the above criteria. The client can
request a legal review.
explain competent/incompetent client in regards to involuntary admissions - ANS-can be
competent or incompetent.if competent- the client can make decisions regarding refusal
of treatment/meds. if incompetent- by the court, someone will sign the consent for the
client.
,how long is an involuntary admission lasting? - ANS-60 days
least restrictive restraint measures include: - ANS--verbal intervention
-diversion or redirection
-providing a calm, quiet environment
-offering medication (chemical restraint is less restrictive than mechanical restraint)
we should never use restraints or seclusion for: - ANS--punishment
-convenience of staff
-clients who are physically or mentally unstable
if a restraint or seclusion is used, we should do the following: - ANS-have the provider
prescribe it in writing, see the patient face to face, have a order rewritten every 24 hrs,
assess frequently every 30 mins safety, behavior, food, fluids, toiling, vitals, pain, skin
assessment.
how long should restraints be applied to someone 18 years or older? - ANS-4
hrs
how long should restraints be applied to someone 9-17 years old ? - ANS-2 hrs
how long should restraints be applied to someone 8 years or younger? - ANS-1 hr
,explain what a crisis is - ANS-psychological disequilibrium in a person who experiences a
situation that constitutes a problem that cannot be escaped or solved with usual problem
solving techniques.
what does the client need while they are in a crisis that the nurse can help with? - ANS- In
this type situation, guidance and support must be provided to help mobilize resources
needed to resolve the crisis and restore equilibrium.
phase 1 of the crisis development stage is: - ANS-The individual is exposed to a
precipitating stressor.
phase 2 of the crisis development stage is: - ANS-When previous techniques to handle the
stressor are not effective,the individual begins to feel a great deal of discomfort.
phase 3 of the crisis development stage is: - ANS-Resources, both internal and external are
called upon to resolve the problem but fail,and the individual becomes more anxious.
phase 4 of the crisis development stage is: - ANS-Anxiety reaches a panic level. Cognitive
functions are disordered, emotions are labile and behavior may reflect unrealistic thoughts
and actions.
what can we do if there is a emergency and a patient needs restraints or seclusion quickly?
- ANS-In an emergency, the nurse can use seclusion or restraint without first obtaining an
order, but must obtain the written order within a certain amount of time.
*The nurse must be aware of state, federal, and facility policies that govern the use of
seclusion and restraints.
explain the purpose of crisis intervention - ANS-is designed to provide rapid assistance to
the client
, what is the initial intervention when giving interventions to one in a crisis situation? - ANS-
assess the client's potential for suicide or homicide.
what are some of the other interventions we can do for a client needing crisis
interventions? - ANS--Identify the problem and direct intervention for resolution
-Take an active, directive role with the client
-Help the client set realistic goals
-Provide for client safety
-Attend to physical needs first Use reality-oriented approach
-Remain with the individual
-Show unconditional acceptance
-Practice active listening
-Discourage lengthy explanations
-Set firm limits
-Clarify the problem with the individual through a problem-solving process
-Discuss alternative strategies
-Identify external support
what is the role of the nurse when a disaster occurs? - ANS-an event that overwhelms local
resources and threatens the function and safety of the community. Can cause destruction
and leave victims with a sense of anxiety and damaged sense of safety.
The nurse can provide interventions that not only help the patient but help the community
to address needs.
what are protective factors for a client in crisis? - ANS-Resilient temperament Social
competency
