NURS 6670 FINAL EXAM STUDY GUIDE CHAPTER 1 TO 39. GOLD EXPERT RECOMMENDS

NURS 6670 FINAL EXAM STUDY GUIDE CHAPTER 1 TO 39 Case Study, Mohr: CHAPTER 1, Introduction to Psychiatric–Mental Health Nursing 1. Karen is a 25-year-old white woman who lives alone in an apartment with her dog. Karen has been divorced for 2 years and is taking Prozac prescribed by her psychiatrist for depression. Karen and her boyfriend had been discussing marriage until he told her that he wanted to end their relationship. Karen became even more depressed and could not work for a week. Karen returned to work, refusing to discuss her issues with family, friends, or coworkers. She did, however, make an appointment to see a psychiatric nurse practitioner. Karen told the nurse that she was making some changes in her life. Karen said that she and a girlfriend were joining a gym program for workouts and a social group for young men and women. Karen stated that she realizes that her former boyfriend had not been committed to her, and she anticipates meeting and dating other young men from the adult social group. Karen also said that she thinks that the gym exercise will be beneficial to her mentally and physically. (Learning Objectives: 1, 4) A-How will the psychiatric nurse assess if Karen has made progress toward self-realization?  Karen had suffered from depression which is a form of mental disorder because of divorce and a broken relationship with her boyfriend. This situation according to Hypocritical in 15th century BC, upholds the brain as the organ of consciousness; this occurs when both normal and abnormal behavior arise from the brain.  The psychiatric nurse can assess if Karen has made progress towards self-realization by committing to diagnosing and treating her responses to the problems that caused her psychiatric disorder. In-addition, the nurse can make assessment based on Karen’s psychoanalytical disposition such as: transference, defense mechanism, countertransference, acting out, denial of the reality befallen her and projection. B-Identify strengths that Karen has for progress in personal growth. The strengths Karen has for progress in personal growth include the followings:  Her cognitive behavioral responses showed optimism towards a better life as well as fighting against her depressed state. Hence, her willingness to date younger men.  Karen sought immediate medical attention where she was administered with Prozac to help mitigate her depression state.  Ability to make use of social support, that is, she visited a psychiatric nurse, social group and registered in a gym.  She was realistic about her situation, therefore made herself ready to face the reality before her. C-Karen has been seeking treatment for her depression. Analyze the factors that might contribute to Karen’s reluctance to discuss her depression with others.  Karen’s reluctance to discuss her depression with others hinges on the fact that her depression was a kind called social depression. Social depression is a psychological disorder caused by several factors such as: interpersonal relationship which involves the relationship between a person and the interactions of emotions of everyone expressed directly and discreetly to each other.  Another is a Common interpersonal relationship, this includes: Family, social environment (work place), and interaction among age groups and genders. Because Karen had divorce and broken relationship, she didn’t feel safe in herself discussing her depression with family and friends but to seek a professional whose job is to attend to her depressed case. Hence, her neuroticism was calm and strong willed. Case Study, Mohr: CHAPTER 2, Neuroscience: Biology and Behavior 1. Michael is a 22-year-old college senior whose GPA has declined with this semester’s grades. Michael plans to apply to medical school and thinks that the lower GPA may prevent his acceptance to medical school. For the last 2 weeks, Michael has skipped most classes because he has insomnia and fatigue. Michael is now very depressed and has been thinking of suicide. He took a loaded gun from his father’s gun cabinet and then wrote a suicide note to his family. At the last moment, he telephoned 911 and told them of his suicide plan. The police came, took the gun away, and then took Michael to the city hospital to be admitted for psychiatric treatment. In the admission interview with the psychiatric nurse, Michael said that his pastor thought that only weak-willed people experienced depression and that it was a punishment for personal sins and the sins of one’s ancestors. Michael told the nurse that he must be weak-willed and will never be able to accomplish anything. The psychiatric nurse explained that multiple factors are the cause of depression. The nurse told Michael that one theory holds that an imbalance of neurotransmitters, or chemical messengers of the brain, occurs in depression. Neurotransmitters influence the individual’s emotions, thoughts, and subsequent behavior. Recent research implies that neurobiology, heredity, as well as Psychological and environmental factors may be involved in the development and progression of depression. (Learning Objectives: 5, 6) A-Will Michael think that the psychiatric nurse’s explanation for the cause of depression is more correct than that of his pastor?  No. It is indeed difficult for Michael to accept the doctor’s opinion since before he fell sick, he had information from the pastor on depression on which he solely believed and now he is a living prove. B-Michael asks the nurse why he has to have psychotherapy. He states that he only needs to take a couple of pills to get better. How should the nurse respond to Michael’s question and comment?  The nurse has to explain to Michael why he should consider psychotherapy. Because of the many misconceptions about psychotherapy, you may be reluctant to try it out. Even if you know the realities instead of the myths, you may feel nervous about trying it yourself.  Overcoming that nervousness is worth it. That’s because any time your quality of life isn’t what you want it to be, psychotherapy can help. Taking only pills will not help but increase the effects because most of these medications have side effects which would have been avoided by psychotherapy. C-Develop an assessment question for each of the following possible causes of Michael’s development of depression: Genetic, Environment and Stress.  From the Geriatric Depression Scale: “Do you prefer to stay at home rather than going out and doing new things?” This question asks for a yes or no answer and recognizes that isolation and withdrawal are common signs of depression — especially in the elderly.  From the MADRS: “How is your sleep?” Answers include: Sleeping as usual, slight difficulty, sleep reduced by at least two hours, or getting less than three hours of sleep at night. Greater sleep disturbance signals a greater risk for depression.  From the Beck Depression Inventory: “How is your energy?” Declines in energy level are a common sign of depression the more significant your lack of energy, the higher your depression risk rating. Possible answers to this question include: As much energy as ever, less energy than before, not enough to do much, or not enough to do anything Case Study, Mohr: CHAPTER 3, Conceptual Frameworks and Theories: 1. The student nurse has been assigned a 37-year-old woman admitted to the psychiatric hospital with an anxiety disorder. This morning, the student notices that the client has a tense facial expression and is walking constantly around the group room. The student walked over to the client and used reflective communication by stating, “I see that you have a tense expression and are walking around almost all of the time. Is there something that we could discuss?” The client replied that she has talked on the telephone to her mother who was keeping her children while she was in the hospital. The client said that her mother had told her that she was not a good mother, and then said, “I guess I am a bad mother, but I could never measure up to my mother’s expectations.” The student has learned that negative self-talk can greatly aggravate anxiety and lead to depression. The student decided to use a behavioral intervention with the client and asked the client who is a good artist and why the client liked the artist’s works. The student and the client then made a list of activities that the client liked. The student taught the client to engage in one of these activities when an unpleasant experience evoked negative thoughts. The following day, the student decided that the client needed some cognitive restructuring for her relationship with her mother. The student taught the client that during discussions with her mother, feelings of incompetence might be experienced when the mother made negative comments. The client was instructed that if her mother made negative comments about parenting, she was to immediately tell her mother that she was a good parent to her children and terminate the conversation at the first opportunity. (Learning Objective: 3) A-Will the client be able to learn cognitive restructuring in her relationship with her mother?  Yes, she will learn because by keeping positive thought, her cognitive restructure will develop to the positive. Based on the above facts and behavioral intervention made between client and the student nurse it is possible to establish a good and collaborative relationship with her mother. Besides, client can also be able to gain of cognition to maintain a fruitful relationship with her mother.  Anxiety is a normal reaction to certain situations. A small level of anxiety is normal, but severe anxiety can be a serious problem. Academic anxiety can become more detrimental over time than community-based anxiety. Much evidence supports the notion that social anxiety causes impairment in many domains of life, such as romantic relationships, friendships, work, and physical health. B-How will engaging in activities help the client with her anxiety?  Based on the everyday behavior of client the patient nurse decided a plan that how to solve this problem. Then the student nurse asks client what happened? From this nurse learn that some phone call received from home relative to negative thought. The student has learned that negative self-talk can greatly aggravate anxiety and lead to depression. That is why nurse decided some plan and asked to each client who great artist their favorite items or activities are.  Then, according to that nurse can able to engage the client into her favorite hobbies, when an unpleasant experience evoked negative thought. The next day, the student decided that the client has been gaining some cognitive restructuring for her relationship with her mother.  Finally, the student nurse had advice to the client that in future when her mother made some negative thought or narration regarding parenting she should immediately and confidently tell her mother that she was a good parent to her children and closed this conversation immediately and if possible divert the topic to some extent. So, that mental thought can be diversified to some extent could be able to help to prevent anxiety. Case Study, Mohr: CHAPTER 4, Evidence-Based Practice 1. Jessica, a 17-year-old girl who came with her family from Romania to the United States 10 years ago, is brought to the mental health clinic by her mother. At the admission psychiatric interview, the mother stated that Jessica has been saying for 6 months that aliens have been conducting experiments on her and will soon take her in a spaceship to their planet. Jessica is often awake at night and roams the house with a hammer and sharp knife, searching for aliens. Jessica’s mother says that she fears that some night Jessica will harm a family member whom she believes to be an alien. The mother then said that she did not bring Jessica for psychiatric care earlier because she had heard that much of mental health treatment was quackery and a waste of money. The psychiatric nurse explains to Jessica’s mother that all mental health treatment is based on scientific principles. (Learning Objective: 3) A-How would the nurse best explain that the care Jessica will receive at the psychiatric facility is based on evidence? Give two examples of psychiatric evidence-based care, and explain the scientific evidence that supports your examples.  The nurse will have to explain to Jessica the evidence that psychosis can be treated. She can will give some examples of case like here’s which has been treated and get out of situation. The effort to hold practitioners to evidence-based directives is widespread.  Roughly two-thirds of Americans with private health insurance are enrolled in managed behavioral health care organizations (MBHOs), and these have used efficacy research to limit types and duration of care. In the public sector, the District of Columbia Department of Mental Health (DMH) has proposed a policy regarding evidence-based psychotherapy in that system.  According to the draft policy, all psychotherapy services delivered to community-based adult consumers will conform to a short list of EBPs. Case Study, Mohr: CHAPTER 5, Legal and Ethical Aspects 1. Gerald, a 22-year-old black man, has a diagnosis of schizoaffective disorder. Gerald has been living at home, but this afternoon he had a physical fight with the neighbors and set a fire in their garage to burn their house. His father took him to the local psychiatric hospital and said that he wants an involuntary commitment for Gerald since he will not agree to the hospitalization. The father expressed concern over Gerald’s legal rights. The psychiatric nurse practitioner recommends to the father that he commit Gerald on involuntarily for emergency care for a period of 72 hours since he is clearly a danger to others. The nurse explains that Gerald will be evaluated to determine if he needs involuntary detention for observation and treatment for a longer period of time. The nurse explains that Gerald will be periodically evaluated, and that when it is determined that he is no longer a danger to others or himself, Gerald will be released from the hospital. (Learning Objectives: 4, 5) A-What basic legal rights does Gerald have at the time of this illness?  Right to humane and dignified treatment and must be treated in accordance with a specialized treatment plan, including a discharge plan.  Right to examined by a psychiatrist within 48 hours of being hospitalized and at least every six months thereafter.  Right to receive a physical exam within five days of being hospitalized and at least annually thereafter.  Right to safe and sanitary environment.  Right to appropriate personal clothing.  Right to balance and nutritious diet.  Basic legal rights. B-Why can Gerald not make the decision for himself about being an involuntary emergency commitment to the hospital?  Gerald cannot make the decision for himself about being an involuntary emergency commitment to the hospital because he lacks insight about his illness at the time of admission hence he cannot accept to be admitted. Moreover, he is a threat to himself and others and thus he should be admitted even without his consent. Case Study, Mohr: CHAPTER 6, Culture 1. Mrs. Maria Gonzalez is a Mexican National, age 58, who was brought to a health clinic by her adult son. She is complaining that she has had aches and pains all over her body for 2 days. Mrs. Gonzalez states that her neighbor is a witch who gave her the mal do ojo (evil eye) and cast a spell on her to cause her death. The clinic nurse takes an oral temperature and it is 101º F. The clinic nurse refers Mrs. Gonzales to the clinic physician because she believes that the client has influenza. Mrs. Gonzales is reluctant to see the doctor and states that the doctor cannot prevent her death. (Learning Objective: 8) A-How can the nurse provide culturally competent care to Mrs. Gonzalez and convince her to see the clinic doctor?  People have different health seeking behaviors. culture plays a very significant role in determining someone health seeking behavior. in this case, the nurse must understand Gonzalez culture, be in his shoes then try to convince him to see a doctor. The nurse can achieve this by looking for someone who can communicate better with Gonzalez and slowly convince him that he is suffering from an infection. B-Can Mrs. Gonzalez be convinced that there is no spell cast on her to cause her death? Explain your answer.  Yes, though it will take time. Getting a family member or a relative to talk to Gonzalez and convince him can work. Alternatively, getting someone from Gonzalez culture and explain to him that he had the same problem before and it was discovered that it was an infection and not evil eye will really help. Case Study, Mohr: CHAPTER 7, Spirituality in Psychiatric Care 1. Marta, a 16-year-old high school teenager, has been depressed over a recent break-up with her boyfriend. Marta, accompanied by her mother, is seen in the community mental health clinic. A mild antidepressant is prescribed for Marta with weekly counseling sessions. Marta and her mother ask if it would be beneficial for Marta to attend a 1-week church camp to begin in 2 months. Marta would like to reconnect with her religion and voices a belief that the camp experience will help her. The psychiatric nurse practitioner informs them that research reveals that involvement in religious activities has been helpful in social support and in coping with depression. Marta appears relieved and said that she will register for the church camp. (Learning Objective: 2) A-Why might Marta want to reconnect with her religion, and how will attendance at the church camp benefit Marta?  Marta would want to reconnect with her religion because when she had a boyfriend, she might have gone away from church because of commitment to their relationship thus forgetting about her religion.  The attendance of the church camp will help her forget about the break-up and gain moral values during the camp. B-If Marta attends the church camp, will this pose a problem to counseling sessions?  No. In fact it will be of help to her because she might get some teaching during the camp and the prescription will just be like an addition. Case Study, Mohr: CHAPTER 8 Nursing Values, Attitudes, and Self-Awareness 1. Joe, a 26-year-old Caucasian man, is a client in a state prison system. Joe is admitted to the prison clinic after being involved in a fight in which he sustained a stab wound to the chest that did not penetrate the lungs or major blood vessels. The clinic doctor on duty was an employee of several years at the prison. The doctor showed little compassion for Joe, stating, “He is a convicted criminal, and he is just getting back some of what he deserves.” The new graduate nurse who was being oriented to the clinic thought that the doctor did not exhibit professional behavior toward Joe. The clinic nursing supervisor later explained that the doctor was influenced by situational factors. (Learning Objective: 3) A-What is a situational factor, and how can this influence the behavior of healthcare workers? Provide an example where a situational factor impacted on your behavior while in a healthcare setting.  Situational factor is an external factor that influences one's perception towards something or somebody. like in this case, the doctor perceived the prisoner as a criminal and such perception affected the services he rendered to the prisoner.  During practice, as health practitioners we may perceive certain groups of people such as gays in a different way which may affect the quality of services we give. some practitioners perceive gays as immoral and often give them poor services Case Study, Mohr: CHAPTER 9, the Nursing Process in Psychiatric–Mental Health Care 1. The student nurse is assigned to assist the psychiatric nurse with the admission interview of a client at the psychiatric hospital. The nurse explains to the student that the interview is very important in obtaining a total health history of the client. The nurse should be courteous and respectful of the client to obtain as much information from the client as possible. Assessment information should include the subjective information from the client with the reason for needing treatment, the cause of the present problem(s), and the client’s expectation of the outcome of treatment regimen. The nurse alerts the student to the need to be sensitive to both verbal and nonverbal behavior of the client and to focus on topics that seem important to the client. (Learning Objective: 1) A-How can attention to the client’s nonverbal cues be of value in an interview?  Nonverbal cues contribute significantly to all interpersonal communication. There may be additional diagnostic and therapeutic information to be gained from watching the nonverbal behaviors expressed by a patient.  Nonverbal signals can alert a psychiatrist to important affective states that may otherwise be overlooked or denied. They can also help identify how comfortable a patient is with a given topic of discussion.  In an interview, nonverbal cues include elements like patient's baseline general appearance and behavior, affect, eye contact, and psychomotor functioning. Changes in these parameters from session to session allow the psychiatrist to gather important information about the patient.  Being aware of these cues can offer a psychiatrist valuable information that a patient may be unwilling or unable to put into words. B-Why is the interview the most important aspect of the nursing process?  Interview is a way in which the nurse collects mostly subjective data, as well as objective data so that he plans for the care of the patient Case Study, Mohr: CHAPTER 10, the Interview and Assessment Process 1. The student nurse is accompanying the psychiatric nurse during the nursing interview and assessment of a newly admitted patient. The psychiatric nurse told the student that preparation with subjective and objective data collection is an important part of the process. The nurse explains that assessment has reference to the interviewer’s interpretation and prioritization of all data for the client. The nurse must have self-awareness and self-knowledge to be objective and avoid influencing the responses of the client. Anxiety on the part of the nurse may limit the ability for thorough data collection and interpretation. Anxiety in the nurse may evoke anxiety on the part of the client. The psychiatric nurse stressed that a process recording, or written analysis of the interaction between the client and nurse, is essential for nurses to recognize the effects of their communication style in the assessment process. A review of the client’s history is important, and a private setting for the interview is necessary. The content of the nursing assessment should include the ability and reliability of the client’s response to questions of the interviewer and the skill of the nurse in identification of relevant facts. The nurse should discuss with the client prior health history, any present illness, and the reason for seeking healthcare at this time. Medication history with compliance and allergies of the client require investigation. Substance use by the client, past illnesses, and family history need exploration. (Learning Objective: 2) A-The student nurse asked the clinical psychiatric nurse practitioner to explain what she considered the most essential part of the assessment process. How should the psychiatric nurse respond to the student’s question? Explain your answer.  Mental Status Examination (MSE) is the most important assessment tools a psychiatrist uses to obtain information to make an accurate diagnosis. It is used to test the cognitive function of a patient and it reflects a snapshot of a person's psychological functioning at a given point in time. Case Study, Mohr: CHAPTER 11, Therapeutic Relationships and Communication 1. Two student nurses are preparing for psychiatric–mental health clinical learning experiences. They decided to review the assigned reading and lecture notes from their class on therapeutic communication. After discussion, the students decided that the elements of respect, genuineness, and caring in talking to clients could lead to a trusting relationship. Both students voiced concern over their ability to develop and maintain a professional and not a social relationship. (Learning Objectives: 1, 6) A-How can the student nurses convey the essential elements of a therapeutic relationship in talking to clients?  Therapeutic communication for creating a beneficial outcome for the client, is the hallmark of the nurse-client relationship. A therapeutic relationship is essential to psychiatric/mental health nursing practice. The therapeutic nurse-client relationship is the basis, the very core of all psychiatric nursing treatment approaches.  First, it is necessary to establish an understanding in the client that the nurse students are entering a relationship with the client. The relationship should be essentially safe, confidential, reliable, and consistent with appropriate and clear boundaries. B-How can the student nurses maintain a professional relationship and avoid a social one for clients in psychiatric settings?  The professional relationship clearly established the limits that can allow for safe the connections between student nurses and their clients. For psychiatric setting the service providers i.e., the student nurses have maintained professionalism without compromise the social relationship with the psychiatric or mental clients. It is necessary to maintain professionalism without social relationship with the clients due to some reasons.  Firstly, staying focused on one’s responsibilities to the client and the provision of helpful and to provide appropriate services to the client.  Secondly, keep this relationship for the maintenance of physical and emotional safety concern to the client.  Thirdly, to establish clear agreements with the client regarding the role as a service provider i.e., student nurses.  Fourthly, to ensure that the information is related to the client’s goals.  Finally, the student nurses must use a professional judgment, when interacting with the client regarding psychiatric setting without undergoing any types of social relationship to the clients. Case Study, Mohr: CHAPTER 12, Working with the Multidisciplinary Team 1. A multidisciplinary team meeting is in progress for Cindy, a 21-year-old college student who has recently been diagnosed with schizophrenia. Cindy had been an excellent student on the dean’s list until 2 weeks ago, when she stopped attending classes, stayed in her room with the blinds drawn, and refused to eat because “they have poisoned the food.” The team includes Cindy’s psychiatrist, primary nurse, unit psychologist, social worker, occupational therapist, and a registered dietician. Cindy and her parents attend the team meeting. The team members introduced themselves and stated that they would monitor and coordinate the treatment plan for Cindy, evaluate her progress in treatment, and plan for her discharge. (Learning Objective: 1) A-How will the multidisciplinary team help Cindy and her family in the treatment of her schizophrenia?  Treatment of schizophrenia requires integration of medical, psychological, and psychosocial inputs. The bulk of care occurs in an outpatient setting and probably is best carried out by a multidisciplinary team, including some combination of the psychiatrist, primary nurse, unit psychologist, social worker, occupational therapist, and a registered dietician  The psychiatrist will prescribe Antipsychotic to diminish the positive symptoms of schizophrenia and prevent relapses.  Nutritional counseling should be done by the registered dietician to ensure Cindy’s nutritional status is well maintained  Other remedies include;  Social skills training  Cognitive-behavioral therapy  Cognitive remediation  Social cognition training  The multidisciplinary team plays many important roles, including providing education about the disease, identifying and managing comorbidities, and encouraging positive lifestyle changes for patients and patient families. The presence of the multidisciplinary team ensures easy, systematic and continuous access to medication may improve schizophrenia prognosis.  The team may provide family members with psychoeducation on the symptoms and treatment options for schizophrenia. Furthermore, they may assist family members to build empathy for her. Case Study, Mohr: CHAPTER 13, Individual Therapies and Nursing Interventions 1. Frank, a 16-year-old adolescent, is a high school sophomore. Frank is on the verge of failing his Spanish class. After his grade fell to a “D” grade, Frank procrastinated about doing his Spanish homework, postponing it until last. Then, saying he was tired, Frank played video games until bedtime and rationalized that he would get up early in the morning and do his homework. Frank often sleeps late and does not have time to complete his Spanish homework. Frank is now very distressed over his grade in the Spanish class. His mother brought Frank to the counselor to help with his problem. The counselor suggested a parent-teacher conference to explore any learning difficulties and the possibility of a tutor to help Frank. The counselor also said that perhaps Frank’s mother could supervise the completion of his Spanish homework as the first step. Frank appeared relieved at these suggestions, and said, “That sounds great! Maybe I can improve my Spanish grade and pass the class. Then I won’t be a loser!” (Learning Objective: 2) A-Using a cognitive-behavioral approach, write three goals for Frank’s individual counseling sessions.  The goal of cognitive behavioral therapy is to help a person learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking. Therefore, goals specific to frank include.  To help frank recognize his negative attitude towards Spanish lessons.  To evaluate whether his getting of a D grade in Spanish is warranted,  To change his perspective towards his Spanish lessons. B-Explain why cognitive-behavioral therapy (CBT) can be successful for Frank.  It can be successful because frank does not want to fail his Spanish lessons, is willing to change, and the interventions instituted (mothers/tutor involvement) are appropriate. Case Study, Mohr: CHAPTER 14, Groups and Group Interventions 1. Mary, a student nurse, is studying for an upcoming examination in her psychiatric–mental health nursing class. Mary is reviewing group psychiatric therapy and made some practice test questions on this topic. Help Mary study by answering the following questions. (Learning Objectives: 7, 10) A-Why does group therapy benefit clients with a psychiatric diagnosis?  Benefits of group therapy  Many people feel they are somehow weird or strange because of their problems or the way they feel; it is encouraging to hear that other people have similar difficulties and can grow past them.  The group therapy environment provides a safe confine to experiment with alternative ways of treating yourself and others that may be more satisfying.  When people learn to interact freely with other group members, they tend to recreate the same patterns of interactions that have proved troublesome to them outside of the group. B-How can the psychiatric nurse best facilitate a community support group?  Psychiatric nurse best facilitates a community support group by:  Considers the needs and strengths of the whole person, the family and the community to assess mental health needs, formulate diagnoses, and plan, implement and evaluate nursing care.  Designing and implementing mental health prevention and early intervention initiatives that build social networks, promote and support community capacity building.  Facilitating self-help and mutual aid to strengthen the capacity of people to be self-reliant.  Using many strategies to help strengthen individuals, families and communities. Case Study, Mohr: CHAPTER 15, Families and Family Interventions 1. Wanda, a 17-year-old high school senior, has been rejected by a boy in her chemistry class whom she wanted to date for the senior prom. Wanda became severely depressed and attempted suicide with an overdose of barbiturates. Wanda’s mother found her unconscious and called an emergency ambulance to take her to the emergency department at the local hospital. After Wanda’s recovery, she was in individual counseling, and the psychiatrist referred all family members for counseling. Naomi, her younger sister, refused to go, saying that she did not have a problem and that Wanda was the one who had tried to commit suicide. Her older brother, Matthew, had a similar response and added that Wanda had embarrassed the family. Wanda’s parents stated that they would attend and urged both Naomi and Matthew to attend family counseling. (Learning Objective: 1) A-Wanda’s family must reorganize to survive the disturbance created by the suicide attempt. Describe the family as a system adapting to change.  In this case, Wanda's suicide attempts cause a ripple effect in the family. For example, Mathew says that he felt embarrassed with his sister's actions. Wanda's parents are being supportive to their daughter while Mathew and Naomi are not.  In recent years, the view of the family as a "system" has become an increasingly popular and important theoretical framework for counselors and family therapy professionals. A family system functions because it is a unit, and every family member plays a critical, if not unique, role in the system. As such, it is not possible that one member of the system can change without causing a ripple effect of change throughout the family system Case Study, Mohr: CHAPTER 16, Psychopharmacology 1. The student was reviewing the medication record for a client diagnosed with major depressive disorder with psychotic features. The client has been on medications for the past 12 years, has exhibited many side effects, and experienced multiple medication changes. On this admission, the client has developed abnormal movements of the tongue, a masklike face, shuffling gait, and constipation. The client is taking a selective serotonin reuptake inhibitor (SSRI) and an antipsychotic.(Learning Objective: 6) A-Identify the medication classification that may be responsible for the side effects and explain your choice.  Medication Classification:  Selective Serotonin Reuptake Inhibitors (SSRIS) include;  Select Prototype Medication:  Fluoxetine (Prozac)  Other Medications  Citalopram (Celexa)  Escitalopram (Lexapro) Paroxetine (Paxil)  Sertraline (Zoloft)  Vilazodone (Viibryd)  These medications are Pregnancy Risk Category C. Fluoxetine and paroxetine increase the risk of birth defects. Therefore, other SSRIs are recommended. Late in pregnancy, use of SSRIs increases the risk of withdrawal symptoms or pulmonary hypertension in the newborn.  SSRIs are contraindicated in clients taking MAOIs or tricyclic antidepressants (TCAs).  Use cautiously in clients who have liver and renal dysfunction, cardiac disease, seizure disorders, diabetes, ulcers, and a history of GI bleeding.  SSRIs selectively block reuptake of the monoamine neurotransmitter serotonin in the synaptic space, thereby intensifying the effects of serotonin.  Withdrawal syndrome resulting in headache, nausea, visual disturbances, anxiety, dizziness, and tremors.  CNS stimulation (inability to sleep, agitation, anxiety).  Weight loss early in therapy, may be followed by weight gain with long-term treatment.  Serotonin syndrome may begin 2 to 72 hr after starting treatment and may be lethal.  Hyponatremia (more likely in older adult clients taking diuretics).  Sleepiness, faintness, lightheadedness.  Gastrointestinal bleeding.  Sexual dysfunction.  Bruxism.  Rash. B-Discuss the most important nursing implication related to the side effects the client is experiencing.  Nursing Implications-Assessment & Drug Effects  Observe for and promptly report rash or urticaria and S&S of fever, leukocytosis, arthralgias, carpal tunnel syndrome, edema, respiratory distress, and proteinuria. Drug may have to be discontinued or adjunctive therapy instituted with steroids or antihistamines.  Monitor patients with hepatic or renal impairment carefully for S&S of toxicity (e.g., agitation, restlessness, nausea, vomiting, seizures).  Monitor diabetics for loss of glycemic control; hypoglycemia has occurred during initiation of therapy, and hyperglycemia during drug withdrawal.  Monitor serum sodium level for development of hyponatremia, especially in patients who are taking diuretics or are otherwise hypovolemic.  Observe for dizziness and drowsiness and employ safety measures (up with assistance, side rails, etc.) as indicated.  Monitor for S&S of improved affect. Requires approximately 2–3 wk for therapeutic effects to be felt.  Monitor for and report increased anxiety, nervousness, or insomnia; may need modification of drug dose.  Monitor for seizures in patients with a history of seizures. Use appropriate safety precau