NR 326 Exam 1

NR 326 Exam 1 What is needed for involuntary admission to a psychiatric inpatient unit? 1. Petition needed. 2. The RN will assess the pt for lethality; assess the inability of client to care for self; assess judgment and thought. 3. At first, clinical certification is needed from a clinical eval done by physician or psychologist. 4. A second clinical cert from a clinical eval by a psychiatrist is needed within 24 hrs after initial cert. Examples of non-therapeutic communication techniques -Offering false reassurance -Giving opinions -Asking "why" questions -Asking too many questions without first establishing rapport or allowing pt to verbalize judgement; interrupting -Focusing on the person's character weaknesses vs. strengths, opportunities for improvement, and behavioral motivation Therapeutic communication techniques -Active listening skills -Redirecting patient to healthy ways of coping and interacting -Providing dignity and respect -Observing and relating the person's strengths to 1:1 and group interactions -Identify and focus on the person's strengths, motivations What are active listening techniques? Clarifying, reflecting, summarizing, emotional labeling, silence, offering self, exploring (possible options and previous coping that has worked) Nursing interventions for a pt exhibiting threatening behavior and violence -Have staff nearby -One person talks to the pt with a calm, non-threatening voice -De-escalation skills -Redirect pt (let's walk, I have time to listen, let's solve this together) What are your priority actions during a situational crisis? -Determine if the client has psychotic thinking (Clients experiencing a situational crisis are at greatest risk for injury to themselves or others) What do you do for a pt exhibiting panic level anxiety? Remain with the pt for awhile (the nurse should not leave a pt who has severe anxiety alone. The nurse's priority is to use the least restrictive intervention, such as staying with the pt and calmly encouraging them to express their feelings) Repression A patient who just got assaulted and can't remember circumstances of the event Denial A nurse manager expects the nurse abusing alcohol to demonstrate the defense mechanism of denial. Denial is the most common defense mechanism, especially used by people dealing with the problems and missed responsibilities associated with substance abuse behavior. Rationalization A pt states they have to drink a bottle of alcohol daily to relax due to a veery high stress job. Rationalization is when a person creates reasonable and acceptable explanations for unacceptable behavior. Somatization A pt indicates they keep feelings nauseated and sick to their stomach, chest pains, and a headache, every time they are asked to go to art therapy and be with other people (Somatization is developing physical symptoms in place of anxiety) Reaction formation A pt dislikes his roommate and speaks ill of him to everyone who will listen; but, when the roommate returns, he offers the roommate a cookie and a snack (Reaction formation is overcompensating or demonstrating the opposite behavior of what the person feels) Displacement A pt kicks a chair after emotionally yelling and screaming at a psychiatrist for prescribing a med (displacement is shifting feelings r/t an object, person, or situation to another less threatening object, person, or situation) Regression A pt is describing what he does to cope with things not working out the way he expects (Regression is reverting to an earlier, more primitive and child-like pattern of behavior) What does a crisis situation contain? A crisis situation contains the potential for psychological growth or deterioration What may be prescribed for a pt experiencing anxiety? Paroxetine and Lorazepam (benzo) Nursing interventions for a pt experiencing a crisis r/t anxiety -Establish rapport with the pt -Identify the cause of the anxiety -Validate the client's feelings What are usual findings for panic level anxiety? Increased pulse rate, respirations, and blood pressure. *Elevated temp and decreased CO2 are not usual findings What does a nurse do if a pt verbalizes that they are better off dead than alive? The nurse needs to do a lethality assessment. "Do you have a plan to harm yourself?" (When a pt expresses suicidal intent, it is the nurse's priority to determine the seriousness of the content and the lethality of the means. What is the nurse's priority if the pt has hallucinations, is responding to internal stimuli, and is delusional and/or paranoid? The nurse's priority is to place the pt on suicide precautions, monitoring within line of sight, or 1:1 supervision/monitoring *Assess TMAPI: thoughts, means, ability, plan, and intent Nursing interventions for pts who have a history of panic level anxiety Provide continuity of care by assigning the same staff (consistent interactions are important in any care setting, but especially in mental health. This will help pts establish trust and a sense of seecurity) What should the nurse do if a pt gets angry and throws a chair? The first action the nurse should take using the safety/risk reduction priority-setting framework is to attempt to de-escalate the pt's anger and aggression by talking the pt down in a calm, nonthreatening manner. Give examples of patient rights •Dignity and Respect •Freedom from Abuse/Neglect •Confidentiality •Access to Record •Environmental Rights •Civil Rights •Treatment and Support •Person-Centered Planning Voluntarily denying unpleasant thoughts and feelings •Adaptive use: A student stops thinking about an argument he had earlier with a family member so he can focus on the test •Maladaptive use: A person who has lost his job states he will worry about paying his bills next month. Suppression •Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness •Adaptive use: A Clinical Director preparing to give a speech unconsciously forgets the time when she was in high school and kids laughed at her while on stage •Maladaptive use: A nursing student who has a fear of dentists consciously forgets to go to his dental appointments Repression Sudden use of childlike or primitive behaviors that don't correlate with the person's current developmental level. •Adaptive use: A school age child temporarily wets the bed when she learns that her pet died •Maladaptive use: A nurse manager who has a nasty disagreement with a staff nurse starts throwing things around in her office Regression Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation. •Adaptive use: A high school football player angrily punches a punching bag after losing a game •Maladaptive use: A dad who is angry about his wife divorcing him destroys his child's favorite toy Displacement Performing an act to make up for prior behavior. •Adaptive use: A adolescent does his chores daily without being prompted after arguing with his parent •Maladaptive use: A man brings his wife flowers and gifts every time he visits in the hospital following repeated incidences of physical and mental abuse Undoing Dealing with impulses and unfavorable feelings and substituting acceptable forms of expression. •Adaptive use: A person feeling anger and hostility to ward his supervisor at work sublimates these feelings by working out for a long time at the gym during his lunch period •Maladaptive use: n/a Sublimation Overcompensating or demonstrating the opposite behavior of what is felt. •Adaptive use: A Nurse who is currently trying to stop smoking repeatedly talks daily to adolescents on the unit about dangers of nicotine •Maladaptive use: A neighbor you know who greatly dislikes the neighbor who is unpopular in your neighborhood continually tells others what a great neighbor he is Reaction formation Creating reasonable and acceptable explanations for unacceptable behavior. •Adaptive use: An RN says, "that nurse must have had a bad day at home" •Maladaptive use: A young adult tells the nurse he had to drive home for a party after drinking alcohol because he had to feed his dog Rationalization Pretending the truth is not reality to manage the anxiety felt of acknowledging what is real. •Adaptive use: A relative initially saying, "No, that can't be true," when they are told they have cancer •Maladaptive use: A parent informed his son was killed in combat tells everyone one month later that he is coming home for the holidays Denial Emphasizing strengths to make up for weaknesses. •Adaptive use: An adolescent physically unable to play contact sports excels in academics •Maladaptive use: A person introverted and overwhelmed around people works at computer skills to avoid socialization Compensation Conscious or unconscious assumption of the characteristics of another individual or group. •Adaptive use: A little girl with chronic illness pretends to be a nurse for her dolls •Maladaptive use: A child daily observing his dad abuse his mom becomes a bully at school Identification Separating emotions and logical facts when analyzing or coping with a situation or event. •Adaptive use: A law enforcement officer blocks out the emotional aspect of a crime so he can objectively focus on the investigation •Maladaptive use: A person who learns he has a terminal illness focuses on creating a will and organizing financial affairs, rather than acknowledging his grief intellectualization Responding to stress by unconsciously developing physical manifestation not caused by a physical illness. •Adaptive use: n/a •Maladaptive use: A person experiences deafness after a partner tells him she wants a divorce Conversion Demonstrating an inability to reconcile negative and positive attributes of self or others. •Adaptive use: n/a •Maladaptive use: A client tells a nurse that the nurse is the only one who cares about her; but, the following day, the same client refuses to talk to the nurse What is altruism and sublimation? Altruism and sublimation are healthy defense mechanism. Altruism is dealing with anxiety by reaching out to others. Sublimation is dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression What are the 3 defense mechanisms that do not have an adaptive use? •Conversion- responding to stress by unconsciously developing physical manifestation not caused by a physical illness. •Splitting- Demonstrating an inability to reconcile negative and positive attributes of self or others. •Projection- Attributing one's thoughts and feelings onto another who does not have them. A client hates her mother because of childhood neglect. The nurse determines which client statement represents the use of the defense mechanism of reaction formation? a)"I don't like to talk about my relationship with my mother." b)"My mother hates me." c)"I have a very wonderful mother whom I love very much." d)"My mom always loved my sister more than she loved me." C. The client hides her negative unacceptable feelings by the exaggerated expression of positive feelings. This is an example of reaction formation. Tim, RN, is caring for a patient exhibiting moderate anxiety. Which actions should the RN take when giving important information to this patient? A.Gather information from the patient using closed-ended statement. B.Demonstrate a calm manner while using simple, clear directions. C.Ignore the patient's anxiety to not embarrass the patient. D.Discuss prior use of coping mechanisms with the patient. E.Reassure the patient that everything will be okay. B and D. Discussing prior use of coping assists patient in identifying what worked in the past to use if again currently to cope with current stressors. Calm presence assists patients to feel safe and secure, promoting relaxation. Those experiencing moderate level anxiety benefit from the direction of others. A widow of 23 years has not removed any of her husband's possessions, including the slippers beside their bed. Which pathological grief response is being exhibited by this client? a)Prolonged grief response b)Delayed grief response c)Distorted grief response d)Inhibited grief response A. The prolonged grief response is characterized by intense preoccupation with memories of the lost person years after the loss has occurred. Eric, RN, states to the charge nurse: "Please don't assign me to that patient again today. I can't stand him making excuses about using cocaine just because his brother died...My brother died and I'm not using..." This statement is an example of (select all that apply): A.A crisis situation B.Non-professional action by the RN C.An ethical dilemma D.Veracity E.Nonmaleficence C, D, E. Ethical dilemmas occur when moral appeals can be made for taking either of two opposing courses of action. •Taking no action is considered an action taken. •Veracity is a principle that refers to one's duty to always be truthful •Nonmaleficence is abstaining from negative acts toward another, includes acting carefully to avoid harm. Sylvia needs to meet with a patient who is demonstrating escalating hostility. Which would be the most appropriate location for the nurse to meet with this patient to de-escalate emotions? (Select all that apply): a)The patient's room with the door shut b)A quiet corner of the day room c)The nursing station, while administering scheduled medications d)The unit's treatment room e)Offering a choice of walking the hallway B and E. A quiet corner of the day room provides for some privacy in a neutral space while not limiting access to help if safety issues arise. •Offering a choice of walking the hallway and talking to the patient may de-escalate a patient's emotions by helping to release tension and offering presence of active listening by the nurse. •The nursing station is too distracting with other patients obtaining their scheduled medications •The unit's treatment room often has too many equipment which can be used as weapons 3.A nurse gave a client 5 mg of haloperidol (Haldol) for agitation. The client's chart was clearly stamped "Allergic HALDOL." The client suffered anaphylactic shock and died. How would the nurse's actions be labeled? A. Intentional tort B. Negligence C. Battery D. Assault B. The nursing action was an unreasonable and careless act. The nurse was negligent and could be held liable for the client's death. Tony refuses his evening dose of Haloperidol (Haldol), then becomes extremely agitated in the dayroom while other clients are watching television. He begins cursing and throwing furniture. Nurse Oliver first action is to: A. Check the client's medical record for an order for an as-needed I.M. dose of medication for agitation. B. Place the client in full leather restraints. C. Call the attending physician and report the behavior. D. Remove all other clients from the dayroom. D. The nurse's first priority is to consider the safety of the clients in the therapeutic setting. Options A, B, and C: The other actions are appropriate responses after ensuring the safety of other clients. Mr. Marquez reports of losing his job, not being able to sleep at night, and feeling upset with his wife. Nurse John responds to the client, "You may want to talk about your employment situation in group today." The Nurse is using which therapeutic technique? A. Observations B. Restating C. Exploring D. Focusing D. The nurse is using focusing by suggesting that the client discuss a specific issue. Options A, B, and C: The nurse didn't restate the question, make observation, or ask further question (exploring/probing). An RN is working in a mental health unit and his patient experiences a crisis after ending a phone call with their partner who wants to end the relationship. Which of the following is a correct assumption regarding the concept of crisis? A. Crisis occurs only occurs in individuals with psychopathology. B. The stressful event that precipitates crisis is seldom identifiable. C. A crisis situation contains the potential for psychological growth or deterioration. D. Crises are chronic situations that recur many times during an individual's life. C. A crisis situation contains the potential for psychological growth or deterioration. A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (select all that apply) A. Lithium carbonate B. Paroxetine C. Risperidone D. Haloperidol E. Lorazepam F. Hydroxyzine B. Paroxetine E. Lorazepam A 32 year old female presents in the emergency room with her sister who claims that the 32 year old is hearing more voices the last 2 days and is threatening to poison the family. The nurse's assessment reveals the 32 year old client disheveled, responding internally to voices, and laughing at the nurse inappropriately. The nurse identifies the client has not been taking her prescribed medications, not eating, not sleeping, not showering, or changing clothes. The following factors are necessary for involuntary hospitalization admission,