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PSYCHIATRIC NURSING THERAPEUTIC COMMUNICATION TREATMENT MODALITIES: 1.

After the 4th group meeting, the informal leader makes a statement that she believes she can help the group more than the assigned facilitator and has better credentials. Identify the group dynamics and stage of development. The informal leader is testing, which is a behavior indicative of a new group trying to establish trust. This group is still in the orientation phase of development. On an in-patient psychiatric unit, clients are expected to get up at a certain time, attend breakfast at a certain time, and come for their medication at the correct time. What form of therapy is incorporated into this unit? - Milieu. The wife of a man killed in a motor vehicle accident has just arrived at the emergency room and is told of her husbands death. What nursing actions are appropriate for dealing with this crisis? Take woman to a quiet room, ask her if there are family, friends, or clergy you can call for her. Assess her need for medication and discuss with physician. Stay with her, be firm and directive, and assess previous successful coping strategies. A 10 yr. old is admitted to the childrens unit of the psychiatric facility after stabbing his sister. His behavior is extremely aggressive with the other children on the unit. Using a behavior modification approach with positive reinforcement, design a treatment plan for this child. Assess what activities he enjoys. Set up a token system when he displays non-aggressive behavior, he earns a token good towards participating in the activity selected. He loses a token when he becomes aggressive. The 10 yr. old, his sister, mother, and the mothers live in boyfriend are asked to attend a therapy meeting. Who is the client that will be treated during this session? The entire family. A 66 yr. old woman is admitted to the psychiatric unit with agitated depression. She has not responded to antidepressants in the past. What would be the medical treatment of choice for this client? Electroconvulsive therapy (ECT). Describe the nurses role in preparing clients for electroconvulsive therapy (ECT). Give accurate, non-judgmental information about the treatment. Explore clients concerns. Administer the following as ordered: Atropine sulfate to dry oral secretions, a quick-acting barbiturate to induce anesthesia such as Brevital Sodium, and a muscle relaxant such as Anectine. Check emergency equipment and O2 are available. Describe the nursing interventions used to care for a client during and after electroconvulsive therapy. Maintain patent airway. Check vital signs every 15 minutes until alert. Remain with client following treatment until conscious. Reorient, if confused.

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ANXIETY DISORDERS: 1. 2. 3. State 5 autonomic responses to anxiety. Shortness of breath, heart palpitations, dizziness, diaphoresis, frequent urination. Identify the defense mechanism used by a person who feels guilty about masturbating as a child, and develops a hand-washing compulsion as an adult. Undoing. Identify anxiety-reducing strategies the nurse can teach. Deep breathing techniques, visualization, relaxation techniques, exercise, biofeedback.

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Which levels of anxiety facilitate learning? Mild to moderate. A Vietnam veteran is plagued by nightmares and is found trying to strangle his roommate one night. List, in order of priority, the appropriate nursing interventions. Protect roommate from harm. Stay with client. If the client is agitated, administer anti-anxiety medications as ordered. Arrange for private room. Place client on homicidal precautions at night. A client displays a phobic response to flying. Describe the desensitization process, which would probably be implemented. Talk about planes. Look at pictures of planes. Make plans to accompany client during a visit to airport. Accompany client into a plane. Allow the client to board a plane alone. Accompany the client on a short flight while listening to a relaxation tape. A client is in the middle of an extensive ritual, which focuses on food during lunch. However, the client is scheduled for group therapy, which is about to start. What action should the nurse take? Allow client to complete the ritual. Discuss with the group leader the possibility of allowing the client to enter the group late. Arrange for client to begin lunch either so that the ritual can be completed prior to scheduled activities.

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SOMATOFORM DISORDERS: 1. Describe the difference between primary and secondary gains. Primary gain is a decrease in anxiety, which results from some effort made to deal with stress. Secondary gain is the advantage, other than reduced anxiety, which occurs from the sick role. Explain the difference between somatization and hypochondriasis. Somatization is used to describe a person who has many recurrent complaints with no organic basis as opposed to someone with hypochondriasis who has unrealistic or exaggerated that they interfere with social and occupational functioning. An air traffic controller suddenly suddenly develops blindness. All physical findings are negative. The clients history reveals an increased anxiety about job performance and fear about job security. What type of disorder is this? What purpose is the blindness serving? What nursing interventions are indicated? Conversion reaction. Decreases the anxiety about job. Assist with ADL, encourage expression of anger, teach relaxation techniques, and assist with the identification of anxiety related to job security and performance. A 42 yr. old secretary has visited 7 different doctors in the last year with a complaint of chest pain, heart palpitations, and shortness of breath. She is certain she is having a heart attack in spite of the physicians reassurance that all tests are normal. What type of disorder is this? What nursing actions are indicated? Hypochondriacal disorder. Decrease anxiety, teach relaxation techniques, explore relationship between the symptoms and past experiences with heart disease. Focus interactions away from bodily concerns. Five years ago, a woman was involved in a motor vehicle accident that killed her friend who was a passenger in the car she was driving. Since that time, she has been unable to work because of sever back pain. The pain in unrelieved by prescribed medications. What type of disorder is this? What are the contributing causes? Describe the nursing care. Somatization disorder. Unresolved grief, anxiety. Evaluate pain medication use and/or abuse. Document duration and intensity of pain. Assist client to identify precipitating factors related to request for medication.

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DISSOCIATIVE DISORDERS: 1. Describe the difference between psychogenic amnesia and a psychogenic fugue. Psychogenic amnesia is the sudden inability to recall certain events in ones life. A psychogenic fugue state is characterized by the individual leaving home and being unable to recall their identity or their past.

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What is a multiple personality disorder? Presence of two or more distinct personalities within an individual. The personalities emerge during stress. List 3 possible causes of psychogenic amnesia. Traumatic event such as a threat of death or injury, an intolerable life situation, or a natural disaster. Describe depersonalization disorder. A temporary loss of ones reality, a loss of the ability to feel and express emotions, or a sense of strangeness in the surrounding environment. These individuals express a fear of going crazy.

PERSONALITY DISORDERS: 1. 2. 3. 4. Obsessive-Compulsive Personality = Orderliness, rigid. Passive-Aggressive Personality = Passively resistant Antisocial Personality = Inability to conform to social norms Borderline Personality = Needy, always in a crisis, self-mutilating, unable to sustain relationships, splitting behavior 5. Dependent Personality = Unable to make decisions for self, allows others to assume responsibility for his/her life. 6. Narcissistic Personality = Feelings of self-importance and entitlement. May exploit others to get own needs met. 7. Histrionic Personality = Dramatic, flamboyant, needs to be the center of attention 8. Paranoid Personality = Suspicious, shows, mistrust of others, is watchful and secretive 9. Schizoid Personality = Isolated and introverted, has no close friends 10. Maladaptive Personality = Does not think anything he/she does is wrong, e.g., authorities are out to get them. EATING DISORDERS: 1. Describe the clinical symptoms of anorexia nervosa. weight loss of at least 15% of ideal/original body weight; hair loss; dry skin; irregular heart rate; decreased pulse; decreased blood pressure; Amenorrhea; dehydration; electrolyte imbalance. State 2 psychodynamic differences between anorexia and bulimia. Anorexia nervosa deals with issues of control and a struggle between dependence and independence. Bulimia deals with loss of control (Binge eating) and guilt (purging). An anorectic client has her friend bring her several cookbooks so she can plan a party when she is discharged. What nursing intervention is appropriate in addressing this behavior? Discuss activities that dont involve food, which may take place after discharge. Discuss the cookbooks with the treatment team and, if the treatment plan indicates, take books from client. Anorexia nervosa may be precipitated by what etiologic factors? Mother-daughter conflicts usually focusing on independence/dependence issues; discomfort with maturation; need for control; desire for perfection What might the initial treatment include for a client admitted to the hospital with a diagnosis of bulimia nervosa? Blood work to evaluate electrolyte status; replenish electrolytes and fluids as indicated; carefully monitor for evidence of vomiting.

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AFFECTIVE DISORDERS: 1. Identify physiologic changes, which often occur with depression. Weight change (loss or gain), constipation, fatigue, lack of sexual interest, somatic complaints, and sleep disturbances.

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A client, who has been withdrawn and tearful, comes to breakfast one morning smiling and interacting with her peers. Prior to breakfast, she gave her roommate her favorite necklace. What actions should the nurse take and why? Assess for suicidal ideation, plan and means to carry out plan. Place on precautions as indicated. A sudden change in mood and giving away possessions are two possible signs that a suicide plan has been developed. Name the components of a suicide assessment. Existence of a plan, method, availability of method chosen, lethality of method chosen, identified support system, and history of previous attempts. A client on your unit refuses to go to group therapy. What is the most appropriate nursing interventions? Accompany client to the group; do not give client option. Client needs to be mobilized. A client is standing on a table loudly singing the Star Spangled Banner encircled by sheets, which have been set afire. In order of priority, describe appropriate nursing actions. Remove client and other persons in the vicinity to a safe area and activate hospital fire plan. When area is safe, place client in quiet environment with low stimulation and medicate as indicated.

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SCHIZOPHRENIC/PARANOID DISORDERS: 1. A client is sitting alone, talking quietly. There is no one around. What nursing action should be taken? Quietly approach client and note the behavior. Assess content of the hallucinations, e.g., I noticed you talking. Are you hearing voices? Can you tell me about the voices you are hearing? A client dials 222-2222 and asks for his fiance, Candice Bergen. This is an example of what type of thought disorder? Delusion of grandeur A client has been sitting in the same position for 2 hours. He is mute. What type of schizophrenia is this client experiencing? Describe appropriate nursing interventions for this client? Catatonic: Spend time with client; assist with ADL; be alert to potential for violence toward self/others; be aware of fluid and nutrition needs. A client is very agitated. He believes that the CIA has tapped the phone, is sending messages through the television, and that you are an agent who has been planted by the agency. In order of priority, list the appropriate nursing actions to intervene in this situation. What type of delusion is this client experiencing? Approach client and offer solitary activity to distract. Assess need for medication. Encourage verbalization of feelings and promote outlet for expression. Paranoid disorder with delusions of reference (CIA). The nurse asks the client, What brought you to the hospital? The clients response is, The bus. What type of thinking is this client exhibiting? Concrete.

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SUBSTANCE ABUSE: 1. Three days ago, a client was admitted to the medical unit for a GI bleed. His BP and pulse rate gradually increased, and he developed a low-grade fever. What assessment data should the nurse obtain? What kind of anticipatory planning should the nurse develop? Obtain a drug and alcohol consumption assessment including type, frequency, and time of last dose/drink. Call the physician and report findings. Anticipate withdrawal/delirium tremens. Provide a quiet, safe environment. Place on seizure precautions. Anticipate giving a medication like Librium. What physical signs might indicate that a client is abusing intravenous medications? Needle track marks; cellulitis at puncture site; poor nutritional status.

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What behaviors would indicate to the nurse manager that an employee has a possible substance abuse problem? Change in work performance, withdrawal, increase in absences (especially Monday or Friday), increase in number of times tardy, long breaks, late returning from lunch. A client becomes extremely agitated, abusive, and very suspicious. He is currently undergoing detoxification from alcohol with Librium 25 mg q6h. What nursing actions are indicated? Notify the physician immediately and anticipate an increase in dose or frequency of Librium. Provide a quiet, safe environment. Approach in a quiet, calm manner. Avoid touching client. A client, in the third week of cocaine rehabilitation program, returns from an unsupervised pass. The nurse notices that he is euphoric and is socializing with the other clients more than he has in the past. What nursing actions are indicated? Notify the physician of observed behavior change. Get a urine drug screen as ordered. Confront client with observed behavior change.

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ABUSE: 1. What family dynamics are often seen in child abuse cases? Parent sees child as different from other children. Parent sees child to meet their own needs. Parent seldom touches or responds to child. Parent may be very critical of child. Family history of frequent moves, unstable employment, marital discord, and family violence. One parent answers all the questions. What behavior might the nurse observe in a child who is abused? Child may appear frightened and withdrawn in the presence of parent or adult. Identify nursing interventions for dealing with an abused child. Must report all cases of suspected abuse to appropriate local/state agency. Take color photographs of injuries. Document factual, objective statements of childs physical condition, child-family interactions, and interviews with family. Establish trust, and care for the childs physical problems. These are the PRIMARY and IMMEDIATE needs of these children. Recognize own feelings of disgust and contempt for the parents. Teach basic child development and parenting skills to family. When does battering of women often begin or escalate? During pregnancy. What dynamics prevent a battered spouse from leaving the battering situation? A woman in a battering relationship usually lacks self-confidence and feels trapped. She is often embarrassed to tell friends and family, so she becomes isolated and dependent upon the abuser. Why is elder abuse so under reported? It is difficult for an elderly person to admit abuse for fear of being placed in a nursing home or being abandoned. What types of abuse are seen in the elderly? Abuse can be physical, verbal, psychosocial, exploitive, or physical neglect. Identify nursing interventions for working with a rape survivor? Communicate non-judgmental acceptance. Provide physical care to treat injuries. Give clear, concise explanations of all procedures to be performed. Notify police, encourage victim to prosecute. Collect and label evidence carefully in the presence of a witness. Document factual, objective statements of physical condition; record clients EXACT WORDS in describing the assault. Notify Rape Crisis Team or counselor if available in the community. Allow discussion of feelings about the assault. Advise of potential for venereal disease, HIV, or pregnancy and describe medical care available.

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ORGANIC MENTAL DISEASES: 1. List 5 causes of delirium.

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Infection, alcohol withdrawal, electrolyte imbalance, sleep deprivation, brain injury, i.e., subdural hematomas Describe the nursing care for a client with Alzheimers disease. Provide a safe, consistent environment. (Do not make changes if possible. Change increases anxiety and confusion.) Stick to routines. If client wanders, make sure they have a nametag. Provide assistance as needed with ADL. Make sure bathroom is clearly labeled. Identify 3 or more causes of dementia. Alzheimers disease, multi-infarcts (brain), Huntingtons chorea, multiple sclerosis, Parkinsons disease.

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CHILDHOOD AND ADOLESCENT DISORDERS: 1. A 7 yr. old boy is disruptive in the classroom and is described by his parents as hyperactive. What is the most probable psychiatric disorder? What are the signs and symptoms of this disorder? What drug is usually prescribed for this disorder? Attention deficit disorder (ADD/ADHD). More prevalent in boys, failure to listen or follow instructions. Difficulty playing quietly, disruptive, impulsive behavior, difficulty sitting still, distractibility to external stimuli, excessive talking, shifts from one unfinished task to another, and underachievement in school performance. Ritalin. A 15 yr. old boy is threatening to drop out of school. His parents, both alcoholics, say they cant stop him. He has just been arrested for stealing a car and breaking into a house. What is the most probable disorder? Develop nursing diagnoses and interventions for this disorder. Conduct disorder. A. Potential for violence related todepending on client. B. Disturbance in self-esteem related todepending on client. C. Ineffective family coping related todepending on client. D. Assess verbal/nonverbal cues for escalating behavior to decrease outbursts. Use a non-authoritarian approach. Avoid asking why questions. Initiate a show of force for a child who is out of control. Initiate suicide precautions when assessment indicates risk. Use quiet room when external control is needed. Clarify expressions or jargon if meaning is unclear. Redirect angry feelings to safe alternative such as pillow or punching bag. Implement behavior modification therapy if indicated. Role-play new coping strategies.

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