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Final Exam NSG 335
Final Exam
| Question | Answer |
|---|---|
| etiologic factors associated with anger, aggression, and violence | genetic factors- biologically predisposed neurobiological factors- brain tumors, dementia, TBI, temporal lobe epilepsy neurotransmitters- serotonin, GABA, dopamine |
| Assessment of angry, aggressive, or violent patients | understand the predictors of violence, ask about coping skill, doing a good self assessment |
| interventions for angry, aggressive, or violent patients | develop rapport, remain controlled and calm, allow physical space, speak in calm fashion with short sentences, be aware of environment |
| primary prevention of abuse | focused on prevention of violence by education on topics such as stress reduction, increased use of positive coping skills and increasing social support |
| secondary prevention of abuse | early intervention in abusive situations to minimize long-term effects, screening and support groups |
| tertiary prevention of abuse | in mental health setting in which support is given to the victims as they recover and begin to achieve their optimal level of safety, health and wellbeing |
| importance of self-assessment of the nurse who is caring for a client experiencing aggression, abuse or sexual assault | strong negative feelings towards abuse may cloud judgement and interfere with assessment and intervention personal history of abuse may cause nurse to identify too closely with victims talking to someone may help with the feelings and prevent clouding |
| acts of commission | deliberate and intentional acts |
| acts of omission | neglect or lack of protection |
| elder abuse | fear of being alone with caregiver, has signs of malnutrition, has bedsores or skin lesions, is in need or medical or dental care, reports abuse or neglect |
| intimate partner violence | includes physical violence, rape, stalking and/or psychological aggression by a current or former intimate partner |
| rape trauma | physical and psychological condition after forced participation in sexual relations or intercourse |
| rape-trauma response | maladaptive response that occurs to victim after rape associated with disorganizing lifestyle and long-term process or reorganization of lifestyle |
| acute phase of rape-trauma syndrome | Occurs immediately after the assault Expressed: survivor is openly emotional Controlled: survivor appears to be without emotion and acts as if “nothing happened” Shocked Disbelief: survivor reacts with strong sense of disorientation |
| outward-adjustment phase | Individual resumes what appears to be “normal life” but is suffering internally Minimization: pretends everything is fine Dramatization: cannot stop talking about assault Suppression: refuses to discuss Clinical manifestations appear |
| resolution phase | Assault is no longer central focus of victim’s life Victim may recognize they will never forget assault, but pain and negative outcomes lessen over time Victim will often begin to accept rape as part of their life and choose to move on |
| clinical manifestations of rape-trauma syndrome | Shame, guilt, helplessness, powerlessness, dependence Low self-esteem, depression Anxiety, fear Disturbed sleep, nightmares Dissociation, disorganization Shock, confusion, paranoia |
| components of the MSE | appearance, behavior, mood, affect, speech, thought process, thought content, orientation, memory/intelligence, judgement, insight, motivation for treatment |
| preorientation | begins with chart review and speaking with other team members, recognize own feelings and beliefs regarding pt Remember to keep in mind the space you’ll be interviewing in, be at same height, avoid a desk barrier, seated closer to door |
| orientation | Pt begins to express his or her thoughts and feelings and begins to identify problems and discuss realistic goals Tasks include: establishing rapport, specifying a contract, and explaining confidentiality Always initiate with an open ended question |
| working | Gather further data, identify problem-solving skills and self-esteem, provide psychoeducation, promote symptom management, evaluate progress |
| termination | Summarize goals and objectives Discuss ways to incorporate new coping skills Validate the experience Promote closure |
| open-ended questions | encourage patients to share information about experiences, perceptions or responses to a situation |
| focused questions | used to elicit specific and needed answers |
| active listening | fully concentrating, understanding, responding and remembering |
| restating | involves repeating the same words the patient has just spoken |
| reflecting | may take form of a question or simple statement that conveys the nurse’s observation of the patient, makes patient aware of inner feelings |
| cognitive behavioral therapy | evidence-based therapy that targets rapid responses based on irrational automatic thoughts by identifying, reality-testing, and correcting distorted conceptualizations Challenges negative thought patterns Active, directive, time-limited |
| milieu therapy | involves secure environment including people, settings, structure, and emotional climate to support recovery Takes naturally occurring events in environment and uses them as learning opportunities Consistent routine and structure maintained Safety! |
| ACT | work intensively with patients in their homes or in agencies, hospitals and clinics. takes into account people need support and resources after 5 pm- teams on call 24 hrs a day |
| coping skills for management of stress and anxiety | get correct amount of sleep, exercise on regular basis, reduce caffeine intake, include music in routine, get a pet, get a massage, progressive relaxation! |
| ineffective coping skills and defense mechanisms | aggression, rage, substance abuse, gambling, sex addictions, hoarding denial, dissociation, projection, splitting, suppression |
| interventions for a psychiatric-crisis | ask patient to express feelings, clarify reality, discourage in-depth take of hallucinations, avoid arguing or attempting to reason, use distraction techniques |
| interventions for severe to panic levels of anxiety | maintain a calm manner, always remain with the person, minimize environmental stimuli, use clear and simple statements and repetition, attend to safety needs first, reinforce reality if distortions occur |
| beneficence | duty to act to benefit good of others |
| autonomy | respecting right of every individual to make their own decisions |
| jjustice | duty to distribute care and resources equally |
| fidelity | maintaining loyalty and commitment to patient while doing no wrong |
| veracity | duty to communicate truth |
| voluntary psych hospitalization | patient signs themselves in for care and must have official evaluation before leaving |
| involuntary psych hospitalization | patient deemed threat to themselves, to others, or considered gravely disabled |
| positive symptoms | presence of something that should NOT be present |
| negative symptoms | absence of something that SHOULD be present |
| appropriate milieu for patients with psychotic disorders | audio and visual monitoring of patient rooms and milieu monitor tv selections decrease stimuli provide outlet for excessive energy |
| symptoms of MDD | flat or blunted affect, decreased ability to problem-solve, indecisiveness, negatively-focused thoughts, anhedonia, guilt, helpesslessness or anger, sleep or appetite alterations |
| nurse role in ECT | education, pre and post procedure MMSE, presence during procedure, no BENZOS before treatment |
| milieu management for someone with suicidal ideations | Determine if suicidal ideations are passive or active Assess safety of milieu and limit use of items to self-harm Closely observe for signs of self-harm behavior Care for patient’s wounds and injuries Encourage expression of feelings |
| mania | period of intense mood disturbance characterized by high energy levels and expansive mood - intense mania may move into psychosis Lasts about a week Bipolar 1 |
| hypomania | period of excessive energy with expansive mood less dramatic than mania - not accompanied by psychosis Lasts about 4 days Bipolar 2 |
| milieu management for someone experiencing a manic episode | Monitor milieu for safety concerns Provide solitary activity practice consistency in rule enforcement and limit-setting Reduce environmental stimuli Avoid escalating patient Reinforce appropriate hygiene and dress Monitor nutrition and sleep |
| management of a monopolizer | privately or publicly address those who monopolize the time, limit contributions or time spent in sharing for the entire group |
| management of a disruptive group member | listen objectively and remind them the group is there to support them, address anger directly |
| management of a silent group member | allow extra time to share, assign everyone in the group a task |
| double-bind messages | two or more conflicting messages; a positive command (typically verbal) followed by a negative command (typically nonverbal) leaving the recipient confused |
| scapegoating | when a less powerful member of the family is blamed for another family member’s distress |
| triangulation | inserting a third person into a two-person relationship to balance anxiety, distance, and conflict |
| interventions for anorexia nervosa | Close monitoring of intake and body weight occurs patient is encouraged to participate in groups and the milieu activities Coping skills and problem-solving skills are developed Additional monitoring may be needed to ensure compliance |
| interventions for bulimia | Close monitoring of intake and body weight The patient is closely monitored to prevent purging and excessive exercise educate on healthy diet and exercise patterns Effort is made to disrupt the compulsive nature of the binge-purge cycle |
| risks of untreated anorexia nervosa | Amenorrhea: stop having menstrual cycles due to lack of nutrition Lanugo: baby fine hair throughout the body Peripheral edema Muscle weakening Constipation Abnormal lab values Abnormal CT scans and ECG changes |
| untreated bulimia | Dehydration, which can lead to major medical problems, such as kidney failure Cavities/gum disease Intestinal problems Hair loss Dry skin Sleep problems Stroke Organ failure |
| untreated binge-eating disorder | Extreme weight gain and problems that occur due to obesity (including increased risk of arthritis, heart disease, type 2 diabetes, and cancer) Changes to the metabolism Hormonal fluctuations Changes in size of organs |
| appropriate sleep hygiene | Adequate sleep schedule Quiet, dark, and calm sleeping environment Limit caffeine and heavy food intake Avoid daytime napping Exercise daily |
| mild anxiety | person able to perceive, hear, and grasp more information - considered to be “normal” anxiety experienced in situations |
| moderate anxiety | person sees, hears, and grasps less information and exhibits selective inattention - impaired ability to think, but teaching may still occur |
| severe anxiety | person unable to focus on details and perception lowered - unable to learn or problem-solve, and teaching is NOT possible |
| panic | person unable to process and may lose touch with reality Supportive and directive |
| milieu management for a patient with OCD | Allow the patient to complete rituals/compulsions or anxiety will continue to rise |
| appropriate assessment and management of patient with somatoform disorder | Assess if the symptoms have some sort of underlying cause or not Do not feed into somatic complaints Discuss with the patient about their symptoms and “condition” Advise the patient to avoid WebMD and social media for self-diagnoses |
| dependent personality disorder | Pattern of submissive and clinging behavior Intense fear of separation Great need to be taken care of Manipulation of others or vulnerability to exploitation by others |
| interventions for DPD | Help identify stressors Help patients express emotions appropriately Teach assertiveness training Be aware of increased potential for countertransference CBT Antianxiety and antidepressants |
| narcissistic personality disorder | Feelings of entitlement Egocentric behavior Exaggerated belief in one’s own importance Lack of empathy Struggle with poor self-esteem and hypersensitivity to criticism Significant fear of abandonment |
| interventions for NPD | Remain neutral Model healthy communication and empathy Do not engage in power struggles CBT and group therapy Lithium and antidepressants |
| borderline personality disorder | Instability, impulsivity, and identity or self-image distortions Unstable mood and interpersonal relationships Emotional dysregulation and lability Self-harm, risky behaviors, and/or substance abuse SPLITTING utilized as primary defense mechanism |
| BPD interventions | Establish therapeutic relationship Monitor for manipulation and splitting Monitor for self-harm and ensure safety Mood stabilizers and antidepressants help Dialectical behavior therapy |
| antisocial personality disorder | Pattern of disregard for rights of others and frequent violation of these rights Exhibiting antagonist behaviors for personal gain Risk-taking, disregarding responsibility, and acting impulsively Criminal misconduct and substance abuse common |
| interventions for APD | Monitor for violence and manipulation Emphasize coping skills that focus on healthy behaviors, effects of decisions, and taking responsibility Therapy focused on understanding how actions cause distress Mood stabilizers, antidepressants, benzos |
| alcohol withdrawal | Shakes or jitters begin 6-8 hours after alcohol cessation Agitation, lack of appetite, nausea, vomiting, insomnia, impaired cognition, and mild perceptual changes Systolic and diastolic BP increase, pulse increase, body temp increases seizures |
| opiate intoxication | Psychomotor retardation, drowsiness, slurred speech, altered mood, and impaired memory and attention Intense drowsiness can lead to coma |
| opiate withdrawal | Mood dysphoria, nausea, vomiting, diarrhea, muscle aches, fever, and insomnia Lacrimation, rhinorrhea, pupillary dilation, and yawning |
| assessment for alcohol withdrawal | CIWA (components include N/V, tremors, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache/fullness in head, orientation and clouding of sensorium |
| benzodiazepine assessment withdrawal | symptoms of sleep disturbance, irritability, increased tension and anxiety, panic attacks, hand tremors, sweating, difficulty in concentration, dry retching and nausea, some weight loss, palpitations, headache, muscular pain |
| opiates withdrawal assessment | COWS (components include resting HR, sweating, restlessness, pupil size, bone/joint aches, runny nose/tearing, GI upset, tremors, yawning, anxiety/irritability, gooseflesh skin) |
| interventions for delirium | Monitoring neurological status and V/S Keep patient safe Keep communication simple and direct Acknowledge patients’ feelings Maintain well-lit, hazard free, and low stimulus environment Assist with personal care Orient patient to the environment |
| mild/early stage of alzheimer's | memory lapse occurs, but may still function independently |
| moderate stage of alzheimers | symptoms become noticeable and behavior is markedly changed |
| severe/late stage of alzheimers | may have difficulty with communication and will need 24-hour care |
| oppositional defiant disorder | mood dysregulation and defiance to authority figures in two or more settings Behavior impacts ability to develop relationships, function in family unit, and attend school |
| conduct disorder | pattern of behavior in which rights of others are violated and societal norms or rules are disregarded Abnormally aggressive behavior Likely will develop to antisocial personality disorder if left untreated |
| autism spectrum disorder | complex neurobiological and developmental disability characterized by deficits in social-emotional interactions, repetitive speech and/or behaviors, sensory processing issues, and difficulty with changes in routine |
| ADHD | common neurodevelopmental disorder of inappropriate degree of inattention, impulsiveness, and hyperactivity Strained relationships due to invasive behaviors and poor boundaries Low frustration tolerance and labile mood |
| interventions for alzheimers | Gradually restrict use of motor vehicles Minimize sensory stimulation Listen and be supportive if patient is verbally upset Label all rooms and drawers Put medical alert bracelet on patient Encourage physical activity during the day |
| Adverse Childhood Experiences | potentially traumatic events that occur before age 18 and put children at risk for developing mental disorders As ACEs increase, mental health conditions increase |
| common ACEs | Physical, verbal, or sexual abuse Emotional or physical neglect Mental illness of household member Criminal activity of household member Illegal street or prescription drug use or addiction by household member |
Created by:
ellabrewer3
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