I.

Coping Mechanisms (also called defense mechanisms) A. Definition: psychological techniques that the personality develops to manage anxiety, aggression, hostility, etc. B. Coping mechanisms represent conflicts between the id and superego C. Used by both mentally healthy and ill individuals D. May be used consciously, but are usually unconscious

E.

Types of coping mechanisms

Types of Coping Mechanisms

1. 2. 3.

Compensation - extra effort in one area to offset real or imagined lack in another area o Example: Short man becomes assertively verbal and excels in business. Conversion - A mental conflict is expressed through physical symptoms o Example: Woman becomes blind after seeing her husband with another woman. Denial - treating obvious reality factors as though they do not exist because they are consciously intolerable o Example: Mother refuses to believe her child has been diagnosed with leukemia. "She just has the flu." Displacement - transferring unacceptable feelings aroused by one object to another, more acceptable substitute o Example: Adolescent lashes out at parents after not being invited to party. Dissociation - walling off specific areas of the personality from consciousness o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about them. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a cardiac arrest. Fixation - becoming stagnated in a level of emotional development in which one is comfortable o Example: A sixty year old man who dresses and acts as if he were still in the 1960's. Identification - subconsciously attributing to oneself qualities of others o Example: Elvis impersonators. Intellectualization - use of thinking, ideas, or intellect to avoid emotions o Example: Parent becomes extremely knowledgeable about child's diabetes.

4. 5. 6. 7. 8. 9.

10. Introjection - incorporating the traits of others
o o
Example: Husband's symptoms mimic wife's before she died.

11. Projection - unconsciously projecting one's own unacceptable qualities or feelings onto others 12.
Example: Woman who is jealous of another woman's wealth accuses her of being a golddigger. Rationalization - justifying behaviors, emotions, motives, considered intolerable through acceptable excuses o Example: "I didn't get chosen for the team because the coach plays favorites."

13. Reaction Formation - expressing unacceptable wishes or behavior by opposite overt behavior
o o
Example: Recovered smoker preaches about the dangers of second hand smoke. Example: Four year old insists on climbing into crib with younger sibling.

14. Regression - retreating to an earlier and more comfortable emotional level of development 15. Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses,
feelings or acts o Example: Adolescent "forgets" appointment with counselor to discuss final grades.

16. Sublimation - diversion of unacceptable instinctual drives into personally and socially acceptable
areas.

o Example: Young woman who hated school becomes a teacher. 17. Therapeutic Communication - Characterizes the Nurse-Client Relationship o Nurse-client relationship: a therapeutic professional relationship in which two people interact

1.
2.

The nurse who possesses the skills and ability to provide counseling, crisis intervention, health teaching, etc. and The client who seeks help for some problem

o o

Phases of the nurse-client relationship Five characteristics of nurse-client relationship

1. 2. 3. 4. 5.
18. Grief

Mutual definition: together, nurse and client define relationship Goal direction: purpose, time, and place are specific Specified boundaries: in time, space, content, and confidentiality Therapeutic communication: nurse eases trust and open communication by these interpersonal techniques Nurse helps client toward resolution

o

Loss 1. 2. A universal phenomenon; it occurs across the lifespan There are many types of loss 1. loss of external objects 2. loss of significant other: through death, divorce 3. loss of environment: by moving, taking a new job, hospitalization 4. loss of an aspect of self: may include a body part, physiologic or psychologic function Response to loss depends on 1. one's personality 2. culture 3. previous experience with loss 4. one's values 5. perceived value of loss 6. support system Types of Grief 1. Anticipatory grief: person learns of impending loss and responds with processes of mourning, coping, interaction, planning, and psychosocial reorganization 2. Disenfranchised grief: person experiences a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported 3. Mourning: process used to resolve grief 4. Tasks of mourning (common to the models of grief) spell R-E-A-L

3.

4.

1. 2. 3. 4.
5.

Real: accept that the loss is real Experience the emotions associated with the loss Adjust or re-adjust to life and activities Let go: move on with one's own life

5. Grief theory models Nursing care in grief 1. Support client's effective coping mechanisms 2. Don't take client's responses personally 3. Listen attentively 4. Help client with problem solving and decision making as indicated 5. Encourage the client and/or significant others to ventilate 6. Utilize therapeutic touch as appropriate 7. Assist in discussions of future plans as appropriate

19. Stress Management o Stress: a universal phenomenon, stress requires change or adaptation so that the person can maintain equilibrium o Stress can be internal or external o Nature of stressor involves: 1. Intensity 2. Scope 3. Duration 4. Other stressors: their number and nature o Categories of stressors - and examples

o o

1. Physical - drugs or alcohol 2. Psychological - such as adolescent emotional upheaval, or unexpressed anger 3. Social - isolation, interpersonal loss 4. Cultural - ideal body image 5. Microbiologic - infection The greater the stressor as preceived by the client, the greater the stress response Stress response involves both localized and general adaptation

G.

Factors affecting stress response 1. Personal: heredity, gender, race, age personality, cognitive ability 2. Sociocultural: finances, support systems 3. Interpersonal: self-esteem, prior coping mechanisms 4. Spiritual: belief system 5. Environmental: crowding, pollution, climate 6. Occupational: work overload, conflict, risk Physiologic indicators of stress Emotional/behavioral indicators of stress Stress can cause a variety of emotional and physical disorders Stress management strategies The non-compliant client does not cooperate with the treatment plan 1. Behavior characteristics a. does not take prescrived medication b. continues activities restricted by provider of care, such as smoking c. does not follow prescribed activities, such as exercise 1. Nursing interventions a. explore the reasons for non-compliance i. lack of understanding - reinforce teaching ii. lack of family support - involve family and support groups iii. side effects - refer to provider of care iv. finances and access - refer to Social Services v. negative attitude toward treatment - encourage expression a. b. express genuine concern for client discuss imporvement potential

G. H. I. J.
K.

2.

Schizophrenia G. Definition: a multifaceted psychosis with early onset; criteria from DSM IV as follows:

1. 2.
3. 4. 5. 6.

7. H. 1. 2. 3. 4.

When disease is in active phase, client shows psychotic behaviors. (Psychosis is severe ego dysfunction. Psychosis is also part of other DSM-IV diagnoses of dysfunctions of thought and sensorium.) Findings involve many psychological processes Previously, client had functioned at a higher level Schizophrenia normally sets in before 30 years of age Findings last six months or more Not caused by affective or organic mental disorder Involves hallucinations and/or delusions - six losses: S-S-O-B-E-R Self-care often fails Social adjustment is impaired Orientation to the environment is lost Boundaries between self/others dissolve

General characteristics of schizophrenia

I.

Reality testing fails Etiologies of Schizophrenia 1. Biogenetic (possible hereditary factor) 2. Biochemical

5. 6.

External/internal stimuli are confused (delusions/hallucinations)

c. d.
3.

dopamine hydrochloride - too much neurotransmitter for neural activity research has suggested abnormalities of neurotransmitters norepinephrine, serotonin, acetylcholine and GABA (gamma aminobutyric acid).

Contributing factors a. poor relationships with primary caretaker b. dysfunctional family systems c. double-bind communication d. stressful life events e. decreased socio-economic status (SES)

D.

E.

F.

G.

Findings of schizophrenia 3. Positive findings a. hallucinations b. delusions c. looseness of associations d. agitated or bizarre behaviors 4. Negative findings a. apathy b. poverty of speech or content of speech c. poor social functioning d. anhedonia e. Social withdrawal Positive findings 3. Acute onset 4. Normal premorbid functioning 5. Normal social functioning during remission 6. Normal CT scan 7. Normal neuropsychological test results 8. Favorable response to antipsychotic meds 9. Appear early in illness 10. Often precipitate hospitalization 11. Alterations in thinking, perceiving and behavior Negative findings 3. Insidious onset 4. Premorbid history of emotional problems 5. Chronic deterioration 6. Demonstration of atrophy on CT scan 7. Abnormalities on neuro-psychological testing 8. Poor response to antipsychotic meds 9. Interferes with person's ability to: a. initiate and maintain relationships b. initiate and maintain conversations c. hold a job d. make decisions e. maintain adequate hygiene and grooming Alterations in thinking 3. Types of delusions a. ideas of reference b. persecution c. grandeur d. somatic delusions e. jealousy f. control/being controlled g. thought-broadcasting

H.

I.

J.

h. thought insertion i. thought withdrawal 4. Associative looseness 5. Neologisms 6. Concrete thinking 7. Echolalia 8. Clang association 9. Word salad Alterations in perceiving 3. Hallucinations a. auditory b. visual c. olfactory d. gustatory e. tactile 4. Loss of ego boundaries Alterations in behavior 3. Bizarre behavior a. extreme motor agitation b. stereotyped behaviors c. automatic obedience d. waxy flexibility 4. Stupor 5. Negativism 6. Agitated behavior Associated findings 3. Depression/suicide 4. Water intoxication 5. Substance abuse 6. Violent behavior Treatments in schizophrenia 1. Psychopharmacology

K.

a.

antipsychotic agents

and neuroleptics

i. decrease psychotic symptoms ii. decrease agitation iii. less effective with negative symptoms iv. decrease dopamine - dependent neural activity in the brain and other parts of the body (causing extrapyramidal symptoms)

b.
1.

antiparkinsonian agents: used to counteract these extrapyramidal symptoms

2.

3. 4.

Individual psychotherapy a. long-term therapy b. difficult because schizophrenia impairs interpersonal functioning c. focused, supportive problem-solving is most useful Group therapy in schizophrenia a. oriented toward providing support, an environment in which the client can develop social skills, and a format that allows friendships to begin b. some success with long-term work c. less success if client actively delusional and/or psychotic Social skills training a. role play to simulate anticipated interactions b. teach eye contact, interpersonal skills, voice, posture Vocational/rehabilitation often succeeds a. long-term treatment

5.

b. includes job training c. promotes semi-independent daily activities d. raises self esteem Family therapy a. to help families cope with psychotic and residual symptoms of schizophrenia b. to help reduce relapse rate

L.

Nursing care in schizophrenia

6.
7. 8. 9. 10.

11. 12. 13. 14.

Protect client and others from harm, including suicide precautions Administer medications as ordered Monitor for extrapyramidal symptoms Establish trust, decrease anxiety Encourage or reinforce: a. client's sense of control b. reality orientation c. self-care Help client set realistic goals Provide safe and successful experiences Assist with hygiene and/or feeding as indicated Teach client a. importance of medication compliance b. medications and side effects

as indicated

12. Mood Disorders (Affective Disorders) K. Definition: 15. Elevated or depressed mood, with disturbances in behavioral response 16. Divided into bipolar and depressive disorders L. Bipolar disorders: mood disorders that include one or more manic or hypomanic episodes and usually one or more depressive episodes M. Mania: 17. 18. 19. 20. 21. 22. 23. N. Person's elevated mood described as euphoric Inflated self-esteem Impaired judgment Constant physical activity Pressured speech Racing thought patterns Requires hospitalization

Hypomania: 24. Findings less severe 25. Does not impair social, occupational or interpersonal functioning 26. Treated in outpatient setting

O.

The seven traits typical of mood disorders 27. 28. 29. 30. Impair job functioning Impair social activities Impair relationships Necessitate hospitalization (in most cases) No time longer than two weeks has client had delusions or hallucinations without the mood disturbance Findings are not superimposed on a. schizophrenia

31. 32.

33.
P.

b. delusional disorder c. psychotic disorder Findings are not caused by organic disease

Etiology - unknown; possible genetic, biochemical predisposition 34. Psychosocial theories of depression a. Freud: anger internalized and directed against ego b. Seligman: depression results from learned helplessness: individual who fails over time learns to expect poor outcomes and eventually gives up c. Beck: cognitive theory: over time, cognition is altered, resulting in negative attitudes; events can trigger depression 35. Biological cycles affect mood (via Circadian rhythm) a. light affects mood by increasing melatonin b. melatonin is a mood modulator which decreases in depression c. Seasonal Affective Disorder 3. Biochemical theories of mood disorders a. mania i. probably a genetic factor ii. biochemical influences • possible deficiency of neurotransmitter GABA (gamma aminobutyric acid) • possible excess of norepinephrine and dopamine hydrochloride

b.

• possible increase in electrolytes: sodium and calcium depression i. possible deficit of serotonin, dopamine, norepinephrine ii. possible deficit of TSH (thyroid-stimulating hormone) and/or other neuroendocrine disturbances iii. depression is more common in viral infections (AIDS, mononucleosis, hepatitis) iv. possible deficit in vitamin intake or metabolism: (vitamin B complex, folic acid) v. genetics may be involved

G. Types of mood disorders: mania, bipolar, depression 3. Mania - DSM IV criteria for mania a. period of abnormally/persistently elevated mood or irritability b. at least three of these six signs i. grandiosity ii. decreased sleep iii. hypertalkative, with pressured speech and flight of ideas or racing thoughts iv. highly goal-directed activity (sexual, work) v. highly distractible vi. pursues pleasure, but overestimates own skill and luck Bipolar disorders onset usually before age 30 a. bipolar disorder, mixed: both manic and depressive episodes present i. bipolar I

2.

• • • •
ii. bipolar II

consists of one or more periods of major depression plus one or more periods of clear-cut mania findings as in Definition of mood disorder (on page 15 of this lesson) no marked drop in social and job functioning manic episode requires hospitalization

3.

consists of one or more periods of major depression plus periods of hypomania • includes all symptoms in Definition of mood disorder (on page 15 of this lesson) and does not require hospitalization b. bipolar disorder, manic: fulfills criteria for manic episode (see Findings below) c. bipolar disorder, depressed: major depressive episode and at least one manic episode, current or past d. cyclothymic mood disorder: i. many milder findings of mania and depression ii. periods of normal mood are short iii. usually does not require hospitalization Depression

a. b.
I. Findings

includes all 7 typical traits of mood disorders specific criteria for depression (see Findings below)

2.

Mania

a.
b.

c.
d. e. f. g. 2.

elation, euphoria; inappropriate laughter; very talkative irritable, hostile, aggressive flight of ideas, delusions of grandeur, exhibitionism, sexual acting-out reduced sleep unlimited energy; no time for food or drink impulsive, easily distracted manipulative behavior

J.

Depression a. melancholia, crying, absence of pleasure; slumped posture b. apathy; loss of desire for food and/or sex c. slower reactions d. low self-confidence; inhibition, introversion e. ruminating, decreased communication, social isolation f. fatigue and/or insomnia g. decreased concentration h. poor hygiene i. hopelessness, pessimism j. self-destructiveness Treatments 2. Treatments for mania a. pharmacologic i. lithium carbonate (Lithane), carbamazapine (Carbatrol), valproic acid (Depakene) ii. antipsychotics: chlorpromazine (Thorazine), haloperidol (Haldol) b. occupational therapy c. recreational therapy Depression

2.

a.

pharmacologic antidepressants

K.

tricyclic antidepressants - amitriptyline HCl (Elavil), doxepin (Sinequan), imipramine (Tofranil) ii. monoamine oxidase inhibitors - phenelzine (Nardil), tranylcypromine (Parnate) iii. selective serotonin reuptake inhibitors (SSRI) - fluoxetine (Prozac), sertraline (Zoloft) b. ECT: electroconvulsive therapy c. psychotherapy d. occupational therapy e. recreational therapy f. cognitive therapy Nursing care in mood disorders 2. Mania a. b. c. d. e. f. g. h. i. j. k. l.

i.

protect client and others from harm provide quiet environment with few stimuli give medications as ordered; be sure client swallows meds establish trust relationship do not argue with client or provoke hostility redirect client to task at hand set firm, consistent limits; explain them simply allow client to express anger in positive ways offer finger foods increase client's fluid intake to at least 1000cc/day allow client to pace teach client i. acceptable ways to release anger ii. medications and side effects iii. importance of taking medication

IV.

Types J.

V. VI. VII. VIII. IX. X.

Tricyclics and tetracyclic antidepressants 2. Prevent nerve endings from taking up norepinephrine and serotonin 3. Increase the action of norepinephrine and serotonin in nerve cells K. MAO Inhibitors (Monoamine oxidase inhibitors) 2. Lower the production of monoamine oxidase 3. Thus the central nervous system stores more endogenous epinephrine, norepinephrine, serotonin, and dopamine Contraindications: convulsive disorders, prostatic hypertrophy, severe renal, cardiac or hepatic disease Administer with food to prevent GI disturbance Therapeutic effect may take up to three weeks Teach client about potential for drowsiness or dizziness Teach client to avoid drinking alcohol Do not stop taking antidepressants suddenly 2. Depression a. monitor suicidal thoughts b. take suicide precautions as indicated and observe for SUICIDE PRECAUTIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. Remove all harmful objects from the environment One to one monitoring of the client day and night, having the client in view at all times even during toileting, gradually progress to 15 minute and then hourly checks Ask client exactly how she/he would commit suicide. Assess how lethal the attempt would be, and how quickly it could be carried out. Keep client within one arm's length distance or less at all times Use plastic utensils Keep electrical cords to a minimum length Take all potentially harmful gifts from visitors Keep all windows locked and if possible keep client in room with unbreakable glass in windows Do not assign a private room

c.
d. e. f. g. h. i. j. k. l. m.

suicide warning signs build trust with client speak slowly and clearly in simple sentences administer medications as ordered encourage client to ventilate provide relaxation exercises help with hygiene and feeding as indicated help client assess negative thoughts more objectively divert client from morose thoughts encourage client to focus on positive attributes teach client i. medications and side effects ii. importance of taking medication iii. problem-solving techniques

VII.

Anxiety Disorders A. Definition: group of disorders in which anxiety is predominant symptom. Degrees range from mild anxiety to severe (panic attack) 1. Seven types a. GAD: generalized anxiety disorder b. phobic disorders c. panic disorder

d. e. f. g.
A.

dissociative disorder somatoform disorder obsessive-compulsive disorder (OCD) PTSD: Post-traumatic stress disorder

B.

C.

D.

Etiology 1. Found equally in men and women 2. Hereditary predisposition 3. Biochemical factors: neurotransmitters may play a role 4. Psychologic and interpersonal factors a. early psychic trauma, b. pathogenic parent-child relationship, c. pathogenic family patterns d. loss of social supports Findings 1. Fear, dread, or apprehension 2. Feeling powerless 3. Crying 4. Irritability 5. Scattered thoughts, inability to concentrate or solve problems 6. Preoccupation with self 7. Rapid speech, hyperventilation, tachycardia 8. Palpitations, chest pains, jittery behavior 9. Diaphoresis 10. Insomnia 11. Diarrhea and/or urinary urgency and frequency Treatments for anxiety disorders 1. Pharmacologic: anxiolytics (antianxiety drugs) such as alprazolam (Xanax) and diazepam (Valium) 2. Psychotherapy 3. Occupational therapy 4. Recreational therapy Nursing care 1. Provide a nondemanding environment; stay with client if indicated 2. Acknowledge client's feelings of fear, worry, helplessness 3. Do not force contact with feared item or situation

4. 5. 6. 7. 8. 9. 10. 11. 12.

If client demonstrates compulsive behavior, allow the compulsion but set reasonable limits Provide distracting activities Allow temporary dependence Speak calmly, slowly and clearly Assist client in ADL as indicated Encourage relaxation techniques and regular physical exercise Administer medications as ordered Limit caffeine intake Teach client a. medications and side effects b. relaxation techniques

VIII.

Borderline Personality Disorder E. Definition 1. Client shows personality traits that are long-lasting, inflexible and maladaptive. 2. Client may appear to function normally until stressed 3. Generally begins in childhood or adolescence 4. More common in women Etiology 1. Impaired development of object relations; separation-individuation process is arrested 2. Issues of dependence, independence, and control are mixed with fear of abandonment, loss of love, or engulfment by mother Findings 1. Personal relationships are unstable; lonely; emotions shallow 2. Images of self and others are primarily bad; feels inadequate 3. Anger, hostility 4. Projection of hostility onto others 5. Acts out and denies responsibility for actions 6. Poor judgment 7. Impaired problem solving 8. Very "black or white" thinking 9. Regression 10. Marked mood swings 11. Demanding 12. Sarcastic 13. Manipulative 14. Behaves self-destructively 15. Splitting Treatment 1. Pharmacologic a. antianxiety agents: oxazepam (Serax) b. antidepressants: carbamazapine (Carbatrol) 2. Psychotherapy Nursing care in borderline personality disorder 1. Protect client and others from harm 2. Administer medications as ordered 3. Establish a trusting relationship 4. Set limits, and provide a structured environment 5. Use a calm, controlled approach; see that other staff stay consistent 6. Do not argue with client 7. Encourage client to evaluate consequences of actions 8. Divert anger, or let client ventilate it in positive ways 9. Set limits on manipulative behaviors by communicating expected behaviors 10. Teach client a. medications and their side effects b. anger-control strategies c. relaxation strategies

F.

G.

H.

I.

IX.

Suicide Prevention

J.

K.

L.

Definitions: 1. Suicide is a self-harming act intended to produce death 2. Degrees a. completed suicide: life ends b. attempted suicide: failed self-destructive act c. suicide ideation: thoughts of ending one's life Epidemiology 1. Women attempt more than men 2. Men are more often successful 3. Second leading cause of death in adolescence 4. Black males have higher incidence Etiology 1. Depression 2. Delusions/hallucinations in psychotic clients 3. Hopelessness 4. Environmental factors: work or school performance, loss of job, death of loved one, unsatisfying interpersonal relationships Findings 1. Statements about suicide 2. Anger, sadness, hopelessness, negative view of future 3. Recent loss of job, loved one 4. Perceived lack of support system 5. Self-mutilation Treatment for suicidal condition 1. Objective: to treat the condition that underlies the suicidal thoughts 2. Medications: amitriptyline (Elavil), chlorpromazine (Thorazine)

M.

N.

O.

3. Suicide precautions Nursing care 1. Administer medications as ordered 2. Institute suicide precautions 3. Encourage relaxation strategies

X.

Crisis Intervention P. Q. Definition - crisis: temporary personality disorganization with an acute emotional state. Crisis is a normal response to threatening environment. Types and phases of crisis response 1. Panic state: acute crisis where client temporarily loses control a. emotional reactions are overwhelming b. decision making and problem solving abilities are inoperative c. thinking is scattered d. social isolation e. immobilization (unable to act) 2. Exhaustion crisis a. under emergency conditions b. person has lost effective coping c. cannot continue to function 3. Shock crisis a. sudden external change b. causes release of emotions c. overwhelms client 4. Four phases of crisis (average crisis four to six weeks but may vary widely) a. vulnerable state b. precipitating event 2. developmental change (maturational crisis) 3. a life change (situational crisis) 4. loss of loved one or job (situational crisis) 5. environmental disaster or war (adventitious crisis) c. acute crisis d. reorganization Findings of crisis

R.

S.

T.

Mild to severe anxiety Anger Crying, social isolation, helplessness Impaired cognitive processes; inability to concentrate; confusion Insomnia 6. Regression 7. Nausea and vomiting Treatment: crisis intervention 1. Objective: to help the client through the current crisis 2. Brief supportive interventions focused on the phase of crisis 3. Allow free discharge of emotions 4. Enhance client's cognitive processes 5. Pharmacologic: trazodone (Desyrel), alprazolam (Xanax) 6. Occupational therapy 7. Recreational therapy Nursing care in crisis 1. Provide a quiet, restful environment 2. Help the client solve problems 3. Let the client ventilate 4. Correct any misperceptions about the crisis that the client may have 5. Help the client to identify support systems, alternative solutions 6. Help the client to deal with long term impact of crisis 7. Encourage relaxation strategies 8. Assist the client in the development of new coping skills 9. Give medications as ordered

1. 2. 3. 4. 5.

XI.

Substance Abuse U. Definitions 1. Maladaptive behaviors resulting from the regular intake of large amounts of addictive chemicals 2. Addictive chemicals include alcohol, stimulants, depressants, hallucinogens, narcotics. 3. Levels of substance abuse a. abuse is pathologic use of mood-altering chemicals that continues for at least 1 month, which impairs social or occupational functioning b. dependence is a more severe level of abuse that involves impaired ability to control use of substance and results in withdrawal (adverse consequences) when substance is discontinued or reduced. There are three types of dependence 2. psychologic dependence: pleasure that intensifies craving for substance; often begins in teens and twenties. 3. physiologic dependence: after repeated use, physiology changes; and after substance is reduced or removed, withdrawal symptoms appear 4. tolerance: drug dosage must keep increasing to achieve same effect Alcohol Although alcohol is a legal substance, problem drinking has detrimental physiologic and social effects. 1. Dependence a. daily intake of large quantities, or b. excessive drinking limited to weekends; or c. periods of abstinence with binges lasting for weeks or longer 2. Etiology unknown a. stress has been implicated b. some research suggests a familial tendency

V.

3.
4.

Produces withdrawal symptoms Findings of chronic alcohol use a. anemia

b. c. d.

hypertension tachycardia hepatomegaly

5.

6.

malabsorption syndrome j. fatigue k. depression l. impaired judgment; cognitive impairment m. tremors n. wernicke-Korsakoff syndrome Treatment of alcohol dependence a. antianxiety agents: chlordiazepoxide (Librium) b. vitamin and nutritional therapy c. disulfiram (Antabuse) - alcohol abuse deterrent d. support groups (Alcoholics Anonymous) Nursing care in alcohol dependence a. during acute withdrawal 2. stay with client 3. provide quiet environment 4. administer medications as ordered 5. protect the client from harm 6. institute seizure precautions as indicated 7. maintain adequate fluid intake b. during abstinence 2. provide emotional support 3. provide nutritious diet 4. encourage the development of new coping skills 5. provide relaxation exercises 6. inform client about support groups and rehab programs

e. f. g. h. i.

ascites cirrhosis gastritis esophagitis

C.

Use of psychoactive drugs (prescription or "street"): stimulants, depressants, hallucinogens, and narcotics 1. Stimulants a. include cocaine, crack, amphetamines b. effects of abuse of stimulants i. psychomotor agitation ii. mood swings iii. tachycardia iv. hypertension v. dilated pupils vi. perspiration and chills vii. insomnia viii. impaired cognitive function ix. seizures

2.

x. if discontinued, withdrawal follows c. overdose may cause lethal cardiac or respiratory arrest d. emergency care of overdose on stimulants: cardiopulmonary support Depressants a. include barbiturates, tranquilizers, sedatives and hypnotics b. findings of depressant use i. slurred speech ii. impaired cognitive function; confusion iii. emotional lability iv. lack of coordination v. cold and clammy skin
c.

vi. produce withdrawal symptoms overdose can lead to respiratory depression, coma

d. 3.

emergency care of overdose i. respiratory support ii. keep client awake and moving

Narcotics a. include: heroin, morphine, meperidine, codeine, methadone b. findings i. euphoria ii. tranquility iii. drowsiness iv. constricted pupils v. clouded sensorium c. overdose threatens life: depresses respiratory function and alters level of consciousness

d.
4.

emergency care includes cardiopulmonary support (illustration 1

D. E.

illustration 2 illustration 3 ) Hallucinogens a. include: LSD, PCP, marijuana, mescaline, psilocybin b. findings i. tachycardia ii. hypertension iii. dilated pupils iv. hallucinations v. nausea vi. impaired attention and judgment vii. aggressive behavior c. potentially life threatening d. potentially psychotic long-term effects Treatment: drug rehabilitation Nursing care in substance abuse 1. Protect the client and others from harm 2. Help client through drug rehabilitation as indicated 3. Provide emotional support 4. Help the client develop a support system 5. Provide emergency care for overdose

IX.

Autism C.

X.

Definition: syndrome in which child does not relate to people 1. May become attached to objects 2. Develops before age three D. Etiology unknown E. Findings 1. Does not respond to human touch 2. Lack of eye contact 3. Talks poorly or not at all 4. Ritualistic behavior 5. Cannot deal with change 6. Emotional lability 7. May be self destructive (head-banging, hair pulling, finger/hand biting) 8. Failure to develop friendships or play with other children 9. Posture or gait abnormalities: poor coordination, tiptoe walking, peculiar hand movements (flapping, clapping) F. Treatment 1. Special education 2. May need full time care (institution) G. Nursing care 1. Support parents emotionally 2. Protect the child from self harm 3. Help child with hygiene and feeding as indicated 4. Maintain consistency in schedule 5. Allow ritualistic behavior Abuse Syndromes C. Definition - abuse may be physical, sexual, psychological or physiological 1. Victims powerless to stop abuse

2. 3. 4.

May be directed toward a child, a spouse, the elderly Rape is a violent sexual abuse Abusers a. often blame victim b. demonstrate poor impulse control c. have frequently been victims of abuse themselves

XI.

Findings 1. Physical abuse a. broken bones and/or dislocations b. welts, and/or bruises 2. Sexual abuse a. bruising or bleeding in genital or anal area, b. pain or itching in genital area, c. rape, evidence of sexual intercourse, d. genitourinary infections 3. General neglect a. malnutrition b. habitual behaviors: rocking, head banging c. learning disorders d. social isolation e. aggressive behavior E. Treatment 1. In general, cases of abuse must be reported (refer to state statutes for variations) 2. Removal of victim from source of abuse 3. Protective services 4. Directing abuser to help or therapy F. Nursing care 1. Provide emotional support 2. Document all signs of abuse 3. File appropriate reports (report of suspected abuse is mandatory in most states) 4. Assist in placement for protection 5. Assist abuser in obtaining appropriate counseling Eating Disorders C. A subcategory of disorders that includes multiple types of eating behavior disturbances D. Types of eating disorders 1. Anorexia nervosa a. weight loss through restriction of food intake leading to emaciation b. may involve purging behaviors c. tend to reject mature-appearing body d. tendency to asceticism 2. Bulimia nervosa a. eating binges alternate with dieting or purging b. purging behaviors may include self-induced vomiting, misuse of emetics and cathartics or laxatives c. more likely than those with anorexia to show impulsive or chaotic behavior d. usually near normal weight e. tend to be outgoing and sensitive to others f. major issue: control self/environment through eating behaviors g. drive for thinness h. population at risk i. adolescents and young adults ii. in industrialized countries iii. models, dancers and gymnasts at higher risk i. potentially life threatening E. Etiology 1. Psychoanalytic theory a. conflicts stem from oral phase of development b. clients often have anxious, compulsive mothers c. obsessive-compulsive control of body and life, via food d. controlling bodily functions is critical to client's attempt at self-control 2. Interpersonal theory a. results from dysfunctional family relationships b. parents avoid their own conflicts by controlling child

D.

F.

G.

H.

c. child's self-identity becomes blurred d. during adolescence parents become overcontrolling and demanding e. demands thwart client's attempts at autonomy f. adolescent attempts to control self through controlling food intake. 3. Cognitive theory a. eating-disorder behaviors are learned b. society glorifies thinness c. for the adolescent or young adult, thinness equates with self-worth. Findings of eating disorder 1. Personal relationships become superficial and distant 2. Social contact avoided especially if food is involved 3. Preoccupation with food, meal planning, caloric intake and methods to avoid eating 4. Eats in private 5. Mood irritable and defiant 6. Exercises excessively 7. Physical findings a. weight falls below 85% of normal b. bradycardia c. anemia d. amenorrhea e. decreased renal function f. dental problems g. fluid and electrolyte imbalances h. delayed skeletal maturation Treatment of eating disorders 1. Objective: to correct underlying cause and prevent complications of weight loss 2. Client may require hospital care 3. Nutritional planning 4. Psychotherapy: individual and/or family 5. Group therapy 6. Occupational therapy 7. Recreational therapy 8. If underlying depression, treat with antidepressants Nursing care 1. Monitor weight as prescribed 2. Monitor client's eating/record intake and output 3. Administer nasogastric feedings if ordered 4. Encourage oral hygiene 5. Set limits on eating including time allotted for meals 6. Stay with client during meals 7. Accompany client to bathroom after meals to prevent self-induced vomiting 8. Encourage client to express feelings 9. Encourage socialization 10. Monitor for findings of electrolyte imbalance or dehydration 11. Assist client to identify strengths 12. Teach client a. relaxation techniques b. alternative coping methods c. assertiveness skills

Coping Mechanisms

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People use coping mechanisms, also called ego defense mechanisms, to relieve anxiety. They are usually unconscious; that is, the client is not aware of their use. Watch for excessive use of these mechanisms.

Therapeutic Communication

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Show positive regard for the client. Give eye contact without staring.

• • • • •
Grief

Show empathy and genuine caring. Show respect. Use open-ended questions. Be aware of your own body language. Appear relaxed. Use an open body posture. Do not cross your arms. Respect confidentiality.

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The distinction between grieving and depression can be a matter of degree. Look for signs of clinical depression. Grieving takes time; the amount of time varies with individuals. The stages of grief are not linear; they may come and go. Grief follows death; but also follows divorce, loss of job, loss of financial status, loss of limb or other physical disability, etc. Chronic grief is an exaggerated, prolonged grief response characterized by efforts to keep the deceased alive; chronic grief does not reach resolution. The mourner is unable to get on with life. Pay attention to culturally diverse ways of responding to grief. This is important in assessment of grief reaction and in respecting the customs and rituals of a cultural group. Encourage client and family to talk about their feelings. Beware of personal reaction to death and over identification with client. When necessary, seek assistance to cope with personal issues. Teach clients and their families about the up-and-down process of grieving. Refer to appropriate support groups

Stress Management

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Severity of reaction to a stressor depends on how it is interpreted/perceived by the individual, the meaning or significance given to it. Learn about support groups in your community for appropriate referral. Stress is a normal part of life. People differ in how they cope with stressors. Physical and emotional stressors trigger the same stress response; however the magnitude of the response may vary. There are individual differences in response to same stress. Duration and intensity of physiologic indicators are directly related to the duration and intensity of the stress. Stress is classified as mild, moderate or severe. Prolonged stress decreases the adaptive capacity of the body. There are limits to a client's ability to handle stress. Schizophrenia is the most common psychotic disorder. It originates from complex genetic, biological, and psychosocial factors. Extrapyramidal side effects of antipsychotic medications must be treated. Depression can be mild, moderate, or severe. Mild depression is often undiagnosed. Antidepressants take 2 to 3 weeks to take effect. Many people have fleeting thoughts of killing themselves at some point in their lives. Cognitive Triad of Depression - negative view of self, negative view of the world, negative view of the future. Anorexia nervosa and bulimia are conditions that primarily occur among adolescent and young women. The 3 phases of a therapeutic relationship are: (1) initial phase, (2) working phase and (3) termination phase. AmbivalenceAnticipatory griefAutismBiofeedback Catharsis Confrontation Dementia Distress Kinesics MeditationMelancholia Milieu Neologism Obsessions Paranoia Relaxation Response Withdrawal Autonomic System Cardiopulmonary Resuscitation External Chest COVPression

Question Number 1 of 20 A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first? A) B) C) D) Ask client if there are any old injuries also present Interview the client without the persons who came with the client Gain client's trust by not being hurried during the intake process Photograph the specific injuries in question

The correct answer is B: Interview the client without the persons who came with the client It is critical to separate the client from their partner or significant other. With the use of the nursing process the nurse’s first action when a client is unstable or has potential problems is further assessment of the situation Question Number 2 of 20 Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A) B) C) D) "You look upset. Would you like to talk about it?" "I'd like to know more about your family. Tell me about them." "I understand that you lost your partner. I don't think I could go on if that happened to me." "You look very sad. How long have you been this way?"

The correct answer is A: "You look upset. Would you like to talk about it?" Giving broad opening statements and making observations are examples of therapeutic communication. The other options are too specific or focused to be therapeutic. Question Number 3 of 20 Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? A) B) C) D) "I think all children should have their heads shaved." "I have been restricted in thought and harmed." "I have powers to get you whatever you wish, no matter the cost." "I think all of my contacts last week have attempted to poison me."

The correct answer is C: "I have powers to get you whatever you wish, no matter the cost." Grandiosity is characteristic of a manic episode.

Question Number 4 of 20 Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence? A) B) C) D) "I am determined to leave my house in a week." "No one else in the family has been treated like this." "I have only been married for 2 months." "I have tried leaving, but have always gone back."

The correct answer is D: "I have tried leaving, but have always gone back." Victims develop a high tolerance for abuse. They blame themselves for being victimized. All members in the family suffer from the effects of abuse, even if they are not the actual victims. For these reasons, victims often have an extensive history of abuse and struggle for a long time before they can leave permanently Question Number 5 of 20 A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? A) The results of a standardized tool that measures depression B) Observation of affect and behavior C) Inquiry about use of alcohol D) Family history of emotional problems or mental illness Question Number 5 of 20 A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? A) B) C) D) The results of a standardized tool that measures depression Observation of affect and behavior Inquiry about use of alcohol Family history of emotional problems or mental illness

The correct answer is B: Observation of affect and behavior Although it is important to begin an assessment for depression immediately, the assessment should not be aggressive unless the nurse has confirmed the observation of the family member or if there are concerns about the risk of suicide

Question Number 6 of 20 A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do?

A) The refusal of any treatment for self and the neonate until she talks to a reader

The placement of a rosary necklace around the neonate's neck and not to remove it unless absolutely necessary Arrange for a church elder to be at the emergency department when the ambulance arrives so a C) "laying on hands" can be done Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the D) name of the father, the son and the holy spirit. Amen." B) The correct answer is D: Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen." Infant baptism is madatory in the Roman Catholic belief especially if a neonate is not expected to live. Anyone may perform this if an infant or child is gravely ill. Option A refers to the Christian Science belief. Option B is a belief of Russian Orthodoxy. Mormons believe of devine healing with the laying on of hands, as represented in option C. Question Number 7 of 20 A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is A) B) C) D) "I apologize for the delay. I was involved in an emergency." "Let's talk. Why are you upset about this?" "I am surprised that you are upset. The request could have waited a few more minutes." "I see this is frustrating for you. I have a few minutes so let's talk."

The correct answer is D: "I see this is frustrating for you. I have a few minutes so let''s talk." This is the best response because it gives credence to the client''s feelings and then concerns. Option B does not acknowledge or validate the client''s feelings. Question Number 8 of 20 An American Indian chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague "I wonder if he has any idea how ridiculous he looks -he's a grown man!" The nurse's response is an example of . A) Discrimination B) Stereotyping C) Ethnocentrism D) Prejudice The correct answer is D: Prejudice Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group, or culture that limit a full and accurate understanding of the individual, culture, gender, race, event, or situation. Question Number 9 of 20 During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice? A) B) C) D) "I wonder who is paying for this trip to the hospital?" "I think she needs to go to the city hospital." "All those people indulge in large families!" "Doesn't she know there's such a thing as birth control?"

The correct answer is D: "Doesn''t she know there''s such a thing as birth control?"

Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group, or culture that limit a full and accurate understanding of the individual, culture, gender, race, event, or situation. Question Number 10 of 20 A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action? After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist B) The elders may be with the client during the process of the client dying and no last rites are given The family must be with the client during the process of dying and be the only ones to wash the C) body after death D) The body is ritually cleansed and burial is to be as soon as possible after the death occurs A) The correct answer is A: After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client''s wirst This action indicates a blessing in the practice of Hinduism. The family of a client who has the belief of Hinduism is particular about who touches the dead body and cremation is preferred. Also last rites are carefully prescribed. The actions in option B are expected with persons from the Church of Jesus Christ of Latter Day Saints (also known as Mormon). Also with this belief cremation is discouraged. Option C lists practices of the Islam religion. In addition only the family and friend may touch the body. Option D lists practices of Judaism. In addition autopsy is prohibited and organ donation or transplants are first approved by a rabbi

Question Number 11 of 20 A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be A) B) C) D) "These pills aren’t antacids since they are all different." "Some teenagers use pills to lose weight." "Tell me about your week prior to being admitted." "Are you taking pills to change your weight?"

The correct answer is C: "Tell me about your week prior to being admitted." This is an open-ended question which is nonjudgemental and allows for further discussion. The topic is also nonthreatening yet will give the nurse insight into the client''s view of events leading up to admission. It is the only option that is client centered. The other options focus on the pills Question Number 12 of 20 An elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in calling the

daughter from daily to once a week, and the client's tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients? A) B) C) D) An adolescent who was admitted the day before with acute situational depression A middle aged person who has been on the unit for 72 hours with a dysthymia An elderly person who was admitted 3 hours ago with cycothymia A young adult who was admitted 24 hours ago for detoxification

The correct answer is B: A middle aged person who has been on the unit for 72 hours with a dysthymia The findings suggest a client who is depressed. The most therapeutic mileu or environment for this client would be the client with a similar problem and a client that might be more stable. A secondary consideration is to match the age as close as possible. The client in option A has depression and would be more likely to be unstable since they have been in the agency for 24 hours. Dysthymia is defined as a mild depression with findings of trouble falling asleep or no difficulty falling asleep but then wakes up in the middle of the night and with difficulty is able to fall back asleep. Cycothymia is the occurance of periods for behaviors that do not meet the criteria for manic or major depressive episodes Question Number 13 of 20 A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states “everyone’s life is in God's hands.” The next action for the nurse to take is to A) B) C) D) Report the situation to the health care provider Discuss the situation with the client's family Ask the client if talking with a priest would be desired Document the situation on the notes

The correct answer is C: Ask the client if talking with a priest would be desired Beliefs regarding pain are one of the oldest culturally related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health-care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework. Question Number 14 of 20 An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? A) B) C) D) Help the student to identify a specific problem Ask the parent to identify the major problem Ask the student to think of different alternatives Examine with the parent a varitey of options

The correct answer is B: Ask the parent to identify the major problem If a client is unable to participate in problem solving because of developmental delays or altered mental status, then crisis intervention should not be attempted. However the family can be approached with the use of crisis intervention methods. The crisis intervention method includes 5 steps: identify the problem and then the alternatives, selection of an alternative, implementation, and evaluation. Question Number 15 of 20 A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as A) Perseveration

B) Circumstantiality C) Neologisms D) Flight of ideas The correct answer is D: Flight of ideas Flight of ideas is characterized by over productivity of talk and verbal skipping from 1 idea to another. It is classic with clients diagnosed as bipolar disorder and occurs in the manic state of this disease. Question Number 16 of 20 Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? The client A) B) C) D) Has revitalized a relationship with her family to help cope with the death of a daughter Had recognized regressive behavior as a defense mechanism Expresses a desire to be cared for and pampered Recognizes feelings with appropriate expression of feelings

The correct answer is D: Recognizes feelings with appropriate expression of feelings During the working phase, the client is able to focus on pleasant or unpleasant feelings and express them appropriately. Question Number 17 of 20 A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? A) B) C) D) Depression Anger Frustration Disbelief

The correct answer is D: Disbelief The first phase of the grieving process is shock, denial or disbelief. Then follows anger, bargaining, depression and acceptance. Each stage can take any amount of time to work through. Clients often go back and forth the stages before acceptance occurs. Some client get stuck in 1 or 2 of the stages. Question Number 18 of 20 A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time? A) B) C) D) Allow the client to randomly move about the holding area until a hosptial room is available Engage the client in an activity that requires focus and individual effort Isolate the client in a secure room until control is regained by the client Locate a room that has minimal stimulation outside of it for admission process

The correct answer is D: Locate a room that has minimal stimulation outside of it for admission process This intervention allows the client with moderate anxiety to have human contact in an environment with minimal stimulation. It also facilitates efficiency in the initial screening and admission process to the emergency department.

Question Number 19 of 20 A client diagnosed with anorexia nervosa states after lunch, "I shouldn’t have eaten all of that sandwich, I don’t know why I ate it, I wasn’t hungry." The client’s comments indicate that the client is likely experiencing A) B) C) D) Guilt Bloating Anxiety Fear

The correct answer is A: Guilt If people with anorexia lose control and eat more than they believe to be appropriate, they experience guilt. Question Number 20 of 20 A nurse states: "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of A) B) C) D) Prejudice Discrimination Stereotyping Racism

The correct answer is C: Stereotyping Stereotyping refers to placing people and institutions, mentally or by attitudes, into a narrow, fixed trait, rigid pattern, or within inflexible "boxlike" characteristics. Stereotyping is one of the most common concerns of nurses when they begin to study different cultures and learn about transcultural nursing.

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