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What does a mental health assessment consist of? · physical assessment · psychosocial history · mental status exam · screening tools What does a psychosocial history consist of? · cultural/religious/spiritual considera9ons · support systems · diet · sleep pa:erns · depression, anxiety, thoughts of suicide · coping mechanisms · alcohol/recrea9onal drug/tobacco use · physical ac9vity · medica9on history · use of vitamins/supplements/otc meds · "feel safe at home?" What does a mental status examina9on (mse) consist of? · loc · physical appearance · behavior
MH - EXAM 1 (ACTUAL
QUESTIONS AND ANSWERS)
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· cogni9ve/intellectual · gcs What does a mini-mental state examina9on (mmse) consist of? · orienta9on to 9me & place · a:en9on span, ability to count backward · memory & recall · language, ability to write · pain!! What standardized tool would you use with mentally ill children? · headss (home, environment, educa9on/employment, ac9vi9es, drug & substance use, sexuality, suicide/depression, safety) What standardized tools would you use with mentally ill older adults? · geriatric depression scale · michigan alcoholism screening test for geriatric clients What is the diagnos9c & sta9s9cal manual of mental disorders (dsm-5)? American psychiatric associa9on manual
- used to iden9fy mental health diagnosis and standardized assessment findings What are the rights of the mental health pa9ent? · humane treatment · right to medica9on/dental care · right to vote, obtain a driver's license · right to legal services What are some specific mental health rights for pa9ents? · right to have consent for treatment & refusal · interpreter services · confiden9ality
· client enters facility against their own will for an indefinite period of 9me · client must be evaluated by a judge · up to 60 days What is long-term involuntary admission? Must be imposed by courts, 60-180 days Which type of pa9ent is seclusion contraindicated? Suicidal pa9ents What are the limits for seclusion? · 18 & older - 4 hr · 9-17 yr - 2 hour · 8 & younger - 1 hour What are the inten9onal torts? · false imprisonment · assault · ba:ery What is an example of false imprisonment? Confining a pa9ent to a seclusion room What is an example of assault? Making a threat to a client What is an example of ba:ery? Touching a client in a harmful way What are the uninten9onal torts? · negligence · malprac9ce What is an example of negligence? A pa9ent needs cpr, and it was not given to them in a 9mely manner What is an example of malprac9ce?
Medica9on error Characteris9cs of the therapeu9c milieu - physical seang · unit should be clean · seang should include comfortable furniture · color scheme should be appropriate for client age · floors such be a:rac9ve, clean & safe · traffic-flow considera9ons should be conduc9ve to client & staff movement Characteris9cs of the therapeu9c milieu - health care team member responsibili9es · promote independence for self-care & growth · treat clients as individuals · allow choices for clients · apply rules of fair treatment · model good social behavior · work coopera9vely as a team · maintain boundaries · promote safe & sa9sfying peer interac9ons · prac9ce open communica9on techniques · promote feelings of self-worth & hope Characteris9cs of the therapeu9c milieu - emo9onal climate · clients should feel safe from harm · clients should feel cared for & accepted by staff What are the roles of the nurse in a therapeu9c nurse-client rela9onship? · embrace an aatude of life-long learning · remain pa9ent-centered · encourage posi9ve behaviors · be empathe9c
· express own feelings about sessions to validate experience with client · make plans for future & accept termina9on as final Focus & goals for individual therapy? · focus on needs & problems, create therapeu9c rela9onship · be:er decision-making strategies to help live produc9ve lives, develop strong sense of self Focus & goals for group therapy? · help develop healthy rela9onships within a group seang · learn about self & others, improve quality of life, gain coping skills, improve interpersonal rela9onships, decrease isola9on, obtain feedback Focus & goals for family therapy? · focus on needs of family & improve func9oning for each member · learn how to deal with mental illness within family, improve understanding Role of community seang (primary care) for mental health care? · includes clinics, schools, & day-care centers, par9al hospitaliza9on, substance treatment facili9es, & home healthcare · nurses help to stabilize or improve clients' mental func9oning within a community. Also teach, support, & make referrals What is the role of telehealth? · meets the needs of those who cannot a:end physical in-person treatment · many clients use telehealth as their primary means of receiving treatment What is the maintenance role in group therapy? · help maintain purpose & process of the group (ex. Harmonizer a:empts to prevent conflict) What is the task role in group therapy? · take on various tasks, such as being the recorder of sessions What is the individual role in group therapy?
· tend to prevent teamwork b/c individuals take on roles to promote their own agenda (ex. Dominator trying to control other members) Blaming in dysfunc9onal families Members blame others to shig focus away from themselves Manipula9ng in dysfunc9onal families Members use dishonesty to support their own agendas Placa9ng in dysfunc9onal families One member takes responsibility for problems to keep peace at all costs Distrac9ng in dysfunc9onal families A member inserts irrelevant informa9on during a:empts at problem-solving Generalizing in dysfunc9onal families Members use overall descrip9ons (always, never) in describing encounters Scapegoa9ng A member of the family with li:le power is blamed for problems within the family Triangula9on A third party is drawn into the rela9onship with two members whose rela9onship is unstable What is schizophrenia? Psycho9c thinking for at least 6 months. Areas of func9oning are significantly impaired.
- affects how people perceive reality, think, and act socially What is schizoaffec9ve disorder? The client's disorder meets the criteria for both schizophrenia & depressive or bipolar disorder What is psychosis?
Lack of pleasure or joy Avoli9on Lack of mo9va9on in ac9vi9es & hygiene Ideas of reference delusion Believing others are talking about them Persecu9on delusion Belief that others are out to get them, hunted by the mi Grandeur delusion Believes they are like a god Thought broadcas9ng delusion Believes their thoughts are being heard by others Thought withdrawal delusion Believes that their thoughts have been removed from their mind by an outside agency Thought inser9on delusion Believes the others' thoughts are being inserted into their mind Religiosity delusion Obsesses with religious beliefs Magical thinking Believes their ac9ons or thoughts are able to control a situa9on or affect others What is the most dangerous type of hallucina9on and how would you ask the client about this? Command hallucina9ons: "are the voices telling you to do this?" Gustatory hallucina9ons Experiencing tastes Tac9le hallucina9ons Feeling bodily sensa9ons
Associa9ve looseness (flight of ideas) altera9ons in speech Client may say sentence ager sentence but each may relate to a different topic and the listener is unable to follow the clients thoughts Neologisms altera9ons in speech Made-up words that have meaning only to client Echolalia altera9ons in speech The client repeats words spoken to them Clang associa9on altera9ons in speech Meaningless rhyming words - fox, box, lox Word salad altera9ons in speech Words jumbled together with li:le meaning Waxy flexibility altera9ons in behavior Maintaining a specific posi9on for an extended period of 9me Echopraxia altera9ons in behavior Purposeful imita9on of movements made by others (child copying hand movements of mother) Catatonia altera9ons in behavior Pronounced decrease or increase in the amount of movement First-genera9on an9psycho9c medica9on treats which type of schizophrenia symptoms? Only posi9ve symptoms Therapeu9c uses for 1st genera9on (conven9onal) an9psycho9c medica9ons? · tx of acute & chronic psycho9c disorder · preven9on of n/v through blocking of dopamine in the chemoreceptor trigger zone of medulla What are the first-genera9on (conven9onal) an9psycho9c medica9ons?
· hypercholesterolemia · sexual dysfunc9on Clients taking asenapine (2nd genera9on) should avoid ea9ng or drinking for how long ager each dose? 10 min. What are the second-genera9on (atypical) an9psycho9c medica9ons? · risperidone (risperdal) · olanzapine (zyprexa) · clozapine (clozaril) · asenapine Precau9ons for 2nd & 3rd genera9on (atypical)? Use cau9ously with cardiovascular, cerebrovascular, or seizures Therapeu9c uses for 2nd genera9on (conven9onal) an9psycho9c medica9ons? · schizophrenia · management of sx of psycho9c disorders · acute mania associated with bipolar disorder Which class of an9psycho9c medica9ons are contraindicated in older adults who have demen9a? All (1st, 2nd, & 3rd) Olanzapine (zyprexa) nursing considera9ons · smoking decreases effec9veness · comes in short & long ac9ng im injec9on Risperidone nursing considera9ons · lower risk of eps but increased risk for hyperglycemia, metabolic syndrome, orthosta9c hypotension · monitor for malignant syndrome · comes in long-ac9ng im injec9on given every 2-4 weeks
S/sx of metabolic syndrome? · new onset of dm · dyslipidemia with increased risk for htn & other cardiovascular disease Client educa9on for metabolic syndrome · report indica9ons of increased thirst, urina9on, appe9te · follow a healthy, low-calorie diet, engage in exercise, monitor weight gain Clozapine (clozaril) nursing considera9ons Increased risk for agranulocytosis or seizures · monitor wbc, hold & call physician if below 3 S/sx of tardive dyskinesia? · involuntary movements of the tongue & face, such as lip smacking · involuntary movements of arms & legs Tardive dyskinesia nursing ac9ons · once it develops, it usually does not decrease · no reliable tx for td · instruct client that purposeful movement helps to control involuntary td S/sx of neurolep9c malignant syndrome? · sudden high fever · blood pressure fluctua9ons · diaphoresis · tachycardia · muscle rigidity · decreased loc · coma Nursing ac9ons for neurolep9c malignant syndrome · stop an9psycho9c med · monitor vs
Locked eyes, severe spasm of the tongue, neck, face, & back What is an an9dote for acute dystonia? Iv or im an9cholinergic agents (benztropine) Symptoms of akathisia? Tapping foot, rocking forward/backward, pacing What is used to treat akathisia? Benzodiazepine Why do we teach clients to avoid alcohol use and substances alike when taking an9psycho9c medica9ons? Addi9ve cns depressant effects What is the aims scale? Used to monitor involuntary movements & tardive dyskinesia in clients who take an9psycho9c medica9on How do you administer the aims scale? Have client sit in chair with hands on knees, legs slightly apart, & feet flat on floor. Monitor for body movements Denial defense mechanism in neurocogni9ve disorders Both client & family member refuse to believe that changes are taking place (loss of memory) Confabula9on defense mechanism in neurocogni9ve disorders The client makes up stories when ques9oned about events they do do not remember. A:empt to save self-esteem Persevera9on defense mechanism in neurocogni9ve disorders Client avoids answering ques9ons by repea9ng phrases. Another a:empt to save self-esteem Which screening tool is used frequently in alzheimer's pa9ents? Mini mental status exam
Which two screening tools will you interview the pa9ent for alzheimer's? Func9onal assessment screening tool (fast) mini-mental status exam (mmse) Which screening tool is based on family interviews? Blessed demen9a scale Delirium onset? Rapid over a short period of 9me Delirium manifesta9ons? · impairments in memory, ability to focus, judgment, and calculate which fluctuate throughout day · loc fluctuates · restlessness, anxiety, motor agita9on, personality change is rapid · unstable vs · should be considered a medical emergency
- reversible Delirium causes? · ogen associated with hospitaliza9on of older adults · medical condi9ons, malnutri9on fluid & electrolyte imbalances Demen9a onset? Gradual deteriora9on of func9on over months or years Demen9a manifesta9ons? · impairments in memory, judgement, speech, impairments do not change throughout day · loc unchanged · restlessness & agita9on are common · vs are stable Demen9a causes?
· monitor orthosta9c hypotension · monitor i&o for urinary reten9on Donepezil for neurocogni9ve disorders Effec9ve in early stages to slow mild progression Rivas9gmine for neurocogni9ve disorders Available in patch for clients with difficulty swallowing (always take w food) What are the cholinesterase inhibitors? · donepezil · rivas9gmine · galantamine Moa for cholinesterase inhibitors? · improve ability to perform self-care · decreased cogni9ve deteriora9on A/e of cholinesterase inhibitors? · bronchoconstric9on · n/v, diarrhea · can reduce the effec9veness of donepezil · bradycardia, syncope Pa9ent educa9on for cholinesterase inhibitors? · dosage should start low & gradually increase · take at bed9me with or without food · taper dose An9histamines, tricyclic an9depressants, and conven9onal an9psycho9cs can reduce the therapeu9c effects of _______? Donepezil Which medica9on is the only fda approved medica9on for severe alzheimer's disease?
Meman9ne Meman9ne nursing considera9ons · slows brain cell death · can be used with cholinesterase inhibitor · s/e: dizziness, ha, confusion, cons9pa9on Safety issues with demen9a? · malnutri9on · dehydra9on · non-compliance · geang lost: allow for safe pacing · falls: remove sca:er rugs, bed alarms, no cords · burns: turn water heater down Which disorder can mimic a neurocogni9ve disorder in the elderly? Depression List 3 symptoms of depression that mimic demen9a · inability to perform adl's · decreased a:en9on span · difficulty concentra9ng Compare psychosocial and psychosexual theories of development Freud's psychosexual theory emphasizes the importance of basic needs & biological forces, while erikson's psychosocial theory is more focused upon social & environmental factors Describe growth & development Growth: irreversible, constant increase in size development: increased psychomotor capacity both depend on gene9cs, environment & nutri9onal factors Role of the environment in human growth & development?
