N292: QUIZ ONE STUDY GUIDE (34 QUESTIONS Communication Techniques (2 Questions): Therapeutic o Using silence: allows client

t to take control of the discussion Nodding; maintaining eye contact o Accepting: conveys positive regard Yes, um-hmm, I follow what you said o Giving recognition: acknowledging, indicating awareness I noticed youve combed your hair. I see youre dressed this morning o Offering self: making oneself available Ill sit with you Ill stay with you for 15 minutes o Giving broad openings: allows client to select the topic Where would you like to start? What is on your mind this morning? o Offering general leads: encourages client to continue And then? Go on o Placing event in time or sequence: clarifies the relationship of events in time Was that before or after? What happened just before that? o Encouraging description of perception: asking client to verbalize what is being perceived What is happening? Describe what you are hearing o Encouraging comparison: asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships Has this happened before does this remind you of anything? o Restating: lets client know whether an expressed statement has or has not been understood o Reflecting: directs questions or feelings back to client so that they may be recognized and accepted Are you wondering if? Do you think that? o Focusing: taking notice of a single idea or even a single word o Exploring: delving further into a subject, idea, experience, or relationship Tell me more about that. Describe that to me o Seeking clarification and validation: striving to explain what is vague and searching for mutual understanding Im not sure I follow what you are saying. Do you mean to say that? o Presenting reality: clarifying misconceptions that client may be expressing I dont hear anyone talking I am your nurse, this is a hospital o Voicing doubt: expressing uncertainty as to the reality of clients perception I find that hard to believe. That seems quite unusual o Verbalizing the implied: putting into words what client has only implied

Attempting to translate words into feelings: putting into words the feelings the client has expressed indirectly o Formulating plan of action: striving to prevent anger or anxiety escalating to unmanageable level when stressor recurs How might you handle this next time? What are some safe ways you could express your anger? o Summarizing: clarifying main points of discussion and providing closure Today I have understood you to say Nontherapeutic o Reassurance: indicating there is no cause for concern; may discourage client from further expression of feelings if client believes the feelings will only be downplayed or ridiculed Youre going to be fine. I wouldnt even worry about that if I were you. o Rejecting: refusing to consider clients ideas, feelings or behavior I dont want to hear about that. Lets not discuss depressing subjects o Approving or disapproving: implies that the nurse has the right to pass judgment on the goodness or badness of client behavior Oh yes, thats what Id do. Thats good o Agreeing or disagreeing: implies that the nurse has the right to pass judgment on whether clients ideas or opinions are right or wrong o Giving advice: tell the client what to do; implies that the nurse knows what is best for client and that client is incapable of any self-direction. I think you shouldwhy dont you? o Probing: asking persistent questions; pushing for answers to issues client does not wish to discuss causes client to feel used and valued only for what is shared with nurse tell me your psychiatric history o Defending: to defend what client has criticized implies the client has no right to express ideas, opinions, or feelings All staff here is caring people. Your doctor is the best in the city o Requesting an explanation: asking for reasons; asking why implies the client must defend his or her behavior or feelings Why would you say a thing like that? Why do you feel that way? o Indicating the existence of an external source of power: encourages client to project blame for his or her thoughts What made you do that? What makes you say that? o Belittling feelings expressed: dismissing importance of clients feelings (usually an attempt to be cheerful) causes client to feel insignificant or unimportant o Making stereotyped comments, clichs, and trite expressions: meaningless in a nurseclient relationship Tomorrow will be a better day. This too shall pass. o Using denial: blocks discussion with client and avoids helping client identify and explore areas of difficulty

o o

Interpreting: results in therapist telling client meaning of his or her experience. Introducing an unrelated topic: causes the nurse to take over the direction of the discussion.

Defense Mechanisms (1 question): Compensation: over achievement in one area to offset real or perceived deficiencies in another area o Student with little interest in sports works hard to be on honor roll Conversion: expression of emotional conflict through development of a physical symptom o Child who is expected to go to college develops blindness but is unconcerned about it Denial: failure to acknowledge obvious ideas, conflicts, or situations that are emotionally painful or anxiety provoking o Person with newly diagnosed terminal illness is cheerful and makes no mention of illness Displacement: ventilation of intense feelings toward persons less threatening than the one9s) who aroused those feelings o Person who is mad at the boss yells at his/her spouse Identification: unconscious modeling of the behaviors, attitudes, and values of another person o Teenager espouses beliefs and behavior of an admired relative, although unaware of doing so Intellectualization: separation of emotion of a painful event or situation from the facts involved; acknowledging the facts but not emotion o Person involved in a serious car accident discusses what happened with no emotional expression Introjection: acceptance of another persons values, beliefs, and attitudes as ones own; act like someone else o Person who dislikes guns becomes an avid hunter, just like best friend Projection: attributing unacceptable thoughts, feelings or actions to someone else o Person with many prejudices loudly identifies others as bigots Rationalization: justification of unacceptable thoughts, feelings or behavior with logical sounding reasons o Student cheats on test and claims everyone does it, therefore it is necessary to cheat to be able to get passing grades Reaction formation: unacceptable thoughts and feelings are handled by exhibiting the opposite behavior o Person with sexist ideas does volunteer work for a womans organization Regression: go backward in developmental level; act like a child Repression: exclusion of emotionally painful or anxiety provoking thoughts and feelings from conscious awareness Sublimation: substitution of socially acceptable behavior for impulses or desires that are unacceptable to the person

o Person who is trying o stop smoking chews gum constantly Suppression: conscious exclusion of unacceptable thoughts and feelings from conscious awareness o Student decides not to think about a parents illness in order to study for a test Undoing: exhibiting acceptable behavior to make up or negate previous unacceptable behavior o Person who has been cheating on a spouse sends the spouse a bouquet of roses Nurse-Client Relationship (3 questions): Therapeutic nurse-client relationship: must have mutual respect, and be purposeful, goal oriented, and client focused. Essential conditions for development of relationship include: o Rapport: acceptance, warmth, interest o Trust: basis of therapeutic relationship o Respect: positive regard o Genuineness: honest, real, truthful o Empathy: communicate understanding of clients thoughts or feelings o Sympathy: shared feelings; less objective; focus on relieving nurses distress Transference: client transfers feelings and behavioral dispositions formed towards a person from past; how patient feels and acts towards nurse Counter transference: nurses behavioral and emotional response to client; signs of counter transference: o Over-identifying with client o Social or personal relationship o Give advice o Encourages dependence o Uncomfortable with client o Difficulty setting limits o Defends client to other staff Phases: o Pre Interaction: review record; consider own feelings, attitude o Orientation: establish trust, set goals, collect data, develop plan o Working: promote insight, problem solve, overcome resistance o Termination: make plans for continuing care, share feelings. Legal/Ethical Issues (2 questions): Scope of practice: includes legal boundaries set by the state and standards set by ANA o State practice act provides legal definition o ANA Standards of Nursing Practice Act Assessment quality of practice Diagnosis education Outcomes identification practice evaluation Planning collegiality

 collaboration ethics research resource utilization leadership ANA code of ethics: respect, dignity, privacy, protection of information, protection of patients health & safety, accountability, professional relationships o Guiding principles of ethics: Autonomy: clients right to make decisions Beneficence: act in clients best interest; do no harm Justice: treat people equally and fairly Veracity: tell t he truth Nonmaleficence: avoid causing harm Confidentiality: non-disclosure of information with which we are entrusted Informed consent: (principle of autonomy) must have capacity to understand, be informed of choices, risks, side effects, and alternatives, document discussion Patient rights: humane treatment, adequate staff, therapeutic setting, participate in treatment plan, safe discharge plan, least restrictive environment, advanced directives, refuse treatment (including medications) Implementation evaluation Conceptual Frameworks for Treatment and Personality Development (4 questions): Conceptual Model: framework of related concepts o Ericksons eight stages of Man: personality develops through stages which over lap, and individuals work on tasks from more than one stage at a time. May become fixed in a certain stage and remain developmentally delayed; however it is possible for behaviors to be modified and corrected in a later stage Trust vs. Mistrust (0-1) Autonomy vs. Shame and doubt (1-3); separation from parent, starts to get control over environment Initiative vs. guilt (3-6) Industry vs. Inferiority(6-12) Identity vs. Role confusion (12-18) Intimacy vs. Isolation (18-25) Generativity vs. stagnation (25-45); focuses on doing something productive Ego integrity vs. Despair (45-death) o Maslows Hierarchy: works upward Self Actualization (feeling of self-fulfillment & realization of potential) Self-esteem & esteem of others Love & belonging Safety & security Physiological Needs o Psychoanalytical Model (Freud)

Levels of consciousness: conscious, preconscious, unconscious (largest level) Structure of personality: Id, ego, super ego Psychosexual development: Oral (nursing baby), Anal (potty training), Phallic (sexual interests) Genital (reproduction) Interpersonal model (Sullivan) Persons relationship with others, need for satisfaction & security, dynamisms, anxiety as a central factor, security operations (apathy, preoccupation), self concept (good me, bad me not me) Theory of Object Relations (Mahler) Based on separation; the individuation process of infant from the maternal figure or primary caregiver Phase I: Autistic Phase II: Symbiotic Phase III: Separation/individuation o Differentiation (5-10 months) o Practicing (10-16 months) o Rapprochement (16-24months); if emotional needs not met results in fear of abandonment o Consolidation (24-36 months)- mother seen as separate but loving person; able to integrate good and bad Attachment theory (Bowlby) Attachment refers to a lasting emotional bond between infant & caregiver Secure attachments linked to ability to modulate stress, tolerate frustration & develop intimate relationship; affect development of right hemisphere of brain (limbic system) Behavioral Model (Pavlov & Skinner): any therapy that work with shaping behavior Classical conditioning(Pavlov- dog/bell): involuntary behavior associated with event Operant Conditioning(skinner): voluntary behavior related to environment Increasing desired behavior with positive (rewards) and Negative (undesired stimulus) reinforcement Decreasing a behavior by punishment, response cost & extinction Cognitive Model: any therapy that works with changing behavior and how someone thinks about something distorted or negative thought patters -> maladaptive feelings and behaviors; patterns of thinking are learned& become automatic Neurobiological Model: neurons, transmitters, receptors Brain & nervous system basic to understanding mental illnesses and disorders Neurotransmitters: chemical signal that activate postsynaptic receptors

Mental Status Exam (3questions):

 B.E.S.T. o Behavior and general appearance o Emotions: mood and affect o Speech: rate, style, tone, oddities o Thought content/ process, obsessions, circumstantiality, tangentiality, flight of ideas, thought blocking, confabulation, concrete vs. abstract P.I.C.K. o Perceptual disturbances: illusions (misinterpretation of stimulus), hallucinations (hear or see something no one else sees), depersonalization, derealization o Impulse control o Cognition & Sensorium: level of consciousness, orientation, concentration, memory, MMSE, intellectual functioning o Knowledge, insight judgment ABCS o Appearance & Affect Clothing, neatness, cleanliness, makeup, hygiene, grooming, odor; overall physical appearance/health Stated mood, appropriate/inappropriate, attitude toward interviewer range (depth or diversity): wide/full, constricted/narrow, blunted/flat Stability (change)L stable/consistent, labile/rapidly changing o Behavior Activity, gait, abnormal movements, coordination, pace, energy level, posture, restless arm/leg movements o Cognitive Functioning Intellect Attention and concentration: sufficient/deficient, easily distracted, short attention span, poor concentration o Test: serial sevens, repeat series of numbers forwards & backwards, spell WORLD backwards Capacity for abstraction: ability to abstract or concrete thinking o Test: give meaning of 2 proverbs; explain how 2 items are similar Fund of knowledge: adequate/inadequate o Test: name 5 large cities in U.S.; name current president, governor Insight: present or absent o Test: understanding of why they are in the hospital; what they see as their problem Orientation: to person, place, time o Test: ask name, where they are and date Short-term Memory: intact or impairs

o Speech

Test: repeat names of 3 objects immediately and after 5 minutes Judgment: good, fair, poor o Test: what would you do if discovered fire in a movie theater or if found stamped, addressed envelope in the street Thought Clarity: coherent, incoherent, confused, vague, unclear in meaning Content: rhymes, homicidal or suicidal ideation, delusions, hallucinations, ideas of reference, paranoia, obsessions, compulsions, grandiosity, phobias Flow: spontaneous, guarded, blocking, flight of ideas, tangential, circumstantial, poverty of thought (single word answers) Level of Consciousness Describe as alert, responsive, drowsy, stuporous, comatose Amount: talkative, taciturn, silent Rate: rapid, fast, slow, hesitant Clarity: clear, slurred, mumbling, lisping Pressure: pressured, intense, explosive Volume: loud, soft, whispering, inaudible

DSM (1 question) Axis I: Clinical disorders o Primary Issue they are dealing with Axis II: Personality disorders and mental retardation Axis III: Physical or Medical disorders Axis IV: Psychosocial and environmental factors o Social stressors: divorced, homeless, unemployed Axis V: Global Assessment of Functioning (scale 1-100)

Schizophrenia (10 questions) including application of nursing process, antipsychotic meds (general & side effects, not specific meds) Schizophrenia Psychotic symptoms for at least 6 months not related to medical condition or substance use Impaired social, academic and occupational functioning Can be single episode, episodic, continuous, in full or partial remission Paranoid type suspicious, may be argumentative, auditory hallucinations are common

Disorganized type (hebephrenic) regressed, giggling, bizarre behavior, impaired socialization and affect, incoherent communication Catatonic type extreme psychomotor retardation (stupor) or purposeless movements (excitement) Undifferentiated bizarre behavior, hallucinations, delusions, incoherent speech (not fit other types)

Schizophrenia disturbs Thought processes (delusions) Perception (hallucinations) Affect (impaired socialization) Speech & Behavior (disorganized, bizarre)

Premorbid Phase shy, withdrawn, few friends, poor school performance Prodromal phase poor functioning, non-specific symptoms, thought & perceptual disturbance develop late in this phase Active phase Psychotic symptoms are prominent Delusions Hallucinations Disorganized speech and behavior Impairment in work, social relations, and self-care

Residual phase Follows an acute episode Symptoms similar to prodromal phase Flat affect and impairment in role functioning are prominent Negative symptoms remain

Positive Symptoms Hallucinations Illusions

Negative Symptoms Affective flattening Apathy

Delusions

Anhedonia

Thought disorders

Avolition

Disorganized speech and behaviors

Ambivalence

Attentional problems

Alogia

Appearance deteriorated

ABCs of Mental Status Appearance & Affect Behavior Cognitive Functioning Speech

Thought Content Delusions False personal beliefs Inconsistent with reality Not generally accepted by others with same cultural background Content relates to underlying anxiety or fear

Types of Delusions (False Beliefs)

Delusions of Persecution (threatened) Delusions of Grandeur (special powers) Delusions of Reference (insignificant remarks have personal meaning newspaper headlines) Delusions of Control (another person controls thoughts, behavior) Somatic Delusions (about bodily function disease, pregnancy) Nihilistic Delusions (nonexistence of self, world ending)

Other types of thought disturbance Perceptions Hallucinations - False sensory perceptions Auditory (most common in schizophrenia) Visual Tactile Religious Preoccupation (use religious ideas to explain behavior) Paranoia (suspicious; food poisoned) Magical Thinking (thoughts or behavior can cause or prevent something happening) Looseness of association Unrelated topics Nonsensical speech -Neologisms new words Concrete thinking literal interpretations Clang associations often rhyming Word salad random words without meaning Repeat anothers words Echolalia Circumstantiality overly detailed Tangentiality unrelated topics; doesnt get to the point Mutism inability or refusal to speak Perseveration repeats same word or idea

Olfactory Gustatory Kinetic

Illusions misperceptions of real external stimuli

Disorganized Behavior Repeat actions of others Echopraxia Repeat words - Echolalia Catatonia decreased reactivity to surroundings Complications Risk of Suicide Risk of Chronic Fluid Imbalance polydipsia, water intoxication, seizures, hyponatremia, (heavy smoking increases risk) Medication side-effects Catatonic stupor (immobility, posturing, waxy flexibility, mutism) Excitement (unprovoked, excessive motor activity)

Nursing Diagnoses Outcomes Will not harm self or others Will shower and wash clothes Will be compliant with medications Will exhibit less agitated behavior Will decrease hallucinations

Interventions Establish trusting relationship Frequent, short contact Monitor symptoms & intervene early

Facilitate adherence to medications Distract client from hallucinations Provide safe, structured environment and reduce stimuli in environment Connect symptom improvement to medication effect Individual approach rather than group Risk for violence: Protect client from harming self or others Decrease stimuli Remove dangerous objects Provide physical outlets Medications Observation Assess for suicidal ideation

Disturbed thought processes (delusions): Reassure in safe place Help identify underlying anxiety (may reduce delusions) Accept but do not share belief Dont challenge delusions (they are not rational) Use reasonable doubt Talk about real events and people; Evaluate but dont dwell on irrational thoughts Provide reality based activities If suspicious, avoid touch, laughing or talking where client can see but not hear If suspicious, use same staff as much as possible

Disturbed sensory perception (Hallucinations):

Observe for signs client is hallucinating Early interventions can prevent aggression Evaluate content of hallucinations (commands) Do not touch without warning; allow space Accepting, non-judgmental attitude Do not reinforce hallucination, say voices Reassure voices may be frightening, but not real Help client learn relationship between anxiety and the hallucination; explore what precipitates hallucination Provide reality based activities to help distract from hallucinations and reduce anxiety

Impaired verbal communication: Seek validation & clarification (Do you mean...?) Give feedback (I do not understand what you mean.) Helps client see he is not understood and engages client in improving communication Consistent staff assignments to promote trust Convey empathy: Verbalize the implied; That must have been upsetting. Anticipate and meet clients needs for safety and comfort until able to communicate effectively Orient to reality; call by name

Social Isolation Acceptance Brief, frequent contacts Slow introduction to group activities Initially accompany to groups to help client feel more secure Give recognition for interactions with others

Evaluation Absence of threats to safety of self and others

Takes medications as prescribed Interacts appropriately with others Participates in unit activities and groups Begins to modify responses to hallucinations

Antipsychotic Meds Typical Atypical

Chlorpromazine (Thorazine) Thioridazine (Mellaril)

Risperidone (Risperdal)

Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Clozapine (Clozaril) Aripiprazole (Abilify)

Fluphenazine (Prolixin) Perphenazine (Trilafon) Trifluoperzine (Stelazine) Thiothixene (Navane) Haloperidol (Haldol)

**** DepotLong acting preparations Fluphenazine decanoate (Prolixin) Haloperidol decanoate (Haldol) Risperidone microspheres (Risperdal Consta)

Symptoms Controlled by Antipsychotics Agitation Apathy* Delusions Emotional withdrawal* Feelings of unreality Hallucinations Ideas of reference Lack of motivation* Lack of pleasure* Lack of spontaneity* Paranoia Racing thoughts Rage Severe impulsiveness Social discomfort or isolation* Unclear thoughts Uncontrollable hostility Uncontrollable negativism

Common Side Effects EPS Orthostatic Hypotension Sedation Weight Gain Temperature Dysregulation Neuroleptic Malignant Syndrome Photosensitivity Seizures (Typicals, Clozaril) Hypergylcemia (Atypicals) Hypercholesterolimia Hypertriglycerides Diabetes mellitus Agranulocytosis (Clozaril) Myocarditis (with Clozaril) Prolonged QT (Invega, Geodon)

Antidyskinetic meds (3) Used to treat muscular side effects of Antipsychotics Benztropine (Cogentin) Biperiden (Akineton) Orphenadrine (Norflex) Diphenhydramine (Benadryl) Procyclidine (Kemadrin) Trihexyphenidyl (Artane)

Amantadine (Symmetrel)

Med math (1). n c r e a s e d s a l i v a t i o n ( A b i l i f y , C l o z a r i l )