List the three foundations that set the standards for client care in the mental health setting
2. American Psychiatric Nurses Association
3. International Society of Psychiatric-Mental Health Nurses
b) holistic approach
f) and spiritual aspects
2. Lethargy- can open eyes & respond but easily falls asleep
3. Obtundation- needs to be lightly shaken, may be confused and slow to respond
4. Stupor- requires painful stimuli to elicit brief response, may not be able to respond verbally
5. Coma- no response achieved via painful stimuli, abnormal posturing may be present
–>*A-L-O-S-C – (all alphabetical except C)*
2. Decerebrate rigidity
2. Decerebrate rigidity – neck & elbow extension, wrist & finger flexion –> Sounds like vertebrae – which is straight, whereas decorticate is all flexed up and twisted in
–> “He says he is in a good mood, but he seems to have such a flat affect all the time”
a) And a score of 3 would represent?
b) A score of 15?
a) Score of 3 = coma
b) Score of 15 = alert, awake, oriented
2. Michigan Alcoholism Screening Test
3. MMSE (all age groups)
4. Wong-Baker FACES pain scale, McGill Pain Questionnaire MPQ, or Pain Assessment in Advanced Dementia scale PAINAD
Axis II – Personality disorders and mental retardation
Axis III – Any General medical diagnosis (ie asthma)
Axis IV – Psychosocial problems that may affect dx, tx, prog
Axis V – Global Assessment of Functioning (GAF)
1. Score 80-100
2. Score 60-80
3. Score 40 and below
4. GAF of 50/80 means what?
2. Score 60-80 = moderate problems
3. Score 40 and below = serious mental/functional disability
4. GAF of 50/80 means what? Patient has gone from near normal fxn of 80 the previous year, down to moderately severe functional disabilities this year
–> Inpatient therapy in psych setting with prescription of social interactions & activities to meet client’s specific needs
2. Judgement – weighing right & wrong to make a decision
3. Knowledge – learned information
4. Memory – remembering past events
What is foundational to the nurse-client relationship?
2. Interpersonal – between 2+ people
3. Public Communication – large group setting
4. Transpersonal Communication – addresses spiritual needs of an individual
2. Denotative/connotative meaning
2. Denotative/connotative meaning – denote=define (words is what it seems), connotate=representative meaning
3. Clarity/brevity – short, simple, effective communication
4. Timing/relevance -knowing when to communicate
5. Pacing – rate of speech
6. Intonation – tone of voice
Bad- “why,” false reassurance, minimize feelings, opinions, advice, personal questions that are irrelevant
What causes anxiety?
–>jk Stress causes anxiety
b) Sublimination- dealing with negative feelings/emotions unconsciously via a more positive method of expression
c) Suppression- voluntarily denying negative feelings
d) Humor- using humor, laughing at the situation
1. Robby said he didn’t mind getting fired, he’d get a better job by the end of next week.
2. After finding out her mother was diagnosed with breast cancer, Joanrae raises money for cancer awareness.
3. Sean laughed off the teacher’s remark, he knew he’d pass the skills exam, even if she doubted him.
4. Alia was upset at her husband, so she began working out vigorously at the gym every day.
2. Joanrae is dealing with her stress by helping others: Altruism
3. Sean is laughing at a stressful situation: Humor
4. Alia is taking out her feelings for her husband via an unconscious, acceptable form of expression: Sublimination
2. Reaction Formation
2. Reaction formation- overcompensating by doing the opposite of what one feels
3. Somatization- anxiety becomes a physical symptom
4. Displacement- shifting anxiety about one thing to a lesser thing/person/object
5. Rationalization- creating rational explanations for one’s unacceptable behavior
6. Undoing- Performing an act to try and make up for previous behavior
1. Pat hated going to the doctor so much, that every time he was supposed to go, he got a headache.
2. I brought cupcakes to school for Nikki’s birthday, even though I despise that girl, I felt guilty…
3. When David’s girlfriend dumped him, he threw his phone and it broke all over the floor.
2. Reaction formation: overcompensating for negative feelings by doing the opposite
3. Displacement: took out anger on inanimate object
1. Passive aggressive
2. Acting-out- managing emotional conflict physically
3. Dissociation- temporarily blocking one’s memory/perception, often due to traumatic event
4. Devaluation- expressing negative thoughts about self or others
5. Idealization- expressing extremely positive thoughts about self or others
6. Splitting- inability to reconcile positive/negative attributes of self or others
7. Denial- ignoring reality, pretending never happened
8. Projection- blaming others for unacceptable thoughts or behaviors
1. “Yesterday he said he loved me and would give me the world, today he hates me and said he wanted to kill me” Sheila said about her bf
2. Sam said she’d watch Leslie’s house while she was out of town to be nice, but she really just wants to throw a party there.
3. Kyle said he only liked young girls because they were always coming on to him, he had no choice.
2. Passive aggressive- seems nice, bad reasons
3. Projection- blaming others for unacceptable thoughts
Acute anxiety is __________
Chronic anxiety is _________
Acute anxiety is: a temporary state
Chronic anxiety is: a trait that develops over time
-Mild, moderate, severe, or panic-level
1. The girl was visibly shaking, having a difficult time answering the policeman’s questions. She didn’t seems to notice the rest of the onlookers gathering around.
2. The client was acting out, screaming, shaking, not making sense, and yelling that “they were coming to get him.” He didn’t seem to realize any of us were there.
3. Jess was overwhelmed with all the information she had taken in over the day, she was having difficulty concentrating or sitting still
4. Standing in line was making Suzie anxious, she couldn’t be late for school again.
2. Countertransference- nurse views patient a certain way because they remind her of someone -> reminds her of ex so she dislikes him
2. Group- scheduled sessions w/group
3. Psychoeducational- for specific need of client
4. Recreational- game or outing
5. Unstructured- observation of normal play/communication
1. Primary level of prevention
2. Secondary level of prevention
3. Tertiary level of prevention
2. Secondary – nurse works to screen/detect the MH problems early on
3. Tertiary – nurse works to help rehabilitate and prevent further problems