Mental Health Nursing – ATI

Unit1 Ch1: Basic Concepts
List the three foundations that set the standards for client care in the mental health setting
1. American Nurses Association
2. American Psychiatric Nurses Association
3. International Society of Psychiatric-Mental Health Nurses

Mental health nurses should use the _________ process, as well as a ___________ approach, which includes ____, _____, ______, & _____ aspects. in client care.
a) Nursing process
b) holistic approach
c) biological
d) social
e) psychological
f) and spiritual aspects

Describe the levels of consciousness:
1. Alert
2. Lethargy
3. Obtundation
4. Stupor
5. Coma
1. Alert- client is responsive, eyes open, fully able to respond, answer questions normally, appropriately
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)*

1. Decorticate rigidity
2. Decerebrate rigidity
1. Decorticate rigidity – flexion and internal rotation of upper extremity & joints
2. Decerebrate rigidity – neck & elbow extension, wrist & finger flexion –> Sounds like vertebrae – which is straight, whereas decorticate is all flexed up and twisted in

Difference between a client’s mood and affect
Mood is the subjective information supplied about their emotions while affect is an objective expression of their mood
–> “He says he is in a good mood, but he seems to have such a flat affect all the time”

The Glasgow Coma Scale evaluates what?
a) And a score of 3 would represent?
b) A score of 15?
The GCS obtains a baseline assessment of a client’s consciousness for ongoing assessment
a) Score of 3 = coma
b) Score of 15 = alert, awake, oriented

What is a good assessment for assessing psychosocial risk factors in an adolescent?
The psychosocial assessment tool: HEADSS – Home, Education/employment, peer group, Activities, Drugs, Sexuality, and Suicide/depression

What are some assessment scales that would be used with the older adult patient?
1. Geriatric Depression Scale
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

DSMV-IV Multiaxial system for assessment
Axis I
Axis II
Axis III
Axis IV
Axis V
Axis I – All disorders except for axis II disorders
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)
–> *A-P-A-P-G*

Global Assessment of Functioning
1. Score 80-100
2. Score 60-80
3. Score 40 and below
4. GAF of 50/80 means what?
1. Score 80-100 = normal, near normal fxn
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

Milieu Therapy
Type of therapy in which a substantial change in the client’s immediate environment is made to enhance other forms of therapy
–> Inpatient therapy in psych setting with prescription of social interactions & activities to meet client’s specific needs

Difference between the objective noticing of:
1. Insight
2. Judgement
3. Knowledge
4. Memory
1. Insight – client’s understanding of current situation and medical condition
2. Judgement – weighing right & wrong to make a decision
3. Knowledge – learned information
4. Memory – remembering past events

Unit 1 Ch3: Communication
What is foundational to the nurse-client relationship?
Therapeutic communication

What are the levels of basic communication? (3 +1)
1. Intrapersonal – self-talk
2. Interpersonal – between 2+ people
3. Public Communication – large group setting
4. Transpersonal Communication – addresses spiritual needs of an individual

Define/differentiate between these methods of communicating:
1. Vocabulary
2. Denotative/connotative meaning
3. Clarity/brevity
4. Timing/relevance
5. Pacing
6. Intonation
1. Vocabulary – written or spoken words
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

When speaking with children, the nurse should?
Use simple straightforward language, implement play, child’s eye level, know children are sensitive to nonverbal cues

When speaking to an older adult what should the nurse keep in mind?
Recognize may need sound amplification, vision may be bad, minimize distractions and face client, allow time to respond, do not rush, ask family and caregivers for input

Know good communication techniques and barriers to effective communication
Good- touch, empathy, sharing, focusing, present reality, silence, active listening
Bad- “why,” false reassurance, minimize feelings, opinions, advice, personal questions that are irrelevant

Unit1 Ch4: Anxiety & Defense Mechanism
What causes anxiety?
Nursing school
–>jk Stress causes anxiety

1. Healthy defense mechanisms:
a) Altruism
b) Sublimination
c) Suppression
d) Humor
a) Altruism- dealing w/anxiety by reaching out to others
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

Match the healthy defense mechanism to the example:
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.
1. Robby is voluntarily denying his anxiety: Suppression
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

Intermediate defense mechanisms:
1. Repression
2. Reaction Formation
3. Somatization
4. Displacement
5. Rationalization
6. Undoing
1. Repression- putting negative ideas “outside” of one’s conscious
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

Match the intermediate defense mechanism to the example:
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.
1. Somatization: mental anguish -> physical pain
2. Reaction formation: overcompensating for negative feelings by doing the opposite
3. Displacement: took out anger on inanimate object

Immature defense mechanisms:
1. Passive aggressive
2. Acting-out
3. Dissociation
4. Devaluation
5. Idealization
6. Splitting
7. Denial
8. Projection
1. Passive aggressive- indirectly behaving aggressive tho acting appropriately
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

Match the immature defense mechanism to the example:
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.
1. Splitting- cant reconcile positive/negative attributes
2. Passive aggressive- seems nice, bad reasons
3. Projection- blaming others for unacceptable thoughts

Normal anxiety is ________
Acute anxiety is __________
Chronic anxiety is _________
Normal anxiety is: a healthy life force
Acute anxiety is: a temporary state
Chronic anxiety is: a trait that develops over time

What level of anxiety is the situation representing?
-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.
1. Severe
2. Panic
3. Moderate
4. Mild

Unit1 Ch5: Creating & Maintaining a Therapeutic and Safe Environment
1. Transference
2. Countertransference
1. Transference- client views member of healthcare team as having characteristics of someone else ->dislikes nurse who reminds him of his mother
2. Countertransference- nurse views patient a certain way because they remind her of someone -> reminds her of ex so she dislikes him

Community setting therapy:
1. Individual
2. Group
3. Psychoeducational
4. Recreational
5. Unstructured
1. Individual- 1on1, scheduled sessions
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

Unit1 Ch6: Diverse Practice Settings
1. Primary level of prevention
2. Secondary level of prevention
3. Tertiary level of prevention
1. Primary – nurse works to prevent MH problems from occurring
2. Secondary – nurse works to screen/detect the MH problems early on
3. Tertiary – nurse works to help rehabilitate and prevent further problems

Alert The client is responsive and able to fully respond by opening her eyes and attending to a normal tone of voice and speech. Answers questions spontaneously and appropriately. Lethargy The client is able to open her eyes and respond …


What do you assess for during a Mental Status Exam (MSE)? 1. level of consciousness 2. physical appearance 3. behavior 4. cognitive and intellectual abilities alert able to fully respond by opening eyes, attend to normal tone of voice and …

Assessment: Psychosocial History – perception of own health beliefs about illness and wellness – activity/leisure activities, how a pt passes time – substance use or disorder – stress level and coping abilities (coping strategies, support systems) – cultural beliefs and …

Nursing Process A systematic framework for the delivery of nursing care. It is goal-directed, with the objective being delivery of quality client care. Consists of six steps; assessment, diagnosis, outcome identification, planning, implementation, evaluation. 1. Assessment A systematic, dynamic process …

A nurse in a mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first? Accompany the client to a quiet room. A nurse is obtaining a history …

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