Anger/ legal/ethics
Nursing intervention for agitated client
What is ID source of distress, be firm and calm, If PRN medication give, find activities to vent frustration e.g. gym, running, punching bag, Ask staff to stand by.
Risk factors for abuse older adults
What is dependent on caregivers for ADLs, lack of own source of income, caregiver perception of client being a burden.
Judgment vs insight
What is "making an appropriate decision" vs. understanding what is happening?"
Nursing consideration during assessment
What is collect both subjective and objective data, understand factors that affect individual's mental health. use interpreter, be aware of cultural values.
Kubler Ross stages of Grief
What is Denial, Bargaining, Depression, Acceptance, Anger
Symptoms of PTSD
What is nightmares, avoiding, flashbacks, hyperaoursal.
Risk factors for aggression
What is a client with delusions (paranoid), history of violence, growing up in a violent family, low-frustration threshold, and certain mental illnesses?
Risk factors for abuse children
What is child look different, born disabled, does not meet the expectation of parent/guardian, born premature, very strict disciplinarian parents?
Nursing consideration of culture
What is care must be culturally sensitive, respectful, nonjudgmental, nurse self-awareness of own culture. aske the client about their culture beliefs.
Thought process
abstract thinking, neologism, flight of ideas, clang association, thought blocking, tangentiality, circmustantiality
Complicated grief
What is prolonged, affects functionality-closet untouched, quit a job, develop clinical depression?
Phobias
Irrational fear of: agoraphobia-situations one cannot escape or save self, social phobia-fear of social performance, specific objects, or animals.
Principles of ethics
What is beneficence, nonmaleficence, confidentiality, autonomy, justice, veracity, fidelity? Ethical dilemma- no clear choices
Characteristic of perpetrators of violence
What is spouses of older adults, substance abusers, history of family violence, poor coping skills, low self- esteem.
Individual view of self and their abilities
What is self-concept?
Thought content
What is suicide ideation, homicidal ideation, delusions, hallucination?
Disenfranchised grief
What is grief that is postponed due to unavoidable circumstances, not socially sanctioned, or violent death?cannot be acknowledged publicly.
Mild and moderate level of anxiety
Client is functional- you can teach a client, Have a conversation.
Torts
What is intentional( assault(threaten client), false imprisonment(inappropriate seclusion), battery(physical contact) and unintentional (negligence)?
Nursing intervention for child abuse
What is ID injuries that are suspicious, report any suspicion, ensure child safety, interview child alone, tell child not their fault,
abstract thinking
Able to interpret a proverb.
Delusions
What is persecutory delusions (highest priority), magical thinking, ideas of references, thought insertion, grandiose, somatic.
Anticipatory grief
What is grieving expected loss such as a terminal illness with a poor prognosis?
Systematic desensatization
A behavioral therapy where, a client is gradually introduced to anxiety causing object while teahcing relaxation techniques to lower their anxiety.
Involuntary commitment
What is client who is danger to self or others. Client have al the rights like any other client apart from the freedom to leave at will
Nursing intervention on Intimate partner violence
What is let client know they are safe, they did not deserve what is done to them, offer to call 911, shelter but respect their decision if decline, give them safety plan, believe them. be non-judgmental?
Components of culture
A system of beliefs, practices, and values, variations in non-verbal meaning
Mood
Flat affect, excited, irritable, labile-frequent change in mood
Nursing intervention for grieving client
What is proper nutrition, understand anger and aggression are acceptable form of grief response, support client during grieving
Nursing consideration for PTSD
Do not touch a client experiencing flashback, do not give too much information about the trauma, assess for suicide and encourage clients to express feelings.
Confidentiality/ autonomy
What is right to make own decisions, consent to invasive procedures, privacy and confidentiality. Exception is when threat to harm a third party or suspected child or elder abuse
Signs of child abuse
What is Lacerations in different stages of healing, belt buckle marks, bite marks, malnourished, low-self esteem, fidgeting, anxiety, spiral fractures, sexualized behaviors, and cigarette burn marks? SID-bulging fontanel, retinal hemorrhage..
Individual factors
What is self-efficacy, hardiness, Resilience, (biologic/ethnicity -drug interactions and response), age, spirituality.
Assessing for knowledge, understanding, thinking and memory in MSE
What is cognition?
Grief myth busters
What is it is okay to be vulnerable and to feel weak, there is no right and wrong way to grieve, There is no time frame to grief, Expressing how your feel is normal grieving process. It is okay to be angry and resentful.
Disossiative disorders
Disconnect from self/reality/loss of memory due to trauma. e.g. depersonalization-see oneself like in a movie, derealization-the room around is moving or changing, fugue-loss of identity, relocate, amnesia-do not remember events around trauma.
Side effects of antipsychotics
What are anticholinergic effects, metabolic syndrome (weight gain, HTN, hyperglycemia), sedation, and orthostatic hypotension?
Intimate partner violence
What is prioritize safety by developing and offering a safe escape plan in case things get worse.
Nursing Process
AAPIE- in order of priority: Assessment>analysis>planning>implementation>Evaluation
Components of Mental Status Exam
Appearance, behavior, orientation, mood, thought process and content, judgement, insight, level of consciousness. memory.
Risk factors for complicated grief
What is low trust in others, death by suicide, violent death, lack of support, existing mental illness
Severe/panic level of anxiety
Client highest risk for injury, stay with the client, postpone teaching.
this is acute-use simple short statements, direct and clear words.