Chapters 15 + 16
1. Define anger and when it becomes a problem?
2. name some techniques for dealing with aggression.
1. anger is not always a negative expression, its a normal human emotion that when handled appropriately and expressed assertively, can provide an individual with a positive force to solve problems
- It becomes a problem when:
2. talking down, physical outlets, medications, call for assistance, restraints, observation and documentation, ongoing assessment, staff debriefing
What is the difference between delirium and dementia?
Delirium: abrupt onset, fluctuating cognition, hypo/hyperactive, usually reversible if cause is treated
Dementia: progressive decline in cognitive ability in the presences of clear consciousness
- involved many cognitive deficits and significantly impairs social and occupational functioning
1. Define Somatic Disorder
2. Define illness anxiety
3. Define Conversion Disorder
4. Define Factitious Disorder
1. characterized by physical symptoms suggesting medical disease but without demonstrable organic pathology
2. unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation with and fear of having a serious disease
3. loss or change in body motor or sensory function that cannot be explained (stress converts to physical symptoms)
4. pretending to be ill to receive emotional care and support can be imposed on others as well
Define the following:
1. Paranoid Personality Disorder
2. Schizoid Personality Disorder
3. Schizotypal Personality Disorder
4. Antisocial Personality Disorder
5. Borderline Personality Disorder
Paranoid Personality Disorder: pervasive, persistent and inappropriate mistrust of others (assume others are out to harm or exploit them)
Schizoid Personality Disorder: profound defect in the ability to form personal relationships → failure to respond to others in meaningful ways, emotionally cold, no close friends, lifelong pattern of social withdrawal
Schizotypal Personality Disorder: aloof and isolated, magical thinking, ideas of reference, illusions, depersonalization, superstitious, bizarre speech pattern (THE STEP BEFORE SCHIZOPHRENIA)
Antisocial Personality Disorder: socially irresponsible/exploitative/guiltless behavior → fails to sustain employment, exploits and manipulates others, fails to develop stable relationships, lacks remorse, won't take responsibility, impulsive and reckless
Borderline Personality Disorder: pattern of intense chaotic relationships with affective instability, HIGHLY impulsive, fluctuating and extreme attitudes regarding others, emotionally unstable, lacks sense of identity
Define the following types of Maladaptive Grief:
1. delayed or inhibited grief
2. Distorted (exaggerated grief)
3. Chronic or Prolonged Grieving
Delayed or inhibited grief: absence of grief when it ordinarily would be expected, remains fixed in the denial stage of grief process, grief may be triggered much later in response to subsequent loss
Distorted (exaggerated grief): all symptoms of normal grieving are exaggerated, individual is incapable of managing activities of daily living, remains fixed in the anger stage of grief process, depressed mood disorder is a type of distorted grief response
Chronic or Prolonged Grieving: behaviors aimed at keeping the lost loved one alive and behaviors prevent normal ADLs
Practice questions:
1. A client in an inpatient psychiatric unit begins pacing, clenching fists, and yelling obscenities at staff. The nurse identifies escalating signs of aggression. What is the most appropriate initial action?
A. Administer the prescribed PRN benzodiazepine immediately
B. Attempt to talk the client down in a calm and non-threatening manner
C. Activate the hospital code for violent behavior and prepare for restraints
D. Encourage the client to use the punching bag in the day room to release tension
2. Following a violent outburst from a client that required restraint use, which action is most critical for the nurse to take after the client is stabilized?
A. Update the client’s family about the incident
B. Conduct a staff debriefing session
C. Reassess the need for continuation of restraints
D. Complete documentation regarding the restraint procedure
1. B. Attempt to talk the client down in a calm and non-threatening manner
2. B. Conduct a staff debriefing session
What are symptoms of delirium?
Difficulty paying attention
Difficulty shifting attention
Highly distractible
Disorganized thinking prevails
Impaired reasoning ability and goal directed behavior
Disorientation to time and place
Impairment of recent memory
Illusions and hallucinations
Disturbances in sleep wake cycle
what are treatment of somatic disorders.
Relief of discomfort from the physical symptoms
Assist clients in developing strategies for coping with stress
Define the following:
1. Histrionic Personality Disorder
2. Narcissistic Personality Disorder
3. Avoidant Personality Disorder
4. Dependent Personality Disorder
5. Obsessive Compulsive Disorder
Borderline Personality Disorder: pattern of intense chaotic relationships with affective instability, HIGHLY impulsive, fluctuating and extreme attitudes regarding others, emotionally unstable, lacks sense of identity
Histrionic Personality Disorder: colorful/dramatic/extroverted behavior in excitable, emotional people, engages in seductive.flirtatious behavior, attention seeking, overly generous, Use manipulative and exhibitionistic behaviors in their demands to be center of attention
Narcissistic Personality Disorder: exaggerated sense of self worth and lack of empathy
Avoidant Personality Disorder: extreme sensitivity to rejection, social withdrawal, awkward and uncomfortable in social situations
Dependent Personality Disorder: lack of self confidence and extreme reliance on others to take responsibility for them, RELIES ON OTHERS
Obsessive Compulsive Personality Disorder, inflexibility about the way things are done, very concerned with organizations, rigid/unbending, rank conscious, formal
What marks the transition from normal grief to maladaptive grief?
Decide if the following are facts or myth.
1. women attempt suicide more often, but more men succeed.
2. most individuals commit suicide by taking an overdose of drugs.
3. 8/10 individuals who commit give warning about their intentions
4. Most suicidal individuals are ambivalent about their feelings (want help but may feel hopeless)
5. Initial mood improvement may precipitate suicide
1. fact
2. myth - overdose is one method of suicide its not the most common, firearms are the most common
3. fact
4. fact
5. fact
1. CIWA
2. COWS
3. CAGE
4. MAST
5. SBIRT
6. Wernicke's encephalopathy
1. alcohol withdrawal assessment
2. opioid withdrawal assessment
3. alcohol reliance
4. general screening
5. thiamine
Define the following terms:
1. Dissociative Disorders
2. Dissociative Amnesia
3. Dissociative Identity Disorder
4. Depersonalization-Derealization Disorder
1. disruption in the usually integrated sanctions of consciousness, memory, and identity, perception, behavior, emotion, body, representation, and motor control
2. inability to recall important personal information
3. existence of 2 or more personality states in a single individual
4. temporary change in the quality of self-awareness, takes form of feelings of unreality, changes in body image, feelings of detachment from environment, sense of observing oneself from the outside
Treatment Options:
THERAPY = group, cognitive, interpersonal
Dialectical behavioral therapy
Meds
Name some interventions for bereaved individuals
Develop trust, show empathy, concern, and unconditional positive regard
Help client actualize the loss by talking about it
Help the client identify and express feelings
Identify pathological defenses the client might be using
Encourage client to make an honest review of the relationship with the lost entity
What are interventions to use if someone is suicidal?
Single interventions, such as hospitalization, medication alone, and “no suicide”contracts, are not effective in reducing suicide alone.
Clients need to be actively engaged as partners in each step of the assessment and intervention process
Treatment Options:
1. alchohol:
2. Opioids
3. stimulants
4. hallucinogens/cannabis
1. Alcohol: disulfiram, naltrexone, acamprosate, benzo, thiamine, anticonvulsant
2. Opioids: narcotic antagonists, methadone, buprenorphine
3. Depressants: phenobarbital, long acting benzo
4. Stimulants: tranquilizers, anticonvulsants, antidepressants
5. hallucinogens/cannabis: benzo, antipsychotics
Treatment of Dissociative Disorders
1. restoring normal though process
2. assisting client in developing coping strategies for stress
3. medication
4. hypnosis
1. A nurse is caring for a client diagnosed with antisocial personality disorder. Which nursing intervention is the most appropriate to include in the plan of care?
A. Encourage the client to explore feelings of guilt and remorse
B. Provide immediate and consistent consequences for rule violations
C. Assign the client to a quiet room away from others to reduce stimuli
D. Allow the client to negotiate unit rules to increase feelings of control
2. A client with borderline personality disorder becomes angry and verbally abusive after being informed that privileges were revoked due to inappropriate behavior. What is the nurse’s best response?
A. “You need to calm down before I continue this conversation.”
B. “I understand you’re upset, but the consequences are based on your behavior.”
C. “If you continue acting like this, you’ll lose even more privileges.”
D. “You shouldn’t be surprised, you were warned about this before.”
3. A client with schizotypal personality disorder tells the nurse, “I think the staff is using codes when they talk—it’s about me, I just know it.” What is the best therapeutic response?
A. “Those are just thoughts you’re having and not based in reality.”
B. “You are safe here. We are professionals and follow strict rules.”
C. “I don’t hear anyone using codes. Can you tell me more about this feeling?”
D. “Let’s focus on something else so you can avoid getting upset.”
1. B – Clients with antisocial personality disorder respond best to firm, clear boundaries and immediate, consistent consequences. Emotional appeals or leniency reinforce manipulative behavior.
2. B – Borderline clients are emotionally labile and often exhibit splitting or manipulation. The nurse should maintain firm limits while acknowledging emotions without reinforcing negative behaviors.
3. C – Schizotypal clients exhibit magical thinking and ideas of reference. The nurse should validate feelings, avoid confrontation, and gather more information without reinforcing delusional content.
Practice Questions:
1.
A nurse is caring for a client whose spouse died 11 months ago. The client reports still setting a place at the table for their spouse, keeping all their belongings untouched, and struggling to complete routine tasks. Which type of maladaptive grief response should the nurse suspect?
A. Delayed grief
B. Distorted grief
C. Chronic grief
D. Anticipatory grief
2.
A nurse is evaluating a bereaved client who lost a child 4 months ago. The client states, “I’m fine. There’s nothing to talk about,” and immediately changes the topic. The client appears cheerful and focused on work but becomes tearful when another patient shares a story about losing a pet. Which nursing intervention is most appropriate?
A. Encourage the client to keep busy to distract from emotional pain
B. Confront the client about avoidance behaviors related to the loss
C. Acknowledge the difficulty of talking about grief and offer to listen when ready
D. Suggest journaling as a way to document memories with the lost loved one
1. C – Chronic grief
Chronic (or prolonged) grief is characterized by persistent behaviors aimed at maintaining a connection to the deceased and an inability to complete ADLs. Keeping a place at the table and being unable to function daily are hallmarks of this type.
2. C – Acknowledge the difficulty of talking about grief and offer to listen when ready
This client is showing signs of delayed or inhibited grief, remaining fixed in denial and avoiding emotional processing. The nurse must approach gently and create space for trust and future disclosure without confrontation
Practice Questions
1. A 17-year-old male is brought to the ED after telling a friend, “I don’t want to live anymore.” He has a history of depression and is now calm and smiling. Which interpretation of the client's mood is most concerning?
A. He is relieved after speaking with someone about his feelings
B. He has decided to seek help and is feeling hopeful
C. He is at increased risk for suicide due to resolution of ambivalence
D. He is likely to use manipulation to avoid consequences at home
2. During suicide risk assessment, a client says, “I’m not planning anything, I just think everyone would be better off without me.” What is the best response by the nurse?
A. “That sounds like you might be considering suicide. Can we talk more about that?”
B. “You’re not saying you want to hurt yourself, right?”
C. “I need to notify your family about this right away.”
D. “You seem a little overwhelmed. Let’s focus on positive thoughts right now.”
1. C. He is at increased risk for suicide due to resolution of ambivalence
2. A. “That sounds like you might be considering suicide. Can we talk more about that?”
Practice Questions:
1. A client admitted for a urinary tract infection suddenly becomes disoriented, agitated, and begins seeing “spiders crawling on the walls.” Which assessment finding would help the nurse distinguish delirium from dementia?
A. Disorganized speech and impaired long-term memory
B. Gradual onset of disorientation and forgetfulness
C. Fluctuating levels of consciousness with recent memory impairment
D. Presence of visual hallucinations and poor hygiene
2. Which client situation requires the most immediate nursing intervention?
A. A client with dementia who is pacing the hallway at night
B. A client with delirium who is attempting to pull out their IV
C. A client newly diagnosed with Alzheimer's disease refusing to eat lunch
D. A client with mild cognitive impairment asking repetitive questions
3. A client with alcohol use disorder is admitted to the medical unit for detoxification. Which order should the nurse question?
A. Lorazepam 1 mg IV q4h PRN for tremors
B. Administer thiamine 100 mg IM daily
C. Disulfiram 250 mg PO daily starting on admission
D. Monitor using the CIWA protocol every 4 hours
4. The nurse is caring for a client with opioid use disorder undergoing withdrawal. Which finding requires immediate notification of the provider?
A. Yawning and dilated pupils
B. Elevated score on the COWS tool with report of severe muscle aches
C. Mild tremors and gooseflesh
D. Respiratory rate of 8 and unresponsiveness to verbal stimuli
1. C. Fluctuating levels of consciousness with recent memory impairment
2. B – A delirious client attempting to remove their IV is an acute safety concern. Delirium has a higher risk of injury due to confusion and impulsive behavior.
3. C – Disulfiram (Antabuse) should not be started until at least 12 hours after the last drink and the blood alcohol level is zero. Giving it during detox can cause a dangerous reaction.
4. D – A respiratory rate of 8 and unresponsiveness suggest opioid overdose, which is a medical emergency. The provider should be notified immediately for possible naloxone administration.
Practice Questions
1. A client with suspected somatic symptom disorder frequently visits the clinic with complaints of chest pain, headache, and joint pain. All diagnostic tests have been negative. Which is the most appropriate nursing intervention?
A. Refer the client to a cardiologist for further evaluation
B. Schedule frequent visits to reinforce the validity of symptoms
C. Limit discussion of physical symptoms and focus on coping strategies
D. Challenge the client directly about the lack of medical findings
2. A nurse is caring for a client recently diagnosed with illness anxiety disorder. Which client statement requires further education about the diagnosis?
A. “I feel like something serious is wrong, even when the doctors say I'm fine.”
B. “I’ve been tracking every small change in my body because I know it means something.”
C. “If I distract myself when I start to worry, it usually helps me feel better.”
D. “So the pain I’m having is all in my head, and I should ignore it.”
3. A client presents with sudden blindness after witnessing a traumatic accident. Neurological workup is negative. What is the nurse's best initial response to this client’s concern?
A. “There’s no physical reason for your blindness, so this must be psychological.”
B. “Let’s explore what was happening around the time your vision changed.”
C. “You should consider that this may be an attempt to avoid responsibilities.”
D. “You might need to stay in the hospital until you regain your sight.”
4.
A client with a history of trauma is diagnosed with dissociative identity disorder (DID). Which finding would the nurse expect during assessment?
A. Obsessive concern over developing a serious illness
B. Feelings of depersonalization following panic episodes
C. Recurrent gaps in memory accompanied by distinct personality shifts
D. Exaggerated physical complaints without organic cause
1. C – The nurse should limit reinforcement of somatic complaints and redirect focus to coping mechanisms and psychosocial stressors. A validating, nonjudgmental, yet therapeutic redirection is the most appropriate.
2. D – The statement “it’s all in my head and I should ignore it” reflects misunderstanding. Symptoms in illness anxiety disorder are real to the client, even if no organic cause is found. Education should focus on anxiety management, not dismissal.
3. B – This client likely has conversion disorder. A therapeutic, non-confrontational response that gently helps connect symptoms to stressors is most appropriate.
4. C – DID is characterized by two or more personality states and recurrent amnesia. Clients may lose time or experience shifts in behavior they cannot recall.
Practice Exam
1.
A client with borderline personality disorder is admitted to the psychiatric unit. On the third day, the client tells the nurse, “You’re the only one here who really understands me. The night nurse is useless and rude.” What is the best nursing response?
A. “I’ll speak with the night nurse about your concerns.”
B. “It sounds like you’re frustrated. Let’s talk about what’s bothering you.”
C. “You shouldn't speak about other staff that way.”
D. “All the staff here are qualified to help you.”
2.
A client with a history of heavy alcohol use is admitted for withdrawal management. The nurse notes tremors, agitation, BP 160/96, and a CIWA-Ar score of 22. Which intervention is the highest priority?
A. Provide a quiet, low-stimulation environment
B. Initiate seizure precautions
C. Administer prescribed lorazepam
D. Offer thiamine 100 mg PO
3.
A client with a diagnosis of conversion disorder presents with sudden-onset blindness. Diagnostic tests show no organic cause. Which response by the nurse reflects best therapeutic communication?
A. “Let’s talk about what was happening before you lost your vision.”
B. “The test results were normal, so there is nothing physically wrong.”
C. “You’ll regain your sight once the stress resolves.”
D. “Try not to focus on the blindness and concentrate on getting better.”
4.
A client with distorted (exaggerated) grief is hospitalized after being unable to care for herself following the death of her spouse 6 months ago. She is tearful, withdrawn, and expresses feelings of hopelessness. What is the nurse’s priority intervention?
A. Encourage expression of positive memories
B. Promote participation in ADLs
C. Assess for suicidal ideation
D. Refer to a bereavement support group
5.
A nurse is assessing a client admitted with delirium secondary to infection. Which finding would the nurse expect?
A. Gradual onset of memory deficits with preserved attention
B. Sudden onset of confusion and fluctuating consciousness
C. Persistent personality changes over several months
D. Flat affect and slow thought processing
1. B. “It sounds like you’re frustrated. Let’s talk about what’s bothering you.”
2. C – Administer prescribed lorazepam
With a CIWA-Ar score >20, the client is in severe withdrawal at high risk for seizures or delirium tremens. Benzodiazepines are the priority to prevent life-threatening complications.
3. A – “Let’s talk about what was happening before you lost your vision.”
This response gently redirects the focus from the symptom to underlying stress. Clients with conversion disorder unconsciously convert stress into physical symptoms and benefit from emotional exploration.
4. C – Assess for suicidal ideation
In distorted grief, clients may have intense anger turned inward, leading to major depressive episodes and suicide risk. This must be prioritized before other supportive interventions.
5. B – Sudden onset of confusion and fluctuating consciousness
Delirium is marked by abrupt onset, fluctuating cognition, and impaired attention/awareness. This distinguishes it from dementia, which has a gradual progression and preserved alertness early on.