Transcript MENTAL HEALTH NURSING - Wilkes

30 Hours
Presented by:
Mrs. Mary Elizabeth Pacuska, M.S.N.
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2 Unit Examinations
Complete Practice Questions, Unit 19,
Chapters 63,64,65,66and 67 in Silvestri’s
Comprehensive Review for NCLEX-PN
Examination -5 points from final grade if not
completed
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“successful performance of mental function,
resulting in productive activities, fulfilling
relationships, and the ability to adapt to
change and cope with adversity”
State in which one is responsible, displays
self awareness, is self directive, reasonably
worry free, and can cope
Function in society, accepted in a group, and
generally satisfied with their lives.
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Self-awareness:
ability to recognize nature of one’s own
attitude, emotions, and behavior
Do you have any prejudices about patients
with psychiatric disorders?
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Self-governance
Progress toward growth
Tolerance of uncertainty
Self-esteem
Reality Orientation
Mastery of environment
Stress Management
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Inherited Characteristics (Biologic)
Nurturing during childhood (Psychological)
I.Q., self-concept, emotional development
Life Circumstances(Socio-cultural)
i.e. family stability, ethnicity, economic level,
religion, values, beliefs
1. Mental health includes the ability to
A. Be flexible
B. Be successful
C. Make appropriate judgments
D. Solve problems
E. All of the above
Correct answer: D
Rationale: These abilities are all aspects of good
mental health as well as close personal
relationships and positive sense of self
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Culture
Ethnicity
Economic considerations
Abuse
Poor parenting
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Def: A clinically significant behavioral or
psychological syndrome experienced and
marked by distress, disability.
Not dealing with problems through rational
decisions.
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All ages, races, gender and socioeconomic
levels
In US 48 Million/year (1in5), 20% of children
2nd leading cause of disability in US
15% have co-occurring substance abuse
or Dual diagnosis
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Unknown
Complex set of interactions involving genetic
predisposition and environmental influences
Mental Health, the ability
to:
 be flexible
 be successful
 form close relationships
 make appropriate
judgements
 solve problems
 cope with daily stresses
 have a positive sense of
self
Mental illness:
 Impairment of ability to
think, feel, or make
sound judgements
 Difficulty or inability to
cope with reality or to
form strong personal
relationship
Stress
Anxiety
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Condition that develops from a threat to
one’s well-being requiring one to adjust to
environment
May be acute (fight or flight) or chronic
Physical Response (stress reaction)- arousal
of autonomic nervous system
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A feeling of apprehension, uneasiness, or
uncertainty in response to a real or perceived
threat.
Automatic and unconscious biologic response
to a stressor
Impossible to avoid, instinctive
May be present whether there is danger or
not
External
Physical environment (noise,
lights, weather, crowds)
Major life events ( death, divorce,
loss of job, marriage)
Work related (rules, deadlines,
production pressures, gossip)
Social (bossy or aggressive
individuals, strained
friendships, marital affairs)
Everyday life (schedules,
household duties, family
conflict)
Internal
Personality traits (perfectionist,
workaholic, worrier, loner)
Negative self talk (pessimism,
irrational thinking, selfcriticism)
Thinking snags (all or none
approach, unrealistic and
inflexible expectations)
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Assess situation and see if it real is what it seems
to be
Adaptation- successful management of stress
Adaptive coping- using rational management of
stress and anxiety
Palliative coping- solution which temporarily
relieves anxiety, problem still exists
Maladaptive coping- unsuccessful attempts made
to decrease anxiety
Dysfunctional coping- not attempting to reduce
anxiety or solve problem
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Positive self talk
Assertiveness
training
Problem solving
skills
Communication
skills
Relaxation
techniques
meditation
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Support systems
Practical attitude
Sense of humor
Self-care
Faith in spiritual
power and in self
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“an enduring pattern of perceiving, relating
to, and thinking about oneself and the
environment that is demonstrated in our
social and interpersonal interrelationships.”
Personality traits- unique
Genetic transmission of personality traits
from both parents, family patterns, society
and environmental influences
Psyche made up of three components:
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Conscious- present awareness
Preconscious- below current awareness,
easily retrieved
Unconscious- past experiences and related
emotions- contributes to emotional
discomfort and disturbances
Personality has three aspects:
 ID
 EGO
 SUPEREGO
MUST BE IN BALANCE FOR REASONABLE
MENTAL HEALTH
Pleasure principle:“I want what I want when I
want it.”
Present at birth
Functions in the irrational and emotional part
of mind.
Basic needs and feelings: hunger, aggression,
sex, protection, and warmth
ID too strong: self gratification and uncaring
to others
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Rational part of mind, begins development
6-8 months, well developed by 2 years
Reality principle: Grows out of knowing
can’t always get what we want.
Ego strength refers to how well ego copes
with ID and Superego
Sensations, feelings, adjustments, solutions
and defenses formed here
Too strong: Extremely rational, cold,
boring, distant
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Last part of mind to develop, starts at 3-4 years,
well developed by 10-11.
Controls, inhibits, and regulates impulses and
socially unacceptable instinctive urges
Moral part of mind; parental & societal values
Strives for perfection, causes anxiety
Conscience
Operates at conscious and unconscious level
Too Strong: guilty, insufferable saintly personality
1. The part of Freud’s personality theory that
allows people to determine what is right,
wrong, good, and bad:
A. Id
B. Superego
C. It
D. Ego
Correct answer: B
Rationale: The third part of the personality
theory of Sigmund Freud is the superego. The
superego could be called the “kill joy” of the
personality. It is the conscience. It is the part of
the personality that allows people to determine
what is right, wrong, good, and bad.
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Asylums for “lunatics”, “the insane’, Locked in cells, beaten,
starved.
Hospitals- 1753 (Dr. Thomas Bond & Ben Franklin)
Pennsylvania Hospital
19th century- beginning of change- recognized as an illness
and treatment questioned
20th century- 1937 psychiatric nursing added to all
curriculums
1946- National Mental Health Act- funding for research and
nursing
1946- Hill-Burton Act money for psychiatric units
Protects the uninsured
1955- 1st antipsychotic drugs (psychotropic medications)put end to lobotomies and began deinstitutionalization
1963- Community Mental Health Act was passed
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1950-1980 institutionalized dropped from
500,000 to less than 100,000
Improved, more compassionate care
Legislation for research, development of
patient rights
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Stigma and lack of social awareness
Access to Care: cultural disparity, cultural
incompetence among mental health providers
Cost of care- managed care
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Unique techniques of communication to elicit
information
Individualized to patient
Purposeful
Involves active listening
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A way of framing statements and questions
Theory’s tenant- Humans cannot fail to
communicate
Communicate 3 ways: hearing, seeing and
touching
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False Reassurance
Minimizing/belittling
Asking “Why?”
Advising
Agreeing or Disagreeing
Closed-ended questions
Providing the answer with the question
Changing the subject
Approving or Disapproving
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Reflecting
Clarifying and
validating
Using broad and openended questions
Asking for what you
need
Identifying thoughts
and feelings
Using empathy
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Silence
Giving information
Using general leads
General leads
Stating implied
thoughts and feelings
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1. “Have you shared your feelings with your
family?”
2. “I think we should talk more about your anger
with your family.”
3. “You’re feeling angry that your family continues
to hope for you to be cured.”
4. “Well it sounds like you’re pretty pessimistic.
After all, years ago people died of pneumonia.”
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1. “I don’t see you as a failure.”
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2. “You have everything to live for.”
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3. “Feeling like this is all part of being ill.”
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4 “You’ve been feeling like a failure for a
while?”
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1. “I hate being asked these kinds of
questions too.”
2. “I am a nurse and as such I’ll have you
know that all information is kept
confidential.”
3. “I know that some of these questions are
difficult for you, but as a nurse, I must legally
respect your confidentiality.”
“This is difficult for you to speak about, but I
am trying to perform a complete data
collection and I need this information.”
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1.”If you didn’t want our care, why did you
come here?”
2. “ Why are you being so difficult? I only want
to help you.”
3. ”Sounds like you’re feeling pretty troubled
by all of us. Let’s work together so you can
do everything for yourself as you request.”
4. ”I will respect your feelings. I’ll just leave
this cup for you to collect your urine in. After
breakfast, I will take more blood from you.”
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Nurse Practice Act
Standards of Care (Appendix D)
Confidentiality
Doctrine of Privileged Information
Good Samaritan Laws
Involuntary Commitment
Voluntary Commitment
Patient Bill of Rights
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Culture-shared way of life, combination of
traditions and beliefs
Ethnicity- personal traits from shared
heritage: language, country of origin, skin
color
Homelessness
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Cultural Phenomena nurses must understand:
1.Communication- language problems, eye contact
2. Space- personal space, touch
3. Social organizations-varying degrees of
enculturation
4. Time- past vs. living in present
5. Environmental Control-controlling nature
6. Biological Variation- body structure, skin color,
hair texture, genetic variations, susceptibility to
disease, nutritional deficiencies and preference
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Axis I: clinical disorders and
delirium,dementia, mental disorders as
the result of a general medical condition
Axis II: personality disorders/mental
retardation
Axis III: General medical conditions
Axis IV: Psychosocial and environmental
problems
Axis V: global assessment of functioning
(GAF)
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Coded from 0-100
Psychological, social, and occupational
functioning
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Axis I: 300.4 Dysthymic Disorder
315.00 Reading Disorder
Axis II:
No Diagnosis
Axis III: 382.9 Otitis Media
Axis IV:
Victim of Child Neglect
Axis V: GAF= 53 (current)
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Biologic
Psychological
Cultural
Spiritual
Social needs
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Specific data regarding a particular problem
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Used in crisis
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Assess mood, affect and behavior
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Brief Psychiatric Rating Scale (BPRS)
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Drug Attitude Inventory (DAI-10)
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Hamilton Rating Scale for Depression (HRSD)
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Appearance
Affect, Emotional
State
Behavior,
Attitude, Coping
patterns
Communication
and Social Skills
Content of
Thought
Orientation
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Memory
Intellectual ability
Insight
Spirituality
Sexuality
Neurovegitative
Changes
Medical Issues
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Physical characteristics
Peculiarity of dress
Cleanliness
Use of cosmetics
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Outward manifestation of one’s emotions
Flat or blunted
Inappropriate
Labile- rapid changes
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Strange, threatening, suicidal, abusive
Unusual mannerisms
Friendly, fearful, angry , aggressive
Overactive or underactive
Ask how they normally cope with problems
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Impaired Communication:
Blocking – sudden stoppage
Circumstatiality- unnecessary detail
Flight of Ideas- ideas fragmented
Perseveration- same verbal response
Verbigeration- meaningless repetition of
specific words or phrases
Neologism- self invented
Mutism- refusal to speak
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Delusions: fixed false beliefs
Hallucinations: sensory perceptions without
actual stimuli
Depersonalization: feeling of unreality, out of
body sensation
Obsessions: insistent thoughts
Compulsions: insistent, repetitive, intrusive,
and unwanted urges to perform acts
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Person, place, time
Where they are, who they are, date?”
Levels of orientation
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Ability to recall past experiences
Recent memory: recall immediate past-two
weeks
Long-term memory: recall remote past
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Name past presidents
Simple math problems
Evaluate abstract and concrete thinking
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Self-understanding
Do they consider themselves ill?
Do they understand what’s happening?
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Clients beliefs, culture and religious culture
Are beliefs and values helping or hindering
client?
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Concerns about sexual identity, activity and
function
Does client prefer male or female clinician to
discuss concerns?
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Changes in psychophysiologic functions:
sleep patterns, eating patterns, energy levels,
sexual functioning, bowel functioning
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Constant need for ego to reconcile conflicts between id and
superego causes anxiety. Anxiety cases need to preserve
sense of self. (Mental Pressure Valves)
For ego to remain in control automatic psychological
processes (ego defense mechanisms) are mobilized
“Unconscious, protective barriers used to manage instinct and
affect in stressful situations.” Sigmund Freud
Therapeutic used in relation to problem solving- short term
allowing us to work to realistic outcome or solution.
Maladaptive DM lead to distortion of reality and selfdeception regulating the response to protect oneself
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Denial
Repression
Dissociation
Rationalization
Compensation
Reaction-formation
Regression
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Sublimation
Projection
Displacement
Restitution
Isolation
Conversion Reaction
Avoidance
Scapegoating
2. This describes which defense mechanism?
“Unconscious refusal to see reality.”
A. Denial
B. Repression
C. Dissociation
D. Rationalizations
Correct answer: A
Rationale: Denial: usually the first defense
learned and used. It is an unconscious refusal to
see reality.
4. This describes which defense mechanism?
“Use of logical-sounding excuse to cover up
true thoughts and feelings.”
A. Dissociation
B. Rationalizations
C. Compensation
D. Sublimation
Correct answer: B
Rationale: Substituting acceptable reasons for
the true reasons for personal behavior because
admitting true reasons is too threatening.
(Source: Gorman and Sultan, 2008)
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Psychopharmacology
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Milieu Therapy
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Psychotherapies
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Antipsychotics
Antianxiety
Agents
Antidepressants
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Stimulants
Mood Stabilizers
Anticonvulsants
Antiparkinson
Agents
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Milieu- the physical and social environment
in which an individual is receiving treatment.
Safe environment
Treatment team
Community meetings, activity groups,
physical exercise
One-to-one relationship with staff
Goals:
 Decrease patient’s emotional discomfort
 Increase patient’s social functioning
 Increase the ability of the patient to behave
or perform in a manner appropriate to the
situation.
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Sigmund Freud
Focus on cause- buried in unconscious
Couch
Free Association, Dream Analysis, Hypnosis,
Catharsis
Behavior modification- positive or negative
reinforcement (Skinner and Pavlov)behaviors can be learned and unlearned
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Principle: how an individual feels and behaves
is determined by way in which they think
about the world and their place in it.
Rational-Emotive Therapy
Person centered/Humanistic
Unconditional Positive Regard
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Help patients gain insight and receive tools to
make changes
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Teaching
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Pastoral or cultural
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Decreased isolation
Opportunities to help others
Development of coping skills
Decreased transference to therapist
Open groups: no boundaries
Closed groups: set rules
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Humor
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Pet Therapy
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Crisis Intervention
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Couple Therapy
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Family Therapy
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Procedure: uses electric current to induce
seizures
Side Effects: headache, disorientation,
memory disturbance
Effects are cumulative
Postictal Agitation
Informed Consent
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Inpatient: Voluntary and involuntary
Outpatient- private, community, support
groups, marriage and family counseling
Nonpsychiatric facilities- holistic
Dual diagnosis treatment facilities
Correctional Facilities- antisocial thoughts
and behaviors, loss of sense of self, denial
that situation is due to their own choices,
aggressive behaviors
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Provide holistic care
Set appropriate limits and boundaries
Trust
Professionalism
Mutual Respect
Caring, empathy, and genuineness
Therapeutic communication
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Acupressure/acu
puncture
Aromatherapy
Homeopathy
Hypnotherapy
Imagery
Biofeedback
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Herbal and
Nutritional
Meditation
Reiki
Reflexology
Art/Music
Therapy
Pet Therapy
Yoga
1. Holistic treatments address:
A. Only illness
B. Both the illness and the person
C. Only the person
D. A person’s religion
Correct answer: B
Rationale: The mind-body connection is an
important concept in all types of medical
treatment. Disease and wellness affect a whole
person. Holistic treatments address both the
illness and the person.
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Stress produces anxiety
Anxiety: “the uncomfortable feeling of dread
that is a response to extreme or prolonged
periods of stress.”
Mild, moderate, severe, or panic
Free-floating anxiety
Signal anxiety
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Conflict between id and superego, repressed
and emerges in adulthood
Fight or Flight response
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Difficult to differentiate between normal
anxiety and anxiety disorder
Need to do physical assessment- diabetes,
menopause, med side effects, etc….
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Muscle aches
Shakes
Dry Mouth
Nausea
Vomiting
Diarrhea
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Hot Flashes
Chills
Polyuria
Insomnia
Difficulty swallowing
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Generalized Anxiety Disorder (GAD)
Panic disorder
Phobia
Obsessive-Compulsive Disorder
Post-traumatic Stress Disorder (PTSD)
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DSM: related to 2 or
more things and last 6
months
Symptoms:
Must show 3 or more to
be considered GAD
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Restlessness
Easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbances
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A state of
extreme fear that
cannot be
controlled
With or without
agoraphobia
Episodes present
quickly
DSM: at least 4
symptoms
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Symptoms:
Fear (usually of dying,
losing control, or going
crazy)
Dissociation (feeling that
it’s happening to
someone else)
Nausea
Diaphoresis
Chest pain
Increased pulse
Shaking
Unsteadiness
Feelings of being
suffocated
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Most common
Phobia: irrational
fear
700 different
phobias
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Subcategories:
agoraphobia
social phobia
simple phobia
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Recurring thoughts, ideas and actions which
interfere with ability to function
Obsession: repetitive thought, urge or
emotion
Compulsion: repetitive act that may appear
purposeful
Hoarding
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Ensure basic needs are met
Identify precipitating events
Show empathy
Allow compulsive behaviors as long as not a
danger to patient or others
Implement distracters of behaviors
Reinforce non-ritualistic behaviors
Establish written contract to decrease
frequency
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New Category:
Trauma and stress or
related disorder more
Sadness, aggressive
behaviors and
dissociative symptoms
such as flashbacks
(Recurring, intrusive,
disturbing memories)
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Response to an
unexpected emotional or
physical trauma that
could not be controlled.
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Symptoms:
Social withdrawal
Insomnia and nightmares
feelings of low selfesteem
Changes in relationships
Irritability, anger,
outbursts
Depression
Distress when thinking
of event
Effort to avoid reminders
“Survivor Guilt”
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Psychopharmacol
ogy:
Anti-anxiety:
benzodiazepines
or Atarax,
Catapres, Zoloft
Antidepressants:
SSRI’s- primary
Rx
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Aromatherapy
Biofeedback
Hypnotherapy
Yoga
Acupuncture
Relaxation
techniques
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Calm Milieu
Open Communication
Observe for suicidal thoughts
Document changes in behavior
Encourage activities
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Characterized by somatic symptoms very
distressing, significant disruption in
functioning
Excessive and disproportionate thoughts,
feelings and behaviors
Must be persistently symptomatic (6 Months)
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Possible genetic or biological predisposition
Psychological theories- physical symptoms
rooted in unconscious mechanisms, develop
to deny, repress, or displace anxiety
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Converting anxiety into a physical
symptom
Due to overuse of conversion
reaction
Denial
Paralysis and blindness
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Not supportive of organic disease, very real to the
patient
Gives impression of not really caring, “ La belle
indifference”
Symptom allows person to avoid unacceptable
situation or extreme anxiety; dysfunction is
relieving the anxiety (primary gain), (secondary
gain) extra benefits from staying ill.
Malingering: conscious effort to avoid unpleasant
situations, faking
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Anxiety about meaning, significance or cause
of complaint
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“Hypochondriacs”
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Afraid they will get a serious disease
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Falsification of medical or psychological signs
and symptoms in oneself.
By proxy (in others)
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Often hospitalized
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Focuses on symptoms
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Individualized
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Medical and psychological
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Painful, debilitating disease
NOT the “blues” or depressed mood.
Affects all ages, ethnic groups, and
socioeconomic groups
Twice as many woman as men
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Symptoms:
Must last at least 2 weeks for diagnosis
Sad mood
sleep pattern disturbance
increased fatigue
increased agitation
feelings of guilt or worthlessness
weight loss or gain
Loss of pleasure in usually pleasurable things(anhedonia)
decreased ability to think, remember or concentrate
suicidal thoughts or thoughts of death
1. Which of the following is not a symptom of
Major Depressive Disorder?
A. Sad mood that lifts in a few days
B. Two weeks of loss of pleasure in usual
activities
C. Negative self-image that persists for months
D. Excessive sleeping for the past month
Correct answer: A
Rationale: Feelings of sadness that can last a few
hours or days are normal intermittently in life.
Major Depressive Disorder is diagnosed when
the individual remains continually sad for at
least 2 weeks and nothing brings pleasure to
him/her.



Less severe and more chronic
Depressed mood for most of the day, for
more days than not, as indicated by
subjective account or observation of others
For at least 2 years or 1 year in children

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Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty in making
decisions
Feelings of hopelessness





Postpartum Depression
Major Depressive Disorder with Seasonal
Pattern
Substance-Induced Depressive Disorder
Depressive Disorder Associated with Another
Medical Condition
Premenstrual Dysphoric Disorder

Combination of pharmacologic and
psychotherapeutic approaches

Light Therapy

Herbal and Nutritional Therapy

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Small, achievable goals
Encourage patient to speak about concerns
Encourage independence
Avoid activities that may tax memory or concentration
Monitor compliance and side effects of medications
Encourage activity
Promote a trusting relationship
Challenge negative thinking
Promote physical activity
Promote self-esteem
Watch for suicidal thoughts
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

2 Million Americans
Condition in which both extreme mania
(extreme elation or agitation) and extreme
depression exist
Tend to cycle
Change from depression to manic phase
drastic and obvious

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Easily distracted
Little need for sleep
Poor temper control
Reckless behaviors;
Abuse of drugs and
alcohol, poor
judgment, sex with
many partners,
spending sprees


Very elevated mood;
Excess activity
Increased energy
Racing thoughts
Talking a lot
Very high self-esteem
Very involved in activities
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Clear, firm limits
Focus on reality
Reduce external
stimulation
Outlets for excessive
energy
Remove hazards
Assess client for
fatigue
Provide rest periods
Monitor sleep patterns
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Private room
Encourage client to
express feelings
Use calm, slow
interactions
Help client focus
Ignore or distract from
grandiose thinking
Do not argue with
client
Supervise clothing
Avoid competitive
games
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



Persistent sad, anxious
or empty mood
Feelings of hopelessness
or pessimism
Feelings of guilt,
worthlessness, or
hopelessness
Loss of interest or
pleasure in ordinary
activities, including sex
Decreased energy, a
feeling of fatigue or
being slowed down






Difficulty concentrating,
remembering, making
decisions
Restlessness or
irritability
Sleep disturbances
Loss of appetite and
weight loss or weight
gain
Chronic pain or other
persistent bodily
symptoms that are not
caused by physical
disease
Thoughts of death or
suicide, suicide attempts

An imbalance in neurotransmitters,
particularly nor epinephrine, dopamine, and
serotonin

Genetic link

Environmental Triggers





Lithium- close monitoring of levels
Monitor for signs of dehydration
Chamomile and valerian help with mild
anxiety and insomnia
Psychotherapy
Electroconvulsive therapy (ECT)
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President - Abraham LINCOLN
Musician - Adam ANT
Actor - Ben STILLER
Actor - Burgess MEREDITH
Astronaut - Buzz ALDRIN
Author - Charles DICKENS
Nurse - Florence NIGHTINGALE
Director - Francis Ford COPPOLA
Boxer - Frank BRUNO
Scientist - Isaac NEWTON
Actor - Jean Claude VAN DAMME
Musician - Jimi HENDRIX
Actor - Linda HAMILTON
Composer - Ludwig Van
BEETHOVEN
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Prime Minister - Winston
CHURCHILL
Music Producer - Phil SPECTOR
Director - Tim BURTON
Actor - Richard DREYFUSS
Musician - Ray DAVIES
Model - Sophie ANDERTON
Musician – STING
Musician - Kurt COBAIN
Actor - Ned BEATTY
Musician - Ozzy OSBOURNE
Actor - Jim CAREY
Actor - Robert DOWNEY JR
Actor - Robin WILLIAMS
Actor - Spike MILLIGAN
Actor - Stephen FRY
Artist - Vincent VAN GOGH
Act of killing oneself purposely.





39% of people over 65 attempt suicide
Third leading cause of death in adolescents
250,000 suicide attempts annually, 30,00
succeed
Depression major cause
Men more violent; guns, hangings, cars,
women; overdose




Noticeable improvement in mood
Giving away personal items
Talking about death or has preoccupation
Difficulty sleeping
1. Which of the following is true about suicide?
A. It is rare in the United States
B. A previous attempt means the person is at
low risk to make another one
C. Any talk of suicide means that person is at
risk to attempt it
D. Talking about suicide means the person is at
low risk to attempt it
Correct answer: C
Rationale: Anyone who talks about suicide must
be considered at risk to attempt suicide. Those
who commit suicide have frequently made
previous attempts.
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A maladaptive behavior that results from
ineffective personality development. Affects
the way one interprets and fits in the world
we live in.
Stress exacerbates manifestations
May deteriorate to psychotic state
Seldom seen for treatment
Originate in early childhood
Due to overuse of defense mechanisms

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Poor impulse control
Feelings of abandonment and depression
Rage, guilt, fear and emptiness
Impaired judgment
Projects own feelings on to others
Rigid and inflexible
Distorted self-perception; self-hate or selfidealization
Concrete or diffuse thinking

Cluster A (odd-eccentric)
Schizoid
Schizotypal
Paranoid

Cluster B (overemotional, erratic types)
Histrionic
Narcissistic
Borderline
Antisocial

Cluster C (anxious, fearful types)
Obsessive-compulsive
Avoidant
Dependent

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Don’t want involvement in interpersonal or
social relationships
Due to ineffective and unemotional
parenting
Described as“loners”
Very engrossed in books
Intellectual and successful in careers
Appear shy and introverted
Respond in very serious, factual manner
that is pleasant but not warm or inviting

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
Displays abnormal, highly unusual thoughts,
perceptions, speech and behavior
Suspicious
Paranoid
Magical thinking
Odd thinking and speech
Relationship deficits

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Suspiciousness and mistrust
May seem “normal”, but feel treated unfairly
Prone to filing lawsuits
Difficulty maintaining eye contact
Take themselves very seriously
Cold and calculating in relationships
Take comments and events very seriously
Don’t confuse with Paranoid Schizophrenia: no
hallucinations or delusions
Familial



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Pervasive and excessive emotionality and
attention seeking behavior
Behavior often inappropriate
Overly concerned with impressing people
Excessively upset with criticism

Histrionic

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
Almost opposite of schizoid
Exaggerated impression of themselves
self-centered and self-important
Friends chosen according to how good they
make narcissist feel
Seem to take criticism lightly; actually
repressing deep feelings of anger and
resentment
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Causes the greatest amount of trouble for society
Requires immediate self-gratification
Often in trouble with the law
Difficulty handling frustration and anger
Seldom feel affection, loyalty, remorse, or guilt
High risk for substance abuse
Family with few or inconsistent rules, no guidelines for
appropriate social behavior
Inability to feel or show affection
Usually gregarious, intelligent and likable
Very serious maladaptive behavior: serial killers
Manipulative in treatment

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
Common, more frequent in females
Behavioral responses are unpredictable
Moods unstable, uncertain of sexual preference or
self-concept
Substance abuse, suicidal tendencies
Anhedonia
Feel bored and empty
Etiology may be ineffective nurturing by parents
Conflicts between love/hate,
abandonment/domination,
dependency/detachment
2. Which nursing intervention is usually most
appropriate with borderline personality?
A. Maintain close, intense relationship with
patient to develop trust
B. Set limits
C. Have different staff care for patient
D. Administer anxiolytics frequently
Correct answer: B
Rationale: Setting limits is the most common
intervention needed with patients with
personality disorders. The other choices hide or
reinforce negative behaviors.

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Difficulty expressing warm and tender
emotions
Perfectionist, stubborn and controlling
Inflexible with details and rules
Miserly
Hoarders
Ritualistic

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
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Characterized by social withdrawal
Sensitive to potential rejection
Feelings of inadequacy
Hypersensitive to reactions of others
Lack of support system

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
DSM: A pervasive pattern of dependent and
submissive behavior.”
Want others to make decisions for them
Feel inferior, suggestible, feelings of selfdoubt
Avoid responsibility
Try to satisfy and please others
Inordinate amount of fear

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
Often don’t perceive they have a problem,
rarely hospitalized
Often leave treatment when confronted with
problem
Psychotherapy, individual and group, or
cognitive
Therapy long; stop and start
Most will not improve
Medications; Prozac

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Maintain safety
Allow client to make choices
Encourage to discuss feelings not act out
Discuss expectations
Assist with anger management
Trust
Limit setting
Communication
Role modeling
1. Which personality disorder is most associated
with erratic, demanding, manipulative
behavior?
A. Antisocial
B. Narcissistic
C. Borderline
D. Schizotypal
Correct answer: C
Rationale: Borderline personality disorder is
characterized by unstable, erratic behavior that
often leads to dramatic and manipulative
behaviors to achieve one’s goals

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

Group of disorders characterized by psychotic
Disturbances in affect, mood, behavior and
thought
Begins about 16-25 years of age
3 Million Americans
Thought disorder

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Quietness
Withdrawal
Grades drop
Change in personality
Change in relationships

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

Chronic, intermittent, acute psychotic
episodes,progressive downhill course
Relapse rate as high as 60% in first 2 years
12 year follow-up: 78% deterioration in
functioning, 3% attempt suicide
Not curable
High incidence in Homeless

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
At least two of the following present for a
significant portion of time during a one
month period:
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic
behavior
Negative symptoms
Social/Occupational dysfunction
Positive
Symptoms


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Hallucinations
Delusions
Loose Associations
Combativeness
Hostility
Paranoia
Negative
Symptoms


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
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
Social & emotional
withdrawal
Apathy
Flat affect
Poor
insight/judgment
Amotivation
Mutism or
catatonia

Circumstaniality

Neologisms

Confabulation

Thought blocking

Flight of ideas

Word Salad

Looseness of
association
Delusions
 A false fixed belief


Types; Grandeur,
jealousy and
persecution
Hallucinations
 A sense perception
with no external
stimuli
 Types: auditory,
gustatory,
olfactory, tactile,
and visual
3. Which statement reflects the best approach by the
nurse to a schizophrenic patient who tells you she
sees a snake in her room?
A. “I will catch the snake and then you can eat.”
B. “I don’t see a snake in the room. Let’s get you
ready for lunch.”
C. “I am afraid of snakes. Please don’t talk about
them.”
D. “That’s interesting. Describe the snake to me.”
Correct answer: B
Rationale: This response acknowledges that the
snake does not exist in reality and then changes
the focus on reality for the next activity. This
way the image is not dwelled on. If the nurse
focused on the snake hallucination, it would
reinforce this as reality.

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Clang association
Echolalia
Mutism
Neologism
Pressured speech
Verbigeration
Word salad
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

Unusual suspiciousness (main symptom) and
fear
Hostile and aggressive behavior
Also, catatonia, incongruent affect, and loose
associations in speech
Delusions of persecution and grandeur
Voices common

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Unusual behavior and facial contortions
Speech bizarre and incoherent
“word salad”
Inappropriate emotions
Disorganized auditory hallucinations
Most severe, poor prognosis




Less frequent
Disturbed motor activity, vacillate between
extreme rigidity and agitation
Rigid (catatonic stupor) not move for hours
or days
Very suggestible
Echolalia
Echoprexia

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


Establish nurse-patient relationship
Stress situational reality
Accept the patient as he or she is
Do not foster a dependency
relationship
Avoid stressful situations
Use only therapeutic communication
Hay Lo Soul,
Good To Too Two 2 here from you. I thought things got so good for you
that you just 4 GOT WHAT you could of remembered or could remember
what you don't forgit. Where is your mind—must you watch TV all day to
go to night school to be a D.A. JUST to forgit I didn't take your money
when I had ALL your credit cards locked up in [continued on second page]
my dreams—Rife with Con Va Lution due 2 subjewgashen. My spelling got
better—see when you go to school you learn to spell—oh well I'm just
playing clown words to say I didn't forgit Hellbilly—Bill we always had good
days + I'm glad your gonna be a D.A. Be one who works for justice + not
one who wants to win win + and don't care if people didn't do rong—
anyway be as good as you are when you git a job + don't let the job make
you bad you make the JOB good.
Easy Charles Manson
Letter Marginalia:
You even typing now—Cool. A HILLBILLY that can type—FAR OUT.
I know if you payed what you owe you would be brok brok in like broak
ones a panter brock + that they is a crook
1. Which statement is most true about
schizophrenia?
A. It is a disorder of the frail elderly
B. It can be diagnosed at birth
C. Initial psychotic break often occurs when
away at college
D. Can become evident at any age
Correct answer: C
Rationale: Schizophrenia is most often
diagnosed in young people with the first
psychotic break occurring in the teens and 20s.



The new global term that includes the
diagnoses of delirium and dementia
In the past these were referred to as organic
mental syndromes and disorders by the
American Psychiatric Association
Either temporarily or permanently affect the
patient’s ability to think, remember, and make
sound judgments



Acute condition
Develops quickly (usually)
Often develops in response to
◦ Prescription medications use or misuse (evaluate
use of medications that have side effects of
confusion)
◦ Alcohol use, abuse, withdrawal
◦ Fever
◦ Systemic illness (e.g., dehydration, UTI, hypoxia,
electrolyte imbalance)
1. Which of the following is a common cause of
delirium?
A. Brain damage from head injury
B. Dehydration after a bout of diarrhea
C. Plaque changes in the brain
D. All of the above
Correct answer: B
Rationale: Delirium is characterized by sudden
onset. Dehydration from diarrhea causes
electrolyte imbalances that can contribute to
sudden onset of confusion and other cognitive
changes.

Primary degenerative dementia
◦ Alzheimer’s type
◦ Also seen in HIV

Multi-infarct type
◦
◦
◦
◦
Strokes
TIAs
Head injury
Drug/alcohol-induced




Not part of normal aging, though risk
increases with age
Severe memory loss, disorientation, impaired
attention/judgment, inability to acquire new
information, impaired executive functions
(e.g., planning or problem-solving)
Irreversible
Damage is at the cellular level
2. Which of the following is the best choice for
intervention with an Alzheimer’s patient?
A. Isolate the patient when he/she is agitated
B. Provide firm directives on behavior
C. Repeatedly correct patient on current
location
D. Gently guide patient to next activity
Correct answer: D
Rationale: Gentle support and redirecting patient
to current activities is most important. Isolating
patient may increase anxiety. Firm approach
may increase agitation. Reorientation can
increase frustration as patient can’t remember.



No longer considered two distinct diagnoses
Now gradient of mild, moderate, and severe
substance use disorder is preferred
terminology
Substance can be any mood- or mind-altering
drug or alcohol


Addiction: a chronic brain disease
characterized by compulsive and maladaptive
use of a substance or behavior (e.g.,
gambling)
Alcoholism: a complex progressive disease
characterized by significant physical, social,
and/or mental impairment directly related to
alcohol dependence and addiction

Codependency: maladaptive coping behaviors
that reinforce another person’s addictive
behavior by allowing that person to avoid
consequences of his/her actions



Many people with drug and/or alcohol
disorders have co-existing psychiatric
disorders (or dual diagnosis)
Substance may be used to treat uncomfortable
symptoms (e.g., anxiety, depression)
This makes treatment more complicated
 A need for markedly increased amounts of the substance to
achieve intoxication or desired effect (tolerance)



Markedly diminished effect with continued use of
the same amount of the substance
Recurrent substance-related problems including
legal, relationship, work, social
Substance use continues despite knowledge of the
problems being created by it
1. Which statement is most true regarding early
signs of Substance Use Disorder?
A. Uses substance weekly as stress reliever
B. Amnesia after last night’s drinking binge
C. Car accident after using drugs with friends
D. Days of intoxication followed by drying out
period
Correct answer: A
Rationale: Regular use of substance to relieve
stress is one of the early signs of a potential
problem developing. Other choices indicate
more advanced disorder.

Generally substance use becomes a problem
when it
◦ Interferes with normal functioning
◦ Continues despite negative consequences
◦ Hurts others





Brain disorder/genetics
Oral gratification (Freud)
Perception of being high is pleasant and
person becomes addicted to this pleasure
Learned behavior
Use of substance relieves anxiety,
depression





Chemical deposits found in the brain are made of
degenerating nerve cells and proteins called beta
amyloid and tangles (malformed nerve cells)
These plaques and tangles are greatly increased in
someone with this form of dementia
As they increase they create a toxic environment
for normal brain cells
Enzyme used to produce the neurochemical
acetylcholine is reduced as well
New medications to slow the progression of
Alzheimer’s is based on this knowledge



Much research is being conducted to find the
cause
There are currently many theories
Inherited form of Alzheimer’s exists in small
percentage



Currently no cure for Alzheimer’s disease
Treatment geared to slowing progression,
promoting quality of life and safety
Medications include Cholinesterase inhibitors
◦ Effective for only about half of the individuals who take
them
◦ Examples include: Donepezel and Rivastigmine (among
others)

Antipsychotic and antianxiety medications may
also be useful to manage behavior






Stay calm
Do not argue
Reality orientation is usually not effective in
advanced dementia; more effective in delirium
Use clear, simple communication appropriate
to the patient (verbal, pictures, etc.)
Allow sufficient time for the person to respond
Avoid overloading with information or
questions


Use touch when appropriate and nonthreatening to
the patient
Provide adequate, appropriate stimulation
◦ Therapeutic recreation programming
◦ 1:1 interaction

Decrease unnecessary stimulation
◦ Minimize noise from paging, radios, televisions, etc.
◦ Remove mirrors as allowed
◦ Provide a safe environment

Use environmental cues to decrease
behaviors such as wandering
◦ Locks on stairwells for safety
◦ “STOP” signs as reminder
◦ Changing color of the unit

Maintain milieu of acceptance


Do not allow medications to replace other
direct nursing interventions
Physical and chemical restraints to be
avoided as much as possible
2. Which of the following is the best choice for
intervention with an Alzheimer’s patient?
A. Isolate the patient when he/she is agitated
B. Provide firm directives on behavior
C. Repeatedly correct patient on current
location
D. Gently guide patient to next activity
Correct answer: D
Rationale: Gentle support and redirecting patient
to current activities is most important. Isolating
patient may increase anxiety. Firm approach
may increase agitation. Reorientation can
increase frustration as patient can’t remember.

A complex progressive disease
characterized by significant physical,
social, and/or mental impairment directly
related to alcohol dependence and
addiction
◦ Daily use is common; cannot “cut down”
◦ Binges last two days or more
◦ “Blackouts” (amnesia while intoxicated)
◦ Social functioning impaired
◦ Denial is used extensively
◦ Alcohol is a depressant
2. Alcohol is a
A. Stimulant
B. Depressant
C. Neither
D. Both
Correct answer: B
Rationale: Though initial effects may appear to
stimulate, this is caused by reduction of
inhibitions not stimulation when someone gets
“buzzed” from a few drinks.






Heart disease
Liver disease
Diabetes
Falls
Accidents
Dementia

Treatment is usually a slow process

Alcoholics Anonymous (AA)
◦ Usually refer to being in recovery rather than ever
being recovered
◦
◦
◦
◦
12-step program with reported high success rate
Cost-free
Meetings for the user
Separate meetings for codependents/teens/
children

Medications
◦
◦
◦
◦

Inconsistent success
Side effects can be unpleasant
Disulfiram (Antabuse) is controversial
Antidepressants
Newer medications
◦ Acampresate
◦ Naltrexone (Revia)
◦ Campral


Detoxification for safe withdrawal
Family and individual therapy for all involved
to learn new coping skills without the
presence of the alcohol






Maintain honesty
Observe patient for use of defense
mechanisms
Support patient; use positive reinforcement
Promote safety
Demonstrate “tough love”; encourage patient
to be self-responsible
Challenge denial


Symptoms can look similar to those of
alcohol-related conditions
Other symptoms may include
◦
◦
◦
◦
◦
◦
Red, watery eyes
Runny nose
Hostility
Paranoia
Deviant behavior
Needle tracks on arms/legs





Narcotics Anonymous (NA) uses 12-step
approach
Group therapy
Individual psychotherapy
Detoxification required for some drugs
Drug-specific programs based on substance
abused [e.g., Methadone programs (heroin) or
Suboxone (opioids)]


Similar to those for alcohol-related
conditions
Caution: Nurses and others in the medical
professions are high-risk groups for
becoming chemically dependent. Be a role
model and seek help if you or a coworker is
at risk.
Mind or mood altering substances:
Alcohol
Sedatives/hypnotics
Narcotic analgesics
Stimulants
Hallucinogens
Cannabis
Psychoactive drugs
Designer Drugs


14.6% in US- substance abuse disorder
20.6 million persons 12 or older in the last
year
3. Which defense mechanism is generally most
common in someone abusing
methamphetamines?
A. Denial
B. Alteration in coping
C. Manipulation
D. Avoidance
Correct answer: A
Rationale: Even though any of these responses
may be utilized, denial remains the most
common used by those with substance use
disorders.
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Anorexia Nervosa
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Bulimia Nervosa
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Morbid Obesity
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“aversion to food”
Usually in
adolescent girls
Negative feelings
towards their
mothers
Distorted body
image
Symptoms:
Excessive weight loss
Refusal to maintain normal
weight
Intense fear of gaining
weight
Restricting food intake to
200-300 calories
Obsessive thoughts
Perfectionist
Excessive exercise
Perfectionist
Amenorrhea
Etiology
 Genetic, biological and
psychological
 Dopamine regulation and
dysfunction of
hypothalamus
 “fear of maturing, stops
sexual maturation”
 Overly demanding parents
and poor mother/child
relationship
 Way to maintain control
over parents
Treatment
Collaborative:
internal medicine
behavioral approaches
nutrition counseling,
Individual, group and family
pharmacologic management
Mortality rate high
1. Which of the following are most common
with anorexia nervosa?
A. Eating large quantities at one sitting in
private
B. Wearing loose clothing to hide weight loss
C. Trying latest diet with girlfriends despite
being normal weight
D. Snacking excessively in secret
Correct answer: B
Rationale: Anorexics often hide their extreme
weight loss from family by wearing large size
clothing to hide starvation.
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“binge eating”
Followed by forced vomiting
Adolescence
Binge-Purge
May appear to have normal weight
Consume huge amount of food in short time
Manifests in adolescence
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Extreme dieting
Use and abuse of
laxatives
Diuretics
Obsession with
food and eating
Extreme
sensitivity to
body shape and
weight
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Poor self-concept
Suicidal ideation
Impulsiveness
Depression, guilt,
worthlessness
Erosion of teeth
enamel,
hoarseness
Routine use of
bathroom after
eating
Etiology:
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Abnormal levels of
serotonin
Impaired satiety
mechanism
Co-morbid psych
issues- borderline,
panic, substance
abuse, major
depression
Childhood obesity
Treatment:
Individual, group and
family therapy
Food diary assoc with
feelings
SSRI Antidepressants
2. Which of the following women is at highest
risk for bulimia nervosa?
A. Teenager in power struggle with stepmother
B. Schizophrenic girl who is paranoid about source of
her food
C. 20 year old who has struggled with her weight and
gains/loses same weight over and over
D. 40-year-old woman who starts liquid diet program
Correct answer: C
Rationale: Chronic weight struggles may indicate
poor self-esteem, depression, and poor impulse
control.
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Obesity: body weight greater than 15% of
ideal body weight
Morbid obesity: More than 100 pounds over
ideal weight BMI ≥30
Fixated at oral stage
Genetics, thyroid disease, ⇩Insulin
production
Weight loss drugs 2102
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Electrolyte imbalances
Cardiac irregularities
Edema and dehydration
Gastrointestinal problems
1. Which of the following are most common
with anorexia nervosa?
A. Eating large quantities at one sitting in
private
B. Wearing loose clothing to hide weight loss
C. Trying latest diet with girlfriends despite
being normal weight
D. Snacking excessively in secret
Correct answer: B
Rationale: Anorexics often hide their extreme
weight loss from family by wearing large size
clothing to hide starvation.
3. Which is the best approach for your patient
with an eating disorder during meal times?
A. Expect patient to eat everything as
prescribed
B. Recognize that meal time is associated with
anxiety so give extra support
C. Give patient privacy at meal time
D. Remind patient of weight gain/loss goals
Correct answer: B
Meal times are often very stressful for patients
with eating disorders so extra support and
reassurance are important.
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Child abuse
Spousal/domestic violence
Sexual abuse
Elder abuse
Any of these can include violence, emotional
abuse, or neglect

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We are all exposed to violence regularly from
news stories
Road rage, school shootings, and terrorism
are unfortunately no longer rare
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Have usually been abused himself/herself
Usually know their “victims”
Have low self-esteem and a need for power
Often alcohol or drug dependent
May be parents of an unwanted child or
child with special needs
Could have brain dysfunction, genetic
predisposition
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Dependent or codependent-type
personality
Low self-esteem
Relies on abuser
◦
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◦
Physically
Financially
Emotionally
“For the children”
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Bruising/bleeding in unexpected areas
Unexplained, recurrent injuries
Absence from work/school
Withdrawal from friends/social activities
Frequent bladder infections
Physical abnormalities
Frequent visits to the Emergency Department
Fear of partner/caretaker
Self-blame for abuser’s actions
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Can include physical, emotional, sexual,
neglect
The most vulnerable victims
Ages birth to 2 years have highest death rate
1. Which child is most likely to be a victim of
child abuse?
A. Baby of the family
B. Autistic child
C. Teenager who admits to breaking rules
D. None of the above
Correct answer: B
Rationale: Parent susceptible to being abuser
may be more frustrated by continuing demands
of an autistic child.
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Violent or nonviolent sexual contact or sexual
activity that is not wanted by the receiver
Abuser usually knows victim
Includes rape, incest, sexual harassment
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May be called spousal or intimate partner
abuse
Can include physical, emotional, sexual, and
economic abuse
More often women are victims, but men can
also be victims
Cycle of Abuse includes: tension building,
battering incident, honeymoon
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Can include physical, emotional, sexual, and
economic
Abuser is usually in a caregiver role (e.g.,
hired caregiver, family)
Victim is often dependent on abuser
Victim reports of abuse may be ignored
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Access to specialized counseling
Respite care
Support groups
Anger management
Parenting skills
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Support to acknowledge the abuse and stop
the cycle of abuse
Resources to ensure safety for self, children,
and pets
Individual and group therapy with specialists
to treat type of abuse
Medications for anxiety, depression
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Ensure safety for the person and those in
his/her care as well as yourself
Know your own thoughts/feelings about abuse
◦ You may be caring for both the abuser and the survivor
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Be nonjudgmental/show empathy
Know your agency policy
Educate yourself on specific interventions for
each type of abuse
2. What is your first action if you suspect your
patient has been abused?
A. Call the police
B. Call the physician
C. Ensure patient is safe from potential abuser
D. Wait to gather more information before acting
Correct answer: C
Rationale: Ensuring patient safety is always the
first intervention. The other ones may be
appropriate given a specific situation but would
not be your first action.
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Community programs for victims/survivors
Volunteer advocacy programs
Nurses are mandatory reporters for child
abuse
Know laws in your state regarding
mandatory reporting of other types of abuse
LPNs/LVNs can serve as volunteers for
abuse cases or may be employed by
community agencies