Mental Health ATI Study Guide PDF

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Mental Health ATI Study Guide Management of Care Confidentiality/Information Security - (2) -

Creating and Maintaining a Therapeutic and Safe Environment: Establishing a Therapeutic Nurse-Client Relationship (MH RN 11.0 Chp 5

Ans: Nurse factors consist of consistent approached interaction, adjustment of pace the clients need, attentive listening, positive initial impression, comfort level during the relationship, self awareness of own thoughts and feelings, and consistent availability Client factors include trusting attitude, willingness to talk, active participation, and consistent availability.

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Legal and Ethical Issues: Maintaining Client Confidentiality (Active Learning Template Basic Concept, RM MH RN 11.0 Chp 2 Legal and Ethical Issues)

Ans: It is important to gain an understanding of the federal law and of state laws as they relate to confidentiality in specific health care facility. The nurse should share information about the client, either verbal or written, only to those who are responsible for implementing the clients treatment plan. The nurse should not discuss client information in public places, and social media should never be used to discuss client or their information. Only if the client provides consent should the nurse share information with other persons not involved in the client's treatment plan. Specific mental health issues were health care professional skin break confidentiality include the duty to warn and protect third parties, and the reporting of child and vulnerable adult abuse. If the nurse becomes aware that the client's rights to privacy is being violated, for example if a conversation on the elevator is overheard, they should immediately take action to stop the violation.

Continuity of Care - (1) -

Diverse Practice Settings: Referral to a Health Care Professional (MH RN 11.0 Chp 6)

Ans: Referral of clients and their families to organizations and agencies that provide additional resources can provide significant support to individuals. Nurses working in community care programs help to stabilize or improve clients mental functioning with a community. They also teach support and make referrals in order to promote positive social activity.

Establishing Priorities - (1) -

Suicide: Priority Nursing Assessment (MH RN 11.0 Chp 30 Suicide)

Ans: Assess for potential suicide risk using a standardized assessment tool, such as the SAD person scale. Physical assessment findings include lacerations, scratches, and spars that could indicate previous attempt at self harm.

Safety and Infection Control Accident/Error/Injury Prevention - (2) -

Bipolar Disorders: Providing Care to a Client Who is Experiencing a Manic Episode (MH RN 11.0 Chp 14)

Ans: Focus on safety and maintaining physical health. Monitor sleep, fluid intake, and nutrition. Provide portable, nutritious food because the client might not be able to sit down to eat. Supervising choice of closed. Giving step-by-step reminders for hygiene and dress. -

Legal and Ethical Issues: Use of Restraints on a School-Age Child (MH RN 11.0 Chp 2)

Ans: Restraint times ages 18 years or older: 4 hours ages 9 to 17 years: 2 hours ages 8 years and younger: one hour

Use of Restraints/Safety Devices - (2) -

Legal and Ethical Issues: Caring for a Client Who Is in Restraints (MH RN 11.0 Chp 2)

Ans: If the need for seclusion or restraint continues the provider must reassess the client and rewrite the prescription, specifying the type of restraint, every 24 hours or the frequency of time specified by facility policy . The facility protocol should identify the nursing responsibility including how often the client should be assessed and client behavior documented, offered food and fluids, toileted, monitor for vital signs, and monitoring for pain.

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Legal and Ethical Issues: Guidelines for the Use of Mechanical Restraints (MH RN 11.0 Chp 2)

Ans: Use of seclusion room and restraints can be warranted an authorized for clients in some cases. Restraints are either physical or chemical. A client can voluntarily request a temporary timeout in cases in which the environment is disturbing or seems too stimulating. A timeout is different from prescribe seclusions because a timeout is by the request of the client. In general, the provider should prescribe seclusion In restraints for the shortest duration Necessary, and only if less restrictive measures are not sufficient. They are for the physical protection of the client and the protection of other clients and staff

Health Promotion and Maintenance Aging Process - (1) -

Older Adults (65 Years and Older): Teaching About Expected Age-Related Changes (Fund 10.0 Chp 25)

Ans: Cognitive: -Delirium: acute, temporary and can have physiologic source (infection, sleep deprivation, pain). Delirium is normally the first manifestation of infection (UTI) in older adults -Dementia: Chronic, progressive and possibly with an unknown cause (Alzheimer’s, vascular dementia) -Depression: chronic, acute, gradual onset (present for atleast 6 wks). Depression is often due to loss of a loved one, feeling isolated, or chronic disease. Psychosocial -Self concept development: seeing self as an aging person, finding ways to maintain good quality of life, becoming dependent -Body Image change: adjustment to decrease in physical strength. Many feel frustrated that their body is limiting what they desire to do. -Social development: find ways to remain socially active and overcome isolation, maintain sexual health

Psychosocial Integrity

Abuse/Neglect - (1) -

Family and Community Violence: Risk Factors for Child Abuse(MH RN 11.0 Chp 32)

Ans: The child is under four years of age. The perpetrator perceives the child as being different (the child is the result of an unwanted pregnancy, is physically disabled, or has some other trait that makes them particularly vulnerable)

Behavioral Interventions - (1) -

Mental Health Issues of Children and Adolescents: Behavioral Management of Autism Spectrum Disorder(MH RN 11.0 Chp 28)

Ans: Initiate referral example physical therapy and speech therapy , as indicated for early intervention. Provide for a structure environment. Consult with parents to provide consistent an individualized care period. Encourage parents to participate in the child care and treatment plan as much as possible. Use short, concise, and developmentally appropriate communication. Identify desired behaviors and reward them. Role models social skills. Role play situations that involve conflict and conflict resolution strategies. Encourage verbal communication. Limit self stimulating and ritualistic behaviors by providing alternative play activities. Determine emotional and situational triggers. Give plenty of notice before changing routine. Carefully monitor the child's behavior to ensure safety

Coping Mechanisms - (1) -

Stress and Defense Mechanisms: Evaluating Constructive Use of Defense Mechanisms (MH RN 11.0 Chp 4)

Ans: Altruism and sublimation are defense mechanisms that are always healthy. Other defense Mechanisms can be used in a healthy manner. However they can become maladaptive if used inappropriately or repetitively. Consider the frequency, intensity, aGoogle nd duration of use of the client's defense mechanisms to determine whether they are adaptive or maladaptive

Crisis Intervention - (3) -

Crisis Management: Priority Intervention for a Client Who Is Grieving (MH RN 11.0 Chp 29)

Ans: The initial task of the nurses to promote a sense of safety for the For the client and protect the client by assessing the client's potential for suicide and homicide.

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Crisis Management: Priority Nursing Interventions (MH RN 11.0 Chp 29)

Ans: Identifying the current problem -

Medications for Depressive Disorders: Analyzing Client Behavior (RM MH RN 11.0 Chp 22)

Ans:

End-of-Life Care - (1) -

Suicide: Priority Interventions for a Client Who is Grieving(MH RN 11.0 Chp 30)

Ans: Assess for verbal and nonverbal clues.

Family Dynamics - (1) -

Group and Family Therapy: Recognizing Boundaries(MH RN 11.0 Chp 8)

Ans: Healthy family boundaries: boundaries are distinguishable between family roles. Clear boundaries defined goals of each member and are understood by all. Each family member is able to function appropriately. Enmeshed boundaries: thoughts,, feelings so much that individual rules are unclear. Rigid boundaries: rules are rules. These families tend to have members that isolate themselves and communication is minimal. Members do not share thoughts or feelings.

Grief and Loss - (2) -

Care of Clients Who are Dying and/or Grieving: Assisting a Client With Grieving(MH RN 11.0 Chp 27)

Ans: clients were experiencing a complicated grief response commonly experience as a loss of self esteem and a sense of worthlessness not associated with normal grief period assessed the client for risk factors and identify a normal versus complicated. Allow time for client to grieve. Use therapeutic communication -

Care of Clients Who are Dying and/or Grieving: Planning Care for Bereavement(MH RN 11.0 Chp 27)

Ans: allow time for the grieving process period educate the client and family on the stage is an task associated with the grieving. Identify expected grieving behaviors, use therapeutic communication, use silence and personal presence to facilitate mourning of feelings, Avoid communication that inhibits open expression of feelings. When relating to someone who is

bereaved, avoid cliches. Rather encouraged the individual to share memories about the deceased. support the clients efforts to move on in the face of the loss.

Mental Health Concepts - (2) -

Bipolar Disorders: Alterations in Mood(MH RN 11.0 Chp 14)

Ans: -Mania: abnormally elevated mood, which can be described as expansive or irritable; usually requires hospitalization. Manic episodes last at least 1 week -Hypomania: less severe, last at least 4 days, followed by 3 more manifestations of mania. Hospitalization not required. Can progress to mania -Rapid cycling: 4 or more episodes of hypomania and acute mania within 1 year and associated with increase recurrence rate and resistance treatment.

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Stress and Defense Mechanisms: Identifying Defense Mechanisms(RM MH RN 11.0 Chp 4)

Ans: -Altruism: dealing with anxiety by reaching out to others -sublimation: dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression -Suppression: voluntarily denying unpleasant thoughts and feelings -Repression: unconsciously putting unacceptable ideas, thoughts and emotions out of awareness. -Regression: sudden use of childlike or primitive behaviors that do not corelate with the persons current developmental level. -Displacement: shifting feelings related to object, person, or situation to another less threatening object/person/situation. -Reaction Formation: Call acceptable feelings or behaviors are controlled or kept out of awareness by overcompensating or demonstrating. -Undoing: Performing an act to make up for prior behavior , most commonly seen in children. -Rationalization: Creating reasonable and acceptable explanation for unacceptable behavior -Dissociation: A disruption in consciousness, memory, identity, perception of the environment that results in compartmentalization of uncomfortable or unpleasant aspect of oneself. Denial: pretending the truth is not a reality to manage unpleasant anxiety causing thoughts/feelings.

-Compensation: emphasizing strength to make up for weaknesses -Identification: Conscious or unconscious assumptions of the characteristics of another individual or group -Intellectualization: Separating emotions and logical facts went analyzing or coping with the situation -Conversion: responding to stress through the unconscious development of physical manifestation not caused by a physical illness. -Splitting: demonstrating an inability to Negative and positive attributes of self or others into a cohesive image -Projection: Attribute in one unacceptable thoughts and feelings unto another who does not have them

Substance Use and Other Disorders and Dependencies - (1) -

Substance Use and Addictive Disorders: Medication to Administer for Alcohol Withdrawal (MH RN 11.0 Chp 18)

Ans: Diazepam: decreases anxiety and sedation Carbamazepine: anticonvulsant and mood stabilizer Clonidine: antihypertensive, ADHD, opioid withdrawals Chlordiazepoxide: treats anxiety, alcohol withdrawal symptoms, and tremors Phenobarbital: Naltrexone: prevent relapse into alcohol or drug abuse

Support Systems - (1) -

Neurocognitive Disorders: Home Safety for a Client Who Has Alzheimer's Disease (MH RN 11.0 Chp 17)

Ans: Remove scatter drugs, install door locks that cannot be easily opened, lock water heater thermostat and turn water temperature down to a safe level, provide good lighting especially on stairs , install a handrail on stairs and mark step edges with colored tape, place mattress is on The floor, remove clutter and keep clear wide pathways for walking through a room, secure electrical cords to baseboards, store cleaning supplies in locked cupboards, and install hand rails in bathroom.

Therapeutic Environment - (1)

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Bipolar Disorders: Interventions for the Client Experiencing Mania (MH RN 11.0 Chp 14)

Ans: -Acute mania: provide a safe environment during the acute phase. Assess the client regularly for suicidal thoughts, intentions, and escalating behaviors. Decrease stimulation without isolating the client if possible. Follow agency protocols for providing client protection such as restraints, seclusion, one to one observation if the threat of self injury or injury to others exist. Implement frequent rest periods. Provide outlets for physical activities That lasts a long time or that require a high level of concentration and detailed instructions. protect client from poor judgment and impulsive behavior, such as giving money away and sexual indiscretions. -Self care: Monitoring sleep, fluid intake, and nutrition. Providing portable, nutritious food because the client might not be able to sit down to eat. Supervising choices of clothes. Giving step-by-step reminders for hygiene and dress. -Communication: Use a com, matter-of-fact, specific approach. Give concise explanation. Provide for consistency with expectations an limit setting. Avoid power struggles, and do not react personally to the client's comments. Listened to an act on legitimate client grievance. Reinforced non manipulative behavior. Used therapeutic communication techniques

Basic Care and Comfort Rest and Sleep - (1) -

Rest and Sleep: Recommendations to Promote Sleep(Fund 10.0 Chp 38)

Ans: Help clients establish and follow a bedtime routine. Limit walking clients during the night. Quiet hospital environment. Help with personal hygiene for a back rub prior to sleep to increase comfort. Consider CPAP devices for clients who have sleep apnea. Consult with provider about trying sleep promoting over-the-counter products such as melatonin and chamomile. As a last resort, that the provider prescribes a pharmacological agent. Medications of choice for insomnia are benzodiazepine like medication. Adjust impatient routines when possible to conform with clients home routine such as bathing and bedtime. Exercise regularly at least 2 hours before bedtime. Establish a bedtime routine and a regular sleep pattern. Arranged the sleep environment for comfort. Limit alcohol, caffeine, and nicotine at least four hours before bedtime. Limit fluids 2-4 hours before bedtime . Engage in muscle relaxation if actions were stressed

Pharmacological and Parenteral Therapies

Medication Administration - (1) -

Substance Use and Addictive Disorders: Teaching About Disulfiram (MH RN 11.0 Chp 18)

Ans: Advise client taking Disulfiram to avoid all alcohol. Disulfiram is an alcohol abstinence drug

Reduction of Risk Potential Changes/Abnormalities in Vital Signs - (1) -

Medications for Depressive Disorders: Planning Interventions for a Client Who Has Serotonin Syndrome (MH RN 11.0 Chp 22)

Ans: Can begin 2-7 hours after the stary of treatment and can be lethal. Start symptomatic treatment (medications to create serotonin receptor blockade and muscle rigidity, cooling blankets, anticonvulsants, artificial ventilation)...