Notes for ATI Mental Health practice exam PDF

Preview

Summary

Notes from ati practice exam 2019 rationals from questions...

Description

ATI Mental Health LOC      

Alert: responsive, answer questions appropriately, opens eyes spontaneously. Lethargic: open their eyes, can answer questions but easily falls asleep. Stupor: barely responds to painful stimuli (like rubbing the patients’ sternum) Comatose: unconscious/does not respond to painful stimuli Decorticate: flexion/ internal rotation of upper extremities, joints and legs Decerebrate: neck/elbows extension, wrist and finger flexion

Torts: unintentional torts- negligence: forgetting to set the bed alarm for a patient who is at risk for falling and falls out of bed. Malpractice- giving the wrong medication to the patient, error that harms the patient. Intentional torts:

Assault vs Battery:   

Assault is if you threaten someone, “If you do not take this pill, I will smack you.” Battery: when you actually hurt someone, “You actually act by smacking the patient.” False imprisonment: Nurse will purposely restrain the patient or give them a chemical to a pt. for the nurse convenience, instead of doing alternatives techniques.

Six Ethical Principles      

Beneficence – Doing good by the patient, what is best for the patient. Making the patient feel safe in the environment that their in. Autonomy- respecting their rights by what they decide for their health care. Clients making decisions but the patient must accept consequences of those decisions. *Veracity- truthfulness “Being honest with the patient’s treatment” Justice- fair/equal rights for everyone. *Fidelity- being loyal to the patient, keeping promises. Non-maleficence: Doing No Harm

Legal Rights of the patients in Mental Health      

Pt has the right to refuse treatment even if they’re in a mental health facility. Pts confidentiality: HIPPA: cannot be released without the consent of the patient If someone calls the unit asking about the patient refer them to contact the patient’s family regarding the patient well being Over hear a conversation in a public place: tell them to go have the conversation in a private setting. Mandated that abuse is reported, with a child or an older adult. Our duty to warn third parties if they’re at risk for harm.

Informed Consent: Provider:    

Communicate the purpose of the procedure Give a clear description of the procedure in the patient primary language. Explain the risks vs the benefits Other options in treating the condition

RN Role:  

 make sure the provider gives this information to the patient. Pt is competent in receiving the information, they must be an adult or an emancipated child, THERE CAN BE NO IMPAIRMENTS! If they do not understand the information then we do not answer the questions, have the provider answer the questions.

Restraints:     

Physical- vest, belt, and mittens. LAST RESORT Chemical- sedative/antipsychotic medications Alternatives before restraints: verbal interventions, calm/quiet environment, diversions. Prescriptions must be written Write an order for restraints to be placed on patient. If the orders need to be renewed it has to be renewed within 24 hours.



Care for the Patient:    

Assessing the patient vital signs q 15 mins Offer them food and fluid- Every hour Make sure they get the chance to toilet- Every hour Monitor vital signs.

Emergency Restraints Placed:  

get an order from the doctor within 15-30 mins Time limits: 18 and older: 4 hours, 9-17: 2 hours, 8 and under= 1-hour, extra documentation: event that caused the restraints to be placed, alternative interventions that were attempted, time treatment began, med administered, patient assessment including current behavior, v/s, pain. Pts care provided: food, helping them to the bathroom.

Therapeutic Communication:   

*Always try to get more information from the patient. You never want to shut down communication between you and the patient. *“Always go for tell me more response” Intrapersonal communication: self-talk, thinking thoughts, not verbalizing them. Interpersonal communication: one on one communication with another person.

 

Open ended questions: promote interactive discussions “Tell me more, can you share more about x y,z Closed ended= when looking for a specific answer/ Medical History. Yes/no answers

Clarifying techniques: Restating = repeating back the patient exact words Reflecting= returning focus back to the patient Paraphrasing = restating the patients’ feelings and thoughts to confirm what has been communicated. “What I think I hear you saying is this” Exploring= gathering more information about something that the patient has mentioned. “You mentioned this can you tell me little more about that.” General leads= allows the patient to guide the discussion *Presenting reality= focus on what is actually happening to stop the hallucination, delusions, faulty beliefs. “Must be really scary to hear voices can you tell me what their saying” Offering self: demonstrates a willingness to spend time, and the nurse has a genuine concern.

Barriers:        

Do not offer personal opinions: Never say “ You should do this” Do not give advice Do not give false reassurance. *NEVER ASK WHY! Never offer value judgements Don’t do excessive questioning. Respond approvingly or disapprovingly Always stay neutral while talking. “ I know exactly how you feel” Never say this!

Best Practices when working with older adults: Minimize distractions, discuss health in a private setting, face the patient when speaking, use a low-pitched voice, in the beginning of the interview identify the concerns/needs of the patient, limit the number of items on the questionnaire,* give the patient plenty of time to respond to questions when gathering data*

Defense Mechanisms:  

*Repression: putting unacceptable ideas out of unconscious awareness. “ Pushing it out of your mind and not thinking about it actively. Displacement: Substituting a different target, Ex: A person who loses his job at work but comes home and destroys his son favorite toy.

       

     



*Disassociation: temporarily blocking memories from conscious thought. “Going through a sexual assault, forgetting who they are, having an out of body experience” *Projection: projecting your thoughts on someone else. “Other people are having your feeling” Denial: Not happening, pretending the truth is not reality to manage anxiety. Rationalization: creating an excuse or unacceptable reason for someone’s behavior. “I had to do this .to do this thing” Altruism: dealing with anxiety but reaching out to others, if their experiencing a loss or anxiety cope by reaching out to others. Sublimination: “Substitute” negative impulses into an acceptable form of expression. “Really angry go to the gym and work out really hard” Suppression: voluntarily denying unpleasant thoughts/feelings. “Putting it in the back of your mind and not wanting to think about it” Regression=reverting back to child like behaviors that do not go with the adult developmental stage. “When a new baby enters the family, the older child decides to not utilize the bathroom even though they have already been toilet trained.” Reaction: overcompensating/demonstrating the opposite behavior of what is felt. “I love nursing exams; I love select all that apply questions” Undoing= performing an act, to make up for prior behavior “Husband hits wife, then brings home flowers to make up for that behavior” Compensation= emphazing strengths to make up for weakness. “disabled person is compensating by being great at academics” Identification= adopting one’s ideas from a group or individual Intellectualization=Separating emotions/feelings from logical facts to help with coping. Conversion= responding to stress through unconscious development of physical symptoms not caused by physical illness “A person experiences deafness after his partner tells him he wants a divorce. ***Splitting = in ability to recognize positive/negative attributes of others or self “All or nothing mentality”

Levels of Anxiety:   



Mild: daily occurrence; can be a good thing; increase one’s ability to perceive reality, gets one to focus. Negative symptom: fidgeting, restlessness, toe tapping, irritability. Moderate: Increase HR, RR. Reduction of perception of reality, other side effects include headache, back ache, insomnia. Pacing, difficulty concentrating Severe: greatly reduced perception of field. Have feeling of impending doom, tachycardia, loud and rapid speech, hyperventilation, aimless activity, learning and problem solving cannot happen, cannot take direction from others. Panic: marking disturbed behavior, lose touch with reality, severe hyperactivity or flight, hallucinations, severe withdraw symptoms, dilatated pupils.

Nursing Interventions: Mild: * evaluate the patients pts coping mechanisms that have helped in the past *, “What have you done in the past to help with coping?”, Active listening, assist patient with

problem solving, teach relaxation techniques: Abd breathing exercises, encourage exercise to reduce anxiety Severe: Provide a quiet environment/ No stimulation, remain with patient, set limits with short simple statements, help patient focus on reality. Milieu Therapy: environment that patient is in. Make sure that it is safe and therapeutic.

Stages of a Therapeutic Relationship:  



Stage 1- Orientation Phase: Introduce, discuss confidentiality with the patient, set goal and expectations with the patient, set boundaries and parameters. Stage 2: Working: Assessment, help to understand their needs, help them with problem-solving * Evaluate coping strategies that were successful in the past, this is with crisis, suicide and grieving process., introduce others on unit, readvise plans and goals as needed. Stage 3: Termination: how they feel about the end of the relationship. Summarize achievements, discuss how to incorporate new healthy behaviors into their life.

Transference vs Countertransference:  

Transference: Nurse reminds the patient of someone they know. It can be positive or negative Countertransference: When the patient reminds the nurse of someone they know from their past. Be alert for behaviors changes. You may be irritable, have to have yourself assigned to another patient.

Theories:      1. 2. 3. 4. 5.

Psychoanalysis Theory: dive into past relationships, assess unconscious thoughts or feelings, stem from early childhood experiences, Ex: relationship with mother or father. Free association: Having the patient say whatever comes to mind Cognitive reframing: identifies negative thoughts, examines the cause, replaces the thoughts with more constructive thinking. “Positive thought statements” “Stop thinking =reframing” Dream analysis: Cognitive Therapy: Goal: to change the patient’s thought process. Priority restructuring Journal Keeping Assertiveness Training Monitoring Thoughts Want the patient to write down their thoughts and monitor them. If a negative thought comes to mind, be aware of the negative thought and change it.

Behavior Therapy: 

Operant Conditioning: get a reward for a positive behavior “Rat who pushes the lever, gets the food”

   

Systematic Desensitization: The patient is scared of something or creates anxiety. Gradually expose them to the fear overtime. Practice relaxation techniques. “Step by step process” Aversion Therapy: pair maladaptive behavior with a punishment. Ex: Alcoholic is prescribed Antabuse to have the side effects from being in withdrawal. Modeling: therapist serves as a role model for the pt., demonstrate appropriate behavior Mediation, muscle relaxation, guided imagery, biofeedback.

Group Therapy: Goal: allow members to share common feelings and experiences, learn alternative ways to solve problems. Focus: Common feelings and problem-solving techniques. Dealing with person not wanting to talk in the group setting: Divide the groups into pairs, and then have everyone comeback into a bigger group and have them summarize what everyone discussed in the larger group. * Engaging/Sharing. Dealing with the person who is constantly talking: Ask the group to discuss the members behavior who is talking too much, ask another member about what they think of the person talking to much and that person may be frustrated. Dealing with the Angry or Agitated Person: Have group members move away from other members to prevent injury, get 4-5 other people to show a sign of force and hope the person backs down.

Dysfunctional Families- Family therapy: Enmeshed boundaries:  

Thoughts, roles, feelings blend so much that the individual’s roles are unclear. Ex: Families that have a lot of children, parents are gone all the time, possibly substance abusing, 13 or 15-year-old are caring for babies and they are acting as the parents in the relationship. The roles of the family members are confused.

Stress: acute stress- Fight/Flight: Increase BP, RR, HR, decreased appetite, feeling of apprehension, increased metabolism. These are all normal expected findings.

Prolonged stress- leads to chronic issues- chronic anxiety, depression, increase of heart disease, stroke, diabetes and infection. ECT/ Brain stimulation Therapies  

Indication: Depression, Major Depressive Disorder, Schizophrenia, acute manic episodes. Use of electrical activity to induce seizure in patient to enhance the effects of neurotransmitters in the brain.

Treatment: Scheduled three times a week for 6-12 treatments.  

Short acting anesthetic: Propofol, muscle relaxant acetylcholine: paralyze the muscle during the seizure to help prevent injury in patient. Hypertension can occur immediately after the procedure.

  

Give Atropine to decrease secretions during the procedure. *Fasting prior to the procedure, due to sedation. Monitor v/s, have EEG monitored during procedure, give an anesthetic and a muscle relaxer, follow with the electrical stimulus, monitor the seizure activity, then after done with the induced seizure activity, discontinue the anesthetic.

After the procedure:   

Position the patient on the side to prevent aspiration *Make sure that the patient ‘s gag reflex has returned prior to eating. *Short term memory loss is very common.

Nursing Care: Informed consent, adult not impaired and not hallucinating, treat hypertension and dysrhythmias before ECT, Monitor v/s and mental status before, during and after the procedure. Provide on going cardiac monitoring-ECG, BP/SPO2, Complications: short term memory loss can occur for several weeks, relapse of depression.

Transcranial Magnetic Stimulation: use of magnetic stimulation to stimulate the cerebral cortex of the brain. It is outpatient, daily for 4-6 weeks of treatment. An electromagnetic is placed on the patient’s scalp, pt. will report feeling symptoms of: tapping, tingling, and tighten of the jaw. Used in depression if antidepressants are resistant.

Vagus Nerve Stimulation: invasive procedure, device surgically implanted in the patient chest provides electrical stimulation through the Vagus nerve to the brain. It increases levels of serotonin, norepinephrine, dopamine. Can be turned off by the patient by placing an external magnet over the site of implant. Used if when the patient has depression but the ECT and pharmacological agents are resistant. Somatic Symptom Related Disorders: 

Form of a mental illness pt. experiences physical symptoms result of psychological factors instead of pathological factors.

Conversion Disorder: Risk factors: being female, young adults/teens, childhood trauma mental illnesses such as Depression/Anxiety/Personality Disorder, recent stressful event.

Nursing Care: 

Acknowledge the symptoms, help the patient with retribution treatment and therapy, identify the link between the psychological factors and physical manifestations, administer medications as prescribed antidepressants/antianxiety medication.

Factious Disorder: drives a person to report physical and psychological symptoms in an effort to fill emotional need for attention Imposed on another: deliberating causes injury /illness to a person to get attention or relief of responsibility.

Nursing Care: Avoid confrontation, build rapport/trust with the patient, ensure the safety of the patient of a vulnerable person, communication to the health care team.

Malingering: not a mental illness, someone lies/exaggerates about symptoms to escape work or duty or to collect disability.

Psychobiological Disorder: 

Bipolar Disorder: going in between episodes of manic/depression anxiety.

Personality Disorders: There are 10 of these    



    

Paranoid: suspicious that someone is out to get you Schizoid: emotional detachment/indifference to others situations. *Schizotypal: Magical thinking, odd beliefs, perceptual distortions. *****Antisocial: disregard for others and exploitation, repeated unlawful actions, deceit, failure to accept personal responsibility, manipulative, exploit others. *Watch these patients carefully. Do not put them in charge of anything. *****Borderline: instability of affect, identity in relationships, *splitting behaviors: all good/ all bad, manipulation, impulsiveness, fear of abandonment, *often try to hurt themselves “Selfinjury”, suicidal. *Historian: emotional attention seeking, behaviors are seductive, flirtiest, want to be the center of attention. Ex: Scarlet o’ Hara who is always dramatic needs to be the center of attention. Narcissist: ignorant, self-important, consistent admiration. Avoidant: avoid social situation/interpersonal contact due to extreme fear of rejection/abandonment. Obsessive/Compulsive: focus on perfection, order and control may prevent them from completing a task. Dependent: dependent on others to fill their needs, extreme dependency in a close relationship, always in search of a new relationship when the other one ends.

Nursing Care:   

 Safety, risk for self-injury/violence: Borderline. Provide limits/consistency: Borderline/Antisocial. Provide assertiveness training: Dependent and Historic. Respect the need: Schizotypal/Schizoid they will normally isolate themselves.

Neurocognitive Disorders:



Alzheimer’s Disease ***not reversible accompanies memory loss, problems with judgement, changes in personality.



Stages 1: Mild: memory lapses, frequent misplacement of items, changes become noticeable by families and friends, difficulty concentrating, they will not have issues with ADL’s, takes 2-4 yrs., Loss of initiative, difficulty driving to new destinations.



Stage 2: Moderate:



Stage 3: Severe: **requires assistances with their ADL; s incontinent during this phase,

Difficulty planning/organizing, ***Issues with wandering** SAFETY, personality behavior changes, 2-10 yrs., “Longest stage”, they have remote memory, can not remember family or friends, behaviors tend to worsen in late afternoon (sundowning), psychotic s/s: paranoia, hallucinations. lose the ability to move, death can relate to difficulty swallowing and eating: death by chocking/ and or infection, pressure ulcers and contractures can occur. Takes 1-3 yrs.

Defense Mech used:   

Denial: Refusal of the patient to believe that changes are taking place. Confabulation: makes up stories to prevent admitting they don’t remember things. It is not done purposely. Preservation: repeats phrases or behaviors to avoid questions

Medication...