Mental Health Final

Chapter 1
Mental Health and Mental Illness

It can be said that a person is only in a complete state of health when physical,
mental and social well-being are intact.

Cultural Heritage — Beliefs, Norms, and Values

Culture is a term that describes a common heritage and a set of beliefs,

norms, values, and behaviors that are unique to each. This binding force between
members of each group is often referred to as cultural identity. Cultural identity
may include a common language, family customs, country of origin, religious and
political beliefs, sexual orientation, gender, and an established culture within the
geographic locale where the group resides.

Defining Stress

Eustress, on the other hand, is positive and motivating, as shown by one’s

confidence in the ability to master a challenge or stressor. This type of stress may
actually enhance the feeling of well-being. Acute stress constitutes the reaction to
an immediate threat, commonly called the “fight or flight” response when there
is a surge of the adrenal hormone epinephrine or Adrenalin into the bloodstream.
It is referred to in this way because it provides the energy or instant strength to
either fight or run away from a danger or threat. The response is usually reversed
to a relaxation mode once the danger is past.

Coping Strategies

If the solution temporarily relieves the anxiety but the problem still exists and
must be dealt with again at a later time, this strategy is termed palliative coping.

Promoting Adaptive Coping Strategies

 Reframing is a way of restructuring our thinking about a stressful event into one
that is less disturbing and over which we can have some control.

Adults may view loss as temporary or permanent, and most adults are able to
accept their losses and grow from these situations.

Dysfunctional Grief

Dysfunctional grief is a failure to complete the grieving process and cope

successfully with a loss. These extended feelings a person has while attempting to
deal with the loss are described as chronic sorrow. Unresolved grief describes
situations when the grief process is incomplete and life is burdened with
maladaptive symptoms continuing months after the loss has occurred. Factors
that may contribute to unresolved grief, which then leads to the dysfunction
include the following:

 Socially unacceptable death such as suicide or homicide

 Missing person related to war, mysterious disappearance, or abduction
 Multiple losses or losses in close succession (loss of several family members
in short period with financial loss or disaster loss)
 Ambivalent feelings toward the lost person or object
 Unresolved grieving from a previous loss
 Guilt with regard to circumstances at or near the time of death
 Feelings of the survivor that he or she should have died with or instead of
the deceased
 Consuming feelings of worthlessness with suicidal tendencies
 Physiological response to the loss with marked decrease in functioning
 Delusional thinking or hallucinations of seeing the image or hearing the
voice of the deceased

Coping with Grief and Loss

The nurse must face the reality of his or her own mortality and concept of death.
The nurse needs to respect and attempt to understand the importance of grieving
for oneself and for others. It is important to avoid reassuring cliches.

Using open-ended statements, the nurse can determine what support

systems are available through family and friends, and what coping strategies the
person may have used in the past that could be used to deal with the present
situation.

Interventions that will assist individuals to cope in the grieving process

should encourage clients to be open and honest about their feelings with
reassurance they are acceptable and normal as the process follows its course.

Chapter 2
The delivery of Mental Health Care

In 1953, the National League for Nursing endorsement the inclusion of psychiatric
nursing in all nursing programs.

the Americans with Disabilities Act (ADA) was signed; it was the first federal civil
rights law to prohibit discrimination against persons with mental and physical
disabilities. This legislation protects those persons with disabilities in the
employment setting, while using public health transportation or facilities, and in
areas of mass communication.

Cultural incompetence among mental health providers and professional is

perhaps the single most pivotal barrier to equality in the delivery of mental health
care.

Legal and Ethical Considerations in Mental Health Care

Many decision of health care professionals involve matters that include

both legal and ethical issues.

Clients Rights
 All clients entering a treatment facility have certain rights that have been
documented in the Patient Bill of Rights. Clients are given the opportunity to read
these rights at the time of admission for treatment. This document is usually
displayed in a prominent area for the client service units so that it is available to
clients and families. It is a nurse’s responsibility to be knowledgeable of these
rights and to ensure that they are preserved and protected for the client.

Just the Facts

Least restrictive environments can include locked or unlocked hospitals

units, community living centers, or outpatient treatment centers, depending on
the individual needs of the client

The agency representative also explains insurance benefits or payment options, as

well as the contracts between the treating professionals and third-party payment
reimbursement. The client should be afforded the opportunity to discuss
treatment options with a health care provider.

Confidentiality

Confidentiality refers to the client’s right to prevent written or verbal

communications from being disclosed to outside parties without authorization.
The Nurse Practice Act of each state’s Board of Nursing requires nurses to protect
the client’s right to privacy by maintaining confidentiality.

This law ensures that security procedures protect the privacy and confidentiality
of this information. Clients have the right to know the content of their medical
records, what information is being disclosed for payment benefits or other
treatment reasons, and to whom any disclosures are being given.

Protecting the client’s record from unauthorized personnel is a nursing

responsibility. These may be include the following:
 Intent to commit a crime
 Duty to warn endangered individuals
 Evidence of child abuse
 Initiation of involuntary hospitalization
  Infection by human immunodeficiency virus (HIV)

Appeals and Complaints

Regardless of the setting in which clients receive mental health services,

they have the right to receive information about how to channel complaints
about their care or the professionals providing their treatment. This should be
explained to the clients at at the time services are anticipated, whether in a
hospital unit or an outpatient setting. Should the person with to file a complaint
to a professional board, the person should be advised of the procedure to do so.

Physical restraints are used to prevent harm to self or others and require careful
monitoring. These may consist of padded or cloth devices for the wrist, ankles,
waist or fingers. Chemical restraint refers to the use of medication to calm a
client and prevent the need for physical restraints. Chemical restraint is less
restrictive and is generally the initial choice unless the situation warrants
otherwise.

Nurses have an obligation to maintain current licensure and educational

requirements required by their board of nursing. In the area of psychiatric-mental
health care, the nurse is also responsible for knowing institutional and
governmental policies regarding client admission and rights.

An involuntary commitment occurs when a person is admitted to a psychiatric

unit against his or her will. This amount of time a person can be detained is
determined by law, which varies from state to state. The order for protective
custody (OPC) is given by a court official. The client care be detained on an
emergency statues against his or her will for an interval of 48 to 72 hours.

Non psychiatric Health Care Facilities

The holistic concept of nursing care incorporates the entire scope of human
needs, addressing the physical, psychological, cultural, and spiritual issues of the
individual client. Non-psychiatric settings may include hospitals, providers’ offices,
long-term care facilities, home health care, and hospice care among others. In
some instances, mentally healthy individuals may experience temporary mental
instability as a result of a situational disaster.
 Outpatient Health Care Settings

Client who experience the psychological effects related to a physical illness

are seen in many outpatient practice settings. Sometimes the factors may
interfere with treatment of the medical condition such as continued
noncompliance with diet or medication therapy in the client with diabetes, or
continued smoking by the client with chronic pulmonary disease.

A physical illness that imposes a severe threat to a person’s health status

and lifetime of chronic disease may elicit a grief response to this real or perceived
loss.

Acute Care Settings for the Client with Dual Diagnosis

The client with a diagnosed mental illness who is hospitalized can present a
nursing challenge. Whereas the nurse may prioritize the medical surgical needs of
the client, the secondary mental illness diagnosis must be considered in all
aspects of care planning.

While these and any new medical problems are legitimate health care needs,
there is often an additional manipulative effort by the inmate to acquire personal
gain from the medical personnel, such as special privileges, medications, or
personal articles.

Nurses who work in a correctional facility must learn to separate what is

real from what is a manipulative endeavor by the inmate. While it is important to
accept the inmate as a person it’s human feelings and needs, the nurse must be
vigilant to avoid being victimized by these actions.

Seclusion / Restraints – every 15 minutes documented

RN has to be there for a client to be restrained, has to monitor the patient.
LPN can apply restraints.

Chapter 3
Theories of Personality Development
Personality is defined as an enduring pattern of perceiving, relating to, and
thinking about oneself and the environment that is demonstrated in our social
and interpersonal interrelationships. Integrated into this personal portfolio are
established characteristics and consistent behaviors responses or personality
traits that are unique to each person. This explains why everyone does not act the
same in similar situations. Central traits are those general prominent features
that are most often descriptive of the person, some of which are seen in all the
behavior patterns. Secondary traits are those that many surface in some
circumstances, or situations. For example, one could be referred to as someone
who has a quick temper or one who gets excited easily.
A person’s natural tendencies are the result of a combined genetic transmission
of personality traits from both parents.

As the more basic needs are satisfied, we can move upward to meet other higher
needs Physiologic needs form the first level, or those considered essential for
basic functioning. These include oxygen, food, sleep, elimination, and sex.

Freud also identified the concept of transference or the unconscious transfer of

feelings and attitudes from a person or situation in one’s past to a person or
situation in the present.

Countertransference is the response that is elicited in the person receiving the

transferred feelings or communications.
The super-ego, is often referred to as the conscience, starts developing at about 3
to 4 years of age and is fairly well develop by the age of 10 to 11 years. It controls,
inhibits, and regulates those impulses and instinctive urges whose unrestricted
expression would be socially unacceptable. The superego operates at both the
conscious and unconscious levels, decides right from wrong, and offers both
critical self-evaluation and self-praise.

When environmental stressors create conflicts between the id and the

superego, the ego is the peacemaker and balance between the instinctual drives
and the societal demands influencing the superego.

Ego-Defense Mechanisms

Freud theorized that for the ego to remain in control, automatic

psychological processes called defense mechanisms are mobilized to protect us
from anxiety and the awareness of internal or external stressors. Most of these
mechanisms are mobilized at the unconscious level.

These mechanisms differ from one another and may be adaptive as well as
maladaptive. Maladaptive defense mechanisms, on the other hand, may lead to
distraction of reality and actual self—deception that can interfere with personal
growth and interaction with society.
According to Freud, this gives rise to the Oedipal conflict (boys) and the Electra
conflict (girls) in which the child begins to feel romantic feelings for the parent of
the opposite sex but fears the wrath of the parent of the same sex. Freud
believed these feelings are put into the latency stage during middle childhood
when the sexual desires remain subdued.
Stage 1: Trust versus Mistrust (Birth to 1 year)
The emphasis in this stage is on the oral-sensory gratification received during
feeding through with the infant develops a trusting relationship with the parent
or caregiver.

The pre-operational stage of development occurs from 2 to 7 years.

Communication of thoughts that is largely egocentric without regard for another
view point. The world exists solely to meet the demands of the child’s ego.
The child begins to think logically, classify objects, and recognize that objects and
people can have more than one label.

According to Piaget, the person moves into the stage of formal operations
during the years of 11 to 12 and older. Abstract thought processes, problem
solving, and systematic purposeful mental relationships. They are able to visualize
beyond what is known and formulate hypothetical reasoning.

Sullivan believed that behavior and personality developments are the direct
result of these interpersonal relationships. As a result, three images of self
develop:
 Good-me develops in response to a positive feedback
 Bad-me develops in response to criticism from caregivers
 Not-me develops in response to intense anxiety and dread with resulting
denial and repression of the situation to avoid the anxiety (this avoidance
of emotions can result in mental disorders in the adult)
 Hildegard Peplau (Psychodynamic Nursing)

Peplau applied the interpersonal theory to nursing and the nurse-
client relationship. She saw the stages of developmental growth a the basis
for therapeutic interaction with clients, including many whose behaviors
reflect a failure to understand their own feelings and actions, and the
results of those actions.

Murray Bowen (Family Systems Theory)

This awareness can lead to an intentional desire to make changes and a

refusal to function in the way that has been perpetuated by members of
the family.
Bowen identifies two major variables that affect our behavior in terms of
relationships
The person who behavior is based on internal convictions and principles is
defined as a solid self, as opposed to the pseudoself whose behavior reflects
on external locus of control.

Chapter 4
Treatment of Mental Illness
Establishing a Therapeutic Milieu

A therapeutic milieu is a safe and secure structured environment that facilitates the
therapeutic interaction between clients and members of the professional team. The nurse is
often in a position to maintain the milieu as a place where dignity and acceptance allow the
client to practice skills without reprisal (an act of retaliation).
 The nurse is also a role model for social behaviors and communication skills, which
reinforces the trusting relationship needed for successful treatment. This structured milieu
helps the client toward normalization, improved social skills, and functioning as a member of
society.

-telephone privileges

Psychiatric Nurse

The RN is responsible for developing the individualized care plan and ensuring that it is
implemented within a safe and therapeutic environment.

Mental Health Technician

A mental health technician assists clients with physical and hygiene needs as needed,
monitors unit activities, and assists with group or recreational activities.

Role of the Nurse

Able to maintain an objective view of the client’s situation by understanding his or her own
feelings and emotional responses toward the client.
The Nurse as Caregiver
Basic to the nursing assessment is the observation of appropriate and inappropriate behaviors,
noting both precipitating factors and situational reinforcers. The nurse documents this
information in the client record and provides feedback for other members of the mental health
care team for evaluating effectiveness and progress of the treatment plan. Important for the
nurse to positively reinforce appropriate behavior and encourage clients to participate in all
accepts of the psychotherapeutic process.

The Nurse as Counselor

Nurses are often the person who is available and wiling to provide an attitude of
genuine concern for the client through active listening and therapeutic communication.

The Nurse as Educator

 Nurses are often the link between clients and information about their illnesses and
treatment. Nurses need to provide duration at the client’s level of understanding through
verbal explanations, demonstration, and printed materials about the illness and treatment
regime. Important for the nurse to evaluate the client’s understanding of the instructions by
verbal response or return demonstration.
Psychotherapy

Psychotherapy is a dialog between a mental health practitioner and the client with a goal of
reducing the symptoms of the emotional disturbance or disorder and improving that
individual’s personal and social well-being.

Humanistic therapy centers on the client’s view of the world and his or her problems. Non-
directive but focuses on helping the client to explore and clarify his or her own feelings an
choices, while emphasizing potential and individual strengths.

Biomedical Therapy (combined with therapy)

The use of drugs is often combined with psychotherapy for a more successful outcome. The
medication prescribed depends on the disorder being treated and the client’s overall medical
condition.

Other Types of Therapy

Biofeedback is a training program used for specific types of anxiety that is. Designed to
develop the client’s ability to control heart rate, muscle tension, and other autonomic (things
our body just does automatically without a thought) or involuntary functions.

Play therapy is often used with children and allows the therapist to treat he child during the
dynamic process of play.

Psychotropic agents, also called psychoactive drugs, have their impact on target sites or
receptors of the nervous system to induce changes that affect psychiatric function, behavior, or
experience

Action of psychotropic Drugs on Neurotransmitters

Psychotropic drug agents have their primary effect on neurotransmitter systems of the body.
Neurotransmitters are the chemical messenger proteins stored in the presynaptic
compartment located before the nerve synapse.

.
Psychotropic drugs are effective because they either enhance or decrease the brain’s ability to
use a specific neurotransmitter.

PsychotropicDrug Agents and the Older Client

The Omnibus Budget Reconciliation Act (OBRA) of 1987 limited the use of psychotropic
medications for residents in long-term care facilities. The newer generation of psychotropic
drugs is associated with fewer side effects, and they have thus become drugs of choice for older
clients. Research data on the safety and response of the older client to psychotropic
medications is limited further suggesting a cautious approach to the use of these drugs.

When caring for the client with outbursts of uncontrolled anger, which
of the following nursing actions would most reinforced the desired
outcome?
A. Model an appropriate response to the situation
B. Provide insight into the cause of the observed response
C. Reprimand the client for the inappropriate actions
D. Observe and document a detailed description of the incident

A client has contracted with a therapist to demonstrated decreased

inappropriate language outbursts on the nursing unit. Which of the
following nursing actions would best support the client toward a
positive outcome?
A. Ignore negative behavior and report to the therapist
B. Separating the client from other clients if outbursts occur
C. Modeling appropriate ways to communicate feelings
D. Reprimanding the client for language outbursts

Chapter 5
Establishing and Maintaining a Therapeutic Relationship

The concept of a holistic being views a person s the totality of biologic, psychological, social,
and spiritual functioning that results in a unique person.

Empathy is vital to the establishment of trust. It is important for the nurse to maintain enough
distance from the. Situation to be objective and remain in touch with his or her own feelings.
Trust is vital in the nurse-client relationship related to the vulnerable position in which the
client is placed. Genuineness or realness is an attribute of concern that fosters an hones and
caring foundation for the trust that is forming.

The nurse’s acceptance of the client as a person with worth and dignity who is not
judged or labeled by the nurse’s standards is also necessary for the establishment oof a trusting
climate. It is the nurse’s willingness to recognize the emotionally ill person as one who deserves
respect and needs approval that helps the client to accept the environment. The foundation of
the relationship is based on dependable interactions that demonstrate honesty, integrity, and
consistency.

Orientation Phase

The orientation phase involves getting to know the client. It involves an explanation of
the purpose for the nurse-client interaction as a means of building trust, establishing roles, and
identifying problems and expectations. Rules and boundaries are explained to provide structure
with guidelines for behavior. It is important to assess the content of any negative feelings the
client may be experiencing while reinforcing the limits for behavior. The nurse can also use this
time to assess other client behaviors, immediate concerns and needs, and perceived reason for
treatment.

Working Stage

The second phase is often referred to as the working stage. This is a period in which
outcomes and interventions toward behavior change are planned and goals are developed to
improve the client’s well-being. This involves work by both the nurse and the client to develop
an awareness of the problem and possible solutions to it. Through the use of problem-solving
skills, the nurse assists he client to express feelings and thoughts about the present situation.
The nurse becomes a role model an teaches appropriate coping skills.

Termination

The third phase or termination phase of the relationship is necessary to allow the client
to depend on his or her own strengths while developing improved adaptive skills. The. Nurse
should encourage the client to have increased social interaction and participate in all activities.
This promotes independence.

Professional Boundaries
Within the therapeutic nurse-client relationship, I is the nurse’s responsibility to initiate and
maintain limits or professional boundaries.
Clarification of the nurse’s role may be necessary in situations in which the boundary may be
violated. Situations such as involvement in personal relationships of the client, financial affairs
unrelated to the treatment process, or a third-party liaison that is not treatment related are
issues that must be clearly understood. For example, if a client asks the nurse to relay a
personal message to his girlfriend who happens to live next-door to the nurse, the line must be
clearly drawn and an explanation given to the client that the request is outside the professional
role of the nurse.

Acts that may fall into this category of boundary violations include unnecessary personal
disclosure by the nurse, secrecy, sexual misconduct, over-helping, controlling and role reversal
in the nurse-client relationship.

Manipulation

The nursing approach is to recognize what the client is attempting to do and reinforce limits.

Limits should be fair and explained thoroughly to the client. In response to manipulation,
nurses should avoid reinforcing the negative behavior and focus on the feelings the client is
experiencing at the present time.

Sexually Inappropriate Behaviors or Aggression

Most clients will refrain from making suggestive or sexually oriented comments or advances
once they are asked to do so. The nurse should be direct in letting the client know that the
actions are disturbing and unacceptable.

The nurse is explaining the content of a contract with underlines for behavior to a client on the
nursing unit. Which phase of the therapeutic relationship is the nurse facilitating?
A. Orientation phase
B. Working phase
C. Termination phase
D. Self-awareness

Chapter 6
Dynamics of Anger, Violence, and Crisis

Defining Anger

Anger is an emotion triggered in response to threats, insulting situations, or anything

that seriously hampers the intended actions of an individual. Anger is a natural adaptive
response needed for survival in the face of a threat or danger.
 Trait Anger

Trait anger is often referred to as a general biologic leaning toward a volatile personality
ha may be described by the person themselves as a “quick-temper”, a feeling of becoming
“hot” or feeling one’s heart rate accelerate, or behavior that reflects a quick response of
irritation and fury.

Violence and abusive behaviors are often learned responses in an environment where this is
the norm.

The child who is constantly subjected to a violent verbal or physical response to unleashed
anger by adults in his or her living environment learns this behavior as a norm.

Bullying results in absenteeism, violence at schools, and adolescent suicide.

Risk Factors

There are factors that indicate the potential or warning signs for violence in people.
These may include the following:
 A past history or family history of violence
 Are moody and over sensitive to criticism
 Are power-seeking or overly competitive
 Degrade or put down women
 Drug or alcohol abuse
 Always blame others for their problems or feelings
 Rationalize the use of violent behaviors as needed to resolve a situation
 Expect others to meet their needs or wait on them
 Frequent arguing, curing, or physical fighting
 Verbal threats against others
 Vandalism or harming animals

Recognizing these characteristics and their potential to triggers destructive behavior can
contribute to the efforts to avert the continued escalating incidence of violence-related events.

Cycle of Violence and Abuse

This presumed sorrow sets the victim up for the next step of abuse in which the perpetrator
justifies the behavior by projecting the blame to the victim. The victim feels guilt and accepts
the blame.

Crisis Intervention
 Intervention deals with the present situation and resolution of the immediate issue. It is
important to assess the events that led up to the crisis. Listening to what the client says both
verbally and no verbally gives insight into the event or problem from the client’s perspective. It
is important that the intervention offers hope to the individual and a plan for resolution of the
crisis with specific steps. Focusing on the present situation and keeping a reality-base approach
helps the person to concentrate on a specific task.

Suicide

Firearms, suffocation, and poisoning tend to be the most common methods used.

There are four levels of risk that apply to the person who may be contemplating suicide. A
verbalized thought or idea that indicates the person’s desire to do self-harm or destruction is
suicidal ideation. A statement of intent is considered a suicidal threat and is usually
accompanied by behavior changes that indicate the person has defined their plan. Action that
indicates the person may be about ready to carry out the plan is considered a suicidal gesture.
If the person actually caries out a suicide attempt, the possibility of success is a reality. This is
often the last desperate cry for help by a person who sees no other alternative.

A client is brought to he emergency room in a state of crisis following a

motor vehicle accident in which her mother was killed. Which of the
following statements by the nurse would be most appropriate to
determine the client’s perception of the situation?
A. “What family members are available to be here with you?”
B. “Can you tell me what brought you to the hospital today?”
C. “How have you handled things like this in the past?”
D. “It will take time to realize what happened.”

A call is received by the crisis hotline with the person stating, “I have a
gun and I am going to shoot myself.” Which level of lethality is
demonstrated by this individual?
A. Suicidal erosion
B. Suicidal ideation
C. Suicidal gesture
D. Suicidal attempt
Which statement would be correct in describing the perpetrator in a
situation of domestic violence? (Choose all that apply).
A. History of degrading or putting down women
B. Family history of alcohol abuse or violence
C. Likes to watch action-packed movies on television
D. Frequently involved in fights and vandalism
E. Has had numerous intimate relationships

Chapter 7
Communication in Mental Health Nursing

Communication is a process of exchanging information involving the person sending a message,

the person receiving the message, and the message itself.
Speech Patterns Common to Clients with Mental Illness

These speech patterns often reflect disorder thoughts and processing flaws that occur as
the person is attempting to transmit a message.
 Blocking – In loss of thought process and causes the client to stop speaking (ex. “Then
my father… What was I saying?”).
 Echolalia – vocally repeats last word heard (ex. “Please wait here” is responded with,
“here, here, here, here…”).
 Loose association – exhibits continuous speech, shifting between loosely related topics
(ex. “Martha married Jim. You know Jim is a good cook. I can cook. Chickens are
something we can cook.”).

Nonverbal Communication Techniques

Body movements or kinesics such as hand gestures, facial expressions, can invite the trust
of the client or block further interaction.

Specific nonverbal techniques the nurse can employ to improve communication in a

therapeutic exchange with the client include the following:
 Intermittent eye contact – helps provide reassurance that you are interested and
concentrating on what the client is saying.
 A facial expression that is congruent with other gestures – assures the client of your
interest and attention.
 Arms or legs that are not crossed – conveys a sense of openness to the client.
 Respecting the physical or personal space between the client and yourself – help the
client feel safe.
  Use of touch – helps convey caring and understanding.

Active Listening

Active listening is a learned skill that includes observing nonverbal behaviors, giving
critical attention to verbal comments, listening for inconsistencies that may need clarification,
and attempting to understand the client’s perception of the situation.

Using Silence – Therapeutic effect: conveys willingness to continue listening — allows both the
nurse and the client time to collect thoughts.

Verbigeration – “Need a bath, need a bath, need a bath”

A client tells the nurse, “The voices that that I am evil, and I am going to be punished” Which of
the following would be the most therapeutic response?
A. “The voices are not real so why are you worrying about it?”
B. “I don’t hear the voices, but the words must be frightening for you”
C. “You are imagining the worst when nothin it going to happen”
D. “How can you hear voices when you and I are the only ones in this room?”

During a conversation a client tells the nurse, “My husband left me 6 months ago.” The nurse
notes that the client is repeatedly twisting strands of her hair. The most appropriate technique
for the nurse to utilize at this time would be:
A. Silence
B. Verification
C. Restating
D. Focusing

Chapter 8
The Nursing Process in Mental Health Nursing
The nurse is often the first member of the team that is in contact with the client.

Subjective data are provided by the client and typically include the client’s history and
perception of the present situation or problem, in addition to feelings, thoughts, symptoms, or
emotions that he or she may be experiencing.

Objective data are observed and gathered by the nurse or provided by others who are familiar
with the client including additional members of the health care team. Assessments should
include not only the factors that put the client at risk emotionally and psychologically (ex.
Recent changes r stressors, history of mental disorders, drug use and abuse), but also those
positive factors that suggest the likelihood that the client can recover from the current
situation, such as positive coping strategies, a strong support system, and willingness to receive
treatment.

A nursing diagnosis is not a medical diagnosis, but an identification of a client problem based
on conclusions about the collected data. A nursing diagnosis may be an actual or potential
health problem, depending on the situation. The most commonly used standard is that of
NANDA, an approved list of problems that the nurse can legally address toward a measurable
outcome.

It is also important to give priority to the problem that the client is currently
experiencing (actual) over a problem that may happen (potential). An actual problem has
priority over one that could possible occur during the course of the illness.

Planning Expected Outcomes

These outcomes are defined in terms of short-term goals that address the immediate client’s
immediate unmet need and long-term goals that achieve the maximal level of health that is
realistic for the indictable client at the time of discharge and as a meme er of society.

Implementation of Nursing Interventions

Nursing interventions are actions taken by the nurse to assist the client in achieving the
anticipated outcome.

The evaluation phase is a form of validation for the entire nursing process in the delivery of care
to the client. Criteria are reevaluated to clarify realistic and measurable terms for the individual
client.

Assessment – collection of subjective and objective data concerning the

psychosocial needs of the client
Prioritize - defining in immediately or intensity of problems to
determine the order in which they will be addressed
Nursing Diagnosis – actual or potential problem the nurse can legally
address
Nursing Interventions – actions taken to assist client to achieve
anticipate outcomes
Evaluation – determine success of strategies used in meeting
anticipated criteria
Expected outcome – measurable and realistic goal that anticipates the
improvement or stabilization of the client

The nurse is assessing a client with chronic schizophrenia who has

stopped taking medication and is being with acute psychotic symptoms.
The client’s perception of the present problem would best be
documented by the nurse:
A. Using exact words in client statements
B. With information obtained from the family
C. By observing behavior for several hours
D. As interpreted from the clients thoughts
Chapter 9
Anxiety Disorders

In generalized anxiety disorder, the person experiences an increased level of anxiety and
worry about various situations on most days over a period of at least 6 months.

In addition to the excessive worry and anxiety, the person also experiences, at least three
other symptoms that include restlessness, irritability muscle tension, difficulty falling or
staying asleep, and fatigue. Other somatic complaints may also be reported such as chest
pain, hyperventilation, headaches, tremors, increased urinary frequency, or gastrointestinal
disturbances.

A state of panic results in sympathetic nervous system symptoms of heart pounding,

palpitations, shortness of breath, dizziness, sweating, weakness, and numbness. The person
may also feel shaky and chilled with accompanying nausea, chest pain, tingling or numbness of
the hands, feelings of suffocation, and being out of control. Attacks may occur daily, weekly, or
monthly.

Social anxiety disorder, also known as social phobia, is characterized by an excessive fear of any
social situation in which embarrassment is possible. The person with this disorder experiences
intense discomfort when being watched or at risk of being judged or ridiculed by others. This
experience typically occurs during social activities where the person will be speaking, dinning,
or writing in public.
Physical symptoms of anxiety are usually experienced by the person with social anxiety
disorder. These may include hyperventilation, palpitations, trembling hands or voice, inability to
speck correctly, blushing, sweating muscle tension, or diarrhea.

Posttraumatic stress disorder (PTSD) is characteristically sen when a person has been
subjected to a situation that involve an actual death or threat of severe injury. The person with
PTSD experiences an intense feeling of fear and dreads with each recurring mental rerun of the
event.

Obsessions or the reoccurrence of persistent unwanted thoughts or images that cause the
person intense anxiety. Compulsions are the restive behaviors or rituals the person engages in
to reduce the high level of anxiety. It also addresses related disorders including hoarding
disorder, or a persistent difficult discarding possessions regardless of their actual value;
disorders involving body-focused repetitive behaviors such as body dysmorphic disorder in
which the person has a preoccupation with an imagined defect in appearance of an over
concern with an existing slight physical defect and experience distress over the imagined or
existing defect; trichotrillomania (hair-pulling disorder); and excoriation (skin-picking) disorder.

In OCD, the thoughts tend to be related to sexuality, violence, illness, death, or

contamination. These thoughts are frequently invasive and inappropriate.

The ability to finish a task is impaired by lack of concentration, invasion of the obsessive
thoughts and need to perform the actions. Symptoms may be intermittent or get worse over
time.

Treatment of Anxiety Disorders

Treatment of anxiety disorders focuses on reducing the client’s anxiety level. The
medications used are ant anxiety drugs (anixolytics), such as the benzodiazepines.

Antianxiety agents (anxiolytics) along with some antidepressants agents are used to
counteract or dismiss anxiety. In the 1950s drugs chemically related to the barbiturates were
developed and remain in existence. Their use, however, has been replaced by more effective
drugs that are less addicting than the barbiturate drugs and produce lesser side effects.

Because these medications have a potential for abuse with the development of tolerance,
dependence, and withdrawal, they are usually prescribed for short periods of time.

They should be used with caution in older adults, those with hepatic or renal dysfunction, a
history of drug dependence or abuse, and depression.

Client and Family Teaching

 Important information to teaching the client and family members about antianxiety
agents includes the following:
 The most common side effects of antianxiety medication a drowsiness, fatigue,
confusion, and loss of coordination.
 Avoid driving or operating dangerous machinery while taking the drug.
 Do not take over-the-counter (OTC) or nonprescription drugs without the permission of
your provider.

Application of the Nursing Process to the Client with an Anxiety

Disorder

When establishing a nurse-client relationship with the person experiencing excessive

anxiety, it is important to initially take steps to lower the anxiety level. The person cannot
identify the problem until this is accomplished. The nurse can best encourage trust by a calm
and reassuring approach.
Use directive questions to elicit subjective information about how the client is currently feeling
and what happened before the onset of symptoms.

Social phobia is characterized by excessive fear of any social situation in which

Embarrassment is possible.
Obsessions are recurrent persistent and unwanted thoughts or images that cause intense
anxiety for the person experiencing them.

Initially which of the following nursing interventions would be the most important to
implement when a client is experiencing a panic attack?
A. Administer a PRN dose of anti-anxiety medication
B. Provide a detailed explanation of what causes panic attacks
C. Assure the client you will remain until the panic attack subsides
D. Hug the client to show empathy for the distress he or she is experiencing

1. A college student with known social phobia or social anxiety disorder receives an
assignment that requires a class presentation. The student is so distraught over the
assignment that he drops the class, even though it is require for his degree plan. What
term would be applied to the dread felt by this student that leads to his actions?
A. Free-floating anxiety
B. Automatic relief behavior
C. Uncued Anxiety
D. Anticipatory anxiety

Chapter 10
 Mood Disorders

Affect describes the facial expression an individual displays in association with the mood
(smiling when happy; grimacing when angry).

In the depressive disorders, a common symptom of a sad and empty mood along with
psychosomatic changes is present, whereas in bipolar and related disorders, there is a pattern
of mood swings between mania or euphoria and depression which often include a psychotic
component.

Persistent Depressive Disorder (Dysthymia) Disorder

The person with persistent depressive disorder or dysthymia experiences a recurrent

state of depression over a period of at least 2 years. The symptoms of persistent depressive
disorder are less severe than those of major depression, but the disorder tends to be more
chronic.
Auditory and visual hallucinations may occur during the height of the manic episode.

ECT is used in cases where the client has experienced several episodes of severe
depression and nothing else has worked.

Depression results from a decrease in monoamine neurotransmitter (norepinephrine,

serotonin, and dopamine) concentration to a level insufficient to stimulate the receptors.

Monoamine Oxidase is an enzyme that metabolizes or inactivates the monoamine

neurotransmitters. Specifically, MAOIs work by releasing monoamine neurotransmitters in
the brain, blocking their reuptake into the presynaptic compartments, or mimicking the
effects of the monoamine at the receptors.

These drugs work to correct the chemical imbalance of neurotransmitter concentrations

in the synaptic cleft of CNS nerve cells. They effectively inhibit the reuptake of the
neurotransmitters back into the cells, promoting a higher concentration of the
neurotransmitters within the brain. TCAs also affect other body chemicals and characteristically
produce a number of adverse and potentially dangerous side effects, including cardiac
arrhythmias. This factor requires that all clients taking these agents by monitored closely.

It is important that the client continues taking the medication, even if it does not seem
to be helping.

Antidepressant medication combined with therapy and counseling is usually the

preferred approach to treating clients with depression.
 TCAs are also contraindicated in the acute recovery period following a myocardial
infarction. They should be used with caution in clients with a history of urinary retention or
benign prostatic hypertrophy, glaucoma, asthma, or hepatic or renal disease.

MAOIs are further contraindicated in clients with hepatic or renal insufficiency, a history of
or existing cardiovascular disease, hypertension, or severe headaches, or children younger
than 16 years.

A health provider or pharmacist should be consulted before combining these drugs with
any other prescription or nonprescription (OTC) drugs.

Nursing Diagnoses

Nursing diagnoses applicable to the client receiving antidepressants may include the
following:

 Risk for injury

 Risk for self-directed violence
 Situational low self esteem
 Risk for suicide

Nursing interventions applicable to the client taking antidepressants may include the following:
 Provide explanations of drug action and side effects
 Monitor vital signs
 Assess for suicidal ideation

Outcome Evaluation

Criteria that may be used to evaluate the effectiveness of antidepressants in the client may
include the following:
 Is free of injury or adverse effects of drugs
 Has not harmed self
 Interacts with and communicates with staff and others
 Participates in unit activities

Treatment of Bipolar and Related Disorders

 Mood stabilizing agents are the drugs of choice to treat clients with bipolar disorders.
These drugs may be used alone or in combination with selected atypical antipsychotics and are
used along with psychotherapy to stabilize and control the initial extreme mood swings.

Lithium Carbonate was the first to be named a mood stabilizer drug because of its combined
anti-manic and antidepressant properties.

Therapeutic serum levels are 0.6 to 1.2 mEq/L.

Indication for Use

Mood stabilizing agents are indicated for manic episodes associated with bipolar disorder and
maintenance therapy to prevent or diminish future episodes.

Nursing Interventions

Nursing Interventions applicable to the client taking mood-stabilizing agents may include the
following:

 Assess for signs of toxicity in the client taking lithium carbonate (muscle weakness,
diplopia or blurred vision, severe diarrhea, persistent nausea and vomiting, tinnitus and
vertigo).
 Maintain consistent dietary intake sodium, and increase sodium if activity results in
heavy perspiration

Delusions of persecution occur during interpersonal conflicts where a perceived injustice is

viewed as a threat of harm.
Lithium carbonate is the most common mood-stabilizing drug agent used in the
treatment of bipolar illness.

Anhedonia – lack of pleasure in previously enjoyed activities

Clang association — strings of words in rhyming phrases
Anergia – being tired with decreased energy

A client tells the nurse how difficult recent weeks have been. She states she used to enjoy
taking her grandchildren to the park but this is no longer pleasurable for her. The client is
describing feelings related to which of the following symptoms?
A. Anhedonia
B. Anergia
C. Euphoria
D. Negativism
A client who has been admitted after a suicide attempt from an overdose of antidepressant
medications tells the nurse, “Why couldn’t I just die. There is nothing left here for me.” The
most therapeutic response for the nurse is:
A. “Why did you want to die?”
B. “There is always a reason things happen as they do.”
C. “What do you mean there is nothing here for you?”
D. “You are feeling as though life is meaningless right now?”
The nurse planning interventions for a client with major depressive disorder would give first
priority to which of the following individual needs?
A. Social isolation
B. Self-care deficit
C. Low self-esteem

Chapter 11
Psychotic Disorders

Hallucinations are false sensory perceptions that have no relation to reality and are not
supported by actual environmental stimuli.

Others may be delusions of reference, a false belief that the behavior of others in the
environment refers to oneself. Content can also include a belief that thought broadcasting
occurs, in which the person’s thoughts can be heard by others.

Catatonic behaviors involve a decreases reaction to environmental surroundings. Wavy

flexibility occurs when the person remains in one position until someone changes it.

Patterns of strange, bizarre, and unusual behavior can occur in many forms. The person may
dress oddly, assume strange positions, or demonstrate restless physical movement. Agitation is
often relieved by pacing, with some clients walking great distances without realizing how far
they have gone.

Disorganized Type

Those with disorganized type schizophrenia exhibit disorganized and unintelligible

speech, bizarre behavior, and a flat affect. They may demonstrate inappropriate laughter or be
strangely silly. It is not unusual to see these individuals sitting in an empty room laughing and
acting theatrical.

Residual Type
 The person with residual type of schizophrenia has experienced prominent psychotic
symptoms with a previous diagnosis of schizophrenia but no longer has them. There is lingering
evidence of unusual behavior, a blunted affect, some unrealistic thinking, or social withdrawal.

Treatment of Psychotic Disorders

Most types of psychotic disorders are treated with a combined approach of medications
and psychotherapy. The most. Common type of psychotropic agents used is the antipsychotic
drugs.

Various types of psychotherapy including individual, group, and family therapy may be used
in conjunction with the administration of the drugs.

Thorazine (chlorpromazine), a typical antipsychotic agent in symptoms and resulted in a

dramatic decrease in the number of clients confined to institutions and hospitals for the
mentally ill.

Typical or traditional antipsychotics block various dopamine receptors in the brain.

The term potency indicates how much of the drug is required for it to be effective. The potency
of the drug also influences the level and frequency of side effects experienced by the client.
Low-potency agents cause more anti-cholinergic effects, whereas high-potency agents cause
more extrapyramidal effects.

negative symptoms of psychoses (those developed over a prolonged period of time such as
flattened affect, verbal deficits, and diminished drive) with a reduced risk of extrapyramidal
effects.

The lower-potency drugs tend to produce the anticholinergic (dry mouth, urine retention,
constipation, blurred vision) and antiadrenergic (hypotension) actions, whereas the higher
potency drugs can produce severe extrapyramidal side effects. These side effects block the
neurotransmitter dopamine causing irritation of the pyramidal tracts of the CNS that coordinate
involuntary movements. Extrapyramidal side effects include the following:
 Tardive dyskinesia – late-appearing and irreversible movements of the mouth and face
that include lip-smacking and grinding of teeth, protruding tongue movements. A mask-
like facial appearance, tremors, shuffling gait, cogwheel rigidity, pill-rolling, and stooped
posture are common indications that long-term use of these drugs has occurred
 Drug-induced Parkinsonism – symptoms that mimic Parkinsonism such as tremors,
rigidity, akinesia, or absence of movement with dismissed mental state
 Neuroleptic malignant syndrome – a potentially fatal reaction most often seen with the
high-potency antipsychotic agents. This response typically has an onset from 3 to 9 days
after treatment is initiated. Symptoms include muscular rigidity, tremors, inability to
speak, altered level of consciousness, hyperthermia, autonomic dysfunction
 (hypertension, tachycardia, tachypnea, diaphoresis), and elevated white blood cell
count.

Indications for Use

All antipsychotic drugs are used in the treatment of acute and chronic psychoses, mania,
and dementia-induced psychosis.

 Avoid alcoholic beverages while taking the drugs (will potentiate CNS action)

Antiparkinson Drug Agents

Antiparkinson drug agents are used to relieve the drug-induced extrapyramidal

symptoms associated with the antipsychotic drug agents.

Psychotropic Drugs and the Older Client

The Omnibus Budget Reconciliation Act (OBRA) of 1987 limited the use of psychotropic
medications for residents in long-term care facilities. These guidelines have been modified but
with specific diagnostic and monitoring specifications. Antipsychotic medications can cause
serious side effects such as tardive dyskinesia and other extrapyramidal side effects.

All of these factors highlight the importance of monitoring the response to and
recognizing the adverse effects of antipsychotic agents in the older client.

Data are most often compiled according to the nature of the symptoms, including perceptual
alterations such as hallucinations or illusions.
 Assess the person’s appearance, hygiene, and ability to perform self-care activities.
 Determine any suicidal intent or recent attempts that may have been made.

Selected Nursing Diagnoses

 Risk for Self-Directed or Other-Directed Violence
 Hopelessness

The person with schizophrenia typically has a Blunted or flat affect that is expressionless and
blank.

Thought broadcasting – “I know all the judges can hear what I am thinking”
The health care provider has ordered the drug benztropine (Cogentin) for a client who has been
taking the antipsychotic medication haloperidol (Haldol). Which of the following would the
nurse expect to assess in this client?
A. Increased delusional thinking
B. Intractable hiccups
C. Diminished drive and apathy
D. Protruding tongue movements

A client with paranoid schizophrenia believes her medications are tainted with poisonous
substances and refuses to take them. Which action should the nurse take?
A. Matter-of-fact reinforcement of the need to take the medication
B. Ask the client what the medication is tainted with
C. Ask the client why he thinks the medication is tainted
D. Withhold the medication and try again later

Chapter 12
Personality Disorders
Personality disorders are deeply ingrained, persistent, inflexible, and maladaptive patterns of
behavior that are in conflict with a cultural norm.
People with personality disorders tend to share some common characteristics that define them
as having inflexible and maladaptive behaviors.

Cluster A Personality Disorders

Cluster A personality disorders include paranoid, schizoid, and schizotypal variations.

Persons with these disorders tend to demonstrate odd or eccentric behaviors.

Schizoid Personality Disorder

People with a schizoid personality disorder are with drawn and secluded and
demonstrate an emotional indifference toward social relationships.

Facial expression or affect is usually bland and unresponsive to positive emotions in others.

Schizotypal Personality Disorder

In addition to being secluded and withdrawn from social situations, persons with
schizotypal personality disorder exhibit strange and usual patterns of thinking and
communicating.
 Cluster B Personality Disorders

Dramatic, emotional, or erratic behavior is characteristics of individuals with a cluster B

personality disorder. The category includes the antisocial, borderline, narcissistic, and histrionic
personality disorders.

Antisocial Personality Disorder

Those with an antisocial personality disorder exhibit a persistent pattern of disregard

and infringement on the rights of others in a society. A false sense of privileged revenge against
others is demonstrated by their basic cold indifference to the laws of society and humanity.
Lying and stealing are common, along with a failure to accept or follow through with
responsibilities of everyday living, parenting, or work-related tasks. A childhood and early
adolescence marred with abuse and neglect add to the risk of adults with antisocial behaviors.
This disorder tends to be chronic and perhaps one of the most difficult to treat.

Vandalism, fighting, explosive anger and verbal assault are common. School expulsion, truancy,
and delinquency are among the problems in the person’s history.

Borderline Personality Disorder

Persons diagnosed with borderline personality disorder have a persistent pattern of

unstable interpersonal relationships, insecure self-image, and mood swings. They are impulsive
and intense in their outbursts of anger. Anger is often preceded by anxiety with a recurrent
emotional swing between anxiety, sadness, and anger.

Self-mutilation is an intentional act of inflicting bodily injury to oneself without intent to die as
a result. Self-injury stimulates a release of endorphins that leads to the release of inner tension.
This reinforces and feeds the repetitive pattern of the self-injurious behaviors. The physical pain
of the self-injury serves as a coping mechanism that distracts from and allows the individual to
avoid dealing with the emotional pain. The person also may engage in impulsive behaviors that
have the potential for self-destruction such as substance abuse, gambling, sexual promiscuity,
reckless activity, or excessive eating pattens.

Narcissistic Personality Disorder

The term narcissism is a Greek word, meaning “excessive love and attention given to
one’s own self-image.” The person with a narcissistic personality disorder has a continued need
for lavish attention and admiration with little regard for the feelings of others. Other people
may be used unfairly to satisfy this person’s desires.
This is exhibited as arrogance and claims of entitlement that others owe them because of their
superiority. When shopping for services of er handles, for example, the person will ask to see
the manager or owner of the establishment, indicating their sense of importance.

People who develop the disorder rarely seek treatment and often blame the negative results of
their behaviors on society. Narcissistic personality disorder is more common in men than
women and usually has an onset during early adulthood.

Histrionic Personality Disorder

Typically, the person with histrionic personality disorder displays patterns of egocentric
and. Excessive emotion. In a demanding manner to gain personal attention. Individuals with this
disorder are uncomfortable in situations where center stage is not afforded to them.

Cluster C Personality Disorders

Persons with cluster C personality disorders exhibit anxious and fearful types of heavier
such as the avoidant, dependent, and obsessive-compulsive personality disorders.

Avoidant Personality Disorders

The person with an avoidant personality disorder is typically shy and very sensitive to
negative comments from others. Feelings of inadequacy and intense discomfort are felt in
social situations that involve people other than family.

Dependent Personality Disorder

Individuals with dependent personality disorder demonstrate a consistent and extreme

need to be cared for that leads to a reliance on others. At the same time, they perceive
themselves as helpless and incompetent.

There is an increased incidence of abuse and surrender that is tolerated in these relationships.
Because the abused person is so afraid of being alone, the abuse is endured even when help is
offered to leave the situation.

Obsessive-Compulsive Personality Disorder

People with obsessive-compulsive personality disorder are conscientious, highly

organized, and preoccupied with order and perfection.

Signs and Symptoms

 They are highly critical of others and of themselves if mistakes are made or deviations
made from the instructions. It is difficult for people with this disorder to feel satisfaction of
their accomplishments. They experience high anxiety levels if deadlines or prioritizing are
expected of them. Relationships are often more serious and shallow.

Group therapy and behaviors modification help clients improve interaction skills in addition to
gaining an understanding of how they are perceived by others. Clients can learn how to
ventilate anxiety and trust others in a safe environment. Problem-solving methods can be
practiced within the group to resolve community issues.

A combination of psychotherapy and medication is preferred approach to treatment of

personality disorders, although the symptoms of these disorders are less responsive to drugs.

Some assessment techniques that could be used with individuals with personality disorders
may include the following:
 Use direct quotes to find out what events or behaviors led to the admission
 Look for inconsistencies between what is said and mannerisms and behavior
 Ask if suicidal thoughts have occurred and verify whether a plan has been made.

Those who exhibit a a sense of Entitlement feel that others owe them because of their
superior and powerful status.
Self-mutilation is an intentional act of inflicting bodily injury to oneself that demonstrates an
outward focus of control over inner pain.
A persistent pattern of disregard and infringement on the rights of others in a society is
characteristic of the Antisocial personality.

Splitting- Extreme view of all good or all bad

Narcissism- Grandiose view of self-importance
Dependency- Perceived state of helplessness leading to extreme reliance on others

Which of the following statements is true regarding clients with personality disorders?
A. They are aware that they have a behavior problem
B. Manipulative patterns often render treatment ineffective
C. Most have a sincere motivation to change behaviors
D. Most recognize how their behaviors affects others

Which of the following terms would be characteristics common to all personality disorders?
A. Inflexible and maladaptive behaviors
B. Odd or eccentric behaviors
C. Cold, aloof, and suspicious tendencies
D. Display ideas of reference in everyday occurrences