Alcohol Abuse

Alcoholic Beverage

An alcoholic drink contains ethanol, commonly termed as alcohol. Alcohol is a psychoactive drug that is central
nervous system depressant and rapidly absorbed in the bloodstream. It can be addictive and the state of alcohol
addiction is known as alcoholism.

Physiologic Effects of Alcohol Use

When a person drinks alcohol, he or she may experience relaxation and loss of inhibitions initially. However,
when large amount of alcohol is ingested intoxication may occur. The person who is intoxicated may experience
the following manifestations.

 Slurred speech
 Unsteady gait
 Lack of coordination
 Decreased attention span
 Reduced concentration
 Impaired memory
 Impaired judgment
An overdose of alcohol in a short period of time can result to the following manifestations:

 Vomiting
 Loss of consciousness
 Respiratory depression
Physiologic Effects of Long-term Alcohol Use

 Cardiac myopathy
 Wernicke’s encepalopathy
 Korsakoff’s psychosis
 Pacreatitis
 Esophagitis
 Hepatitis
 Cirrhosis
 Leucopenia
 Thrombocytopenia
 Ascites
Treatment of Alcohol Overdose

1. Gastric lavage or dialysis. The procedure is performed to remove the drug from the systemic circulation.
2. Support of respiratory and cardiovascular functioning.
Alcohol Withdrawal

When an alcoholic withdraws from alcohol use, withdrawal symptoms usually starts at about 4 to 12 hours after
a marked reduction or cessation of alcohol intake. The withdrawal may take 1 to 2 weeks. It can be life-
threatening thus, prompt treatment and management is required or necessary. If you feel that you need help with
the withdrawal process as this can often be a stressful time, you are not alone. Many people choose to
visit Avante Institute and Retreat in order to help with their addiction. Keep reading to find out more about the
symptoms you might need help with.
Symptoms of alcohol withdrawal are:

 Coarse hand tremors

 Sweating
 Elevated pulse
 Increase blood pressure
 Insomnia
  Anxiety
 Nausea and vomiting
Delirium Tremens (DT’s)

In cases where the withdrawal signs and symptoms are not treated or becomes severe, the condition may
progress to a condition called delirium tremens. Delirium tremens is an acute episode of delirium that is mainly
caused after a long period of drinking and being stop abruptly and the person experiences withdrawal. It may
also be triggered by head injury, infection, or illness in people with a history of heavy use of alcohol. A list of
the Signs and Symptoms of Delirium Temens is below.
Signs and Symptoms of Delirium Temens:

 Transient hallucinations
 Seizures
 Delirium
Management for Alcohol Withdrawal

1. Detoxification under medical supervision

2. For mild alcohol withdrawal symptoms and the client can abstain from alcohol, home treatment is
possible.
3. For severe cases where the client cannot abstain from alcohol during detoxification, a short admission
(about 3-5 days) is done.
4. Safe withdrawal is accomplished through the administration of benzodiazepines such as Chlordiaxepoxide
(Librium), Lorazepam (Ativan) or Diazepam (Valium) to suppress the withdrawal symptoms.
Alcohol Detoxification
Alcohol detoxification from the los angeles detox center is the removal of alcohol from the body of an
individual who is alcohol dependent or alcoholic. It is the abrupt cessation of alcohol intake coupled with the
substitution of alcohol with drugs used to prevent alcohol withdrawal. Alcohol detoxification is not possible
without support from friends and family. Most of all it needs a commitment on the part of the individual who
will undergo detoxification to abstain from alcohol use.
Alcohol Detoxification Process

The process of alcohol detoxification requires that alcohol be eliminated from the human body and that any
withdrawal or other symptoms that are bound to occur are treated medically or psychologically or both. As
mentioned earlier, the detoxification process is largely determined by the alcoholic himself. The detoxification
process is determined by the person’s condition and by his approach.

In some cases, patients who undergo the alcohol detoxification process may suffer from hallucinations, delirium
tremens and convulsions, which require immediate attention and treatment. To minimize these symptoms,
medical drugs are given. However, the administration of these medications has to be monitored and accurately
controlled. Usually such medications have are given at high dosages initially, but is gradually tampered down
over a week.

Withdrawal symptoms can be quite distressing and can even become fatal if the addiction to alcohol is very
severe. Safe withdrawal is accomplished with the administration of benzodiazepines to suppress the withdrawal
symptoms. Drugs under this category are:

 Chlordiaxepoxide (Librium) – is the benzodiazepine of choice in uncomplicated alcohol withdrawal due to

its long half-life.
 Diazepam (Valium) – is available as an injection for patients who cannot safely take medications by
mouth.
 Lorazepam (Ativan) – is available as an injection for patients who cannot safely take medications by
mouth. This is also indicated in patients with impaired liver function because they are metabolized outside
of the liver.
The most common drugs used for alcohol detoxification are benzodiazepines, with Chlordiazepoxide being the
most preferred benzodiazepine used. Diazepam is also widely used, but fatal effects may occur if it is mixed
with huge doses of alcohol. Hence, supervision is necessary for use of diazepam as a detoxifier.

Where is alcohol detoxification done?

In most cases, alcohol detoxification can be done at home. This is applicable when the alcohol consumption is
just moderate. However, in cases where hallucinations, severe withdrawal symptoms and multi-substance
misuse are noted, an inpatient detoxification is required.

Anorexia Nervosa

Definition

 Anorexia Nervosa is a disorder with an insidious onset that often affects adolescent girls.

 Sufferers are typically high achievers, with good grades and described by parents as perfect children.
Disorder occurs commonly in upper middle class families. Usually the youngest child is affected.

 Unlike bulimics, anorexics uses denial and do not accept that they have a problem, thus, they are more
difficult to treat.

 10-20 % of anorexics die and half of these deaths are due to suicide.

 They are often not recognized because they eat normally in social situations but after eating they
retreat to the nearest bathroom and purge themselves.

 In order to prevent themselves from eating and to help maintain their very restrictive dietary program,
they avoid socializations such as parties, even family meals, thus becoming increasingly socially
isolated.

 They often start as chubby children or overweight adolescents. The disorder begins with somebody
took notice of their being overweight. Because the self-esteem of this person is based on the acceptance
of others, they go on dieting to lose weight and feel accepted again.

 The personality is perfectionist, introverted, with low self-esteem and often has problems with peer
relationships. They are good children who are conscientious, hard working, and ideal students.
Typically they are people pleasers who seek approval and avoid conflict.

 The person may have low tolerance to change and do not adjust well to new situations. Often they are
overly engaged with or dependent on parents or family. Dieting may represent avoidance or, or
ineffective attempts to cope with, the demands of a new life stage such as adolescence.

 They may fear growing up and assuming adult responsibilities including an adult lifestyle. The
symptoms of anorexia are thought to be a kind of symbolic language that expresses: ” I’m not ready to
grow up yet,” or ” I’m starving for attention”.

 Another factor is that this individual may have felt worthless and helpless. They try to combat these
feelings by taking over those parts of their life that they can control, that is, their weight and the food
that they eat.

Types:

1. Restricting – weight loss by dieting, fasting and excessive exercise.

2. Binge eating or purging – uses self induced vomiting, abuses laxatives, diuretics or enema.

Assessment

 Behaviors directed toward weight loss like dieting, exercise and purging.
  Withdrawn and socially isolated, refuses to eat with family on the table.

 Distorted body image, they see themselves as fat despite being emaciated.

 Intense fear of becoming fat.

 Due to misconception that food can make them obese and look ugly, their life is dominated by behavior
directed at avoiding food intake and weight loss. They then become preoccupied with food and engage
in bizarre behaviors such as peculiar way on handling food, hoarding food, collecting recipes,
rearranging food on plate repeatedly, dawdling, reading multiple materials about food to the point of
thinking that they have superior knowledge

 Depressed, sleep disturbances, suicidal tendencies and crying spells.

 Compulsive rituals.

 In women, amenorrhea for at least four months and lack of interest in sexual activity due to lack of
nourishment, menstruation can occur only if a woman is able to maintain at least 17% of body fat.

 In men, level of sex hormones drop. Males develop eating disorders too. About 10% of patient with
eating disorders are male.

 Physical symptoms include bradycardia, hypothermia, dehydration, dependent edema, hypotension due
to decreased metabolic rate as a compensatory mechanism of the body to low food intake.

 Induce vomiting, uses enema, diet pills, excessive exercise, diuretics and laxatives.

 As disease progresses, becomes deceitful, stubborn, hostile, and manipulative.

Nursing Interventions

1. Cognitive and Behavioral therapy to positive and negative reinforcement: focus is on client’s
responsibility to gain weight.

 Privileges are gained with weight gain.

 Privileges are lost with weight loss.

2. Increase self-esteem by acceptance and non-judgmental approach so the patient will realize that they do
not need to artificial perfection they believe thinness provides. Assist to find other positive qualities
about self.

3. Teach about the disorder. The more information they receive that validates their problem, the less
likely they will deny it.

4. Monitor weight three times a week but weigh with the patient facing away from the weighing scale to
help them reduce their focus on weight. Make sure the patient is not hiding heavy objects under her
clothing.

5. As soon as the ideal weight is gained, allow patient to regulate his or her own progression and program.

6. High protein and high carbohydrate diet, serve foods the patient prefer in small frequent feedings. NGT
if the patient refuses to eat.
 7. Setting limits to avoid manipulative behavior:

 Restrict use of bathroom for 2 hour after eating.

 Accompany to the bathroom to ensure that they will not self induce vomiting.

 Stay with client during meals.

 Do not accept excuses to leave eating area.

8. Help the patient identify and express feelings. Avoid being judgmental. People with eating disorders
are thought to be afraid of expressing strong emotions; they express their feelings unconsciously by
vomiting, starvation, and purging.

9. Help the patient to identify and express other bodily concerns such as hairstyle, clothing. Typically
anorectic patients have little bodily awareness other than a distorted perception of their size.

10. Identify the patients non-weight related interests. This could help reduce anxiety, become creative
outlet for energy, raise self-esteem and divert attention from eating and weight.

11. Avoid being confrontational and engaging in long discussions or explanations about food or body.

12. Ignore manipulative behaviors.

13. Refer to self-help groups.

Anxiety
Definition:

 Is a subjective, individual experience characterized by a feeling of apprehension, uneasiness, uncertainty,

or dread.
 It occurs as a result of threats that may be actual or imagined, misperceived or misinterpreted, or from a
threat to identity or self-esteem.
 It often precedes new experiences.
 May be treated by therapy, counselling. Some trials say CBD seems to have a positive effect on anxiety.

Types of Anxiety:

1. Normal
 A healthy type of anxiety that mobilizes a person to action.
2. Acute
 Precipitated by imminent loss or change that threatens the sense of security.
3. Chronic
 Anxiety that the individual has lived with for a long time.
Levels of Anxiety:

1.Mild/ Alertness Level (+1)

 This is the type of anxiety associated with the normal tension of everyday life.
 The individual is alert
 Perceptual field is increased
 Produce growth and creativity, as it increases learning
 The person uses adaptive coping mechanisms to solve problems and alleviate anxiety.
Nursing Interventions:
1. Recognize the anxiety by statements such as “I notice you being restless today”.
 2. Explore causes of anxiety and ways to solve problems that cause anxiety by statements such as “Let’s
discuss ways to…”
2. Moderate/ Apprehension Level (+2)
 The response of the body to immediate danger and focus is directed to immediate concerns.
 Narrows the perceptual field to pay attention to particular details.
 Selective inattentiveness occurs
 The increased tension makes this the optimal time for learning
 The person uses palliative coping mechanisms.
Nursing Interventions:
1. Provide outlets for anxiety such as crying or talking.
2. Tell client “It’s all right to cry”.
3. Encourage in motor activity to reduce tension.
4. Make client be aware of his behavior and feelings by statements such as “ I know you feel scare…”
5. Encourage client to move from affecting (feeling) to cognitive mode (thinking).
6. Refocus attention
7. Encourage the client to talk about felings and concerns.
8. Help the client identify thoughts and feelings that occurred prior to the onset of anxiety.
9. Provide anti-anxiety oral medications.
3. Severe/ Free-floating Level (+3)
 Creates a feeling that something bad is about to happen, or feeling of an impending doom.
 Fight and flight response sets in
 Narrow perceptual field occurs and focus is on specific details or scaterred details so that learning and
problem-solving is not possible.
 All behaviors are directed at alternative the anxiety
 The individual needs direction to focus
 Dilated pupils, fixed vision
 The person uses maladaptive coping mechanisms.
Nursing Interventions:
1. Do not focus on coping mechanisms
2. Stay calm and stay with the client
3. Give short and explicit direction
4. Modify the environment by setting limits or seclusion, limit interaction with others, and reduce
environmental stimuli to calm client.
5. Provide IM antianxiety medications.
4. Panic Level (+4)
 Feelings of helplessness and terror
 The personality and behavior is disorganized
 The individual lessens perception of the environment to protect the ego from awareness and anxiety
causing distorted perceptions and loss of rational thoughts.
 Is unable to communicate or function effectively
 Inability to concentrate
 If prolonged, panic can lead to exhaustion and death
 The person uses dysfunctional coping mechanisms.
Nursing Interventions:
1. Guide patient step by step to action
2. Restrain if necessary.

Behavior Modification
Definition

Behavior modification is a method of strengthening desired behavior or response through a positive or negative
reinforcement of adaptive behavior or the reduction of a maladaptive behavior through extinction, punishment
or therapy.
For example you are an employee. You worked extra hours just to finish your tasks, arrives at work on time and
sometimes you skip lunch just to complete the assigned job. A hard worker – that’s what you are! Now after a
month of hard work your paycheck is delayed. Weeks and months passed and still the salary is not released.
Would you perform the same effort towards your job now that you are still unpaid? You might still go to work
with a change behavior or stop working.

For working people, receiving a regular and on-time paycheck is a positive reinforcer that motivates the
employees to do their job well. If this motivating factor is lacking, expect a less efficient job performance from
the employees. Behaviorists believed that a behavior can be change through a system of rewards and
punishments.
Positive and Negative Reinforcement

A positive reinforcement is provided by giving a person attention and positive feedback. For example, a child
has successfully made it through the night without wetting the bed. The mother acknowledges the child’s
behavior in front of the family during breakfast period.

A negative reinforcement on the other hand is done by removing a stimulus after a behavior occurred to prevent
it from occurring again. For example, a student becomes anxious when he is seated at the back during classes.
He or she may ask the professor to be seated in front to prevent such anxiety.

Indication

 Obsessive-compulsive behavior (OCD)

 Attention deficit hyperactivity disorder (ADHD)
 Phobias
 Enuresis (bed-wetting)
 Generalized anxiety disorder
 Separation anxiety disorder
Behavior Modification Techniques

ABC approach

A – Antecedents
Antecedents are the events that occur before a particular behavior is demonstrated. “What comes directly before
the behavior?”

B – Behaviors
The behavior developed as a result of the presence of antecedent. “What does the behavior look like?”

C – Consequences
These are the events that occur after the behavior. “What comes directly after the behavior?”

After the ABC’s are assessed, the data gathered is analyzed and identified as inappropriate and appropriate
behavior. Inappropriate behaviors are observed, targeted and stopped while the appropriate ones are identified,
developed, strengthened and maintained.

Some Behavioral Theories and Theorists

Theorists such as Ivan Pavlov and Burrhus Frederick Skinner focused on observable behaviors and factors that
bring about behavioral changes.

Classical Conditioning by Ivan Petrovich Pavlov

Ivan Pavlov is a Russian psychologist, physiologist and physician widely known for providing the best example
of classical conditioning through experimentation on dogs. Classical conditioning principle states that a
behavior can be modified or changed through conditioning of the external stimuli or conditions.

Operant conditioning by Burrhus Frederick Skinner

B.F. Skinner is an American psychologist who developed the operant conditioning. Operant conditioning states
that people learn their behaviors from their past experiences particularly those which as constantly reinforced.
Bipolar and Unipolar Comparison
Bipolar

 Results from disturbances in the areas of the brain that regulate mood
 It involves periods of excitability (mania) alternating with periods of depression
 This may affects men and women equally
 Usually appears between ages 15 – 25
Cause

 Unknown
 It occurs more often in relatives of people with bipolar disorder, if you believe you have bipolar you might
want to visit somewhere like https://www.therecoveryvillage.com/mental-health/bipolar-disorder/ for
more information.
Symptoms

Manic Phase

1. Agitation or irritation
2. Elevated mood (hyperactivity, increased energy, lack of self-control, racing thoughts)
3. Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
4. Little need for sleep
5. Over-involvement in activities
6. Poor temper control
7. Reckless behavior (binge eating, drinking, and/or drug use, impaired judgment, sexual promiscuity,
spending sprees)
8. Tendency to be easily distracted
Depressed Phase

1. Difficulty concentrating, remembering, or making decisions

2. Eating disturbances
3. Fatigue or listlessness
4. Feelings of worthlessness, hopelessness and/or guilt
5. Loss of self-esteem
6. Persistent sadness and thoughts of death
7. Sleep disturbances
8. Suicidal thoughts
9. Withdrawal from activities that were once enjoyed
Medical Intervention

 Proper History Taking and Observation

 Antipsychotic medications (such as lithium and mood stabilizers or antidepressant for depressive phase)
 Electroconvulsive therapy (ECT)
Nursing Interventions

1. Provide a calm environment

2. Giving health teachings about regular exercise, and proper diet
3. Explain to patient that getting enough sleep helps keep a stable mood
Unipolar

 Another name for major depressive disorder

 Occurs when a person experiences the symptoms for longer than a two-week period
Causes

 The biopsychosocial model proposes that biological, psychological, and social factors all play a role in
causing depression
 The diathesis–stress model specifies that depression results when a preexisting vulnerability, or diathesis,
is activated by stressful life events
Symptoms
 1. Depressed mood
2. A lack of interest in activities normally enjoyed
3. Changes in weight and sleep
4. Fatigue
5. Feelings of worthlessness and guilt
6. Difficulty concentrating
7. Has thoughts of death and suicide
Medical Interventions

 Antidepressants
 Tricyclic antidepressants
 Monoamine oxidase inhibitors
 Selective serotonin re-uptake inhibitors
 Electroconvulsive therapy
Nursing Interventions

1. Interpersonal Therapy
2. Psychotherapy
3. Encourage client to have a regular exercise
4. Cognitive behavioral therapy
5. Behavioral modification therapy

Difference between Bipolar and Unipolar Disorder

UNIPOLAR BIPOLAR

Gender and Age Affects women more often than men, appears Affects men and woman equally, average age of onset
of Onset later in life suspected to be 18 years

Generally insomnia, difficulty falling asleep or Generally hypersomnia, excessive tiredness and
Sleep waking repeatedly during the night difficulty waking in the morning

Often has a loss of appetite and diminished Often binge-eating and cravings for carbohydrates, may
Appetite interest in eating alternate with loss of appetite

Agitated, pacing and restlessness are more Inactivity, somnolence, a slowing down of movements
Activity Level common (psychomotor retardation) more common

Same as for unipolar, although guilt is often much more

Mood Sadness, hopelessness, feelings of worthlessness prominent

Episodes often last longer, sometimes more Risk of drug abuse and suicide higher than in unipolar
Other responsive to treatment depression

Bipolar Disorder
Description
A mood disorder, formerly known as manic depression is characterized by recurrent episodes of depression and
mania. Either phase may be predominant at any given time or elements of both phases may be present
simultaneously.

Risk Factors

1. Biochemical imbalances
2. Family genetics – one parent, child has 25% risk; two parents, 50-75% risk.
3. Environmental factors such as stress, losses, poverty, social isolation.
4. Psychological influences – inadequate coping, denial of disordered behavior.
Specific Biological Factors

1. Possible excess of norepinephrine, serotonin, and dopamine.

2. Increased intracellular sodium and calcium
3. Neurotransmitters supersensitive to transmission of impulses
4. Defective feedback mechanism in limbic system.

Signs and Symptoms

1. Risk for self or others

2. Impaired social interactions
3. Mania

 Persistent elevated or irritable mood
 Poor judgment
 Increase in talking and activities, grandiose view of self and abilities.
 Impulsivity such as spending money, giving away money or possessions.
 Impairment in social and occupational functioning
 Decreased sleep
 Distractibility
 Delusions, paranoia, and hallucinations
 Dislike of interference or intolerance of criticism
 Denial of illness
 Agitation
 Attention seeking behavior
 Depression
Nursing Diagnoses

1. High risk for violence, directed at self or others

2. Impaired verbal communication
3. Anxiety
4. Individual coping, ineffective
5. Disturbance of self-esteem
6. Alteration in though processes
7. Alteration in sensory perceptions
8. Self-care deficits
9. Sleep pattern disturbances
10. Alteration in nutrition
Therapeutic Nursing Management

1. Environment
2. Psychological treatment
 Individual Psychotherapy – may be used to identify stressors and pattern of behavior.
 Group therapy – establishes a supportive environment and redirect inappropriate behavior.
 Family therapy – verbalizes family frustration and establishes a treatment plan for outpatient use.
3. Somatic and Psychopharmacologic treatments
 electroconvulsive therapy
 Psychopharmacology
Nursing Interventions

1. Assess client’s suicidal feelings and intentions and escalating behavior regularly.
 2. Set consistent limits on inappropriate behavior to help the client de-escalate.
3. Establish a calm environment for the client.
4. Reinforce and focus on reality.
5. Provide outlets for physical activity but prevent client for escalating.
6. Client may be very likable during “high periods”. Staff members need to avoid participating in this
behavior, at other times, client may be very irritable and staff members should approach client quietly and
with limits, if necessary.
7. If the client cannot control self and other methods are not successful, staff may need to provide client
protection if a threat of a self-harm or injury to other exist.
8. Monitor client’s nutrition, fluid intake and sleep.
9. Discuss with the client and family the possible environment or situational causes, contributing factors and
triggers for a mood disorder with recurrent episodes of depression and mania.

Bulimia Nervosa
Definition

 “The Diet-Binge-Purge Disorder”.

 Is a disorder characterized by alternating dieting, binging and purging through vomiting, enema, and
laxatives.
 The person engages in episodes of starvation and other methods of controlling weight (diet pills, excessive
exercise, enemas, diuretics, laxatives), then engages in uncontrolled and rapid eating for about two hours
(over 8000 calories in 2 hours and 50,000 in 1 day) then terminates binging by inducing self to vomit,
going to sleep or going to social activities.
 Weight fluctuations are due to alternating fasting and binging.
1.
1. Bulimia means insatiable appetite.
2. Binging means eating an unusually large amount of food over a short period of time.
3. Purging is an attempt to compensate for calories consumed via self-induced vomiting or abuse of
laxatives, diuretics, or enemas.
 A chronic disorder that usually manifest first during late adolescence and early adulthood, around the ages
15-24 years. It almost always occurs after a period ofdieting.
 The bulimic often belong to a family and society that place great value on external appearance. The person
strives to be thin to be accepted because they believe self-worth requires being thin.
 Usually of normal weight or obese, extrovert, reports self loathing, low self-esteem, has symptoms of
depression, of fear of losing control, with self-destructive tendencies such as suicide.
 These individuals are known to be perfectionist, achievers scholastically and professionally and highly
dependent on the approval of others to maintain self-esteem. They hide their disorder because of fear of
rejection.
 Like anorexia, bulimia can kill. Even though bulimics put up a brave front, they are often depressed,
lonely, ashamed, and empty inside. Friends may describe them as competent and fun to be with, but
underneath, when they hide their guilty secrets, they are hurting. Feeling unworthy, they suffered from
great difficulty talking about their feelings, which almost always include anxiety, depression, self-doubt,
and deeply buried anger. Impulse control may be a problem like shoplifting, sexual adventurousness,
alcohol and drug abuse, and other kinds of risk taking behavior in which the person acts with little
consideration of consequences.
 The person is aware that the behavior is abnormal, but is unable to stop because she is immobilized by her
fear that she cannot stop her behavior voluntarily. The binge episode usually ends when the person
becomes exhausted eating, develops GIT discomfort, runs out of food or is noticed by others.
 After the episode she becomes guilty and depressed that she was unable to control herself, and engages in
self-critism. Then she purges her self as a form of cleansing and punishment.

Common Complications Related to the Manner of Purging

 Chronic inflammation of the lining of the esophagus due to induced vomiting, acidic gastric secretions
irritates esophageal mucosa.
 Rupture of esophagus and stomach.
 Electrolyte imbalance causing cardiac arrythmias, hypokalemia due to diarrhea,hypochloremia due to
vomiting, hyponatremia due to vomiting and diarrhea.
 Dehydration.
  Enlargement of the parotid gland.
 Irritable bowel syndrome.
 Rectal prolapse or abscess.
 Dental erosion.
 Chronic edema.
 Fungal infection of vagina and rectum.
Nursing Diagnosis

 Alterations in health maintenance.

 Altered nutrition: Less than body requirements.
 Altered nutrition: More than body requirements
 Anxiety
 Body image disturbance
 Ineffective family coping; compromised
 Ineffective individual coping
 Self-esteem disturbance

Nursing Interventions

1. Patient with bulimia are aware of their problems and they want to be helped because they feel helpless and
unable to control themselves during episodes of binging. But because of their intense desire to please and
need to conform they may resort to manipulative behavior and tell half-truths during interview to gain trust
and acceptance of nurses. Create an atmosphere of trust. Accept person as worthwhile individual. If they
know that no rejection or punishment is forthcoming they disclose their problem, they will be more open
and honest.
2. Develop strength to cope with problems. Encourage patient to discuss positive qualities about themselves
to increase self-esteem.
3. Help patient identify feelings and situations associated with or that triggers binge eating.
 Assist to explore alternative and positive ways of coping.
 Encourage making a journal of incident and feelings before-during and after a binge episode.
 Make a contract with the patient to approach the nurse when they feel the urge to binge so that
feelings and alternative ways of coping can be explored.
4. Encourage adhering to meal and snack schedule of hospital. This decreases the incidence of binging,
which is often precipitated by starvation and fasting.
5. Encourage participating in group activities with other persons having the same eating disorder to gain
additional support.
6. For young adolescent living at home, encourage family therapy to correct dysfunctional family patterns.
7. Cognitive behavioral therapy is the ideal therapy to help the bulimic understand the problem and explore
appropriate behaviors.

Cognitive Disorders
Definition

 Cognitive disorders are characterized by the disruption of thinking, memory, processing, and problem
solving.
 Types of cognitive disorders include: delirium, dementia, and memory loss disorders (amnesia or
dissociative fugue).
Risk Factors

1. Physiological changes such as neurological, metabolic, and cardiovascular disease.

2. Cognitive changes
3. Family genetics
4. Infections
5. Tumors
6. Sleep disorders
7. Substance abuse
8. Drug intoxications and withdrawals
Signs and Symptoms

1. Irritability; mood most frequently seen in organic brain disorder.

2. Change in level of consciousness.
3. Difficulty thinking with sudden onset.
4. State of awareness ranging from hyper vigilance to stupor or coma.
5. Impairment in cognition and thought process, particularly short-term memory.
6. Anxiety
7. Confabulation
Therapeutic Nursing Management

1. The nurse plays a primary role in providing a safe environment for the client and others.
2. Exogenous stimuli in the environment can intensify the client’s level of orientation.
3. Cognitive changes may often include a period of confusion or forgetfulness.
4. The nurse may encourage family members to bring photographs or familiar items as strategy to orient the
client.
5. Psychological treatment may focus more on the family to offer them support during this stressful time.
6. Cognitive changes affect the family and care providers. Cognitive decline often means a change in the
family roles and activities of daily living.
7. Pharmacologic therapy is implemented to reduce or alleviate the associated symptoms such as antianxiety
medications, antidepressants, and antipsychotics.
Nursing Interventions

1. Determine the cause and treatment of the underlying causes.

2. Remain with the client, monitoring behavior, providing reorientation and assurance.
3. Provide a room with a low level of visual and auditory stimuli.
4. Provide palliative care with the focus on nutritional support.
5. Reinforce orientation to time, place, and person.
6. Establish a routine.
7. Client protection may be required.
8. Have client wear an identification bracelet, in case she or he gets lost.
9. The client should not be left alone at home
10. Break test into small steps, giving one instruction at a time.

Crisis Intervention
Definition
Crisis is a situation or period in an individual’s life that produces an overwhelming emotional response. This
event occurs when an individual is confronted by a certain life circumstance or stressor that he or she cannot
effectively manage by using his or her usual coping skills. Crisis is an unexpected event that can create
uncertainty to an individual and has been viewed as a threat to a person’s important goals.

Stages of Crisis

The first stage of crisis occurs when the person is confronted by a stressor. Exposure to this stressor would result
to anxiety. The individual then tries to handle things by using his or her customary coping skills. Second stage
of crisis occurs when the person realizes that his usual coping ability is ineffective in dealing with anxiety. As
the person becomes aware of his unsuccessful effort in dealing with the perceived stressor, he moves on to the
next stage of crisis where the individual tries to deal with the crisis using new methods of coping. The fourth
stage of crisis takes place when the person’s coping attempts of resolving the crisis fail. The individual then
experiences disequilibrium and significant distress.

Types of crisis

1. Maturational crisis – also called developmental crisis. These are predictable events in a person’s life which
includes getting married, having a baby and leaving home for the first time.
2. Situational crises – unexpected or sudden events that imperils ones integrity. Included in this type of crisis
are: loss of a job, death of a loved one or relative and physical and emotional illness of a family member or
an individual.
 3. Adventitious crisis – also called social crisis. Included in this category are: natural disasters like floods,
earthquakes or hurricanes, war, terrorist attacks, riots and violent crimes such as rape and murder.
Crisis Intervention

Crisis intervention refers to the methods used to offer immediate, short-term help to individuals who experience
an event that produces emotional, mental, physical, and behavioral distress or problems.

Guide for an effective crisis intervention:

1. Assist the person to view the event or issue in a different perspective.

2. Assist the individual to use the existing support systems. It is vital to help the person find new sources of
support that can help in decreasing the feelings of being alone or overwhelmed.
3. Assist the individual in learning new methods of coping that will help resolve the current crisis and give
him or her new coping skills to be used in the future when dealing with another overwhelming situation.

Defense Mechanisms
People use defense, or coping, mechanisms to relieve anxiety. The definitions below will help you determine
whether your patient is using one or more of these mechanisms.

1. Acting Out
 Acting out refers to repeating certain actions to ward off anxiety without weighing the possible
consequences of those action.
 Example: A husband gets angry with his wife and starts staying at work later.
2. Compensation
 Also called substitution.
 It involves trying to make up for feelings of inadequacy or frustration in one area by excelling or
overindulging in another.
 Example: An adolescent takes up jogging because he failed to make the swimming team.
3. Denial
 A person in denial protects himself from reality – especially the unpleasant aspects of life – by
refusing to perceive, acknowledge, or face it.
 Example: A woman newly diagnosed with end-stage-cancer says, “I’ll be okay, it’s not a big deal”.
4. Displacement
 In displacement, the person redirects his impulses (commonly anger) from the real target (because
that target is too dangerous) to a safer but innocent person.
 Example: A patient yells at a nurse after becoming angry at his mother for not calling him.
5. Fantasy
 Fantasy refers to creation of unrealistic or improbable images as a way of escaping from daily
pressures and responsibilities or to relieve boredom.
 Example: A person may daydream excessively, watch TV for hours on end, or imagine being highly
successful when he feels unsuccessful. Engaging in such activities makes him feel better for a brief
period.
6. Identification
 In identification, the person unconsciously adopts the personality characteristics, attitudes, values,
and behavior of someone else (such as a hero he emulates and admires) as a way to allay anxiety. He
may identify with a group to be more accepted by them.
 Example: An adolescent girl begins to dress and act like her favorite pop star.
7. Intellectualization
 Also called isolation.
 Intellectualization refers to hiding one’s emotional responses or problems under a façade of big
words and pretending there’s no problem.
 Example: After failing to obtain a job promotion, a worker explains that the position failed to meet
his expectations for climbing the corporate ladder.
8. Introjection
 A person introjects when he adopts someone else’s values and standards without exploring whether
they fit him.
 Example: An individual begins to follow a strict vegetarian diet for no apparent reason.
 9. Projection
 In projection, the person attributes to others his own unacceptable thoughts, feelings, and impulses.
 Example: A student who fails a test blames his parents for having the television on too loud when he
was trying to study.
10. Rationalization
 Rationalization occurs when a person substitutes acceptable reasons for the real or actual reasons that
are motivating his behavior.
 The rationalizing patient makes excuses for shortcomings and avoids self-condemnation,
displacements, and criticisms.
 Example: An individual states that she didn’t win the race because she hadn’t gotten a good night’s
sleep.
11. Reaction Formation
 In reaction formation, the person behaves the opposite of the way he feels.
 Example: Love turns to hate and hate into love.
12. Regression
 Under stress, a person may regress by returning to the behaviors he used in an earlier, more
comfortable time in his life.
 Example: A previously toilet-trained preschool child begins to wet his bed every night after his baby
brother is born.
13. Repression
 Repression refers to unconsciously blocking out painful or unacceptable thoughts and feelings,
leaving them to operate in the subconscious.
 Example: A woman who was sexually abused as a young child can’t remember the abuse but
experiences uneasy feelings when she goes near the place where the abuse occurred.
14. Sublimation
 In sublimation, a person transforms unacceptable needs in acceptable ambitions and actions.
 Example: He may channel his sex drive into his sports or hobbies.
15. Undoing
 In undoing, the person tries to undo the harm he feels he has done to others.
 Example: A patient who says something bad about a friend may try to undo the harm by saying nice
things about her or by being nice to her and apologizing.

Developmental Theories
Theorists consider that emotional, social, cognitive and moral skills develop in stages.

1. Psychosocial – Erik Erikson’s theory of psychosocial development is most widely used. At each stage,
children confront a crisis that requires the integration of personal needs and skills with social and cultural
expectations. Each stage has two possible components, favorable and unfavorable.
2. Psychosexual – Sigmund Freud considered sexual instincts to be significant in the development of
personality. At each stage, regions of the body assume prominent psychologic significance as source of
pleasure.
3. Cognitive – Jean Piaget proposed four major stages of development for logical thinking. Each stage arises
from and builds on the previous stage in an orderly fashion.
4. Moral – Lawrence Kohlberg’s theory of moral development is based on cognitive development and
consists of three major levels, each containing two stages.
Stage Erikson Freud Piaget Kohlberg

Infancy
(birth to 1 year) Sensorimotor (birth to
Trust vs. mistrust Oral 2 years)

Sensorimotor (1-2
Toddlerhood years); preoperational
(1-3 years old) Autonomy vs. same (preconceptual) (2-4
and doubt Anal years) Preconventional

Preoperational
Preschool (preconceptual) (2-4
(3-6 years old) years); preoperational
Initiative vs. guilt Phallic (intuitive) (4-7 years) Preconventional

School Age Concrete operations

(6-12 years) Industry vs. (7-11 years)
inferiority Latency Conventional

Adolescence Formal operations

(12-18 years) Identity vs. role (11-15 years)
diffusion (confusion) Genital Postconventional

Eating Disorders
Overview

Eating is very important in every human being. Not only that it is necessary for survival but it is also a social
activity and has been part of many occasions all around the world. For some individuals, eating is one source of
their worries, anxiety and problems.

Many people are worried and apprehensive about how they look. Most of the time, they can feel self-conscious
about their bodies. Amongst the population, the teens are the ones most concerned about their body figure. This
can be true, especially that they are going through puberty and they undergo dramatic physical changes and face
social pressures.

Definition

Eating disorders refer to a group of conditions that are described and typified by the abnormal eating habits that
are involved. The food intake in this case are either insufficient or excessive that results to detriment of an
individual’s physical and emotional health.

List of Common Eating Disorders

 Anorexia Nervosa (AN). AN is a life-threatening eating disorder. It is characterized by the client’s refusal
or inability to maintain a minimally normal weight and an intense fear of gaining weight. Clients with
anorexia nervosa have a disturbed perception of the size and shape of their body. These people have body
weight that is 85% or less of that expected for their age and height. Anorexia can cause menstruation to
stop, and often leads to bone loss, loss of skin integrity, etc. It greatly stresses the heart, increasing the risk
of heart attacks and related heart problems. The risk of death is greatly increased in individuals with this
disease.
  Bulimia Nervosa. Bulimia is characterized by recurrent binge eating followed by compensatory behaviors
such as purging (self-induced vomiting, excessive use of laxatives/diuretics, or excessive exercise). The
amount of food consumed during a binge episode is quite larger than a person would normally
eat. Bulimics may also fast for a certain amount of time following a binge. Clients with bulimia binge
because of strong emotions which are then followed by guilt and shame.
 Binge Eating Disorder. This type of eating disorder is characterized by a compulsive overeating. However,
unlike bulimia nervosa no compensatory behavior is noted after the binge episode.
 Purging Disorder. Individuals who are eating normally but are recurrently purging to promote weight loss
are under this category.
 Pica. Individuals who cannot distinguish between food and non-food items have PICA. In this type of
eating disorder, a person is craving to eat, chew or lick non-food items or foods containing no nutrition.
These things include chalk, paper, plaster, paint chips, baking soda, starch, glue, rust, ice, coffee grounds
and cigarette ashes.

Erik Erikson’s Theory of Psychosocial Development

AKA Erik Homburger Erikson

Born: June 15, 1902 Birthplace: Frankfurt am Main, Germany

Died: May 12, 1994
Location of death: Harwich, MA
Cause of death: unspecified
Religion: Jewish
Race or Ethnicity: White
Occupation: Psychologist
Nationality: United States
Executive summary: Eight Stages of Childhood
Psychosocial development as articulated by Erik Erikson describes eight developmental stages through which a
healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and
hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The
challenges of stages not successfully completed may be expected to reappear as problems in the future.
 Psychosocial Development Stages Summary

Important
Stage Basic Conflict Events Outcome

Infancy (birth to Trust vs. Children develop a sense of trust when caregivers provide
18 months) Mistrust Feeding reliabilty, care, and affection. A lack of this will lead to mistrust.

Autonomy vs. Children need to develop a sense of personal control over physical
Early Childhood Shame and skills and a sense of independence. Success leads to feelings of
(2 to 3 years) Doubt Toilet Training autonomy, failure results in feelings of shame and doubt.

Children need to begin asserting control and power over the

environment. Success in this stage leads to a sense of purpose.
Preschool (3 to 5 Initiative vs. Children who try to exert too much power experience disapproval,
years) Guilt Exploration resulting in a sense of guilt.

Children need to cope with new social and academic demands.

School Age (6 to Industry vs. Success leads to a sense of competence, while failure results in
11 years) Inferiority School feelings of inferiority.

Teens needs to develop a sense of self and personal identity.

Adolescence (12 Identity vs. Role Social Success leads to an ability to stay true to yourself, while failure
to 18 years) Confusion Relationships leads to role confusion and a weak sense of self.

Young Young adults need to form intimate, loving relationships with

Adulthood (19 to Intimacy vs. other people. Success leads to strong relationships, while failure
40 years) Isolation Relationships results in loneliness and isolation.

Adults need to create or nurture things that will outlast them, often
by having children or creating a positive change that benefits other
Middle people. Success leads to feelings of usefulness and
Adulthood (40 to Generativity vs. Work and accomplishment, while failure results in shallow involvement in
65 years) Stagnation Parenthood the world.

Older adults need to look back on life and feel a sense of

Maturity(65 to Ego Integrity Reflection on fulfillment. Success at this stage leads to feelings of wisdom,
death) vs. Despair Life while failure results in regret, bitterness, and despair.
Psychosocial Development Stages

Infancy (Birth -18 months)

 Psychosocial Crisis: Trust vs. Mistrust
Developing trust is the first task of the ego, and it is never complete. The child will let its mother out of sight
without anxiety and rage because she has become an inner certainty as well as an outer predictability. The
balance of trust with mistrust depends largely on the quality of the maternal relationship.

 Main question asked: Is my environment trustworthy or not?

 Central Task: Receiving care
 Positive Outcome: Trust in people and the environment
 Ego Quality: Hope
 Definition: Enduring belief that one can attain one’s deep and essential wishes
 Developmental Task: Social attachment; Maturation of sensory, perceptual, and motor functions; Primitive
causality.
 Significant Relations: Maternal parent
Erikson proposed that the concept of trust versus mistrust is present throughout an individual’s entire life.
Therefore if the concept is not addressed, taught and handled properly during infancy (when it is first
introduced), an individual may be negatively affected and never fully immerse themselves in the world. For
example, a person may hide themselves from the outside world and be unable to form healthy and long-lasting
relationships with others, or even themselves. If an individual does not learn to trust themselves, others and the
world they may lose the virtue of hope, which is directly linked to this concept. If a person loses their belief in
hope they will struggle with overcoming hard times and failures in their lives, and may never fully recover from
them. This would prevent them from learning and maturing into a fully-developed person if the concept of trust
versus mistrust was improperly learned, understood and used in all aspects of their lives.

Younger Years (1 1/2 – 3 Years)

 Psychosocial Crisis: Autonomy vs. Shame & doubt
If denied independence, the child will turn against his/her urges to manipulate and discriminate. Shame develops
with the child’s self-consciousness. Doubt has to do with having a front and back — a “behind” subject to its
own rules. Left over doubt may become paranoia. The sense of autonomy fostered in the child and modified as
life progresses serves the preservation in economic and political life of a sense of justice.

 Main question asked: Do I need help from others or not?

Early Childhood (3-6 Years)
 Psychosocial Crisis: Initiative vs. Guilt
Initiative adds to autonomy the quality of undertaking, planning, and attacking a task for the sake of being active
and on the move. The child is learning to master the world around them, learning basic skills and principles of
physics; things fall to the ground, not up; round things roll, how to zip and tie, count and speak with ease. At
this stage the child wants to begin and complete their own actions for a purpose. Guilt is a new emotion and is
confusing to the child; she may feel guilty over things which are not logically guilt producing, and she will feel
guilt when her initiative does not produce the desired results.

 Main question asked: How moral am I?

Middle Childhood (7-12 Years)

 Psychosocial Crisis: Industry vs. Inferiority

To bring a productive situation to completion is an aim which gradually supersedes the whims and wishes of
play. The fundamentals of technology are developed. To lose the hope of such “industrious” association may
pull the child back to the more isolated, less conscious familial rivalry of the oedipal time.

 Main question asked: Am I good at what I do?

Adolescence (12-18 Years)
 Psychosocial Crisis: Identity vs. Role Confusion
The adolescent is newly concerned with how they appear to others. Ego identity is the accrued confidence that
the inner sameness and continuity prepared in the past are matched by the sameness and continuity of one’s
meaning for others, as evidenced in the promise of a career. The inability to settle on a school or occupational
identity is disturbing.

 Main question asked: “Who am I, and what is my goal in life?”

Early Adulthood (19-34 years)
 Psychosocial Crisis: Intimacy vs. Isolation
Body and ego must be masters of organ modes and of the other nuclear conflicts in order to face the fear of ego
loss in situations which call for self-abandon. The avoidance of these experiences leads to openness and self-
absorption.

Middle Adulthood (35-60 Years)

 Psychosocial Crisis: Generativity vs. Stagnation
Generativity is the concern of establishing and guiding the next generation. Simply having or wanting children
doesn’t achieve generativity. Socially-valued work and disciplines are also expressions of generativity.

 Main question asked: Will I ever accomplish anything useful?…

Later Adulthood (60 years – Death)
 Psychosocial Crisis: Ego integrity vs. despair
Ego integrity is the ego’s accumulated assurance of its capacity for order and meaning. Despair is signified by a
fear of one’s own death, as well as the loss of self-sufficiency, and of loved partners and friends.
General Nursing Interventions for the Mental Health Client
Forming a one-to-one relationship with the client

 It will help the client to enhance communication, problem solving, and social skills.
 Coping skills and trust in relationships may be learned or enhanced.
 The nurse who establishes this relationship needs to be clear about its purpose and provide positive
interaction with the client.
 Establishment of a specific meeting time, expectations for interaction, and the duration of therapy are
important boundaries to establish.
Constructive Feedback

 Given to the client so that the client’s self-esteem will not be compromised.
 When the confrontation technique is used, the nurse needs to discuss the discrepancies between the client’s
verbalized intensions and non-verbal behavior carefully, without appearing to be attacking the client.
Trust

 Essential to establish a therapeutic relationship.

 Consistency is the key.
 If the nurse cannot meet with client at an appointed time, the client must be informed at the earliest
possible time.
 A new meeting time is scheduled.
 Direct communication is essential for the building of a therapeutic relationship.
 Other factors that facilitate trust within the nurse/client relationship include:
1.
1. Recognizing the client’s feelings.
2. Honesty
3. Respect for the client
4. Non-judgmental attitude
Emphasize Positive Results

 Do not argue with the client.

 Recognize that the client is experiencing pain but do not dwell on that pain.
Assessment

 Critical of their behavior at the time of admission or initial treatment. Reassessment is indicated at
appropriate intervals.
 The client must also learn how to self-monitor his or her symptoms.
 This communicates to the client that he or she is respected and can control his or her symptoms.
Safety

 The primary concern.

 The client may require protection interventions; these must be provided in a safe manner with respect for
the client.
 The milieu may need to be evaluated for safety
Environment

 Provide privacy and time with decreased stimuli.

 It should be a calm environment in which the client feels safe from psychological and physical threats.
Physical needs

 Intricately related to psychological function.

 Ensure that the client’s nutritional, fluid, sleep, hygiene, activities of daily leaving, and exercise needs are
met.
Treatment planning

 The client should encourage to participate in every planning.

Medications

 Approach the confused or combative client in a calm, firm manner when administering client.
  Restrains or the assistance of another care provider may be necessary for injections.
 Ensure that the client takes medications and is not hoarding pills.
 Client will need to learn about his or her medications and hot to maintain this treatment without direct staff
supervision.
Education

 Very important throughout treatment.

Discharge planning

 Begins with the client is admitted, whether it is in the hospital, home care, or any other treatment program.
 The family must be involved in the process to become successful.

Gestalt Therapy
Definition

Gestalt therapy is a form of psychotherapy, based on the experiential ideal of “here and now,” and relationships
with others and the world. It is an existential or experiential form of psychotherapy that emphasizes personal
responsibility. Gestalt therapy is used often to increase a client’s self-awareness by putting the past to rest and
focus on the present.

History

Gestalt therapy was originally developed by Frederick “Fritz” Perls, Laura Perls, and Paul Goodman in the
1940s. Perls believed that self-awareness leads to self-acceptance and responsibility for one’s thoughts and
feelings. Gestalt therapy rose from its beginnings in the middle of the 20th century to rapid and widespread
popularity during the decade of the 1960s and early 1970s. During the 70s and 80s Gestalt therapy training
centers spread globally, but they were, for the most part, not aligned with formal academic settings.

Focus of the therapy

The therapy focuses upon the individual’s experience in the present moment, the therapist-client relationship,
the environmental and social contexts of a person’s life, and the self-regulating adjustments people make as a
result of their overall situation.

Goals that are encouraged to achieved by the patient during Gestalt Therapy

1. Identifying the person’s action or becoming aware of what they are doing.
2. Becoming aware of how they are doing a certain behavior.
3. Learning how to change the behaviors that keeps him or her from achieving life goals.
4. Accepting and valuing him or herself as a person.
5. Emphasizes of what is being done, thought and felt at the present time rather than what might have been,
should have been, was or might be. It FOCUSES on what is happening instead of on the subject being
discussed.
Gestalt Techniques

1. Increasing the awareness of body language and of negative internal messages.

2. Making a client speak continually in the present tense and in the first person to emphasize self-awareness.
3. Creation of episodes by the therapist and diversions that clearly demonstrate a point rather that explaining
in words.
4. Asking the client to concentrate on a part of his or her personality or one emotion. The therapist would
then ask the client to address it as if it were sitting by itself in the client’s chair.
5. To increase self-awareness the therapist often use this therapy by having then write and read letters, keep
journals and perform other activities designed to put the past tp rest and focus on the present.

Group Therapy
Definition
 Group therapy is a form of psychotherapy which as small, carefully selected group of individuals meets
regularly with a therapist. The client participates in sessions with a group of people. These individuals share a
common purpose and are expected to contribute to the group to benefit from others in return.

In group therapy approximately 6-10 individuals meet face-to-face with a trained group therapist. During the
group meeting time, members decide what they want to talk about. Members are encouraged to give feedback to
others. Feedback includes expressing your own feelings about what someone says or does. Group rules are
established that all members must observe. These set of rules vary according to the type of group.

Purpose of a Group Therapy

1. It helps an individual gain new information or learning

2. It helps an individual gain inspiration or hope.
3. The group also allows a person to develop new ways of relating to people.
4. During group therapy, people begin to see that they are not alone and that there is hope and help. It is
comforting to hear that other people have a similar difficulty, or have already worked through a problem
that deeply disturbs another group member.
5. In a group, a person feels accepted.
6. Group therapy sessions allow an individual to interact freely with other members that shares the same past
or present difficulties and problems. The individual then, becomes aware that he is not alone and that
others share the same problem.
7. A person gains insight into one’s problem and behaviors and how they affect to others.
8. Altruistic behavior is practiced. Altruism is the giving of oneself for the benefit of others.
As the group members begin to feel more comfortable, they will be able to speak freely. The psychological
safety of the group will allow the expression of those feelings which are often difficult to express outside of
group. The client will begin to ask for the support he or she needs.

Types of Group Therapy

1. Psychotherapy Groups
2. Family therapy
3. Education groups
4. Support groups
5. Self-help groups

Human Growth and Development

Definition

The term growth and development both refers to dynamic process. Often used interchangeably, these terms have
different meanings. Growth and development are interdependent, interrelated process. Growth generally takes
place during the first 20 years of life.; development continues after that.
Growth:

1. Is physical change and increase in size.

2. It can be measured quantitatively.
3. Indicators of growth includes height, weight, bone size, and dentition.
4. Growth rates vary during different stages of growth and development.
5. The growth rate is rapid during the prenatal, neonatal, infancy and adolescent stages and slows during
childhood.
6. Physical growth is minimal during adulthood.
Development:
1. Is an increase in the complexity of function and skill progression.
2. It is the capacity and skill of a person to adapt to the environment.
3. Development is the behavioral aspect of growth
Freud’s Psychosexual Development Theory

STAGE AGE CHARACTERISTICS

 Center of pleasure: mouth (major source of gratification & exploration)

Primary need: Security

1. Oral Birth to 1½ y/o Major conflict: weaning

Source of pleasure: anus & bladder (sensual satisfaction & self-control)

2. Anal 1½ to 3 y/o Major conflict: toilet training

Center of pleasure: child’s genital (masturbation)

3. Phallic 4 to 6 y/o Major conflict: Oedipus & Electra Complex

Energy directed to physical & intellectual activities

Sexual impulses repressed

4. 6 y/o to
Latency puberty Relationship between peers of same sex

Puberty Energy directed towards full sexual maturity & function & development of skills to cope with the
5. Genital onwards environment

Erikson’s Stages of Psychosocial Development Theory

STAGE AGE CENTRAL TASK (+) RESOLUTION (-) RESOLUTION

Mistrust, withdrawal,
1. Infancy Birth-18 mos Trust vs Mistrust Learn to trust others estrangement

Self control w/o loss of self

esteem Compulsive, self-restraint
or compliance.
Autonomy vs Ability of cooperate &
2. Early childhood 1½ to 3 y/o Shame & doubt express oneself Willfulness & defiance.

Lack of self-confidence.

Pessimism, fear of
Learns to become assertive wrongdoing.

Ability to evaluate one’s Over-control & over-

3. Late childhood 3 to 5 y/o Initiative vs guilt own behavior restriction.
 Learns to create, develop &
manipulate. Loss of hope, sense of
being mediocre.
Develop sense of
Industry vs competence & Withdrawal from school &
4. School Age 6 to 12 y/o Inferiority perseverance. peers.

Coherent sense of self.

Feelings of confusion,
Identity vs role Plans to actualize one’s indecisiveness, & possible
5. Adolescence 12–20 y/o confusion abilities anti-social behavior.

Intimate relationship with Impersonal relationships.

another person.
Avoidance of relationship,
6. Young Intimacy vs Commitment to work and career or lifestyle
Adulthood 18-25 y/o isolation relationships. commitments.

Self-indulgence, self-
Generativity vs Creativity, productivity, concern, lack of interests
7. Adulthood 25-65 y/o stagnation concern for others. & commitments.

Acceptance of worth &

uniqueness of one’s own
life.
Sense of loss, contempt for
8. Maturity 65 y/o to death Integrity vs despair Acceptance of death. others.

Havighurst’s Developmental Stage and Tasks

DEVELOPMENTAL STAGE DEVELOPMENTAL TASK

 eat solid foods

1. Infancy & early childhood
 walk
 talk
 control elimination of wastes
 relate emotionally to others
 distinguish right from wrong through development of a conscience
 learn sex differences and sexual modesty
 achieve personal independence
 form simple concepts of social & physical reality

 learn physical skills, required for games

 build healthy attitudes towards oneself
 learn to socialize with peers
 learn appropriate masculine or feminine role
 gain basic reading, writing & mathematical skills
 develop concepts necessary for everyday living
 formulate a conscience based on a value system
2. Middle childhood  achieve personal independence
 develop attitudes toward social groups & institutions
  establish more mature relationships with same-age individuals of both sexes
 achieve a masculine or feminine social role
 accept own body
 establish emotional independence from parents
 achieve assurance of economic independence
 prepare for an occupation
 prepare for marriage & establishment of a family
3. Adolescence  acquire skills necessary to fulfill civic responsibilities
 develop a set of values that guides behavior

 select a partner
 learn to live with a partner
 start a family
 manage a home
 establish self in a career/occupation
4. Early Adulthood  assume civic responsibilities
 become part of a social group

 fulfill civic & social responsibilities

 maintain an economic standard of living
 assist adolescent children to become responsible, happy adults
 relate one’s partner
5. Middle Adulthood  adjust to physiological changes
 adjust to aging parents

 – adjust to physiological changes & alterations in health status

 – adjust to retirement & altered income
 – adjust to death of spouse
 – develop affiliation with one’s age group
6. Later Maturity  – meet civic & social responsibilities
 – establish satisfactory living arrangements

Levinson’s Seasons of Adulthood

AGE SEASON CHARACTERISTICS

18-20 yrs Early adult transition Seeks independence by separating from family

21-27 yrs Entrance into the adult world Experiments with different careers & lifestyles

28-32 yrs Transition Makes lifestyle adjustments

33-39 yrs Settling down Experiences greater stability

45-65 yrs Pay-off years Is self-directed & engages in self-evaluation

Sullivan’s Interpersonal Model of Personality Development

STAGE AGE DESCRIPTION

1. Infancy Birth to 1½ Infant learns to rely on caregivers to meet needs & desires
 yrs

2. Childhood 1½ to 6 yrs Child begins learning to delay immediate gratification of needs & desires

3. Juvenile 6 to 9 yrs Child forms fulfilling peer relationships

4. Preadolescence 9 to 12 yrs Child relates successfully to same-sex peers

5. Early Adolescent learns to be independent & forms relationships with members of opposite
Adolescence 12 to 14 yrs sex

Person establishes an intimate, long-lasting relationship with someone of the opposite

6. Late Adolescence 14 to 21 yrs sex

Piaget’s Phases of Cognitive Development

PHASE AGE DESCRIPTION

a. Sensorimotor Birth to 2 yrs Sensory organs & muscles become more functional

Stage 1: Use of reflexes Birth to 1 month Movements are primarily reflexive

Perceptions center around one’s body.

Stage 2: Primary circular reaction 1-4 months Objects are perceived as extensions of the self.

Becomes aware of external environment.

Stage 3: Secondary circular reaction 4-8 months Initiates acts to change the movement.

Stage 4: Coordination of secondary schemata 8-12 months Differentiates goals and goal-directed activities.

Experiments with methods to reach goals.

Stage 5: Tertiary circular reaction 12-18 months Develops rituals that become significant.

Uses mental imagery to understand the environment.

Stage 6: Invention of new means 18-24 months Uses fantasy.

b. Pre-operational 2-7 years Emerging ability to think

 Thinking tends to be egocentric.

Pre-conceptual stage 2-4 year Exhibits use of symbolism.

Unable to break down a whole into separate parts.

Intuitive stage 4-7 years Able to classify objects according to one trait.

c. Concrete Operations 7-11 years Learns to reason about events in the here-and-now.

d. Formal Operations 11+ years Able to see relationships and to reason in the abstract.

Kohlberg’s Stages of Moral Development

LEVEL AND STAGE DESCRIPTION

LEVEL I: Pre-conventional Authority figures are obeyed.

(Birth to 9 years) Misbehavior is viewed in terms of damage done.

Stage 1: Punishment & obedience A deed is perceived as “wrong” if one is punished; the activity is “right” if one is not
orientation punished.

“Right” is defined as that which is acceptable to & approved by the self.

Stage 2: Instrumental-relativist
orientation When actions satisfy one’s needs, they are “right.”

LEVEL II: Conventional Cordial interpersonal relationships are maintained.

(9-13 years) Approval of others is sought through one’s actions.

Stage 3: Interpersonal concordance Authority is respected.

Individual feels “duty bound” to maintain social order.

Stage 4: Law and order orientation Behavior is “right” when it conforms to the rules.

LEVEL III: Post-conventional Individual understands the morality of having democratically established laws.

(13+ years)

Stage 5: Social contract orientation It is “wrong” to violate others’ rights.

 The person understands the principles of human rights & personal conscience.

Stage 6: Universal ethics orientation Person believes that trust is basis for relationships.

Gilligan’s Theory of Moral Development

LEVEL CHARACTERISTICS

Concentrates on what is best for self.

Selfish.
I. Orientation of Individual Survival
Transition Dependent on others.

Recognizes connections to others.

Transition 1: From Selfishness to
Responsibility Makes responsible choices in terms of self and others.

Puts needs of others ahead of own.

Feels responsible for others.

Is dependent.

II. Goodness as Self-sacrifice May use guilt to manipulate others when attempting to “help.”

Decisions based on intentions & consequences, not on others’ responses.

Considers needs of self and others.

Wants to help others while being responsible to self.

Transition 2: From Goodness to Truth Increased social participation.

Sees self and others as morally equal

Assumes responsibilities for own decisions.

Basic tenet to hurt no one including self.

Conflict between selfishness and selflessness.

Self-judgment is not dependent on others’ perceptions but rather on consequences &

III. Morality of Nonviolence intentions of actions.

Fowler’s Stages of Faith

STAGE AGE CHARACTERISTICS
Pre-stage: Undifferentiated Trust, hope and love compete with environmental inconsistencies or
faith Infant threats if abandonment.

Imitates parental behaviors and attitudes about religion and

spirituality.
Stage 1: Intuitive-projective
faith Toddler-preschooler Has no real understanding of spiritual concepts.

Accepts existence of a deity.

Religious & moral beliefs are symbolized by stories.

Appreciates others’ viewpoints.

Stage 2: Mythical-literal faith School-aged child Accepts concept of reciprocal fairness.

Stage 3: Synthetic- Questions values & religious beliefs in an attempt to form own
conventional faith Adolescent identity.

Stage 4: Individuative- Late adolescent &

reflective faith young adult Assumes responsibility for own attitudes & beliefs.

Stage 5: Conjunctive faith Adult Integrates other perspectives about faith into own definition of truth.

Stage 6: Universalizing faith Adult Makes concepts of love & justice tangible.

Jean Piaget’s Theory of Cognitive Development

Born: Aug 9, 1896
Birthplace: Neuchâtel, Switzerland
Died: September 17, 1980
Location of death: Geneva, Switzerland
Cause of death: unspecified
Gender: Male
Race or Ethnicity: White
Occupation: Psychologist
Nationality: Switzerland
Executive summary: Elaborated the stages of childhood
Cognitive development refers to how a person perceives, thinks, and gains understanding of his or her world
through the interaction of genetic and learned factors. Among the areas of cognitive development are
information processing, intelligence, reasoning, language development, and memory.

Cognitive Stages of Development

Sensorimotor (0-2 years) Development proceeds from reflex activity to representation and sensorimotor solutions to problems

Pre-operational (2-7 years) Problems solved through representation; language development; (2-4 years); thoughts and language
 both egocentric; cannot solve conservation problems.

Concrete Operation (7-11 Reversibility attained; can solve conservation problems; Logical operation developed and applied to
years) concrete problems; cannot solve complex verbal problems.

Formal Operation (11 years- Logically solves all types of problems; thinks scientifically; solves complex problems; cognitive
adulthood) structures mature.
 Sensorimotor stage (infancy): In this period, which has six sub-stages, intelligence is demonstrated
through motor activity without the use of symbols. Knowledge of the world is limited, but developing,
because it is based on physical interactions and experiences. Children acquire object permanence at about
seven months of age (memory). Physical development (mobility) allows the child to begin developing new
intellectual abilities. Some symbolic (language) abilities are developed at the end of this stage.
 Pre-operational stage (toddlerhood and early childhood): In this period, which has two sub stages,
intelligence is demonstrated through the use of symbols, language use matures, and memory and
imagination are developed, but thinking is done in a non-logical, non-reversible manner. Egocentric
thinking predominates.
 Concrete operational stage (elementary and early adolescence): In this stage, characterized by seven types
of conservation (number, length, liquid, mass, weight, area, and volume), intelligence is demonstrated
through logical and systematic manipulation of symbols related to concrete objects. Operational thinking
develops (mental actions that are reversible). Egocentric thought diminishes.
 Formal operational stage (adolescence and adulthood): In this stage, intelligence is demonstrated through
the logical use of symbols related to abstract concepts. Early in the period there is a return to egocentric
thought. Only 35 percent of high school graduates in industrialized countries obtain formal operations;
many people do not think formally during adulthood.

Johari Window
Description

As a nurse, dealing with physically and/or mentally ill patients requires a great deal of patience and
understanding. However, before a person can understand and empathize with others, he or she must first know
himself or herself. The process of knowing ones own principle, beliefs, feelings, personality, strengths,
weaknesses, preconceptions, attitudes and responses in different situations is called self awareness. Discerning
ones own capabilities and limitations allow a nurse to consider, observe and pay attention to the bizarre or subtle
reactions of clients.
Self-awareness gives the nurse a skill in establishing relationships with clients of different values, beliefs,
attitudes and principles. This is achieved by the nurse’s utilization of aspects in his or her personality, values,
feelings and coping skills commonly known as the therapeutic use of self.

Johari window is a psychological tool used to develop self-awareness and promote better relationshipsamong
people. It was created by two American Psychologists Joseph Luft and Harry Ingham in 1955. The word
“JOHARI” comes from the first names of its developers Joseph and Harry (Joharry). It is also known
as “disclosure or feedback model of self awareness.”
Utilizing this tool creates a portrait of someone; this is done by giving the person a psychosocial exercise. A list
of 56 adjectives is given to the subject and he or she is instructed to choose five or six words that best describe
him or her. The same list is given to the subject’s peers, friends and colleagues. These people will also choose 5
or 6 adjectives that best describe the subject. After the test, the answers are mapped, compared and categorized
in four areas. The four areas are as follows:

Quadrant 1: Open Arena or Public self

 These pertain to the qualities known to others and the subject himself.
 If quadrant 1 is the longest, it means that the subject is open to others and has gained self-awareness.
 If this area is the shortest, the subject shares little about him or her.
Area or Quadrant 2: Blind spot or Blind Area

 These refer to the subject’s attributes that are unknown to him but are known by his or her peers.
Area or Quadrant 3: Hidden or Private self

 The things that the subject knows about himself.

Area or Quadrant 4: Unknown
  An empty quadrant which symbolizes the qualities undiscovered by the neither the subject nor others.
The success of the test depends on the honesty of the opinions given. A person is represented with little insight
if quadrants 1 and 3 have the smallest adjective listed. The main goal the subject is to work towards moving the
qualities from quadrants 2, 3, and 4 to the first area.

Kohlberg’s Theory of Moral Development

Born: October 25, 1927

Birthplace: Bronxville, New York, United States
Died: January 19, 1987
Location of death: Cape Cod, Massachusetts, United States
Nationality: American
Occupation: Psychologist, College Teacher
Moral development is the process thought which children develop proper attitudes and behaviours toward other
people in society, based on social and cultural norms, rules, and laws.
Moral Development by Lawrence Kohlberg

Level of Moral
development Stage of Reasoning Approximate Age

Stage 1: (Punishment and Obedience Orientation).

 Right is obedience to power and avoidance of punishment.
 (“I must follow the rules otherwise I will be punished”).
Stage 2: Instrumental Relativist Orientation.
 Right is taking responsibility and leaving others to be responsible for
Preconventional themselves.
“do’s and don’ts”  (”I must follow the rules for the reward and favor it gives”). <11

Stage 3: Good-Boy-Nice Girl Orientation.

 Right is being considerate: “uphold the values of other adolescents and
adults” rules of society”.
 (”I must follow the rules so I will be accepted”)
Stage 4: Society-Maintaining Orientation.
 Right is being good, with the values and norms of family and society at
large. adolescence and
Conventional  (”I must follow rules so there is order in the society”). adulthood

Stage 5: Social Contract Reorientation.

 Right is finding inner “universal rights” balance between self-rights and
societal rules – a social contract.
 (”I must follow rules as there are reasonable laws for it”).
Stage 6: Universal Ethical Principle orientation.
 Right is based on a higher order of applying principles to all human-
kind; being non-judgmental and respecting all human life.
Postconventional  (”I must follow rules because my conscience tells me”). after 20
Three Levels of Moral Development

PRECONVENTIONAL LEVEL.
The child at the first and most basic level, the preconventional level, is concerned with avoiding punishment and
getting needs met. This level has two stages and applies to children up to 10 years of age.

 Punishment-Obedience stage. Children obey rules because they are told to do so by an authority figure
(parent or teacher), and they fear punishment if they do not follow rules. Children at this stage are not able
to see someone else’s side.
 Individual, Instrumentation, and Exchange stage. Here, the behavior is governed by moral reciprocity.
The child will follow rules if there is a known benefit to him or her. Children at this stage also mete out
justice in an eye-for-an-eye manner or according to Golden Rule logic. In other words, if one child hits
another, the injured child will hit back. This is considered equitable justice. Children in this stage are very
 concerned with what is fair.Children will also make deals with each other and even adults. They will agree
to behave in a certain way for a payoff. “I’ll do this, if you will do that.” Sometimes, the payoff is in the
knowledge that behaving correctly is in the child’s own best interest. They receive approval from authority
figures or admiration from peers, avoids blame, or behaves in accordance with their concept of self. They
are just beginning to understand that others have their own needs and drives.
CONVENTIONAL LEVEL.

This level broadens the scope of human wants and needs. Children in this level are concerned about being
accepted by others and living up to their expectations. This stage begins around age 10 but lasts well into
adulthood, and is the stage most adults remain at throughout their lives.

 Interpersonal Conformity is often called the “good boy/good girl” stage. Here, children do the right thing
because it is good for the family, peer group, team, school, or church. They understand the concepts of
trust, loyalty, and gratitude. They abide by the Golden Rule as it applies to people around them every day.
Morality is acting in accordance to what the social group says is right and moral.
 Law and Order or Social System and Conscience stage. Children and adults at this stage abide by the rules
of the society in which they live. These laws and rules become the backbone for all right and wrong
actions. Children and adults feel compelled to do their duty and show respect for authority. This is still
moral behavior based on authority, but reflects a shift from the social group to society at large.
POST-CONVENTIONAL LEVEL.

Some teenagers and adults move beyond conventional morality and enter morality based on reason, examining
the relative values and opinions of the groups with which they interact. Few adults reach this stage.

 Social Contract and Individual Rights stage. Individuals in this stage understand that codes of conduct are
relative to their social group. This varies from culture to culture and subgroup to subgroup. With that in
mind, the individual enters into a contract with fellow human beings to treat them fairly and kindly and to
respect authority when it is equally moral and deserved. They also agree to obey laws and social rules of
conduct that promote respect for individuals and value the few universal moral values that they recognize.
Moral behavior and moral decisions are based on the greatest good for the greatest number.
 Principled Conscience or the Universal/Ethical Principles stage. Here, individuals examine the validity of
society’s laws and govern themselves by what they consider to be universal moral principles, usually
involving equal rights and respect. They obey laws and social rules that fall in line with these universal
principles, but not others they deem as aberrant. Adults here are motivated by individual conscience that
transcends cultural, religious, or social convention rules. Kohlberg recognized this last stage but found so
few people who lived by this concept of moral behavior that he could not study it in detail.

Korsakoff’s Syndrome (Korsakoff’s Psychosis)

Definition

Korsakoff’s syndrome is a condition that mainly affects chronic alcoholics. It is also called Korsakov’s
syndrome, Korsakoff’s psychosis or amnesic-confabulatory syndrome. It is a brain or neurological disorder
caused by thiamine or Vitamin B1 deficiency. The syndrome is named after Sergie Korsakoff, a
neuropsychiatrist who popularized the theory.
Causes

1. Chronic Alcoholism. This syndrome is due to the direct effects of alcohol or to the severe nutritional
deficiencies that are associated with chronic alcoholism. A lack of Vitamin B1 is common in people with
alcoholism thus, Vitamin B deficiency is noted. In chronic alcoholism the condition usually occurs
following delirium tremens.
2. Malabsorption. It is also common in persons whose bodies do not absorb food properly (malabsorption).
3. Other severe brain disturbances. The syndrome also occurs in other severe brain disturbances such as
paralysis, dementia, brain damage, infections and poisonings.
4. Dietary deficiencies
5. Prolonged vomiting
6. Eating disorders
7. Effects of chemotherapy
8. Hyperemesis gravidarum
 9. Severe malnutrition. Alcoholism may be an indicator of poor nutrition, which in addition to inflammation
of the stomach lining causes thiamine deficiency.
Disease Process

A deficiency of thiamine or Vitamin B causes damage to the medial thalamus and to the mammillary bodies of
the hypothalamus. As a result, generalized cerebral atrophy may occur. In cases where Wernicke’s
encephalopathy, a neurological disorder that causes brain damage in lower parts of the brain called the thalamus
and hypothalamus, accompanies Korsakoff’s syndrome the disorder is called Wernicke-Korsakoff syndrome.

In most cases, Korsakoff syndrome, or Korsakoff psychosis, tends to develop as Wernicke’s symptoms go
away. It results from damage to areas of the brain involved with memory, thus, Korsakoff’s syndrome involves:

 Neuronal loss or damage to neurons

 Gliosis, which is a result of injury to the supporting cells of the central nervous system.
 Hemorrhage or bleeding of the mammilary bodies.
Signs and Symptoms

1. Anterograde amnesia or the inability to form new memories

2. Retrograde amnesia or the loss of memory (can be severe)
3. Confabulation or the reciting of imaginary experiences.
4. Lack of insight
5. Apathy or the absence of interest in or concern about emotional, social, or physical life
6. Hallucinations or seeing and hearing things are not really present
7. Delirium
8. Anxiety
9. Fear
10. Depression
11. Confusion
12. Delusions and insomnia
13. Painful extremities
Treatment

1. Thiamine by injection into a vein or a muscle or by mouth. Usually, thiamine does not improve loss of
memory and intellect that occur with Korsakoff’s psychosis. However it may improve symptoms such as
delirium or confusion.
2. Stopping alcohol use to prevent additional loss of brain function and damage to the nerves.
3. Eating a well balanced and nourishing diet with increase intake of foods containing Vitamin B1.

Kubler-Ross Stages of Dying / Grief

Precipitating Factors of Grief

 Death in family
 Separation
 Divorce
 Physical Illness
 Work failure disappointments
1. Denial
 Initial response to protect the self from anxiety.
 “No not me”, “Its not true”, “Its not impossible”
 May continue to make impractical/unrealistic plans
 May comment that a mistake has been made about the diagnosis of terminal illness
 May appear normal and can continued ADL as if nothing is wrong
 May not conform with the advised treatment regimen
 Adaptive response – crying, verbal denial
 Maladptive response – absence or reaction such as crying.
2. Anger
 Individual feel that they are victims of incompetence or a vengeful God (they did something wrong so they
are being punished), fate (karma), circumstances (wrong place and wrong time).
  “Why me”, “What did I do to deserve this?”
 They seek for reasons, answers and explanations
 May express anger overtly – being irritable, impatient, critical verbally abusive.
 May express anger covertly by neglecting self, not eating, nor going to check ups, committing suicide,
drinking alcohol.
 Adaptive response – verbal expression
 Maladaptive – persistent guilt or low self esteem, aggression, self destructive ideation or behavior.
3. Bargaining
 The person try to inhibit good behavior, make up for perceived wrong doings or other engage in behaviors
that would please GOD so he will be given more time-an extension of life or granted recovery.
 “Yes, me but”
 “If I live until Christmas or until my child’s graduation ( So many if’s), I will do this…”
 Adaptive response – bargains for treatment control, express wish to be alive for specific events in the near
future.
 Maladaptive response – bargains for unrealistic activities or events in the distant future.
4. Depression
 Occurs when the reality of loss or impending loss cannot be ignored anymore and the person grieves for
himself and those he will leave behind, for the things that he can no longer accomplish or experience.
 “Yes, I’m dying”
 Withdrawn, has no energy and interest to interact.
 Cries
 Makes few demands
 Adaptive response – crying, withdrawing from interaction
 Maladaptive response – self destructive actions, despair.
5. Acceptance
 Occurs when the person has come to peace with himself and others
 “Yes, I am ready”
 Stage of affective void – not happy nor sad
 Only persons who are highly significant to him stimulates a reaction. Others are merely tolerated.
 Makes realistic preparation
 Adaptive response – may wish to be alone, limit conversation, complete personal and family business.
Nursing Interventions:

 Assess; specific loss, meaning of loss, coping skills, support persons.

 Accept the client; do not respond personally to the client.
 Support adaptive responses; allow to express feelings
 Support defense mechanism – reassure client that denial and wanting to be alone is normal.
 Help find constructive outlets of anger. Do not take clients hostility personally. Do no retaliate.
 Monitor for self destructive behaviors
 Help express feelings: Ask how they feel
 Meet needs
 Allow as much decision making as possible to maintain dignity by giving choices and alternatives.

Major Depressive Disorder

Description

 A mood disorder may include symptoms of depressed mood, feelings or hopelessness and helplessness,
decreased interest in usual activities, disinterest in relationship with others or cycles of depression and
mania.
 Depression is often concurrent with other psychiatric diagnoses. Almost have of clients with major
depressive disorders have histories of non-mood psychiatric disorders.
 A high incidence exists for persons with chronic illness or prolonges hospitalization or institutional care.
Risk Factors

1. Biological factors – brainchemicals

2. Family genetics – parent with depression, child 10-13% risk of depression.
3. Gender – higher rate for women
4. Age – often less than 40 when begins
5. Marital status – more frequently single, widowed
 6. Season of year – Seasonal Affective Disorder (SAD) occurs when client experiences recurrent depression
that occurs annually at the same time.
7. Psychological influences – low self-esteem, unresolved grief.
8. Environmental factors – lack of social support, stressful life events.
9. Medical co-morbidity – clients with chronic or terminal illness, postpartum, and current substance abuse
are especially prone to becoming depresses.
Signs and Symptoms

1. Sexual disinterest
2. Suicidal and homicidal ideations
3. Decrease in personal hygiene
4. Tearfulness, crying, and melancholy
5. Altered thought process; difficulty concentrating, self-destructive behavior.
6. Loss of energy or restlessness
7. Anhedonia or loss of pleasure
8. Gain or loss of weight
9. Anger, self-directed
10. Psychomotor retardation or agitation
11. Insomnia or hypersomnia
12. Feelings of hopelessness, worthlessness, and helplessness.
Medical Diagnosis
A number of tests should be conducted to diagnose major depression:

 Beck Depression Inventory is a psychological test used to determine symptom onset, severity, duration,
and progression.
 Dexamethasone suppression test showing failure to suppress cortisol secretion in depressed patients
(although test has high false-negative rate).
 Toxicology screening suggesting drug-induced depression.
 Diagnosis is confirmed if DSM-V-TR criteria is met.
Nursing Diagnoses

 Risk for violence, self-directed or directed at others

 Impaired verbal communication
 Decisional conflict
 Altered role performance
 Hopelessness
 Deficit in diversional activity
 Fatigue
 Sel-care deficit
 Altered thought processes
 Self-esteem
 Anxiety
Medical Management
Medications are the primary treatment for major depression. Ideally, medications should be combined with
various therapies. Drugs generally work by modifying the activity of relevant neurotransmitter pathways.

 Antidepressants are classified according to class:

 The first-line treatment for patients with depression because these drugs lack the most of disturbing effects
of TCAs and MAOIs. Examples include citalopram (Celexa), paroxetine (Paxil), and sertraline (Zoloft).
 Generally used as second-line agents for patients with major depressive disorder. Example include
venlafaxine (Effexor)
 Atypical antidepressants. Their mechanism of action is not clearly understood. Some examples include
bupropion (Wellbutrin) and mirtazapine (Remeron). They are used as second-line agents too.
 An older class of antidepressants. Some examples include amitriptyline (Elavil) and amoxapine (Asendin).
 May be prescribed for patients with atypical depression (e.g. depression marked by increased appetite and
sleep). Rarely used today because of high risk for adverse effects like hypertensive crisis and dangerous
interactions with foods and medications.
 Improve treatment outcome by helping patient cope with low self-esteem and self-demoralization.
 Electroconvulsive therapy. To treat severe depression.
Therapeutic Nursing Management
 1. Safe environment
2. Psychological treatment
 Individual psychotherapy – long –term therapeutic approach or short term solution-oriented, may
focus on in-depth exploration, specific stress situations, or problem solving.
 Behavioral therapy – modifying behavior to assist in reducing depressive symptoms and increasing
coping skills.
 Behavioral contacts – focus on specific client problems and need to help the client resolve them.
3. Social treatment
 Milieu therapy – incorporates day to day living experiences in a therapeutic environment to expect
changes in perception and behavior.
 Family therapy – aimed at assisting the family cope with the client’s illness and supporting the client
in therapeutic ways.
 Group therapy – focuses on assisting clients with interpersonal communication, coping, and
problem-solving skills.
4. Psychopharmacologic and Somatic treatments
 Administer antidepressant medications
 Continued assessment by monitoring client’s mental health status is critical, particularly interms of
agitation and suicidal ideation.
 Electroconvulsive therapy
Nursing Interventions

1. Priority for care is always the client’s safety.

2. Use of behavioral contacts. Use this technique to meet outcomes relating to “no self-harm” or no suicidal
ideation or plan.
3. Assess regularly for suicidal ideation or plan.
4. Observe client for distorted, negative thinking.
5. Assist client to learn and use problem solving and stress management skills.
6. Avoid doing too much for the client, as this will only increase client’s dependence and decrease self-
esteem.
7. The nurse’s role in the physical care of the client experiencing major depressive disorder is to provide
assessment and interventions related to appropriate nutrition, fluids, sleep, exercise, and hygieme, and to
provide health education.
8. Explore meaningful losses in the client’s life.
9. Help the client and family to identify the internal and external indicators of major depressive disorder.

Osessive Compulsive Disorder (OCD)

Description
Obsessive Compulsive Disorder (OCD) is characterized by persistent thought and urges to perform repeated acts
or rituals, usually as a means of releasing tension or anxiety. The frequency and intensity of the ritualistic
behaviors, such as handwashing, ordering, or checking, are time consuming (taking more than one hour per day)
and cause marked distress, significant impairment, or interfere with daily living.
1. Obsession
 The person experiences recurrent and persistent thoughts, impulses, images that are intrusive,
disturbing, inappropriate, and usually triggered by anxiety.
 The thoughts, images, and impulses are not simply excessive worries about real life problems.
 The person recognizes the thoughts, images, and impulses are from within own mind.
2. Compulsion
 Repetitive behaviors or mental acts that a person feels driven to perform, which usually adhere to a
rigid and specifically defined routine.
 The behaviors and ideations are typically aimed at reducing anxiety or preventing some dreaded
situation from occurring.
Specific Biological Factors

 There is some evidence that indicates OCD is linked to a deficiency in serotonin.

 Clients have also been shown to have abnormalities in frontal lobes and basal ganglia; it is unclear what
the implications are for clinical care.
Signs and Symptoms
  Obsessions – recurrent, persistent ideas, thoughts or impulses, involuntarily coming to awareness.
 Ruminations – forced preoccupation with thoughts about a particular topic, associated with brooding and
inconclusive speculation.
 Cognitive rituals – elaborate series of mental acts the client feels compelled to complete.
 Compulsive motor rituals – elaborate rituals of everyday functioning such as grooming, dressing, eating,
washing or checking doors or appliances.
 Other symptoms – chronic anxiety, low self-esteem, difficulty expressing positive feelings and depressed
mood.
Nursing Diagnoses

 Anxiety
 Powerlessness
 Ineffective verbal communication
 Self-esteem disturbance
 Impaired social interaction
 Risk for injury
 Sleep pattern disturbances
 Ineffective breathing pattern
Nursing Interventions

1. Limit, but do not interrupt, the compulsive acts.

2. Teach the client to use alternate coping methods to decrease anxiety.
3. Client’s behavior maybe frustrating to staff and family. Power struggles often result. Consistency to the
approach to care is critical.
4. Assess the client’s needs carefully.
5. Provide an environment that has structure and predictability as a strategy to decrease anxiety.
6. Risk associated with the use of alcohol and drug abuse.

Personality Disorders
Definition

Personality disorder is defined as the totality of a person’s unique biopsychosocial and spiritual traits that
consistently influence behavior.
The following traits are likely in individuals with a personality disorder:

1. Interpersonal relations that ranges from distant to overprotective.

2. Suspiciousness
3. Social anxiety
4. Failure to conform to social norms.
5. Self-destructive behaviors
6. Manipulation and splitting.
Prognosis is poor, and clients experience long term disability and may have other psychiatric disorders.

Diagnosis

A personality disorder is diagnosed when a person exhibits deviation on the following areas:

1. Cognition – ways a person interprets and perceives him or herself, other people and events.
2. Affect – ranges, lability and appropriateness of emotional response
3. Impulse control – ability to control impulses or express behavior at the appropriate time and place.
Cluster A: Personality Disorders ( The Eccentric and Mad group)
1. Paranoid Personality disorder– People with a paranoid personality disorder are characterized by an overly
suspicious and mistrustful behavior.
Clinical Manifestation
a. Aloof and withdrawn
b. Appear guarded and hypervigilant
c. Have a restricted affect
d. Unable to demonstrate a warm and empathetic emotional responses
 e. Shows constant mistrust and suspicion
f. Frequently see malevolence in the actions when none exists
g. Spends disproportionate time examining and analyzing the behavior and motive of others to discover
hidden and threatening meanings
h. Often feel attacked by others
i. Devises plans or fantasies for protection
j. Uses the defense mechanism of projection (blaming other people, institution or events for their own
difficulties)
2. Schizoid Personality Disorder- People who are showing a pervasive pattern of social relationship detachment
and a limited range of emotional expression in the interpersonal settings falls under this type of personality
disorder.
Clinical Manifestations:
a. Displays restricted affect
b. Shows little emotion
c. Aloof, emotionally cold and uncaring
d. Have rich and extensive fantasy life
e. Accomplished intellectually and often involved with computers or electronics in hobbies or job
f. Spends long hours solving puzzles and mathematical problems
g. Indecisive
h. Lacks future goals or direction
i. Impaired insight
j. Self-absorbed and loners
k. Lacks desire for involvement with others
l. No disordered or delusional thought processes present
3. Schizotypal Personality Disorder– Schizoid and schizotypal personality disorder are both characterized by
pervasive pattern of social and interpersonal deficits, however, the latter is noted with cognitive and perceptual
distortions and behavioral eccentricities.
Clinical Manifestations:
a. Odd appearance (stained or dirty clothes, unkempt and disheveled)
b. Wander aimlessly
c. Loose, bizarre or vague speech
d. Restricted range of emotions
e. Ideas or reference and magical thinking is noted
f. Expresses ideas of suspicions regarding the motives of others
g. Experiences anxiety with people
Cluster B: Personality Disorders ( The Erratic and Bad group)
1. Antisocial Personality Disorder– Antisocial Personality disorder is characterized by a persistent pattern of
violation and disregard for the rights of others, deceit and manipulation
Clinical Manifestations:
a. Violation of the rights of others
b. Lack of remorse for behaviors
c. Shallow emotions
d. Lying
e. Rationalization of own behavior
f. Poor judgment
g. Impulsivity
h. Irritability and aggressiveness
i. Lack of insight
j. Thrill seeking behaviors
k. Exploitation of people in relationships
l. Poor work history
m. Consistent irresponsibility
2. Borderline Personality Disorder– Borderline personality disorder is the most common personality disorder
found in clinical settings. This disorder is characterized by a persistent pattern of unstable relationships, self
image, affect and has marked impulsivity. It is more common in females than in males. Self-mutilation injuries
such ascutting or burning are noted in this type of personality disorder.
Clinical manifestations:
a. Fear of abandonment (real or perceived)
b. Unstable and intense relationship
c. Unstable self-image
 d. Impulsivity or recklessness
e. Recurrent self-mutilating behavior or suicidal threats or gestures
f. Chronic feelings of emptiness and boredom
g. Labile mood
h. Irritability
i. Splitting
j. Impaired judgment
k. Lack of insight
l. Transient psychotic symptoms such as hallucinations demanding self-harm
3. Narcissistic Personality Disorder– A person with a narcissistic personality disorder shows a persistent pattern
of grandiosity either in fantasy or behavior, a need for admiration and a lack of empathy.
Clinical Manifestations:
a. Arrogant and haughty attitude
b. Lack the ability to recognize or to empathize with the feelings of others
c. Express envy and begrudge others of any recognition of material success (they believe it rightfully should
be theirs)
d. Belittle or disparage other’s feelings
e. Expresses grandiosity overtly
f. Expect to be recognized for their perceived greatness
g. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
h. Compares themselves with famous or privileged people
i. Poor or limited insight
j. Fragile and vulnerable self-esteem
k. Ambitious and confident
l. Exploit relationships to elevate their own status
4. Histrionic Personality disorder– Excessive emotionality and attention-seeking behaviors are pervasive
patterns noted in people with a histrionic personality disorder.
Clinical manifestations:
a. Exaggerate closeness of relationships or intimacy
b. Uses colorful speech
c. Tends to overdress
d. Concerned with impressing others
e. Emotionally expressive
f. Experiences rapid mood and emotion shifts
g. Self-absorbed
h. Highly suggestible and will agree with almost anyone to gain attention
i. Always want to be the center of attraction
Cluster C: Personality Disorders ( The anxious and Sad group)
1. Avoidant Personality Disorder
Avoidant personality disorder is characterized by a persistent pattern of:
a. Social uneasiness and reticence
b. Low self-esteem
c. Hypersensitivity to negative reaction
Clinical Manifestations
a. Shy
b. Unusually fearful of rejection, criticism, shame or disapproval
c. Socially awkward
d. Easily devastated by real or perceived criticism
e. Have a very low self-esteem
f. Believes that they are inferior
2. Dependent Personality Disorder– People who are noted to excessively need someone to take care of them that
lead to their persistent clingy and submissive behavior have a dependent personality disorder. These individuals
have fear of being separated from the person whom they cling on to. The behavior elicits caretaking from others.
Clinical Manifestations
a. Pessimistic
b. Self-critical
c. Can be easily be hurt by other people
d. Frequently reports feeling unhappy or depressed ( due to actual or perceived loss of support from a person)
e. Preoccupied with unrealistic fears of being alone and left alone to take care for themselves
f. Has difficulty deciding on their own even how simple the problem is
 g. Constantly seeks advice from others and repeated assurances about all types of decisions
h. Lacks confidence
i. Uncomfortable and helpless when alone
j. Has difficulty initiating or completing simple daily tasks on their own
3. Obsessive Compulsive Personality Disorder– Individuals who are preoccupied with perfectionism, mental
and interpersonal control and orderliness have an obsessive compulsive personality disorder. Persons with an
obsessive compulsive personality are serious and formal and answer questions with precision and much detail.
These people often seek treatment because of their recognition that life has no pleasure or because they are
experiencing problems at work and in their relationships.
Clinical Manifestations
a. Formal and serious
b. Precise and detail-oriented
c. Perfectionist
d. Constricted emotional range (has difficulty expressing emotions)
e. Stubborn and reluctant to relinquish control
f. Restricted affect
g. Preoccupation to orderliness
h. Have low self-esteem
i. Harsh
j. Have difficulty in relationships
Signs and Symptoms
1. Inappropriate response to stress and inflexible approach to problem solving.
2. Long term difficulties in relating to others, in school and in work situations.
3. Demanding and manipulative.
4. Ability to cause others to react with extreme annoyance or irritability.
5. Poor interpersonal skills.
6. Anxiety
7. Depression
8. Anger and aggression
9. Difficulty with adherence to treatment.
10. Harm to self or others.
Nursing Diagnoses
 Ineffective individual coping
 Social isolation
 Impaired social interaction
 High risk for violence to self or others
 Anxiety
Nursing Interventions
1. Work with the client to increase coping skills and identify need for improvement coping.
2. Respond to the client’s specific symptoms and needs.
3. Keep communication clear and consistent.
4. Client may require physical restraints, seclusion/observation room, one to one supervision.
5. Keep the client involved in treatment planning.
6. Avoid becoming victim to the client’s involvement in appropriate self-help groups.
7. Require the client take responsibility for his/her own behavior and the consequences for actions.
8. Discuss with the client and family the possible environment and situational causes, contributing factors,
and triggers.

Psychiatric Mental Health Assessment

Definition

 Accuracy in assessment determines whether the following steps of the nursing process will produce
accurate nursing diagnoses, palnning, and intervention.
 Psychiatric-mental health assessment is the gathering, organizing, and documenting of data about the
psychiatric and mental health needs of the client and family.
Assessment

 The first step of the nursing process.

Interview
  The degree to which the interview is therapeutic, or helpful, to the client may determine the extent and
honesty of the information shared by the client.
 Clients expect the interviewer to be an expert who is confident in the professional role, maintains
confidentiality, demonstrates warmth and genuineness, is nonjudgmental toward them and their past or
current behavior, and recognizes that clients are experts on themselves and their behavior.
Assessment Data

1. Subjective
 Client’s current problem and reason for seeking help.
 Past mental illness and treatment
 Family history and mental illness
 Medical history
 Allergies to medications, foods, and other substances
 Past and present medications and their effects
 Past and present abuse
 Substance abuse history
 Educational and/or vocational history
 Health habits
 Safety issues
 Cultural beliefs and practices
2. Objective
 Behavior
 Communication
 Physical assessment
 Laboratory or testing data
 Mental status
Appearance
 Hygiene, grooming, appropriateness of clothing, posture, and gestures.
Behavior
 Eye contact, motor behavior, body language, behavioral responses to others and environment, volume and
speed of speech, tone of voice, flow of words.
Affect and Mood
 Happy, sad, anxious, sullen, hostile, inappropriate for situation, silly, and range of emotions.
Orientation
 To person, place, time, situation, relationship with others.
Memory
 Immediate recall, recent and remote memory.
Sensorium or Attention
 Ability to concentrate on a task or conversation, perception of stimuli.
Intellectual functioning
 General fund of knowledge about the world, cognitive abilities such as a simple arithmetic.
 Ability to think abstractly or symbolically.
Judgement
 Decision making ability, especially regarding delay of gratification.
Insight
 Awareness of one’s responsibility for and analysis of current problem, understanding of how client arrived
in current situation.
Thought Content
 Recurrent topics of conversation, themes.
Thought process
 Processing of events in the situation, awareness of one’s thoughts, logic of thought.
Perception
 Awareness of reality vs. fantasy, hallucinations, delusions, illusions, suicidal or homicidal ideation or
plans.

Restraint Application
Definition
Restraint application is a technique of physically restricting a person’s freedom of movement, physical activity
or normal access to his body. A physical restraint is a piece of equipment or device that restricts a patient’s
ability to move. It is any manual method or physical or mechanical device, material, or equipment attached or
adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or
normal access to one’s body.
The definition of restraint is based not on the equipment or device but rather on the functional status of the
client. If the client cannot release himself from the device physically, then the said device is considered a
restraint.

Purpose of Restraint Application

Restraints are used to control a patient who is at risk of harming him or her self and/or others. In some cases,
restraints are also used for children who are not capable of remaining still when they are frightened or in pain
during administration of medication or performing other procedures. However, using restraints in any health
care facility should be used as the last option in dealing with patients.

When to use restraints?

Physical restraint should be used only when other, less restrictive, measures prove ineffective in protecting the
patient and others from harm.

Types of Restraints

1. Soft restraints. This type of physical restraint device is used to limit movement of patients who are
confused, disoriented or combative. The main goal of using this restraint is to prevent the patient from
injuring him or her self and/or others.
2. Vest and Belt Restraints. In using this device full movement of arms and legs are permitted. This is used to
prevent the patient from falling from bed or a chair.
3. Limb Restraints. Patients who are removing supportive equipments such as I.V. lines, indwelling
catheters, NGTs and etc. are placed on limb restraints. This device allows only slight limb motion.
4. Mitts. This device prevents the patient from removing supportive equipment, scratching rashes or sores
and injuring him or herself and/or others.
5. Body restraints. When patients become combative and hysterical they can be controlled by applying body
restraints. This immobilizes almost all of the body.
6. Leather Restraints. This restraint is only used when soft restraints are not sufficient to control the patient
and when sedation is either dangerous to the patient or ineffective.
Precautions of Restraint Application

1. Before applying restraints it is important to try other methods of promoting patient safety. Alternative
methods that might be effective are reorientation of the patient to the physical surroundings, moving the
patient’s room near to the staff members, teaching relaxation techniques in order to decrease anxiety and
fear and decrease overstimulation.
2. Documentation of any alternative method used is extremely important. Restraint application should be
documented thoroughly.\
Situations that Requires Restraint Application

1. Confused client tries to endanger him or herself

2. Confused client attempts to remove supportive equipments such as necessary tubes, IV lines or protective
dressings.
3. The client is at risk for falls.
4. The client is suicidal.
5. The client poses harm or threat of inflicting harm to health care staff, other clients and/or visitors.
6. A child is unable to remain still during a minor surgical procedure.
Equipments

Soft restraints
 Vest restraint
 Limb restraint
 Mitt restraint
 Belt restraint
  Body restraint as needed
 Padding if needed (large gauze pads can be used)
 Restrain flow sheet (washcloth can be used)
Leather restraints
 Two wrist and two ankle leather restraints
 Four straps
 Key
 Large gauze pads – this is used to cushion each extremity
 Restraint flow sheet (washcloth can be used)
Restraint Application Key Steps
1. Make sure that the restraints are correct size for the patient’s build and weight.
2. Explain the need for restraint to the patient. Assure him or her that they are used to protect him from injury
rather than to punish him. It is necessary to inform the patient of the conditions necessary to release him or
her from restraints.
3. Restraints are ONLY used when all other methods have failed to keep the patient from harming himself or
others. Restraints used should be least restrictive to the patient.
4. Obtain adequate assistance to manually restrain the patient.
5. After an hour of placing a restraint, the patient should be evaluated by a licensed independent practitioner
and an order must be written for restraints.
6. The order must ne time limited: 4 hours for adults; 2 hours for patients ages 9 to 17 years old; 1 hour for
patients younger than 9 years old.
7. The original order expires in 24 hours. Thus, the same order cannot be used the following day.
8. To promote safety and ensure the patient is not harmed with restraint application, the patient should be
assessed every 2 hours or according to the facility policy.
9. In cases where the client consented to have his family informed of his care, the family should be notified
of the use of restraints.

Schizophrenia Nursing Care Plan & Management

DEFINITION

Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as
one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that
schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown
illness in late adolescence or early adulthood.

Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot
be defined as a single illness;

rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually
diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of
onset is 15 to 25 years of age for men and 25 to 35 years of age for women.

The symptoms of schizophrenia are categorized into two major categories, the positive or hard symptoms which
include delusion, hallucinations, and grossly disorganized thinking, speech, and behavior, and negative or soft
symptoms as flat affect, lack of volition, and social withdrawal or discomfort. Medication treatment can control
the positive symptoms but frequently the negative symptoms persist after positive symptoms have abated. The
persistence of these negative symptoms over time presents a major barrier to recovery and improved the
functioning of client’s daily life.
PATHOPHYSIOLOGY
TYPES OF SCHIZOPHRENIA:
The diagnosis is made according to the client’s predominant symptoms:

 Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose
delusions, hallucinations, and occasionally, excessively religiosity (delusional focus) or hostile and
aggressive behavior.
 Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect, incoherence,
loose associations, and extremely disorganized behavior.
 Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either motionless or
excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor.
 Schizophrenia, undifferentiated type is characterized by mixed schizophrenic symptoms (of other types)
along with disturbances of thought, affect, and behavior.
 Schizophrenia, residual type is characterized by at least one previous, though not a current, episode, social
withdrawal, flat affect and looseness of associations.
Paranoid Schizophrenia
 Is characterized by persecutory or grandiose delusional thought content and, possibly, delusional jealousy.
 Some patients also have gender identity problems, such as fears of being thought of as homosexual or of
being approached by homosexuals.
 Stress may worsen the patient’s symptoms.
 Paranoid schizophrenia may cause only minimal impairment in the patient’s level of functioning – as long
as he doesn’t act on delusional thoughts.
 Although patients with paranoid schizophrenia may experience frequent auditory hallucinations (usually
related to a single theme), they typically lack some of the symptoms of other schizophrenia subtypes –
 notably, incoherent, loose associations, flat or grossly inappropriate affect, and catatonic or grossly
disorganized behavior.
 Tend to be less severely disabled than other schizophrenia.
 Those with late onset of disease and good pre-illness functioning (ironically, the very patients who have
the best prognosis) are at the greatest risk for suicide.

Signs and Symptoms

 Persecutory or grandiose delusional thoughts

 Auditory hallucinations
 Unfocused anxiety
 Anger
 Tendency to argue
 Stilted formality or intensity when interacting with others
 Violent behavior
Diagnosis

 Ruling out other causes of the patient’s symptoms.

 Meeting the DSM-IV-TR criteria.
Treatment

 Antipsychotic drug therapy.

 Psychosocial therapies and rehabilitation, including group and individual psychotherapy.
Nursing Interventions

1. Build trust, and be honest and dependable, don’t threaten or make promises you can’t fulfill.
2. Be aware that brief patient contacts may be most useful initially.
3. When the patient is newly admitted, minimize his contact with the staff.
4. Don’t touch the patient without telling him first exactly what you’re going to be doing and before
obtaining his permission to touch him.
5. Approach him in a calm, unhurried manner.
6. Avoid crowding him physically or psychologically; he may strike out to protect himself.
7. Respond neutrally to his condescending remarks; don’t let him put you on the defensive, and don’t take his
remarks personally.
8. If he tells you to leave him alone, do leave- but make sure you return soon.
9. Set limits firmly but without anger, avoid a punitive attitude.
10. Be flexible, giving the patient as much control as possible.
11. Consider postponing procedures that require physical contact with hospital personnel if the patient
becomes suspicious or agitated.
12. If the patient has auditory hallucinations, explore the content of the hallucinations (what voices are saying
to him, whether he thinks he must do what they command) tell him you don’t hear voices, but you know
they’re real to him.
Disorganized Schizophrenia
 Is marked by incoherent, disorganized speech and behaviors and by blunted or inappropriate affect.
 May have fragmented hallucinations and delusions with no coherent theme.
 Usually includes extreme social impairment.
 This type of schizophrenia may start early and insidiously, with no significant remissions.
Signs and Symptoms

 Incoherent, disorganized speech, with markedly loose associations.

 Grossly disorganized behavior.
 Blunted, silly, superficial, or inappropriate affect.
 Grimacing
 Hypochondriacal complaints.
 Extreme social withdrawal.
Diagnosis

 Ruling out other causes of the patients symptoms.

 Meeting the DSM-IV-TR criteria.
Treatment
  Treatments described for other types of schizophrenia.
 Antipsychotic drugs and psychotherapy.
Nursing Interventions

1. Spend time with the patient even if he’s mute and unresponsive, to promote reassurance and support.
2. Remember that, despite appearances, the patient is acutely aware of his environment, assume the patient
can hear – speak to him directly and don’t talk about him in his presence.
3. Emphasize reality during all patient contacts, to reduce distorted perceptions (for example, say, “The
leaves on the trees are turning colors and the air is cooler, It’s fall”)
4. Verbalize for the patient the message that his behavior seems to convey, encourage him to do the same.
5. Tell the patient directly, specifically, and concisely what needs to be done; don’t give him choice (for
example, say, “It’s time to go for a walk, lets go.”)
6. Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he won’t complain of
pain or physical symptoms.
7. Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or decreased circulation.
8. Provide range-of-motion exercises.
9. Encourage to ambulate every 2 hours.
10. During periods of hyperactivity, try to prevent him from experiencing physical exhaustion and injury.
11. As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow orders with
respect to nutrition, urinary catheterization, and enema use.
12. Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for yourself, the
patient, and others.
Catatonic Schizophrenia
 Is a rare disease form in which the patient tends to remain in a fixed stupor or position for long periods,
periodically yielding to brief spurts of extreme excitement.
 Many catatonic schizophrenia have an increased potential for destructive, violent behavior when agitated.
Signs and Symptoms

 Remaining mute; refusal to move about or tend to personal needs.

 Exhibiting bizarre mannerisms, such as facial grimacing and sucking mouth movements.
 Rapid swing between stupor and excitement (extreme psychomotor agitation with excessive, senseless, or
incoherent shouting or talking).
 Bizarre posture such as holding the body (especially the arms and legs) rigidly in one position for a long
time.
 Diminished sensitivity to painful stimuli.
 Echolalia (repeating words or phrases spoken by others).
 Echopraxia (imitating other’s movements).
Diagnosis

 Ruling out other possible causes of the patient’s symptoms.

 Meeting the DSM-IV-TR criteria.
Treatment

 ECT and benzodiazepines (such as diazepam or lorazepam) for catatonic schizophrenia.

 Avoiding conventional antipsychotic drugs (they may worsen catatonic symptoms).
 Investigating atypical antipsychotic drugs to treat catatonic schizophrenia (requires further evaluation).
Nursing Interventions

1. Spend time with the patient even if he’s mute and unresponsive, to promote reassurance and support.
2. Remember that, despite appearances, the patient is acutely aware of his environment, assume the patient
can hear – speak to him directly and don’t talk about him in his presence.
3. Emphasize reality during all patient contacts, to reduce distorted perceptions (for example, say, “The
leaves on the trees are turning colors and the air is cooler, It’s fall”)
4. Verbalize for the patient the message that his behavior seems to convey, encourage him to do the same.
5. Tell the patient directly, specifically, and concisely what needs to be done; don’t give him choice (for
example, say, “It’s time to go for a walk, lets go.”)
6. Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he won’t complain of
pain or physical symptoms.
7. Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or decreased circulation.
8. Provide range-of-motion exercises.
9. Encourage to ambulate every 2 hours.
 10. During periods of hyperactivity, try to prevent him from experiencing physical exhaustion and injury.
11. As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow orders with
respect to nutrition, urinary catheterization, and enema use.
12. Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for yourself, the
patient, and others.
DIAGNOSTIC TEST:
1. Clinical diagnosis is developed on historical information and thorough mental status examination.
2. No laboratory findings have been identified that are diagnostic of schizophrenia.
3. Routine battery of laboratory test may be useful in ruling out possible organic etiologies, including CBC,
urinalysis, liver function tests, thyroid function test, RPR, HIV test, serum ceruloplasmin ( rules out an
inherited disease, wilson’s disease, in which the body retains excessive amounts of copper), PET scan, CT
scan, and MRI.
4. Rating scale assessment:

 Scale for the assessment of negative symptoms.
 Scale for the assessment of positive symptoms.
 Brief psychiatric rating scale
TREATMENTS AND MEDICATIONS:
Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the impact of
disease depends mainly on early diagnosis and, appropriate pharmacological and psycho-social treatments.
Hospitalization may be required to stabilize ill persons during an acute episode. The need for hospitalization will
depend on the severity of the episode. Mild or moderate episodes may be appropriately addressed by intense
outpatient treatment. A person with schizophrenia should leave the hospital or outpatient facility with a
treatment plan that will minimize symptoms and maximize quality of life.

A comprehensive treatment program can include:

 Antipsychotic medication
 Education & support, for both ill individuals and families
 Social skills training
 Rehabilitation to improve activities of daily living
 Vocational and recreational support
 Cognitive therapy
Medication is one of the cornerstones of treatment. Once the acute stage of a psychotic episode has passed, most
people with schizophrenia will need to take medicine indefinitely. This is because vulnerability to psychosis
doesn’t go away, even though some or all of the symptoms do. In North America, atypical or second generation
antipsychotic medications are the most widely used. However, there are many first-generation antipsychotic
medications available that may still be prescribed. A doctor will prescribe the medication that is the most
effective for the ill individual
Another important part of treatment is psychosocial programs and initiatives. Combined with medication, they
can help ill individuals effectively manage their disorder. Talking with your treatment team will ensure you are
aware of all available programs and medications.

In addition, persons living with schizophrenia may have access to or qualify for income support
programs/initiatives, supportive housing, and/or skills development programs, designed to promote integration
and recovery.

Therapeutic Community ( Milieu Therapy)

Sullivan envisioned the goal of treatment as the establishment of satisfying interpersonal relationships. The
therapist provides a corrective interpersonal relationship for the client. Sullivan coined the term participant
observer for the therapist’s role, meaning that the therapist both participates in and observes the progress of the
relationship.
Credit is also given to Sullivan for the developing the first therapeutic community or milieu therapy with young
men with schizophrenia in 1929 (although that term was not used extensively until Maxwell Jones published
The Therapeutic Community in 1953). In the concept of therapeutic or milieu therapy, the interaction among
clients is seen as beneficial, and treatment emphasizes the role of this client-to-client interaction. Until this time,
it was believed that the interaction between the client and psychiatrist was the one essential component to the
client’s treatment. Sullivan and later Jones observed that interactions among clients in safe, therapeutic setting
provided great benefits to clients. The concept of milieu therapy, originally developed by Sullivan, involved
clients’ interactions with one another; i.e., practicing interpersonal relationship skills, giving one another
feedback about behavior, and working cooperatively as a group to solve day-to-day problems.
Milieu therapy was one of the primary modes of treatment in the acute hospital setting. In today’s health care
environment, however, inpatient hospital stays are often too short for clients to develop meaningful relationships
with one another. Therefore the concept of milieu therapy receives little attention. Management of the milieu or
environment is still a primary role for the nurse in terms of providing safety and protection for all the clients and
promoting social interaction.

Three Phases of Nurse-Client Relationship

Nurse-Client Relationship

 The nurse and the client work together to assist client to grow and solve his problems. This relationship
exists for the benefit of the client so that it is important that at every interaction, the nurse uses self
therapeutically. This is achieved by maintaining the nurses’ self-awareness to prevent her unrecognized
needs from influencing her perception of and behavior towards the client.

Three Phases of Nurse-Client Relationship:

1. Orientation Stage
 Establishing therapeutic environment.
 The roles, goals, rules and limitations of the relationship are defined, nurse gains trust of the client, and the
mode of communication are acceptable for both nurse and patient is set.
 Acceptance is the foundation of all therapeutic relationship
 Acceptance of others requires acceptance of self first.
 Rapport is built by demonstrating acceptance and non-judgmental attitude.
 Acceptance of patient means encouraging the patient verbally and non-verbally to express both positive
and negative feelings even if these are divergent from accepted norms and general viewpoint.
 The nurse can encourage the client to share his/her feelings by making the client understand that no
feeling is wrong.
 Trust of patient is gained by being consistent.
 Assessment of the client is made by obtaining data from primary and secondary sources.
 The patient set the pace of the relationship.
 During this phase, the problems are not yet been resolved but the client’s feelings especially anxiety is
reduced, by using palliative measures, to enable the client to relax enough to talk about his distressing
feelings and thoughts.
 This stage progresses well when the nurses show empathy provide support to client and temporary
structure until the client can control his own feelings and behavior.
 Reality testing – is accepting the patient’s perceptions, feelings and thoughts as neither right nor
wrong, but at the same time offering other options or points of view to the client in a non-
argumentative manner for the purpose of helping the client arrive at more realistic conclusions.
 To provide structure is to intervene when the client loses control of his own feelings and behaviors
by medications, offering self, restrain, seclusion and by assisting client to observe a consistent daily
schedule.
2. Working/ Exploration/ Identification Stage – at this point, the client’s problems are identified and solutions
are explored, applied and evaluated.
 The focus of the assessment and of the relationship is the client’s behavior and the focus of the interaction
is the client’s feelings.
 The nurse should realize that the client’s feelings of security are developed by being consistent at all times.
 Perception of reality, coping mechanisms and support systems are identified.
 The nurse assists the patient to develop coping skills, positive self concept and independence in order to
change the behavior of the client to one that is adaptive and appropriate.
 The nurse uses the techniques of communication and assumes different roles to help the client.
3. Termination/ Resolution stage
 the nurse terminates the relationship when the mutually agreed goals are met, the patient is discharged or
transferred or the rotation is finished. The focus of this stage is the growth that has occurred in the client
and the nurse helps the patient to become independent and responsible in making his own decisions. The
relationship and the growth or change that has occurred in both the nurse and the patient is summarized.
 Client may become anxious and react with increased dependence, hostility and withdrawal, these are
normal reactions and are signs of separation anxiety, these feelings and behavior should be discussed with
the client.
 The nurse should be firm in maintaining professionalism until the end of the relationship. She should not
promise the client that the relationship will be continued.
 The time parameters should be made early in the relationship and meetings are set further and further apart
near the end to foster independence of the patient and prepare the latter gradually for the separation.
 The nurse should not give her address or telephone numbers to the patient.
 Referral for continuing health care and support after discharge provides additional resources for the client
and the family.
 The goal of the therapeutic relationship have been met when the patient has developed emotional stability,
cope positively, recognized sources or causes of anxiety, demonstrates ability to handle anxiety and
independence, and is able to perform self-care.
 Preparation of the termination phase begins at the orientation phase, when the duration and length of
the nurse-client relationship was established.
 · It is normal for the client to experience separation anxiety such as sleeplessness, anorexia, physical
symptoms, withdrawal and hostility.

 1.
 A 17-year-old client has a record of being absent in the class without permission, and
“borrowing” other people’s things without asking permission. The client denies stealing;
rationalizing instead that as long as no one was using the items, there is no problem to use it by
other people. It is important for the nurse to understand that psychodynamically, the behavior of
the client may be largely attributed to a development defect related to the:

o AOedipal complex
o B.Superego
o C.Id
o D.Ego

 Correct Answer
B. Superego
Explanation
This shows a weak sense of moral consciousness. According to Freudian theory, personality
disorders stem from a weak superego.

 2. A client tells the nurse, “Yesterday, I was planning to kill myself.” What is the best nursing
response to this client?

o A.“What are you going to do this time?”

o B.Say nothing. Wait for the client’s next comment
o C.“You seem upset. I am going to be here with you; perhaps you will want to talk about
it”
o D.“Have you felt this way before?”

 Correct Answer
C. “You seem upset. I am going to be here with you; perhaps you will want to talk about it”
Explanation
The client needs to have his or her feelings acknowledged, with encouragement to discuss
feelings, and be reassured about the nurse’s presence.

 3. In crisis intervention therapy, which of the following principles will the nurse use to plan
her/his goals?

o A.Crises are related to deep, underlying problems

o B.Crises seldom occur in normal people’s lives
o C.Crises may go on indefinitely.
 o D.Crises are usually resolved in 4-6 weeks.

 Correct Answer
D. Crises usually resolved in 4-6 weeks.
Explanation
Part of the definition of a crisis is a time span of 4-6 weeks.

 4. The nurse enters the room of the male client and found out that the client urinates on the floor.
The client hides when the nurse is about to talk to him. Which of the following is the best nursing
intervention?

o A.Place restriction on the client’s activities when his behavior occurs.

o B.Ask the client to clean the soiled floor.
o C.Take the client to the bathroom at regular intervals.
o D.Limit fluid intake.

 Correct Answer
C. Take the client to the bathroom at regular intervals.
Explanation
The client is most likely confused, rather than exhibiting acting-out, hostile behavior. Frequent
toileting will allow urination in an appropriate place.

 5. A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric unit. In
the past two months, the client has poor appetite, experienced difficulty in sleeping, was mute for
long periods of time, just stayed in her room, grinning and pointing at things. What would be the
initial nursing action on admitting the client to the unit?

o A.Assure the client that “ You will be well cared for.”

o B.Introduce the client to some of the other clients.
o C.Ask “Do you know where you are?”
o D.Take the client to the assigned room.

 Correct Answer
D. Take the client to the assigned room.
Explanation
The client needs basic, simple orientation that directly relates to the here-and-now, and does not
require verbal interaction.

 6. A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of the
nurse?

o A.
o What food she likes.
o B.
o Her desired weight.
o C.
o Her body image.
o D.
o What causes her behavior.

 Correct Answer
A. What food she likes.
Explanation
Although all options may appear correct. Knowing what food she likes is the best because it
focuses on a range of possible positive reinforcers, a basis for an effective behavior modification
program. It can lead to concrete, specific nursing interventions right away and provides a
therapeutic use of “control” for the 16-year-old.
 7. On an adolescent unit, a nurse caring for a client was informed that her client’s closest
roommate dies at night. What would be the most appropriate nursing action?

o A.Do not bring it up unless the client asks.

o B.Tell the client that her roommate went home.
o C.Tell the client, if asked, “You should ask the doctor.”
o D.Tell the client that her closest roommate died.

 Correct Answer
A. Do not bring it up unless the client asks.
Explanation
The nurse needs to wait and see: do not “jump the gun”; do not assume that the client wants to
know now.

 8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse should
expect the woman’s initial reactions to include:

o A.Depression
o B.Withdrawal
o C.Apathy
o D.Anger

 Correct Answer
D. Anger
Explanation
The woman is experiencing an actual loss and will probably exhibit many of the same symptoms
as a person who has lost someone to death.

 9.A client in the psychiatric unit is shouting out loud and tells the nurse, “Please, help me. They
are coming to get me.” What would be the appropriate nursing response?

o A.“ I won’t let anyone get you.”

o B.“Who are they?”
o C.“I don’t see anyone coming.”
o D.“You look frightened.”

 Correct Answer
C. “I don’t see anyone coming.”
Explanation
This option is an example of pointing out reality- the nurse’s perception.

 10. A client who is severely obese tells the nurse, “My therapist told me that I eat a lot because I
didn’t get any attention and love from my mother. What does the therapist mean?” What is the
best nursing response?

o A.“What do you think is the connection between your not getting enough love and
overeating?”
o B.“Tell me what you think the therapist means.”
o C.“You need to ask your therapist.”
o D.“ We are here to deal with your diet, not with your psychological problems.”

 Correct Answer
B. “Tell me what you think the therapist means.”
Explanation
This response asks information that the nurse can use. If the client understands the statement, the
nurse can support the therapist when focusing on connection between food, love, and mother. If
the client does not understand the statement, the nurse can help get clarification from the therapist.
 11. After the discussion about the procedure the physician scheduled the client for mastectomy.
The client tells the nurse, “If my breasts will be removed, I’m afraid my husband will not love me
anymore and maybe he will never touch me.” What should the nurse’s response?

o A.“I doubt that he feels that way.”

o B.“What makes you feel that way?”
o C.“Have you discussed your feelings with your husband?”
o D.Ask the husband, in front of the wife, how he feels about this.

 Correct Answer
C. “Have you discussed your feelings with your husband?”
Explanation
This option redirects the client to talk to her husband.

 12. The child is brought to the hospital by the parents. During assessment of the nurse, what
parental behavior toward a child should alert the nurse to suspect child abuse?

o A.Ignoring the child.

o B.Flat affect.
o C.Expressions of guilt.
o D.Acting overly solicitous toward the child

 Correct Answer
D. Acting overly solicitous toward the child
Explanation
This is an example of reaction formation, a coping mechanism.
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
 13. A nurse is caring to a client with manic disorder in the psychiatric ward. On the morning shift,
the nurse is talking with the client who is now exhibiting a manic episode with flight of ideas. The
nurse primarily needs to:

o A.Focus on the feelings conveyed rather than the thoughts expressed.

o B.Speak loudly and rapidly to keep the client’s attention, because the client is easily
distracted.
o C.Allow the client to talk freely.
o D.Encourage the client to complete one thought at a time.

 Correct Answer
A. Focus on the feelings conveyed rather than the thoughts expressed.
Explanation
Often the verbalized ideas are jumbled, but the underlying feelings are discernible and must be
acknowledged.

 14. The nurse is caring to an autistic child. Which of the following play behavior would the nurse
expect to see in a child?

o ACompetitive play
o B.Nonverbal play
o C.Cooperative play
o D.Solitary play

 Correct Answer
D. Solitary play
Explanation
Autistic children do best with solitary play because they typically do not interact with others in a
socially comprehensible and acceptable way.
 15. The client is telling the nurse in the psychiatric ward, “I hate them.” Which of the following is
the most appropriate nursing response to the client?

o A.“Tell me about your hate.”

o B.“I will stay with you as long as you feel this way.”
o C.“For whom do you have these feelings?”
o D.“I understand how you can feel this way.”

 Correct Answer
A. “Tell me about your hate.”
Explanation
The nurse is asking the client to clarify and further discuss feelings.

 16. The mother visits her son with major depression in the psychiatric unit. After the conversation
of the client and the mother, the nurse asks the mother how it is talking to her son. The mother
tells the nurse that it was a stressful time. During an interview with the client, the client says, “we
had a marvelous visit.” Which of the following coping mechanism can be described to
thestatement of the client?

o A.Identification.
o B.Rationalization.
o C.Denial.
o D.Compensation.

 Correct Answer
C. Denial.
Explanation
Denial is the act of avoiding disagreeable realities by ignoring them.

 17. A male client is quiet when the physician told him that he has stage IV cancer and has 4
months to live. The nurse determines that this reaction may be an example of:

o A.Indifference
o B.Denial
o C.Resignation
o D.Anger

 Correct Answer
B. Denial
Explanation
Reactions when told of a life-threatening illness stem from Kübler-Ross’ ideas on death and dying.
Denial is a typical grief response, and usually is a first reaction.
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
 18. A nurse is caring to a female client with five young children. The family member told the
client that her ex-husband has died 2 days ago. The reaction of the client is stunned silence,
followed by anger that the ex-husband left no insurance money for their young children. The nurse
should understand that:

o A.The children and the injustice done to them by their father’s death are the woman’s
main concern.
o B.To explain the woman’s reaction, the nurse needs more information about the
relationship and breakup.
o C.The woman is not reacting normally to the news.
o D.The woman is experiencing a normal bereavement reaction.

 Correct Answer
D. The woman is experiencing a normal bereavement reaction.
Explanation
 Shock and anger are commonly the primary initial reactions.

 19. A client who is manic comes to the outpatient department. The nurse is assigning an activity
for the client. What activity is best for the nurse to encourage for a client in a manic phase?

o A.Solitary activity, such as walking with the nurse, to decrease stimulation.

o B.Competitive activity, such as bingo, to increase the client’s self-esteem.
o C.Group activity, such as basketball, to decrease isolation.
o D.Intellectual activity, such as scrabble, to increase concentration.

 Correct Answer
A. Solitary activity, such as walking with the nurse, to decrease stimulation.
Explanation
This option avoids external stimuli, yet channels the excess motor activity that is often part of the
manic phase.

 20. The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client says, “Why
should I take this?” The doctor started me on this 10days ago; it didn’t help me at all.” Which of
the following is the best nursing response:

o A.“What were you expecting to happen?”

o B.“It usually takes 2-3 weeks to be effective.”
o C.“Do you want to refuse this medication? You have the right.”
o D.“That’s a long time wait when you feel so depressed.”

 Correct Answer
B. “It usually takes 2-3 weeks to be effective.”
Explanation
The patient needs a brief, factual answer.

 21.Which of the following drugs the nurse should choose to administer to a client to prevent
pseudoparkinsonism?

o A.Isocarboxazid (Marplan)
o B.Chlorpromazine HCI (Thorazine)
o C.Trihexyphenidyl HCI (Artane)
o D.Trifluoperazine HCI (Stelazine)

 Correct Answer
C. Trihexyphenidyl HCI (Artane)
Explanation
Trihexyphenidyl HCI (Artane) is often used to counteract side effect of pseudoparkinsonism,
which often accompanies the use of phenothiazine, such as chlorpromazine HCI (Thorazine or
Trifluoperazine HCI (Stelazine).

 22. The nurse is caring to an 80-year-old client with dementia? What is the most important
psychosocial need for this client?

o A.Focus on the there-and-then rather the here-and-now.

o B.Limit in the number of visitors, to minimize confusion.
o C.Variety in their daily life, to decrease depression.
o D.A structured environment, to minimize regressive behaviors.

 Correct Answer
D. A structured environment, to minimize regressive behaviors.
Explanation
Persons with dementia needs sameness, consistency, structure, routine, and predictability.
 23. A client tells the nurse, “I don’t want to eat any meals offered in this hospital because the food
is poisoned.” The nurse is aware that the client is expressing an example of:

o A.Delusion.
o B.Hallucination.
o C.Negativism.
o D.Illusion.

 Correct Answer
A. Delusion.
Explanation
This is a false belief developed in response to an emotional need.

 24. A client is admitted in the hospital. On assessment, the nurse found out that the client had
several suicidal attempts. Which of the following is the most important nursing action?

o A.Ignore the client as long as he or she is talking about suicide, because suicide attempt is
unlikely.
o B.Administer medication.
o C.Relax vigilance when the client seems to be recovering from depression.
o D.Maintain constant awareness of the client’s whereabouts.

 Correct Answer
D. Maintain constant awareness of the client’s whereabouts.
Explanation
The client must be constantly observed.
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
 25. The nurse suspects that the client is suffering from depression. During assessment, what are
the most characteristic signs and symptoms of depression the nurse would note?

o A.Constipation, increased appetite.

o B.Anorexia, insomnia.
o C.Diarrhea, anger.
o D.Verbosity, increased social interaction.

 Correct Answer
B. Anorexia, insomnia.
Explanation
The appetite is diminished and sleeping is affected to a client with depression.


 26. The client in the psychiatric unit states that, “The goodas are coming! I must be ready.” In
response to this neologism, the nurse’s initial response is to:

o A.Acknowledge that the word has some special meaning for the client.
o B.Try to interpret what the client means.
o C.Divert the client’s attention to an aspect of reality.
o D.State that what the client is saying has not been understood and then divert attention to
something that is really bound.

 Correct Answer
A. Acknowledge that the word has some special meaning for the client.
Explanation
It is important to acknowledge a statement, even if it is not understood.
 27. A male client diagnosed with depression tells the nurse, “I don’t want to look weak and I don’t
even cry because my wife and my kids can’t bear it.” The nurse understands that this is an
example of:

o A.Repression.
o B.Suppression.
o C.Undoing.
o D.Rationalization.

 Correct Answer
D. Rationalization.
Explanation
Rationalization is the process of constructing plausible reasons for one’s responses.

 28. A female client tells the nurse that she is afraid to go out from her room because she thinks that
the other client might kill her. The nurse is aware that this behavior is related to:

o A.Hallucination.
o B.Ideas of reference.
o C.Delusion of persecution.
o D.Illusion.

 Correct Answer
C. Delusion of persecution.
Explanation
The client has ideas that someone is out to kill her.

 29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows less
awareness of the physical body. What problem would the nurse be most concerned?

o A.Nausea.
o B.Gait disturbances.
o C.Bowel movements.
o D.Voiding.

 Correct Answer
D. Voiding.
Explanation
A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding problems)


 30. A 6-year-old client dies in the nursing unit. The parents want to see the child. What is the most
appropriate nursing action?

o A.Give the parents time alone with the body.

o B.Ask the physician for permission.
o C.Complete the postmortem care and quietly accompany the family to the child’s room.
o D.Suggest the parents to wait until the funeral service to say “good-bye.”

 Correct Answer
A. Give the parents time alone with the body.
Explanation
This allows the parents/family to grieve over the loss of the child, by going through the steps of
leave taking.

 31. A 20-year-old female client is diagnosed with anxiety disorder. The physician prescribed
Flouxetine (Prozac). What is the most important side effects should a nurse be concerned?
 o A.Tremor, drowsiness.
o B.Seizures, suicidal tendencies.
o C.Visual disturbance, headache.
o D.Excessive diaphoresis, diarrhea.

 Correct Answer
B. Seizures, suicidal tendencies.
Explanation
Assess for suicidal tendencies, especially during early therapy. There is an increased risk of
seizures in debilitated client and those with a history of seizures.

 32.A nurse is assigned to activate a client who is withdrawn, hears voices and negativistic. What
would be the best nursing approach?

o A.Mention that the “voices” would want the client to participate.

o B.Demand that the client must join a group activity.
o C.Give the client a long explanation of the benefits of activity.
o D.Tell the client that the nurse needs a partner for an activity.

 Correct Answer
D. Tell the client that the nurse needs a partner for an activity.
Explanation
The nurse helps to activate by doing something with the client.
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
 33. A nurse is going to give a rectal suppository as a preoperative medication to a 4-year-old boy.
The boy is very anxious and frightened. Which of the following statement by the nurse would be
most appropriate to gain the child’s cooperation?

o A.“Be a big kid! Everyone’s waiting for you.”

o B.“Lie still now and I’ll let you have one of your presents before you even have your
operation.”
o C.“Take a nice, big, deep breath and then let me hear you count to five.”
o D.“You look so scared. Want to know a secret? This won’t hurt a bit!”

 Correct Answer
C. “Take a nice, big, deep breath and then let me hear you count to five.”
Explanation
Preschool children commonly experience fears and fantasies regarding invasive procedures. The
nurse should attempts to momentarily distract the child with a simple task that can be easily
accomplished while the child remains in the side-lying position. The suppository can be slipped
into place while the child is counting, and then the nurse can praise the child for cooperating,
while holding the buttocks together to prevent expulsion of the suppository.

 34. A depressed client is on an MAO inhibitor? What should the nurse watch out for?

o A.Hypertensive crisis.
o B.Diet restrictions.
o C.Taking medication with meals.
o D.Exposure to sunlight.

 Correct Answer
A. Hypertensive crisis.
Explanation
This is the more inclusive answer, although diet restrictions (answer1) are important, their purpose
is to prevent hypertensive crisis (answer 2).
 35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the nurse caring
to her that her step-father has made sexual advances to her. She got the chance to tell it to her
mother but refuses to believe. What is the most therapeutic action of the nurse would be:

o A.Tell the client to work it out with her father.

o B.Tell the client to discuss it with her mother.
o C.Ask the father about it.
o D.Ask the mother what she thinks.

 Correct Answer
D. Ask the mother what she thinks.
Explanation
This comes closest to beginning to focus on family-centered approach to intervene in the
“conspiracy of silence”. This is therefore the best among the options.

 36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital. The client
tells the nurse, “the FBI is following me. These people are plotting against me.” With this
statement the nurse will need to:

o A.Acknowledge that this is the client’s belief but not the nurse’s belief.
o B.Ask how that makes the client feel.
o C.Show the client that no one is behind.
o D.Use logic to help the client doubt this belief.

 Correct Answer
A. Acknowledge that this is the client’s belief but not the nurse’s belief.
Explanation
The nurse should neither challenge nor use logic to dispel an irrational belief.

 37. A nurse is completing the routine physical examination to a healthy 16-year-old male client.
The client shares to the nurse that he feels like killing his girlfriend because he found out that her
girlfriend had another boyfriend. He then laughs, and asks the nurse to keep this a secret just
between the two of them. The nurse reviews his chart and notes that there is no previously history
of violence or psychiatric illness. Which of the following would be the best action of the nurse to
take at this time?

o
o A.Suggest the teen meet with a counselor to discuss his feelings about his girlfriend.
o B.Tell the teen that his feelings are normal, and recommend that he find another
girlfriend to take his mind off the problem.
o C.Recall the teenage boys often say things they really do not mean and ignore the
comment.
o D.Regard the comment seriously and notify the teen’s primary health care provider and
parents

 Correct Answer
D. Regard the comment seriously and notify the teen’s primary health care provider and parents
Explanation
Any threat to the safety of oneself or other should always be taken seriously and never disregarded
by the nurse.

 38. Which of the following person will be at highest risk for suicide?

o A.A student at exam time

o B.A married woman, age 40, with 6 children.
o C.A person who is an alcoholic.
o D.A person who made a previous suicide attempt.
 Correct Answer
C. A person who is an alcoholic.
Explanation
The likelihood of multiple contributing factors may make this person at higher risk for suicide.
Some factors that may exist are physical illness related to alcoholism, emotional factors ( anxiety,
guilt, remorse), social isolation due to impaired relationships and economic problems related to
employment.
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
 39. A male client is repetitively doing the handwashing every time he touches things. It is
important for a nurse to understand that the client’s behavior is probably an attempt to:

o A.Seek attention from the staff.

o B.Control unacceptable impulses or feelings.
o C.Do what the voices the patient hears tell him or her to do.
o D.Punish himself or herself for guilt feeling.

 Correct Answer
B. Control unacceptable impulses or feelings.
Explanation
A ritual, such as compulsive hand washing, is an attempt to allay anxiety caused by unconscious
impulses that are frightening.
40.In a mental health settings, the basic goal of nursing is to:

o A.Advance the science of psychiatry by initiating research and gathering data for current
statistics on emotional illness.
o B.Plan activity programs for clients.
o C.Understand various types of family therapy and psychological tests and how to
interpret them.
o D.Maintain a therapeutic environment.

 Correct Answer
D. Maintain a therapeutic environment.
Explanation
This is the most neutral answer by process of elimination.

 41. A 3-year-old boy is brought to the emergency department. After an hour, the boy dies of
respiratory failure. The mother of the boy becomes upset, shouting and abusive, saying to the
nurse, “If it had been your son, they would have done more to save it. “What should the nurse say
or do?

o A.Touch her and tell her exactly what was done for her baby.
o B.Allow the mother to continue her present behavior while sitting quietly with her.
o C.“No, all clients are given the same good care.”
o D.“Yes, you’re probably right. Your son did not get better care.”

 Correct Answer
B. Allow the mother to continue her present behavior while sitting quietly with her.
Explanation
This option allows a normal grief response (anger).
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
 42.
 The nurse is interacting to a client with an antisocial personality disorder. What would be the most
therapeutic approach of the nurse to an antisocial behavior?

o A.
 o Gratify the client’s inner needs.
o B.
o Give the client opportunities to test reality.
o C.
o Provide external controls.
o D.
o Reinforce the client’s self-concept.

 Correct Answer
C. Provide external controls.
Explanation
Personality disorders stem from a weak superego, implying a lack of adequate controls.

 43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with him in
the recovery room after the surgery, or he will be upset for not granting his request. What is the
appropriate nursing response?

o A.“Do you get upset and confused often?”

o B.“You won’t need your glasses or hearing aid. The nurses will take care of you.”
o C.“I understand. You will be able to cooperate best if you know what is going on, so I
will find out how I can arrange to have your glasses and hearing aid available to you in
the recovery room.”
o D.I understand you might be more cooperative if you have your aid and glasses, but that
is just not possible. Rules, you know.”

 Correct Answer
C. “I understand. You will be able to cooperate best if you know what is going on, so I will find
out how I can arrange to have your glasses and hearing aid available to you in the recovery room.”
Explanation
The client will be easier to care for if he has his hearing aid and glasses.


 44. The male client had fight with his roommates in the psychiatric unit. The client agitated client
is placed in isolation for seclusion. The nurse knows it is essential that:

o A.A staff member has frequent contacts with the client.

o B.Restraints are applied.
o C.The client is allowed to come out after 4 hours.
o D.All the furniture is removed form the isolation room.

 Correct Answer
A. A staff member has frequent contacts with the client.
Explanation
Frequent contacts at times of stress are important, especially when a client is isolated.

 45. A medical representative comes to the hospital unit for the promotion of a new product. A
female client, admitted for hysterical behavior, is found embracing him. What should the nurse
say?

o A.“Have you considered birth control?”

o B.“This isn’t the purpose of either of you being here.”
o C.“I see you’ve made a new friend.”
o D.“Think about what you are doing.”

 Correct Answer
B. “This isn’t the purpose of either of you being here.”
Explanation
 This response is aimed at redirecting the inappropriate behavior.

 46. A client with dementia is for discharge. The nurse is providing a discharge instruction to the
family member regarding safety measures at home. What suggestion can the nurse make to the
family members?

o A.Avoid stairs without banisters.

o B.Use restraints while the client is in bed to keep him or her from wandering off during
the night.
o C.Use restraints while the client is sitting in a chair to keep him or her from wandering
off during the day.
o D.Provide a night-light and a big clock.

 Correct Answer
D. Provide a night-light and a big clock.
Explanation
This option is best to decrease confusion and disorientation to place and time.

 47. A 30-year-old married woman comes to the hospital for treatment of fractures. The woman
tells the nurse that she was physically abused by her husband. The woman receives a call from her
husband telling her to get home and things will be different. He felt sorry of what he did. What can
the nurse advise her?

o A.“Do you think so?”

o B.“It’s not likely.”
o C.“What will be different?”
o D.“I hope so, for your sake.”

 Correct Answer
C. “What will be different?”
Explanation
This option helps the woman to think through and elaborate on her own thoughts and prognosis.
Rate this question:

 48. A female client was diagnosed with breast cancer. It is found to be stage IV, and a modified
mastectomy is performed. After the procedure, what behaviors could the nurse expects the client
to display?

o A.Denial of the possibility of carcinoma.

o B.Signs of grief reaction.
o C.Relief that the operation is over.
o D.Signs of deep depression.

 Correct Answer
B. Signs of grief reaction.
Explanation
It is mostly likely that grief would be expressed because of object loss.

 49.A client is withdrawn and does not want to interact to anybody even to the nurse. What is the
best initial nursing approach to encourage communication with this client?

o A.Use simple questions that call for a response.

o B.Encourage discussion of feelings.
o C.Look through a photo album together.
o D.Bring up neutral topics.

 Correct Answer
D. Bring up neutral topics.
Explanation
 Neutral, nonthreatening topics are best in attempting to encourage a response.

 50. Which of the following nursing approach is most important in a client with depression?

o A.Deemphasizing preoccupation with elimination, nourishment, and sleep.

o B.Protecting against harm to others.
o C.Providing motor outlets for aggressive, hostile feelings.
o D.Reducing interpersonal contacts.

 Correct Answer
C. Providing motor outlets for aggressive, hostile feelings.
Explanation
It is important to externalize the anger away from self.

Psychiatric Nursing Practice Exam for Defense Mechanism

1. On a sunny afternoon at the pediatric clinic, Nurse Olivia observes baby Mia during her regular checkup.
Amid the coos and giggles, she knows there’s a particular developmental milestone that Mia should reach soon.
At what age can she anticipate Mia will start sitting up without any assistance?
A. When she’s 4 months old.
B. At the age of 6 months.
C. Once she turned 8 months old.
D. By the time she’s 10 months old.
2. As an experienced nurse, Robert is caring for a patient who exhibits signs of paranoid delusions. Robert
understands there’s a connection between these delusions and a particular psychological defense mechanism.
Which defense mechanism is generally linked with the occurrence of paranoid delusions in Robert’s patient?
A. The possibility is Regression.
B. Another potential mechanism could be Repression.
C. Identification might also be the defense mechanism at play.
D. It could be a case of Projection.
3. In the realm of psychiatric nursing, Nurse Emily comes across different coping mechanisms her patients use,
some healthier than others. She knows there’s one specific term that refers to the unconscious act of attributing
one’s undesirable characteristic to someone else. Which of these terms aligns with this definition?
A. The act of Compensation.
B. The process of Projection.
C. The mechanism of Rationalization.
D. The state of Dysphoria.
4. While attending a seminar on grief counseling, Nurse Alex encounters a question: “Out of the listed phases,
can you pinpoint which one does not fall within the standard stages of the grieving process?”
A. Anger
B. Denial
C. Rejection
D. Bargaining
5. During her shift, Nurse Jenna takes a quick break and engages in a quiz meant to reinforce her understanding
of psychological defense mechanisms. A question reads: “Can you identify the term used when an individual
creates seemingly logical excuses for actions that were driven by different, often subconscious, motivations?”
A. Compensation
B. Projection
C. Rationalization
D. Dysphoria
6. As Nurse John navigates his bustling day on the neurology floor, he comes across various psychological
disorders. Among these, he reflects on one particular disorder where severe emotional stress provokes an
involuntary disruption in physical functions. What is this disorder known as?
A. Alzheimer’s disease.
B. Conversion disorder.
C. Depressive reaction.
D. Bipolar disorder.
7. In the bustling world of a hospital’s sleep disorders clinic, Nurse Emily is analyzing EEG
(electroencephalogram) recordings of various patients. While reviewing the different waveforms observed
during wakefulness, she wonders which one is the most commonly found. Which waveform is it?
A. Beta
B. Theta
C. Zeta
D. Alpha
8. In the serene atmosphere of the sleep laboratory, Nurse Michelle is closely monitoring a patient’s sleep
patterns. As she observes the different stages of sleep, she contemplates the frequency of the REM (Rapid Eye
Movement) sleep cycle. How often does the REM sleep cycle occur, approximately?
A. 75 minutes
B. 60 minutes
C. 90 minutes
D. 45 minutes
9. In the nurturing environment of a maternity ward, Nurse Sarah is conducting routine neonatal assessments.
While examining the newborns, she recalls the various reflexes present in these infants. Which of the following
reflexes is absent at birth?
A. Moro reflex
B. Rooting reflex
C. Pincer grasp reflex
D. Sucking reflex
10. In a vibrant and joyful preschool setting, Nurse Lily is observing toddlers as they engage in various
activities. While witnessing the children’s interactions, she reflects on the development of parallel play. During
which age range does parallel play typically emerge?
A. Between the ages of 5 to 10 months.
B. Around 10 to 14 months of age.
C. Typically seen in toddlers aged 12 to 24 months.
D. Emerging during the period of 24 to 48 months.
11. In the midst of her day at a bustling city healthcare facility, Nurse Jane finds herself reflecting on
psychological defense mechanisms, specifically those she’s observed in her patient interactions. In this context,
which mechanism could be defined as covering up a weakness by emphasizing a desirable or stronger trait?
A. Experiencing feelings of dysphoria.
B. Engaging in rationalization as a coping mechanism.
C. Utilizing compensation to address weaknesses.
D. Projecting emotions onto others.
12. As Nurse Amanda tends to her patients in a busy emergency room, she ponders the various signs and
symptoms of anxiety. Among the listed options, which one is not typically considered a sign of anxiety?
A. Experiencing a moist mouth.
B. Feeling dyspnea (shortness of breath).
C. Exhibiting gastrointestinal (GI) symptoms.
D. Demonstrating hyperventilation (rapid breathing).
13. In a bustling sleep disorders clinic, Nurse Michelle encounters a unique case where an individual who is
fully awake suddenly falls asleep without warning. How can this condition be best described?
A. Experiencing narcolepsy.
B. Undergoing transitional sleep.
C. Experiencing REM absence.
D. Experiencing cataplexy.
14. Amidst the bustling activity of a neurology clinic, Nurse Sarah encounters a patient with a unique condition.
The patient has difficulty identifying the location of their hand or foot. Which term best describes this
condition?
A. Experiencing symptoms of cataplexy.
B. Dealing with feelings of ergophobia.
C. Showing signs of anosognosia.
D. Having difficulties related to autotopagnosia.
15. In a bustling emergency department, Nurse Alex encounters patients with various medical conditions. As he
reviews the symptoms associated with panic disorder, he identifies some common characteristics. Among the
following options, which one is not typically associated with panic disorder?
A. Experiencing chest pain.
B. Dealing with excessive perspiration.
C. Experiencing nausea.
D. Feeling the urge to urinate.
16. In a vibrant and supportive senior living community, Nurse Lisa interacts with elderly residents daily. As
she contemplates the psychological stages of development in older adults, she wonders which category a 70-
year-old adult would fall into.
A. Experiencing the stage of integrity vs. despair.
B. Going through the stage of generativity vs. stagnation.
C. Engaging in the stage of longevity vs. guilt.
D. Encountering the stage of intimacy vs. isolation.
17. In a vibrant and supportive senior living community, Nurse Lisa interacts with elderly residents daily. As
she contemplates the psychological stages of development in older adults, she wonders which category a 60-
year-old adult would fall into.
A. Experiencing the stage of longevity vs. guilt.
B. Going through the stage of intimacy vs. isolation.
C. Engaging in the stage of generativity vs. stagnation.
D. Encountering the stage of integrity vs. despair.
18. In a bustling university campus, Nurse Lisa engages with young adults daily. As she contemplates the
psychological stages of development in young adulthood, she wonders which category a 20-year-old adult
would fall into.
A. Experiencing the stage of generativity vs. stagnation.
B. Going through the stage of intimacy vs. isolation.
C. Engaging in the stage of integrity vs. despair.
D. Encountering the stage of longevity vs. guilt.
19. In a serene sleep clinic, Nurse Michelle observes various sleep patterns in different individuals. Among
these, she contemplates the most common waveform associated with light sleepers. What is this waveform?
A. Experiencing brainwave activity in the Theta frequency range.
B. Having brainwave activity in the Beta frequency range.
C. Showing brainwave activity in the Alpha frequency range.
D. Zeta that is commonly found in sleep patterns.
20. In a bustling psychiatric ward, Nurse Sarah encounters a patient who is using words with no known
meaning. As she ponders the condition associated with this language pattern, which term best describes it?
A. Neolithic
B. Displaying neologisms.
C. Demonstrating verbalism.
D. Experiencing delusional blocking.
Answers & Rationales
1. Correct answer:
B. At the age of 6 months. Most babies start sitting up on their own around the age of 6 months. This is a
significant developmental milestone as it indicates that the baby’s muscles in the neck, back, and abdomen have
developed enough strength to keep them upright. This also coincides with the development of their balance and
coordination skills.
Imagine learning to ride a bicycle. Initially, you need training wheels (like the support of a caregiver or a baby
seat for the baby) to stay upright. But as you practice and your muscles get stronger, you can balance and ride
the bike without any assistance. Similarly, as babies grow and their muscles strengthen, they learn to sit up
independently.
2. Correct answer:
D. It could be a case of Projection. Projection is a psychological defense mechanism where individuals attribute
their own unacceptable thoughts, feelings, or motives to another person. In the case of paranoid delusions, the
individual often projects their own feelings of hostility, aggression, or other negative sentiments onto others,
believing that these others are out to harm them.
For example, a person who is harboring dishonest thoughts might accuse others of being deceitful without any
evidence. They are “projecting” their own dishonesty onto others.
3. Correct answer:
B. The process of Projection. Projection is a psychological defense mechanism where individuals attribute
characteristics, feelings, or impulses which are perceived as undesirable or unacceptable to someone else. It’s an
unconscious process that helps the individual cope with difficult feelings or emotions.
Imagine you’re watching a movie in a theater. The projector takes the images from the film and throws them
onto the screen for everyone to see. Similarly, in the psychological process of projection, an individual
“projects” their own undesirable characteristics or feelings onto someone else.
For example, a person who is being unfaithful in a relationship may accuse their partner of infidelity. In this
case, the person is not consciously aware that the infidelity exists within themselves, so they project it onto their
partner.
Projection serves as a defense mechanism because it allows individuals to avoid the discomfort or anxiety that
can come from acknowledging these undesirable feelings or traits in themselves. It’s like wearing a pair of
sunglasses that change the color of everything you see; the world hasn’t changed color, but your perception of it
has.
4. Correct answer:
C. Rejection. The standard stages of the grieving process, as proposed by psychiatrist Elisabeth Kübler-Ross in
her 1969 book “On Death and Dying,” include five stages: Denial, Anger, Bargaining, Depression, and
Acceptance. These stages are often referred to by the acronym DABDA.
Rejection is not considered a standard stage of the grieving process according to Kübler-Ross’s model. The term
“rejection” in the context of grief is not typically used in professional literature and does not align with the
established stages of grief.
Imagine you’re on a journey through a difficult terrain, like a dense forest or a steep mountain. This journey
represents the process of grieving. The stages (Denial, Anger, Bargaining, Depression, and Acceptance) are like
the different types of challenges or landscapes you encounter on your journey. For instance, denial could be
compared to a thick fog that prevents you from seeing the path ahead. Anger might be a steep, rocky incline
that’s difficult to climb. Bargaining could be a confusing crossroads where you’re not sure which way to go.
Depression might be a dark, shadowy valley, and acceptance is the moment you see the light at the end of the
tunnel.
Rejection, in this context, doesn’t fit into the landscape of this journey. It’s like a sudden cliff or a river that
doesn’t naturally occur on the path you’re following. It might be part of someone’s personal experience, but it’s
not a recognized stage in the established model of grief.
5. Correct answer:
C. Rationalization.Rationalization is a defense mechanism in which controversial behaviors or feelings are
justified and explained in a seemingly rational or logical manner to avoid the true explanation, and are made
consciously tolerable—or even admirable and superior—by plausible means. It is a form of making excuses.
Imagine you’re driving a car and you accidentally run a red light. Instead of acknowledging that you made a
mistake, you might rationalize it by saying, “Well, there were no other cars around, so it was safe,” or “I’m in a
hurry, so it’s okay this time.” In reality, the subconscious motivation might be impatience or lack of attention,
but rationalization allows you to avoid confronting these less favorable traits.
Rationalization not only prevents anxiety, it may also protect self-esteem and self-concept. When conducted in
moderation, rationalization can be an effective defense mechanism. However, when done habitually, it can
prevent growth and development, and can lead to harmful behaviors being overlooked.
6. Correct answer:
B. Conversion disorder. Conversion disorder, also known as functional neurological symptom disorder, is a
condition where patients present with physical neurological symptoms, such as weakness, numbness, or
seizures, but no neurological explanation can be found. It’s believed that these symptoms arise in response to
stressful or traumatic situations, representing an attempt to resolve the conflict psychologically.
Imagine your brain as a computer that’s been working hard, processing a lot of data. Suddenly, a particularly
complex piece of data (representing a stressful or traumatic event) comes in, and the computer can’t process it.
Instead of simply shutting down, the computer redirects the processing power into another task, like running a
screensaver. In the case of conversion disorder, the brain “redirects” the stress into physical symptoms.
Conversion disorder is a complex and poorly understood condition. It’s important to note that the symptoms are
not under the patient’s conscious control and are not considered to be feigned or intentionally produced.
7. Correct answer:
A. Beta. Beta waves are the most commonly observed waveform in an awake, alert individual who is actively
thinking or concentrating. They are high frequency (13-30 Hz), low amplitude brain waves that are typically
associated with active, busy or anxious thinking and active concentration.
To visualize this, imagine a calm sea with small, frequent waves. These waves represent the beta waves in our
brain when we are awake and actively engaged in mental activities. Just as the frequent waves on the sea surface
indicate a lot of activity, beta waves indicate a lot of mental activity.
8. Correct answer:
C. 90 minutes. During a typical night’s sleep, a person goes through several sleep cycles, each lasting
approximately 90 to 110 minutes. Each cycle includes stages of non-rapid eye movement (NREM) sleep and a
period of rapid eye movement (REM) sleep.
Imagine sleep as a journey on a circular train track. Each complete loop around the track represents a sleep
cycle. The train makes several stops along the way, which represent the different stages of sleep. The REM
sleep stage is like a special stop where the train stays a bit longer and where dreams occur. The train reaches this
stop approximately every 90 minutes.
During the first sleep cycle, the REM sleep period is relatively short, around 10 minutes. As the night
progresses, REM sleep periods get longer, with the final one lasting up to an hour.
9. Correct answer:
C. Pincer grasp reflex. The pincer grasp reflex, which involves the coordinated movement of the thumb and
index finger to hold an object, is not present at birth. This is a more complex motor skill that typically develops
around 9-10 months of age.
Imagine a baby’s motor skills as a building under construction. At birth, the building’s foundation and first few
floors (representing basic reflexes and motor skills) are already built. However, the upper floors (representing
more complex skills like the pincer grasp) are still under construction. As the baby grows and develops,
construction progresses, and these upper floors are gradually completed.
The development of the pincer grasp is a significant milestone in a baby’s life because it allows them to feed
themselves and explore their environment in a more detailed way. It’s like giving the baby a set of tools to
interact more effectively with the world around them.
10. Correct answer:
C. Typically seen in toddlers aged 12 to 24 months.Parallel play is a form of play in which children play
adjacent to each other, but do not try to influence one another’s behavior. Children usually play alone during
parallel play but are interested in what other children are doing. This is an important stage in a child’s social
development.
Imagine two toddlers as two ships sailing in the sea. During parallel play, the ships are sailing in the same
direction and can see each other, but they are not interacting or influencing each other’s course. They are aware
of each other’s presence, but they are doing their own thing.
Parallel play allows children to enjoy the company of their peers without the complexities of interaction. It’s
like a stepping stone towards more complex social interactions that come later in development, such as
associative play and cooperative play.
11. Correct answer:
C. Utilizing compensation to address weaknesses. Compensation is a psychological defense mechanism where
people overachieve in one area to compensate for failures or inadequacies in another. It’s a way of covering up a
perceived weakness by emphasizing a strength or a trait that one considers more desirable.
Imagine a soccer player who isn’t very good at scoring goals. To compensate for this weakness, the player
might focus on becoming excellent at passing the ball or defending, areas where they feel more competent or
confident. This way, they can still contribute significantly to their team and feel valuable, despite their difficulty
with scoring goals.
Compensation can be a healthy defense mechanism if it leads to development of skills and doesn’t cause distress
or harm. However, it can be unhealthy if it leads to an imbalance in the person’s life or if it’s used to cover up a
problem that needs to be addressed directly.
12. Correct answer:
A. Experiencing a moist mouth. A moist or wet mouth is not typically associated with anxiety. In fact, the
opposite is often true. Anxiety and stress can activate the body’s “fight or flight” response, which can lead to dry
mouth, as the body diverts resources away from non-essential functions like saliva production to more
immediate needs.
Imagine being in a desert, where water is scarce. In this situation, you would want to conserve water for the
most essential functions, like maintaining your body temperature and vital organ function. Similarly, when
you’re anxious, your body conserves resources for dealing with the perceived threat, which can lead to a dry
mouth.
13. Correct answer:
A. Experiencing narcolepsy. Narcolepsy is a neurological disorder that affects the control of sleep and
wakefulness. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable
episodes of falling asleep during the daytime. These sudden sleep attacks may occur during any type of activity
at any time of the day.
In a typical sleep cycle, a person enters the early stages of sleep, followed by deeper sleep stages and ultimately
(after about 90 minutes) REM sleep. For people suffering from narcolepsy, REM sleep occurs almost
immediately in the sleep cycle, as well as periodically during the waking hours. It is in REM sleep that we can
experience dreams and muscle paralysis — which explains some of the symptoms of narcolepsy.
14. Correct answer:
D. Having difficulties related to autotopagnosia. Autotopagnosia, also known as autotopagnosia, is a condition
where a person is unable to comprehend the orientation of different parts of their body. This means they struggle
to identify or acknowledge their own body parts, such as their hand or foot, and their spatial relationships. This
condition is usually due to damage to the parietal lobe of the brain, which is responsible for spatial sense and
navigation.
Think of it like being lost in a city without a map or GPS. You know where you want to go, but you can’t figure
out which direction to take or how far you need to go. Similarly, a person with autotopagnosia knows they have
a hand or foot, but they can’t figure out where it is in relation to the rest of their body.
15. Correct answer:
D. Feeling the urge to urinate. Panic disorder is characterized by recurrent, unexpected panic attacks. Panic
attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath,
numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs
within minutes and typically lasts for about 20 to 30 minutes.
While the urge to urinate can be a symptom of anxiety, it is not typically associated with panic disorder. This
symptom is more commonly associated with conditions affecting the urinary system, such as urinary tract
infections or overactive bladder syndrome.
It’s like having a faulty alarm system in a building that goes off at the slightest hint of trouble, even when
there’s no real danger.
16. Correct answer:
A. Experiencing the stage of integrity vs. despair. According to Erik Erikson’s theory of psychosocial
development, a 70-year-old adult would be in the stage of integrity vs. despair. This is the final stage of life,
typically beginning at retirement and continuing until death. During this stage, individuals reflect on the life
they have lived and come to terms with it.
If they look back on a life well-lived, they feel a sense of integrity and satisfaction. It’s like reading a good book
and feeling content when you reach the end, even if there were some difficult chapters.
However, if they look back with regret and a sense of missed opportunities, they may feel despair. This is akin
to looking back on a journey and regretting the paths not taken or the sights not seen.
17. Correct answer:
C. Engaging in the stage of generativity vs. stagnation. According to Erik Erikson’s theory of psychosocial
development, a 60-year-old adult would typically be in the stage of generativity vs. stagnation. This stage
generally occurs between the ages of 40 and 65. During this period, adults strive to create or nurture things that
will outlast them; often this takes the form of parenting or mentoring, but it can also involve other forms of
creative output and productivity. Generativity is the sense of contribution to future generations, while stagnation
is the feeling of being unproductive or uninvolved in the world.
Think of it like gardening. A person in the generativity stage is like a gardener who plants seeds and nurtures
them to grow, taking satisfaction in knowing that these plants will continue to live and bloom even after they’re
gone. On the other hand, someone experiencing stagnation might feel like a gardener who’s stopped tending to
their garden, leading to a sense of dissatisfaction as they see the garden wither and fail to thrive.
18. Correct answer:
B. Going through the stage of intimacy vs. isolation. According to Erik Erikson’s theory of psychosocial
development, a 20-year-old adult would typically be in the stage of intimacy vs. isolation. This stage generally
occurs during early adulthood, from around 20 to 40 years of age. During this period, the main focus is on
forming intimate, loving relationships with other people. Success in this stage will lead to the virtue of love. If
young adults can form intimate relationships and get through this stage, they can avoid feeling isolated and
lonely.
Imagine this stage as a team-building exercise. The individual is like a team member trying to form strong,
supportive relationships with their peers. If they succeed, they feel a sense of camaraderie and belonging
(intimacy). If they fail, they may feel like an outsider, disconnected and alone (isolation).
19. Correct answer:
A. Experiencing brainwave activity in the Theta frequency range. During light sleep, which includes the first
two stages of the sleep cycle, the brain primarily exhibits Theta wave activity. Theta waves, which have a
frequency range of about 4 to 7 Hz, are associated with reduced consciousness, relaxation, and light sleep. This
is the stage where you can be awakened easily, and if you were to wake up, you might feel like you haven’t
really been sleeping.
Think of Theta waves as the background music in a movie scene where a character is just starting to drift off to
sleep. It’s not the deep, dream-filled sleep (which would be represented by different music), but the initial,
lighter stages of sleep.
20. Correct answer:
B. Displaying neologisms. Neologisms, in the context of psychiatry, refer to made-up words or phrases that only
have meaning to the individual who uses them. This is often seen in conditions like schizophrenia or other types
of psychotic disorders. It’s like creating a new language that only the individual understands.
Think of it like inventing a new word in a game of Scrabble that only makes sense to you, but not to the other
players. It’s a word that fits your understanding of the game, but it doesn’t fit within the established rules or
language of the game.