Meeting the Needs of Clients with Psychiatric Disorders, Exams of Nursing

Download Meeting the Needs of Clients with Psychiatric Disorders and more Exams Nursing in PDF only on Docsity! Addressing Higher-Level Needs and Treatment Choices in Psychiatric Care Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice Understanding Mental Illness and Mental Health Assessing Mental Health and Illness: The nurse should assess that the client's daily functioning is not impaired when experiencing occasional feelings of sadness due to the loss of a pet. This does not indicate the presence of mental illness. The nurse should determine that the client is at risk for mental illness when maladaptive responses to stress are coupled with interference in daily functioning. Reactions to stress can vary between individuals, even in identical twins, due to factors such as environmental influences and temperament. Receptiveness to Psychiatric Treatment: Clients of Jewish culture and female clients are more likely to be receptive to psychiatric treatment compared to other demographic groups. Defense Mechanisms: Defense mechanisms can be appropriate responses to stress and do not necessarily need to be eliminated. The nurse should expect that a client using the defense mechanism of displacement would criticize a coworker after being confronted by the boss. The nurse should identify that a fourth-grade boy teasing a girl in his class is using the defense mechanism of reaction formation. Concepts of Neurosis and Psychosis: Clients experiencing neurosis feel helpless to change their situation, are aware of their distress, and are aware that their behaviors are maladaptive, but are unaware of the psychological causes. Clients experiencing psychosis experience little distress due to their lack of awareness of reality. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Stages of Grief: The nurse should evaluate that a client is in the acceptance stage of grief when they can focus on the reality of the loss and its meaning in relation to life. Maslow's Hierarchy of Needs: The client who possesses a feeling of self-fulfillment and realizes their full potential has achieved self-actualization, the highest level on Maslow's hierarchy of needs. The nurse should immediately intervene when a client exhibits aggressive behavior toward another client, as safety and security are considered lower-level needs that must be fulfilled before other higher- level needs can be met. DSM-5 Definition of Mental Disorder: The new DSM-5 definition of a mental disorder is a health condition characterized by significant dysfunction in an individual's cognitions or behaviors that reflects a disturbance in the psychological, biological, or developmental process underlying mental functioning. Assessing Anxiety Symptoms The nurse should assess that the following symptoms may indicate anxiety in a client: - Fidgeting - Laughing inappropriately - Nail biting Biological Implications Anxiety and Grief Other indicators of more serious anxiety are restlessness, difficulty concentrating, muscle tension, and sleep disturbance. Anxiety is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. Grief is a subjective state of emotional, physical, and social responses to the loss of a valued entity. Biological Factors in Depression Medications only address biological factors. Environmental and interpersonal factors must also be considered. The limbic system is largely responsible for one's emotional state. This system is often called the "emotional brain" and is associated with feelings, sexuality, and social behavior. The sympathetic nervous system plays a major role during stressful situations, preparing the body for the fight-or-flight response. Circadian rhythms may influence a variety of regulatory functions, including the sleep-wake cycle, regulation of body temperature, and patterns of activity. 14. 15. 16. 17. 18. 19. 20. 1. 2. 3. 4. Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager's policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager's policy preserve? ANS: 2. Autonomy Rationale: The unit manager's policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions. Which is an example of an intentional tort? ANS: 2. A nurse physically places an irritating client in four-point restraints. Rationale: A tort, which can be intentional or unintentional, is a violation of civil law in which an individual has been wronged. A nurse who intentionally physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort. An involuntarily committed client is verbally abusive to the staff, repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? ANS: 4. Continue professional attempts to establish a positive working relationship with the client. Rationale: The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed. Which statement should a nurse identify as correct regarding a client's right to refuse treatment? ANS: 4. Professionals can override treatment refusal by an actively suicidal or homicidal client. Rationale: The nurse should understand that health-care professionals could override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be in danger or a danger to others. This situation should be treated as an emergency, and treatment may be performed without informed consent. Which potential client should a nurse identify as a candidate for involuntarily commitment? ANS: 2. The client threatening to commit suicide Rationale: The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is in danger and needs emergency treatment. A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client's wishes? ANS: 3. A client physically attacks another client after being confronted in group therapy. Rationale: The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making informed choices. 4. 5. 6. 7. 8. 9. The client's refusal to accept treatment can be challenged, because the client is endangering the safety of others. A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? ANS: 1. The nurse refuses to give any information to the caller, citing rules of confidentiality. Rationale: The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent. A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? ANS: 1. Autonomy Rationale: The nurse should provide the information to support the client's autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent. An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which ethical principle should a nurse determine has been violated based on these actions? ANS: 4. Justice Rationale: The nurse should determine that the ethical principle of justice has been violated by the physician's actions. The principle of justice requires that individuals should be treated equally, regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief. Which situation reflects violation of the ethical principle of veracity? ANS: 3. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. Rationale: The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to one's duty to always be truthful and not intentionally deceive or mislead clients. A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? ANS: 3. The client incorrectly reports his or her spouse's name, date, and time of day. Rationale: The nurse should question the validity of informed consent when the client incorrectly reports the spouse's name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices. A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? ANS: 1. 10. 11. 12. 13. 14. 15. Allow the client to decline the medication and document the decision. Rationale: It is ethically appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client's right to refuse treatment should be upheld, unless the refusal puts the client or others in harm's way. Which situation exemplifies both assault and battery? ANS: 2. The nurse threatens to tie down the client and then does so, against the client's wishes. Rationale: The nurse in this situation has committed both the acts of assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent. A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? ANS: 2. The client is placed in a locked unit. Rationale: Placing the confused and wandering client in a locked unit is the least restrictive alternative, as it allows the client to move around freely within a secure environment, rather than being placed in seclusion or physically restrained. Least-Restrictive Alternative for Client Monitoring Rationale for Ankle Bracelet Monitoring The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified. The least-restrictive alternative for this client would be monitoring by an ankle bracelet. Violation of HIPAA by Nurse Revealing Client's Psychiatric Admission The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client. Criteria for Involuntary Commitment Conditions Enabling Involuntary Commitment The physician could consider involuntary commitment when a client is: Dangerous to others Gravely disabled and unable to meet basic needs 16. 17. • • • • • • • Side Effects of Clomipramine (Anafranil) Anticipated Side Effects Patients taking clomipramine should be monitored for side effects such as orthostatic hypotension and constipation, which are related to the medication's alpha-1 blockade and cholinergic blockade, respectively. Dietary Restrictions with Monoamine Oxidase Inhibitors (MAOIs) Importance of Tyramine-Free Diet Patients taking MAOIs, such as phenelzine (Nardil), must be instructed to restrict their intake of foods high in tyramine, such as liver, to prevent a hypertensive crisis. Prioritizing Patient Complaints with MAOI Therapy Hypertensive Crisis Warning Signs If a patient taking an MAOI, such as tranylcypromine (Parnate), reports a headache after consuming caffeinated beverages, this should be the priority concern, as it may be a sign of a potentially life-threatening hypertensive crisis. Factors Influencing SSRI Prescription Advantages of SSRIs The good side-effect profile of SSRIs, such as sertraline (Zoloft), is likely the most important factor in the physician's decision to prescribe them for a patient with major depression. Lithium Therapy and Dietary Salt Intake Importance of Maintaining Sodium Intake Patients on lithium therapy must be instructed that changing their dietary salt intake can affect lithium levels, as reducing salt can result in lithium toxicity. • • • • • Benzodiazepine Withdrawal Concerns Difficulty of Withdrawal with Short-Acting Benzodiazepines Shorter-acting benzodiazepines, such as alprazolam (Xanax), are more difficult to taper and can potentially cause more problems with withdrawal compared to longer-acting benzodiazepines. Precautions with Benzodiazepine Use Avoiding Alcohol Patients taking benzodiazepines must be advised to avoid alcohol, as the combination can be potentially fatal. Contraindications to Lithium Therapy Lithium and Pregnancy Lithium is contraindicated during pregnancy due to its teratogenic effects. Timing of SSRI Administration Preventing Insomnia SSRIs are often administered at breakfast and midday to prevent insomnia, as CNS stimulants may cause insomnia if given late in the day. Management of Lithium Toxicity Priority Nursing Action If a patient receiving lithium exhibits symptoms of toxicity, such as coarse hand tremor, diarrhea, vomiting, lethargy, and mild confusion, the priority nursing action is to hold the lithium, obtain a stat lithium level, and notify the physician. Elaboration of the Given Text Cogentin and Lithium Toxicity Cogentin (benztropine) is inappropriate as the symptoms described are not extrapyramidal side effects (EPS). The nurse should not suggest that the symptoms will resolve over time. • • • • • • Minimizing salt intake would worsen lithium toxicity, as this could increase the serum lithium level. Rapid Cycling Bipolar Disorder and Lithium Therapy A patient with rapid cycling bipolar disorder is not responding well to lithium therapy. The appropriate response based on knowledge of current therapy would be: "Another drug, valproic acid, is proving effective for rapid cycling." Valproic acid is a first-line agent for the treatment of bipolar disorder, particularly effective in cases of rapid cycling. Generalized Anxiety Disorder and Lorazepam (Ativan) The statement that suggests the patient understands the purpose of the lorazepam (Ativan) medication is: "I can talk with my therapist more easily after my medication takes effect." This patient recognizes the therapeutic effects of the medication in assisting her to work effectively with the therapist. Chlorpromazine (Thorazine) and Pseudoparkinsonism A patient has been taking chlorpromazine (Thorazine) for the past 2 weeks and is experiencing drooling, hand tremors, and a shuffling gait. The nurse would correctly attribute these behaviors to pseudoparkinsonism, which is associated with dopamine blockade. Valproate Therapy and Gastrointestinal Side Effects For a patient reporting gastrointestinal side effects related to valproate therapy, the nurse will request a histamine-2 antagonist, such as famotidine (Pepcid), as this can help alleviate the indigestion, heartburn, and nausea. Lithium Toxicity and Serum Lithium Level With a serum lithium level of 1.9 mEq/L, the nurse should immediately assess the patient for signs and symptoms of lithium toxicity. Restricting sodium and fluid intake would raise the serum lithium level, and transferring the patient to the ICU may not be necessary without a clinical assessment. Typical Antipsychotic Drug Therapy and Schizophrenia To evaluate outcomes for a patient with schizophrenia receiving typical antipsychotic drug therapy, the nurse would look for improvement in positive symptoms, such as hallucinations and delusions. Negative symptoms and cognitive functioning tend to show less improvement with typical antipsychotic medications. • • • • • • • • • • • • • Disturbed Body Image Related to Major Depressive Disorder Elaboration The client is experiencing a disturbed body image related to a major depressive disorder, as evidenced by a mood rating of 2/10. This indicates that the client is struggling with negative perceptions and feelings about their physical appearance and self-worth, which is likely exacerbated by the symptoms of depression. The disturbed body image can manifest in various ways, such as the client engaging in negative self-talk, avoiding mirrors or social situations, or experiencing a distorted view of their physical attributes. This disturbance in self-perception can further contribute to the client's overall mental health challenges and impact their ability to engage in self-care and daily activities. Examples/Evidence The text does not provide any specific examples or evidence related to the client's disturbed body image. However, it is common for individuals with major depressive disorder to experience negative body image and low self- esteem as a result of the cognitive and emotional disturbances associated with the condition. Risk for Disturbed Self-Concept Related to Hopelessness Elaboration The client is also at risk for a disturbed self-concept related to feelings of hopelessness, as evidenced by a previous suicide attempt. This suggests that the client may have a negative or distorted view of themselves, their abilities, and their overall sense of self-worth, which can lead to a heightened risk of self-harm or suicidal behavior. The risk for a disturbed self-concept can be characterized by the client's perceived inability to cope with their current situation, a lack of belief in their own potential for positive change, and a sense of helplessness or despair. These feelings can further contribute to the client's overall mental health challenges and impair their ability to engage in effective self-care and coping strategies. Examples/Evidence The text does not provide any specific examples or evidence related to the client's risk for a disturbed self-concept. However, a history of a suicide attempt is a significant indicator of the client's struggle with hopelessness and a negative self-perception. Nursing Diagnoses and Outcomes The text suggests that the nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome of listing personal strengths by the end of the first day. This indicates that the nurse should focus on interventions that aim to improve the client's self-esteem and self-perception, such as encouraging the client to identify and acknowledge their positive qualities and achievements. Additionally, the text mentions that the self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written. This suggests that the nurse should carefully consider the appropriate wording and formulation of the nursing diagnoses to accurately reflect the client's needs and guide the development of specific, measurable, and achievable outcomes. Psychological Testing and the Interdisciplinary Team Consulting the Clinical Psychologist When a nurse needs to obtain psychological testing for a client, the appropriate member of the interdisciplinary team to consult is the clinical psychologist. Clinical psychologists are trained to administer, interpret, and evaluate psychological tests, which can assist in the diagnostic process. The Interdisciplinary Treatment Team in Psychiatry The typical members of the interdisciplinary treatment team in psychiatry include: Psychiatrist Psychiatric nurse Psychiatric social worker Psychologist Occupational therapist Recreational therapist Art therapist Mental health technician Chaplain Music therapist Psychodramatist Dietitian Respiratory therapists and hospital volunteers are not typically included in the psychiatric interdisciplinary treatment team. • • • • • • • • • • • • Milieu Therapy and the Therapeutic Community Promoting a Therapeutic Community Conditions that promote a therapeutic community include: Assigning unit responsibilities according to client capabilities Establishing a democratic form of government Conditions that do not promote a therapeutic community include: Unlimited free time for personal reflection A flexible schedule determined by client needs The individual being the sole focus of therapy Defining Milieu Therapy Milieu therapy is the scientific structuring of the environment to effect behavioral changes and improve the psychological health and functioning of the individual. The goal of milieu therapy is to manipulate the environment so that all aspects of the client's hospital experience are considered therapeutic. Group Therapy and Leadership Styles Leadership Styles in Group Therapy Laissez-faire leadership style: The nurse sits silently and allows the group to stray from the assigned topic, demonstrating a hands-off approach. Democratic leadership style: The nurse encourages clients to present unit problems and discuss possible solutions, promoting group decision- making. Autocratic leadership style: The nurse mandates decisions without consulting the group, demonstrating a directive approach. Yalom's Curative Group Factors Imparting of information: Group members share knowledge, advice, and suggestions. Instillation of hope: Group members observe the progress of others and begin to believe their own problems can be resolved. Altruism: Group members provide assistance and support to each other, promoting self-growth. Universality: Group members realize they are not alone in their problems, thoughts, and feelings. • • • • • • • • 1. 2. 3. 4. Group Development and Leadership The nurse should be familiar with the different phases of group development and the corresponding leadership expectations: Orientation Phase: The leader promotes an environment of trust, ensures that rules do not interfere with goal fulfillment, and establishes the importance of confidentiality. Working Phase: The leader helps to resolve conflicts, fosters cohesiveness, and ensures that members do not deviate from the intended task. Termination Phase: The leader encourages members to provide feedback to each other, review goals, and discuss outcomes. Definition of a Group A group is a collection of individuals whose association is founded on shared commonalities of interest, values, norms, or purpose. Recovery Model The Recovery Model in Mental Illness The recovery model is a framework for understanding and supporting the process of recovery from mental illness and substance use disorders. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as "a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential." Guiding Principles of the Recovery Model According to SAMHSA, the guiding principles of the recovery model include: Recovery emerges from hope: Recovery is catalyzed by the belief that one's life and future can improve. Recovery is person-driven: Individuals have primary control over decisions about their own care. Recovery occurs via many pathways: There are multiple routes to achieving recovery, and individuals may choose different paths. Recovery is holistic: It encompasses an individual's physical, mental, emotional, social, and spiritual well-being. Recovery is supported by peers and allies: Relationships and social networks play a crucial role in the recovery process. Recovery is supported through relationship and social networks: Supportive relationships and community involvement are essential. Recovery is culturally based and influenced: Cultural beliefs and traditions can shape the recovery experience. 1. 2. 3. 1. 2. 3. 4. 5. 6. 7. Recovery is supported by addressing trauma: Addressing past trauma is often an important aspect of recovery. Recovery involves individual, family, and community strengths and responsibility: Recovery is a shared responsibility involving the individual, their support system, and the broader community. Recovery is based on respect: Individuals in recovery must be treated with dignity and respect. Dimensions of Recovery SAMHSA identifies four key dimensions that support a life in recovery: Health: Overcoming or managing one's disease(s) or symptoms and making informed, healthy choices that support physical and emotional well-being. Home: Having a stable and safe place to live. Purpose: Engaging in meaningful daily activities and having the independence, income, and resources to participate in society. Community: Having relationships and social networks that provide support, friendship, love, and hope. The Tidal Model of Recovery The Tidal Model is another recovery-oriented framework developed by Barker and Buchanan-Barker. It is based on 10 essential values or "Tidal Commitments": Value the Voice Respect the Language Develop Genuine Curiosity Become the Apprentice Use the Available Toolkit Craft the Step Beyond Give the Gift of Time Reveal Personal Wisdom Know that Change Is Constant Be Transparent The Role of the Nurse in Recovery Nurses play a crucial role in supporting clients' recovery by: Maintaining a calm and empathetic demeanor Clearly communicating expectations and consequences Setting appropriate limits on behavior Protecting client confidentiality and treating clients with respect Involving clients in their own care planning and decision-making Connecting clients with peer support and community resources By adhering to the principles of the recovery model, nurses can empower clients to take an active role in their own healing and wellness. 8. 9. 10. 1. 2. 3. 4. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. • • • • • • Wellness Recovery Action Plan (WRAP) and Psychological Recovery Model WRAP Model The Wellness Recovery Action Plan (WRAP) is a step-wise process through which an individual can monitor and manage distressing symptoms that occur in daily life. The six steps of the WRAP model are: Develop a Wellness Toolbox Daily Maintenance List Triggers Early Warning Signs Things Are Breaking Down or Getting Worse Crisis Planning In step 6 (Crisis Planning), when the client can no longer care for themselves, make independent decisions, or keep themselves safe, caregivers take an active role and implement the plan that the client has previously developed. All other steps require the client to be functionally capable. Psychological Recovery Model Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model: Moratorium: This stage is identified by dark despair and confusion, where it seems that life is on hold. Awareness: In this stage, the individual comes to a realization that a possibility for recovery exists. Preparation: The individual begins to actively take control of their life. Rebuilding: The individual mobilizes personal and external resources. Growth: The individual feels a sense of optimism and hope of a rewarding future. Skills that have been nurtured in the previous stages are applied with confidence, and the individual strives for higher levels of well-being. SAMHSA's Dimensions of Recovery The Substance Abuse and Mental Health Services Administration (SAMHSA) has described four major dimensions that support a life of recovery: Health Home Purpose Community 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 1. 2. 3. 4. system is a vital sociological aspect that is greatly affected when a patient has this dual diagnosis, which is crucial for relapse prevention. Intravenous Drug Abuse and Infections Injecting drug users have one of the highest rates of hepatitis B virus (HBV) among all risk groups and account for at least half of all new hepatitis C virus (HCV) cases. Screening the patient for HBV demonstrates the nurse's understanding of the severity of the problem and the relationship between confirmed intravenous drug abuse and specific infections. Questioning Alcohol Consumption Patterns Peripheral nerve deterioration in both hands and feet is a result of chronic alcohol intake. This assessment data would bring into question a patient's statement that they only have a few drinks on special occasions, as peripheral neuropathy occurs in about 10% of alcoholics after years of heavy drinking. Reporting Suspected Impaired Practice When a nurse suspects a staff member of providing patient care while being impaired by alcohol or drugs, the priority intervention is to report the staff member's suspicious behavior to the nursing supervisor on duty. This is a professional obligation to ensure patient safety. Substance Use Disorder in Older Adults The most common form of drug abuse among older adults is the misuse of prescription medications. Asking the patient to identify all the medications, both prescribed and over-the-counter, that they regularly take demonstrates the nurse's understanding of this primary form of substance use disorder in this population. Substance Abuse and Delirium Ingesting large amounts of caffeine can lead to the development of delirium. Determining the amount of caffeine the patient ingested in the last 24 hours demonstrates the nurse's understanding of the relationship between substance abuse and the development of symptoms characteristic of delirium. Alcohol Intoxication and Withdrawal The course of alcohol intoxication is usually self-limiting to approximately 24 hours, after which withdrawal symptoms can occur for a time period unique to each patient. Medication interventions for a patient experiencing alcohol intoxication should be based on the presence of withdrawal symptoms. Antabuse Reaction When a patient recently discharged from an alcohol rehabilitation program is brought to the hospital in a state of prostration with severe throbbing headache, tachycardia, a beet-red face, dyspnea, and continuous vomiting, the nurse should suspect that the patient is reacting to disulfiram (Antabuse), a commonly prescribed alcohol deterrent drug in recovering alcoholic treatment. Intravenous Drug Use and Fever Intravenous drug users are at risk for subacute bacterial endocarditis and other circulatory compromise created by foreign substances introduced during the process of intravenous use. When assessing a patient exhibiting symptoms of a systemic infection, including a fever of unknown origin, the most appropriate question is "Are you an intravenous drug user?" Anabolic Steroid Abuse and Mood Swings For all individuals abusing anabolic steroids, extreme mood swings occur, and these may be accompanied by violent behaviors. Observing a teenage patient throwing a chair when told it was time to turn off the television supports the suspicion of anabolic steroid abuse. Genetic Influence on Alcoholism Problems with alcohol increase with the number of relatives with alcoholism. The nurse's best response to a patient's wife who is concerned about the possibility that their children may develop alcoholism is that the risk for developing alcoholism is increased if there is a family history of alcoholism. Relapse and Recovery in Alcoholism Sobriety is the goal of complete abstention from drugs, alcohol, and addictive behaviors. Sobriety often involves several attempts, and many patients relapse 9 or 10 times before achieving and sustaining sobriety. This information is the basis for the physical and emotional support provided by the nurse when a patient relapses and is hospitalized for alcohol detox treatment. Neurocognitive Disorders (NCDs) Facilitating Communication and Providing Assistive Devices The most appropriate intervention in the seventh stage of Alzheimer's disease (AD) is to promote the client's dignity by providing comfort, safety, and self-care measures. This stage is characterized by severe cognitive decline, in which the client is unable to recognize family members and is most commonly bedfast and aphasic. Reasons for the Proliferation of NCDs The proliferation of NCDs has occurred because more people now survive into the high-risk period for neurocognitive disorders, which is middle age and beyond. Donepezil (Aricept) and its Mechanism of Action The appropriate nursing response to the client's spouse's inquiry about how donepezil (Aricept) works is that this medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease. Differentiating Symptoms between NCDs and Mood Disorders The symptom that differentiates clients diagnosed with NCDs from clients diagnosed with mood disorders is impaired memory. Neurocognitive disorder is classified in the DSM-5 as either mild or major, with the distinction primarily being one of severity of symptomatology. Nursing Interventions for a Client with AD The most appropriate nursing intervention for a client with AD who exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration is to schedule structured daily routines. This will reduce frustration and thereby reduce verbal aggression. Questioning the Diagnosis of AD The nurse should question the diagnosis of AD if the client's symptoms develop suddenly, as AD does not typically develop in this manner. The onset of AD symptoms is slow and insidious, and the disease is generally progressive and deteriorating. Priority Nursing Intervention for a Client with AD The priority nursing intervention for a client with AD who has impairments of memory and judgment and is incapable of performing activities of daily living is to assist with bathing and toileting. This client requires assistance in these areas to ensure health and safety. Nursing Priorities for a Client with Major NCD Exhibiting Behavioral Problems The priority nursing action for a client with major NCD exhibiting behavioral problems is to first medicate the client to avoid injury to self or others. It is important to assess environmental triggers and potential unmet needs in Substitution Therapy for Alcohol Withdrawal The administration of a central nervous system (CNS) depressant, such as chlordiazepoxide, during alcohol withdrawal is referred to as "substitution therapy." This type of therapy is used to decrease the intensity of withdrawal symptoms and reduce the life-threatening effects of alcohol withdrawal. Discharge Planning and Alcoholics Anonymous (AA) Attending 90 AA Meetings in 90 Days The most appropriate client outcome for a nurse to discuss during discharge teaching for a client with chronic alcohol addiction is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcohol addiction, and this level of engagement is recommended to support long-term recovery. Alcohol Withdrawal Symptoms Reporting High Blood Pressure When a client with a history of heavy alcohol use is brought to the emergency department, the nurse should prioritize reporting high blood pressure as a symptom of alcohol withdrawal syndrome. Complications associated with alcohol withdrawal syndrome, such as alcohol withdrawal delirium, can progress rapidly and require prompt medical intervention. Progress in Substance Use Disorder Recovery Acknowledging Consequences A client statement that demonstrates positive progress toward recovery from a substance use disorder is: "Taking those pills got out of control. It cost me my job, marriage, and children." This indicates that the client is taking responsibility for the consequences of their substance use, which is a key step in the recovery process. Assessing for Alcohol Withdrawal Symptoms Evaluating for Fine Tremors When a nurse holds the hand of a client who is withdrawing from alcohol, the rationale is to assess for fine tremors, which are a common symptom of alcohol withdrawal. Other withdrawal symptoms include headache, insomnia, hallucinations, depression, anxiety, and elevated vital signs. Nursing Diagnoses for Alcohol Withdrawal Imbalanced Nutrition The priority nursing diagnosis for a client presenting with symptoms of alcohol withdrawal and malnutrition is "imbalanced nutrition: less than body requirements." The nurse should consult a dietitian, restrict sodium intake, and provide small, frequent feedings to address the client's nutritional needs. Addressing Codependency in Substance Use Disorders Confronting Enabling Behaviors The appropriate nursing response to a client's wife who is making excuses for her alcoholic husband's work absences is: "Your husband needs to deal with the consequences of his drinking." This confronts the enabling behavior and encourages the wife to take responsibility for her own actions rather than assuming responsibility for her husband's behaviors. Medication Management for Benzodiazepine Withdrawal Chlordiazepoxide and Phenytoin For a client with a history of benzodiazepine withdrawal delirium, the nurse should anticipate that the physician will order chlordiazepoxide (Librium) and phenytoin (Dilantin). Chlordiazepoxide is a long-acting benzodiazepine used for substitution therapy, and phenytoin is an anticonvulsant used to prevent seizures during withdrawal. Promoting Success in Substance Use Disorder Recovery Correlating Problems with Alcohol Use To promote success in the recovery process, the nurse should expect the client to initially accomplish the outcome of correlating life problems with alcohol use. Acceptance of the problem is the first step in the recovery process. Blood Alcohol Levels and Intoxication Minimum Level for Intoxication The nurse should expect that a blood alcohol level of 100 mg/dL is the minimum level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL, and death has been reported at levels ranging from 400 to 700 mg/dL. Nonpharmacological Interventions for Substance Use Disorders Avoiding Sedative-Hypnotics The nurse should encourage a client with a substance use disorder and major depressive episode to first try nonpharmacological interventions for sleep disturbances, as sedative-hypnotics are potentially addictive and their effectiveness may be compromised due to tolerance. Medications for Gambling Disorder Lithium and Sertraline The medications that the nurse would provide information about to a client with a gambling disorder are lithium carbonate (Lithobid) and sertraline (Zoloft). These medications, specifically selective serotonin reuptake inhibitors (SSRIs) and mood stabilizers, have been shown to be effective in the treatment of pathological gambling. Differentiating Pathological and Non- Pathological Gambling Neurotransmitter Abnormalities The key difference between pathological and non-pathological gambling is that pathological gamblers have abnormal levels of neurotransmitters, such as serotonin, noradrenaline, and dopamine, which is not the case for non- pathological gamblers. Impaired Nursing Practice Reporting Impairment to the Board of Nursing A statement indicating that further instruction is needed is: "All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice." In reality, state boards of nursing require factual documentation of impairment and may allow impaired nurses to Peer support is provided through regular contact with the impaired nurse One of the program goals is to intervene early in order to reduce hazards to clients The supervisor should not mention that a verbal contract detailing the method of treatment will be initiated prior to the program, as a written contract is typically used. Additionally, the duration of peer support is usually two years, not one year. Codependency When assessing a client suffering from codependency, the nursing counselor should look for the following data to further support the assessment: The client has a long history of focusing thoughts and behaviors on other people The client is a people pleaser and does almost anything to gain approval The client can achieve a sense of control only through fulfilling the needs of others The counselor should not rely on the client exhibiting helpless behaviors but actually feeling very competent, as this is not a characteristic of codependency. Additionally, the client's experience of overindulgent and overprotective parents as a child is a common factor in the development of codependency. Stages of Codependency Recovery The correct order of the stages of the codependency recovery process according to Cermak is: The Core Issues Stage The Reintegration Stage The Survival Stage The Reidentification Stage In the core issues stage, the individual must face the fact that relationships cannot be managed by force or will. In the reintegration stage, control is achieved through self-discipline and self-confidence. In the survival stage, the codependent must begin to let go of denial. In the reidentification stage, the individual begins to glimpse their true selves. • • • • • 1. 2. 3. 4. Schizophrenia Spectrum Disorders: Comprehensive Nursing Considerations Risk for Violence and Injury Clients with schizophrenia spectrum disorders may be at risk for violence directed towards others. Risk factors include aggressive body language, verbal aggression, catatonic excitement, and rage reactions. Clients may also be at risk for self-injury, which should be prioritized by the nurse. Nursing Interventions for Acute Agitation The most appropriate nursing intervention for an acutely agitated paranoid client is to provide personal space to respect the client's boundaries. This can help reduce anxiety and the risk for violence. Other inappropriate interventions include providing neon lights and soft music, maintaining continual eye contact, and using therapeutic touch. Establishing Trust in the Nurse-Client Relationship Nurses can enhance the establishment of a trusting relationship by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior. Identifying and Responding to Symptoms Clients may exhibit positive symptoms, such as paranoid delusions, neologisms, and echolalia, or negative symptoms, such as flat affect, anhedonia, and anergia. The nurse has a legal responsibility to warn the psychiatrist if a client is exhibiting command hallucinations that could lead to harm. Managing Medication Side Effects Extrapyramidal symptoms, such as restlessness and muscle rigidity, may warrant the administration of an anticholinergic medication like benztropine. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication. Clients taking antipsychotics and beta-blockers are at risk for orthostatic hypotension and should be instructed to rise slowly when changing positions. Agranulocytosis, a serious side effect of clozapine, requires immediate intervention if the client experiences a sore throat, fever, and malaise. • • • • • • • • • • • • Differential Diagnosis Considerations Brief psychotic disorder is characterized by sudden onset of psychotic symptoms lasting at least 1 day but less than 1 month. Substance-induced psychotic disorder is distinguished from brief psychotic disorder by the presence of catatonic features. Comprehensive Rehabilitation Approach An effective rehabilitative program for clients with schizophrenia spectrum disorders should include group therapy, medication management, supportive family therapy, and social skills training. Schizophrenia Spectrum Disorders Risperidone (Risperdal) and Symptom Management Risperidone is an atypical antipsychotic medication effective in the treatment of positive symptoms of schizophrenia, such as: Somatic delusions Gustatory hallucinations Clang associations Risperidone is used in the maintenance therapy of schizophrenia to prevent exacerbation of symptoms. Prolactin Levels and Negative Symptoms Decreased levels of prolactin in clients with schizophrenia spectrum disorders may lead to the following negative symptoms: Apathy Social withdrawal Anhedonia Catatonic Disorder Associated with Medical Conditions The diagnosis of catatonic disorder associated with another medical condition is made when the client's medical history, physical examination, or laboratory findings provide evidence that the symptoms are directly attributed to the following conditions: Hyperthyroidism Hypothyroidism Hyperadrenalism Hypoadrenalism • • • • • • • • • • • • • • • • • Mini-Mental Status Exam Rationale A mini-mental status exam should be performed to rule out neurocognitive disorder. The client may be experiencing reversible dementia, which can occur as a result of depression. Amitriptyline (Elavil) Intervention Rationale The healthcare provider should provide no more than a 1-week supply of amitriptyline, with refills contingent on follow-up appointments. Antidepressants, which are central nervous system depressants, can be used to commit suicide. Limiting the amount of medication and monitoring the client weekly would be appropriate interventions to address the client's risk for suicide. Serotonin Syndrome Rationale The nurse should suspect that the client is suffering from serotonin syndrome, possibly caused by ingesting two different SSRIs (sertraline and paroxetine). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor. Combining MAOI and SSRI Rationale The nurse should explain to the client that combining an MAOI and fluvoxamine, an SSRI, can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches, with occasional photophobia, sensations of choking, palpitations, and a feeling of dread. Depression Assessment Scales Rationale One of the most widely used clinician-administered scales is the Hamilton Depression Rating Scale. • • • • • • • • • • The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that measures involuntary movements associated with tardive dyskinesia. Postpartum Mood Disorders Rationale Symptoms of postpartum depression are associated with fatigue, irritability, loss of appetite, sleep disturbances, loss of libido, and expressions of great concern about her inability to care for her baby. Both postpartum melancholia and postpartum depressive psychosis are characterized by a lack of interest in, or rejection of, the baby, or a morbid fear that the baby may be harmed. Cognitive Distortions Rationale Examples of automatic thoughts in depression include personalizing, all or nothing thinking, and discounting positives. Transdermal Selegiline (Emsam) Rationale Dietary restrictions are not recommended for the 6 mg/24 hr dosage of selegiline transdermal system. Dietary modifications are recommended, however, at the 9 mg/24 hr and 12 mg/24 hr dosages. Imipramine (Tofranil) Rationale Smoking increases the metabolism of tricyclics, requiring an adjustment in dosage to achieve the therapeutic effect. Dysthymic Disorder Rationale The essential feature of dysthymia is a chronically depressed mood, which can have an early or late onset. • • • • • • • • Seasonal Affective Disorder Rationale A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November). Phenelzine (Nardil) Discharge Teaching Rationale The client needs to be aware of the potential interactions between phenelzine and other medications, as well as the need to avoid foods high in tyramine and the risk of abrupt discontinuation. Disruptive Mood Dysregulation Disorder (DMDD) Rationale DMDD is characterized by severe recurrent temper outbursts, which are manifested both behaviorally and/or verbally. Symptoms of DMDD must be present for 12 months to meet diagnostic criteria. Affective Symptoms in Depression Mild Depression Affective symptoms include sadness, dejection, feeling downhearted, having the blues. Symptoms at the mild level of depression are identified by those associated with uncomplicated grieving. Moderate Depression (Dysthymic Disorder) Affective symptoms include feelings of sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self- esteem; difficulty experiencing pleasure in activities. Severe Depression (Major Depressive Episode) Affective symptoms include feelings of total despair, hopelessness, and worthlessness; flat (unchanging) affect, appearing devoid of emotional tone; prevalent feelings of nothingness and emptiness; apathy; loneliness; sadness; inability to feel pleasure. • • • • • • • • Challenges in Diagnosing Bipolar Disorder in Children and Adolescents It is difficult to diagnose a child or adolescent with bipolar disorder for the following reasons: Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. Children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder. Mania Mania is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition. Specific Phobias Clients with specific phobias have a panic level of fear that is overwhelming and unreasonable when exposed to the specific object or situation. Social Anxiety Disorder vs. Schizoid Personality Disorder (SPD) Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Panic Disorder vs. Generalized Anxiety Disorder (GAD) The key difference between panic disorder and GAD is that clients with panic disorder experience depersonalization, which is a common symptom absent in GAD. Treatment for Generalized Anxiety Disorder (GAD) The most appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients diagnosed with GAD and does not have the dependency concerns of other anxiolytics. 1. 2. Obsessive-Compulsive Disorder (OCD) vs. Obsessive- Compulsive Personality Disorder Clients diagnosed with OCD experience both obsessions and compulsions, whereas clients with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, but do not experience obsessions and compulsions. Panic Disorder and Nursing Diagnosis When a client exhibits signs and symptoms of a panic disorder, the priority nursing diagnosis should be anxiety. Medications for Panic Disorder Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder. It can be used on an as-needed basis to reduce anxiety and related symptoms. Abnormal Anxiety in the Elderly Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning. If an elderly client's anxiety meets these criteria, the nurse should recommend seeking psychiatric help. Nursing Interventions for Panic Attacks If a client is experiencing a severe panic attack, the nurse can meet the client's physiological need by having the client breathe into a paper bag. This can help address the hyperventilation that may occur during periods of extreme anxiety. Trauma- and Stressor-Related Disorders Nursing Diagnosis and Interventions Non-adherence R/T test taking This is not the appropriate nursing diagnosis for the given scenario. The student is unable to take a final exam due to severe test anxiety, not due to non-adherence. Ineffective role performance R/T helplessness This is not the appropriate nursing diagnosis. The scenario does not indicate that the student is experiencing ineffective role performance or helplessness. Altered coping R/T anxiety 1. 2. 3. 4. 5. This is the appropriate nursing diagnosis for the given scenario. The student is relieving stress by attending a movie instead of studying, indicating altered coping mechanisms due to anxiety. The nurse should assist the student in implementing interventions to improve healthy coping skills and reduce anxiety. Systematic Desensitization Using your imagination, we will attempt to achieve a state of relaxation. This is not an accurate explanation of systematic desensitization. Systematic desensitization involves gradually exposing the client to increasingly anxiety-provoking situations, not just using imagination. Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response. This is not an accurate explanation of systematic desensitization. The goal is to gradually increase the client's tolerance to anxiety, not to substitute relaxation for anxiety. Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety. This is the correct explanation of systematic desensitization. The nurse should explain to the client that they will go through a series of increasingly anxiety-provoking steps to gradually increase their tolerance to anxiety. In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate. This is not an accurate explanation of systematic desensitization. Systematic desensitization involves a gradual, step-by-step approach, not a single intense exposure. Obsessive-Compulsive Disorder (OCD) The client will refrain from ritualistic behaviors during daylight hours. This is not an appropriate initial client outcome for a client with OCD. Refraining from rituals during the day may be a long-term goal, but an initial outcome should focus on more gradual changes. The client will wake early enough to complete rituals prior to breakfast. This is an appropriate initial client outcome. The nurse should provide a structured schedule and begin to gradually limit the time allowed for rituals. 6. 7. 1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3. 4. The dose of Luvox is low because of the side effect of daytime drowsiness. This is not accurate. The high dose of Luvox (fluvoxamine) is not due to the side effect of daytime drowsiness. The dose of this selective serotonin reuptake inhibitor (SSRI) is outside the therapeutic range and needs to be questioned. This is not accurate. The high dose of Luvox (300 mg daily) is within the therapeutic range for the treatment of OCD. Alprazolam (Xanax) Prescription Considerations History of alcohol use disorder This history should cause the nurse to question the prescription of alprazolam, as it increases the risk of physiological dependence and abuse in clients with a history of substance use disorder. History of personality disorder This history does not necessarily require the nurse to question the alprazolam prescription, as personality disorders alone do not increase the risk of abuse. History of schizophrenia This history does not require the nurse to question the alprazolam prescription, as schizophrenia is not a contraindication for benzodiazepine use. History of hypertension This history does not require the nurse to question the alprazolam prescription, as hypertension alone does not increase the risk of abuse. Nursing Diagnosis for a Child Experiencing Grief Complicated grieving This is not the appropriate nursing diagnosis. The child's behavior of hair-pulling indicates ineffective coping, not complicated grieving. Altered family processes This is not the appropriate nursing diagnosis. The scenario does not indicate any issues with the family's functioning. Ineffective coping 5. 6. 7. 8. 1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3. 4. 5. This is the appropriate nursing diagnosis. The child is coping with the anxiety generated by viewing her deceased aunt by pulling out her hair, indicating ineffective coping mechanisms. Body image disturbance This is not the appropriate nursing diagnosis. The child's behavior is not related to body image disturbance. Agoraphobia Symptom Onset Onset of symptoms most commonly occurs in early adolescence and persists until midlife. This is not accurate. The onset of agoraphobia symptoms most commonly occurs in the 20s and 30s. Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years. This is the correct statement. The onset of agoraphobia symptoms most commonly occurs in the 20s and 30s and persists for many years. Onset of symptoms most commonly occurs in the 40s and 50s and persists until death. This is not accurate. The onset of agoraphobia symptoms typically occurs earlier in life, not in the 40s and 50s. Onset of symptoms most commonly occurs after the age of 60 and persists for at least 6 years. This is not accurate. Agoraphobia typically develops earlier in life, not after the age of 60. Symptoms of Generalized Anxiety Disorder (GAD) Fatigue This is a common symptom of GAD that the nurse should expect the client to exhibit. Anorexia This is not a common symptom of GAD. Clients with GAD may experience changes in appetite, but anorexia is not a typical symptom. Hyperventilation This is not a common symptom of GAD. Hyperventilation is more commonly associated with panic attacks. Insomnia 6. 7. 8. 1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3. 4. 5. 6. 7. This is a common symptom of GAD that the nurse should expect the client to exhibit. Irritability This is a common symptom of GAD that the nurse should expect the client to exhibit. Behavioral Therapies for Phobias Benzodiazepine therapy This is not a behavioral therapy for phobias. Benzodiazepines are a pharmacological treatment option. Systematic desensitization This is a commonly used behavioral therapy for phobias that the nurse should explain to the client. Imploding (flooding) This is also a commonly used behavioral therapy for phobias that the nurse should explain to the client. Assertiveness training This is not a behavioral therapy specifically for phobias. Aversion therapy This is not a commonly used behavioral therapy for phobias. Nursing Interventions for Generalized Anxiety Disorder (GAD) Encourage the client to recognize the signs of escalating anxiety. This is an appropriate nursing intervention for a client with GAD. Encourage the client to avoid any situation that causes stress. This is not an appropriate intervention, as it does not help the client overcome anxiety and some stressful situations may not be easily avoidable. Encourage the client to employ newly learned relaxation techniques. This is an appropriate nursing intervention for a client with GAD. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. 8. 9. 10. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. 2. 3. 4. 5. 6. 7. coping strategies, the presence of psychiatric illness, degree of flexibility, and level of intelligence. Treatment: Psychotherapy is the most common treatment used for AD. Anxiolytic and antidepressant medications may be prescribed as adjuncts to psychotherapy but should not be given as the first line of treatment. Post-Traumatic Stress Disorder (PTSD) Prevalence: Research shows that PTSD is more common in women than in men. Differentiation from Adjustment Disorder: PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to normal daily events. Depressive symptoms can occur in both PTSD and AD. Nursing Diagnosis: Survivor guilt is a symptom that would be addressed by the nursing diagnosis of complicated grieving. Treatment: Eye movement desensitization and reprocessing (EMDR) therapy has been empirically validated for the treatment of PTSD, although the exact biological mechanism by which it achieves its therapeutic effect is unknown. Nursing Interventions: Realistic goals for a client with PTSD may include obtaining adequate sleep without medication by discharge, as opposed to unrealistic goals such as having no flashbacks or experiencing a full range of emotions by discharge. Medication: Paliperidone (Invega), an antipsychotic medication, may be used to address the symptom of flashbacks in a client with PTSD. In summary, this document provides a comprehensive overview of the key concepts and distinctions between adjustment disorders and post-traumatic stress disorder, including their etiology, prevalence, clinical presentation, relevant nursing diagnoses and interventions, and treatment approaches. Somatic Symptom and Dissociative Disorders Somatic Symptom Disorder (SSD) Clients diagnosed with SSD are likely to exhibit personality disorder characteristics associated with histrionic personality disorder, such as: Self-dramatizing Attention-seeking Overly gregarious Seductive 5. 1. 2. 3. 4. 5. 6. • ◦ ◦ ◦ ◦ Differentiating SSD from Illness Anxiety Disorder (IAD): Clients with SSD experience physical symptoms in various body systems, while clients with IAD do not. Clients with SSD experience a change in the quality of self- awareness, which is not present in IAD. Clients with SSD have a perceived disturbance in body image or appearance, which is not seen in IAD. Clients with IAD only experience anxiety about the possibility of illness, without significant somatic complaints. Appropriate outcome when planning care for an inpatient client with SSD: The client will list three potential adaptive coping strategies to deal with stress by day two. Primary and secondary gains that clients with SSD (predominantly pain) may experience: Primary gain: Pain prevents attending a stressful family reunion. Secondary gain: Receives get-well cards. Illness Anxiety Disorder (IAD) From a psychoanalytical perspective, clients with IAD express personal worthlessness through physical symptoms, as physical problems are more acceptable than psychological problems. Dissociative Identity Disorder (DID) When working with a client newly diagnosed with DID stemming from severe childhood sexual abuse, the nurse should prioritize establishing trust and rapport. The dissociation in DID serves to isolate painful events so that the primary self is protected when the client is confronted with destructive behavior. The primary goal of therapy for a client with DID is to collaborate among sub-personalities to improve functioning. Dissociative Amnesia (DA) Diagnostic Criteria for Dissociative Fugue According to the DSM-5 diagnostic criteria for dissociative amnesia (DA), the essential symptom to meet the criteria for the subcategory of dissociative fugue would be: Sudden unexpected travel or bewildered wandering • ◦ ◦ ◦ ◦ • ◦ • ◦ ◦ • • • • 1. The DSM-5 states that dissociative fugue is characterized by a sudden, unexpected travel away from customary place of daily activities, or by bewildered wandering, with the inability to recall some or all of one's past. Types of Disturbance in Recall The three types of disturbance in recall identified in the DSM-5 are: Localized amnesia Selective amnesia Generalized amnesia In selective amnesia, the individual can recall only certain incidents associated with a stressful event for a specific period after the event. In the generalized type, the individual has amnesia for his or her identity and total life history. Nursing Care for Conversion Disorder When neurological tests have ruled out pathology in a client's sudden lower- extremity paralysis, the appropriate nursing care should include: Dealing with physical symptoms in a detached manner Conversion disorder involves symptoms affecting voluntary motor or sensory functioning with or without apparent impairment of consciousness, such as paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, and hallucinations. Pharmacological Treatments The correct combination of diagnoses and appropriate pharmacological treatments is: Somatic Symptom Disorder (SSD): predominantly pain; treated with venlafaxine (Effexor) Antidepressants are often used with somatic symptom disorder when the predominant symptom is pain, as they have been shown to be effective in relieving pain, independent of influences on mood. Factitious Disorder Factitious disorders involve conscious, intentional feigning of physical or psychological symptoms. Individuals with factitious disorder pretend to be ill in order to receive emotional care and support commonly associated with the role of patient. Examples include self-inflicted wounds, injection or insertion of contaminated substances, manipulating a thermometer to feign a fever, urinary tract manipulation, and surreptitious use of medications. 1. 2. 3. 1. 1. Distress regarding binge eating must be present. Factors Contributing to Excessive Weight Gain Lesions in the appetite and satiety centers in the hypothalamus may contribute to overeating and lead to obesity. Decreased insulin production in diabetes mellitus and increased cortisone production in Cushing's disease can lead to weight gain. Low levels of the neurotransmitter serotonin may play a role in compulsive eating. Definitions Anorexia nervosa includes the symptoms of gross distortion of body image, preoccupation with food, and refusal to eat. Bingeing is the episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period of time. Purging is the act of ridding the body of excessive calories, which includes self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Personality Disorders Childhood Nurturance and Independent Behaviors Childhood nurturance was provided exclusively from one source, and independent behaviors were encouraged. Childhood nurturance was provided from many sources, and independent behaviors were discouraged. The behaviors presented in the question represent symptoms of dependent personality disorder. Nurturance provided from one source and discouragement of independent behaviors can contribute to the development of this personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy. Schizoid and Avoidant Personality Disorders Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder may exhibit odd and eccentric behaviors but not to the extent of psychosis. 3. 1. 2. 3. 1. 2. 3. • • • • Nursing Diagnosis for Schizoid Personality Disorder An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are not sociable. Histrionic Personality Disorder The nurse should identify the behavior of a client who screams, "Somebody help me quick!" when looking at a slightly bleeding paper cut as characteristic of histrionic personality disorder. Individuals with this disorder tend to be self-dramatizing, attention seeking, over gregarious, and seductive. Borderline Personality Disorder The nurse should expect that a client diagnosed with borderline personality disorder may use suicidal gestures to elicit a rescue response from others. Repetitive, self-mutilating behaviors are common in borderline personality disorders that result from feelings of abandonment following separation from significant others. Obsessive-Compulsive Personality Disorder The nurse should identify that a client with obsessive-compulsive personality disorder would have a difficult time accepting changes. This disorder is characterized by inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules. Avoidant Personality Disorder The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for a compliment but would fear later rejection and humiliation. Individuals diagnosed with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations. Differentiating Social Phobia and Schizoid Personality Disorder Clients diagnosed with schizoid personality disorder exhibit a profound deficit in the ability to form personal relationships and prefer being alone to being with others, avoiding social situations, social contacts, and activities. • • • • • • • • • • • Clients diagnosed with social phobia avoid attending birthday parties, whereas clients diagnosed with schizoid personality disorder would isolate themselves on a continual basis. Obsessive-Compulsive Personality Disorder Symptoms The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules. Inpatient Admission for Self-Destructive Behaviors The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self- mutilating behaviors, and most gestures are designed to elicit a rescue response. Treatment Goals for Personality Disorders The goal of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. There are no psychotropic medications approved specifically for the treatment of personality disorders. Impulsive Behavior in Borderline Personality Disorder The client who states, "I cut myself because you are leaving me" reflects impulsive behavior that is commonly associated with borderline personality disorder. Repetitive, self-mutilating behaviors are common in clients diagnosed with borderline personality disorders that result from feelings of abandonment following separation from significant others. Nursing Diagnosis for Paranoid Personality Disorder The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T paranoid thinking. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that result in a constant threat readiness, increasing the likelihood of violent behavior. • • • • • • • • • • • efforts. These individuals can perform some activities independently and may be capable of academic skills up to a second-grade level. Autism Spectrum Disorder The most appropriate response to a parent's distress about their child's autism diagnosis is to explain that the disorder is believed to be caused by abnormalities in brain structure or function, not poor parenting. A realistic client outcome for a child with autism spectrum disorder is for the client to establish trust with at least one caregiver, as evidenced by facial responsiveness and eye contact. Attention Deficit-Hyperactivity Disorder (ADHD) The weight loss often seen in an adolescent with ADHD who begins methylphenidate (Ritalin) therapy is best explained by the pharmacological action of the medication causing a decrease in appetite. Conduct Disorder Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals are more likely to develop antisocial personality disorder in adulthood. Childhood-Onset Conduct Disorder Characteristics and Prognosis Childhood-onset conduct disorder is a more severe form of the disorder compared to the adolescent-onset type. Individuals with childhood-onset conduct disorder are likely to develop antisocial personality disorder in adulthood. These individuals are usually boys and frequently display physical aggression and have disturbed peer relationships. There is no treatment or cure for childhood-onset conduct disorder, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder. Separation Anxiety Disorder When assessing a child with separation anxiety disorder, the nurse should expect to find that the child's mother is diagnosed with an anxiety disorder. Some parents instill anxiety in their children by being overprotective or by exaggerating dangers. Research studies speculate that there is a hereditary influence in the development of separation anxiety disorder. • • • • • • • Mild Intellectual Developmental Disorder (IDD) Children with mild IDD develop academic skills up to a sixth-grade level. Individuals with mild IDD are capable of independent living, developing social skills, and have normal psychomotor skills. Moderate Intellectual Developmental Disorder (IDD) Individuals diagnosed with moderate IDD are capable of academic skills up to a second-grade level. Moderate IDD reflects an IQ range of 35 to 49. Autistic Spectrum Disorder To help a child with autistic spectrum disorder feel more secure on a psychiatric unit, the nurse should provide consistent caregivers. Children diagnosed with autistic spectrum disorder have an inability to trust, and providing consistent caregivers allows the client to develop trust and a sense of security. Interventions for Head-Banging Behavior The most appropriate intervention for head-banging behavior in a child with autistic spectrum disorder is to hold the client's head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the client's head from injury. Treatment of Tourette's Syndrome Neuroleptic (antipsychotic) medications are effective in the treatment of Tourette's syndrome. These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy. Behavioral Approach for Disruptive Behavior Disorders The nurse should reinforce positive actions to encourage repetition of desirable behaviors when caring for children diagnosed with disruptive behavior disorders. Behavior therapy is based on the concepts of classical conditioning and operant conditioning. Nursing Diagnosis for Disturbed Personal Identity An appropriate outcome for a client with severe autistic spectrum disorder and the nursing diagnosis of disturbed personal identity is for the client to name their own body parts as separate from others. • • • • • • • • • • • • • The nurse should assist the client in the recognition of separateness during self-care activities, such as dressing and feeding. Evaluating Behavior According to Developmental Norms The student's evaluation of a three-year-old child's constant motion and inability to sit still during story time is appropriate when indicating a need for the client to be evaluated according to developmental norms. The DSM-5 indicates that emotional problems exist if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning. Nursing Diagnosis for Moderate Intellectual Developmental Disorder (IDD) The appropriate nursing diagnosis associated with a client with an IQ of 47 (moderate IDD) is altered social interaction R/T non-adherence to social convention. A client with moderate IDD may also experience some limitations in speech communications. Methylphenidate (Ritalin) for ADHD The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and development. Priority Nursing Intervention for Conduct Disorder The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behavior and to intervene before violence occurs. This intervention serves to keep the client as well as others safe, which is the priority nursing concern. Decreased Effectiveness of Methylphenidate (Ritalin) The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate is a central nervous system stimulant, and tolerance can develop rapidly. Physical and psychological dependence can also occur. Symptoms of Oppositional Defiant Disorder (ODD) Arguing with authority figures for more than six months is listed by the DSM-5 as a symptom for the diagnosis of ODD. • • • • • • • • • • • • Reminiscence Therapy Student Statement Indicating Learning The student statement that indicates learning about reminiscence therapy is: "Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution." Reminiscence therapy is a therapeutic approach that involves the stimulation of life memories to help older clients work through their losses and maintain self-esteem. By encouraging the sharing of both positive and negative memories, the therapy can promote resolution and emotional processing. Rationale Reminiscence therapy is a valuable intervention for older adults, as it allows them to reflect on their life experiences and work through unresolved issues. The key aspect of this therapy is the encouragement to share both positive and negative memories, which can facilitate emotional processing and self- acceptance. Responding to Delusional Thoughts Appropriate Nursing Response When a client in a long-term care facility expresses delusional thoughts, such as believing his wife is having an affair, the appropriate nursing response is to empathize with the client and encourage him to talk about the situation. The nurse should remain nonjudgmental and help maintain the client's orientation, memory, and recognition. Rationale Clients with cognitive impairment or mental health issues may experience delusional thoughts that are not based in reality. The nurse's role is to provide a supportive and empathetic response, rather than directly challenging the delusion. By encouraging the client to discuss their concerns, the nurse can better understand the client's perspective and work to maintain their emotional well-being. Psychiatric Disorders in the Elderly Instructor Response The instructor response that gives the student accurate information is: "Major depressive disorder is most likely to be identified later in life." Depression is a common psychiatric disorder among older adults, and it can be influenced by factors such as physical illness, functional disability, cognitive impairment, and the loss of a spouse. Rationale Major depressive disorder is more likely to be diagnosed in the elderly population compared to other psychiatric disorders. This is due to the increased prevalence of risk factors for depression in older adults, such as physical health problems, cognitive decline, and social isolation. Addressing Sudden Symptoms in an Older Client Initial Nursing Intervention The initial nursing intervention for an older client attending an adult day care program who suddenly experiences dizziness, weakness, and confusion should be to advocate for a complete physical exam. Sudden onset of these symptoms could indicate a problem with the client's cardiovascular or respiratory system, and should be thoroughly assessed before attributing them to psychological causes. Rationale Sudden changes in an older adult's physical condition, such as dizziness, weakness, and confusion, should be addressed through a comprehensive medical evaluation. These symptoms may be indicative of an underlying physical health issue, and it is important to rule out any medical causes before considering psychological factors. Identifying Elder Abuse or Neglect Suspected Condition Based on the information provided, the nurse should suspect that the older client with a fractured arm, soaked in urine, and with dried fecal matter on their lower extremities is a victim of elder abuse or neglect. Indicators of elder physical abuse include bruises, fractures, burns, and other physical injuries. Neglect may be manifested as poor hygiene, unattended physical problems, or abandonment. Rationale The client's physical condition, including the fractured arm, poor hygiene, and presence of bodily waste, strongly suggests that they are experiencing elder abuse or neglect. These are clear signs that the client's caregiver is not meeting their basic needs and may be neglecting or mistreating them. Responding to Clients Experiencing Abuse Anticipated Client Response When directly asked about their injuries, the nurse should anticipate that the older, emaciated client with bruises and abrasions may deny or minimize the injuries. Older clients who are experiencing abuse may be unwilling to disclose information due to fear of retaliation, embarrassment, protectiveness toward the abuser, or a desire to avoid legal action. Rationale Clients who are victims of abuse, especially in the context of a dependent relationship with a caregiver, often feel reluctant to openly discuss or acknowledge the abuse. They may deny or downplay the severity of their injuries out of fear, shame, or a desire to protect the abuser. The nurse should be prepared for this type of response and approach the situation with sensitivity and understanding. Communicating with Clients with Alzheimer's Disease Appropriate Nursing Intervention The appropriate nursing intervention to improve communication with a client in the middle stage of Alzheimer's disease who has difficulty communicating due to cognitive deterioration is to verbalize the nurse's perception of the client's implied communication. The nurse should also keep explanations simple, use face-to-face interaction, and speak slowly without shouting. Rationale As Alzheimer's disease progresses, clients often experience difficulties with verbal communication. By verbalizing the nurse's perception of the client's implied communication, the nurse can help the client feel understood and validated, even if they are unable to express themselves clearly. Additionally, using simple language, face-to-face interaction, and a calm, slow tone can help facilitate better communication. Rationale The "rocking chair" personality type, as described by Reichard, Livson, and Peterson, represents older men who have a passive and dependent approach to aging. These individuals are often content to rely on others for support and withdraw from active engagement in life. Genetic Theory of Aging Findings Supporting Genetic Theory The findings that support the genetic theory of aging include: - The development of collagen - The development of lipofuscin - The increased frequency of cancer - The increased frequency of autoimmune disorders The genetic theory suggests that aging is an involuntarily inherited process that operates over time to alter cellular or tissue structures. Rationale The genetic theory of aging proposes that the aging process is predetermined and driven by inherent genetic factors. The development of collagen and lipofuscin, as well as the increased incidence of cancer and autoimmune disorders, are all changes that can be attributed to the genetic alterations associated with the aging process. The Aging Body and Health Conditions The development of free radicals, collagen, and lipofuscin in the aging body, as well as an increased frequency in the occurrence of cancer and autoimmune disorders, provide some evidence for the theory that error or mutation occurs at the molecular and cellular level. Additionally, the normal aging process of the endocrine system includes decreased amounts of adrenocorticotropic hormone, resulting in a less-efficient stress response. Geropsychiatry Geropsychiatry is the branch of clinical medicine specializing in the psychopathology of the elderly population. Survivors of Abuse and Neglect Physical Abuse Indicators When assessing a child who may have been physically abused, the nurse should look for the following symptom in addition to bruises and burns: the child shrinks at the approach of adults. Intimate Partner Abuse When a woman presents with a history of physical and emotional abuse in her intimate relationships, the nurse should suspect that the woman may be a victim of incest. Many women who are battered have low self-esteem and feelings of guilt, anger, fear, and shame, often due to growing up in an abusive home. Dynamics of Domestic Violence Power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession. Responding to Rape Victims When a client is brought to the emergency department after being violently raped, the nurse should remain nonjudgmental and actively listen to the client's description of the event. This provides an avenue for catharsis, which contributes to the healing process. Rape Victim Response Patterns A client who exhibits a controlled response pattern after a rape, answering questions in a monotone voice with single words, appearing calm, and exhibiting a blunt affect, is likely demonstrating a controlled response pattern. In this pattern, the client's feelings are masked or hidden. Barriers to Leaving Abusive Relationships Clients who are in abusive relationships are often paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Factors such as financial dependence, religious beliefs, and lack of support networks can also contribute to a client's decision to stay in an abusive relationship. Responding to Abused Clients When working with a client who has symptoms of domestic physical abuse, the nurse should provide information about the accessibility of safe houses for battered women. Many women feel powerless within the abusive relationship and may be staying out of fear. Behavioral Responses to Rape A survivor of rape who presents in the emergency department crying, pacing, and cursing her attacker is exhibiting an expressed response pattern. In this pattern, feelings of fear, anger, and anxiety are expressed through overt behaviors. Signs of Physical Neglect A child who is often absent from school and seems apathetic and tired may be a victim of neglect. Other indicators of neglect include stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care. Incest and Trauma Responses A client diagnosed with an eating disorder who experiences insomnia, nightmares, and panic attacks before bedtime, has never married or dated, and lives alone with a recently returned father, may have a history of childhood incest. Adult survivors of incest are at risk for developing various mental health and behavioral issues. Considerations in Domestic Abuse Care Planning When planning care for a woman who is a survivor of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported. Nursing Diagnoses for Incest Survivors Appropriate nursing diagnoses for an adult survivor of incest typically include low self-esteem and powerlessness. Adult Survivors of Incest Adult survivors of incest are at risk for developing various mental health issues, including: Post-Traumatic Stress Disorder (PTSD) Incest can lead to the development of PTSD, which is characterized by intrusive thoughts, flashbacks, nightmares, and hyperarousal. Sexual Dysfunction Incest can negatively impact an individual's sexual functioning and intimacy. Somatization Disorders Incest survivors may experience physical symptoms without a clear medical cause, such as chronic pain or gastrointestinal issues. • • • serious and persistent mental illnesses. PACT is characterized by the following: It is a type of case-management program. The PACT team provides services 24 hours a day, 7 days a week, 365 days a year. The PACT team provides highly individualized services directly to consumers. It is a multidisciplinary team approach, including members from psychiatry, social work, nursing, substance abuse, and vocational rehabilitation. Prevalence of Mental Illness among Homeless Individuals Studies have identified the most common types of mental illness among homeless individuals as: Schizophrenia Antisocial personality disorder Neurocognitive disorders (e.g., dementia) Other prevalent disorders include bipolar disorder, substance abuse and dependence, and depression. Levels of Prevention in the Public Health Model The goals of the levels of prevention in the public health model, as set forth by Gerald Caplan, progress as follows: Secondary prevention: Aimed at minimizing early symptoms of psychiatric illness and reducing the prevalence and duration of the illness. Tertiary prevention: Aimed at providing services that reduce the residual defects associated with severe and persistent mental illness. Primary prevention: Aimed at reducing the incidence of mental disorders within the population. Deinstitutionalization The deinstitutionalization movement closed state mental hospitals and caused the discharge of individuals with mental illness. This was followed by the passage of the Mental Retardation Facilities and Community Mental Health Centers Construction Act in 1963, which called for the construction of comprehensive community health centers. However, many state governments did not have the capability to match the federal funds required for the establishment of these mental health centers. 1. 2. 3. 4. 1. 2. 3. 1. 2. 3. Elaboration of the Given Text Widow Who Removed Life Support After Husband's Vegetative State This individual is at a lower risk for complicated grieving due to having a year to process the grief while her husband was in a vegetative state. The prolonged period of her husband's vegetative state allowed her to gradually accept the reality of the loss, which is an important task in the grief process according to Worden's model. The extended time frame provided an opportunity for her to work through the pain of the loss and adjust to a world without her husband, reducing the likelihood of complicated grieving. Woman with Competitive Relationship with Deceased Brother The relationship between this woman and her recently deceased brother was highly ambivalent, which increases the risk for complicated grieving according to the rationale provided. Ambivalent relationships, where there is both love and hostility towards the lost entity, can lead to unresolved feelings and a more complex grief process. The competitive nature of their relationship may have prevented the woman from fully processing the loss and accepting the reality of her brother's death. Young Couple Whose Child Died of Genetic Disorder The loss of a young person, in this case a child, is identified as a risk factor for complicated grieving. The death of a child is considered a particularly devastating loss, as it goes against the natural order of life and can be more difficult for parents to accept. The genetic nature of the child's disorder may also contribute to the complexity of the grief, as the parents may feel a sense of responsibility or guilt related to the cause of the loss. Overall, the text highlights several key risk factors for complicated grieving, including strong dependence on the lost entity, ambivalent relationships, multiple recent losses, the loss of a young person, and perceived responsibility for the loss. The elaboration provides more detailed explanations for how these factors can influence the grief process and increase the likelihood of complicated grieving. • • • • • • • • • Developmental Theories in Nursing The Symbiotic Phase The symbiotic phase is the first stage of Margaret Mahler's developmental theory, which usually occurs between 1 and 5 months of age. In this phase, the child has not yet established a clear understanding of being separate from the mother. The Separation-Individuation Phase The separation-individuation phase is the second stage of Mahler's developmental theory, in which the child establishes the understanding of being separate from the mother. The Rapprochement Phase The rapprochement phase is the third stage of Mahler's developmental theory, in which the child begins to recognize the mother as a separate individual. Peplau's Therapeutic Roles According to Peplau's interpersonal theory, a nurse who provides an abandoned child with parental guidance and praise is serving the role of a surrogate, which is a substitute for the child's parent. Psychoanalytic Theory Psychoanalytic theory, developed by Sigmund Freud, is based on the underlying concept of the structure and dynamics of personality, which includes the id, ego, and superego. Interpersonal Theory Interpersonal theory, developed by Harry Stack Sullivan, is based on the underlying concept of the effects of social processes on personality development. Erikson's Developmental Stages According to Erikson's theory, a physically healthy, 35-year-old, single client who lives with parents and receives total financial support should be assisted by the nurse to accomplish the developmental task of establishing a career, personal relationships, and societal connections. A 10-year-old child who wins a science fair competition and is chosen as a cheerleader for the basketball team is successfully accomplishing the industry versus inferiority stage of Erikson's developmental theory. • • • • • • • • • Herbal remedies are classified as dietary supplements by the Food and Drug Administration (FDA) and, therefore, they are not subject to FDA approval and lack uniform standards of quality control. Attitudes Toward Complementary and Alternative Therapies Some health insurance companies and health maintenance organizations (HMOs) are including providers of alternative therapies, such as acupuncture and massage therapy, in their networks of providers. A large number of U.S. medical schools, including Harvard, Yale, Johns Hopkins, and Georgetown Universities, now offer coursework in holistic methods. The American Medical Association encourages its members to become better informed regarding the practices and techniques of alternative or unconventional medicine. Healthy Lifestyle Guidelines The U.S. Departments of Agriculture and Health and Human Services guidelines to promote health and prevent disease include: Increase physical activity and reduce time spent in sedentary behaviors. Consume less than 10 percent of calories from saturated fatty acids. Limit alcohol consumption to one drink per day for women and two drinks per day for men. The Influence of Cultural Factors on Health and Care Northern European Americans The community health nurse should anticipate that Northern European Americans, especially those who achieve middle-class socioeconomic status, place the most value on preventative medicine and primary health care. This value is most likely related to this group's educational level and financial capability. Native Americans Many members of the Native American, Latino American, and African American subgroups value folk medicine practices. Asian American Culture The Asian American culture is difficult to classify globally because of the number of countries that identify with this culture. The Asian American 2. 1. 2. 3. 1. 2. 3. 4. culture includes peoples and descendants from Japan, China, Vietnam, the Philippines, Thailand, Cambodia, Korea, Laos, India, and the Pacific Islands. Within this culture, there are vast differences in values, religious practices, languages, and attitudes. Latin American Culture The Latin American woman's refusal to participate in an assertiveness training group may be affected by the Latin American cultural definition of the female role. Latin Americans place a high value on the family, which is male-dominated. The father usually possesses the ultimate authority. The nurse should associate the cultural belief that families are male- dominated, with clear male-female role distinctions, with the client's abusive behavior. The father in the Latin American family usually has the ultimate authority. Nursing Considerations The nurse should avoid assuming that all individuals who share a culture or ethnic group are similar. This action constitutes stereotyping and must be avoided. Within each culture, many variations and subcultures exist. Clients should be treated as individuals. To effectively care for Asian American clients, the nurse should be aware that older people in this culture maintain positions of authority. The most appropriate nursing intervention for a Native American client who refuses to talk to a physician unless a shaman is present would be to try to locate a shaman that will agree to come to the emergency department. The nurse should understand that in the Native American culture, religion, and health-care practices are often intertwined. It is characteristic of Latin American culture for a client to contact a curandero when illness is initially encountered. The curandero is the folk healer who is believed to have a gift from God for healing the sick. The nurse should expect that many Asian Americans are most likely to view mental illness as uncontrolled behavior that brings shame to the family. Western European Americans The nurse should identify that most Western European Americans are present-oriented and perceive the future as God's will. Older adults are held in positions of respect and are often cared for in the home instead of in nursing homes. Native American Clients The nurse should recognize that Native American clients might have a history of missed or late medical appointments. Many Native Americans are not ruled by the clock. The concept of time is casual and focused on the present. Arab American Clients When planning effective care for an Arab American male client, the nurse should be aware that limited touch in this culture is acceptable only between members of the same sex, that devout Muslim men may not shake hands with women, and that women are subordinate to the man, who is the head of the household. Native Americans and Asian Americans The nurse should expect that both Native Americans and Asian Americans may be difficult to assess for mood and affect. In both cultures, expressing emotions is difficult. Native Americans are encouraged to not communicate private thoughts. Asian Americans may have a reserved public demeanor and may be perceived as shy or uninterested. Northern European American Culture About half of first marriages end in divorce in this cultural group. Northern European Americans, particularly those who achieve middle-class socioeconomic status, value preventive medicine and primary health care. Punctuality and efficiency are highly valued in the culture that promoted the work ethic, and most within this cultural group tend to be future-oriented. A typical diet for many Northern European Americans is high in fats and cholesterol and low in fiber. U.S. Culture The United States, viewed as a melting pot of multiple worldwide ethnic groups, has its own unique culture that impacts the health and care of individuals. Characteristics common to the U.S. culture include: The culture values independence, self-reliance, and determining one's life. There is a strong emphasis on achievement in jobs, sports, and physical beauty. Constructive criticism is considered personally offensive. The culture favors structured and formal behaviors, speech, and relationships with others. Overconsumption of food in this culture leads to increased obesity and decreased health. • • • • • thorough physical, including a gynecological examination, to assess for any physiological causes of the client's symptoms. Symptoms and Treatment of Female Sexual Interest/ Arousal Disorder The nurse should explain to the client that female sexual interest/arousal disorder is characterized by a reduced or absent frequency or intensity of interest or pleasure in sexual activity, and that senate focus exercises are a treatment for this disorder. Psychological Effects of Sexually Transmitted Diseases (STDs) STDs can carry strong social stigma and generate feelings of hopelessness and helplessness, but antibiotics cannot cure all STDs, such as HIV. Gender Dysphoria vs. Transvestic Disorder Clients diagnosed with gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with transvestic disorder experience intense sexual arousal from dressing in the clothes of the opposite gender but are not dissatisfied with their gender. Sexual Masochistic Disorder vs. Sexual Sadistic Disorder The identifying feature of sexual masochistic disorder is recurrent and intense sexual arousal when being humiliated, beaten, bound, or otherwise made to suffer, and these activities may be performed alone or with a partner. The identifying feature of sexual sadistic disorder is the recurrent and intense sexual arousal from the physical or psychological suffering of another individual. Fetishistic Disorder vs. Frotteuristic Disorder Fetishistic disorder involves the use of nonliving objects to derive sexual excitement, whereas frotteuristic disorder involves touching and rubbing against non-consenting people to derive sexual excitement. Transvestic Disorder Definition and Characteristics Transvestic disorder involves recurrent and intense sexual arousal from dressing in the clothes of the opposite gender. This paraphilic disorder is characterized by a strong desire to wear the clothing of the opposite sex, often for the purpose of sexual gratification. Normal Sexual Development in Children The text provides the following information about normal sexual development in an 11-year-old child: The child experiments with masturbation. The child may experience homosexual play. The child shows little concern about physical attractiveness. The child is unlikely to want to undress in front of others. These characteristics are considered normal in the development of human sexuality for an 11-year-old child. Categories of Paraphilic Disorders The text discusses the following categories of paraphilic disorders and their associated behaviors: Voyeuristic disorder: Observing unsuspecting people who are naked, dressing, or engaged in sexual activity (e.g., John is arrested for peering in a neighbor's bathroom window). Frotteuristic disorder: Touching or rubbing against a non-consenting person (e.g., Peter enjoys subway rush-hour female contact that results in arousal). Fetishistic disorder: Using nonliving objects in sexual ways (e.g., Henry masturbates into his wife's silk panties). The text also mentions other categories of paraphilic disorders, such as sexual masochism disorder, sexual sadism disorder, and transvestic disorder. Medications for Erectile Disorder The text discusses the following medications that can address erectile disorder and their therapeutic actions: Phentolamine (Oraverse): Increases blood flow to the penis. Apomorphine (Apokyn): Acts directly on the dopamine receptors in the brain. Vardenafil (Levitra): Blocks the action of phosphodiesterase-5 (PDE5). Sildenafil (Viagra): Blocks the action of phosphodiesterase-5 (PDE5). Nursing Diagnoses for Gender Dysphoria The text suggests the following potential nursing diagnoses for a child diagnosed with gender dysphoria: Disturbed personal identity related to biological factors or parenting patterns that encourage culturally unacceptable behaviors for assigned gender. Impaired social interaction related to socially and culturally unacceptable behaviors. Low self-esteem related to rejection by peers. 1. 2. 3. 4. 1. 2. 3. 1. 2. 3. 4. 1. 2. 3. Definition of Sexuality The text defines sexuality as "the constitution and life of an individual relative to characteristics regarding intimacy." It reflects the totality of the person and does not relate exclusively to the sex organs or sexual behavior.