NR 548 EXAM BANK 2024-2025, Exams of Nursing

Download NR 548 EXAM BANK 2024-2025 and more Exams Nursing in PDF only on Docsity! 1 | P a g e NR 548 EXAM BANK 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST|GUARANTEED PASS|LATEST UPDATE Match the ethical principles to the scenario it represents: Person A: "I can't believe you deal with these people every day. Schizophrenics would drive ME crazy!" PMHNP: "Actually, schizophrenia is a chronic treatable disease, much like diabetes or other physical illnesses. Clients who have mental illness deserve compassion and care." Respect for the Individual (Provision 1) Rationale: Respect for the individual affirms the worth and dignity of those with PMH disorders by advocating to overcome negative stigmas towards PMH diagnoses to ensure access to care. Match the ethical principles to the scenario it represents: The client presents to the emergency department with hallucinations and is threatening self-harm. The PMHNP signs an involuntary admission order for emergent psychiatric care. Commitment to the Healthcare Consumer (provision 2) Rationale: The PMHNP demonstrates a commitment to the healthcare consumer by balancing the client's human rights with safety, including coercive measures when the client was unable to maintain their own safety. Match the ethical principles to the scenario it represents: The PMHNP is sharing sexually explicit memes with a client that she saw earlier today in a group session. Advocacy for the Healthcare Consumer (provision 3) This is an unethical scenario. The PMHNP recognizes the power differential in the therapeutic relationship and understands that any sort of sexual activity or intimacies with current clients, their close family members, guardians, or significant others is unethical. Match the ethical principles to the scenario it represents: The PMHNP has overbooked her sessions today, so she asks the RN who works in her office to conduct one of her phone therapy sessions today. 2 | P a g e Responsibility and Accountability for Practice (provision 4) Rationale: This is an unethical scenario. The PMHNP must understand the scope of other team members' practice in order to delegate appropriately. Conducting a counseling session is outside of the RN's scope of practice. Match the ethical principles to the scenario it represents: The PMHNP takes time for daily meditation to improve mindfulness and ease stress. Duties to Self and Others (provision 5) Rationale: The PMHNP is committed to practicing self-care, managing stress, and maintaining supportive relationships to meet personal needs outside of therapeutic relationships. Match the ethical principles to the scenario it represents: A PMHNP discovers her colleague is diverting scheduled medications to self-medicate anxiety. The PMHNP reports the concerns to the colleague's supervisor. Contributions to Healthcare Environments (provision 6) Rationale: The PMHNP recognizes signs/symptoms of psychiatric disorders in the workplace reporting peer observations to leadership. The PMHNP helps address problems faced by colleagues that impact client safety or violate public trust, including substance abuse. Match the ethical principles to the scenario it represents: The PMHNP gives a presentation at a national conference on best practices in depression treatment. Advancement of the Nursing Profession (provision 7) Rationale: The PMHNP contributes to advancing the profession through practice, education, administration, and knowledge development. Match the ethical principles to the scenario it represents: The PMHNP is a member of the ANA and NAMI and regularly participates in workgroups that seek to expand access to care for healthcare consumers with PMH disorders. Collaboration to meet health needs (provision 8) Rationale: The PMHNP promotes community, national, and international efforts to meet health needs through collaboration with other healthcare professionals to promote prevention, treatment, and recovery. Match the ethical principles to the scenario it represents: A PMHNP speaks at a school board meeting about the need develop policies to expand mental health services for underserved students. Promotion of the Nursing Profession (provision 9) Rationale: The PMHNP participates in policy development and implementation that recognizes PMH 5 | P a g e provision of psychotherapy provision of psychopharmacological interventions provision of clinical supervision The Standards of Practice and Standards of Professional Performance for Psychiatric and Mental Health Nursing specify the minimum levels of acceptable performance which can legally be used to describe the standard of care that psychiatric mental health nurse practitioners (PMHNPs) must demonstrate -Each standard for the psychiatric mental health registered nurse (PMH-RN) also applies to the PMHNP role 17 standards of professional performance Guide PMHNP practice: Standard 1: Assessment Standard 2: Diagnosis Standard 3: Outcomes Identification Standard 4: Planning Standard 5: Implementation Standard 6: Evaluation Standard 7: Ethics Standard 8: Cultural Humanity Standard 9: Communication Standard 10: Professional Collaboration Standard 11: Leadership Standard 12: Education Standard 13: Evidence-Based Practice and Research Standard 14: Quality of Practice Standard 15: Professional Practice Evaluation Standard 16: Resource Utilization Standard 17: Environmental Health PMHNP standards of Practice: Standard 1 Standard 1: Assessment The PMHNP must be able to perform a comprehensive, person-centered psychiatric and mental health diagnostic evaluation, using relevant diagnostic tests and procedures. Evidence-based clinical practice guidelines inform screening and diagnostic activities when appropriate. Assessment may include a multigenerational family assessment as well as the assessment of interactions between the individual, family, community, and social systems as they relate to mental health. PMHNP standards of Practice: Standard 2 Standard 2: Diagnosis The PMHNP must be able to use data obtained during the interview, examination, and diagnostic procedures to develop standard psychiatric and substance use diagnoses. The PMHNP evaluates the effects of psychiatric disorders on recovery, quality of life, and functional status and may examine the 6 | P a g e impact of stressors, trauma, and situational crisis in the context of the family cycle. The PMHNP may assist other staff in developing competence in the diagnostic process. PMHNP standards of Practice: Standard 3 Standard 3: Outcomes Identification The PMHNP assists the PMH-RN to identify expected outcomes based on scientific evidence. Outcomes identification includes consideration of costs, clinical effectiveness, satisfaction, consistency, and continuity among providers. The PMHNP develops and applies clinical guidelines associated with positive clinical outcomes. PMHNP standards of Practice: Standard 4 Standard 4: Planning The PMHNP applies current evidence and expert clinical knowledge to the identification of assessment and diagnostic strategies and therapeutic interventions. Individualized plans of care incorporate the client's beliefs and values and may include treatment modalities such as psychopharmacology and psychodynamic, cognitive behavioral, and supportive interpersonal therapies. PMHNP standards of Practice: Standard 5 Standard 5: Implementation PMHNPs facilitate the use of system and community resources to implement the plan of care. The implementation standard incorporates coordination of care across disciplines; health teaching and health promotion; consultation; prescriptive authority and treatment; pharmacological, biological, and integrative therapies; milieu therapy, therapeutic relationships and counseling, and psychotherapy. The PMHNP functions as the single point of accountability for all medical and psychiatric services. PMHNP standards of Practice: Standard 6 Standard 6: Evaluation PMHNPs evaluate the accuracy of diagnosis and effectiveness of interventions in reaching the client's desired outcomes. Evaluation includes consideration of the impact of the plan of care on the client, family, group, community, and institutions. Results of evaluations may lead to recommendations for process, protocol, or policy changes. PMHNP standards of Practice: Standard 7 Standard 7: Ethics PMHNPs use the ANA Code of Ethics with Interpretive Statements to guide practice including informing the client of risks, benefits, and outcomes associated with care; participation in interprofessional teams to address ethical concerns; promotion of environments that support ethical care; and use of ethical principles to engage in advocacy for those with mental health problems, psychiatric disorders, and addiction services. PMHNP standards of Practice: Standard 8 Standard 8: Cultural Humanity PMHNPs engage in self-reflection to assess for personal biases when working with culturally diverse individuals, groups, and communities. They strive to cultivate curiosity about the experience and 7 | P a g e treatment desires of clients from diverse backgrounds. They promote an inclusive work environment and participate in lifelong learning to develop and reinforce working effectively and inclusively with diverse populations. PMHNP standards of Practice: Standard 9 Standard 9: Communication PMHNPs assess communication preferences of healthcare consumers, families, and colleagues. They seek to assess and improve personal communication skills, accurately conveying information, and thoroughly documenting care. They maintain communication with other members of the interprofessional and contribute their professional perspective. PMHNP standards of Practice: Standard 10 Standard 10: Professional Collaboration PMHNPs partner with other disciplines to improve care through activities that include consultation, education, research, and technological development. They model expert practice, mentor colleagues, and facilitate interprofessional processes. PMHNP standards of Practice: Standard 11 Standard 11: Leadership PMHNPs provide leadership by influencing decision-making bodies and health policy to promote person- centered, recovery-oriented mental health services, and improvement of the practice environment. They provide direction to interprofessional teams and design innovations to improve practice and health outcomes. PMHNPs model expert practice and mentor colleagues. PMHNP standards of Practice: Standard 12 Standard 12: Education PMHNPs seek current evidence to expand clinical knowledge, improve role performance, and increase understanding of professional issues. In the advanced role, they model expert practice; mentor RNs and other colleagues as appropriate; and participate in interprofessional teams that contribute to the promotion of interprofessional education, role development, advanced nursing practice, and health care. PMHNP standards of Practice: Standard 13 Standard 13: Evidence-Based Practice and Research PMHNPs contribute to nursing knowledge by conducting, appraising, or synthesizing research to improve healthcare practice. PMHNPs engage in activities that promote research and clinical inquiry, including the dissemination of research findings and the integration of current evidence into practice. PMHNP standards of Practice: Standard 14 Standard 14: Quality of Practice PMHNPs obtain and maintain professional certification at the advanced level. PMHNPs may evaluate the practice environment in relation to existing evidence, design quality improvement initiatives, and identify opportunities for the generation or use of research. 10 | P a g e In WWII, many potential military recruits deemed unfit for service due to psychiatric concerns, while many veterans experienced combat-related neuropsychiatric conditions. Laura Fitzsimmons recommended: standards of training for psychiatric nurses, which led to improved education and standards of care. National Mental Health Act (NMHA) of 1946 -psychiatric nursing was recognized as one of the four core disciplines in psychiatric care and treatment -The act increased funding for psychiatric nursing education programs and contributed to a growth in university-based nursing education. 1954 -the first graduate program in psychiatric nursing was established at Rutgers University by Hildegarde Peplau • to prepare nurse therapists. -The first advanced practice nursing role was the psychiatric-mental health clinical nurse specialist (PMHCNS) role. The Community Mental Health Centers Act of 1963 (1950s brought a transition towards deinstitutionalization in care for those with mental illnesses, which led to an increase in the number of psychiatric clients receiving care in the community rather than hospitals) -The Community Mental Health Centers Act of 1963 allowed for the expansion of the PMHCNS role into community and ambulatory settings as they helped those who had been deinstitutionalized adapt 1965 Loretta Ford, RN and Henry Silver MD introduce the nurse practitioner role. 1973 ANA first published: Standards of Psychiatric-Mental Health Nursing Practice 1980s states began to grant: prescriptive authority to advanced practice registered nurse (APRN), adding medication prescribing and management to the traditional therapy role of the psychiatric mental health (PMH) APRN. 2000s these exams were developed: Certification exams for adult and family psychiatric mental health nurse practitioner (PMHNP) developed. -These exams were retired in 2015 when psychiatric certification exams were combined to a single Psychiatric-Mental Health Nurse Practitioner (Across the Lifespan) Certification (PMHNP-BC). The 21st Century Cures Act of 2016: -resulted in the creation of the U.S. Department of Health and Human Services (HHS) Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) 11 | P a g e -group is charged with compiling a summary of advances in serious mental illness (SMI) and serious emotional disturbance (SED) research, evaluating federal programs and treatment services related to SMI and SED, and making specific recommendations to better coordinate the administration of mental health services present: Current trends in care focus on integrated treatment of those with co-occurring medical and psychiatric diagnoses and co-occurring psychiatric and substance use disorders, leading to a need to add content in advanced health assessment, pharmacology, pathophysiology, and the diagnosis of psychiatric illness to graduate psychiatric nursing curricula. -Primary care has become the point of entry to psychiatric care for many clients. -PMHNPs are helping to address the growing need for primary mental health services and mental illness prevention. -Though the number of advanced practice psychiatric nurses has increased, there are still limitations in access for many clients, which has led to disparities in mental health treatment. PMHNP scope of practice broad and includes practice in a variety of possible roles and clinical settings -Education • A master's degree, post master's certificate, or doctoral degree is required for PMH APRN practice. -Clinical Practice Settings • Crisis intervention and psychiatric emergency services • Acute inpatient care • Intermediate and long-term care • Partial hospitalization and intensive outpatient treatment (IOP) • Residential services • Community-based care • Assertive Community Treatment (ACT) -PMHNP APRN Roles • Primary care • Psychotherapy • Psychopharmacological management • Case management • Program, system, and policy development management • Psychiatric Consultation-Liaison Nursing (PCLN) • Clinical Supervision • Self-Employment -PMH APRN Specialty Areas • Integrative programs • Telehealth • Forensic mental health • Disaster psychiatric-mental health nursing match the practice setting with the correct scenario: The PMHNP is providing care to a 29-year-old client who presents with persistent sadness and hopelessness for the last two months. She is having difficulty 12 | P a g e sleeping and has a decreased appetite. This is the client's first contact with the healthcare system about her concerns. Primary Care Rationale: This is the client's initial contact with the healthcare system about her concerns match the practice setting with the correct scenario: The client has experienced depressive symptoms. The PMHNP prescribes a selective serotonin reuptake inhibitor (SSRI). Pharmacologic Intervention Rationale: The PMHNP is prescribing psychopharmacotherapy for the client match the practice setting with the correct scenario: The PMHNP provides the client with some mindfulness techniques to try at home. Psychotherapy Rationale: The PMHNP is utilizing a psychotherapeutic approach to help the client gain insight match the practice setting with the correct scenario: Two weeks after starting on the SSRI, the client begins to experience suicidal ideations and develops a plan to kill herself. A friend brings the client to the emergency room. The PMHNP meets the client at the emergency room and collaborates with the physician to coordinate care. Crisis Intervention Rationale: Suicidal ideation with a plan is a psychiatric emergency requiring immediate intervention match the practice setting with the correct scenario: The client is admitted to the psychiatric and behavioral health unit at the local hospital for a 72-hour observation where the PMHNP works with her team providing treatment. The client remains hospitalized for a week while her medications are managed. The client attends individual and group therapy sessions. Acute PMHNP Care Rationale: Acute inpatient care occurs in an intensive hospital or psychiatric facility setting match the practice setting with the correct scenario: Following hospitalization, the client returns home but commutes to a treatment center for 4 hours a day 5 days per week for ongoing therapy, medication management, and psychoeducation Partial Hospitalization/Intensive Outpatient Treatment Rationale: Partial Hospitalization/Intensive Outpatient Treatment occurs when a client receives intensive therapy on an outpatient basis, often used when a client does not require 24-hour care but still require intense treatment 15 | P a g e a feeling that you should create over the course of the diagnostic interview, a sense of rapport, trust, and warmth -most important goal of the interview process -the cooperative working relationship between the therapist and client • begins during the initial or opening phase of the interview -fundamental component of successful therapy • Without trust, adherence to treatment recommendations may be compromised • interview may not elicit the information needed to formulate an appropriate dx & plan of care without rapport & trust Brainpower Read More Creating rapport: tips -Be Yourself -Be Warm, Courteous, and Emotionally Sensitive -Actively Defuse the Strangeness of the Clinical Situation -Give Your Patient the Opening Word -Gain Your Patient's Trust by Projecting Competence How to approach threatening topics (sensitive/embarrassing material) -Normalization -Symptom Expectation -Symptom Exaggeration -Reduction of Guilt -Use Familiar Language When Asking about Behaviors Normalization Introducing Q with some type of normalizing statement -two principal ways to do this: 1. start the question by implying that the behavior is a normal or understandable response to a mood or situation • ex: Sometimes when people are very depressed, they think of hurting themselves. Has this been true for you? 2. Begin by describing another patient (or patients) who has engaged in the behavior, showing your patient that she is not alone • ex: I've talked to several patients who've said that their depression causes them to have strange experiences, like hearing voices or thinking that strangers are laughing at them. Has that been happening to you? Symptom Expectation communicate that a behavior is in some way normal or expected -Phrase your Q's to imply that you already assume the patient has engaged in some behavior and that 16 | P a g e you will not be offended by a positive response -high index of suspicion of some self-destructive activity -Ex: patient is profoundly depressed and has expressed feelings of hopelessness. You suspect suicidality, but you sense that the patient may be too ashamed to admit it. Rather than gingerly asking "Have you had any thoughts that you'd be better off dead?" you might decide to use symptom expectation. "What kinds of ways to hurt yourself have you thought about?" *reserve this technique for situations in which it seems appropriate Symptom Exaggeration suggesting a frequency of a problematic behavior that is higher than your expectation, so that the patient feels that their actual, lower frequency of the behavior will not be perceived by you as being "bad." -helpful in clarifying the severity of symptoms *reserve this technique for situations in which it seems appropriate Reduction of guilt seeks to directly reduce a patient's guilt about a specific behavior in order to discover what they have been doing -useful in obtaining a hx of domestic violence & other antisocial behavior Domestic Violence -"Have you ever been in situations where fights occurred and you were affected?" • If patient answers "yes," you can flesh out whether role was being a witness, victim, or perpetrator According to Peplau's Theory of Interpersonal Relations, establishing early rapport allows the role of the nurse to evolve from stranger to: resource person, teacher, leader, surrogate, technical expert, and counselor Establishing the Relationship -Trust is essential for a therapeutic alliance -First impressions are important -PMHNP should take time to make introductions and ensure the client is comfortable -Ask general questions to arrive at an empathic understanding of how the client feels -Listen carefully and communicate an appreciation for the client's concerns -Building a trusting relationship based on respect, kindness, and acceptance will break down barriers and allow for client needs to be the center of the plan of care -Being present and openly engaged will enhance the communication experience three phases of the psychiatric interview 1. Opening phase 2. Body of the Interview 3. Closing the Interview 17 | P a g e Opening phase -first 5-10 minutes -establish rapport & therapeutic alliance -often most important phase • establishes the foundation -begins with PMHNP asking "what brought you in to see me today?" Body of the Interview -30-40 minutes -Chief Complaint Established • additional Q's asked to elicit info r/t the complaint -ask about HPI, family hx, social/developmental hx, medical hx, psychiatric ROS -basis for dx and tx formulation Closing the Interview -5-10 minutes, final phase Should include 2 components: discussion of your assessment using patient education techniques & negotiated agreement about tx or f/u plans -wrap-up statement and inquiry about missing info that may be of value -Patient education regarding working dx & recommended plan of tx • education about meds if recommended -Homework may be assigned • especially in CBT -Return visit agreed upon Four Tasks of the Diagnostic Interview 1. Build a therapeutic alliance 2. Obtain the psychiatric database 3. Interview for diagnosis 4. Negotiate a tx plan with your patient Obtain the Psychiatric Database Also known as the psychiatric history -includes historical information relevant to the current clinical presentation • history of present illness, psychiatric history, medical history, family psychiatric history, and aspects of the social and developmental history Tricks for Improving Patient Recall -Anchor Questions to Memorable Events • major transitions (graduations and birthdays), holidays, accidents or illnesses, major purchases (a house or a car), seasonal events ("hurricane Katrina"), or public events (such as 9/11 or President Obama's election) 20 | P a g e therapeutic or nontherapeutic communication & communication technique it represents: Today we have talked about a plan for you to manage feelings of anger. Therapeutic communication technique: Summarizing therapeutic or nontherapeutic communication & communication technique it represents: You shouldn't even think about assisted suicide; it's not right. Nontherapeutic communication technique: Disapproval therapeutic or nontherapeutic communication & communication technique it represents: You seem upset about something. Therapeutic communication technique: Making an Observation therapeutic or nontherapeutic communication & communication technique it represents: No one here would intentionally lie to you. Nontherapeutic communication technique: Defensive Responses therapeutic or nontherapeutic communication & communication technique it represents: Don't worry, everything will be all right. Nontherapeutic communication technique: False Reassurance Translating emotions: Sharing observations Sharing empathy Sharing hope Sharing humor Sharing feelings Non-verbal communication: Active listening Using touch Using silence Information verification/dissemination: Providing information Clarifying Focusing Paraphrasing 21 | P a g e Validation Asking relevant questions Psychiatric Interview versus the Medical Interview most notable difference is that the psychiatric interview is the primary diagnostic tool used to identify psychiatric conditions. -Unlike the diagnostic process in physical medicine, psychiatric diagnoses are not generally established or validated by physical examinations, laboratory tests, or other diagnostic procedures • such processes may be used to rule out physical causes for psychiatric symptoms -need for privacy and confidentiality may be heightened in psychiatric interviewing due to the sensitive nature of the information shared • mental health diagnoses are associated with stigma in certain cultures • Safeguarding privacy is critical for building trust and protecting the client from adverse outcomes Preparing for the Psychiatric Interview consideration of the setting and timing of the interview, as well as the unique needs of the client. -secure a space -protect your time secure a space -Schedule the same time every week -Make your room your own in some way -Arrange the seating so that you can see a clock protect your time -Arrive Earlier than the Patient -Prevent Interruptions -Don't Overbook Patients -Leave Plenty of Time for Notes and Paperwork Psychiatric interview setting typically in either the inpatient or outpatient setting -inpatient interviews in the emergency department, psychiatric unit, or any unit in the hospital, often serving in a consultation-liaison role -Outpatient care: clinics, community mental health centers, residential care facilities, private practice, primary care, homeless shelters, or homecare • may self-refer or be referred by another provider for support, guidance, and medication management, or court-ordered therapy interview environment -comfortable, clean space to put provider & client at ease -a visible clock to monitor time -access to alarms or other safety measures -provider access to the door for safe exiting 22 | P a g e -removal of sharp objects such as scissors or letter openers -a noise-canceling device for privacy interview: Time Considerations Be on time. -Don't be late! -Schedule appointments thoughtfully to ensure promptness. Stay on time. -builds trust and communicates that respect for the client. Discuss follow-up visits in the closure phase of the interview -The timing of subsequent visits is informed by the client's unique circumstances, diagnosis and treatment, and medication regimens. Therapeutic Communication Verbal -Active Listening: listening attentively to insure understanding -Broad Openings: allow clients to take initiative -Accepting: indicate you heard the client without judgment -Clarifying: make vague topics clear -Exploring: examine topics deeper -Focusing: putting attention into a single topic -Reflecting: direct the client's thoughts and feelings back to the client -Restating: repeat the client's words in a different way to make more clear Nonverbal -Positive techniques • relaxed movements • open arm gestures • smiles • respect for personal space • eye contact • nods when clients talk can communicate agreement or understanding -negative body language • finger-pointing • crossed arms • looking at a watch Psychiatric Interview Long Form adapted from the one used by Anthony Erdmann, an attending psychiatrist at MGH. He takes notes on it while talking to patients and puts it in his chart Advantages 25 | P a g e Instead, help them evaluate possible pros and cons of potential decisions -role of PMHNP is to help guide the client in making their own decisions pitfalls: transference and countertransference two phenomena that can impact the therapeutic alliance -Transference: a client's displacement or projection of feelings or wishes towards important individuals in the client's past, such as parents, onto the therapist • not always (-), provides opportunity to bring repressed feelings to the surface, If client is reminded of someone for whom they have fond memories, may allow for a (+) experience during the initial interview. If the feelings are (-) the client may appear angry or make provocative statements -Countertransference: a therapist's conscious or unconscious reactions to a client based on the therapist's psychological needs or conflicts. • can be positive or negative Initial assessment: the psychiatric history -chief complaint -history of present illness (HPI) -psychiatric hx -medical hx -family hx -social & developmental hx Comprehensive Health History -Chief Complaint -History of Present Illness -Past Medical History -Medications and Allergies -Family History -Personal and Social History -Review of Systems chief complaint client's reason for seeking treatment or evaluation -Using the client's own words • even if improbable or nonsensical, conveys valuable information about the client's capacity for self- observation and insight. HPI history of the present illness -concise, clear, and chronological description of the chief complaint which prompted the client's visit • details what the client believes to be causing the present symptoms -guided by the mnemonic "OLDCARTS" 26 | P a g e -gather information about the timeframe of symptom onset or exacerbation, triggers or stressful life events, and recent treatment and treatment changes -nature of the symptoms, when they emerged, and how they have progressed -Documentation: • opening statement • characterization of the chief complaint in chronological order • pertinent positive symptoms • pertinent negative symptoms • other relevant info. from the hx symptom characteristics should be described in detail Obtaining the HPI Two approaches: -History of present crisis approach • Often, psychiatric crises occur over a 1- to 4-week period, so focus your initial questions on this period. • What has been happening over the past week or two that has brought you into the clinic? • Tell me about some of the stressors you've dealt with over the past couple of weeks. -History of the syndrome approach • ascertaining when the patient first remembers signs of the illness. • When did you first begin having these kinds of problems? • When was the last time you remember feeling perfectly well? PMH -past medical history includes all current and old medical problems • childhood illness • adult illness • surgical • obstetric/gynecologic • psychiatric • health maintenance -major medical illness or surgery may precipitate a psychiatric disturbance -name and dosing schedule for all currently meds to avoid risk of adverse interactions with new psychiatric prescriptions Family Hx Document info about the client's parents, grandparents, siblings, children, and grandchildren -regarding age, health, & cause of death. -Include whether they have conditions such as hypertension, coronary artery disease, stroke, diabetes, or cancer. -Many psychiatric disorders have a genetic component 27 | P a g e • info about family psych hx including tx that was successful/unsuccessful may help form dx/tx plan, can help ID those available for support, ID stresses/contributing factors to clients condition Personal and Social Hx Personal Hx: -personality and interests, sources of support, coping style, strengths, and concerns -sexual orientation and gender identification, occupation and education, relationships, safety, spirituality, and support systems -older adults/clients with diabilities: level of function and activities of daily living Social Hx: -tobacco, illicit drug, and alcohol use -sexuality & risk-taking sexual practices -Five Ps+ • Partners (gender & # of partners) • Practices (oral, vaginal, anal) • Protection from STIs • Past hx of STIs • Pregnancy plans • +Plus (assess for trauma, violence, sexual health concerns & provide support for sexual orientation and gender identity) ROS review of systems used to obtain additional info about client's CC & HPI & to uncover any additional symptoms r/t potential problems in systems unrelated to the CC -follow a head-to-toe approach with yes or no questions • follow up when there is a response that indicates an abnormality with open-ended questions -subjective • constitutional • skin • head • eyes • ears • nose/sinuses • allergies • mouth/throat • neck • breast • respiratory/cardiac • gastrointestinal • urinary • peripheral vascular • musculoskeletal 30 | P a g e you live with? -What do you do in your free time? What activities do you enjoy? Focused Questions for The Psychiatric Assessment: Medical History/Screening for General Medical Conditions -Do you have a primary care provider? -Do you have any medical illnesses? -Are you currently taking any medications or herbal supplements? -Do you have any allergies to medications? -Have you ever been hospitalized for any reason? -Have you ever had surgery? Focused Questions for The Psychiatric Assessment: History of Present Illness -How long have you been feeling this way? -Did something happen in your life that may have triggered these emotions? -How is this current situation impacting your life? Common precipitants of psychiatric syndromes -arguments with friends or relatives -rejection or abandonment -death or major illness of loved ones -anniversary of a negative event, such as a death or divorce -major medical illness or age-related deterioration in functioning -stressful events at work or school -mental health clinician going on vacation -medication noncompliance -substance abuse To assess overall functioning: ask about the three basic aspects of life: love -important relationships: family, spouse, close friends work -paid employment, school, volunteer activities, structured day activities fun -hobbies and recreational pursuits essential questions: Syndromal history How old were you when you first had these symptoms? How many episodes have you had? When was the last episode? 31 | P a g e Go CHaMP Mnemonic for tx hx: General questions Current caregivers Hospitalization history Medication history Psychotherapy history MIDAS Mnemonic to ask about medical hx: Medications Illness hx primary care Doctor Allergies Surgical hx relative risk compares the risk for people with such a family history against the risk of people in the general population, who are assigned a relative risk of 1.0. -example, relative risk of developing bipolar disorder is 25; patient's father is bipolar, she is 25 times more likely to develop bipolar disorder than the average person Mental Status Exam (MSE) -best tool for establishing a psychiatric diagnosis -combination of observations, impressions, & interpretation of client responses -Eval of patients: • appearance • behavior • speech • affect • thought process • thought content • cognition mental health "a state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" Brainpower Read More 32 | P a g e mental status -refers to emotional (feeling) and cognitive (knowing) function -functioning is inferred through assessment of an individual's behaviors: • consciousness • language • mood and affect • orientation • attention • memory • abstract reasoning • thought process • thought content • perceptions Factors that affect the interpretation of the MSE culture native language educational level literacy social factors MSE: Appearance -posture -dress -grooming -physical appearance • distinguishable markings; scars or tattoos -facial expressions level of alertness -attitudes -Self-esteem -Personal statement MSE: Behavior how the client presents themselves during the examination -eye contact -psychomotor activity • increased or decreased -movements -mannerisms -stereotypies -posturing -how the client responds to the exam 35 | P a g e *research studies have not endorsed them -SSST given to 132 normal adults, only 42% with errorless performance -325 hospitalized psychiatric pts given SSST, no diff. in performance from 50 healthy control subjects -Digit span test among 60 elderly pts with memory impairment and 44 elderly who were healthy found no difference MMSE -Mini-Mental State Exam -30-point questionnaire -measures cognitive impairment in the areas of orientation, attention, memory, language, and visual- spatial skills -method of monitoring deterioration over time -age, education, and visual or hearing impairment may impact scores • Most studies have defined poorly educated as 8 or fewer years of education—that is, no high school -sensitivity of the test is high, specificity is low Interpret a mini-cog score (Total Possible Score: 0-5): Add the 3-item recall and clock drawing scores together. Recall Score (Total Possible Score: 0-3) -1 point for each word correctly recalled Clock Drawing Score (Total Possible Score: 0-2) -2 points for normal clock (include all numbers, 1-12) -0 points for abnormal clock -must be 2 hands present (one pointing to the 11 and one pointing to 2) -hand length not scored Mini-Cog exam -streamlined dementia screen -score range is from 0-5 -obtained from adding the 3-item recall and clock drawing scores together. -A total score of 0, 1, or 2 indicates higher likelihood of clinically important cognitive impairment -A total score of 3, 4, or 5 indicates lower likelihood of dementia • does not rule out some degree of cognitive impairment. three object recall Recall of three objects after at least 2 minutes has been shown to be a useful test in diagnosing cognitive impairments -Repeat the following three words: ball, chair, purple. -Once you are satisfied that your patient has registered all three words, say: Now I want you to remember those three words, because I'm going to ask you to repeat them in a couple of minutes. -In the meantime, ask your patient general knowledge questions bout general cultural and personal 36 | P a g e information. -Then ask him to repeat the three words. -If trouble, use the following hints: • One of them is something you can play with • One is a piece of furniture. • One is a color. General Cultural Knowledge Inability to recall at least half of these items is presumptive evidence of long-term memory impairment. -Last three presidents -famous figures • George Washington, first president • Abraham Lincoln, freed the slaves • Martin Luther King, Jr., civil rights leader • Princess Diana, British princess killed in car accident • William Shakespeare, writer • Christopher Columbus, discovered America -Famous dates • When did World War II happen? (Any time in the 1930s or 1940s is adequate.) • When was John F. Kennedy assassinated? (Sometime in the 1960s.) -Lists of information • screening for dementia is the set test: patient to name as many items (up to ten) as he can recall in each of four categories: colors, animals, fruits, and towns; max of 40, score of 25 or above excludes dx of dementia Personal Knowledge memory of remote personal events -Cognitively intact patients should be able to tell you: • Current address and phone number • Names and ages of spouse, siblings, and children • Spouse's birthday, wedding anniversary, and date and place of marriage (if married) • Parents' names and birthdays (primarily for younger patients who are not married) MSE: Insight and Judgment -final components of the mental status exam -determined to be good, limited, or poor depending on the actions the client has taken, awareness of their illness, and the plans they have for the future. Insight -client's awareness of their illness or situation Judgment -ability to anticipate the consequences of their behavior and safeguard their well-being -may be measured with a standard question but should be assessed throughout the entire interview 37 | P a g e Q's to probe for degree of insight -So, why do you think you've been having these problems? -What do you think needs to happen for your life to improve? Pt's with poor insight may respond with: -I don't know. You're the doctor. -People need to stop hassling me. (A paranoid patient.) ABSATTC Mnemonic for Elements of the Mental Status Examination -All Borderline Subjects Are Tough, Troubled Characters • Appearance • Behavior • Speech • Affect • Thought process • Thought content • Cognitive examination closure -final phase of the psychiatric interview process -provides the client with a summary and findings of the interview and allows for discussion of future plans -PMHNP may provide education during this phase final step of the psychiatric interview documentation -Thorough, accurate documentation is necessary for clinical and legal purposes Closing the Interview PMHNP explains the diagnosis and treatment options to the client -offers an opportunity for the client to ask questions and give input -discussion includes recommendations for any additional psychological assessments and laboratory testing needed -education regarding recommended medications and therapies -If a need to collaborate with other providers for information or treatment, the PMHNP should seek permission from the client at this time to do so -opportunity to address any client concerns about stigma -discuss need for F/U care Which of the following should be included when providing client education about medication regimens? Select all that apply. explain how the medication targets the symptoms, specific benefits, and expected time course. identify potential side effects, duration of side effects, and adverse effects. 40 | P a g e -includes drug and alcohol use, when used, consequences of use, the recent pattern of use, last use, and treatment -also includes nicotine and caffeine usage Review of Symptoms -includes screening for present and past symptoms related to the diagnostic category -section assists in defending and confirming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5-TR) diagnosis. -go through the major diagnostic categories, indicating whether the patient met any of the criteria and excluding those that you already mentioned in the HPI and in the substance abuse section, if you have included one Family History -includes history of psychiatric disorders, substance abuse, and suicide in the client's family -provides an understanding of the client's home life, their childhood experiences, education, and relationships -genogram will suffice for family psychiatric hx Social hx At a minimum: -Where your patient was born and raised -Number of siblings -Birth order of patient and siblings -Who was present in the household during the formative years -Educational level -Work history -Marital and parenting history of patient -Typical daily activities other than work Medical History includes significant medical illnesses, hospitalizations, surgeries, seizures, head injuries with loss of consciousness, and prescribed medications and the primary care provider -may use mnemonic MIDAS -usually begin with general statement about pt's general health Mental Status Exam includes observational and direct inquiry components and requires vivid description -Describe your patient so well that a reader would be able to recognize him from your description alone Assessment -includes the diagnosis -concise and informative -A list of differential diagnoses may be included, but the initial diagnosis listed is the DSM-5 TR diagnosis. 41 | P a g e DSM-5 TR vs Diagnosis includes all diagnoses involving psychiatric, personality, or medical disorders Treatment Plan includes any diagnostic testing planned, medications, therapy, client education (dosing instructions, side effects, expected benefits, when to note efficacy), referrals, follow-up care How to Educate Your Patient -Briefly state your diagnosis -Find out what your patient knows about the disorder -Give a minilecture about the disorder, if indicated -Ask if there are any questions -Give your patient written educational materials Negotiating a Treatment Plan: Essential Concepts -Elicit the patient's agenda -Negotiate a plan that you and your patient can agree on -Help the patient implement the agreed-on plan Elicit the Patient's Agenda elicit it with a simple question, such as: How do you hope I can help you? How were you hoping that I could help you to feel better? -Sometimes patients have a pretty clear idea of what they'd like; medication, counseling, advice about something, a letter to someone -don't have a specific request or agenda; don't force the issue with these patients Negotiate a Plan treatment adherence is enhanced when the patient and practitioner agree on the nature of the problem -agree at the outset about a plan, go directly to the implementation phase -must negotiate a mutually agreed-on goal Common problematic request - patient seeks hospitalization for a problem that can be treated in an outpatient setting: What is important to keep in mind? possibility that the patient is suffering much more than originally indicated -their request for hospitalization is their way of obliquely disclosing that. -may need to reassess for SI at this point, if still satisfied that hospitalization is not indicated, discuss other options: • Day hospitalization • Respite care • Staying with a friend or relative for a while if the home situation is intolerable • Taking a few days off from work • Having the patient call you (or another clinician) for daily check-ins during a crisis period 42 | P a g e • Setting up more frequent appointments • A short course of an antianxiety medication Implementing the Agreed-On Plan likely fall into one or both of the following categories: -follow-up therapy appointment with you or someone else • highest F/U aherence: wait for F/U appt is short, referrals made to specific clinicians rather than to a clinic, specific appt made at time of disposition, pt speaks directly to someone at referral clinic during evaluation session. -Medication trial • Determine how your patient will pay for medication: Some patients can't afford the copays - if so, you may be able to provide samples • Make sure pt understands the side effect profile of the medication • Simplification increases recall and compliance • Having pt repeat what you say increases recall of instructions Telepsychiatry a provider administers psychiatric care from a distance through a technological interface -a subset of telehealth -telepsychiatric services • psychiatric interview • psychiatric evaluations • therapy • medication management • consultation • client education The American Psychiatric Association (APA, 2020) supports telemedicine as a legitimate component of a mental health delivery system when telepsychiatry services: -benefit the client -maintain client autonomy, confidentiality, and privacy -when used consistent with APA medical ethics policies and established telepsychiatry laws Brainpower Read More Telepsychiatry services are provided in diverse settings, including: • private practice • outpatient clinics • schools 45 | P a g e -cognitive capacity of the client -client history and medical status -geographic distance to emergency facilities -client support system best practices related to special populations: Forensic and Correctional -follow applicable standards of consent in terms of client's legal status and rights -develop clear, site-specific protocols Telemental health Children and Adolescents: environment should facilitate the assessment by providing an adequate room size, furniture arrangement, toys, and activities that allow the youth to engage with the accompanying parent, presenter, and provider and demonstrate age-appropriate skills best practices related to special populations: Children and Adolescents follow the same guidelines presented for adults •modify care based on developmental status (motor functioning, speech and language capabilities, relatedness, and relevant regulatory issues) -include family as appropriate -Providers should consider how the presenter's involvement can affect service delivery -Appropriateness for telemental care shall consider safety of the youth, the availability of supportive adults, the mental health status of those adults, and ability of the site to respond to any urgent or emergent situations. best practices related to special populations: Geriatric -include family as clinically appropriate -adapt care for cognitive or sensory impairment best practices related to special populations: Military and Veteran -be familiar with federal and organizational structures and guidelines -be familiar with military cultural competence best practices related to special populations: Substance Use Disorder Treatment -comply with federal, state, and local regulations related to prescribing controlled substances -coordinate with on-site staff as appropriate to ensure care coordination and monitoring best practices related to special populations: Inpatient and Residential Settings -participate in administration and organizational meetings as appropriate -optimize use of site-staff for consultation and care coordination best practices related to special populations: Primary Care leverage telepsychiatry to support integrated care best practices related to special populations: Rural 46 | P a g e be aware of impact of rural environments in relation to firearm ownership, kinship, and geographic barriers to care Typically, the standard operating procedures (SOP) addresses: roles, responsibilities, licensing, client identification, and systematic quality improvement. -backup plan to address technical difficulties is frequently included standard protocols to support telepsychiatry services: (4 steps) Step 1: Confirm the name and credentials of provider and the name of the client. Step 2: Identify the location of the client. Step 3: Gather contact information for provider and client in case of interruption of session. Step 4: Provide guidance for appropriate contact between sessions and review emergency management protocols for client. -If client is in a location with clinical staff, the provider will inform staff of emergent situations -If client is in another location, the provider may identify a support person to contact for potential emergencies. -If the client requires emergency intervention in the community setting, the provider must coordinate with local emergency staff. Telehealthcare the use of telecommunications technology to remove time and distance barriers from the delivery of health care services and related health care activities -Traditionally, the use of telehealth and tele-mental health care was designed to meet the needs of rural populations and geographic areas with identified shortages of specialty health care professionals Forensic Mental Health Care Any cross between the criminal justice system and psychiatric nursing can be considered forensic mental health -64% of U.S. inmates have mental health concerns or disorders -15% to 20% of inmates in jails and prisons suffer from serious mental illness -Over 90% of federal inmates with mental health conditions are without access to mental health treatment Informed Consent Local, state, and national laws regarding verbal or written consent shall be followed -If written consent is required, then electronic signatures, assuming these are allowed in the relevant jurisdiction, may be used -The provider shall document the provision of consent in the medical record Clinically unsupervised settings 47 | P a g e -Providers should discuss the importance of having consistency in where the patient is located for sessions -knowing a patient's location at the time of care, as it impacts emergency management and local available resources • As patients change locations, providers shall be aware of the impact of location on emergency management protocols (police, emergency rooms, crisis teams) -provider should consider the use of a "Patient Support Person" (PSP) as clinically indicated • a family, friend or community member selected by the patient who could be called upon for support in the case of an emergency If a patient and/or a PSP will not cooperate in his or her own emergency management: providers shall be prepared to work with local emergency personnel in case the patient needs emergency services and/or involuntary hospitalization. Care Coordination With consent from the patient and in accordance with privacy guidelines, telemental health providers should arrange for appropriate and regular communication with other professionals and organizations involved in the care of the patient. TECHNICAL CONSIDERATIONS: VIDEOCONFERENCING PLATFORM REQUIREMENTS should select video conferencing applications that have the appropriate verification, confidentiality, and security parameters necessary to be properly utilized for this purpose -event of a technology breakdown, causing a disruption of the session, the professional shall have a backup plan in place (telephone access) -services at a bandwidth and with sufficient resolutions to ensure the quality of the image and/or audio received is appropriate to the services being delivered TECHNICAL CONSIDERATIONS: security issues -policies and procedures in place to ensure the physical security of telehealth equipment and the electronic security of data -Organizations shall ensure compliance with all relevant safety laws, regulations, and codes for technology and technical safety -HIPAA and state privacy requirements shall be followed at all times to protect patient privacy -mental health and substance use disorder services are afforded a higher degree of patients' rights as well as organizational responsibilities (e.g., need for specific consent from patients to release information around substance use) telemental health PHYSICAL LOCATION/ROOM REQUIREMENTS -both locations shall be considered a patient examination room regardless of a room's intended use -Providers shall ensure privacy so clinical discussion cannot be overheard by others outside of the room -patient and provider cameras should be placed at the same elevation as the eyes with the face clearly visible to the other person -features of the physical environment for both shall be adjusted so the physical space, to the degree possible, maximizes lighting, comfort and ambiance 50 | P a g e Rationale: HIPAA in no way prevents health care providers from listening to family members or other caregivers who may have concerns about the health. John's mother recently had a stroke and is in the neuro intensive care unit (ICU). With his mother out of the home, John has forgotten to take his medications for over a week. He begins to experience hallucinations and paranoia. At his appointment with the PMHNP, he threatens to harm his sister. To whom should the PMHNP disclose this information (select all that apply): -John's sister -John's mother's nurse in the neuro ICU -Law enforcement near the sister's home -A social worker from the Board of Developmental Disabilities who has been working with the family -John's sister -Law enforcement near the sister's home -A social worker from the Board of Developmental Disabilities who has been working with the family Rationale: The Privacy Rule permits a health care provider to disclose necessary information about a client to law enforcement, family members of the client, or other persons when the provider believes the client presents a serious and imminent threat to self or others. Specifically, when a health care provider believes in good faith that such a warning is necessary to prevent or lessen a serious and imminent threat to the health or safety of the client or others, the Privacy Rule allows the provider, consistent with applicable law and standards of ethical conduct, to alert those persons whom the provider believes are reasonably able to prevent or lessen the threat. Informed Consent for care and treatment is a fundamental ethical and legal principle -respects the client's autonomy in medical decision-making -Clients have the right to receive information and ask questions about recommended treatments so they can make decisions about their care that are consistent with their beliefs, values, and goals of treatment -Clients have the right to knowledge about their treatment under "reasonable practitioner" or "reasonable person" standards under U. S. law. -may change over time and in different circumstances • is an ongoing process Steps to Obtaining Informed Consent -Assess client ability to understand medical information & tx options & to make a voluntary decision -Present relevant information with accuracy and sensitivity, Should include information about: • Diagnosis • Nature and purpose of treatment options • Benefits, risks, and burdens of all treatment options, including forgoing treatment -Document informed consent conversation in the medical record, including all consent forms 51 | P a g e Informed Consent: Documentation Documentation of the discussion to obtain informed consent should include: -treatment plans with risks and benefits identified -reasonable alternatives with risks and benefits identified -assessment of client understanding of the discussion *must demonstrate that the client participated in the decision-making process and that the client was not coerced into treatment Exceptions to Informed Consent: -client incapacitation -life-threatening emergencies -voluntary waived consent -client unable to make decisions and has no designated decision-maker -involuntary treatment A client who is alert and oriented declines the PMHNP's treatment recommendation for an antipsychotic in a non-emergent situation: Informed consent required Exception to informed consent Informed consent required Rationale: The client has the capacity to consent and the situation is not emergent. The ethic of autonomy provides for the client to refuse treatment options. An agitated, hallucinating client with a diagnosis of schizophrenia and no designated decision-maker threatens to shoot his neighbors. The client acts out violently towards the security guard in the emergency department. The PMHNP orders haloperidol and lorazepam for the client. Informed consent required Exception to informed consent Exception to informed consent Rationale: The client does not have the capacity to provide consent. A very anxious client is seeking treatment for anxiety symptoms. When the PMHNP begins to explain the treatment options, the client says she is too anxious to hear them and asks that the PMHNP select the best option. Informed consent required Exception to informed consent 52 | P a g e Exception to informed consent Rationale: clients may choose to waive their right to informed consent. A client with depression is unhappy about the performance of the anti-depressant that has been prescribed and would like to discuss alternate treatment options with the PMHNP. Informed consent required Exception to informed consent Informed consent required Rationale: Clients have a right to information about treatment options with associated risks and benefits. ______________________, or __________________, are treated differently than other types of mental health information and receive special protections under HIPAA Psychotherapy notes, or process notes -HIPAA Privacy Rule requires that clients provide authorization, using a HIPAA-compliant authorization form, before the disclosure of the notes for any reason -Providers are not required to provide their psychotherapy notes to the client. psychotherapy notes definition "notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record" Must the PMHNP release a client's medical record to a client's insurer? Yes Must the PMHNP release psychotherapy notes to the client? No Must the PMHNP release medical records to the court with a subpoena? Yes with client authorization Must the PMHNP release medical records to the client? Yes Must the PMHNP release psychotherapy notes to another provider? No Types of development the PMHNP should consider include: 55 | P a g e basic trust in caregivers is not developed in early life, it can impact the creation of trusting relationships later. Which theory would the PMHNP most need to consider when conducting a psychiatric interview in the following situations? A 4-year-old is struggling to understand what she has seen on television about civil protests. Hierarchy of Needs Theory Psychosocial Development Theory Cognitive development Theory Cognitive development Theory Rationale: According to Piaget, children in early childhood do not have the cognitive ability to understand abstract concepts, such as justice. Special Considerations: Children -Legislation regarding minors and informed consent is based on state law • be familiar with the req in state of practice • Children under 17 typically cannot provide informed consent -Parents must give permission for tx in most circumstances, exceptions: • under 18 and married • serving in the military • able to provide financial independence • mother of a child (married or not) -A parent may not be allowed to access info. in the following circumstances: • info. is contained in the therapist's psychotherapy notes • parent not designated as the child's personal representative • parent voluntarily agrees that info can be kept confidential • provider has a reasonable belief that abuse or neglect exists or parent is a danger to the child • provider believes it is not in the child's best interest to treat the parent as the child's representative Interviewing children and adolescents -PMHNP may need to speak with family members separately from the child to gain additional information about the child's mental health concern -Family issues and family dynamics often play a role in the child's or adolescent's psychiatric disorder -Common topics to cover in an adolescent interview include: • interests • school and activities • drug and alcohol use • sexual activity • conduct problems 56 | P a g e In which of these situations would it be appropriate to share a child or adolescent's protected health information with a parent? A 12-year-old who has designated the parent to be the personal representative in a state allowing adolescents to consent to their treatment. Appropriate Inappropriate Appropriate Rationale: In states where consent to treat is required and the child has indicated that the parent should be the personal representative, it would be appropriate to share the information so long as the PMHNP does not suspect abuse, neglect, or that sharing would not be in the child's best interests. In which of these situations would it be appropriate to share a child or adolescent's protected health information with a parent? A 17-year-old on active duty in the Navy. Appropriate Inappropriate Inappropriate Rationale: Under most state laws, an adolescent serving in the military would be considered emancipated, therefore, the parent would not have the right to view the records without the adolescent's permission. In which of these situations would it be appropriate to share a child or adolescent's protected health information with a parent? A parent requesting to see the therapist's psychotherapy notes from sessions with a 6-year-old child. Appropriate Inappropriate Inappropriate Rationale: Parents and clients do not have a right to view a therapist's private psychotherapy notes. Special Considerations: Older Adults When conducting a psychiatric interview with an older adult, the PMHNP must consider the following: -developmental issues of older adulthood -generational perspectives and beliefs -comorbid physical illness -polypharmacy -cognitive or sensory impairments -history of physical/mental disorders 57 | P a g e Sociocultural factors that may influence the experience and expression of health and of psychological problems in later life gender race ethnicity socioeconomic status sexual orientation disability status urban/rural residence Older adults: changes that impact cognitive functioning -Sensory deficits, especially vision and hearing -Physical health -Poverty -Medications -Active use of information processing strategies -Lifestyle factors -Neurodegenerative conditions Stereotypes about Older Adults may include: Older adults have dementia Older adults have high rates of mental illness such as depression Older adults are not productive in the workplace Older adults are ill and frail Older adults are socially isolated Older adults have no interest in sex/intimacy Older adults are stubborn and inflexible Older adults are "cute" or "childlike" Family Educational Rights and Privacy Act (FERPA) A federal law that governs student confidentiality in schools. -requires that schools not divulge, reveal or share any personally identifiable information about a student or his/her family, unless it is with another school employee who needs the information to work with the student.