NR605 Midterm Exam Questions And Answers, Exams of Nursing

Download NR605 Midterm Exam Questions And Answers and more Exams Nursing in PDF only on Docsity!

NR605 Midterm Exam

Psychotherapy - -nonpharmacological intervention -used to tx mental health diagnoses or distress -help clients improve functioning and well-being -talk therapy -provided by psychiatrists, psychologists, social workers, marriage and family therapists, counselors, and PMHNPs -may include individual, couple, family, or group sessions -Goals: symptom reduction, improvement in functioning, relapse prevention, empowerment, achievement of collaborative goals set by the client & therapist. Methods of Collaboration - Intraprofessional Collaboration -the interaction and efforts between two disciplines with the same profession

• Potential barriers: tension, large team size, high turnover, lack of familiarity and common goals, role ambiguity, generational differences, and lack of undergraduate nursing education on intraprofessional practice. Transprofessional Collaboration -includes communication with various disciplines: physicians, physical/occupational therapy, and social services, along with others to ensure care is delivered safely
• Potential barrier: lack of training Role of PMHNPs in Psychotherapy - -unique, full-spectrum approach -may provide psychotherapy in addition to prescribing medications -providing client and family education -coordinating care and referrals as a part of the treatment plan

-provide psychotherapy in a variety of ambulatory, emergency department, inpatient, and outpatient settings Holistic Paradigm of Healing - -holistic model of care with a focus on healing -Holistic therapy respects the complexity of each unique individual

• appreciating the relationship between the client's mind, body, and spirit
• recognizing the interdependence of all parts of the human system -Foundational to healing is the relationship between the client and therapist
• Emotional connection in the relationship is critical to the success of psychotherapy
• PMHNP approaches the nurse-client relationship with acceptance, empathy, patience, and kindness to create a space for healing -psychotherapy can help the individual accept dysregulation and disharmony in the present moment
• achieves acceptance of the present, they may be able to let go of resistance, relax, and release fears Theoretical Models in Psychotherapy - Maslow's Hierarchy of Needs Health Belief Model Transtheoretical Model of Change Maslow's Hierarchy of Needs - framework for understanding client motivation -first four levels of need in the hierarchy (physiological needs, safety, love and belonging, and esteem) are sometimes referred to as deficiency needs (D-needs)
• Motivation decreases once D-needs are met -highest level of need, self-actualization, is considered a growth or being need (B-need)
• Once D-needs are met, clients can focus on self-actualization and personal growth
• As the B-need is met, motivation for further growth increases self-actualized person - is self-fulfilled

• cues to action
• self-efficacy Transtheoretical Model of Change - assumes that behavior changes take place over time and that people move through stages of decision-making to make changes to behavior -stages:
• precontemplation
• contemplation
• preparation
• action
• maintenance Nancy is a 64-year-old who is wondering if losing weight might benefit her self-esteem and self- confidence. Based on the transtheoretical model of change, which of the following actions by the PMHNP would be appropriate for Nancy if she is in the contemplation stage of change? Ask Nancy to create a list of reasons that she wants to lose weight. Refer Nancy to her primary provider to obtain medical clearance for an exercise program. Explore Nancy's anxiety and emotional responses related to be - Ask Nancy to create a list of reasons that she wants to lose weight. Rationale: Creating a list of reasons to lose weight would be appropriate for the contemplation phase. Obtaining medical clearance for exercise is a part of the preparation phase of the Transtheoretical Model of Change. Exploring emotional responses to being overweight would be appropriate for the precontemplation phase. Addressing rewards for reinforcement of behaviors would occur in the action phase.

Treatment Hierarchy Framework - therapeutic aims at the base of the model must be addressed before the client can move up the triangle Top: Stabilization Internal resources External resources Bottom: Foundational needs strategies to support resource development and stabilization: - -case management -provision of safety -stress management -management of physiological arousal -exercise -cognitive or dialectical behavioral therapy -role play Processing - involves helping clients explore the meaning of adverse life events -adapting memory, cognition, behavior, affect, and beliefs surrounding traumatic events

• achieve positive change Cultural Considerations - Culture shapes one's perceptions, attributions, emotions, and judgments in ways that are both conscious and unconscious -PMHNP must consider ethnicity, religion, race, class, cultural identity, and the cultural explanations of illness to effectively diagnose and treat mental health conditions -Outline for Cultural Formulation includes an assessment of the following categories:
• cultural identity of the individual
• cultural conceptualizations of distress

-standardized codes used to communicate services completed to Medicare and other insurance companies for reimbursement -PMHNPs can bill for stand-alone psychotherapy using psychiatry specialty codes

• if the encounter includes diagnosing and/or prescribing medications, a medical evaluation and management (E/M) base code should be used with an add-on psychotherapy procedure code Medical Evaluation and Management Codes - specific five-digit E/M code -based on the type of client, location of service, and level of service XX=20 new client office/inpatient visit XX=21 established client office/outpatient visit XX=24 consultation for office/outpatient XX=22 inpatient care Medical Decision Making - level of medical-decision-making (MDM) is rated as straightforward, low, moderate, or high -based on three components:
• number of diagnoses
• amount of data being reviewed
• risk of mortality/morbidity -The level of MDM is selected based on complexity Psychotherapy Codes - • 90832- psychotherapy duration 16-37 minutes
• 90833- psychotherapy duration 16-37 minutes used as an add on code to a E/M code
• 90834- psychotherapy 38-52 minutes
• 90836- psychotherapy duration 38 or more minutes used as an add on code to a E/M code
• 90837- psychotherapy 53 or more minutes

• 90846- family psychotherapy client not present
• 90847- family psychotherapy with client present
• 90853- group psychotherapy Lori, a 42-year-old female, presents to the office for an initial consultation. She has just experienced a breakup after a 5-year relationship and is feeling "depressed." A comprehensive initial evaluation which includes chief complaint, history or present illness, medical history, previous psychiatric history, family history and a comprehensive review of systems was completed. Psychotherapy was included in the session - 18 minutes time. provide the appropriate CPT code - 99205+ Rationale: The client is new to the practice (20) and presents with one problem which addressed 4 or more elements, had a comprehensive history and interview. No additional testing was needed, treatment was initiated (05). Psychotherapy was included in the session- 18 minutes time. Therapy goals were established and reviewed with the client. Hannibal, a 23-year-old male, is admitted to an inpatient psychiatric facility with symptoms of auditory hallucinations, paranoia, and suicidal ideations. A comprehensive initial evaluation which includes chief complaint, history or present illness, medical history, previous psychiatric history, family history and a comprehensive review of systems was completed. provide the appropriate CPT code - 99223 Rationale: The client presents for initial hospital care (22) and has a high level of medical decision- making due to an acute illness that poses a threat to life (3). Shakina, a 19-year-old transgender female, has been referred to the PMHNP from primary care. The PMHNP reviews the primary provider's note and identifies symptoms of bipolar I disorder. The PMHNP completes a comprehensive assessment and prescribes medications for the client.

• geriatrics, psychiatric emergencies, eating disorders, family therapy, or pediatrics -telehealth services or a support group Disparities in Mental Health Services - Racial, ethnic, gender, and sexual minorities -often experience poor mental health outcomes due to inaccessibility of quality mental health services, discrimination, a cultural stigma surrounding mental health care, and lack of knowledge about mental health
• To address disparities, the American Psychological Association (2022) advocates for the expansion and use of culturally and linguistically competent psychological and behavioral research and services Legal & Ethical Considerations - Provider initiated termination for cause Termination letters Court mandated treatment Process and progress notes Code of Ethics for Nurses - Respect for the Individual Commitment to the Healthcare Consumer Advocacy for the Healthcare Consumer Responsibility and Accountability for Practice Duties to Self and Others Contributions to Healthcare Environments Advancement of the Nursing Profession Collaboration to Meet Health Needs Promotion of the Nursing Profession 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. Exception to informed consent Informed consent required - 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. Exception to informed consent Informed consent required - 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.

Community violence Historical trauma Discrimination Circumstances that increase suicide risk: Societal Risk Factors - Stigma associated with help-seeking and mental illness Easy access to lethal means of suicide among people at risk Unsafe media portrayals of suicide Circumstances that protect against suicide risk: Individual Protective Factors - Effective coping and problem-solving skills Reasons for living (for example, family, friends, pets, etc.) Strong sense of cultural identity Circumstances that protect against suicide risk: Relationship Protective Factors - Support from partners, friends, and family Feeling connected to others Circumstances that protect against suicide risk: Community Protective Factors - Feeling connected to school, community, and other social institutions Availability of consistent and high quality physical and behavioral healthcare Circumstances that protect against suicide risk: Societal Protective Factors - Reduced access to lethal means of suicide among people at risk Cultural, religious, or moral objections to suicide warning signs for suicide: - Talking about being a burden

Being isolated Increased anxiety Talking about feeling trapped or in unbearable pain Increased substance use Looking for a way to access lethal means Increased anger or rage Extreme mood swings Expressing hopelessness Sleeping too little or too much Talking or posting about wanting to die Making plans for suicide Phases of Therapy - Initiation Working Termination Initiation of Therapy - -one of the most important goals of the first session is establishing a therapeutic alliance

• fundamental component of successful therapy -comprehensive history & mental status examination
• collect info to establish a psychiatric history and dx
• guide the development of a tx plan -location, frequency of sessions, and payment -safety, primary consideration in psychotherapy
• safety assessment should be conducted in the initial session, questions regarding suicidal and homicidal thoughts and thoughts of self-harm

frame of the relationship - rules and boundaries -psychotherapist is responsible for setting and keeping the frame during therapy sessions -Common elements:

• process for contacting the provider
• what to do in case of an emergency
• adherence to a schedule
• fees
• confidentiality
• boundaries of the therapeutic relationship
• whether eating & drinking during the session are appropriate
• whether session interruptions are allowed
• whether phone calls between sessions are acceptable
• starting and stopping on time establishing a psychotherapeutic environment - -Safe and therapeutic -Boundaries -Rules -Environment -Contact Processes -Emergency Plan -Miscellaneous -Adherence Setting Goals and Duration of Therapy - -overall goal of psychotherapy is to help clients gain self- awareness and decision-making -psychotherapy is goal-directed

• Goal-setting should be a collaborative process between the therapist and the client -duration of therapy varies
• common for therapy to last for at least 3-4 months
• client's financial situation & insurance coverage may also impact the duration of therapy Practical considerations for psychotherapy - scheduling -outpatient therapy, sessions are typically scheduled in 45 to 50-minute blocks -permits time between sessions to document and prepare for the next -initial intake session may be up to 90 minutes -inpatient psychotherapy will vary based on unit scheduling & ind client needs. Fees -Fees & payment options should be discussed during the initial visit -private practice typically collect insurance co-pays or fees directly -PMHNPs who work within a larger health system may not be responsible for discussing or collecting fees from clients -discuss charges for missed sessions as well as the required notification to prevent charges confidentiality -paramount to establishing a therapeutic alliance -Providers must abide by the standards set by HIPAA as well as any applicable state laws
• must provide clients with information regarding HIPAA and explain what information will be shared and with whom -mandated to report concerns of threat of harm to self or others and child abuse. Psychotherapy Contracts - not required to begin therapy

-Ideally, when goals have been met, the client and therapist mutually decide to terminate the therapy relationship -client can choose to terminate non-court-ordered therapy at any time -Reasons for premature termination include:

• inability to afford therapy
• feelings that therapy is no longer beneficial
• relocation out of the therapist's service area The PMHNP can take steps to prevent client-initiated premature termination. Which strategies can be used to help promote the completion of therapy? Select all that apply. express confidence in the client for seeking therapy assign homework for each session describe the planned duration of therapy during the initial session strengthen the therapeutic alliance educate the client on their role in the therapy sessions discuss progress at the end of the last session - -express confidence in the client for seeking therapy -describe the planned duration of therapy during the initial session -strengthen the therapeutic alliance -educate the client on their role in the therapy sessions Rationale: Providing education to clients about their role in the therapeutic process and the expected duration of therapy, strengthening the therapeutic alliance, and strengthening client hope by expressing confidence can help reduce premature termination by the client. Although assigning homework for each session is an acceptable strategy for therapy, client preferences should be considered. Therapy progress should not be limited to the last session but should be incorporated regularly throughout therapy.

Termination for Cause - provider must ensure that legal and ethical obligations towards the client are met -client's needs are beyond the scope of the provider's competence or license, the provider may refer the client and terminate therapy -PMHNP changes employment or moves, they have a responsibility to provide a referral to another provider -Providers may consider termination for noncompliance or missed sessions -client presents a safety risk to the provider and the provider is unwilling to meet with the client in person, termination may be appropriate -Failure to pay or insurance authorization denial is not acceptable grounds for termination during a crisis -PMHNP should prepare a termination letter that delineates the reasons for termination and provides recommendations regarding further treatment if applicable.copy of the letter should be retained in the client's records. Court-Mandated Treatment - -require treatment for individuals or families. -Mandated therapy may be ordered as an alternative to jail for clients with mental health or substance use disorders -Parents may be compelled to attend therapy during a divorce trial or as a stipulation to regain custody after allegations of abuse or neglect -Sex offenders may also be obligated to attend mandated therapy -Clients who fail to meet the requirements of court-mandated therapy may be found in contempt of court or be required to serve jail time -Confidentiality

• provider may be required to share information with the court
• must frankly discuss the limits of confidentiality with the client psychotherapy documentation: Provider Responsibilities - Clinical Management -Informs the provision of care and provides a review of past proceedings