Mental Health Exam 2

What are some nursing diagnoses for patients w/ sleep disorders?

• Sleep Pattern Disturbance

• Insomnia

• Sleep Deprivation

• Risk for Injury

• Fall Risk

• Social Isolation

• Spiritual Distress

• Grieving

• Caregiver Role Strain

What are appropriate sleep hygiene measures to promote better sleep?

• Establish a regular schedule for going to bed and rising.

• Avoid sleep deprivation and the desire to “catch up” by excessive sleeping.

• Do not eat large meals before bedtime; however, a light snack is permissible, even helpful.

• Avoid daytime naps, unless necessitated by advanced age or physical symptoms.

• Exercise daily, particularly in the late afternoon or early evening, as exercising before retiring may interfere w/ sleep.

• Minimize or eliminate caffeine and nicotine ingestion.

• Do not look at the clock while lying in bed.

• Keep the temperature in the bedroom slightly cool.

• Do not drink alcohol in an attempt to sleep; it will worsen sleep disturbances and produce poor-quality sleep.

• Do not use the bed for reading, working, watching television, and so forth.

• If you are worried about something, try writing it down on paper and assigning a designated time to deal w/ it—then, let it go.

• Soft music, relaxation tapes, or “white noise” may be helpful; experiment w/ different methods to find those that are beneficial

Who is in the LGBTQ+ community?

• Lesbian

• Gay

• Bisexual

• Transgender

• Queer

• +

What are important issues within the LGBTQ+ community?

• Lack of familial support.

• Social isolation and marginalization.

• Discrimination in the community, direct or indirect (e.g., workplace, healthcare setting, housing).

• Violence from lay people as well as police and healthcare providers.

What is a health disparity and what are some within the LGBTQ+ community?

• A specific type of health difference that a group of individuals in a disadvantaged situation will experience.

  • Mental Illness

  • Suicide or Attempted Suicide

  • Substance Use/Misuse

  • HIV and other STIs

What causes health disparities in the LGBTQ+ community?

• Lack of employment

• Lack of health insurance

• Inability to find providers

• Discrimination from healthcare providers or staff

• Lack of data and research

• High-risk behaviors (e.g., sex worker, multiple sex partners, drug dealer, victims of violence, etc.)

Gender Dysphoria is diagnosed…

When an individual has a strong and persistent sense of incongruence between experienced or expressed gender and the gender assigned at birth.

• anatomical: physical characteristics a person is born w/. (e.g., external and internal reproductive organs, chromosomes, and secondary sex characteristics)

• natal: sex assigned at birth, typically based on anatomical traits. (e.g., “natal female" means someone assigned female at birth, and "natal male" means someone assigned male at birth.)

**The incongruence is accompanied by the persistent discomfort of their assigned sex or a sense of inappropriateness in the gender of that assigned sex.**

What is necessary to receive medical intervention for a gender transition?

A diagnosis

What does a person w/ Gender Dysphoria clinically present w/?

Significant distress or impairment in social, occupational, or other important areas of functioning.

Boys & Girls w/ Gender Dysphoria

• Boys: A preoccupation w/ traditionally feminine activities, a preference for dressing in girls’ or women’s clothing, and an expressed desire to be a girl or grow up to be a woman.

• Girls: May resist parental attempts to have them wear dresses or other feminine attire, wear boys’ clothing, have short hair, ask to be called a boy’s name, and express the desire to grow a penis and grow up to be a man.

Anger

_____ is a normal feeling; emotional response to frustration, hurt, or fear. Maybe a secondary emotion r/t another disorder (e.g., depression, anxiety)

Ex: You are talking w/ your friend, and they continually interrupt you; you might start getting a little upset.

Constructive Anger

• If there is an unfair or wrong situation; self-defense.

• “I” statement approach.

  Ex: “I feel angry when you interrupt.”

Destructive Anger

• When denied, suppressed, or expressed inappropriately.

• Increases the risk of health problems (e.g., HTN, ulcers, CAD).

• “You” statement approach.

  Ex: Why do you keep interrupting?” or maybe it is suppressed, and it comes out in a passive aggressive way.

What is hostility?

• Verbal aggression.

• A person might express this when they feel threatened or powerless.

• Expressed thought:

  • Verbal abuse (e.g., yelling, sarcasm, threats, etc.)

  • Lack of cooperation

  • Violation of rules or norms

  • Threatening behavior

• Intended to intimidate or cause emotional harm.

• Can lead to physical aggression.

What is physical aggression?

• Attacking or injuring another person (e.g., hitting, scratching, punching, etc.).

• May destroy property.

• Meant to harm or punish another person.

• Intention is to force someone into compliance.

• Some patients w/ psychiatric disorders display this behavior that represents a challenge to nurses and other staff members.

What are the risk factors of hostility and aggression?

• Past history of violence/rage or aggressive behavior:

  • one of the best predictors of future aggression.

• Poor coping skills

• Destruction of property

• Homicidal or suicidal ideation

• Physical danger to self or others

• Agitation or restlessness

• Lack of impulse control

• Limited support systems

• Comorbidity:

  • Psychotic delusions

  • Command hallucinations

  • Violent angry reactions w/ cognitive disorders

• Living in a violent environment

• Limit setting by the nurse within the therapeutic milieu.

• Thiamine & niacin deficiencies

• Caffeine intake

• PTSD

• Substance use

• Neurological illness

• Financial or legal troubles

What are the expected findings of a patient exhibiting anger/aggression?

• Hyperactivity: Pacing, restlessness.

• Hypersensitivity: Easily offended.

• Intense eye contact/no eye contact at all

• Facial Expressions: Frowning or grimacing.

• Body Language: Clenching fists, waving arms.

• Rapid Breathing.

• Aggressive Postures: Leaning forward, appearing tense.

• Verbal Cues: Loud, rapid talking, yelling, and shouting.

• Drugs or Alcohol intoxication

What are possible explanations of anger, hostility, and aggression (AHA)?

• Neurobiological/Physical

• Psychosocial/Psychological

• Sociocultural

• Substance Misuse

• Economic Disadvantage

• Attitudes Supportive of Violence

AHA: Neurobiological/Physical

• Low serotonin may lead to increased aggressive behavior.

• Increased activity of dopamine and epinephrine in the brain is associated w/ increased impulsivity and violent behavior.

• Damage to the limbic system and frontal and temporal lobes of the brain may alter modulation of emotions and contribute to violent behavior.

AHA: Psychosocial/Psychological

• As a child matures, they are expected to develop impulse control (the ability to delay gratification) and socially appropriate behavior. However, these children are at an increased risk for failing to develop socially appropriate behavior → aggressive behavior:

  • Children in dysfunctional families w/ poor parenting.

  • Children who did not receive consistent responses to their behaviors.

  • Children whose families struggle w/ social determinants of health.

• Poor coping skills, limited support systems.

What would be nursing care for a patient with aggression and/or anger?

• Provide a safe environment for the patient who is aggressive, as well as for the patients and staff on the unit.

• Follow policies of the mental health setting when working w/ patients who demonstrate aggression.

• Assess for triggers or preconditions that escalate patient emotions.

• Self assessment-self awareness.

• Contingency management involves rewarding desired behavior, like maintaining a calm demeanor, w/ quantifiable rewards like handwritten notes or extended time during certain leisure activities.

What are the steps to handle aggressive behavior in a mental health setting?

• Responding quickly.

• Remaining calm and in control.

• Encouraging the patient to express feelings verbally, using therapeutic communication techniques (reflective techniques, silence, active listening).

• Allowing the patient as much personal space as possible.

• Maintaining eye contact and sitting or standing at the same level as the patient.

• Communicating w/ honesty, sincerity, and nonaggressive stance.

• Avoid accusatory or threatening statements.

• Describing options clearly and offering choices.

• Reassuring the patient that staff members are present to help prevent loss of control.

• Setting limits for the patient:

  • Tell the patient calmly and directly what they must do in a particular situation, such as, “I need you to stop yelling and walk with me to the day room where we can talk.”

  • Use physical activity, such as walking, to de-escalate anger and behaviors.

  • Inform the patient of the consequences of their behavior, such as loss of privileges.

  • Use pharmacological interventions if the patient does not respond to calm limit-setting.

  • Plan for 4 to 6 staff members to be available and in sight of the patient as a “show of force” if appropriate.

What are the 5 phases of the aggression cycle?

1. Triggering

2. Escalation

3. Crisis

4. Recovery

5. Post-Crisis

Triggering Phase

• An event or circumstance that initiates response, which is often anger or hostility.

  ______________________________________________

• Signs, Symptoms, and Behaviors:

  • Restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, anger.

• The nurse should approach the patient in a non-threatening, calm manner in order to de-escalate; the nurse should allow the patient time to express themselves.

  • Maybe saying, “I notice you seem…” or “How are you feeling?”

  • The nurse can suggest that the patient go to a quiet area.

  • Consider offering relaxation after allowing the patient time to express themselves.

• If the patient’s behavior continues after offering removal to a quiet area or physical activity, medications should be offered next.

Escalation Phase

• Movement towards a loss of control.

  ______________________________________________

• Signs, Symptoms, and Behaviors:

  • Pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly.

• The nurse must take control of the situation.

• Directions to the patient should be in a calm but firm voice.

• If the patient refused medication in the previous phase, then the nurse should offer it to them again within this phase.

  • Asking why the patient does not want to take their medications would also be appropriate to explore any concerns as to why they do not want to take it.

• If the behavior continues to escalate, the nurse should obtain assistance from other staff members.

Crisis Phase

• Loss of control either emotionally or physically.

  ______________________________________________

• Signs, Symptoms, and Behaviors:

  • Throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, and inability to communicate clearly.

• As the patient’s behavior escalates toward this phase, they lose the ability to perceive events accurately, solve problems, express feeling appropriately, or control their behavior.

• The patient may become physically aggressive.

• The nurse must review their facility’s protocol and standards for restraint and seclusion.

• If a restraint is placed, the nurse should obtain a physician’s order ASAP.

• If PRN medication has not been taken earlier, the nurse may obtain an order for an IM injection in this type of emergency situation.

• Close assessment and documentation is crucial within this phase, especially if the patient is on seclusion or restraints.

Recovery Phase

• Regaining physical and emotional control.

  ______________________________________________

• Signs, Symptoms, and Behaviors:

  • Lowering of voice; decreased muscle tension; clearer, more rational communication; physical relaxation.

• They are encouraged to talk about the situation or triggers that lead to the aggressive behavior.

• Help them explore alternatives.

Post-Crisis Phase

• The patient attempts reconciliation w/ others and returns to the level of functioning before the triggering incident.

  ______________________________________________

• Signs, Symptoms, and Behaviors:

  • Remorse; apologies; crying; withdrawn behavior.

• The patient is removed from restraint or seclusion once they meet the behavioral criteria.

• Behavior should be further assessed in a calm and non-chastising manner.

• The patient should be reintegrating into social activities as soon as they can participate.

Seclusion and restraints must be used only according to legal guidelines and should be the intervention of ____ ______ after other less restrictive options have been tried and there is a risk of harm to the patient and others.

last resort

Less restrictive interventions prior to use of seclusion and restraints are…

• Verbal interventions

• Offering medication as needed (PRN)

• Decreasing stimulation

• Close observation and one-to-one supervision

How can a nurse promote safety when dealing w/ an aggressive patient?

• Provide a safe environment

• Establish therapeutic nurse-patient relationships

• Offer concrete choices

• Provide “teachable moments”

• Make behavioral limits and consequences clear

• Exhibit self-awareness

• Remain with patients when they are angry

Medications for Aggressive & Impulsive Behavior

• Atypical Antipsychotic:

  • Olanzapine

  • Ziprasidone

  → are used more commonly than haloperidol.

• Conventional Antipsychotic:

  • Haloperidol

    • has the most severe side effects.

Nursing Care: Violence and Abuse

• Document subjective and objective data obtained during assessment.

• Provide basic care to treat injuries.

• Make appropriate referrals.

• Help the patient develop a safety plan, identify behaviors that might trigger violence, and provide information regarding safe places to live.

• Use crisis intervention techniques to help resolve family or community situations where violence has been devastating.

Nursing Care: Sexual Assault

• Perform a self-assessment.

  • It is vital that the nurse who works with the patient who has been sexually assaulted be empathetic, objective, and nonjudgmental.

  • If the nurse feels emotional about the assault due to some event or person in their own past, it can be better to allow another nurse to care for the patient.

• Perform an initial and ongoing assessment of the patient’s level of anxiety, coping mechanisms, and available support systems.

  • The nurse should also assess for indications of emotional and/or physical trauma.

• Provide a private environment for an examination with a specially trained nurse-advocate, if available.

  • A sexual assault nurse examiner (SANE) is a specially trained nurse who performs such examinations and collects forensic evidence. 

• Follow national standard protocol for the assessment.

  • Includes patient information, examination, documentation of biological and physical findings, collection of evidence, and follow-up as needed to document additional evidence.

• Provide for patient safety.

  • Let the patient know they are safe. 

• Provide nonjudgmental and empathetic care.

• Obtain informed consent to collect data that can be used as legal evidence (photos, pelvic exam).

  • The rape survivor has the right to refuse either a medical examination or a legal exam, which provides forensic evidence for the police.

• Treat any injuries, and document care given.

• Assist the SANE with the physical examination and the collection, documentation, and preservation of forensic evidence.

  • Sexual assault evidence collection kits are used for collecting blood, oral swabs, hair samples, nail swabs, or scrapings, and genital, anal, or penile swabs. Document physical injuries in narrative and pictorial form, using body maps or photographs. Also document subjective data, using the patient’s verbatim statements.

• Support the patient while legal evidence is being collected (samples of hair, skin, semen).

  • Avoid minimizing the patient’s level of emotional suffering, as psychological responses can be subtle or not easily identifiable. Refrain from asking “Why” questions. Let the patient know that the sexual assault is not their fault.

• Assess for suicidal ideation.

• Administer prophylactic treatment for sexually transmitted infections as outlined by the Centers for Disease Control and Prevention.

  • This can include prophylactic treatment of syphilis, chlamydia, gonorrhea, HIV, and hepatitis exposure.​​​​​​​

• Evaluate for pregnancy risk and provide for prevention (emergency contraception).

• Assess for support systems and call the patient’s available personal support system (a partner or parents) if the patient gives permission.

• Assist the patient during the acute phase of rape-trauma syndrome to prepare for thoughts, manifestations, and emotions that can occur during the long-term phase of the syndrome.

  • Encourage the patient to verbalize their story and emotions.

  • Listen and let the patient talk. Use therapeutic techniques of reflection, open-ended questions, and active listening.

Sexual Assault: Care After Discharge

• Provide phone numbers for 24-hour hotlines for sexual assault survivors.

• Promote self-care activities. Give follow-up instructions in writing, because the patient might be unable to comprehend or remember verbal instructions.

• Initiate referrals for needed resources and support services. Individual psychotherapy and group therapy can be helpful to increase coping skills and prevent long-term disability (depression or suicidal ideation).

• Schedule follow-up calls or visits at prescribed intervals after the assault.

• Emphasize the importance of aftercare, as sexual assault patients historically have poor compliance rates with follow-up visits.

Mandated Reporting

• 0 to 17 years old → can be reported to the authorites!

• 18 to 65 years old → we are not allowed to report to the authorities unless the patient gives us permission!

• Under 65 years old but has a severe disability → we can report!

• Over 65 years old → we can make a report!

What are the 4 phases in the cycle of abuse?

• Tension-Building

• Acute-Battering

• Honeymoon

• Periods of Escalation and De-escalation

Tension-Building Phase

• The perpetrator has minor episodes of anger and can be verbally abusive and responsible for some minor physical violence (pushing or shoving).

• As tension continues to grow, both partners try to reduce it.

• The perpetrator may turn to substances, and the victim dismisses the significance of the violence.

• The vulnerable person is tense during this stage and tends to accept the blame for what is happening.

Acute-Battering Phase

• The tension becomes too much to bear, and serious abuse takes place.

• The victim may provoke the perpetrator to reduce the unbearable tension.

• The vulnerable person can try to cover up the injury or try to get help.

• This stage is the most violent and shortest.

Honeymoon Phase

• The situation is defused for a while after the violent episode.

• The perpetrator becomes loving, promises to change, and is sorry for their behavior.

• The vulnerable person wants to believe this and hopes for a change.

• Eventually, the cycle begins again.

Periods of Escalation and De-escalation Phase

• Usually continues w/ shorter and shorter periods of time between w/o intervention.

• Emotions for the perpetrator and vulnerable person (fear or anger) increase in intensity.

• Repeated episodes of violence lead to feelings of powerlessness.

Rape-Trauma Syndrome: Phase 1

Initial emotional (or impact) reaction

• Expressed Reaction:

  • Overt and consists of emotional outbursts, including crying, laughing, hysteria, anger, and incoherence.

• Controlled Reaction:

  • Ambiguous; Survivor can appear calm and have a blunted affect. Or confused and find it difficult to make decisions. Numb.

Rape-Trauma Syndrome: Phase 2

Variety of emotional reactions

• Embarrassment, desire for revenge, guilt, anger, fear, anxiety, and denial.

• These reactions can persist and become sustained and maladaptive.

Rape-Trauma Syndrome: Phase 3

Somatic Reaction

• Muscle tension, headaches, sleep disturbances, GI (nausea, anorexia, diarrhea, abdominal pain), and GU (vaginal pain or discomfort).

What are Kubler-Ross’ 5 Stages of Grieving?

• Stage 1: Denial (and isolation)—shock and disbelief regarding the loss.

• Stage 2: Anger—may be expressed toward God, relatives, friends, or health care providers.

• Stage 3: Bargaining—when the person asks God or fate for more time to delay the inevitable loss.

• Stage 4: Depression—when the awareness of the loss becomes acute.

• Stage 5: Acceptance—occurs when the person shows evidence of coming to terms with death.

Anticipatory Grief

• When people facing an imminent loss begin to grapple with the possibility of the loss or death in the near future.

  • Implies the “letting go” of an object or person before the loss (e.g., terminal illness).

  • Individuals have the opportunity to grieve before the actual loss.

Complicated Grief & Types

• Occurs when there is a response outside of the “norm.”

  • Abnormal or distorted; void of emotion; expression of grief seems disproportionate to the event.

  • Pathological or unhealthy grief; strategies to cope with loss are maladaptive.

  Types:

  • Chronic or Prolonged

  • Delayed or Inhibited

  • Distorted or Exaggerated

Complicated Grief: Chronic or Prolonged

• This maladaptive response is difficult to identify due to the varying lengths of time required by patients to work through the stages/tasks of grief.

• The patient can remain in the denial stage of grief and be unable to accept the reality of the loss.

• Can result in the patient’s inability to perform ADLs.

Complicated Grief: Delayed or Inhibited

• The patient does not demonstrate the expected behaviors of the normal grief process.

• Cultural expectations can influence the development of this grief.

• The patient can remain in the denial stage for an extended period of time.

• Due to the patient’s inability to progress through the stages/tasks of grief, a subsequent minor loss (even years later) can trigger the grief response.

Complicated Grief: Distorted or Exaggerated

• The patient experiences feelings and somatic manifestations associated with normal grief but at an exaggerated level.

• The patient is unable to perform ADLs.

• The patient can remain in the anger stage of the grief process and may direct the anger toward themselves or others.

• The patient can develop clinical depression.

Disenfranchised Grief

• Grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially.

  • The grief process is more complex due to the absence of support.

  Examples:

  • A relationship that has no legitimacy.

  • The loss itself is not recognized.

  • The griever is not recognized.

  • The loss involves social stigma.

What are some outcome identifications for a patient experiencing grief?

• Identify the effects of their loss.

• Identify the meaning of their loss.

• Seek adequate support while expressing grief.

• Develop a plan for coping with the loss.

• Apply effective coping strategies while expressing and assimilating all dimensions of human response to loss in their life.

• Recognize the negative effects of the loss in their life.

• Seek or accept professional assistance if needed to promote the grieving process.

What are the nursing actions for a patient experiencing grief?

• Explore the patient’s perceptions and meaning of their loss.

• Allow adaptive denial (the patient gradually adjusts to the reality of the loss).

• Encourage or assist the patient in reaching out for and accepting support.

• Encourage the patient to examine patterns of coping in past and present situations of loss.

• Encourage the patient to review personal strengths and personal power.

• Encourage the patient to care for themselves.

• Offer the patient food without pressure to eat.

• Use effective communication:

  • Offer presence and give broad openings.

  • Use open-ended questions.

  • Encourage descriptions.

  • Share observations.

  • Use reflection.

  • Seek validation of perceptions.

  • Provide information.

  • Voice doubt.

  • Use focusing.

  • Attempt to translate into feelings or verbalize the implied.

• Establish rapport and maintain interpersonal skills:

  • Attentive presence.

  • Respect for the patient’s unique grieving process.

  • Respect for the patient’s personal beliefs.

  • Be trustworthy: honest, dependable, consistent.

  • Periodic self-inventory of attitudes and issues related to loss.

Intentional Torts are…

Voluntary acts that result in harm to the patient.

Types of intentional torts

• Assault: Any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious w/o consent or authority. (no physical contact)

• Battery: Harmful or unwarranted contact w/ a patient; actual harm or injury may or may not have occurred.

• False Imprisonment: The unjustifiable detention of a patient, such as the inappropriate use of a restraint or seclusion.

• Invasion of Privacy: Breaking confidences or by taking photographs without permission of the patient.

Intentional Tort: Assault Scenario

A nurse approaches a patient who is visibly agitated and says, "You need to sit down and take your medication now!" The nurse steps forward with an authoritarian stance, raising their hand as if to block the patient's exit, and the patient recoils in fear, believing they are about to be physically restrained.

Intentional Tort: Battery Scenario

A nurse is administering medication to a patient and explains, "This will help you feel better." The patient asks about the medication, and the nurse replies, "You don’t need to know. Just take it." The nurse forces the pill into the patient's mouth without their consent, even though the patient expresses hesitation.

Intentional Tort: False Imprisonment Scenario

A psychiatric nurse places a patient in a seclusion room because the patient is exhibiting aggressive behavior. However, after the patient calms down, the nurse refuses to let the patient leave the room, saying, “You’re staying here until I say you can leave,” even though the patient no longer poses a risk to themselves or others.

Intentional Tort: Invasion of Privacy Scenario

A nurse leaves a patient's medical chart open on the desk in a shared nurses' station where other patients or visitors could easily see it. The chart contains sensitive information about the patient's diagnosis, treatment plan, and personal history. A third party, unrelated to the patient's care, views the chart and learns about the patient's private medical information.

Ethical Principles

• Beneficence

• Autonomy

• Justice

• Fidelity

• Veracity

Beneficience

• The quality of doing good; can be described as charity.

Ex: A nurse helps a newly admitted patient who has a psychotic disorder to feel safe in the environment of the mental health facility.

Beneficience Scenario

A nurse notices a patient who is struggling to breathe and becomes visibly anxious. The nurse quickly provides oxygen and reassures the patient, prioritizing their comfort and well-being, and taking additional actions like notifying the healthcare provider to prevent further complications.

Autonomy

• The patient’s right to make their own decision.

• However, the patient must accept the consequences of those decisions.

• The patient must also respect the decisions of others.

Ex: Rather than giving advice to a patient who has difficulty making decisions, a nurse helps the patient explore all alternatives and arrive at a choice.

Autonomy Scenario

A nurse is caring for an elderly patient who has been advised to undergo surgery. The patient, after thoughtful consideration, declines the procedure, opting for palliative care. The nurse respects the patient’s decision, ensures they understand the potential consequences, and supports their choice without judgment.

Justice

• Fair and equal treatment for all.

Ex: During a treatment team meeting, a nurse leads a discussion regarding whether or not two patients who broke the same facility rule were treated equally.

Justice Scenario

A nurse notices that a new nurse is providing better care to certain patients because they are from the same community. The nurse addresses the issue with the new nurse and ensures that every patient, regardless of their background, receives equal attention and appropriate care.

Fidelity

• Loyalty and faithfulness to the patient and to one’s duty.

Ex: A patient asks a nurse to be present when they talk to their guardian for the first time in a year. The nurse remains with the patient during this interaction.

Fidelity Scenario

A nurse promises a patient they will return in 30 minutes to check on their pain levels. The nurse keeps their word, returning promptly to reassess the patient’s comfort, even though there are other patients that need attention, because the nurse values their commitment to patient care.

Veracity

• Honesty when dealing w/ a patient.

Ex: A patient states, “You and that other staff member were talking about me, weren’t you?” The nurse truthfully replies, “We were discussing ways to help you relate to the other patients in a more positive way.”

Veracity Scenario

A nurse is caring for a patient who is undergoing treatment for cancer. The patient asks the nurse if their treatment is working. The nurse, aware that the patient has had some improvement, responds, "The treatment has shown some positive effects, but it's important to monitor your progress closely. I’ll make sure to keep you updated as we continue the treatment.

When placing a S/R…

• The nurse can use seclusion or restraints w/o first obtaining a provider’s written prescription if it is an emergency situation.

• If this emergency treatment is initiated, the nurse must obtain the written prescription within a specified period of time (usually 15 to 30 min).

• Patients should never be secluded or left alone in a locked room, unsupervised or left in a prone or supine position.

• Continuous in-person or remote supervision is necessary.

A S/R is discontinued…

• When the patient is exhibiting behavior that is safer and quieter.

  • Once discontinued, the nurse must obtain a new prescription before initiating restraints again.

  • Provider must reassess the patient and rewrite the prescription, specifying the type of restraint, every 24 hr or the frequency of time specified by facility policy.

S/R: Documentation

• Clean and objective; factual details.

• Complete documentation every 15 to 30 minutes (or according to facility policy):

  • Precipitating events and behavior of the patient prior to seclusion or restraint.

  • Alternative actions taken to avoid seclusion or restraint.

  • The time treatment began.

  • The patient’s current behavior, what foods or fluids were offered and taken, needs provided for.

  • Medication administration.

  • Time released from restraints.

S/R: Time limits for restraint or seclusion are…

• Age 18 years and older: 4 hours

• Age 9 to 17 years: 2 hours

• Age 8 years and younger: 1 hour

The nurse should never use seclusion or restraint for the:

• Convenience of the staff.

• Punishment of the patient.

• Patients who are extremely physically or mentally unstable.

• Patients who cannot tolerate the decreased stimulation of a seclusion room.

Nursing responsibilities when caring for a patient in seclusion or restraints include ensuring that they are:

• Assessed (including for safety and physical needs), and the patient’s behavior documented.

• Offered food and fluid.

• Toileted.

• Monitored for cardiac, respiratory, and skin integrity, including vital signs.

C) Approach the patient calmly, use a non-threatening tone, and offer to speak privately to discuss their concerns.

A 45-year-old patient in a psychiatric unit is becoming increasingly anxious and agitated. They are pacing the room, speaking loudly, and expressing frustration about their treatment plan. The patient begins to clench their fists and raises their voice at the nurse. What is the least restrictive intervention the nurse should use first?

A) Immediately administer a sedative medication to calm the patient.
B) Ask the patient to sit down and remain silent until they calm down.
C) Approach the patient calmly, use a non-threatening tone, and offer to speak privately to discuss their concerns.
D) Restrain the patient and place them in seclusion to ensure safety.

A) Speak to the patient in a calm voice and ask them to hand over the sharp object voluntarily.

A 19-year-old patient with a history of self-harm is holding a sharp object and appears to be contemplating using it to harm themselves. What is the least restrictive intervention the nurse should use first?

A) Speak to the patient in a calm voice and ask them to hand over the sharp object voluntarily.

B) Immediately restrain the patient to prevent harm.

C) Administer medication to sedate the patient.

D) Leave the patient alone until they calm down.

B) Offer the patient information about the benefits of medication and discuss possible alternatives with the treatment team.

A 60-year-old patient with a chronic psychiatric condition is refusing to take their prescribed medication. They have previously experienced side effects but are reluctant to follow through with alternative options. What is the least restrictive intervention the nurse should use?

A) Tell the patient they will be forced to take the medication.
B) Offer the patient information about the benefits of medication and discuss possible alternatives with the treatment team.
C) Administer the medication without the patient's consent.
D) Restrain the patient and force the medication into their mouth.

B, C, D

A 28-year-old patient with a history of severe anxiety disorder presents to the emergency department in acute distress. They are crying, unable to speak clearly, and express feeling overwhelmed by their situation. Which of the following are appropriate interventions the nurse should consider? Select all that apply.

A) Administer an anxiolytic medication immediately.

B) Offer the patient a quiet space to sit and calm down.

C) Encourage the patient to take deep breaths and focus on the present moment.

D) Engage the patient in a supportive, empathetic conversation.

E) Tell the patient that their anxiety is not real and they should just calm down.

A, C, E

A 60-year-old patient with schizophrenia refuses to take their prescribed antipsychotic medication because they feel fine and believe they don’t need it. What are appropriate actions the nurse should take to address this situation? Select all that apply.

A) Explain the importance of taking the medication consistently to manage symptoms and prevent relapse.

B) Force the medication into the patient's mouth to ensure compliance.

C) Offer education about the benefits of the medication and listen to the patient’s concerns.

D) Tell the patient that if they don’t take the medication, they will be placed in seclusion.

E) Involve a family member or caregiver to support the patient’s decision-making.

B, D, E

A 40-year-old patient with a history of mood instability has been placed in seclusion for their safety after becoming aggressive toward staff. The patient begins to calm down and asks to be released from seclusion. What should the nurse do? Select all that apply.

A) Release the patient immediately, as they are now calm.

B) Assess the patient’s behavior and determine if they are able to safely return to the unit.

C) Leave the patient in seclusion for a longer period to ensure they don’t become aggressive again.

D) Obtain a new order from the provider if further seclusion is necessary.

E) Engage the patient in a calm conversation to explore their feelings and assess their readiness to return to the unit.

What is anxiety?

• When it’s normal, it is a healthy response to stress.

• When it is elevated or persistent, it can lead to behavior changes and impairment in function.

• Is a vague feeling of dread or apprehension.

• A response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms.

• Unavoidable.

• For many people, it is actually a warning sign that they are not dealing w/ stress effectively.

The levels of anxiety are…

• Mild

• Moderate

• Severe

• Panic

Mild Anxiety

• A sensation that something is different and warrants special attention.

• Wide perceptual field.

• Sharpened senses, irritability.

• Restlessness, fidgeting.

• This type of anxiety requires no direct intervention; teaching can be effective.

Moderate Anxiety

• A disturbing feeling that something is definitely wrong.

• Perceptual field narrowed to immediate task.

• Can still process information, solve problems, and learn new things.

• Muscle tension, sweating, headache, GI upset.

• W/ this type of anxiety, the nurse must ensure that the patient is following what the nurse is saying.

  • Speaking in short, simple, and easy-to-understand sentences is effective.

Severe Anxiety

• Trouble thinking and reasoning.

• Perceptual field reduced to one detail or scattered details.

• Cannot complete tasks, cannot solve problems, feels dread, cries.

• Nausea, vomiting, trembling, vertigo, pale, tachycardia, chest pain.

• W/ this type of anxiety, the patient is no longer able to pay attention or take in information.

• The nurse’s goal at this level is to lower the patient’s anxiety level to moderate or mild before continuing with anything else.

• The nurse should also ensure they stay with the patient during this stage.

Panic Anxiety

• Loss of rational thought; cannot communicate verbally; delusions may be suicidal.

• Perceptual field reduced to focus on self.

• May bolt or run, or could be unable to move; dilated pupils; increased blood pressure.

• The patient's safety is the primary concern.

• They cannot perceive potential harm and may have no capacity for rational thought.

• Can last 5-30 minutes.

• The nurse should recommend moving the patient to a small, quiet, and non-stimulating environment.

Generalized Anxiety Disorder

• Uncontrollable, excessive worry for at least 50% of the time for 6 months or more.

• Causes significant impairment in one or more areas of functioning.

• Manifestations include:

  • Restlessness

  • Muscle tension

  • Avoidance of stressful activities or events

  • Increased time and effort to prepare for successful activities or events

  • Procrastination in decision-making

  • Sleep disturbance

Panic Disorder

• Is composed of discrete episodes of panic attacks.

  • These attacks last 15 to 30 minutes and involve rapid, intense, escalating anxiety in which the person experiences great emotional fear as well as physiological discomfort.

  • Can lead to avoidance behavior.

• During a panic attack, the individual may experience 4 or more of the following symptoms:

  • Palpitations (rapid heartbeat)

  • Sweating

  • Tremors (shaking)

  • Shortness of breath

  • Sense of suffocation

  • Chest pain

  • Nausea

  • Abdominal distress

  • Dizziness

  • Paresthesias (numbness or tingling sensations)

  • Chills & Hot flashes

  • Fear of dying or insanity

Panic disorder is diagnosed…

when a person has recurrent, unexpected panic attacks, followed by at least 1 month of persistent concern or worry about future attacks or their consequences, or a significant change in behavior related to the attacks.

Agoraphobia

• Avoids certain places or situations that cause anxiety.

• Fear and manifestations of anxiety are disproportionate to the actual danger.

• Can disrupt the ability to maintain employment and daily functions.

• Involves fearing and avoiding places or situations that might cause panic, feelings of being trapped, helpless, or embarrassed.

• Can occur w/ or w/o panic attacks.

B) Provide a calm and quiet environment and encourage slow, deep breathing.

A nurse is caring for a patient experiencing a panic attack. Which intervention should the nurse prioritize during this acute episode?

A) Help the patient identify specific triggers for the panic attack.
B) Provide a calm and quiet environment and encourage slow, deep breathing.
C) Encourage the patient to leave the environment to remove the trigger.
D) Engage the patient in distracting activities to divert attention from their panic.

A, B, E

Which interventions are appropriate for a nurse to implement when caring for a patient experiencing a panic attack? Select all that apply.

A) Stay with the patient and provide a calm, reassuring presence.
B) Encourage the patient to use deep breathing exercises.
C) Administer medication as soon as the panic attack begins.
D) Offer the patient distractions, such as asking them about their family or hobbies.
E) Ensure the patient is in a quiet, low-stimulation environment.

B, C, E

Which nursing interventions are appropriate for a patient diagnosed with generalized anxiety disorder (GAD)? Select all that apply.

A) Encourage the patient to avoid discussing anxiety-provoking situations to reduce stress.
B) Assist the patient in identifying triggers for anxiety and developing coping mechanisms.
C) Provide information about support groups and psychotherapy options.
D) Discourage the patient from engaging in relaxation techniques, as they may worsen symptoms.
E) Teach the patient to recognize signs of escalating anxiety and employ early interventions.

Non-pharmacological treatment of anxiety disorders

• Cognitive-Behavioral Therapy:

  • Positive Reframing

  • Decatastrophizing

  • Assertiveness Training

• Behavioral Therapies:

  • Relaxation Training

  • Modeling

  • Systematic Desensitization

  • Flooding

  • Response Prevention

Positve Reframing

• Turning negative messages into positive messages.

• The therapist teaches the patient to create positive messages for use during panic episodes.

  Ex: Instead of thinking, “My heart is pounding. I think I’m going to die,” the patient thinks, “I can stand this. This is just anxiety. It will go away.”

Decatastrophizing

• Involves the therapist’s use of questions to more realistically appraise the situation.

• The therapist may ask, “What is the worst thing that could happen? Is that likely? Could you survive that? Is that as bad as you imagine?”

Decatastrophizing Technique Example

• Therapist/Nurse: "What is the worst thing that could realistically happen if you fail?"

• Patient: "I’ll fail the exam, get kicked out of nursing school, and never become a nurse."

• Therapist/Nurse: "Is that outcome likely? What are some other possibilities?"

• Patient: "Well, I could retake the exam or talk to my professor for extra help."

• Therapist/Nurse: "Exactly. Failing one test doesn’t mean you’ll fail nursing school or your career. What steps can you take to improve your chances of passing?"

Assertiveness Training

• Helps the person take more control over life situations.

• They involve using “I” statements to identify feelings and to communicate concerns or needs to others.

• Ex: “I feel angry when you turn your back while I’m talking,” “I want to have 5 minutes of your time for an uninterrupted conversation about something important,” and “I would like to have about 30 minutes in the evening to relax without interruption.”