Personality Disorders and Substance Abuse, Exams of Nursing

Download Personality Disorders and Substance Abuse and more Exams Nursing in PDF only on Docsity! 1 Alexa is a 27-year-old female who has come to group therapy while she is in the city jail. She was arrested for vagrancy because she was sleeping in her car in a parking lot at a local shopping center. She could not post bail, so she is sentenced to 14 days in jail. During group, she contributes that none of this is her fault. Her mother is totally evil because she would not let Alexa stay in the family home. She has some other family. but they are all jerks because they won’t help her. Alexa’s friend Melanie is the absolute best person in the world, but she can’t help because her boss fired her for no reason. Alexa has a history of arrests for buying illegal drugs and prostitution. The last time she was in jail, her sentence was extended for 30 days because she got into a fight with another inmate and beat her up so badly she had to be admitted to the hospital for 6 days. The PMHNP considers which of the following personality disorders? Anne is a 32-year-old female who presented to care after a random drug screening at work was positive for cocaine. She was initially resistant to therapy, maintaining that her use is not a problem and she could stop at any time. Upon further discussion in session, it appears that she uses cocaine every day at work, sometimes 2–3 times, other days more. She also uses it occasionally at home and most weekends. During her third session, she admitted that it is a financial burden, and she basically cannot afford any other form of recreation. She understands that if she uses again she will lose her job, and she admits that she loves her job and that cocaine is not worth losing it. When counseling her about cessation strategies, the PMHNP advises all the following except: NURS 6670 EXAMS MIDTERM AND FINAL 2023/2024 Question 1 Histrionic Narcissistic Borderline Schizoid Question 2 The physiologic symptoms of withdrawal may require a short-term hospitalization Unlike other substances of abuse, there are no medications to help reduce the intensity of withdrawal She will need to be monitored for depression Overcoming the intense craving for cocaine is the biggest issue 2  Question 3 Clare’s history of personal relationships is characterized by complete intolerance of being alone. Whether it is an 5 Among the various types of therapeutic intervention for patients with borderline personality disorder, which of the following is characterized as polymodal, including group skills training, individual therapy, telephone consultation, and a consultation team with a goal of improving interpersonal skills and decreasing self-destructive behavior? History and symptoms are most consistent with antisocial personality disorder Fletcher needs a neurological workup to include an EEG and assessment for neurological soft signs Consistent with his symptoms, Fletcher will likely respond well to a stress interview It is likely that substance abuse is the underlying cause of symptoms and should be explored further Question 9 Which among the following neurotransmitters is decreased in depression and increased in mania? Dopamine Norepinephrine Serotonin Glutamate Question 10 Mentalization-based treatment (MBT) Transference-focused psychotherapy (TFP) last few years; he is able to get hired for jobs because he is very engaging and likeable, and then invariably he gets fired because he misses work and doesn’t do his job properly when he is there. According to the wife, they have known each other since high school, where Fletcher was very happy and well-adjusted. He was on the soccer team, liked by teachers, and never demonstrated the tendencies he does now. Apparently in college he got involved with a fraternity that was notorious for alcohol and drug abuse, and he started drinking heavily; it was ―all downhill from there.‖ The PMHNP considers that: 6 Countertransference-focused psychotherapy (CTFP) Dialectical behavioral therapy (DBT) Question 11 A history of schizophrenia of a first-degree relative Sustained psychosis predating his mother’s death Comorbid Asperger’s syndrome Apparent frank thought disorder Question 12 Which of the following is a true statement with respect to the treatment of narcissistic personality disorder? Mr. Kendall is a 47-year old male who is presented to care by his younger sister, Megan. Mr. Kendall has spent his entire adult life living in an apartment that was attached to his parents’ home. His mother died a few weeks ago, and the property is listed for sale. Mr. Kendall will have to move, and while discussing this with him, Megan became very concerned. He has apparently been considered odd all his life, has never married or even dated as far as Megan knows, but she had no idea how odd he was. When his mother died, he seemed disconnected from reality and had episodes of talking to people who weren’t present. Megan says that sometimes she does not even understand what he is talking about. He seems to think he has psychic powers, and that he doesn’t need to move because he knows the house will not be sold. When considering a diagnosis of schizotypal disorder, the PMHNP expects which of the following to be present in the history? 7 While preparing a class on personality disorders for a class of PMHNP students, the instructor is presenting case studies of patients with cluster A personalities. One of these cases is Clark M., a 41-year-old man who is described as a life-long ―loner.‖ In high school and college, he kept to himself, excelling in his studies in the sciences. Currently described as a brilliant computer programmer, he clearly prefers solitary pursuits and the company of his cat over people. He knows he is socially isolated, but he is just more comfortable this way. This description is most consistent with: Darius is a 26-year-old male who presents for care as part of couple therapy with his wife, who is being seen for dependency issues. Darius himself seems very anxious to ―do the right thing‖ and appears to want to please the therapist. During the evaluation, Darius is impeccably dressed, very formal in his presentation and interaction, and is watchful of time because he has an appointment after the interview and states several times that he cannot be late. The PMHNP considers that Darius may have obsessive compulsive personality disorder (OCPD). In differentiating this from obsessive compulsive disorder (OCD), she explores his history further for: Psychoanalytic psychotherapy has strong empiric support Both serotonergic drugs and lithium are useful Group therapy is rarely helpful Immobilized patients (hospitalized or incarcerated) have the best outcomes Question 13 Schizoid personality disorder Schizotypal personality disorder Paranoid personality disorder Delusional disorder Question 14 A history of racing thoughts Difficulty interacting with others Extremely high expectations of self Significant impairment at work 10 Jeffrey T. is a 27-year-old man who has presented for care after being required to do so by the county court. He was involved in a car accident, and while he was not at fault for the accident, routine blood alcohol screening revealed that he was driving while intoxicated. He is a bit resentful at being required to attend therapy; he is very vocal that his driving was not impaired and that he is able to function normally even after drinking what others might consider excess amounts of alcohol. His wife confirms this; they both admit that what began as one or two beers after work a few years ago has evolved to where he now drinks at least a 12 pack of beer nightly. Regardless, they both confirm that he never ―seems drunk,‖ and this does not interfere with his job or fulfilling his family functions. Jeffrey’s ability to function normally despite high blood alcohol is likely a result of: Danielle is a 31-year-old female who is having a psychiatric evaluation at the insistence of her husband. They have been married for 4 years, and her husband has finally become so frustrated by her jealous behavior that he threatened to leave her if she didn’t ―get help.‖ Her husband insists that he has never been unfaithful, but Danielle repeatedly accuses him of having an affair. If he is even a few minutes late getting home from work, she demands an explanation and then does not believe anything he says. She does not have any real friends—her sister is her closest social contact, but Danielle has been angry with her for several weeks and won’t answer phone calls. Reportedly she does this often, and according to her husband can ―hold a grudge forever.‖ During the interview, Danielle is calm, responsive, but distant. She says she really doesn’t understand why she is there—there is not a problem. The PMHNP considers the most likely diagnosis and discusses with Danielle that the treatment of choice is: Question 20 Dependence Abuse Adaptation Addiction Question 21 Diazepam Pimozide Psychotherapy Group therapy 11 Margo is a 47-year-old female who admits to a history of fairly heavy alcohol use over many years. She admits that she has had periods in the past where she stopped drinking for a brief time, but she has always gone back to it. At this point she says she has been drinking a fifth of bourbon every 2–3 days for over a year. She has a new boyfriend and really wants to stop drinking, but she is afraid she will ―go into the DTs.‖ She has been reading about it on the Internet, and she knows it can be fatal. Other than her drinking, Margo is amazingly healthy. She had a complete physical exam with blood work through her primary doctor, and he says that her drinking does not appear to have affected her physical health at all. While counseling Margo about alcohol withdrawal delirium (delirium tremens), the PMHNP advises Margo that: Anthony is a 41-year-old male patient who presents for evaluation. His wife made the appointment because she is worried about him and he would not seek care on his own. Anthony has become progressively withdrawn over the last few months and is in danger of losing his job because he misses so many days. He has been evaluated by his primary care provider and has no apparent medical conditions. His wife reports that he has been diagnosed with depression in the past, and has even taken medication that seemed to help. This time he just refused to pursue care. After a comprehensive assessment, the PMHNP diagnoses the patient with major depressive episode with psychotic features. Consistent with the Texas Algorithm Medication Project (TAMP), the appropriate choice of initial medication therapy would be: Question 22 She should be admitted for inpatient detoxification People in good physical health rarely have DTs A beta adrenergic antagonist medication can minimize her risk of DTs Women rarely experience DTs Question 23 Venlafaxine and clozapine Fluoxetine and olanzapine Amitriptyline and haloperidol Paroxetine and buspirone Question 24 12 Marie is a 30-year-old woman who presents for follow-up after starting treatment for bipolar disorder. She had been treated on and off for depression for years and had a history of alcohol abuse. After her marriage, she decided to stop drinking and was successful in eliminating alcohol from her life; unfortunately, she then went on to have a manic episode and was finally started on a mood stabilizer 1 month ago. She tolerated medication very well, and within 2 weeks symptoms were much improved. Now, 4 weeks later, she feels much better and wants to come off medication. The PMHNP tells her that: Sense of self-importance Defense mechanisms Self-esteem Interpersonal relationships Question 25 Discontinuing medication presents a marked risk of return to alcohol A program of psychotherapy should be started before stopping medication She needs to continue medication for a minimum of 3 months Cessation of mood stabilizers prematurely increases risk for a depressive episode Question 26 SCID BPRS PANSS Validated and reliable instruments are an important part of assessment for both clinical practice and research in psychiatrics. Which of the following tools is currently considered the standard for assessing clinical outcomes in treatment studies of schizophrenia? Marlene is a 35-year-old female who is in therapy primarily to develop coping mechanisms for living with her husband, who has narcissistic personality disorder. She is committed to the marriage and loves her husband, but finds his inflated sense of self-importance and complete lack of empathy to be especially difficult. She believes he has a good side, but most of her friends have only ever seen extreme arrogance, and she is embarrassed by that. While counseling Marlene, the PMHNP advises her that patients with narcissistic personality disorder have extremely fragile: 15 Tim is a 20-year-old male who has been referred for care by his college counselor. The counselor has noted that Tim engages in virtually no social activities in college, and for that matter avoids day-to-day activities that require social interaction. By his own admission, Tim never participates in class discussions, even in online discussion boards. Tim is so afraid of rejection that he confines himself to his room and his studies. When differentiating schizoid personality from avoidant personality, the PMHNP knows that a primary difference is that: Psychosis Motor coordination Question 32 Avoidant personalities have a strong desire for personal relationships Avoidant personalities may have an active fantasy life Schizoid personalities are perceived as distant and aloof Schizoid personalities may be very attached to animals Question 33 Affect Cognition Thought process Abstract reasoning Cory J. is a 23-year-old male being seen by the PMHNP today for an initial evaluation. He says that he does not think anything is wrong, but his family, including his mother, grandmother, and aunt, have all told him that he must be ―mentally ill.‖ He has been unable to hold a job and has worked as a cook at more than five chain restaurants in the last 6 months. He has no real friends—he says his ―friends‖ only call him when they need something but never help him. He is currently staying with his grandmother but reportedly will soon be homeless ―unless things change.‖ While he is telling his story, the PMHNP appreciates that Cory repeatedly includes details that make it hard to understand his point. When asked why he thinks he will be homeless, he responds by talking about how many hours he has worked and how everything was going well but then his car broke down and he couldn’t afford to fix it because his tax return was held by the IRS. The PMHNP recognizes that this represents an abnormal: 16 Cory is a 23-year-old male recently incarcerated in the county correction facility for a 9-month sentence following his third conviction for battery. As part of an early release program, he is required to participate in the therapy program. During his initial interview, he is very pleasant and engaged, expressing no anxiety or distress with his current circumstances. His psychiatric history is significant for numerous adolescent episodes of running away, truancy, and substance abuse. As a young adult, he reportedly has not held a steady job but rather is constantly coming up with money-making schemes. According to family reports is a personality disorder are very likely to: Mrs. Maxwell is a 75-year-old patient with moderate Alzheimer’s dementia. She lives with her son and his wife and generally does very well with her day to day activities. The family understands the importance of routine and Mrs. Maxwell maintains a regular schedule of activities including her meals, timed toileting, and recreational activities. Which of the following behaviors should prompt and immediate depression screening for Mrs. Maxwell? Question 34 Have a family history of the same disorder Respond well to dialectical behavioral therapy Have impaired emotional defense mechanisms Come from smaller nuclear families Question 35 An acute change in mental status Angry verbal outbursts that seem unwarranted Death of her best friend An unplanned weight loss despite consistent oral intake Question 36 17 Psychoanalytic Behavioral Existential Cognitive Question 37 An SNRI will likely be the most appropriate choice if pharmacotherapy is indicated for this episode This may be an inaccurate characterization, as depressed patients tend to overemphasize negatives In some circumstances patients will purposefully mischaracterize the efficacy of medications they feel were ineffective Some forms of recurrent depression are best managed with nonpharmacologic strategies Question 38 The treatment of dependent personality is rarely successful Occupational dysfunction is rarely impaired Dependent personalities tend to have long-term relationships with one person Dependence is a common feature of many psychiatric disorders. One of the primary distinguishing features that differentiates dependent personality disorder from histrionic and borderline personalities is that: Mrs. Bowen is a 33-year-old female who presents as a new patient requesting medication for depression. She reports a long history of mood disorders on and off going back to adolescence. She is very articulate in describing her history and reports that neither sertraline nor fluoxetine ―worked for her.‖ She was unable to remember the dose or how long she took the medication. With respect to considering Mrs. Bowen’s medication history, the PMHNP knows that: The psychological sciences have contributed theoretical foundations to the etiology and management of anxiety disorders from both conceptual and practical perspectives. The concept that anxiety develops in persons who feel as though they are living in a world devoid of meaning is an example of which theoretical foundation? 20 Jen is a 31-year-old female who presents for care complaining of depressed mood. During the interview, it becomes apparent that she has a long history of depressive symptoms, as well as a long history of being socially isolated and feeling generally inadequate. When considering a diagnosis of dysthymia, the PMHNP considers that the core concept of dysthymia refers to sub-affective or subclinical depressive disorder with all of the following except: Urinary tract infection Mild cognitive impairment Normal pressure hydrocephalus Depression Question 44 Appearance Motor activity Mood Affect Question 45 In documenting a mental status exam (MSE) for Janet, a 54-year-old female, the PMHNP notes that she is bradykinesic, has poverty of speech, is depressed, and appears flat. This includes all the following elements of physical examination except: The PMHNP is asked to evaluate the parent of one of her existing patients, a 49-year-old woman named Sheri. Sheri reports that her father, a 78-year-old man who lives alone, has always been in good health. However, when Sheri went to have breakfast with him this past Sunday, she found her father overtly confused and he did not even seem to recognize her at first. Sheri is concerned that he has Alzheimer’s disease, and she is amazed because two days prior he was ―completely fine.‖ The PMHNP knows that the most likely cause of this presentation is: 21 The PMHNP is evaluating Jared, a 47-year-old male who is brought to care by his wife because ―he’s not the man I married 20 years ago.‖ According to his wife, she and Jared have been married for 20 years, have two children, and have lived a ―normal‖ life. Jared owns a local construction company and their marriage has been a solid one, characterized by the typical day-to-day issues that occur in most marriages, but otherwise happy. For the last 2–3 months, she says Jared has completely changed. He will get angry for no apparent reason and even broke a lamp once. He tells stupid and offensive jokes that no one else thinks are funny, and even had someone call the police when he continued to make inappropriate remarks to a woman in a restaurant. Jared seems unsure what to say, but his wife is adamant that this is a totally different man from the one she has known. The PMHNP knows that Jared should be evaluated for: Low-grade chronicity for at least 2 years Insidious onset, usually in childhood or adolescence Strong family history of depression and bipolar disorder Long asymptomatic periods between episodes Question 46 Which of the following personality disorders is associated with females with fragile X syndrome? Borderline Narcissistic Dependent Schizotypal Question 47 Borderline personality disorder Structural brain damage Substance abuse disorder Cognitive impairment 22 Trudy L. is a 29-year-old female patient who initiated care because she feels like she has no energy. She just had her annual wellness exam and her primary care provider told her that she is in excellent health. Because she complained about this excessive fatigue, her PCP performed a CBC, CMP, UA and thyroid function tests and was told, along with her physical examination, that everything looks normal. Further discussion reveals that Trudy is having some relationship challenges with her boyfriend of 2 years and this seems to be ―spilling over‖ at work, where she is having persistent conflict with her supervisor. Ultimately the PMHNP diagnoses Trudy with major depressive disorder, mild, single episode. The PMHNP and Trudy discuss treatment options, and Trudy would really like to try nonpharmacologic interventions. Which of the following represents the best approach for Trudy? Maurice is a 22-year-old male who is being treated for major depressive episode. He presents today for a follow up visit. He was started on sertraline 50 mg daily 4 weeks ago, and 2 weeks ago, his dose was increased to 150 mg daily. Today he is concerned because he doesn’t really feel much symptom improvement, and he thinks he needs something else. The best response to Maurice is to tell him that: Question 48 Family therapy Behavior therapy Psychoanalytic therapy Interpersonal therapy Question 49 He needs to be increased to 200 mg today and follow up in 4 weeks He should maintain this dose for 4 weeks and reassess He should change his therapy to an SNRI Addition of cognitive behavioral therapy would likely improve response 25 John is a 41-year-old male who presents for management of heroin addiction. He has a long history of opiate abuse spanning decades and has had several unsuccessful attempts at recovery. Because of his lifestyle, he has developed a variety of chronic health problems, including cardiomyopathy and stage 2 chronic kidney disease. He currently takes several psychiatric medications for mood disorder. When considering methadone maintenance as a mechanism of treating his opiate addiction, the PMHNP knows that if he requires more than 100 mg of methadone at the start of therapy he should have a baseline: During the interview of Kevin, a 42-year-old male who presents for treatment because of marital problems, the PMHNP responds to his tears by gently moving a box of tissues toward him. This is a facilitating intervention of interview known as: Response to pharmacotherapy Question 55 Urine drug screen Hepatic function test Pulmonary function test 12-lead ECG Question 56 Reinforcement Reassurance Encouragement Acknowledgement 26 When evaluating the laboratory assessment of a patient with alcohol use disorder, the PMHNP may reasonably expect to find all of the following abnormalities due to chronic alcohol use except: Mr. Henderson is a 69-year-old man who presents for evaluation and care for depression. His wife died 6 months ago following a difficult 2 years with breast cancer. His primary complaint is that he just does not look forward to anything anymore. He cannot get interested in his children and grandchildren, he no longer enjoys any of his hobbies because he and his wife used to do them together. He does not sleep well, and wakes up frequently during the night. He also admits to thinking more and more about dying himself, although he expressly denies suicidal ideation. His medical history is significant for coronary artery disease, osteoarthritis, hypothyroidism, hypertension, and dyslipidemia. He also has atrial fibrillation and is on warfarin for emboli prophylaxis, but he does not remember the names of all of his other medications. When considering pharmacotherapy for Mr. Henderson, the PMHNP considers that which of the following SSRIs is safest with respect for potential drug interactions? Question 57 Macrocytosis Transaminitis Uremia Hypertriglyceridemia Question 58 Fluoxetine Paroxetine Escitalopram Sertraline Question 59 The PMHNP is called to the acute care unit to evaluate a patient who is admitted after being brought in by his friends. They were at a party where there were numerous drugs of abuse as well as alcohol. The patient cannot provide a history, and his friends are unclear as to which drugs he used. Physical examination reveals a patient who is diaphoretic, tremulous, has a pulse of 130 bpm, dilated pupils, and cannot perform fine motor tasks. These physical findings are most consistent with which type of intoxication? 27 Kevin is a 24-year-old male who seeks treatment for anxiety. He thinks he has an anxiety disorder because he has a lot of the same symptoms that his mother does, and she takes medications for anxiety. He reports being ―constantly wired,‖ irritable, and not sleeping well. Kevin says he always has energy, but it’s not a good kind of energy. He does not have isolated panic attacks; he is always just ―amped up.‖ He denies any substance abuse, and he does not smoke cigarettes. When considering organic causes of his symptoms, the PMHNP must evaluate his: Alcohol Cannabis Opiate Hallucinogen Question 60 Caffeine intake Use of dietary supplements Testosterone level Liver function tests Question 61 From a biological perspective, all of the following neurotransmitters are implicit in the anxiety response except: Gamma-aminobutyric acid Norepinephrine 30 The professional relationship between therapist and patient with schizoid personality disorder is a challenge because these patients do not typically seek care independently. However, once a trusting relationship develops, this type of patient may: Question 66 Reveal a very strong desire for an intimate relationship Become very engaged in group therapy Describe an active fantasy life with imaginary friends Demonstrate psychotic or delusional features Question 67 Patients on lithium carbonate for management of bipolar disorder should be subject to routine assessment of: CBC and BMP TSH and serum Na+ CMP and ECG LFTs and EEG 31 The PMHNP is preparing a presentation for a primary care conference on geriatric health care. The topic is geriatric depression, and this presentation is designed to increase recognition of community-dwelling elders at risk. An important talking point in this presentation will include all of the following about geriatric depression except: Sarah is a 23-year-old patient who presents for a follow-up of her major depressive episode. She was titrated up to maximal dose fluoxetine 6 weeks ago after demonstrating tolerance without side effects at lower doses. Today in follow-up, she reports that she still has no sides effects but no therapeutic effect either. There does not appear to be any measurable improvement of her initial presenting symptoms. The PMHNP knows that the most appropriate approach at this point is to: Question 68 Depression presents with more somatic symptoms as compared to younger age groups Ageism may cause primary care clinicians to accept depressive symptoms in the elderly as normal Risk factors include loss of spouse, physical illness, and social isolation Incidence of geriatric depression is estimated at 60–75% of the population Question 69 When differentiating a major depressive episode from dysthymic disorder, the PMHNP considers that: The cognitive theory of depression does not apply to dysthymia Hospitalization is typically indicated early in the course of dysthymia Dysthymia is more subjective in its presentation than depression Insight-oriented therapy is the most effective treatment for dysthymia Question 70 Reconsider the diagnosis of major depressive episode Add bupropion to her medication regimen 32 The PMHNP is working on a graduate program in which he is hoping to develop a new personality assessment tool. After an exhaustive review of the literature and many months of work, he developed a tool to use in a research study and needs to establish its psychometric properties. He distributes the tool to four different professionals in the field and asks that they assess whether the questions appear to measure what they are purported to measure. This is an assessment of: Increase the dose of fluoxetine Change to another antidepressant medication Question 71 Internal consistency reliability Parallel form reliability Construct validity Face validity Question 72 The presence of fixed delusional thought Disdain for weak or sickly people A history of antisocial behavior Extreme ―drama‖ in most personal relationships The PMHNP is considering a diagnosis of paranoid personality disorder in a new patient. When reviewing the history and physical examination, which of the following findings would be most consistent with this diagnosis? realization? I A-How Iwill Ithe Ipsychiatric Inurse Iassess Iif IKaren Ihas Imade Iprogress Itoward Iself- 1. Karen is a 25-year-old white woman who lives alone in an apartment with her dog. Karen has been divorced for 2 years and is taking Prozac prescribed by her psychiatrist for depression. Karen and her boyfriend had been discussing marriage until he told her that he wanted to end their relationship. Karen became even more depressed and could not work for a week. Karen returned to work, refusing to discuss her issues with family, friends, or coworkers. She did, however, make an appointment to see a psychiatric nurse practitioner. Karen told the nurse that she was making some changes in her life. Karen said that she and a girlfriend were joining a gym program for workouts and a social group for young men and women. Karen stated that she realizes that her former boyfriend had not been committed to her, and she anticipates meeting and dating other young men from the adult social group. Karen also said that she thinks that the gym exercise will be beneficial to her mentally and physically. (Learning Objectives: 1, 4)  Karen had suffered from depression which is a form of mental disorder because of divorce and a broken relationship with her boyfriend. This situation according to Hypocritical in 15th century BC, upholds the brain as the organ of consciousness; this occurs when both normal and abnormal behavior arise from the brain.  The psychiatric nurse can assess if Karen has made progress towards self- realization by committing to diagnosing and treating her responses to the problems that caused her psychiatric disorder. In-addition, the nurse can make assessment based on Karen’s psychoanalytical disposition such as: transference, defense mechanism, countertransference, acting out, denial of the reality befallen her and projection. B-Identify Istrengths Ithat IKaren Ihas Ifor Iprogress Iin Ipersonal Igrowth. IThe strengths Karen has for progress in personal growth include the followings:  Her cognitive behavioral responses showed optimism towards a better life as well as fighting against her depressed state. Hence, her willingness to date younger men.  Karen sought immediate medical attention where she was administered with Prozac to help mitigate her depression state.  Ability to make use of social support, that is, she visited a psychiatric nurse, social group and registered in a gym. Icontribute Ito IKaren’s Ireluctance Ito Idiscuss Iher Idepression Iwith Iothers. C-Karen Ihas Ibeen Iseeking Itreatment Ifor Iher Idepression. IAnalyze Ithe Ifactors Ithat Imight Iand Icomment? Ito Itake Ia Icouple Iof Ipills Ito Iget Ibetter. IHow Ishould Ithe Inurse Irespond Ito IMichael’s Iquestion B-Michael Iasks Ithe Inurse Iwhy Ihe Ihas Ito Ihave Ipsychotherapy. IHe Istates Ithat Ihe Ionly Ineeds  She was realistic about her situation, therefore made herself ready to face the reality before her.  Karen’s reluctance to discuss her depression with others hinges on the fact that her depression was a kind called social depression. Social depression is a psychological disorder caused by several factors such as: interpersonal relationship which involves the relationship between a person and the interactions of emotions of everyone expressed directly and discreetly to each other.  Another is a Common interpersonal relationship, this includes: Family, social environment (work place), and interaction among age groups and genders. Because Karen had divorce and broken relationship, she didn’t feel safe in herself discussing her depression with family and friends but to seek a professional whose job is to attend to her depressed case. Hence, her neuroticism was calm and strong willed. Case Study, Mohr: CHAPTER 2, Neuroscience: Biology and Behavior 1. Michael is a 22-year-old college senior whose GPA has declined with this semester’s grades. Michael plans to apply to medical school and thinks that the lower GPA may prevent his acceptance to medical school. For the last 2 weeks, Michael has skipped most classes because he has insomnia and fatigue. Michael is now very depressed and has been thinking of suicide. He took a loaded gun from his father’s gun cabinet and then wrote a suicide note to his family. At the last moment, he telephoned 911 and told them of his suicide plan. The police came, took the gun away, and then took Michael to the city hospital to be admitted for psychiatric treatment. In the admission interview with the psychiatric nurse, Michael said that his pastor thought that only weak-willed people experienced depression and that it was a punishment for personal sins and the sins of one’s ancestors. Michael told the nurse that he must be weak-willed and will never be able to accomplish anything. The psychiatric nurse explained that multiple factors are the cause of depression. The nurse told Michael that one theory holds that an imbalance of neurotransmitters, or chemical messengers of the brain, occurs in depression. Neurotransmitters influence the individual’s emotions, thoughts, and subsequent behavior. Recent research implies that neurobiology, heredity, as well as Psychological and environmental factors may be involved in the development and progression of depression. (Learning Objectives: 5, 6)  No. It is indeed difficult for Michael to accept the doctor’s opinion since before he fell sick, he had information from the pastor on depression on which he solely believed and now he is a living prove. Iis Imore Icorrect Ithan Ithat Iof Ihis Ipastor? A-Will IMichael Ithink Ithat Ithe Ipsychiatric Inurse’s Iexplanation Ifor Ithe Icause Iof Idepression I I Idevelopment Iof Idepression: I IGenetic, IEnvironment Iand IStress. C-Develop Ian Iassessment Iquestion Ifor Ieach Iof Ithe Ifollowing Ipossible Icauses Iof IMichael’s I  The nurse has to explain to Michael why he should consider psychotherapy. Because of the many misconceptions about psychotherapy, you may be reluctant to try it out. Even if you know the realities instead of the myths, you may feel nervous about trying it yourself.  Overcoming that nervousness is worth it. That’s because any time your quality of life isn’t what you want it to be, psychotherapy can help. Taking only pills will not help but increase the effects because most of these medications have side effects which would have been avoided by psychotherapy.  From the Geriatric Depression Scale: “Do you prefer to stay at home rather than going out and doing new things?” This question asks for a yes or no answer and recognizes that isolation and withdrawal are common signs of depression — especially in the elderly.  From the MADRS: “How is your sleep?” Answers include: Sleeping as usual, slight difficulty, sleep reduced by at least two hours, or getting less than three hours of sleep at night. Greater sleep disturbance signals a greater risk for depression.  From the Beck Depression Inventory: “How is your energy?” Declines in energy level are a common sign of depression the more significant your lack of energy, the higher your depression risk rating. Possible answers to this question include: As much energy as ever, less energy than before, not enough to do much, or not enough to do anything Case Study, Mohr: CHAPTER 3, Conceptual Frameworks and Theories: 1. The student nurse has been assigned a 37-year-old woman admitted to the psychiatric hospital with an anxiety disorder. This morning, the student notices that the client has a tense facial expression and is walking constantly around the group room. The student walked over to the client and used reflective communication by stating, “I see that you have a tense expression and are walking around almost all of the time. Is there something that we could discuss?” The client replied that she has talked on the telephone to her mother who was keeping her children while she was in the hospital. The client said that her mother had told her that she was not a good mother, and then said, “I guess I am a bad mother, but I could never measure up to my mother’s expectations.” The student has learned that negative self-talk can greatly aggravate anxiety and lead to depression. The student decided to use a behavioral intervention with the client and asked the client who is a good artist and why the client liked the artist’s works. The student and the client then made a list of activities that the client liked. The student taught the client to engage in one of these activities when an unpleasant experience evoked negative thoughts. The following day, the student decided that the client needed some cognitive restructuring for her relationship with her mother. The student taught the client that during discussions with her mother, feelings of incompetence might be experienced when the mother made negative comments. The client was instructed that if her mother made negative IExplain Iyour Ianswer B-Can IMrs. IGonzalez Ibe Iconvinced Ithat Ithere Iis Ino Ispell Icast Ion Iher Ito Icause Iher Ideath? Iemergency Icommitment Ito Ithe Ihospital? B-Why Ican IGerald Inot Imake Ithe Idecision Ifor Ihimself Iabout Ibeing Ian Iinvoluntary Iher Ito Isee Ithe Iclinic Idoctor? A-How Ican Ithe Inurse Iprovide Iculturally Icompetent Icare Ito IMrs. IGonzalez Iand Iconvince  Basic legal rights.  Gerald cannot make the decision for himself about being an involuntary emergency commitment to the hospital because he lacks insight about his illness at the time of admission hence he cannot accept to be admitted. Moreover, he is a threat to himself and others and thus he should be admitted even without his consent. Case Study, Mohr: CHAPTER 6, Culture 1. Mrs. Maria Gonzalez is a Mexican National, age 58, who was brought to a health clinic by her adult son. She is complaining that she has had aches and pains all over her body for 2 days. Mrs. Gonzalez states that her neighbor is a witch who gave her the mal do ojo (evil eye) and cast a spell on her to cause her death. The clinic nurse takes an oral temperature and it is 101º F. The clinic nurse refers Mrs. Gonzales to the clinic physician because she believes that the client has influenza. Mrs. Gonzales is reluctant to see the doctor and states that the doctor cannot prevent her death. (Learning Objective: 8)  People have different health seeking behaviors. culture plays a very significant role in determining someone health seeking behavior. in this case, the nurse must understand Gonzalez culture, be in his shoes then try to convince him to see a doctor. The nurse can achieve this by looking for someone who can communicate better with Gonzalez and slowly convince him that he is suffering from an infection. .  Yes, though it will take time. Getting a family member or a relative to talk to Gonzalez and convince him can work. Alternatively, getting someone from Gonzalez culture and explain to him that he had the same problem before and it was discovered that it was an infection and not evil eye will really help. Case Study, Mohr: CHAPTER 7, Spirituality in Psychiatric Care 1. Marta, a 16-year-old high school teenager, has been depressed over a recent break-up with her boyfriend. Marta, accompanied by her mother, is seen in the community mental health clinic. A mild antidepressant is prescribed for Marta with weekly counseling sessions. Marta and her mother ask if it would be beneficial for Marta to attend a 1-week church camp to begin in 2 months. Marta would like to reconnect with her religion and voices a belief that the camp experience will help her. The psychiatric nurse practitioner Ichurch Icamp Ibenefit IMarta? A-Why Imight IMarta Iwant Ito Ireconnect Iwith Iher Ireligion, Iand Ihow Iwill Iattendance Iat Ithe B-If IMarta Iattends Ithe Ichurch Icamp, Iwill Ithis Ipose Ia Iproblem Ito Icounseling Isessions? Iin Ia Ihealthcare Isetting. Iworkers? IProvide Ian Iexample Iwhere Ia Isituational Ifactor Iimpacted Ion Iyour Ibehavior Iwhile A-What Iis Ia Isituational Ifactor, Iand Ihow Ican Ithis Iinfluence Ithe Ibehavior Iof Ihealthcare informs them that research reveals that involvement in religious activities has been helpful in social support and in coping with depression. Marta appears relieved and said that she will register for the church camp. (Learning Objective: 2)  Marta would want to reconnect with her religion because when she had a boyfriend, she might have gone away from church because of commitment to their relationship thus forgetting about her religion.  The attendance of the church camp will help her forget about the break-up and gain moral values during the camp.  No. In fact it will be of help to her because she might get some teaching during the camp and the prescription will just be like an addition. Case Study, Mohr: CHAPTER 8 Nursing Values, Attitudes, and Self-Awareness 1. Joe, a 26-year-old Caucasian man, is a client in a state prison system. Joe is admitted to the prison clinic after being involved in a fight in which he sustained a stab wound to the chest that did not penetrate the lungs or major blood vessels. The clinic doctor on duty was an employee of several years at the prison. The doctor showed little compassion for Joe, stating, “He is a convicted criminal, and he is just getting back some of what he deserves.” The new graduate nurse who was being oriented to the clinic thought that the doctor did not exhibit professional behavior toward Joe. The clinic nursing supervisor later explained that the doctor was influenced by situational factors. (Learning Objective: 3)  Situational factor is an external factor that influences one's perception towards something or somebody. like in this case, the doctor perceived the prisoner as a criminal and such perception affected the services he rendered to the prisoner.  During practice, as health practitioners we may perceive certain groups of people such as gays in a different way which may affect the quality of services we give. some practitioners perceive gays as immoral and often give them poor services Case Study, Mohr: CHAPTER 9, the Nursing Process in Psychiatric–Mental Health Care 1. The student nurse is assigned to assist the psychiatric nurse with the admission interview of a client at the psychiatric hospital. The nurse explains to the student that the interview is very important in obtaining a total health history of the client. The nurse should be courteous and respectful of the client to obtain as much information from the client as A-How Ican Iattention Ito Ithe Iclient’s Inonverbal Icues Ibe Iof Ivalue Iin Ian Iinterview? B-Why Iis Ithe Iinterview Ithe Imost Iimportant Iaspect Iof Ithe Inursing Iprocess? possible. Assessment information should include the subjective information from the client with the reason for needing treatment, the cause of the present problem(s), and the client’s expectation of the outcome of treatment regimen. The nurse alerts the student to the need to be sensitive to both verbal and nonverbal behavior of the client and to focus on topics that seem important to the client. (Learning Objective: 1)  Nonverbal cues contribute significantly to all interpersonal communication. There may be additional diagnostic and therapeutic information to be gained from watching the nonverbal behaviors expressed by a patient.  Nonverbal signals can alert a psychiatrist to important affective states that may otherwise be overlooked or denied. They can also help identify how comfortable a patient is with a given topic of discussion.  In an interview, nonverbal cues include elements like patient's baseline general appearance and behavior, affect, eye contact, and psychomotor functioning. Changes in these parameters from session to session allow the psychiatrist to gather important information about the patient.  Being aware of these cues can offer a psychiatrist valuable information that a patient may be unwilling or unable to put into words.  Interview is a way in which the nurse collects mostly subjective data, as well as objective data so that he plans for the care of the patient Case Study, Mohr: CHAPTER 10, the Interview and Assessment Process 1. The student nurse is accompanying the psychiatric nurse during the nursing interview and assessment of a newly admitted patient. The psychiatric nurse told the student that preparation with subjective and objective data collection is an important part of the process. The nurse explains that assessment has reference to the interviewer’s interpretation and prioritization of all data for the client. The nurse must have self- awareness and self-knowledge to be objective and avoid influencing the responses of the client. Anxiety on the part of the nurse may limit the ability for thorough data collection and interpretation. Anxiety in the nurse may evoke anxiety on the part of the client. The psychiatric nurse stressed that a process recording, or written analysis of the interaction between the client and nurse, is essential for nurses to recognize the effects of their communication style in the assessment process. A review of the client’s history is important, and a private setting for the interview is necessary. The content of the nursing assessment should include the ability and reliability of the client’s response to questions of the interviewer and the skill of the nurse in identification of relevant facts. The nurse should discuss with the client prior health history, any present illness, and the reason for seeking healthcare at this time. Medication history with compliance and allergies of the client require investigation. Substance use by the client, past illnesses, and family history need exploration. (Learning Objective: 2) Icounseling Isessions. I A-Using Ia Icognitive-behavioral Iapproach, Iwrite Ithree Igoals Ifor IFrank’s Iindividual A-Why Idoes Igroup Itherapy Ibenefit Iclients Iwith Ia Ipsychiatric Idiagnosis? 1. Frank, a 16-year-old adolescent, is a high school sophomore. Frank is on the verge of failing his Spanish class. After his grade fell to a “D” grade, Frank procrastinated about doing his Spanish homework, postponing it until last. Then, saying he was tired, Frank played video games until bedtime and rationalized that he would get up early in the morning and do his homework. Frank often sleeps late and does not have time to complete his Spanish homework. Frank is now very distressed over his grade in the Spanish class. His mother brought Frank to the counselor to help with his problem. The counselor suggested a parent- teacher conference to explore any learning difficulties and the possibility of a tutor to help Frank. The counselor also said that perhaps Frank’s mother could supervise the completion of his Spanish homework as the first step. Frank appeared relieved at these suggestions, and said, “That sounds great! Maybe I can improve my Spanish grade and pass the class. Then I won’t be a loser!” (Learning Objective: 2)  The goal of cognitive behavioral therapy is to help a person learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking. Therefore, goals specific to frank include.  To help frank recognize his negative attitude towards Spanish lessons.  To evaluate whether his getting of a D grade in Spanish is warranted,  To change his perspective towards his Spanish lessons. B-E xplain why cognitive-behavioral therapy (CBT) can be successful for Frank.  It can be successful because frank does not want to fail his Spanish lessons, is willing to change, and the interventions instituted (mothers/tutor involvement) are appropriate. Case Study, Mohr: CHAPTER 14, Groups and Group Interventions 1. Mary, a student nurse, is studying for an upcoming examination in her psychiatric–mental health nursing class. Mary is reviewing group psychiatric therapy and made some practice test questions on this topic. Help Mary study by answering the following questions. (Learning Objectives: 7, 10)  Benefits of group therapy  Many people feel they are somehow weird or strange because of their problems or the way they feel; it is encouraging to hear that other people have similar difficulties and can grow past them.  The group therapy environment provides a safe confine to experiment with alternative ways of treating yourself and others that may be more satisfying.  When people learn to interact freely with other group members, they tend to recreate the same patterns of interactions that have proved troublesome to them outside of the group.  Psychiatric nurse best facilitates a community support group by:  Considers the needs and strengths of the whole person, the family and the community to assess mental health needs, formulate diagnoses, and plan, implement and evaluate nursing care.  Designing and implementing mental health prevention and early intervention initiatives that build social networks, promote and support community capacity building.  Facilitating self-help and mutual aid to strengthen the capacity of people to be self-reliant.  Using many strategies to help strengthen individuals, families and communities. Case Study, Mohr: CHAPTER 15, Families and Family Interventions 1. Wanda, a 17-year-old high school senior, has been rejected by a boy in her chemistry class whom she wanted to date for the senior prom. Wanda became severely depressed and attempted suicide with an overdose of barbiturates. Wanda’s mother found her unconscious and called an emergency ambulance to take her to the emergency department at the local hospital. After Wanda’s recovery, she was in individual counseling, and the psychiatrist referred all family members for counseling. Naomi, her younger sister, refused to go, saying that she did not have a problem and that Wanda was the one who had tried to commit suicide. Her older brother, Matthew, had a similar response and added that Wanda had embarrassed the family. Wanda’s parents stated that they would attend and urged both Naomi and Matthew to attend family counseling. (Learning Objective: 1)  In this case, Wanda's suicide attempts cause a ripple effect in the family. For example, Mathew says that he felt embarrassed with his sister's actions. Wanda's parents are being supportive to their daughter while Mathew and Naomi are not.  In recent years, the view of the family as a "system" has become an increasingly popular and important theoretical framework for counselors and family therapy professionals. A family system functions because it is a unit, and every family member plays a critical, if not unique, role in the system. As such, it is not possible that one member of the system can change without causing a ripple effect of change throughout the family system Case Study, Mohr: CHAPTER 16, Psychopharmacology 1. The student was reviewing the medication record for a client diagnosed with major depressive disorder with psychotic features. The client has been on medications for the past 12 years, has exhibited many side effects, and experienced multiple medication changes. On this admission, the client has developed abnormal movements of the tongue, Iattempt. IDescribe Ithe Ifamily Ias Ia Isystem Iadapting Ito Ichange. A-Wanda’s Ifamily Imust Ireorganize Ito Isurvive Ithe Idisturbance Icreated Iby Ithe Isuicide B-How Ican Ithe Ipsychiatric Inurse Ibest Ifacilitate Ia Icommunity Isupport Igroup? Iexplain Iyour Ichoice. A-Identify Ithe Imedication Iclassification Ithat Imay Ibe Iresponsible Ifor Ithe Iside Ieffects Iand Iexperiencing. B-Discuss Ithe Imost Iimportant Inursing Iimplication Irelated Ito Ithe Iside Ieffects Ithe Iclient Iis a masklike face, shuffling gait, and constipation. The client is taking a selective serotonin reuptake inhibitor (SSRI) and an antipsychotic.(Learning Objective: 6)  Medication Classification:  Selective Serotonin Reuptake Inhibitors (SSRIS) include;  Select Prototype Medication:  Fluoxetine (Prozac)  Other Medications  Citalopram (Celexa)  Escitalopram (Lexapro) Paroxetine (Paxil)  Sertraline (Zoloft)  Vilazodone (Viibryd)  These medications are Pregnancy Risk Category C. Fluoxetine and paroxetine increase the risk of birth defects. Therefore, other SSRIs are recommended. Late in pregnancy, use of SSRIs increases the risk of withdrawal symptoms or pulmonary hypertension in the newborn.  SSRIs are contraindicated in clients taking MAOIs or tricyclic antidepressants (TCAs).  Use cautiously in clients who have liver and renal dysfunction, cardiac disease, seizure disorders, diabetes, ulcers, and a history of GI bleeding.  SSRIs selectively block reuptake of the monoamine neurotransmitter serotonin in the synaptic space, thereby intensifying the effects of serotonin.  Withdrawal syndrome resulting in headache, nausea, visual disturbances, anxiety, dizziness, and tremors.  CNS stimulation (inability to sleep, agitation, anxiety).  Weight loss early in therapy, may be followed by weight gain with long-term treatment.  Serotonin syndrome may begin 2 to 72 hr after starting treatment and may be lethal.  Hyponatremia (more likely in older adult clients taking diuretics).  Sleepiness, faintness, lightheadedness.  Gastrointestinal bleeding.  Sexual dysfunction.  Bruxism.  Rash.  Nursing Implications-Assessment & Drug Effects  Observe for and promptly report rash or urticaria and S&S of fever, leukocytosis, arthralgias, carpal tunnel syndrome, edema, respiratory distress, and proteinuria. Drug may have to be discontinued or adjunctive therapy instituted with steroids or antihistamines. Iany Iadverse Ieffects? A-What Iinformation Iwill Iyou Iprovide Ito IMr. IAbrams Iconcerning IECT, Ihow Iit Iworks, Iand B-Prioritize Ithe Inursing Icare Iresponsibilities Ifor IJulie. 1. Julie Abrams, a married 45-year-old African American client, is admitted to the hospital for severe depression. Although Julie is taking her antidepressant medication, she seldom leaves her bed, sleeps most of the time, and has refused to eat for 6 days. Her psychiatrist has decided that ECT treatments are necessary to improve Julie’s depression. Mr. Abrams, Julie’s husband, is alarmed to learn that Julie will receive ECT. The psychiatric nurse practitioner explains the ECT procedure and treatment that Julie will receive. Mr. Abrams asked the nurse practitioner what ECT is, how it will help Julie, and if there will be any harmful effects for her. (Learning Objectives: 2, 3)  Electroconvulsive therapy seems to cause changes in brain chemistry that can immediately reverse symptoms of certain mental illnesses. It often works when other treatments are unsuccessful.  Electroconvulsive therapy (ECT) is a procedure in which electric currents are passed through the brain, deliberately triggering a brief seizure.  Procedure  Electrodes are placed on the skull. They can be placed on one side (unilateral ECT - usually on the non-dominant hemisphere) or both sides (bilateral ECT).  Subsequently, an electrical current is delivered to induce a generalized seizure.  Patients are given a general anesthetic and a muscle relaxant.  Indications  Severe depressive illness or refractory depression  A prolonged or severe episode of mania  Catatonia  How it works  It leads to increased release of neurotransmitters or enhances the response of postsynaptic receptors to brain chemicals.  Adverse effects  Cardiovascular instability arrhythmias and hypotension.  Can affect anterograde and retrograde memory  Status epilepticus  Headache  Nausea  Nursing care responsibilities - Pre-treatment  Remove dentures, glasses, contact lenses, hearing aids, hair pins and anything else that she can use hurt herself or someone else.  Ascertain if the client and the family have received a full explanation, including the option to withdraw the consent at any time.  Withhold food and fluids for 6 to 8 hours before treatment.  Give preoperative medications as ordered.  Have client void before the treatment.  Nursing Care during the Procedure Ipsychiatric Imedications? Itherapeutic Ienvironment Iand Istrategies Iassist Ithe Inurse Iin Iensuring Ithat IRobert Itakes Ihis B-The Inurse Iis Iresponsible Ifor Imedication Iadministration Ifor IRobert. IHow Ican Ia  As the intravenous line is inserted and EEC and ECG electrodes are attached, give a brief explanation to the client.  Check if the bite block is placed in prevent biting of the tongue.  Place a blood pressure cuff on one of the client’s arms.  Monitor blood pressure throughout the treatment.  Put on the pulse oximeter to the client’s finger.  Administer necessary medications.  Post treatment nursing care  Check the gag reflex before giving client fluids, medications or breakfast.  Once the client is awake, talk to the client and check the vital signs.  Give frequent orientation and reassurance to allay confusion.  Have the client go to a properly staffed recovery room. Case Study, Mohr: CHAPTER 19, Inpatient Care Settings 1. Robert Woods has been admitted to an inpatient psychiatric facility due to a resurgence of his manic symptoms because he has not been taking his psychiatric medications. His sister has been trying to supervise Robert, who lives in a small apartment a few miles away. The sister is very frustrated and feels she cannot continue to monitor Robert successfully any longer. She asks what kinds of inpatient care options are available to assist in caring for Robert and voices concern about Robert’s noncompliance with his psychiatric medications. (Learning Objectives: 1, 4)  Patient is psychiatrically unstable as determined by:  Suicidal and unable to contract for safety.  Rapidly worsening symptoms.  Levels of inpatient care.  Inpatient.  Residential  Patient is psychiatrically impaired and unable to respond to partial hospital or outpatient treatment.  Partial Hospital  Patient is psychiatrically stable but: Unable to function in normal social, educational, or vocational situations.  Intensive Outpatient/Outpatient  Patient is psychiatrically stable and has symptoms under sufficient control to be able to function in normal social, educational, or vocational situations and continue to make progress in recovery.  For Roberts’ sister, I would recommend Inpatient care level because of the relapse of mania. Iconcerning Iongoing Ipsychiatric Icare. I A-Review Ithe Ilevels Iof Iinpatient Icare Iand Ioffer Isome Isuggestions Ito IRobert’s Isister Iillness. IDiscuss Ieach Ilevel Iof Iprevention Iin Iyour Ianswer. A-Identify Ihow Ithe Ischool Inurse Ican Ihelp IJim Iand Ihis Ifamily Iin Ithe Iprevention Iof Imental  The hospital should be structured in a way that it allows interacting with the patient.  Adaptation of the environment to meet developmental needs  Open communication between the patient and the nurse.  Ensure the patient is contained in a hospital setting.  Involving the patient in making treatment decisions  Family involvement in the treatment process Case Study, Mohr: CHAPTER 20, Community and Home Psychiatric Care 1. Jim is a 10-year-old student in elementary school. The teacher is concerned that Jim may need psychological counseling and possibly psychiatric care since the recent suicide of his father. Jim had formerly been an outgoing child who had excellence performance in schoolwork. Jim is now withdrawn, does not socialize, and is doing poor work in school. Jim’s mother has not responded to a call from the teacher to come to school for a conference to explore ways to help Jim. The teacher consults the school nurse for assistance. (Learning Objectives: 1, 2)  Primary prevention  Primary prevention includes methods to avoid the occurrence of a disorder or disease altogether. This method targets individuals and groups who have a high risk of developing a mental illness based on biological, social, or psychological risk factors.  Primary prevention programs might include teaching parents effective parenting skills and providing social support to Jim after losing his father.  Secondary Prevention  Secondary prevention includes methods to diagnose and treat a disorder or disease in its early stages before it causes significant distress. This approach also aims to lower the rate of established cases. An example of a secondary prevention program effective to Jim is post traumatic counseling.  After the death of his dad, Jim may develop or be in the early stages of developing several disorders such as depression, anxiety, or post-traumatic stress disorder (PTSD). Early intervention through counseling can help minimize the progression of one or more of these mental health issues.  Tertiary Prevention  Tertiary prevention includes methods to reduce the negative impact of existing disorders or diseases by reducing complications and restoring lost function. These methods include interventions that prevent relapse, promote rehabilitation, and reduce the nature of the disorder.  Example of tertiary prevention programs for Jim is to refer him to support groups as well as treatment of the disorder. Case Study, Mohr: CHAPTER 21, Forensic Psychiatric Nursing B-What Iare Isomatoform Idisorders, Iand Iwhat Iare Ithe Itypes Iof Ithis Idisorder?  The differential diagnosis to consider are;  Differential diagnosis.  Mood disorders.  Drug withdrawal.  Cognitive impairment disorders like delirium.  Psychotic disorders.  Personality disorders.  Predisposing factors.  Predisposing factors or etiologies are associated with anxiety disorders are;  Traumatic events such as sexual assault or accidents.  Social Factors such as lack of social connections.  Family History of anxiety disorders. Case Study, Mohr: CHAPTER 24, Somatoform, Dissociative, and Sexual Disorders 1. Roger is a 60-year-old, twice-divorced, Hispanic man who is retired. His only support system is two adult sons with whom he has a distant relationship. Roger has medical insurance from his retirement and constantly complains that he has some medical problem. He “doctor shops” by seeing different doctors for his various complaints. Roger is always asking the doctors if he needs surgery. In the past 5 years, he has undergone an exploratory laparotomy for complaints of abdominal pain, three colonoscopies for complaints of alternate diarrhea and constipation, and numerous diagnostic tests for his many physical complaints. All tests and procedures have negative findings for any physical basis. Roger remains convinced that he has multiple problems that the doctors are unable to diagnose. (Learning Objectives: 1, 3)  Somatoform disorder is a rare mental illness that causes one or more bodily symptoms, including pain. The symptoms may or may not be traceable to a physical cause including general medical conditions, other mental illnesses, or substance abuse. But regardless, they cause excessive and disproportionate levels of distress. The symptoms can involve one or more different organs and body systems.  The following are the types of Somatoform Disorders.  Somatoform Disorder not Otherwise Specified (NOS)  Undifferentiated Somatoform Disorder  Body Dysmorphic Disorder  Conversion Disorder  Hypochondriasis  Pain Disorder B-Based Ion Ithe Iinformation Igiven Iin Ithe Icase Istudy, Iwhat Icontributing Ifactors Ido Iyou Ibelieve IRoger Ihas? IWhat Iother Ifactors, Inot Iincluded, Icould Icontribute Ito Isomatoform Idisorders? IName Ithe Iappropriate Idisciplines Iinvolved Iin Ithe Itreatment Iof IRoger Iand Ithe Iinterdisciplinary Igoals Iand Iinterventions Iin Itreating Ihis Isomatoform Idisorder.  The contributing factors that I believe that Rogers has based in this study case are as follows:  Roger's experience of stressful life events, trauma or violence related to the divorce.  Medical state such as recovering from surgeries may cause another pain disorder.  Having anxiety or depression states related to the divorce.  His advanced age is a contributing factor.  Other factors which are not included and could contribute to the Somatoform disorders are:  Being at risk of developing a medical condition, such as having a strong family history of a disease.  Having experienced past trauma, such as childhood sexual abuse.  Having a lower level of education and socioeconomic status.  Experiencing stressful life events, trauma or violence.  The following are the disciplines involved in the treatment of Rogers and the interdisciplinary goals and interventions in treating Somatoform Disorders:  The interdisciplinary measures that have to be taken should is majorly psychotherapy, especially cognitive behavioral therapy. Medications can be added.  Psychotherapy:  Because physical symptoms can be related to psychological distress and a high level of health anxiety, psychotherapy can help improve physical symptoms.  In this case, Rogers's divorces should be evaluated and counseling on their aftermath effects initiated.  Family therapy may also be helpful by examining family relationships and improving family support and functioning. The long-distance relationship with his sons should be improved probably by frequent visits.  Medications:  Most doctors prescribe antidepressant medication to help reduce symptoms associated with depression and pain that often occur with somatic symptom disorder. Case Study, Mohr: CHAPTER 25, Personality Disorders 1. Charles, a 29-year-old white man, has been admitted to the psychiatric hospital. Charles does not seem depressed and openly discusses that he had attempted suicide after he had burned his employer’s office and truck. Charles told the student nurse that he had been A-What Iis Ian Iantisocial Ipersonality Idisorder, Iand Iwhat Iare Iits Isymptoms? I B-Applying Ithe Inurse Iprocess Ito Ithe Itreatment Iof ICharles, Iwhat Ispecific Iinterventions mad at his boss because he was a “slave driver” and shows no remorse for destroying his employer’s office and truck. Charles has limited contact with his mother, who is his only family support. Charles is divorced and states that his ex-wife just got pregnant so that he would marry her. They have one child, and he is several months behind in child support. Other information that Charles gave the student nurse in an interview included that he was an ex-marine but had a dishonorable discharge due to stealing some extra government supplies that he said no one needed. In the treatment team, the psychiatrist stated that Charles was not suicidal and diagnoses him with antisocial personality disorder. (Learning Objectives: 1, 3)  Antisocial personality disorder(ASPD), (sociopathy) This is a mental condition in which an individual consistently behaves in a manner that ignores the rights and feelings of others. People with antisocial personality disorder tend to antagonize, manipulate or treat others harshly or with callous indifference.  Symptoms:  Unnecessary risk-taking or dangerous behavior with no regard for the safety of self or others.  Using charm or wit to manipulate others for personal gain or personal pleasure.  Repeatedly violating the rights of others through intimidation and dishonesty.  Failure to consider the negative consequences of behavior or learn from them.  Arrogance, a sense of superiority and being extremely opinionated.  Lack of empathy for others and lack of remorse about harming others.  Hostility, significant irritability, agitation, aggression or violence.  Recurring problems with the law, including criminal behavior.  Being callous, cynical and disrespectful of others.  Persistent lying or deceit to exploit others.  Impulsiveness or failure to plan.  Disregard for right and wrong.  Poor or abusive relationships.  Treatment varies from one patient to another depending on everyone’s situation, the severity of symptoms and their willingness to receive treatment. The two main methods used for treatment are  Psychotherapy:  This is also referred to as talk therapy. It may be useful for patients with high tendencies of anger and violence, those with substance abuse problems, and treatment for other mental health conditions.  But psychotherapy is not always effective, especially if symptoms are severe and the person can't admit that he or she contributes to serious problems. Iwould Ibe Imost Iappropriate Ifor Ithe Iindividual Iwith Iantisocial Ipersonality Idisorder? A-What Iare Ithe Isymptoms Iof Idipolar Idisorders?  Nursing Iprocess Iin Imanagement Iof INorma I- IRisk Ifor IOther-Directed IViolence B-Apply Ithe Inursing Iprocess Iwith Isuggested Iinterventions Iin Ithe Itreatment Iof INorma. 1. Norma, a 36-year-old Hispanic woman has been admitted to the psychiatric hospital with a diagnosis of Bipolar I Disorder. Norma has very heavy make-up with dangling earrings and several bracelets, and she is wearing a bright red blouse with tight jeans. Norma is very restless and walks unceasingly around the nursing unit, laughing and talking to other clients in a loud voice, with frequent change of subjects. Norma is very sexually provocative with male clients, following them around the nursing unit. She becomes angry when the male clients do not seem interested in her. (Learning Objectives: 1)  The following are the signs and symptoms of the dipolar disorders:  Do risky things, like spend a lot of money or have reckless sex  Have trouble sleeping, they may sleep too little or too much  Feel like their thoughts are going very fast  Think they can do a lot of things at once  Feel very sad, down, empty, or hopeless  Talk fast about a lot of different things  Feel like they can’t enjoy anything  Be agitated, irritable, or “touchy”  Feel very “up,” “high,” or elated  Become more active than usual  Have decreased activity levels  Have trouble concentrating  Have increased activity levels  Feel “jumpy” or “wired”  Feel worried and empty  Have very little energy  Have trouble sleeping  Have a lot of energy  At risk for behaviors in which Norma demonstrates that she can be emotionally, and/or sexually harmful to others.  RISK FACTORS  Hostile behavior  Hyperactivity  Restlessness  Agitation  EXPECTED OUTCOMES  Norma will; • Demonstrate decreased restlessness, hyperactivity, and agitation within 24 to 48 hours • Demonstrate decreased hostility within 2 to 4 days • Be safe and free from injury throughout hospitalization  IMPLEMENTATION Nursing Interventions Rationale Provide a safe environment. Physical safety of the client and others is a priority. The client may use many common items and environmental situations in a destructive manner. Administer PRN medications judiciously, preferably before the client’s behavior becomes destructive. Medications can help the client regain self- control but should not be used to control the client’s behavior for the staff’s convenience or as a substitute for working with the client’s problems. Decrease environmental stimuli whenever possible. Respond to cues of agitation by removing stimuli and perhaps isolating the client; a private room may be beneficial. The client’s ability to deal with stimuli is impaired Provide a consistent, structured environment. Let the client know what is expected of him or her. Set goals with the client as soon as possible. Consistency and structure can reassure the client. The client must know what is expected before he or she can work toward meeting those expectations. Case Study, Mohr: CHAPTER 29 1. Joyce Mullins is a 31 years old client whose diagnosis is schizophrenia, disorganized type. Joyce is in the state mental hospital for a long-term commitment. The student nurse is escorting Joyce and a group of patients to an art class. Suddenly, Joyce stop and look down at the sidewalk and then says “there are many brains down there on the sidewalk” later, the student is reviewing the symptoms of schizophrenia for a nursing care plan. Learning objectives:  Confused thoughts and speech. People with schizophrenia can have a hard time organizing their thoughts. They might not be able to follow along when you talk to them. Instead, it might seem like they're zoning out or distracted.  Hallucinations. Seeing, feeling, tasting, hearing or smelling something that doesn’t really exist. The most common experience is hearing imaginary voices that give commands or comments to the individual A-Discuss Ithe Isymptoms Iof Ischizophrenia B-Compare Iand Icontrast Ischizophrenia, Idisorganized Itype Ito Iother Itypes Iof Ischizophrenia. Isubstance? A-How Ican Ithe Ipsychiatric Istaff Icounsel Iwith IJohn Ito Iavoid Ihis Iturning Ito Ialcohol Ias  Different movements. Some people with schizophrenia can seem jumpy. Sometimes they'll make the same movements repeatedly. But sometimes they might be perfectly still for hours at a stretch, which experts call being catatonic.  Emotionless. A person with schizophrenia might seem like they have a terrible case of the blahs. They might not talk much or show any feelings. And when they talk, their voice can sound flat, like they have no emotions.  Delusions. False ideas--individuals may believe that someone is spying on him or her, or that they are someone famous  Trouble concentrating. For example, someone might lose track of what's going on in a TV show as they're watching.  Withdrawal. Someone who has the condition might stop making plans with you or become a  Paranoid schizophrenia- a person feels extremely suspicious, persecuted, or grandiose, or experiences a combination of these emotions.  Disorganized schizophrenia- a person is often incoherent in speech and thought but may not have delusions.  Catatonic schizophrenia-a person is withdrawn, mute, negative and often assumes very unusual body positions.  Residual schizophrenia-a person is no longer experiencing delusions or hallucinations but is not motivated or interest in life.  Schizoaffective disorder-a person has symptoms of both schizophrenia and a major mood disorder such as depression. Case Study, Mohr: CHAPTER 30 Substance Use Disorders 1. John, a 23-year-old unemployed man, is addicted to cocaine. John lives with his mother and sister and has been stealing money from them to pay for his cocaine. His mother persuaded John to voluntarily commit himself to the hospital for treatment of his substance abuse. In the initial assessment interview, the nurse learns that John began smoking marijuana at age 19 and occasionally consumes alcohol. John said that he started on cocaine after his father, who had a history of alcoholism, committed suicide. John says that he began to feel anxious then and still has periods of anxiety. John is cooperative with his treatment program and stated that he wants to get completely off drugs and get a good job to help his mother and sister. John also said that if he experienced anxiety, he would take a stiff drink like his father had done when he was anxious. (Learning Objectives: 2) Iand Ifunctioning? A-Is Imaltreatment Iof Ichildren Ia Iproblem, Iand Iwhat Iare Ithe Ieffects Ion Itheir Idevelopment B-Discuss Ithe IEcological IModel Iof IViolence Iand Ihow Iit Iapplies Ito Ithe Icase Iof INita • Brain malfunctions • Excessive hormone release • Problems with neurotransmitters • Brain malfunctions • Frustration Case Study, Mohr: Chapter 33 Violence and Abuse 1. Nita’s mother died when she was an infant. Her father married a young woman 1 year after the death of Nita’s mother. A baby girl was born to the stepmother 2 years later, followed by the birth of a baby boy 4 years later. The stepmother showed much preferential treatment to her own children, while she basically ignored Nita except to routinely ridicule her. The most difficult household chores were given to Nita, with no chores given to her own daughter. The stepmother frequently severely punished Nita without reason. Publicly, the stepmother insisted that she treated Nita and her daughter alike in every way. However, she always praised her own daughter, while continuing to verbally abuse Nita. Nita’s father put his wife in full charge and had almost no interaction with Nita. He, too, showed preferential treatment for his two children with his second wife. When Nita was 14 years old, her aunt insisted that Nita move to live with her. The aunt was very nurturing, and Nita’s life improved tremendously. Nita was very intelligent and excelled in school. Nevertheless, she was slow to make close friends and lacked confidence in social situations. Nita became a successful professional as a college professor. Nita appeared afraid to form a close relationship and was 31 years old when she married. (Learning Objectives: 1)  Yes. Maltreatment is a serious problem that can negatively impact on the development of a child.  Development and function that can result from mistreating a child on mainly include:  Brain/cognitive development such as difficulties in learning.  Attachment such as difficulty in developing relationships.  Low academic achievement academic.  Ecological model of violence is used to explain the factors that lead to violent behaviors. It considers the complex interactions between individual factors, relationship, community and the societal factors that lead to violence.  The goal of the model is to explain the factors that make one susceptible to acts of violence, protected from acts of violence, or have the tendency to perpetrate the acts. A-What Iare Ithe Iwarning Isigns Iof Isuicide? B-What Ifactors Icould Ihave Icontributed Ito IKate’s Idesire Ito Icommit Isuicide?  In the case of Nita, the kind of violence can be categorized in the second level of factors that can predispose one to violence, which is relationship.  This is because her relationship with her farther and step mother can be implicated in the challenges in her development. Case Study, Mohr: CHAPTER 34 Suicide and Suicidal Behavior 1. Kate, a 35-year-old white woman, who moved to another city to take a new job. Kate has a depressive disorder and has no friends in her new city; her only family support is one brother. Kate has lost her new job and is without insurance or funds to purchase her prescribed antidepressants. Kate formerly had excellent credit but now realizes that since she has no money, she may have to declare bankruptcy. Kate became extremely depressed, purchased a gun, wrote suicide letters to her friends, and decided to commit suicide. Kate then called 911 just before pulling the trigger on the gun. However, the gun jammed and did not eject bullets. A policeman came to her apartment in response to the 911 call and took Kate to the local psychiatric hospital. After discharge, Kate went to live with her brother. Kate’s brother is concerned that she is a continued suicide risk. (Learning Objectives: 1)  The following are the suicidal warning;  Sudden, unexpected switch from being very sad to being very calm or appearing to be happy.  Having a "death wish," tempting fate by taking risks that could lead to death.  Making comments about being hopeless, helpless, or worthless.  Putting affairs in order, tying up loose ends, changing a will.  Losing interest in things one used to care about.  Talking about suicide or killing one's self.  Always talking or thinking about death.  Writing suicidal letters to friends.  Attempt to kill oneself by a gun.  Clinical depression.  Cultural and religious beliefs that suicide is noble resolution of a personal dilemma.  History of mental disorders, particularly clinical depression.  Isolation, a feeling of being cut off from other people.  Barriers to accessing mental health treatment.  Easy access to lethal methods.  Feelings of hopelessness.  Loss of work. Iadolescents. A-Identify Isome Iof Ithe Ifactors Ithat Icontribute Ito Ipsychiatric Idisorders Iin Ichildren Iand Case Study, Mohr: CHAPTER 35 Crisis Intervention 1. Frances Gordon is a 42-year-old divorced school teacher. Her 20-year-old daughter, Sarah, has developed schizophrenia and has withdrawn from college. Her youngest daughter, Glenda, is a 19-year-old unmarried mother who is living at home. Glenda has just given birth to a baby boy who has a heart defect. The baby’s father refuses to pay for any of the healthcare costs. Frances’ dire economic situation is very stressful to her. Her ex- husband refuses to help financially, and the bank has refused a second loan to Frances. (Learning Objectives: 1) A-Can you differentiate between maturational, situational, and adventitious crises? What type of crisis is Frances experiencing?  Generate and reasonable solutions to the crises with and develop an action plan.  Assess the psychosocial and lethality of the effects of the events.  Identify the problem she considers as major and their causes.  Deal with her feelings and emotions towards the crises.  Guide her in implementing the action plan.  Rapidly establish a rapport with Frances.  Follow-Up. Case Study, Mohr: CHAPTER 36 Pediatric Clients 1. Jeremy is a 9-year-old child hospitalized in the children’s unit of a psychiatric hospital. Jeremy’s biological father died 2 years ago, and the mother now has a live-in boyfriend who has repeatedly sexually abused Jeremy. Jeremy’s teacher reported this abuse to the Children’s Protective Services, and Jeremy was removed from the home. Jeremy’s biological mother has experienced a depressive disorder for several years. Since he has been living with his foster parents, Jeremy has exhibited numerous problems of angry outbursts with physical violence toward other children living in his foster home. The foster parents are seeking help from the psychiatrist to continue to care for Jeremy in their home. (Learning Objectives: 1, 2)  Biological Influences:  This may be biological abnormalities of the central nervous system due to infections, poor nutrition or exposure to alcohol. All this may influence behavior or thinking and may lead to mental disorder in children.  Psychosocial Influences:  Some of these influences are severe parental relationship problems where children are often beaten and mistreated, overcrowded homes, or children being abused by exposure to acts of violence.