Study Guide EXAM 5

Chapter 25- me
1. How to assess the lethality of suicide plan- three elements to assess: 1) is there a specific plan
with details, 2) how lethal is the proposed method, 3) is there access to the planned method
people who have definite plans for the time, place, and means are at high risk
based on the lethality of a method which indicates how quickly a person would die
by that mode
when patients are experiencing a psychotic episode they are always at high risk
Use the SAD persons scale when triaging patients who are potentially suicidal
(assessing suicidal potential)
When the patient has access to the proposed method it is always more serious

2. Risk factors for suicide- depression, schizophrenia (leading cause of early death in this
population), alcohol (studies have indicated 50 percent of individuals who end their life by
suicide have alcohol in their system) or substance abuse, antisocial disorder, men, increasing
age (after the age of 45 for women and after 55 for men), white males, protestants and jews
have a higher risk than, divorced couples, law enforcments, dentist, artists, mechanics,
insurance agents, and lawyers, physical illnesses (physical immobilitys, disfigurement, and
chronic pain)

3. -major depression also bipolar in depressed stage is the most likely to commit suicide

4. Objective 6-Describe three expected reactions nurse may have when beginning work with
suicidal patients? Couldnt find

5. Objective 7- give examples of primary, secondary, and tertiary interventions?

Primary- practiced in the community, suicide prevention
Secondary-treatment of actual suicidal crisis, practiced in clinics, hospitals and jails,
and on telephone hotlines, determinants of life or death, nurses with good crisis
intervention skills are in this position
Tertiary- refers to intervention with the circle of survivors of a person who has
completed suicide, grief and loss counseling, families who have a member who
committed suicide need to have immediate therapy

6. Gender stats for suicide-males take their own lives four times the rate of females, during their
lifetime women who attempt suicide about two to three times more often than men, 7th
leading cause of death for males and 15th cause for women, males over the age of 75 have the
highest suicidal rates and womens is the ages between 40s and 50s, males and firearms (most
common used method), poisoning is the most common method for women

7. Which among general population has highest rate of suicide-what ages and gender males, 25
to 34 yrs of age (2nd leading cause of death), 15 to 24 is the 3rd leading cause, the older you get
the higher the risk
she put in the slides 48 yr old white male- insurance agent who was recently
demoted or divorced, not married now or partnered, agnostic, who often uses a
wheelchair due to ALS

8. Which disorders are associated with self-injury? Depression, non-heterosexual orientation,

personality disorder, particularly borderline personality disorder, anxiety and substance abuse
(these are co-occurring)

9. No harm contract? Helps the individual establish a mindset in which the individual realizes that
it is never ok to die by suicide, call 911 if in immediate danger of harming myself, I will call any
or all of the following numbers if I am not in immediate danger of harming myself but have
suicidal thoughts (please list names, phone numbers, addresses, and any other relevant contact
information below), then it gives a 1800 number to call
10. -gives the individual the hotline numbers to call
there is no certain effectiveness of this contract, gives them an alternate route if
they feel suicidal, clinical agreement

11. What change in biochemical function is most associated with suicidal behavior?
Genetic variants being studied (tends to run in families), low serotonin levels are
related to depressesion or its metabolites in cerebrospinal fluid
12. How to support staff when there is a suicide on their unit?
Group support is initiated, psychological postmortem assessment
Chapt 26
1. Differentiate among three types of crisis and provide an example of each
a. Maturational crisis

i. Erik Erkson- 8 stages of ego growth and development each developmental

stage represents a maturational crisis that is the critical period of increased
vulnerability and at the same time, heightened potential
ii. Former coping styles are no longer effective when person arrives to a new
stage, so new coping mechanisms have yet to be developed which leads to
increased tension and anxiety
iii. Ex- leaving home during late adolescence , marriage, birth of child, retirement,
and death of parent
b. Situational crisis
i. Arises from events that are extraordinary, external rather than internal, and
often unanticipated
ii. Loss or change of a job, death of a loved one, abortion,divorce
iii. Stressful event involves loss or change that threatens a persons self concept and
self esteem
c. Adventitious crisis
i. Not part of everyday life.. results from events that are unplanned and that may
be accidental, caused by nature, or human made
ii. Ex- natural disaster (flood, fire, earthquake), national disaster (terrorism, war
airplane crashes, riots), a crime of violence (rape, assault, murder, bombing,
child abuse)
iii. Could lead to PTSD
2. Discuss four common problems in the nurse-patient relationship that are frequently
encountered by beginning nurses when starting crisis intervention. Discuss two interventions for
each problem chart on 503
a. Nurse needs to feel needed
i. Ex-allows excessive phone calls, gives direct advice without sufficient knowledge
of situation, attempts to influence pts lifestyle on a judgmental basis
ii. Result- pt becomes dependent on nurse.. nurse projects frustration when pt is
not cured
iii. Intervention- Nurse discourage pt dependency, evaluate personal needs vs pt
needs with experienced professional, Encourage goal setting and problem
solving by pt, taks control only if pt is suicidal or homicidal
b. Nurse sets unrealistic goals for pt
i. Ex-expects physically abused women to leave battering partner, expects man
who abuses alcohol to stop drinking when loss of family or job is imminent
ii. Result- nurse feels responsible when expectations are not met
iii. Intervention-nurse examines realistic expectations of self and pt with an
experienced professional, nurse reevaluates pt level of functioning and works
with pt on his level, encourages setting of goals by pt
c. Nurse has difficulty dealing with a suicidal pt
i. Ex-nurse in inattentive by denying possible cues, changing topic to less
threatening subject when self0destructive themes come up
ii. Result- pt is robbed of opportunity to share feelings and find alternatives to
intolerable situation
iii. Intervention- nurse assesses own feelings and anxieties with help of an
experienced professional, evaluates all clues or slight suspicions and acts on
them
d. Nurse has difficulty terminating after crisis has been resolved

i. Ex-nurse tempted to work on other problems in patients life to prolong contact

with pt
ii. Result- nurse steps into territory of traditional therapy without proper training
iii. Intervention nurse works with an experienced professional to: explore own
feelings about separations and termination, reinforce crisis model; crisis
intervention is a preventive tool, not psychotherapy, nurse becomes better able
to help pt with his/her feelings when nurses own feeling are recognized
3. How to conduct an interview with a patient in crisis
a. Promote sense of safety by assessing pts potential for suicide or homicide.
b. Then the patients perception of the precipitating events- assess the pt or family for the
actual problem
i. What leads you to see help now, how do you see this event affecting you in the
future, what would you need to be done to resolve this situation
c. then patients situational supports- determine the available resources by assessing the
patients support systems
i. who do you live with, who can you trust, where do you go to school or to other
community based activities, how important is spirituality in your life
d. finally the patients personal coping skillsi. what do you usually do to feel better, what do you think might happen how.
4. Compare and contrast the differences among primary, secondary, and tertiary intervention,
including appropriate intervention strategies
a. Primary- promotes mental health and reduces mental illness to decrease the incidence
of crisis
i. Work with pt to recognize potential probs
ii. Teach pt specific coping skills
iii. Assist pt in evaluating the timing or reduction of life changes to decrease the
negative effects of stress as much as possible
b. Secondary
i. Establishes intervention during an acute crisis to prevent prolonged anxiety
from diminishing personal effectiveness and personality organization
ii. Nurse main goal is to ensure safety of pt
iii. Lessens the time a pt is mentally disabled during a crisis
c. tertiary
i. provides support for those who have experienced a severe crisis, and now are
recovering from a disabling mental state
ii. primary goals are to facilitate optimal levels of functioning and prevent further
emotional disruptions
5. Which population would be appropriate for CISD?
a. It is a tertiary intervention directed to a group that has experienced crisis
Chapt 27 me
1. Objectives 3- de-esculation techniques- use a low and calm voice, ask open ended questions,
you think people are always unkind to you?, verbalize the patients options, and encourage the
individual to assume responsibility for choices made, give them choices, choose a quiet place to
talk, but visible to others, other patients should be moved away from objects if things continue
to escalate, maintain calmness, maintain the patients self esteem and dignity remain honest, be
goal oriented, give severel options, utilize a nonegressive posture, use verbal and nonverbal

communication, be assertive no aggressive, assess for personal safety, avoid verbal struggles,
respond clearly as possible, respond as early as possible, identify stressors and stress indicators
2. Objective 4- two criteria for the use of seclusion or restraint over verbal intervention.
seclusion or physical restraint is used only after alternative intervention, behavioral care plan,
medication, decrease in sensory stimulation, removal of a particular problematic stimulus,
presence of significant other, frequent observation, use of a sitter who provides 24 hr, one on
one observation, used only if the patients a clear and present danger to self and others, patient
must still get an opportunity before restraint to regain control
3. How does the RN respond to a patient with escalating anger? The objective number 3 answers
this question, I did the chart and the reading for objective when I think it was only talking about
the chart and this one is talking about the reading, so know the first answer and that shd be
good
4. What issues are considered when debriefing staff after an episode of violence requiring a
restraint? A review is necessary to ensure that quality care was provided to the patient, needs
to examine the response they had to the patient, Could we have done anything that would
have prevented the violence? If yes, then what could have been done? And why was it not done
in this situation Did the team respond as a team? Were team members acting according to
the policies and procedures of the unit? If not, why not? How do staff members feel about
this patient? About this situation? Feelings of fear and anger are discussed and handled,
employee morale, productivity, use of sick leave time, requests, and absenteeism are all
affected by patient violence, is there a need for additional staff education regarding how to
respond to violent patients? How did the actual restraining process go? What could have been
done differently? Do not focus only on whether staff members were acting like a team? If
injury occurred has it been reported and cared for?
5. Best predictor of violence- a history of violence or hyperactivity
6. Nursing DX for the patient who presents violent behaviors- risk for other-directed violence, risk
for self-directed violence, ineffective coping, stress overload, impaired impulse control
7. What areas of hospital does violence occur? ER and psychiatric ward and geriatric unit (I had to
look this up on the internet)
8. Signs of escalating patient- demonstrates feelings of anger, impatientce, reports feeling of
pressure, tension, difficulty in functioning, anger, increased demands, irritability, redness of
face, speech may be increased, or may be slowed, pointed or quiet, behavioral changes,
mumbling to self, clenched jaw or fist, hyperactivity, ( pacing and restlessness), increased
anxiety and tension, shortness of breath, rapid pulse, intense eye contact, or avoidance of eye
contact, stone silence, recent acts of violence, intoxication
9. What characteristics does the violent patient lack? Lack of ability emotions to problem solve,
may be unable to communicate the source of their anger
10. Know which scenarios are least restrictive- ones that dont require hands on approach, verbal
intervention, medication, decrease in stimulus, one-on-one observation, sitter who provides 24

hour, presence of significant other, behavioral care plan, taking time out in his own room,
multisensory room, (snoezelen- snooze room)
11. What is Validation therapy in the cognitively impaired? Patients who misperceive their setting or
life situation may be calmed by validation therapy, treating patient with respect and validating
her emotions, showing that you care
12. How important is teamwork of staff in a restraint? do not focus only on whether staff
members were acting like a team that is what it says in the bool but I feel
13. Remember to get an order from the MD for the restraint or seclusion ASAP after it occurs.
a. It is not legal to have a PRN order for restraint or seclusion

Chapt 28
1. Identify 3 indicators of physical abuse, sexual abuse, neglect, and emotional abuse
a. Physical: Bruises, scars, burnsHeadaches, back trouble dizziness, accidents
b. Sexual: may draw sexual explicit images, demonstate sexual aggression, or act out
sexual interaction in play, masturbation, sexual promiscuity , PTSD, anxiety suicide,
aggression, chronic low self esteem, chronc pain, obesity, self mutiliation, substance
abuse
c. Neglect: Undernourished, dirty, poorly clothed, inadequate medical care
d. Emotional: low self esteem, reports feelings of inadequacy, anxiety and withdraw,
learning disabilities, and poor impulse control
2. Identify 2 common emotional responses the nurse might experience when faced with a person
subjected to abuse
a. Anger- toward to abuser, to those who allow it to happen, and toward society for
condoning itsoccurance through attitude, traditions, and laws
b. Embarrassment- the victim is a symbol of something close to home
c. Confusion- ones view of the family as a haven of safety and privacy is challenged
d. Fear- a small percentage of perpetrators are dangerous to others
e. Anguish the nuse may have experienced abuse
f. Helplessness- the nurse may want to do more, eliminate the problem, or cure the victim
and perpetrator
g. Discouragement- may result if not long term solution has been achieved
h. blame the victim mentality- thinks victim provoked the abuse, can occur when nurse
feels overwhelmed, supervision is a must for therapeutic intervention
3. Formulate four nursing diagnosis for the survivor of abuse, and list supporting detail from the
assessment
a. Whole care plan on pg 549
b. From nursing diagnosis care plan:
i. Anxiety with threat to self-concept, situational crisis of abuse

4.

5.
6.

7.

ii. Impaired verbal communication with psychological barriers of fear

iii. Defensive coping with low self esteem
iv. Dysfunctional family processes with inadequate coping skills
v. Insomnia with psychological stress
vi. PTSD with history of abuse
vii. Powerlessness with lifestyle of helplessness
viii. Chronic low self esteem with negative family interactions
Compare and contrast primary, secondary, and tertiary levels of intervention, giving two
intervention for each level-546
a. Primary- measures take to prevent the occurrence of abuse. Identifying individuals and
families at high risk, providing health teaching and coordinating supportive services to
prevent crisis are examples of primary prevention.
i. Specific strategies include 1) reducing stress, 2) reducing the influence of risk
factors 3) increasing social support 4) increasing coping skills 5) increasing self
esteem
b. Secondary-involves early intervention in abusive situation to minimize their disabling or
long-term effects
c. Tertiary- often occurs in mental health settings, involves nurses facilitating the healing
and rehabilitative process by counseling individuals and families, providing support for
groups of survivors and assisting survivors and well-being
Types of neglect
a. Physical, emotional, educational, and medical
Factors that contribute to family violence
a. Pregnancy can start abuse
b. Lower income families are more frequently victims of violence
c. If its occurred before
d. After termination of relationship- most women get abused by previous boyfriends or
someone they know
Cycle of violence-- stages
a. Tension building stage
i. Abuser- edgy has minor explosions may become verbally abusive, minor hitting,
slapping, and other incidents begin
ii. Victim-feels tense and afraid like walking on eggs feels helpless becomes
compliant, accepts blame
b. Serious battering phase
i. Tension becomes unbearabl; the victim may provoke an incident to get it over
with
ii. The victim may try to cover up the inury or may look for help
c. Honeymoon phase
i. Abuser- loving behavior such as bringing gifts and flowers and doring special
things for the victim- contrite, sorry, makes promises to change
ii. Victim- trusting, hoping for change, wants to believe partners promises

8. When is the nurse mandated to report abusewhat population

a. Suspected or actual cases of a child and vulnerable adult abuse
9. Who most often abuses children? Relationship to the child
a. Parents and more specifically mothers
10. Which older adult is most vulnerable to abuse?
a. Female, over 75, Caucasian living with relative and experiencing physical and or mental
impairment
Chapt 29
Who is most often the perpetrator of sexual assault?
Phases of Rape Trauma Syndrome
Do you need patient consent to collect evidence from their body?
Result of being given Rohypnol? How it affects the body
Always give referral verbally and in writing to rape victimReview questions 1-4 on page 563
Chapt 30
1. What are ways the nurse can show respect for the older adult
a. Be aware of the person's health issues. Older adults may have health problems that add
difficulty to speaking and understanding. Be sure you consider the person's health
before you engage in communication. For example, they may have hearing problems,
speech problems, and memory loss.
b. Limit distractions, like turn off tv in room
c. Speak clearly and make eye contact
d. Employ visual aids if needed
e. Keep it SHORT, but be patient with them
f. Ask about overlooked problems
g. Dont interrupt
h. Include the family in the interview process
2. How do the 5 senses change with age
a. All deline with age
3. Danger of anticholinergic effects in the elderly
a. Can produce increased confusion in older adults
4. How to assess pain in a patient with Alzheimers Dementia
a. PAINAD- the scale evaluates 5 domains
i. Breathing
ii. Negative vocalization
iii. Facial expression
iv. Body language
v. And consolability
vi. Diagram of PAINAD chart on 570

5.

6.
7.

8.

vii. 0-1- no pain; 2-3 mild to moderate pain; 4-6 moderate to severe pain; 7-10severe to very severe pain
Describe mental disorders that may occur in older adults pg 566
a. Depression
i. Accounts for 70% of late life suicides
ii. Mens risk of suicide increases with age
iii. Treated by SSRIs
b. Anxiety
i. Also treated with SSRI
c. Delirium
i. Treatment of delirium starts wth finding out the cause
d. Dementia
i. Aphasia, agnosia, and apraxia
e. Alcohol abuse
i. Risk factor- male and single
ii. Display symptoms of confusion, malnutrition, self-neglect, weight loss,
depression and falls
iii. Alcohol induced dementia
f. Pain
i. Arthritis, peripheral vascular diseaseand diabetic neuropathy
ii. Chronic pain can cause depression, low self esteem social isolation and feeling
of hopelessness
Discuss facts and myths about aging
a. Chart over this on 575
Analyze how ageism may affect attitudes and willingness to care for older adults
a. Ageism is dsicrimiation against older people because of their age so they would not be
very willing to care to older adults and if they had to, they would not have a good
attitude
Describe the role of the nurse in various geriatric care settings
a. Skilled nurse facilities/ nursing home
i. Stabilizing environment for a person with severe mental illness who thrives
within the structure of a therapeutic environment
ii. Nurse can do: medication management, monitoring and documenting
behavioral changes, notifying the physician of behavioral changes, and planning
care for the needs of those residents with mental illnesses
b. Residential care settings
i. For pt with chronic and persistent mental illness (schizophrenia)
c. Partial hospitalization
i. For ambulatory pts who do not need 24 hr nursing care but require and benefit
from intensive, structured psychiatric day treatment
d. Day treatment programs

i. Provide: health promotionand wellness programs, health screening, social

eduacational and recreational activities, meals, and information and referral
services
ii. For those that need mostly custodial care services
iii. Cared for during day and stay in a home environment at night
e. Behavioral health home care
i. Partially recommended to assist the homebound older adult adjust to and
manage illness and disability either before or after hospitalization
ii. Local home care- housekeeping, meal preparations, assistance with daily living,
have enduring mental illness, have behavioral issues related to their physical
illness
f. Community based program
i. Alternate to promote the older adults independence functioning and reduce
the stress on the family system.
ii. Has specialized case management that assist older adults with coordination of
care and with entitlements

Chapt 31
a. Who are the seriously mentally ill?
Someone who has schizophrenia, depression, anxiety, borderline anxiety
disorders
Disorders that last for a lifetime
b. What is the ACT program
c. Anosogosia
They arent aware that they have itthey dont know that anything is wrong
d. What do case managers do for the seriously mentally ill?
e. What is NAMI
National Alliance of the Mental Ill
Where families of the mentally ill and people who work in the mental helath
professions come and lobby to get more resources
They try to educate society on why to not stigmatize the mentally ill
f. Life expectancy of the SMI compared to the general population
a. Its a lot lower, they typically do not live as long
g. What is a depot injection
a. A long acting/lasting antipsychotic (Haldol,Respirdol), its a thick medicine that is given
to patients that are non compliant so they give it to them to calm them down
Chapt 32

a. When would you not restrain a patientwhen would it initiate a severe psychological
reaction?
a. When it has the ability to cause more harm (ex: a patient with PTSD)
b. Assessing for suicide and violence in prisons (pg. 603)
a. Mental healthcare and physical healthcare are a constitutional right to inmates
c. How can the SANE nurse assess the legal sanity of an individual charged with crime?
a. Not guilty by reason of insanitythe nurse can give her opinion on whether she thought
the patient was insane/mentally ill when they committed their crime
d. Does the SANE nurse judge competency to proceed with a trial
e. When is the SANE nurse a Fact witness, expert witness?
a. SANE(sexual assault nurse examiner) Nurse: forensic nurse generalists who seek training
in the care of adult and pediatric victims of sexual assault
b. Fact: An individual that is considered by the court to be capable and qualified to
summarize and explain complex and voluminous medical records and medical
terminology to the jury
c. Expert: Recognized by the court as having a certain level of skill or expertise in a
designated area and possesses superior knowledge because of education or specialized
experience
f. What is a criminal profiler
a. Attempts to provide law enforcement officials with specific information about the type
of individual who may have committed a certain crime
g. What is a forensic hospital
a. A forensic psychiatric hospital is a secure psychiatric hospital, generally used to provide
treatment to individuals with serious mental illness who have been charged with a
crime, but are considered incompetent to stand trial or have been found guilty by
reason of insanity.
h. More mentally ill receive treatment in prisons than is inpatient psych units
i. Required credentials of a nurse expert witness
a. Establishment of Expertise
i. Academic preparation, Professional training, practical working experience in the
field, involvement in professional organizations, research and publications in the
area of expertise
b. Establishment of Trustworthiness and Objectivity
i. Comfortable with self, good presentation style, successful communication to
jury
ii. Dress, manner, and performance that communicate professionalism
Chapt 33
a. Therapeutic factors in groupThey are aspects of the group experience that leaders and
members have identified as curative and facilitative and therapeutic change
a. Group Content: all that is said in the group
b. Group Process: dynamics of interaction amongst members

b.
c.

d.

e.

c. Group Norms: Expectations for behavior in the group that develop over time
d. Group Themes: Members expressed ideas or feelings that recur and share a
commonality
e. Feedback: Providing group members with awareness about how they affect each other
f. Conflict: Open disagreement amongst members
What is universality
a. When members realize that they are not alone with their problems, feelings or thoughts
Subgroup behavior
a. Where people form their own little in the midst of a big group, during a group session
that undermines the purpose of the group
Open vs closed groups
a. Open groups: People are able to walk in whenever they want
b. Closed: Random people are not able to join in the group
Member task roles
a. Keeps the group focused on its main purpose and get the work done
b. Coordinator: tries to connect ideas and suggestions
c. Elaborator: gives examples and follows up meaning of ideas
d. Energizer: Encourages group to make decisions or take action
e. Evaluator: Measures the groups work against objectives
f. Information giver: Provides facts or shares experience as an authority figure
g. Initiator-Contributor: Offers new ideas or a fresh outlook on an issue
h. Opinion Giver: Shares opinions
i. Orienter: Notes the progress of the group toward goals
j. Procedural Technician: Supports group activity with physical tasks
k. Recorder: Keeps notes, acts as the groups memory

Chapt 34
a. What are blended families, nuclear families
b. What does the nurse do first in a family assessment
a. Find out who each member of the family are, know the relationship to the identified
patient
c. Scapegoating
a. One person in the family that they blame all of their problems everything on
d. Identified patient(IP)
a. The patient that the family blames things on and that they feel has the problem
e. Double-bind communication
a. A way that a lot of people communicate (especially couples)
b. They are like mixed messages
c. Guilt Trip: You can go out with you friendsI mean Im miserable but you can go out
with your friends I dont mind
f. Triangulation
g. Boundaries (clear, enmeshed, rigid)

a. Enmeshed: Families that are so closethere are no division of roles in the family
b. There is no individuality within the family, people take on other people problems even
though you may have done nothing wrong

Chapt 35
a. What has research recently shown about benefits of Gingko?
a. Used to improve memory
b. Research shows that it doesnt actually improve memory
b. Who is at risk in aromatherapy
a. If you have asthma this can trigger symptoms
c. What is acupuncture
d. Complementary and alternative medicines
a. Alternative: Meditation, Herbs, natural, movement therapy
e. How does St Johns Wort cause serotonin syndrome
f. How are conventional health and CAM different
g. What are the greatest danger of taking too much Kava and Vit E?
a. They can cause Cirrhosis