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NCLEX-RN (6) Mental Health > Crisis & Abuse > Flashcards

Flashcards in Crisis & Abuse Deck (44)
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Should the nurse ever leave a client in physical or emotional distress?

Never leave a client in distress.


What is a crisis?

A crisis situation is a stressful time when there is a breakdown or disruption in the usual or normal daily activities for a person, group, or community.


What is a maturational crisis?

A maturational crisis relates to normal developmental stages that a client would go through such as marriage, birth of a child, or retirement.

These changes can be very traumatic for some.


What is a situational crisis?

A situational crisis is an unanticipated life event such as losing a job, death of a loved one, divorce, abortion, or severe illness.


What is an adventitious crisis?

An adventitious crisis is the result of a disaster and is not a part of everyday life.

Examples are natural disasters, violence, or abuse.


What is the nurse's role when a client is experiencing a crisis?

  • assess the client's perception of the crisis
  • encouraging expression of feelings and ways to cope

Clients will have different responses to the same crisis.


What is grief?

Grief is a normal emotional response to loss.


What is the first stage of grief?

The first stage of grief is denial.


What is the second stage of grief?

The second stage of grief is anger.


What is the third stage of grief?

The third stage of grief is bargaining.


What is the fourth state of grief?

The fourth stage of grief is depression.


What is the fifth stage of grief?

The fifth stage of grief is acceptance.


What is dysfunctional grief?

Dysfunctional grief is when there is prolonged emotional instability and a lack of moving through the stages of grief.


What is loss?

Loss is the absence of something desired.


What is mourning?

Mourning is the outward and social expression of loss. 


What is bereavement?

Bereavement includes grief and mourning. It is the feeling of sadness and loneliness someone experiences from a loss.


What is the main role of the nurse when a client is experiencing grief and loss?

The nurse's role during grief and loss is to communicate with the client, family members, and significant other:

  • figure out who is the spokesperson for the family
  • consider cultural, religious, or spiritual practices
  • use therapeutic communication
  • seek help if unsure how to respond


Is it OK to cry with the client and family during the grieving process?

Yes, don't be afraid to show some emotion.

Contact a bereavement specialist if unsure how to proceed with client.


What are reported feelings of suicidal clients?

Suicidal clients will report overwhelming feelings of worthlessness, guilt, and hopelessness. 


What are risk factors for suicide?

  • previous attempts and family history of suicide attempts
  • past psychiatric hospitalizations


Which age is most at risk for suicide?

Adolescents and older adults


What types of mental health disorders put a client at risk for suicide?

  • disabled or terminally ill clients
  • dementia
  • depressed
  • psychotic
  • substance abuse

Always ask these clients if they have a plan for suicide.


What are cues that the client may have a plan for suicide?

Immediate complication

  • giving away meaningful belongings
  • sudden improvement in mood
  • making a will or getting an insurance policy
  • statements indicating intent to attempt suicide
  • sudden overall physical and mental deterioration



What is asked in a suicide assessment?

Suicide assessment includes asking:

  • Do you have a suicide plan?
  • Do you have any guns in the house?
  • Have you attempted suicide in the past?
  • Are there any mental health disorders?
  • Do you live alone or alienated from others?


What are the interventions for acute suicide risk?

Acute suicide risk interventions are:

  • one-on-one constant monitoring
  • take out all harmful objects in room
  • develop a no-suicide contract with client
  • document behavior and mood assessment every 15 minutes
  • don't allow client to leave unit unless with a staff member


What are the interventions for suicide after the acute period of suicide risk is over?

Interventions for suicide after the acute period:

  • encourage client to talk about feelings
  • encourage participation in own care
  • keep client active
  • identify support systems


What are some common abusive behaviors exhibited by clients?

  • anger
  • aggression
  • violence


What should the nurse do immediately if a client is being violent?

Immediate complication

  • approach the client calmly and communicate with a calm and clear tone of voice
  • maintain a safe distance away from client
  • maintain a non-aggressive posture
  • listen actively and acknowledge anger
  • determine what their need is
  • call security if client does not calm down


If a client or caretaker's life is in immediate danger what should the nurse do as a last resort?

Implement restraints and/or seclusion.


What is abuse?

Abuse includes nonaccidental physical injury, neglect, and physical/sexual/emotional maltreatment. 


What is a common assessment question for violence and abuse screening that every client should be asked?

Ask the client, "Do you feel safe in your work and home environment?"


What should the nurse teach parents about child abduction?

Teach parents to speak with children about personal safety:

  • don't go anywhere alone
  • Say NO if you are in an uncomfortable situation
  • report to a trusted adult if the child is asked to keep a secret, help to look for a lost dog or gets offers of candy or gifts



What are signs of neglect in a child?

  • poor hygiene
  • malnourished
  • consistent hunger and fatigue
  • misses a lot of school


What are signs of physical abuse in a child?

  • unexplained bruises, burns, and fractures
  • bald spots on head
  • extremely aggressive (seen in boys)
  • very withdrawn (seen in girls)
  • doesn't cry
  • poor school performance


What are signs of emotional abuse in a child?

  • speech disorders
  • habits such as rocking and sucking
  • learning disorders
  • suicide attempts


What are signs of sexual abuse in a child?

  • difficulty walking and sitting
  • pain, swelling, itching, and trauma of genitals
  • bloody and torn underwear
  • refuses to change clothes or participate in gym activities


What are signs of shaken baby syndrome?

  • no obvious outside signs of trauma
  • retinal hemorrhage
  • full and bulging fontanels due to increased ICP

Teach clients to NEVER shake a baby.


What should a nurse do if there is suspected abuse or neglect of a client?

  • report to appropriate authorities
  • assess for injuries
  • help develop a safety plan
  • refer abuser to support groups

Appropriate authorities would be: child protective services or adult protective services.


Which type of older adults are most at risk for abuse?

  • dependent and immobile due to illness
  • altered mental status


What are signs of neglect in an older client?

  • disheveled appearance
  • dehydrated and malnourished
  • missing adaptive needs such as glasses, hearing aids, and dentures


Is an adult rape victim required by law to report the incident?

No, the victim does not have to report.


What should the nurse do if a client is suspected of being raped?

  • stay with victim
  • treat immediate physical injuries
  • assess stress level before treatments and procedures


What should the rape victim avoid before the examination by the nurse?

The rape victim should not shower, bathe, douche or change clothing until the exam is performed.

The evidence can get washed away.


What should be done next after the physical exam for rape is over?

Refer the rape victim to crisis intervention and support groups.