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Flashcards in Exam 1 power points Deck (12)
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1

Assessment

1) Establish rapport
2) Understand the current or chief problem
3) Review physical status and obtain vital signs
4) Assess for risk factors affecting the patient’s safety (assess for SI/HI)
5) Perform a Mental Status Examination (MSE)
6) Assess psychosocial status
7) Identify mutual goals for treatment

2

When performing a nursing assessment for a new intake on the psychiatric unit, the nurse must assess many areas to determine care in treatment planning. Which of the following assessments are vital upon initial assessment for care? (Select all that apply).
A. The mental status exam
B. Risk factors for SI or HI
C. Financial status and concerns
D. Sexual, cultural and spiritual needs E. Physical status and vital signs

A. The mental status exam
B. Risk factors for SI or HI
E. Physical status and vital signs

3

Diagnosis
* NANDA Nursing Diagnosis
* Clinical judgment about a patient’s response, needs, actual & potential psychiatric disorders, mental health problems, and potential physical illnesses lead to diagnosis
* 3-structural components:

1. Problem (unmet need)
2. Etiology (probable cause)
3. Supporting data (signs & symptoms)

4

Implementation

• Coordination of care
• Milieu therapy
• Health teaching & promotion
• Therapy & Pharmacological

5

Documentation is a legal aspect, it includes

1) Client’s Condition
2) Informed Consents (medication & treatments)
3) Reaction to Medications
4) Document Symptoms
5) Concerns of client or incidents
6) Patient Progress

6

Which of these techniques are utilized for clarification in therapeutic communication? (Select all that apply)
A. Restating
B. Interpreting
C. Reflection
D. Paraphrasing
E. Exploration

A. Restating
C. Reflection
D. Paraphrasing
E. Exploration

7

Nurse-client relationship – to establish repoire with client to understand nurse role as being

1) Safe
2) Reliable
3) Consistent
4) Confidential
5) Appropriate, clear boundaries are identified

8

Establishing a Therapeutic Relationship

1) Genuineness
o self awareness of one’s own feelings
2) Empathy
o entering another’s world, being sensitive, without
making judgments
3) Positive Regard
o respect - displayed by attitude’s and actions

9

Therapeutic Skills
1) Facilitating
2) Assisting
3) Helping
4) Promoting

1) Facilitating communication of distressing thoughts and feelings
2) Assisting client’s with problem solving to help facilitate
activities of daily living (ADL’s)
3) Helping client’s examine self-defeating behaviors and test alternatives
4) Promoting self-care and independence

10

Classification system of mental disorders found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
- Former Classification may still be seen in hospital charts in Axis I – V format:
Axis-I -
Axis-II -
Axis-III -
Axis-IV -
Axis V -

Axis-I - Psychiatric Disorder
Axis-II - Personality Disorders/IDD
Axis-III - Medical Conditions
Axis-IV – Psychosocial/Environmental Issues
Axis-V – Global Assessment of Functioning

11

1996 first law enacted which required insurers to provide for mental health and substance abuse that was not being provided and subsequent laws reinforced in 2002

Mental Health Parity

12

organization dedicated to education and advocacy for those with mental illness

NAMI