Final Exam Flashcards

Question

Effects of Alcohol on the Body

Answer 1

Peripheral neuropathy, characterized by: - Peripheral nerve damage - Pain - Burning - Tingling - Prickly sensations of the Extremities Alcoholic myopathy - Thought to result from same B vitamin deficiency that contributes to peripheral neuropathy (thiamine) - Acute: Sudden onset of muscle pain, swelling, and weakness; reddish tinge to the urine; rapid rise in muscle enzymes in the blood - Chronic: Gradual wasting and weakness in skeletal muscles Wernicke’s encephalopathy: Most serious form of thiamine deficiency Korsakoff’s psychosis: Syndrome of confusion, loss of recent memory, and confabulation in alcoholic patients Alcoholic cardiomyopathy: - Effect of alcohol on the heart is an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition. Esophagitis: - Inflammation and pain in the esophagus Gastritis: - Effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention Pancreatitis - Acute: Usually occurs 1 or 2 days after a binge of excessive alcohol consumption. Symptoms include constant, severe epigastric pain; nausea and vomiting; and abdominal distention. - Chronic: Leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus Alcoholic hepatitis - Enlarged, tender liver; nausea and vomiting; lethargy; anorexia; elevated white blood cell count; fever; and jaundice. Cirrhosis of the liver - Portal hypertension, Ascites, Esophageal varices, Hepatic encephalopathy Leukopenia Thrombocytopenia Sexual dysfunction

Answer 2

Alcohol intoxication: - Occurs at blood alcohol levels between 100 and 200 milligrams per deciliter - Legal intoxication: 0.8 g/dL Alcohol withdrawal: - Occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use - Coarse tremor of hands, tongue, or eyelids; Nausea or vomiting; Malaise or weakness; Tachycardia; Sweating; Elevated blood pressure; Anxiety; Depressed mood or irritability; Transient hallucinations or illusions; Headache; and Insomnia Detox: feels like bugs are crawling on them, tremors***

Answer 3

Effects on sleep and dreaming - Decreases the amount of sleep time spent in dreaming. Respiratory depression - Slow breathing*** Cardiovascular effects - Hypotension Hepatic effects - Jaundice Body temperature - Decrease Sexual functioning - Initial increase in libido, then difficulty having an erection Intoxication: - Effects can range from disinhibition and aggressiveness to coma and death - Inappropriate sexual or aggressive behavior, mood lability, impaired judgment, or impaired social or occupational functioning; speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor or coma. Withdrawal: - Onset of symptoms depends on the half-life of the drug from which the person is withdrawing. - Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100), increased hand tremor, insomnia, nausea or vomiting, hallucinations, illusions, depersonalization, psychomotor agitation, anxiety, grand mal seizures, and delirium

Answer 4

Effects on Body - CNS effects: tremor, restlessness, anorexia, insomnia, agitation, and increased motor activity - Cardiovascular effects: Increased heart rate - Pulmonary effects: rhinitis - Gastrointestinal and renal effects: Caffeine = diuretic. Amphetamines = constipation. Nicotine = diarrhea - Sexual functioning: Increase sexual urges Intoxication - Amphetamine and cocaine intoxication produce euphoria, impaired judgment, confusion, and changes in vital signs (even coma or death, depending on amount consumed). - Caffeine intoxication usually occurs following consumption in excess of 250 milligrams. Restlessness and insomnia are the most common symptoms DILATED PUPILS Withdrawal - Amphetamine and cocaine withdrawal may result in dysphoria, fatigue, sleep disturbances, and increased appetite. - Withdrawal from caffeine may include headache, fatigue, drowsiness, irritability, muscle pain and stiffness, and nausea and vomiting. - Withdrawal from nicotine may include dysphoria, anxiety, difficulty concentrating, irritability, restlessness, and increased appetite.

Answer 5

CIWA - Assess risk and severity of withdrawal from alcohol - Nausea and Vomiting? - Tremors? - Paroxysmal sweats? - Anxiety? - Agitation? - Tactile disturbances? - Auditory disturbances? - Visual disturbances? - Headache, fullness in head? - Orientation and clouding of sensorium? MAST - Do you enjoy a drink now and then? - Do you feel you are a normal drinker? - Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening? - Does your wife, husband, parent, or other near relative ever worry or complain about your drinking? - Can you stop drinking without a struggle after one or two drinks? - Do you ever feel guilty about your drinking? - Do friends or relatives think you are a normal drinker? - Are you able to stop drinking when you want to? - Have you ever attended a meeting of Alcoholics Anonymous (AA)? etc.. 5 or more yes: problems with alcohol CAGE - Have you ever felt you should Cut down on your drinking? - Have people Annoyed you by criticizing your drinking? - Have you ever felt bad or Guilty about your drinking? - Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)? 2 or 3 yes: problems with alcohol

Answer 6

Impairment in the cognitive functions of thinking, reasoning, memory, learning, and speaking - Mild has also been called mild cognitive impairment - Major NCD = dementia - Primary NCDs are those in which the disorder itself is the major sign of some organic brain disease not directly related to any other organic illness (Alzheimer's Disease) - Secondary NCDs are caused by or related to another disease or condition (e.g. HIV Disease or Cerebral Trauma)

Answer 7

Impairment exists in abstract thinking, judgment, and impulse control Conventional rules of social conduct are disregarded Personal appearance and hygiene are neglected Language may or may not be affected Personality change is common As disease progresses... - Aphasia: inability to speak - Apraxia: inability to carry out motor activities despite intact motor function - Irritability and moodiness, with sudden outburts over trivial issues - Inability to care for personal needs independently - Wandering away from the home - Incontinence

Answer 8

No apparent symptoms. - There is no apparent decline in memory despite changes that are beginning to occur in the brain - PET scan can detect changes Mean score: 57.2 (9.2)

Answer 9

Very mild change. - Begins to lose things or forget names of people. - Losses in short-term memory are common. - Individual is aware of the intellectual decline; may feel ashamed, anxious and depressed, which in turn may worsen the symptom. - Symptoms often not noticed by others and do not interfere with ability to work or live independently. MSE: 37 (7.8)

Answer 10

Mild cognitive decline. - Changes in thinking and reasoning interfere with work performance and become noticeable to coworkers. - May get lost when driving his or her car - Concentration may be interrupted - Difficulty recalling names or words, becomes noticeable to family and close associates. - Decline occurs in the ability to plan or organize. MSE: 13.4 (8.1)

Answer 11

Moderate cognitive decline. - May forget major events in personal history - Declining ability to perform tasks, such as shopping, cooking, and managing personal finances - Unable to understand current news events. - Confabulation (creating imaginary events to fill in memory gaps) - Depression and social withdrawal are common. - Requires some assistance to maintain safety.

Answer 12

Moderately severe cognitive decline. - Lose the ability to perform some ADLs independently - May forget addresses, phone numbers, and names of close relatives. - May become disoriented about place and time, but maintain knowledge about themselves. - Frustration, withdrawal, and self-absorption are common.

Answer 13

Severe cognitive decline. - May be unable to recall the name of their spouse or may misidentify people - Disorientation to surroundings is common, may be unable to recall the day, season, or year - Unable to manage ADLs without assistance. - Delusions often become apparent - Urinary and fecal incontinence are common - Sleeping problems - Wandering, obsessiveness, agitation, and aggression - Sundowning: Symptoms seem to worsen in the late afternoon and evening - Communication becomes more difficult with increasing loss of language skills.

Answer 14

Very severe decline - Unable to recognize family members. - He or she most commonly is bedfast and aphasic. - Problems of immobility, such as decubiti and contractures, may occur.

Answer 15

NCD occurs as a result of significant cerebrovascular disease There is a more abrupt onset than is seen in Alzheimer’s, and the course is more variable Etiologies may include: - Hypertension - Cerebral Emboli - Cerebral Thrombosis

Answer 16

Characterized by a disturbance in level and awareness and a change in cognition Duration is usually brief and subsides completely on recovery from underlying determinant** Difficulty sustaining and shifting attention Extreme distractibility Disorganized thinking Speech that is rambling, irrelevant, pressured, and incoherent Impaired reasoning ability and goal=directed behavior Disorientation to time and place Impairment of recent memory Misperceptions about the environment, including illusions and hallucinations Disturbance in LOC, with interruption of the sleep-wake cycle Psychomotor activity that fluctuates between agitation and restlessness and a vegetative state Emotional instability Autonomic Manifestations** - Tachycardia - Sweating - Flushed face - Dilated pupils - Elevated Blood Pressure

Answer 17

Infections, febrile illness, metabolic disorders, head trauma, seizures, migraine headaches, brain abscess, stroke, electrolyte imbalance, and others

Answer 18

May be caused by intoxication or withdrawal from certain substances such as: Anticholinergics, antihypertensives, corticosteroids, anticonvulsants, analgesics, and others Alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, and others Toxins, including organic solvents and fuels, lead, mercury, arsenic, carbon monoxide, and others

Answer 19

Reversible may be more appropriately termed temporary dementia It can occur as a result of: Stroke Depression Side effects of medication Nutritional Deficiencies Metabolic Disorders

Answer 20

Occurs as a result of shrinking of the frontal and temporal anterior lobes of the brain Previously called Pick’s Disease Exact cause is unknown, but genetics seem to be a factor Symptoms - Behavioral and personality changes - Speech and language problems

Answer 21

Amnesia is the most common neurobehavioral symptom following head trauma Repeated head trauma can result in dementia pugilistica with symptoms of: - Emotional lability - Dysarthria - Ataxia - Impulsivity

Answer 22

Similar to AD, but progresses more rapidly Appearance of Lewy Bodies in the Cerebral Cortex and Brainstem Progressive and irreversible

Answer 23

Caused by a loss of nerve cells in the substantia nigra and decrease in dopamine activity Cerebral changes in NCD due to parkinson’s disease sometimes resembles those of AD

Answer 24

Caused by Brain Infections with opportunistic organisms or by the HIV-1 virus directly Symptoms may range from barely perceptible changes to acute delirium to profound cognitive impairment

Answer 25

Huntington’s Disease is transmitted as a mendelian dominant gene Damage occurs in the areas of the basal ganglia and the cerebral cortex The patient usually declines into a profound state of dementia and ataxia Average course of the disease is based on age at onset, with juvenile-onset and late-onset having the shortest durations

Answer 26

The disorder is attributable to prion disease (e.g., Creutzfeldt-Jakob Disease or Bovine Spongiform Encephalopathy) Onset of symptoms typically occurs between ages 40 and 60 years, course is extremely rapid, with progression from diagnosis to death in less than 2 years

Answer 27

Hypothyroidism Hyperparathyroidism Pituitary Insufficiency Uremia Encephalitis Brain tumor Pernicious anemia Thiamine deficiency Multiple Sclerosis Pellagra Uncontrolled Epilepsy Cardiopulmonary insufficiency Fluid and electrolyte imbalance CNS and systemic infection SLE

Answer 28

History - Type, frequency, and severity of mood swings - Personality and behavioral changes - Catastrophic emotional reactions - Cognitive changes - Language difficulties - Orientation to person, place, time, and situation - Appropriateness of social behavior - Current and past use of medications, drugs, and alcohol - Possible exposure to toxins - Pt and family history of specific illnesses Assessment - Assessment for diseases of various organ systems that can induce confusion, loss of memory, and behavioral changes - Neuro Exam to assess mental status, alertness, muscle strength, reflexes, sensory perception, language skills, and coordination Labs Include blood and urine to test for: - Various infections - Hepatic and renal dysfunctions - Diabetes or hypoglycemia - Electrolyte imbalances - Metabolism and endocrine disorders - Nutritional deficiencies - Presence of toxic substances Diagnostics - Electroencephalogram - CT Scan - PET scan - MRI - Lumbar Puncture - Amyloid PET scan techniques

Answer 29

Goals - Call for assistance when ambulating or carrying out other activities - Maintain a calm demeanor, with minimal agitated behavior. - Will not experience physical injury. Interventions - Arrange furniture and other items in the room to accommodate patient’s disabilities. - Store frequently used items within easy access. - Do not keep bed in an elevated position. Pad siderails and headboard if client has history of seizures. Keep bedrails up when patient is in bed - Assign room near nurses’ station; observe frequently. - Assist patient with ambulation. - Keep a dim light on at night. - If patient is a smoker, cigarettes and lighter or matches should be kept at the nurses’ station and dispensed only when someone is available to stay with patient while he or she is smoking. - Frequently orient to place, time, and situation. - If patient is prone to wander, provide an area within which wandering can be carried out safely. - Soft restraints may be required if patient is very disoriented and hyperactive.

Answer 30

Goals - Will utilize measures provided (e.g., clocks, calendars, room identification) to maintain reality orientation. - Will experience fewer episodes of acute confusion. - Will maintain reality orientation to the best of his or her cognitive ability. Interventions 1. Frequently orient patient to reality. Use clocks and calendars with large numbers that are easy to read. Notes and large, bold signs may be useful as reminders. Allow patient to have personal belongings. 2. Keep explanations simple. Use face-to-face interaction. Speak slowly and do not shout 3. Discourage rumination or delusional thinking. Talk about real events and real people. But remember that the patient’s level of reality is different from the nurse’s. Do not lie to the patient. May need to use validation therapy and redirection. 4. Monitor for medication side effects. 5. Encourage patient to view old photograph albums and utilize reminiscence therapy.

Answer 31

Goals - Will exhibit fewer manifestations of disturbed sensory perception - Will maintain reality orientation to the best of his or her cognitive ability. Interventions 1. Do not ignore reports of hallucinations when it is clear that the patient is experiencing them. Need to hear from patient. 2. Rule out the disturbed sensory perception as a possible side effect of certain physical conditions or medications. 3. Check to ensure that hearing aid is working properly and that faulty sounds are not being emitted. 4. Check eyeglasses to ensure that the individual is indeed wearing his or her own glasses. 5. Try to determine from where the visual hallucination is emanating and correct the situation by moving or covering the item. 6. Provide distractions for the patient. Focus on real situations and real people 7. It may be better at times to go along with the patient rather than attempting to distract him or her.

Answer 32

Goals - Will participate in ADLs with assistance from caregiver. - Will accomplish ADLs to the best of his or her ability. - Unfulfilled needs will be met by caregivers. Interventions 1. Provide a simple, structured environment: - Identify self-care deficits and provide assistance as required. Promote independent actions as able - Allow plenty of time for patient to perform tasks. - Provide guidance and support for independent actions by talking the patient through the task one step at a time. - Provide a structured schedule of activities that does not change from day to day. - ADLs should follow usual routine as closely as possible. - Provide for consistency in assignment of daily caregivers. 2. Perform ongoing assessment of patient’s ability to fulfill nutritional needs, ensure personal safety, follow medication regimen, and communicate need for assistance with activities that he or she cannot accomplish independently. 3. Assess prospective caregivers’ ability to anticipate and fulfill patient’s unmet needs. Provide information to assist caregivers with this responsibility.

Answer 33

Goals - Will be able to make needs known to primary caregiver. - Able to understand basic communications in interactions with primary caregiver. - Unfulfilled needs will be met by caregivers. Interventions - Keep interactions with the patient calm and reassuring. - Use simple words, speak slowly and distinctly and maintain face-to-face contact with the patient. - Always identify yourself and call the patient by name at each meeting. - Use nonverbal gestures to help the patient understand what you want him or her to accomplish, if appropriate. - Ask only one question/give only one direction at a time and give the patient plenty of time to process the information and respond. Rephrase question only if it is clear that the patient has not understood the meaning of the direction - Approach the patient from the front whenever possible. - Provide for consistency in assignment of daily caregivers.

Answer 34

- Determination and Correction of the underlying causes - Staff to remain with patient at all times to monitor behavior and provide reorientation and assurance - Room with low stimulus level - Low-dose antipsychotic agents to relieve agitation and aggression - Benzodiazepines commonly used when the etiology is substance withdrawal

Answer 35

Physostigmine (Antilirium) Donepezil (Aricept) - Insomnia, dizziness, gastrointestinal (GI) upset, headache Rivastigmine (Exelon) - Dizziness, headache, GI upset, fatigue Galantamine (Razadyne) - Dizziness, headache, GI upset Memantine (Namenda) - Dizziness, headache, constipation

Answer 36

Risperidone (Risperidal) - Agitation, insomnia, headache, extrapyramidal symptoms Olanzapine (Zyprexa) - Hypotension, dizziness, sedation, constipation, weight gain, dry mouth Quetiapine (Seroquel) - Hypotension, tachycardia, dizziness, drowsiness, headache, constipation, dry mouth Ziprasidone (Geodon)- Haloperidol (Haldol)

Answer 37

SSRIS - Often considered first-line due to favorable side effect profile - Sertraline (Zoloft): Fatigue, insomnia, sedation, GI upset, headache, dizziness - Paroxetine (Paxil): Dizziness, headache, insomnia, somnolence, GI upset Tricyclic antidepressant - Often avoided due to anticholinergic and cardiac side effects - Nortriptyline (Pamelor): Anticholinergic, orthostatic hypotension, sedation, arrhythmia Trazodone (Desyrel) - Good choice for patients with insomnia Dopaminergic Agents - Helpful in treatment of severe apathy

Answer 38

Should not be used routinely for prolonged periods due to tolerance Side effects: Drowsiness, dizziness, GI upset, hypotension, tolerance, dependence Chlordiazepoxide (Librium) Alprazolam (Xanax) Lorazepam (Ativan) Oxazepam (Serax) Diazepam (Valium)

Answer 39

For short term therapy only Flurazepam (Dalmane) Temazepam (Restoril) - Drowsiness, dizziness, GI upset, hypotension, tolerance, dependence Triazolam (Halcion) Zolpidem (Ambien) - Headache, drowsiness, dizziness, GI upset Zaleplon (Sonata) - Headache, drowsiness, dizziness, GI upset Ramelteon (Rozerem) - Dizziness, fatigue, drowsiness, GI upset Eszopiclone (Lunesta) - Headache, drowsiness, dizziness, GI upset, unpleasant taste Trazodone (Desyrel) - Dizziness, drowsiness, dry mouth, blurred vision, GI upset Mitrazapine (Remeron) - Somnolence, dry mouth, constipation, increased appetite

Answer 40

Use of the substance interferes with the ability to fulfill role obligations Attempts to cut down or control use fail Intense craving for the substance Excessive amount of time spent trying to procure the substance or recover from its use Use of the substance causes the person difficulty with interpersonal relationships or to become socially isolated Engages in hazardous activities when impaired by the substance Tolerance develops and the amount required to achieve the desired effect increases Substance-specific symptoms occur upon discontinuation of use

Answer 41

Intoxication - Development of a reversible syndrome of symptoms following excessive use of a substance - Direct effect on the central nervous system - Disruption in physical and psychological functioning - Judgment is disturbed and social and occupational functioning is impaired. Withdrawal - Development of symptoms that occurs upon abrupt reduction or discontinuation of a substance that has been used - Symptoms are specific to the substance that has been used. - Disruption in physical and psychological functioning

Answer 42

- Genetics: Apparent hereditary factor, particularly with alcoholism - Biochemical: Alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction. - Developmental influences: Punitive superego; Fixation in the oral stage of psychosexual development - Personality factors: Certain personality traits are thought to increase a tendency toward addictive behavior. - Cognitive factors: Irrational thinking patterns have long been identified as a problem that is central in addictions -> Denial - Social learning: Children and adolescents are more likely to use substances with parents who provide a model for substance use. - Use of substances may also be promoted within a peer group. - Conditioning: Pleasurable effects from substance use act as a positive reinforcement for continued use of the substance. - Cultural and ethnic influences: Some cultures are more prone to substance abuse than are others.

Answer 43

- Phase I. Pre-alcoholic phase: Characterized by use of alcohol to relieve everyday stress and tensions of life - Phase II. Early alcoholic phase: Begins with blackouts—brief periods of amnesia that occur during or immediately following a period of drinking; alcohol is now required by the person. - Phase III. The crucial phase: Person has lost control; physiological dependence is clearly evident. - Phase IV. The chronic phase: Characterized by emotional and physical disintegration. The person is usually intoxicated more often than sober.

Answer 44

Learning difficulties Speech and language delays Intellectual disability Poor reasoning skills Sleep and sucking problems as a baby Vision or hearing problems Problems with the heart, kidneys, or bones Abnormal facial features Small head size Shorter-than-average height Low body weight Poor coordination Hyperactive behavior Difficulty paying attention Poor memory Difficulty in school

Answer 45

Effects on the body - CNS effects: Ataxia, peripheral and sensorimotor neuropathy, speech problems, and tremor - Respiratory effects: Coughing and wheezing to dyspnea, emphysema, and pneumonia. - Gastrointestinal effects: Abdominal pain, nausea, and vomiting - Renal system effects: renal failure, toxicity Intoxication - Develops during or shortly after use of or exposure to volatile inhalants - Symptoms include: Dizziness, ataxia, muscle weakness Euphoria, excitation, disinhibition, slurred speech Nystagmus, blurred or double vision Psychomotor retardation, hypoactive reflexes Stupor or coma

Answer 46

From short-acting drugs (for example, heroin) - Symptoms occur within 6 to 8 hours, peak within 1 to 3 days, and gradually subside in 5 to 10 days. From long-acting drugs (for example, methadone) - Symptoms occur within 1 to 3 days, peak between days 4 and 6, subside in 14 to 21 days. From ultra-short-acting meperidine - Symptoms begin quickly, peak in 8 to 12 hours, and subside in 4 to 5 days.

Answer 47

Physiological - Nausea/vomiting - Chills - Pupil dilation - Increased blood pressure, pulse - Loss of appetite - Insomnia - Elevated blood sugar - Decreased respirations Psychological - Heightened response to color, sounds - Distorted vision - Sense of slowed time - Magnified feelings - Paranoia, panic - Euphoria, peace - Depersonalization - Derealization - Increased libido Intoxication - Occurs during or shortly after using the drug - Symptoms include perceptual alteration, depersonalization, derealization, tachycardia, and palpitations. - Belligerence and assaultive behavior, and may proceed to seizures or coma

Answer 48

Effects on the body - Cardiovascular - Respiratory - Reproductive - CNS - Sexual functioning Intoxication - Symptoms include impaired motor coordination, euphoria, anxiety, sensation of slowed time, and impaired judgment. - Physical symptoms include conjunctival injection, increased appetite, dry mouth, and tachycardia. - Impairment of motor skills lasts for 8 to 12 hours. Withdrawal - Occurs upon cessation of cannabis use that has been heavy and prolonged. - Symptoms occur within a week following cessation of use. - Symptoms include irritability, anger, aggression, anxiety, sleep disturbances, decreased appetite, depressed mood, stomach pain, tremors, sweating, fever, chills, or headache.

Answer 49

Alcohol - Alcoholics Anonymous: Total abstinence is promoted as the only cure; the person can never safely return to social drinking. - Counseling - Group therapy - Disulfiram (Antabuse): makes the person have a bad reaction to drinking alcohol while on drug - Withdrawal: Benzodiazepines, Anticonvulsants, Multivitamin therapy, Thiamine - Naltrexone (ReVia) - Nalmefene (Revex) - SSRI’s - Acamprosate (Campral) Opioids - Naloxone (Narcan) - Naltrexone (ReVia) - Nalmefene (Revex) - Buprenorphine - Methadone - Clonidine Depressants - Phenobarbital (Luminal) - Long-acting benzodiazepines Stimulants - Minor tranquilizers - Major tranquilizers - Anticonvulsants - Antidepressants Hallucinogens and cannabinols - Benzodiazepines - Antipsychotics

Answer 50

Goals - Patient’s condition will stabilize within 72 hours - Will not experience physical injury Interventions 1. Assess patient’s level of disorientation. 2. Obtain a drug history, if possible. It is important to determine the type of substance(s) used, the time and amount of last use, the length and frequency of use, and the amount used on a daily basis. 3. Obtain a urine sample for laboratory analysis of substance content. 4. Keep the patient in as quiet an environment as possible. A private room is ideal. 5. Observe the patient’s behaviors frequently. If seriousness of the condition warrants, it may be necessary to assign a staff person on a one-to-one basis. 6. Accompany and assist the patient when ambulating and use a wheelchair for transporting the patient long distances. 7. Pad the headboard and side rails of the bed with thick towels. 8. Ensure that smoking materials and other potentially harmful objects are stored away from the patient’s access. Institute suicide precautions, if necessary, for patients withdrawing from CNS stimulants. 9. Monitor the patient’s vital signs every 15 minutes, and less frequently as acute symptoms subside. 10. Follow the medication regimen as ordered by the physician.

Answer 51

Goals - Will focus on behavioral outcomes associated with substance use rather than using deflection to focus on external issues. - Will verbalize acceptance of responsibility for own behavior and acknowledge association between substance use and personal problems. Interventions 1. Begin by working to develop a trusting nurse–patient relationship. Be honest. Keep all promises. 2. Convey an attitude of acceptance. Ensure that he or she understands “It is not you but your behavior that is unacceptable.” 3. Provide information to correct misconceptions about substance abuse. 4. Identify recent maladaptive behaviors or situations that have occurred in the patient’s life and discuss how use of substances may have been a contributing factor. 5. Use confrontation with caring. Do not allow patient to fantasize about his or her lifestyle (e.g., “It is my understanding that the last time you drank alcohol, you …”) 6. Do not accept rationalization or projection as patient attempts to make excuses for or blame his or her behavior on other people or situations. 7. Encourage participation in group activities. 8. Offer immediate positive recognition of patient’s expressions of insight gained regarding illness and acceptance of responsibility for his or her own behavior.

Answer 52

Goals - Will express true feelings about using substances as a method of coping with stress. - Will be able to verbalize adaptive coping mechanisms to use, instead of substance abuse, in response to stress (and demonstrate, as applicable). Interventions 1. Spend time with the patient to establish a trusting relationship. 2. Set limits on manipulative behavior. Be sure that the patient knows what is acceptable, what is not, and the consequences for violating the limits set. Ensure that all staff maintains consistency with this intervention. 3. Encourage the patient to verbalize feelings, fears, and anxieties. Answer any questions he or she may have regarding the disorder. 4. Explain the effects of substance abuse on the body. Emphasize that the prognosis is closely related to abstinence. 5. Explore options available to assist with stressful situations rather than resorting to substance abuse 6. Provide positive reinforcement for evidence of gratification delayed appropriately. Encourage the patient to be as independent as possible in performing his or her self-care. Provide positive feedback for independent decision making and effective use of problem-solving skills.

Answer 53

Goals - Abnormal lab values will be restored to normal. - Patient will gain weight on a regular, nutritious diet. - Patient will be free of signs/symptoms of malnutrition/dehydration. Interventions 1. Parenteral support may be required initially. 2. Encourage cessation of smoking. 3. Consult dietitian. Determine the number of calories required based on body size and level of activity. Document intake and output and calorie count, and weigh patient daily. 4. Ensure that the amount of protein in the diet is correct for the individual patient’s condition. Protein intake should be adequate to maintain nitrogen equilibrium but should be drastically decreased or eliminated if there is potential for hepatic coma 5. Sodium may need to be restricted. 6. Provide foods that are nonirritating to patients with esophageal varices. 7. Provide small frequent feeding of patient’s favorite foods. Supplement nutritious meals with multiple vitamin and mineral tablet.

Answer 54

Cluster A: Behaviors described as odd or eccentric. - Paranoid personality disorder - Schizoid personality disorder - Schizotypal personality disorder Cluster B: Behaviors described as dramatic, emotional, or erratic. - Antisocial personality disorder - Borderline personality disorder - Histrionic personality disorder - Narcissistic personality disorder Cluster C: Behaviors described as anxious or fearful. - Avoidant personality disorder - Dependent personality disorder - Obsessive-compulsive personality disorder

Answer 55

- Characterized by a pervasive, persistent, and inappropriate mistrust of others - Individuals with this disorder are suspicious of others’ motives and assume that others intend to exploit, harm, or deceive them. - The disorder is more common in men than in women. Clinical Picture - Constantly on guard - Hypervigilant - Ready for any real or imagined threat - Trusts no one - Constantly tests the honesty of others - Insensitive to the feelings of others - Oversensitive - Tends to misinterpret minute cues - Magnifies and distorts cues in the environment - Does not accept responsibility for his or her own behavior - Attributes shortcomings to others DSM-5 Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her 4. Reads hidden demeaning or threatening meanings into benign remarks or events 5. Persistently bears grudges, (i.e., is unforgiving of insults, injuries, or slights) 6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

Answer 56

- Characterized primarily by a profound defect in the ability to form personal relationships - Failure to respond to others in a meaningful emotional way - Diagnosis occurs more frequently in men than in women. Clinical Picture - Aloof and indifferent to others - Emotionally cold - No close friends; prefers to be alone - Appears shy, anxious, or uneasy in the presence of others - Inappropriately serious about everything and has difficulty acting in a lighthearted manner DSM-5 A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settingsmbeginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Neither desires nor enjoys close relationships, including being part of a family 2. Almost always chooses solitary activities 3. Has little, if any, interest in having sexual experiences with another person 4. Takes pleasure in few, if any, activities 5. Lacks close friends or confidants other than first-degree relatives 6. Appears indifferent to the praise or criticism of others 7. Shows emotional coldness, detachment, or flattened affectivity

Answer 57

A graver form of the pathologically less severe schizoid personality pattern Clinical Picture - Aloof and isolated - Behaves in a bland and apathetic manner - Magical thinking - Ideas of reference - Illusions - Depersonalization - Superstitiousness - Withdrawal into self - Exhibits bizarre speech pattern - When under stress, may decompensate and demonstrate psychotic symptoms - Demonstrates bland, inappropriate affect DSM-5 A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Ideas of reference (excluding delusions of reference) 2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations) 3. Unusual perceptual experiences, including bodily illusions 4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) 5. Suspiciousness or paranoid ideation 6. Inappropriate or constricted affect 7. Behavior or appearance that is odd, eccentric, or peculiar 8. Lack of close friends or confidants other than first-degree relatives 9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

Answer 58

- A pattern of behavior that is socially irresponsible, exploitative, and without remorse - Behavior reflects a disregard for the rights of others. Clinical Picture - Fails to sustain consistent employment - Fails to conform to the law - Exploits and manipulates others for personal gain - Fails to develop stable relationships - More common in men than in women Common Behaviors - Exploitation and manipulation of others for personal gain - Belligerent and argumentative - Lacks remorse - Unable to delay gratification - Low frustration tolerance - Inconsistent work or academic performance - Failure to conform to societal norms - Impulsive and reckless - Inability to function as a responsible parent - Inability to form lasting monogamous relationship DSM-5 A pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure 3. Impulsivity or failure to plan ahead 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults 5. Reckless disregard for safety of self or others 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations 7 Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Answer 59

- Designated as “borderline” because of the tendency of these clients to fall on the border between neuroses and psychoses. - Characterized by a pattern of intense and chaotic relationships with affective instability - Fluctuating and extreme attitudes regarding other people - Highly impulsive Clinical Picture - Emotionally unstable - Directly and indirectly self-destructive - Lacks a clear sense of identity - More common in women than in men - Instability of interpersonal relationships - Unstable self-image - Marked impulsivity - Intensity of affect and behavior - Chronic depression - Bipolar disorder - Inability to be alone - Clinging and distancing behaviors - Splitting: inability to integrate and accept both positive and negative feelings - Manipulation - Self-destructive behaviors - Impulsivity DSM-5 A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. Identity disturbance: markedly and persistently unstable self-image or sense of self 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days) 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Answer 60

- Behavior is: Excitable, Emotional, Colorful, Dramatic, Extroverted - More common in women than in men Clinical Picture - Self-dramatizing - Attention-seeking - Overly gregarious - Seductive - Manipulative - Exhibitionistic - Highly distractible - Difficulty paying attention to detail - Easily influenced by others - Difficulty forming close relationships - Strongly dependent - Somatic complaints are common DSM-5 A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the center of attention 2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior 3. Displays rapidly shifting and shallow expression of emotions 4. Consistently uses physical appearance to draw attention to self 5. Has a style of speech that is excessively impressionistic and lacking in detail 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion 7. Is suggestible (i.e., easily influenced by others or circumstances) 8. Considers relationships to be more intimate than they actually are

Answer 61

- Characterized by an exaggerated sense of self-worth - Lack of empathy - Belief in an inalienable right to receive special consideration - Diagnosed more often in men than in women Clinical Picture - Overly self-centered - Exploits others in an effort to fulfill own desires - Mood, which is often grounded in grandiosity, is usually optimistic, relaxed, cheerful, and care-free. - Because of fragile self-esteem, mood can easily change if clients do not meet self-expectations or receive the positive feedback that they expect - Criticism from others may cause them to respond with rage, shame, and humiliation. DSM-5 A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love 3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) 4. Requires excessive admiration 5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations) 6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends) 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others 8. Is often envious of others or believes that others are envious of him or her 9. Shows arrogant, haughty behaviors or attitudes

Answer 62

- Characterized by: Extreme sensitivity to rejection and Social withdrawal Clinical Picture - Awkward and uncomfortable in social situations - Desire close relationships but avoid them because of fear of being rejected - Perceived as timid, withdrawn, or cold and strange - Often lonely and feel unwanted - View others as critical and betraying DSM-5 A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection 2. Is unwilling to get involved with people unless certain of being liked 3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed 4. Is preoccupied with being criticized or rejected in social situations 5. Is inhibited in new interpersonal situations because of feelings of inadequacy 6. Views self as socially inept, personally unappealing, or inferior to others 7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Answer 63

- Characterized by a pattern of relying on others for emotional support Clinical Picture - Have a notable lack of self-confidence that is often apparent in: Posture, Voice, Mannerisms - Overly generous and thoughtful, while underplaying own attractiveness and achievements - Low self-worth and easily hurt by criticism and disapproval - Avoid positions of responsibility and become anxious when forced into them DSM-5 A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others 2. Needs others to assume responsibility for most major areas of his or her life 3. Has difficulty expressing disagreement with others because of fear of loss of support or approval 4. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy) 5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself 7. Urgently seeks another relationship as a source of care and support when a close relationship ends 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself

Answer 64

- Predisposing Factors: overcontrol by parents, notable parental lack of positive reinforcement for acceptable behavior, frequent punishment for undesirable behavior - Characterized by inflexibility about the way in which things must be done - Devotion to productivity at the exclusion of personal pleasure - Relatively common - Occurs more often in men than in women - Within the family constellation, it appears to be most common in oldest children. Clinical Picture - Especially concerned with matters of organization and efficiency - Tend to be rigid and unbending - Socially polite and formal - Rank-conscious - Ingratiating with authority figures - Autocratic and condemnatory with subordinates - On the surface, appear to be very calm and controlled - Underneath there is a great deal of: Ambivalence, Conflict, Hostility DSM-5 A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost 2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met) 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification) 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes 8. Shows rigidity and stubbornness

Answer 65

Interpersonal psychotherapy Psychoanalytical psychotherapy Milieu or group therapy Cognitive/behavioral therapy Dialectical behavior therapy Psychopharmacology - treat symptoms

Answer 66

Goals - Patient will seek out staff member if feelings of harming self or others emerge. - Patient will not harm self or others. Interventions 1. Observe patient’s behavior frequently. Do this through routine activities and interactions; avoid appearing watchful and suspicious. 2. Encourage the patient to seek out a staff member when the urge for self-injury intensifies. 3. If self-mutilation occurs, care for patient’s wounds in a matter-of-fact manner. Do not give positive reinforcement to this behavior by offering sympathy or additional attention. 4. Encourage patient to talk about feelings he or she was having just before this behavior occurred. 5. Act as a role model for appropriate expression of angry feelings and give positive reinforcement when attempts to conform are made. 6. Remove all dangerous objects from patient’s environment. 7. Redirect violent behavior with physical outlets for the patient’s anxiety (e.g., exercises, jogging). 8. Have sufficient staff available to indicate a show of strength to the patient if it becomes necessary. 9. Administer tranquilizing medications as ordered by the physician or obtain an order if necessary. Monitor the patient for effectiveness of the medication, for the appearance of adverse side effects, and to ensure that patient is not hoarding medication. 10. If patient is not calmed by “talking down” or by medication, use of mechanical restraints may be necessary. 11. If restraint is deemed necessary, ensure that sufficient staff is available to assist. Follow protocol established by the institution. Provide care with consideration for patient’s trauma history. 12. If warranted by high acuity of the situation, staff may need to be assigned on a one-to-one basis. 13. As agitation decreases, assess the patient’s readiness for restraint removal or reduction. Remove one restraint at a time while assessing the patient’s response.

Answer 67

Goals - The patient will discuss with nurse or therapist maladaptive patterns of expressing anger. - The patient will be able to identify the true source of angry feelings, accept ownership of these feelings, and express them in a socially acceptable manner, in an effort to satisfactorily progress through the grieving process. Interventions 1. Convey an accepting attitude—one that creates a nonthreatening environment for the patient to express feelings. Be honest and keep all promises. 2. Identify the function that anger, frustration, and rage serve for the patient. Allow him or her to express these feelings within reason. 3. Encourage patient to discharge pent-up anger through participation in large motor activities (e.g., brisk walks, jogging, physical exercises, volleyball, exercise bike). 4. Explore with patient the true source of the anger. This is a painful therapy that often leads to regression as the patient deals with the feelings of early abandonment or issues of abuse. 5. Because anger may be displaced onto the nurse, caution must be taken to guard against the negative effects of countertransference. 6. Explain the behaviors associated with the normal grieving process. Help the patient recognize his or her position in this process 7. Help the patient understand appropriate ways to express anger. Give positive reinforcement for behaviors used to express anger appropriately. Act as a role model. It is important to let the patient know when he or she has done something that has generated angry feelings in you. 8. Set limits on maladaptive behaviors and explain consequences of violation of those limits. Be supportive, yet consistent and firm in caring for this patient.

Answer 68

Goals - Patient will discuss with nurse or therapist behaviors that impede the development of satisfactory interpersonal relationships. - Patient will interact appropriately with others in the therapy setting in both social and therapeutic activities (evidencing a discontinuation of splitting and clinging and distancing behaviors). Interventions 1. Encourage patient to examine maladaptive behaviors (to recognize that they are occurring). 2. Reinforce that you will be available, without reinforcing dependent behaviors. 3. Rotate staff members who work with the patient in order to avoid patient’s developing dependence on particular individuals. 4. Discuss with patient and other staff members when it is apparent that the patient is pitting one staff member against another.Do not listen as patient tries to degrade other staff members. Suggest instead that the patient discuss the problem directly with the staff person involved. 5. With the patient, explore feelings that relate to fears of abandonment and engulfment. Help him or her to understand that clinging and distancing behaviors are engendered by these fears. 6. Help patient explore how these behaviors interfere with satisfactory relationships. 7. Assist patient to work toward achievement of object constancy. Be available, without promoting dependency. 8. Provide education, support, and referral resources for family members and significant others who may also experience anger and frustration at failed attempts to navigate interpersonal relationships with this individual.

Answer 69

- A reaction to an extreme trauma, which is likely to cause pervasive distress to almost anyone - Symptoms may begin within the first 3 months after the trauma, or there may be a delay of several months or even years. - The full symptom picture must be present for more than 1 month and cause significant interference with social, occupational, and other areas of functioning. The disorder can occur at any age. Characteristic symptoms include - Reexperiencing the traumatic event - A sustained high level of anxiety or arousal - A general numbing of responsiveness - Intrusive recollections or nightmares - Amnesia to certain aspects of the trauma - Depression; survivor’s guilt - Substance abuse - Anger and aggression - Relationship problems

Answer 70

Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. Recurrent distressing dreams in which the content and/or effect of the dream is related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content. 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Persistent avoidance of stimuli associated with the traumatic event(s) beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) 2. Avoidance of or efforts to avoid external reminders Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: 1. Inability to remember an important aspect of the traumatic event(s) 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Answer 71

Similar to PTSD in terms of precipitating traumatic events and symptomatology Symptoms are time limited: up to 1 month following the trauma. If the symptoms last longer than 1 month, the diagnosis is PTSD. Same Symptoms as PTSD Exhibits the characteristic symptoms in the categories of exposure, intrusion, avoidance, negative cognitions/mood, and arousal/reactivity. More prevalent among females than males Rape and Interpersonal Violence more common

Answer 72

Presence of nine (or more) of the following symptoms INTRUSION SYMPTOMS 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. 4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). NEGATIVE MOOD 5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). DISSOCIATIVE SYMPTOMS 6. An altered sense of the reality of one’s surroundings or oneself 7. Inability to remember an important aspect of the traumatic event(s) AVOIDANCE SYMPTOMS 8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 9. Efforts to avoid external reminders AROUSAL SYMPTOMS 10. Sleep disturbance (e.g., difficulty falling or staying asleep, or restless sleep). 11. Irritable behavior and angry outbursts 12. Hypervigilance. 13. Problems with concentration. 14. Exaggerated startle response.

Answer 73

Psychosocial Theory - The Traumatic Experience: Severity and duration of the stressor, Extent of anticipatory preparation before onset, Exposure to death, Numbers affected by life threat, Extent of control over recurrence, Location where trauma was experienced - The Individual: Degree of ego-strength, Effectiveness of coping resources, Presence of preexisting psychopathology, Outcomes of previous experiences with stress/trauma, Behavioral tendencies, Current psychosocial developmental stage, Demographic factors - The Recovery Environment, Availability of social supports, Cohesiveness and protectiveness of family and friends, Attitudes of society regarding the experience, Cultural and subcultural influences Learning Theory - Negative reinforcement leads to the reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. - Avoidance behaviors: avoiding situations/people that remind them of trauma Cognitive Theory - A person is vulnerable to PTSD when fundamental beliefs are invalidated by experiencing trauma that cannot be comprehended and when a sense of helplessness and hopelessness prevail. Biological aspects - Suggested that the symptoms related to the trauma are maintained by the production of endogenous opioid peptides that are produced in the face of arousal, and which result in increased feelings of comfort and control. - When the stressor terminates, the individual may experience opioid withdrawal, the symptoms of which bear a strong resemblance to those of PTSD.

Answer 74

Goals - Patient will begin a healthy grief resolution, initiating the process of psychological healing (within time frame specific to individual) - Patient will demonstrate ability to deal with emotional reactions in an individually appropriate manner. - The patient will integrate the traumatic experience into his or her persona, renew significant relationships, and establish meaningful goals for the future. Interventions 1. Assign the same staff as often as possible. Use a nonthreatening, matter-of-fact but friendly approach. Respect patient’s wishes regarding interaction with individuals of opposite gender at this time Be consistent; keep all promises; convey acceptance; spend time with patient. 2. Stay with patient during periods of flashbacks and nightmares. Offer reassurance of safety and security and that these symptoms are not uncommon following a trauma of the magnitude he or she has experienced. 3. Obtain accurate history from significant others about the trauma and the patient’s specific response. 4. Encourage the patient to talk about the trauma at his or her own pace. Provide a nonthreatening, private environment, and include a significant other if the patient wishes. Acknowledge and validate patient’s feelings as they are expressed. 5. Discuss coping strategies used in response to the trauma as well as those used during stressful situations in the past. Include available support systems, including religious and cultural influences. Identify maladaptive coping strategies 6. Assist the individual to comprehend the trauma if possible. Discuss feelings of vulnerability and the individual’s “place” in the world following the trauma.

Answer 75

Goals - Patient will verbalize feelings (guilt, anger, self-blame, hopelessness) associated with the trauma. - Patient will demonstrate progress in dealing with stages of grief and will verbalize a sense of optimism and hope for the future. Interventions 1. Acknowledge feelings of guilt or self-blame that patient may express. 2. Assess stage of grief in which the patient is fixed. Discuss normalcy of feelings and behaviors related to stages of grief. 3. Assess impact of the trauma on patient’s ability to resume regular activities of daily living (ADLs). Consider employment, marital relationship, and sleep patterns. 4. Assess for self-destructive ideas and behavior. 5. Assess for maladaptive coping strategies, such as substance abuse. 6. Identify available community resources from which the individual may seek assistance if problems with complicated grieving persist.

Answer 76

Cognitive therapy Prolonged exposure therapy Group/family therapy Eye movement desensitization and reprocessing Psychopharmacology - SSRIS: paroxetine and sertraline *Paroxetine is first line treatment for PTSD - Tricyclic: amitriptyline (Elavil) and imipramine (Tofranil) - MAO Inhibitors: phenelzine and trazodone

Answer 77

- Characterized by a maladaptive reaction to an identifiable stressor or stressors that result in the development of clinically significant emotional or behavioral symptoms - Symptoms occur within 3 months of the stressor and last no longer than 6 months. - Exception: The “related to bereavement” subtype - Quite common and can occur at any age - Increased risk of suicide Types With depressed mood: most commonly diagnosed - The clinical presentation is one of predominant mood disturbance, although it is less pronounced than that of major depressive disorder (MDD). - The symptoms, such as depressed mood, tearfulness, and feelings of hopelessness, exceed what is an expected or normative response to an identified stressor. With anxiety With mixed anxiety and depressed mood - Include disturbances in mood (depression, feelings of hopelessness and sadness) and manifestations of anxiety (nervousness, worry, jitteriness) that are more intense than what would be expected or considered to be a normative response to an identified stressor. With disturbance of conduct - Characterized by conduct in which there is violation of the rights of others or of major age-appropriate societal norms and rules. With mixed disturbance of emotions and conduct

Answer 78

Biological aspects - Genetics - Vulnerability related to neurocognitive or intellectual developmental disorders Psychosocial Theories - Childhood trauma, dependency, arrested development - Constitutional factor (birth characteristics) - Developmental stage and timing of the stressor - Available support systems - Dysfunctional grieving process Transactional model of stress/adaptation - Interaction between individual and environment - Type of stressor - Situational factors - Intrapersonal factors

Answer 79

Goals - Patient will express anger toward lost entity. - Patient will be able to verbalize behaviors associated with the normal stages of grief and identify own position in grief process, while progressing at own pace toward resolution. Interventions 1. Determine the stage of grief in which patient is fixed. Identify behaviors associated with this stage. 2. Develop a trusting relationship with the patient. Show empathy and caring. Be honest and keep all promises. 3. Convey an accepting attitude so that the patient is not afraid to express feelings openly. 4. Allow the patient to express anger. Do not become defensive if the initial expression of anger is displaced on the nurse or therapist. Help the patient explore angry feelings so that they may be directed toward the intended object or person. 5. Assist the patient to discharge pent-up anger through participation in large motor activities 6. Explain to the patient the normal stages of grief and the behaviors associated with each stage. Help the patient to understand that feelings such as guilt and anger toward the lost entity/concept are natural and acceptable during the grief process. 7. Encourage the patient to review his or her perception of the loss or change. With support and sensitivity, point out the reality of the situation in areas where misrepresentations are expressed. 8. Communicate to the patient that crying is acceptable. The use of touch is therapeutic and appropriate with most patients. 9. Help the patient to solve problems as he or she attempts to determine methods for more adaptive coping with the stressor. Provide positive feedback for strategies identified and decisions made. 10. Encourage the patient to reach out for spiritual support during this time in whatever form is desirable. Assess the patient’s spiritual needs and assist as necessary in the fulfillment of those needs.

Answer 80

Goals - The patient and primary nurse will discuss the kinds of lifestyle changes that will occur because of the change in health status. - The patient will demonstrate movement toward independence, considering the change in health status. - The patient will demonstrate competence to function independently to his or her optimal ability, considering the change in health status. Interventions 1. Encourage the patient to talk about his or her lifestyle prior to the change in health status. Discuss coping mechanisms that were used at stressful times in the past. 2. Encourage the patient to discuss the change or loss and particularly to express anger associated with 3. Encourage the patient to express fears associated with the change or loss or alteration in lifestyle that it has created. 4. Provide assistance with activities of daily living as required but encourage independence to the limit that the patient’s ability will allow. Give positive feedback for activities accomplished independently. 5. Help the patient with decision making regarding incorporation of the change or loss into his or her lifestyle. Identify problems the change or loss is likely to create. Discuss alternative solutions, weighing potential benefits and consequences of each alternative. Support the patient’s decision in the selection of an alternative. 6. Use role-play to practice stressful situations that might occur in relation to the health status change. 7. Ensure that the patient and family are fully knowledgeable regarding the physiology of the change in health status and understand the necessity of such knowledge for optimal wellness. Encourage them to ask questions, and provide printed material explaining the change to which they may refer. 8. Ensure that the patient can identify resources within the community from which he or she may seek assistance in adapting to the change in health status. Encourage the patient to keep follow-up appointments with his or her physician or to call the physician’s office prior to the follow-up date if problems or concerns arise.

Answer 81

Individual psychotherapy Family therapy Behavior therapy Self-help groups Crisis intervention Psychopharmacology

Answer 82

Neurophysiological influences - Temporal lobe - Limbic system - Amygdaloid nucleus Biochemical influences - Norepinephrine - Serotonin - Dopamine Genetic influences - Possible hereditary factor - Genetic karyotype XYY has been implicated. Disorders of the brain - Organic brain syndromes - Brain tumors/trauma - Encephalitis - Temporal lobe epilepsy Psychodynamic theory - Unmet needs for satisfaction and security result in an underdeveloped ego and a poor self-concept. - Aggression and violence supply the individual with a dose of power and prestige that increases self-esteem. Learning Theory - Children learn to behave by imitating their role models. - Individuals who were abused as children or whose parents disciplined with physical punishment are more likely to behave in an abusive manner as adults. Societal influences - Aggressive behavior is primarily a product of one’s culture and social structure - American culture was founded on a general acceptance of violence as a means of solving problems. - Societal influences also contribute to violence when individuals realize that their needs and desires are not being met relative to other people.

Answer 83

Battering may be defined as a pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner. Profile of the victim - Battered women represent all age, racial, religious, cultural, educational, and socioeconomic groups - Low self-esteem - Inadequate support systems - Some grew up in abusive homes Profile of the victimizer - Low self-esteem - Pathologically jealous - “Dual personality” - Limited coping ability - Severe stress reactions - Views spouse as a personal possession

Answer 84

Three distinct phases - Phase one: Tension-building phase - Phase two: Acute battering incident - Phase three: Calm, loving, respite (honeymoon) phase Why do they stay? - Fear for their lives or the lives of their children - Fear of retaliation by the partner - Fear of losing custody of their children - Lack of financial resources - Lack of a support network - Religious reasons - Having hope that the partner will change, and they can have good times again - Lack of attention to the danger

Answer 85

Physical abuse: Any non-accidental physical injury caused by the parent or caregiver Signs and symptoms - Unexplained injuries - Child is frightened of adults. - Child reports injury by parent or caregiver. - Conflicting or unconvincing explanation for injuries

Answer 86

Emotional abuse: A pattern of behavior on the part of the parent or caretaker that results in serious impairment of the child’s social, emotional, or intellectual functioning Indicators of abuse - Extremes of behavior - Delayed physical or emotional development - Lack of attachment to parent

Answer 87

Physical neglect - Refusal of or delay in seeking healthcare - Abandonment - Expulsion from the home - Refusal to allow a runaway to return home - Inadequate supervision Emotional neglect - Failure to provide the child with the hope, love, and support necessary for the development of a sound, healthy personality Behavioral indicators of neglect - Is frequently absent from school - Begs or steals food or money - Lacks needed medical or dental care, immunizations, or glasses - Is consistently dirty and has severe body odor - Lacks sufficient clothing for the weather - Abuses alcohol or other drugs - States that there is no one at home to provide care

Answer 88

Has difficulty walking or sitting Reports nightmares or bedwetting Experiences a sudden change in appetite Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior Becomes pregnant or contracts a sexually transmitted disease

Answer 89

Parents who abuse their children were likely abused as children themselves. Other influences include: Numerous stresses Poverty Social isolation Absence of adequate support systems Lack of knowledge of child development or care needs

Answer 90

Often, there is an impaired spousal relationship. Father - Domineering, impulsive, physically abusive Mother - Passive, submissive, and denigrates her role of wife and mother - Often aware of the incestuous relationship, but uses denial or keeps quiet out of fear of being abused by her husband The adult survivor of incest - A fundamental lack of trust that arises out of an unsatisfactory parent–child relationship - Low self-esteem and a poor sense of identity - Absence of pleasure with sexual activity - Promiscuity

Answer 91

Profile of the victimizer - It is difficult to profile a rapist. - Sexual sadists: aroused by inflicting pain - Exploitative predators: using the victim to gratify needs such as dominance and power, - Inadequate men: obsessed with fantasies of sex that they believe cannot be achieved without force, - Those displacing anger: Victim - Rape can occur at any age. - The highest risk group appears to be between 16 and 34 years of age. - Most victims are single women. - The attack often occurs near their own neighborhoods. - Victim likely experiences a sense of violation and helplessness. - The long-term effects depend largely on the individual’s: Ego strength, Social support system, Treatment as a victim Victim responses - Expressed response pattern: expresses feelings of fear, anger, and anxiety through such behaviors as crying, sobbing, restlessness, and tension. - Controlled response pattern: the feelings are masked or hidden, and a calm, composed, or subdued affect is seen. - Compounded rape reaction: additional symptoms such as depression and suicide, substance abuse, and even psychotic behaviors may be noted - Silent rape reaction: survivor tells no one about the assault.

Answer 92

Goals - Patient’s physical wounds will heal without complication. - Patient will begin a healthy grief resolution, initiating the process of physical and psychological healing Interventions 1. It is important to communicate the following to the individual who has been sexually assaulted: * You are safe here. * I’m sorry that it happened. * I’m glad you survived. * It’s not your fault. No one deserves to be treated this way. * You did the best that you could. 2. Explain every assessment procedure that will be conducted and why it is being conducted. Ensure that data collection is conducted in a caring, nonjudgmental manner. 3. Ensure that patient has adequate privacy for all immediate postcrisis interventions. Try to have as few people as possible providing the immediate care or collecting immediate evidence. 4. Encourage patient to give an account of the assault. Listen, but do not probe. 5. Discuss with patient whom to call for support or assistance. Provide information about referrals for aftercare.

Answer 93

Goals - Patient will recognize and verbalize choices available, thereby perceiving some control over life situation. - Patient will exhibit control over life situation by making decision about how to maintain personal safety. Interventions 1. In collaboration with physician, ensure that all physical wounds, fractures, and burns receive immediate attention. Take photographs if the individual will permit. 2. Take patient to a private area to do the interview. 3. If patient has come alone or with children, reassure them of their safety. Encourage to discuss the battering incident. Ask questions about whether this has happened before, whether the abuser takes drugs, whether the victim has a safe place to go, and whether he or she is interested in pressing charges. 4. Ensure that “rescue” efforts are not attempted by the nurse. Offer support but remember that the final decision must be made by patient. 5. Stress to patient the importance of safety. Provide information about available resources. These may include crisis hot lines, community groups for victims of abuse, shelters, counseling services, and information regarding the victim’s rights. Respect the patient’s decision about whether to stay or leave the home or marriage.

Answer 94

Goals - Patient will develop trusting relationship with nurse and report how evident injuries were sustained. - Patient will demonstrate behaviors consistent with age-appropriate growth and development. Interventions 1. Perform complete physical assessment of the child. Take particular note of bruises (in various stages of healing), lacerations, and client complaints of pain in specific areas. Do not overlook or discount the possibility of sexual abuse. Assess for nonverbal signs of abuse: aggressive conduct, excessive fears, extreme hyperactivity, apathy, withdrawal, age-inappropriate behaviors. 2. Conduct an in-depth interview with the parent or adult who accompanies the child. Consider: If the injury is being reported as an accident, is the explanation reasonable? Is the injury consistent with the explanation? Is the injury consistent with the child’s developmental capabilities? 3. Use games or play therapy to gain child’s trust. Use these techniques to assist in describing his or her side of the story.

Answer 95

Crisis Intervention Safe house or shelter Family therapy