Podcast
Questions and Answers
A nurse is caring for a client who is exhibiting decerebrate rigidity. Which assessment findings would the nurse expect to observe?
A nurse is caring for a client who is exhibiting decerebrate rigidity. Which assessment findings would the nurse expect to observe?
- Inability to respond to painful stimuli.
- Extended arms and legs. (correct)
- Flexed arms and legs.
- Drowsiness and tendency to fall asleep easily.
During a mental health assessment, a client is asked to recall events from their childhood. Which aspect of the Mental Status Examination (MSE) is being evaluated?
During a mental health assessment, a client is asked to recall events from their childhood. Which aspect of the Mental Status Examination (MSE) is being evaluated?
- Recent memory.
- Abstract thinking.
- Immediate memory.
- Remote memory. (correct)
Which ethical principle is demonstrated when a nurse prioritizes a client's safety and comfort by helping them feel secure in a mental health facility?
Which ethical principle is demonstrated when a nurse prioritizes a client's safety and comfort by helping them feel secure in a mental health facility?
- Beneficence (correct)
- Veracity
- Justice
- Autonomy
A client is admitted voluntarily to a mental health facility. Which of the following rights does this client possess?
A client is admitted voluntarily to a mental health facility. Which of the following rights does this client possess?
A nurse is using the HEADSS tool to assess an adolescent client. What primary areas does this assessment tool cover?
A nurse is using the HEADSS tool to assess an adolescent client. What primary areas does this assessment tool cover?
A patient is admitted to a psychiatric unit due to aggressive behavior towards others, posing a significant risk. According to the guidelines, what type of admission is most appropriate initially?
A patient is admitted to a psychiatric unit due to aggressive behavior towards others, posing a significant risk. According to the guidelines, what type of admission is most appropriate initially?
When assessing a client's affect, which of the following is the MOST important for the nurse to observe?
When assessing a client's affect, which of the following is the MOST important for the nurse to observe?
A mental health nurse discovers that a colleague is falsifying medication administration records. According to ethical principles, what is the nurse's primary responsibility?
A mental health nurse discovers that a colleague is falsifying medication administration records. According to ethical principles, what is the nurse's primary responsibility?
A 16-year-old patient requires physical restraints due to violent outbursts. What is the maximum time frame the patient can be kept in restraints according to established guidelines before a review is required?
A 16-year-old patient requires physical restraints due to violent outbursts. What is the maximum time frame the patient can be kept in restraints according to established guidelines before a review is required?
A healthcare provider is using the DSM-5-TR to diagnose a client's mental health disorder. What is the primary purpose of this manual?
A healthcare provider is using the DSM-5-TR to diagnose a client's mental health disorder. What is the primary purpose of this manual?
A client experiencing a manic episode demands to leave the mental health facility despite expressing intentions to harm others. The treatment team believes the client is a danger to society. What is the priority action?
A client experiencing a manic episode demands to leave the mental health facility despite expressing intentions to harm others. The treatment team believes the client is a danger to society. What is the priority action?
Which of the following therapeutic strategies involves creating a structured and supportive environment to promote a client's mental and emotional well-being?
Which of the following therapeutic strategies involves creating a structured and supportive environment to promote a client's mental and emotional well-being?
A nurse is planning care for a client with a history of trauma. Which intervention demonstrates trauma-informed care?
A nurse is planning care for a client with a history of trauma. Which intervention demonstrates trauma-informed care?
Which of the following actions by a nurse constitutes a violation of HIPAA and client confidentiality?
Which of the following actions by a nurse constitutes a violation of HIPAA and client confidentiality?
A client is prescribed a new antipsychotic medication. What aspect of care should the nurse prioritize to align with the client's legal rights?
A client is prescribed a new antipsychotic medication. What aspect of care should the nurse prioritize to align with the client's legal rights?
A client is described as 'lethargic' in their level of consciousness. What behavior would the nurse expect to observe?
A client is described as 'lethargic' in their level of consciousness. What behavior would the nurse expect to observe?
A nurse threatens a patient with forced medication if they do not comply with a therapy session. If the nurse then physically enforces this threat by administering the medication against the patient's will, the nurse could be charged with:
A nurse threatens a patient with forced medication if they do not comply with a therapy session. If the nurse then physically enforces this threat by administering the medication against the patient's will, the nurse could be charged with:
How can a nurse best apply the principle of justice when managing group therapy sessions in a mental health facility?
How can a nurse best apply the principle of justice when managing group therapy sessions in a mental health facility?
When differentiating between religion and spirituality, which statement BEST describes spirituality?
When differentiating between religion and spirituality, which statement BEST describes spirituality?
A psychiatrist fails to diagnose a known condition due to not ordering common tests, leading to patient harm. This is an example of what?
A psychiatrist fails to diagnose a known condition due to not ordering common tests, leading to patient harm. This is an example of what?
According to documentation guidelines, which note best reflects clear , factual, and objective standards?
According to documentation guidelines, which note best reflects clear , factual, and objective standards?
How should a nurse apply the ethical principle of fidelity in their practice?
How should a nurse apply the ethical principle of fidelity in their practice?
A client makes credible threats to harm a specific individual upon release. According to the Tarasoff Law, what is the appropriate course of action?
A client makes credible threats to harm a specific individual upon release. According to the Tarasoff Law, what is the appropriate course of action?
A nurse confines a patient to their room unjustly because they find the patient annoying. This is an example of:
A nurse confines a patient to their room unjustly because they find the patient annoying. This is an example of:
Flashcards
Ongoing Mental Health Assessment
Ongoing Mental Health Assessment
Continuous monitoring of the client's mental state during each interaction.
Mood vs. Affect
Mood vs. Affect
Subjective: How the client feels. Objective: How the client appears.
Orientation & Memory
Orientation & Memory
Orientation: Person, place, time. Memory: Immediate, recent, remote.
Spirituality vs. Religion
Spirituality vs. Religion
Signup and view all the flashcards
HEADSS Assessment
HEADSS Assessment
Signup and view all the flashcards
Avoid Re-traumatization
Avoid Re-traumatization
Signup and view all the flashcards
DSM-5-TR
DSM-5-TR
Signup and view all the flashcards
Serious Mental Illness (SMI)
Serious Mental Illness (SMI)
Signup and view all the flashcards
Life Changes & Mental Health
Life Changes & Mental Health
Signup and view all the flashcards
Therapeutic Strategies
Therapeutic Strategies
Signup and view all the flashcards
Legal Rights of Clients
Legal Rights of Clients
Signup and view all the flashcards
Beneficence
Beneficence
Signup and view all the flashcards
Autonomy
Autonomy
Signup and view all the flashcards
Justice
Justice
Signup and view all the flashcards
Fidelity
Fidelity
Signup and view all the flashcards
Veracity
Veracity
Signup and view all the flashcards
Temporary Emergency Admission
Temporary Emergency Admission
Signup and view all the flashcards
Involuntary Admission
Involuntary Admission
Signup and view all the flashcards
Long-Term Involuntary Admission
Long-Term Involuntary Admission
Signup and view all the flashcards
Seclusion/Restraint Use
Seclusion/Restraint Use
Signup and view all the flashcards
Restraint Time Limits
Restraint Time Limits
Signup and view all the flashcards
Exceptions to Confidentiality
Exceptions to Confidentiality
Signup and view all the flashcards
False Imprisonment
False Imprisonment
Signup and view all the flashcards
Malpractice
Malpractice
Signup and view all the flashcards
Study Notes
- Here are your study notes regarding mental health and mental health nursing
Assessment in Mental Health Nursing
- Utilize observation, interviews, physical exams, and collaboration for comprehensive assessment.
- Show respect for personal space when communicating therapeutically.
- Obtain a thorough medical and psychosocial history.
- Perform ongoing assessments during each client encounter.
Psychosocial History
- Assess the client's perception of their health and illness.
- Look at activity level and leisure activities
- Look for any substance use history
- Assess coping abilities and support systems.
Mental Status Examination (MSE)
Level of Consciousness
- Alert individuals respond normally.
- Lethargic individuals are drowsy and fall asleep easily.
- Stuporous people need vigorous stimuli to elicit a response.
- Comatose individuals are unconscious and unresponsive to pain.
- Decorticate rigidity involves flexed arms and legs.
- Decerebrate rigidity involves extended arms and legs.
Physical Appearance
- Assess hygiene, grooming, and nutritional status.
- Observe and document behavior objectively.
- Mood reflects the client's subjective feeling.
- Affect is the client's objective expression of mood.
- Evaluate cognitive and intellectual abilities.
- Determine orientation to person, place, and time.
- Assess memory: immediate, recent, and remote.
- Abstract thinking indicates problem-solving ability.
- Judgment reflects decision-making ability.
Cultural & Spiritual Considerations
- Assess cultural beliefs, practices, and dietary restrictions.
- Differentiate between religion (structured beliefs and rituals) and spirituality (internal values and purpose).
Standardized Screening Tools
- These tools include the Adverse Childhood Experiences Questionnaire, Brief Patient Health Questionnaire (Brief PHQ), and Mini-Mental State Examination (MMSE).
- The Mini-Mental State Examination assesses orientation, memory, attention, and language.
Considerations Across the Lifespan
Children & Adolescents
- Consider family dynamics, culture, and developmental stage.
- A HEADSS tool is used to assess Home, Education, Activities, Drugs, Sexuality, Suicide risk, and Safety for children/adolescents.
Older Adults
- Evaluate functional ability, social support, and safety risks.
Trauma-Informed Care
- Recognize signs of trauma and triggers.
- Prevent re-traumatization.
Mental Health Diagnoses
- Use the DSM-5-TR (2022) to find diagnosis for mental health disorders.
- Serious Mental Illness (SMI) involves persistent disorders affecting daily life.
Role & Life Changes
- Major transitions like loss of employment, divorce, or retirement can impact mental health.
- Assess coping strategies, support systems, and functional ability.
Therapeutic Strategies
- Counseling is therapeutic communication.
- Milieu Therapy has a structured, supportive environment.
- Screening is used to assess trauma history and coping skills.
- Provide self-care promotion with independent care skills.
- Psychobiological Interventions include medication management.
- Offer Cognitive-Behavioral Therapy (CBT) techniques.
- Health Promotion can include smoking cessation and lifestyle changes.
- Case Management is holistic care planning.
Chapter 2 - Legal and Ethical Issues in Mental Health Nursing
Legal Rights of Clients in Mental Health Settings
- Mental health clients have the same legal rights as any other citizen.
- These include the right to humane treatment and care, the right to vote, the right to obtain or deny a driver's license, and the right to press charges against another person.
- Further includes informed consent, the right to refuse treatment, confidentiality (HIPAA), freedom from physical or chemical restraint, the right to a psychiatric advance directive, and care in the least restrictive environment.
Ethical Principles in Mental Health Nursing
- Beneficence involves acting in the client's best interest.
- Autonomy is the client's right to make their own decisions like exploring options instead of being told what to do.
- Justice means fair treatment for all.
- Fidelity involves keeping commitments and being loyal.
- Veracity means being truthful.
Types of Admission to a Mental Health Facility
- Informal Admission is least restrictive, client can leave anytime.
- Voluntary Admission is when the client chooses admission and can refuse medication/treatment.
- Temporary Emergency Admission is for emergency mental health care and is usually limited to ≤15 days and requires court review after 60 days.
- Involuntary Admission is against the individual's will based on danger to self/others or severe disability, and there is long-term Court-ordered involuntary admission that lasts 60–180 days or longer.
Client Rights Regarding Seclusion & Restraint
- Use seclusion/restraint only if less restrictive interventions fail.
- Restraint Time Limit for adults (≥18 years old) is 4 hours; 9-17 years old is 2 hours; ≤8 years old is 1 hour.
- Frequent (every 15-30 minutes) monitoring and documentation is required.
- Discontinue seclusion as soon as the client is safe.
- PRN is not allowed when prescribing restraints.
Confidentiality & HIPAA
- Do not discuss client information publicly (e.g., social media, public places).
- Only share information with team members involved in treatment.
- Duty to warn potential victims of harm (Tarasoff Law) may require breaking confidentiality.
- Reporting abuse (child or vulnerable adult) may require breaking confidentiality.
Legal & Ethical Client Issues
- Torts are civil wrongs that cause harm.
Intentional Torts
- False imprisonment involves unjustly confining a client.
- Assault includes verbal threats.
- Battery involves physical harm (e.g., forcing medication).
Unintentional Torts
- Negligence includes the failure to meet the expected standard of care.
- Malpractice involves professional negligence leading to harm.
Documentation Guidelines
- Be clear, factual, and objective.
- Document client behavior, staff response, and when the provider was notified when necessary.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
