Podcast
Questions and Answers
A nurse is assessing a client who is difficult to arouse and needs repeated stimulation to maintain consciousness. Which level of consciousness is the client displaying?
A nurse is assessing a client who is difficult to arouse and needs repeated stimulation to maintain consciousness. Which level of consciousness is the client displaying?
- Comatose
- Alert
- Stuporous (correct)
- Lethargic
During a mental status examination (MSE), a nurse asks the client to explain the meaning of a common proverb. Which cognitive ability is the nurse assessing?
During a mental status examination (MSE), a nurse asks the client to explain the meaning of a common proverb. Which cognitive ability is the nurse assessing?
- Judgment
- Abstract thinking (correct)
- Memory
- Orientation
Which of the following is the primary focus of trauma-informed care in mental health nursing?
Which of the following is the primary focus of trauma-informed care in mental health nursing?
- Identifying and minimizing potential triggers to avoid re-traumatization (correct)
- Providing detailed accounts of the traumatic event to promote catharsis
- Encouraging clients to confront their traumatic experiences directly
- Focusing solely on medication management to stabilize mood
When using the HEADSS assessment tool with an adolescent client, which area is being explored when asking about 'Activities'?
When using the HEADSS assessment tool with an adolescent client, which area is being explored when asking about 'Activities'?
A client consistently displays extended arms and legs, indicative of decerebrate rigidity. What does this presentation suggest about the client's level of consciousness?
A client consistently displays extended arms and legs, indicative of decerebrate rigidity. What does this presentation suggest about the client's level of consciousness?
A nurse is preparing to administer the Mini-Mental State Examination (MMSE). Which domain of cognitive function does this tool primarily assess?
A nurse is preparing to administer the Mini-Mental State Examination (MMSE). Which domain of cognitive function does this tool primarily assess?
Which intervention exemplifies the ethical principle of beneficence in mental health nursing?
Which intervention exemplifies the ethical principle of beneficence in mental health nursing?
During an admission assessment, a client reports experiencing persistent symptoms that significantly impair their ability to maintain employment and social relationships. According to diagnostic criteria, how would these conditions be classified?
During an admission assessment, a client reports experiencing persistent symptoms that significantly impair their ability to maintain employment and social relationships. According to diagnostic criteria, how would these conditions be classified?
A patient's care plan includes interventions to support their spirituality. Which action best reflects this approach?
A patient's care plan includes interventions to support their spirituality. Which action best reflects this approach?
A client undergoing significant life changes, such as retirement, is MOST likely to benefit from therapeutic interventions focused on:
A client undergoing significant life changes, such as retirement, is MOST likely to benefit from therapeutic interventions focused on:
A client with a history of trauma is admitted to a mental health facility. Which of the following is the MOST important initial nursing intervention?
A client with a history of trauma is admitted to a mental health facility. Which of the following is the MOST important initial nursing intervention?
Which of the following scenarios violates a client's right to the least restrictive environment?
Which of the following scenarios violates a client's right to the least restrictive environment?
A nurse observes a colleague consistently arriving late to work and leaving early, resulting in unequal distribution of workload. Which ethical principle is MOST relevant to address this situation?
A nurse observes a colleague consistently arriving late to work and leaving early, resulting in unequal distribution of workload. Which ethical principle is MOST relevant to address this situation?
A client states, "I don't want to take this medication anymore." Based on legal rights of clients in mental health settings, which action should the nurse take FIRST?
A client states, "I don't want to take this medication anymore." Based on legal rights of clients in mental health settings, which action should the nurse take FIRST?
Which nursing intervention demonstrates fidelity?
Which nursing intervention demonstrates fidelity?
A client is admitted on an informal basis to a mental health unit. What is the implication of this type of admission?
A client is admitted on an informal basis to a mental health unit. What is the implication of this type of admission?
A patient is admitted to a psychiatric unit due to expressing suicidal ideations, but refuses voluntary admission. Following assessment, the team determines the patient is a significant danger to themself. What type of admission is MOST appropriate?
A patient is admitted to a psychiatric unit due to expressing suicidal ideations, but refuses voluntary admission. Following assessment, the team determines the patient is a significant danger to themself. What type of admission is MOST appropriate?
A nurse observes a patient escalating and exhibiting aggressive behavior. Which intervention should the nurse implement FIRST?
A nurse observes a patient escalating and exhibiting aggressive behavior. Which intervention should the nurse implement FIRST?
A 10-year-old patient is placed in restraints due to aggressive behavior posing a danger to others. According to established guidelines, what is the MAXIMUM duration for which the initial restraint order can be written?
A 10-year-old patient is placed in restraints due to aggressive behavior posing a danger to others. According to established guidelines, what is the MAXIMUM duration for which the initial restraint order can be written?
Which of the following scenarios represents a violation of patient confidentiality?
Which of the following scenarios represents a violation of patient confidentiality?
A therapist receives information that their patient is planning to cause serious harm to a specific individual. According to the Tarasoff Law, what is the therapist's PRIMARY responsibility?
A therapist receives information that their patient is planning to cause serious harm to a specific individual. According to the Tarasoff Law, what is the therapist's PRIMARY responsibility?
A nurse threatens a patient with physical harm if they do not comply with medication administration. This action would be considered what type of intentional tort?
A nurse threatens a patient with physical harm if they do not comply with medication administration. This action would be considered what type of intentional tort?
A psychiatric nurse fails to monitor a patient appropriately, resulting in the patient eloping from the unit and sustaining an injury. This situation could be categorized as:
A psychiatric nurse fails to monitor a patient appropriately, resulting in the patient eloping from the unit and sustaining an injury. This situation could be categorized as:
Which of the following is the MOST appropriate documentation of a patient's behavior and the staff's response?
Which of the following is the MOST appropriate documentation of a patient's behavior and the staff's response?
Flashcards
Mental Health Assessment
Mental Health Assessment
Using observation, interviews, physical exams, and collaboration to assess a client's mental health.
Psychosocial History
Psychosocial History
A patient's perception of health/illness, substance use, activity levels, coping abilities and support systems.
Mental Status Examination (MSE)
Mental Status Examination (MSE)
A structured assessment of a patient's consciousness, appearance, behavior, mood, affect, and cognitive abilities.
Cultural & Spiritual Considerations
Cultural & Spiritual Considerations
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Standardized Screening Tools
Standardized Screening Tools
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Lifespan Considerations
Lifespan Considerations
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Trauma-Informed Care
Trauma-Informed Care
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DSM-5-TR & SMI
DSM-5-TR & SMI
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Temporary Emergency Admission
Temporary Emergency Admission
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Involuntary Admission
Involuntary Admission
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Long-Term Involuntary Admission
Long-Term Involuntary Admission
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Restraint Usage
Restraint Usage
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Confidentiality
Confidentiality
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Duty to Warn
Duty to Warn
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False Imprisonment
False Imprisonment
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Malpractice
Malpractice
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Life Changes & Mental Health
Life Changes & Mental Health
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Milieu Therapy
Milieu Therapy
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Psychobiological Interventions
Psychobiological Interventions
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Legal Rights of Clients
Legal Rights of Clients
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Beneficence
Beneficence
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Autonomy
Autonomy
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Justice
Justice
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Fidelity
Fidelity
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Study Notes
- Mental Health Nursing covers assessment, psychosocial history, mental status examination, cultural/spiritual considerations, and standardized screening tools.
Assessment in Mental Health Nursing
- Utilize observation, interviewing, physical examination, and collaboration for comprehensive assessment.
- Respect personal space and communicate therapeutically to establish rapport with clients.
- Collect detailed medical and psychosocial histories to understand the client's background.
- Conduct continuous, ongoing assessment with each client encounter to monitor progress and address changing needs.
Psychosocial History
- Assess the client's perception of their health and illness to understand their subjective experience.
- Evaluate activity level and leisure activities to gauge the client's engagement and well-being.
- Obtain a substance use history to identify any potential contributing factors or co-occurring disorders.
- Assess coping abilities and support systems to determine the client's resources and resilience.
Mental Status Examination (MSE)
- MSE includes assessing level of consciousness and physical appearance.
- Evaluating behavior, mood, affect, cognitive and intellectual abilities, orientation, memory, abstract thinking, and judgment.
- Level of Consciousness ranges from alert (responds normally) to comatose (unconscious, no response to pain).
- Lethargic individuals are drowsy and fall asleep easily.
- Stuporous individuals need vigorous stimuli to respond.
- Decorticate rigidity involves flexed arms/legs.
- Decerebrate rigidity involves extended arms/legs.
- Physical Appearance factors include hygiene, grooming, and nutritional status.
- Mood is the client's subjective feeling, while affect is the objective expression of emotion.
- Cognitive and intellectual abilities include orientation (person, place, time), memory (immediate, recent, remote), abstract thinking (problem-solving), and judgment (decision-making ability).
Cultural & Spiritual Considerations
- Assess cultural beliefs, practices, and dietary restrictions to provide culturally sensitive care.
- Understand the difference between religion (structured beliefs and rituals) and spirituality (internal values and purpose).
Considerations Across the Lifespan
- In Children & Adolescents, it is important to consider family dynamics, culture, and development.
- Use the HEADSS tool (Home, Education, Activities, Drugs, Sexuality, Suicide risk, Safety) for assessment.
- In Older Adults, assess functional ability, social support, and safety risks.
Standardized Screening Tools
- Use tools such as the Adverse Childhood Experiences Questionnaire, Brief Patient Health Questionnaire (Brief PHQ), and Mini-Mental State Examination (MMSE).
- The MMSE assesses orientation, memory, attention, and language.
Trauma-Informed Care
- Recognize signs of trauma and potential triggers to avoid re-traumatization.
Mental Health Diagnoses
- Mental health diagnoses are made using DSM-5-TR (2022).
- Serious mental illness (SMI) refers to persistent disorders affecting daily life.
Role & Life Changes
- Assess coping strategies, support systems, and functional ability.
Therapeutic Strategies
- Implement counseling (therapeutic communication), milieu therapy (structured, supportive environment), screening (trauma history, coping skills), self-care promotion (independent care skills), psychobiological interventions (medication management), cognitive-behavioral therapy (CBT techniques), health promotion (lifestyle changes), and case management (holistic care planning).
Chapter 2 - Legal and Ethical Issues in Mental Health Nursing
- Clients with mental health disorders have the same legal rights as any other citizen.
- The right to humane treatment and care (medical, dental, and psychiatric care), to vote, to obtain, forfeit, or deny a driver's license, to press charges against another person, to informed consent and right to refuse treatment.
- The right to confidentiality (HIPAA), freedom from physical or chemical restraint, abuse, or neglect, The right to a psychiatric advance directive.
- Provision of care in the least restrictive environment (avoiding unnecessary seclusion or restraints).
Ethical Principles in Mental Health Nursing
- Beneficence: Acting in the client's best interest, like ensuring a newly admitted client with psychosis feels safe.
- Autonomy: Supporting the client's right to make their own decisions by helping them explore options rather than dictating choices.
- Justice: Ensuring fair treatment for all, such as enforcing facility rules fairly.
- Fidelity: Keeping commitments and being loyal, like staying with a client during a difficult moment.
- Veracity: Being truthful, like honestly explaining the reasons behind staff discussions about a client's behavior.
Types of Admission to a Mental Health Facility
- Informal Admission: Least restrictive; the client can leave anytime.
- Voluntary Admission: Client chooses admission and can refuse medication/treatment.
- Temporary Emergency Admission: Admitted for emergency mental health care, usually limited to ≤15 days.
- Involuntary Admission: Admission against will, based on danger to self or others, severe disability (inability to care for self), with court review required after 60 days.
- Long-Term Involuntary Admission: Court-ordered, lasts 60–180 days or longer.
Client Rights Regarding Seclusion & Restraint
- Seclusion and restraint should be used only if less restrictive interventions fail.
- Restraint Time Limits: ≥18 years old: 4 hours; 9-17 years old: 2 hours; ≤8 years old: 1 hour.
- Frequent monitoring and documentation is required (every 15-30 minutes).
- Seclusion or restraints must be discontinued as soon as the client is safe. PRN (as-needed) prescriptions for restraints are NOT allowed.
Confidentiality & HIPAA
- Do NOT discuss client information publicly (e.g., social media, public places). Share information only with team members involved in treatment.
- Exceptions to confidentiality include the duty to warn potential victims of harm (Tarasoff Law) and reporting abuse (child or vulnerable adult).
Legal & Ethical Client Issues
- Torts are civil wrongs that cause harm.
Intentional Torts
- False imprisonment: Unjustly confining a client.
- Assault: Verbal threats.
- Battery: Physical harm (e.g., forcing medication).
Unintentional Torts
- Negligence: Failure to meet the expected standard of care.
- Malpractice: Professional negligence leading to harm.
Documentation Guidelines
- Be clear, factual, and objective.
- Include client behavior (e.g., "Client ran down the hall screaming").
- Include staff response (e.g., "Nurse calmly redirected the client and ensured safety").
- Include when the provider was notified.
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