Mental Health Nursing Textbook - Legal & Ethical Issues

Chapter 1- Mental Health 1. Assessment in Mental Health Nursing ​ ​ Use observation, interviewing, physical exam, and collaboration. ​ ​ Respect personal space and communicate therapeutically. ​ ​ Gather detailed medical and psychosocial history. ​ ​ Continuous ongoin...

Chapter 1- Mental Health 1. Assessment in Mental Health Nursing ​ ​ Use observation, interviewing, physical exam, and collaboration. ​ ​ Respect personal space and communicate therapeutically. ​ ​ Gather detailed medical and psychosocial history. ​ ​ Continuous ongoing assessment with each client encounter. 2. Psychosocial History ​ ​ Perception of health/illness ​ ​ Activity level & leisure activities ​ ​ Substance use history ​ ​ Coping abilities & support systems 3. Mental Status Examination (MSE) Level of Consciousness: ​ ​ Alert: Responds normally. ​ ​ Lethargic: Drowsy, falls asleep easily. ​ ​ Stuporous: Needs vigorous stimuli to respond. ​ ​ Comatose: Unconscious, no response to pain. ​ ​ Decorticate rigidity: Flexed arms/legs. ​ ​ Decerebrate rigidity: Extended arms/legs. Physical Appearance ​ ​ Hygiene, grooming, nutritional status. ​ ​ Behavior ​ ​ Mood (subjective feeling). ​ ​ Affect (objective expression). ​ ​ Cognitive & Intellectual Abilities ​ ​ Orientation (person, place, time) ​ ​ Memory (immediate, recent, remote) ​ ​ Abstract thinking (problem-solving) ​ ​ Judgment (decision-making ability) 4. Cultural & Spiritual Considerations ​ ​ Assess cultural beliefs, practices, and dietary restrictions. ​ ​ Religion vs. spirituality: ​ ​ Spirituality = internal values and purpose. ​ ​ Religion = structured beliefs and rituals. 5. Standardized Screening Tools ​ ​ Adverse Childhood Experiences Questionnaire ​ ​ Brief Patient Health Questionnaire (Brief PHQ) ​ ​ Mini-Mental State Examination (MMSE) ​ ​ Orientation, memory, attention, language. 6. Considerations Across the Lifespan ​ ​ Children & Adolescents: ​ ​ Consider family dynamics, culture, and development. ​ ​ Use HEADSS tool (Home, Education, Activities, Drugs, Sexuality, Suicide risk, Safety). ​ ​ Older Adults: ​ ​ Functional ability, social support, safety risks. 7. Trauma-Informed Care ​ ​ Recognize signs of trauma and triggers. ​ ​ Avoid re-traumatization. 8. Mental Health Diagnoses ​ ​ DSM-5-TR (2022) is used for diagnosing disorders. ​ ​ Serious mental illness (SMI) = persistent disorders affecting daily life. 9. Role & Life Changes ​ ​ Major transitions like loss of employment, divorce, or retirement can impact mental health. ​ ​ Assess coping strategies, support systems, and functional ability. 10. Therapeutic Strategies ​ ​ 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 (smoking cessation, lifestyle changes). ​ ​ Case Management (holistic care planning). Chapter 2 Legal and Ethical Issues in Mental Health Nursing 1. Legal Rights of Clients in Mental Health Settings Clients with mental health disorders have the same legal rights as any other citizen, including: ​ ​ Right to humane treatment & care (medical, dental, and psychiatric care) ​ ​ Right to vote ​ ​ Right to obtain, forfeit, or deny a driver’s license ​ ​ Right to press charges against another person ​ ​ Informed consent & right to refuse treatment ​ ​ Confidentiality (HIPAA) ​ ​ Freedom from physical or chemical restraint, abuse, or neglect ​ ​ Right to a psychiatric advance directive ​ ​ Provision of care in the least restrictive environment (avoiding unnecessary seclusion or restraints) 2. Ethical Principles in Mental Health Nursing ​ ​ Beneficence – Acting in the client’s best interest Example: A nurse helps a newly admitted client with psychosis feel safe in the environment. ​ ​ Autonomy – Client’s right to make their own decisions Example: Instead of making decisions for a client, a nurse helps them explore options. ​ ​ Justice – Fair treatment for all Example: A nurse leads a discussion to ensure facility rules are enforced fairly. ​ ​ Fidelity – Keeping commitments, being loyal Example: A nurse stays with a client during a difficult moment instead of leaving. ​ ​ Veracity – Being truthful Example: A nurse honestly explains why staff were discussing a client’s behavior. Types of Admission to a Mental Health Facility ​ ​ Informal Admission – Least restrictive, 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 (unable to care for self) ​ ​ Court review required after 60 days ​ ​ Long-Term Involuntary Admission – Court-ordered, lasts 60–180 days or longer. 4. Client Rights Regarding Seclusion & Restraint ​ ​ Use 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 & documentation required (every 15-30 mins). ​ ​ Seclusion or restraints must be discontinued as soon as the client is safe. ​ ​ PRN (as-needed) prescriptions for restraints are NOT allowed. 5. Confidentiality & HIPAA ​ ​ Do NOT discuss client info publicly (e.g., social media, public places). ​ ​ Only share info with team members involved in treatment. Exceptions to confidentiality: ​ ​ Duty to warn potential victims of harm (Tarasoff Law) ​ ​ Reporting abuse (child or vulnerable adult) 6. Legal & Ethical Client Issues ​ ​ Torts = 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. 7. 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. CHAPTER 3 Effective Communication 1. Basic Levels of Communication ​ ​ Intrapersonal Communication: Self-talk or internal dialogue. ​ ​ Interpersonal Communication: One-on-one communication (e.g., nurse-client interaction). ​ ​ Small-group Communication: Communication between multiple people in a group (e.g., therapy sessions). ​ ​ Public Communication: Communication with large groups (e.g., community education). 2. Verbal Communication ​ ​ Vocabulary: Avoid medical jargon; ensure clarity. ​ ​ Denotative vs. Connotative Meaning: Be aware that words can have different meanings in different contexts. ​ ​ Clarity/Brevity: Simple, clear communication is best. ​ ​ Timing/Relevance: Choose appropriate moments for communication. ​ ​ Pacing: Speaking too fast can increase anxiety. ​ ​ Intonation: Tone of voice conveys emotions. 3. Nonverbal Communication ​ ​ Can be more impactful than verbal communication. Pay attention to: ​ ​ Appearance (grooming, hygiene) ​ ​ Posture & Gait ​ ​ Facial Expressions ​ ​ Eye Contact ​ ​ Gestures & Sounds ​ ​ Territoriality & Personal Space ​ ​ Silence (allows time for reflection) 4. Therapeutic Communication ​ ​ Purposeful communication to build a trusting relationship. ​ ​ Used to gather information, provide support, and help clients express their feelings. Characteristics of Therapeutic Communication: ​ ​ Client-centered (focuses on the client, not the nurse). ​ ​ Purposeful, planned, and goal-directed. Essential Components: ​ ​ Time: Allow adequate time, especially for clients with mental disorders (e.g., depression, schizophrenia). ​ ​ Active Listening: Hear, observe, and understand the client’s communication. ​ ​ Caring Attitude: Show concern and emotional connection. ​ ​ Honesty: Be direct and truthful. ​ ​ Trust: Maintain reliability and confidentiality. ​ ​ Empathy: Try to understand the client’s emotions. ​ ​ Nonjudgmental Attitude: Accept the client’s thoughts and emotions. 5. Effective Communication Skills & Techniques ​ ​ Silence: Allows reflection. ​ ​ Active Listening: Engage with the client’s message. Questioning Techniques: ​ ​ Open-ended questions: Encourage deeper responses. ​ ​ Closed-ended questions: Use sparingly to get specific information. ​ ​ Projective questions: “What if” questions to explore thoughts. ​ ​ Presupposition questions: Help clients imagine life without their mental health issue. Clarifying Techniques: ​ ​ Restating: Repeat client’s words. ​ ​ Reflecting: Encourage client to examine feelings. ​ ​ Paraphrasing: Summarize client’s message. ​ ​ Exploring: Encourage deeper discussion. ​ ​ Focusing: Keep the conversation on key issues. ​ ​ Giving Information: Provide relevant facts. ​ ​ Presenting Reality: Help clients distinguish delusions from reality. ​ ​ Summarizing: Reinforce important points. ​ ​ Offering Self: Show availability and support. 6. Barriers to Effective Communication ​ ​ Asking irrelevant personal questions. ​ ​ Offering personal opinions. ​ ​ Giving advice instead of letting clients explore solutions. ​ ​ Providing false reassurance (e.g., “Everything will be fine”). ​ ​ Minimizing feelings (e.g., “It’s not that bad”). ​ ​ Changing the topic. ​ ​ Asking “why” questions (can feel accusatory). ​ ​ Offering value judgments. ​ ​ Using excessive questioning. ​ ​ Giving approval or disapproval (can influence behavior). 7. Communication Adaptations for Different Age Groups ​ ​ Children: ​ ​ Use simple language. ​ ​ Be at eye level. ​ ​ Use play to encourage communication. ​ ​ Adolescents: ​ ​ Consider peer relationships & identity concerns. ​ ​ Determine risk for treatment refusal. ​ ​ Older Adults: ​ ​ Minimize distractions. ​ ​ Speak slowly & clearly. ​ ​ Allow extra time for responses. ​ ​ Get input from family or caregivers if needed. How to Pass Your Test on Chapter 3 ​ ​ Memorize the four types of communication. ​ ​ Understand therapeutic vs. non-therapeutic communication. ​ ​ Know the key verbal & nonverbal communication elements. ​ ​ Learn communication adaptations for children, adolescents, and older adults. ​ ​ Recognize barriers to effective communication. ​ ​ Practice applying communication techniques in different scenarios. Chapter 4 Creating and Maintaining a Therapeutic and Safe Environment 1. Therapeutic Nurse-Client Relationship ​ ​ Purposeful and goal-directed. ​ ​ Well-defined with clear boundaries. ​ ​ Structured to meet client’s needs. ​ ​ Safe, confidential, reliable, and consistent. 2. Milieu Therapy Milieu therapy creates a structured, supportive, and safe environment for clients. ​ ​ Goal: Help clients learn adaptive coping, interaction skills, and relationship-building for recovery. ​ ​ Nurse’s Role: ​ ​ Ensure client and staff safety. ​ ​ Manage behaviors to reduce stress. ​ ​ Encourage self-responsibility and recovery skills. ​ ​ Facilitate group/community meetings. 3. Characteristics of the Therapeutic Milieu ​ ​ Physical Setting: ​ ​ Clean, orderly, and well-furnished to promote relaxation. ​ ​ Areas for solitude and group interactions. ​ ​ Safe furniture, good lighting, and low noise levels. ​ ​ Traffic flow should minimize client agitation. ​ ​ Health Care Team Responsibilities: ​ ​ Promote independence and self-care. ​ ​ Treat clients with fairness and respect. ​ ​ Model good social behavior. ​ ​ Set clear professional boundaries. ​ ​ Encourage self-worth and hope. ​ ​ Emotional Climate: ​ ​ Clients should feel safe from harm (self-harm or others). ​ ​ Clients should feel cared for and accepted. 4. Roles of the Nurse in a Therapeutic Relationship ​ ​ Maintain self-awareness of personal values and beliefs. ​ ​ Focus on the client’s thoughts, feelings, and experiences. ​ ​ Identify client needs and encourage problem-solving. ​ ​ Promote autonomy and self-reliance. ​ ​ Educate the client and family on mental health topics. ​ ​ Encourage positive behavior change. ​ ​ Establish a trauma-informed, nonjudgmental environment. 5. Benefits of the Therapeutic Relationship ​ ​ Promotes well-being for clients with mental illnesses. ​ ​ Positive impact on treatment outcomes. ​ ​ Collaboration with the interdisciplinary team strengthens care. ​ ​ Factors that enhance therapeutic relationships: ​ ​ Consistent approach to interactions. ​ ​ Active listening and attentiveness. ​ ​ Trust-building and professional boundaries. 6. Establishing Boundaries in the Nurse-Client Relationship ​ ​ Blurred Boundaries occur when: ​ ​ The nurse’s needs are met rather than the client’s. ​ ​ The relationship becomes social instead of therapeutic. ​ ​ Types of Relationships: ​ ​ Social Relationship: Focuses on mutual needs (e.g., friendship). ​ ​ Therapeutic Relationship: Focuses on client’s problems to support recovery. 7. Transference & Countertransference ​ ​ Transference: ​ ​ Client projects feelings about someone else onto the nurse. ​ ​ Example: “You remind me of my father.” ​ ​ Nursing Implication: Address transference therapeutically. Countertransference: ​ ​ Nurse projects their personal feelings onto the client. ​ ​ Example: The client reminds the nurse of a friend, affecting objectivity. ​ ​ Nursing Implication: Seek peer or supervisor support if countertransference occurs. 8. Phases of Therapeutic Relationships 1.​ Orientation Phase (Establishing Trust) ​ ​ Introduce self, establish boundaries. ​ ​ Discuss confidentiality. ​ ​ Explore client’s thoughts, feelings, and needs. ​ ​ Identify testing behaviors and trust issues. 2.​ Working Phase (Encouraging Change) ​ ​ Maintain relationship & evaluate client’s progress. ​ ​ Encourage problem-solving and self-esteem. ​ ​ Address resistance and transference issues. ​ ​ Revise plans as needed. 3.​ Termination Phase (Ending Relationship) ​ ​ Summarize progress and discuss future plans. ​ ​ Review coping strategies and prepare for independence. 9. Client Safety in the Milieu ​ ​ Preventing harm: ​ ​ No access to sharp objects or harmful items. ​ ​ Restrict visitors and monitor client behaviors. ​ ​ Limit substance access (alcohol, drugs). ​ ​ Prevent elopement (escaping the facility). ​ ​ Use de-escalation techniques for agitation. ​ ​ Room Assignments: ​ ​ Consider mental health diagnoses. ​ ​ Be mindful of nighttime disruptions. ​ ​ Avoid pairing paranoid clients together. 10. Activities Within the Therapeutic Milieu ​ ​ Community Meetings (Encourage participation, decision-making, and self-worth). ​ ​ Individual Therapy (One-on-one sessions with a provider). ​ ​ Group Therapy (Peer support sessions for mental health concerns). ​ ​ Psychoeducational Groups (Teaching coping strategies and mental health education). ​ ​ Recreational Therapy (Exercise, games, community outings). ​ ​ Unstructured Time (Allows for observation of client behaviors). How to Pass Your Test on Chapter 5 ​ ​ Know the characteristics of a therapeutic milieu. ​ ​ Understand the nurse’s role in the therapeutic relationship. ​ ​ Differentiate between social and therapeutic relationships. ​ ​ Memorize the phases of the therapeutic relationship. ​ ​ Be able to identify transference vs. countertransference. ​ ​ Learn client safety measures and therapeutic activities Chapter 5 Diverse Practice Settings Overview ​ ​ Mental health nursing occurs in acute care, community settings, and forensic nursing. ​ ​ Nurses advocate for clients with mental illnesses and provide referrals to organizations like NAMI (National Alliance on Mental Illness) for support. Settings for Mental Health Care 1. Acute Care ​ ​ Purpose: Intensive treatment and supervision in locked units for clients with severe mental illness who pose a danger to themselves or others. ​ ​ Key Features: ​ ​ Helps stabilize mental illness symptoms for a rapid return to the community. ​ ​ Interprofessional team approach: Nurses, psychiatrists, psychologists, social workers, and more. ​ ​ May be privately owned, state-run, or part of general hospitals. ​ ​ Forensic units exist in correctional facilities for individuals with severe mental illness. ​ ​ Case management programs assist with transitioning clients to community settings post-discharge. 2. Community Settings Includes: ​ ​ Clinics, schools, day-care centers ​ ​ Partial hospitalization programs ​ ​ Crisis counseling centers ​ ​ Home health care ​ ​ Nurses’ Role: ​ ​ Stabilize/improve mental functioning in the community. ​ ​ Provide referrals to other programs. ​ ​ Promote social activities for mental health well-being. ​ ​ Focus on primary, secondary, and tertiary prevention of mental illness. 3. Forensic Nursing ​ ​ Combination of nursing, biophysical education, and forensic science. ​ ​ Purpose: ​ ​ Utilized in public or legal proceedings. Forensic nurses assist with: ​ ​ Investigation & collection of evidence ​ ​ Analysis & prevention of trauma ​ ​ Treatment of victims & perpetrators ​ ​ Involves working with victims of violence, abuse, and trauma. 4. Rehabilitation ​ ​ Structured environment for clients recovering from: ​ ​ Substance use disorders ​ ​ Self-harm, anxiety, PTSD Services: ​ ​ Medication adherence support ​ ​ Daily living assistance (eating, hygiene) ​ ​ Treatment duration: weeks to months History of Mental Health Care in the U.S. ​ ​ Before the 20th century: Clients with severe mental illness were treated in institutional facilities. ​ ​ 1946, 1955, 1963: Congress enacted laws to improve conditions and promote deinstitutionalization. ​ ​ 1970s: Case management introduced to meet mental health needs in community settings. ​ ​ 1980s: HMOs and PPOs limited hospital stays. ​ ​ 1999: Mental illness recognized as a disability under the Americans with Disabilities Act. Acute Mental Health Care Settings Admission Criteria: ​ ​ Danger to self/others. ​ ​ Inability to meet basic needs. ​ ​ Failure of community-based treatments. ​ ​ Medical need coexisting with mental illness. Goals: ​ ​ Prevent harm to self/others. ​ ​ Stabilize mental health crises. ​ ​ Transition to community-based care. Community-Based Mental Health Programs Partial Hospitalization Programs: ​ ​ Intensive short-term treatment for clients stable enough to go home. ​ ​ Includes detox programs for substance use. Assertive Community Treatment (ACT): ​ ​ Helps reduce hospitalizations. ​ ​ Provides crisis intervention & support. ​ ​ Services occur in clients’ homes or community centers. Community Mental Health Centers: ​ ​ Education groups, medication programs, counseling. Psychosocial Rehabilitation Programs: ​ ​ Residential services. ​ ​ Day programs for older adults. Home-Based Services: ​ ​ Mental health care for children, older adults, and medically frail individuals. Telehealth in Mental Health Care ​ ​ Expands mental health care access for those unable to attend in-person therapy. ​ ​ Covered by insurance. ​ ​ Used for various interventions. Levels of Prevention in Mental Health Care Primary Prevention: ​ ​ Goal: Prevent mental illness before it starts. ​ ​ Example: Teaching stress reduction techniques in community programs. Secondary Prevention: ​ ​ Goal: Early detection and intervention. ​ ​ Example: Screening older adults for depression. Tertiary Prevention: ​ ​ Goal: Rehabilitation & relapse prevention. ​ ​ Example: Leading support groups for clients recovering from substance use disorders. Roles of Nurses in Mental Health Practice Registered Nurse (RN) ​ ​ Requires diploma, associate, or bachelor’s degree. ​ ​ Provides medication and nursing interventions. ​ ​ Works in acute or community-based settings. ​ ​ Manages client care within facilities. Advanced Practice Nurse (APN) ​ ​ Requires master’s or doctoral degree in behavioral health. ​ ​ Can work independently. ​ ​ Prescribes medications. ​ ​ Conducts research & quality improvement. Active Learning Scenario ​ ​ Identify criteria for mental health facility admission. ​ ​ Explain concepts of mental health treatment. ​ ​ Describe interventions for acute mental health care. Chapter 6 Psychoanalysis, Psychotherapy, and Behavioral Therapies Overview ​ ​ These therapies address mental health issues using different methods and theories. Nurses do not perform the therapy but: ​ ​ Collect assessment data. ​ ​ Identify the need for therapy. ​ ​ Evaluate treatment progression. ​ ​ Advocate for the client’s right to treatment. ​ ​ Nurses educate clients on the benefits of different therapies and the diagnoses they help treat. Psychoanalysis Classical psychoanalysis: ​ ​ A long-term therapy where clients discuss unconscious thoughts and resolve conflicts with a therapist. ​ ​ Originally developed by Sigmund Freud, focusing on early childhood experiences. ​ ​ Rarely used alone today due to the long duration and insurance restrictions. Common techniques: ​ ​ Transference: Client redirects unconscious feelings from past relationships onto the therapist. ​ ​ Countertransference: The therapist develops unconscious emotional reactions toward the client. Therapeutic Tools ​ 1.​ Free Association: The spontaneous, uncensored verbalization of thoughts. ​ 2.​ Dream Analysis & Interpretation: Freud’s belief that dreams reflect unconscious urges. ​ 3.​ Use of Defense Mechanisms: Unconscious strategies used to cope with anxiety. Psychotherapy ​ ​ More interactive than classic psychoanalysis. ​ ​ Client-therapist trust is key to problem-solving. Types of psychotherapy: Psychodynamic Psychotherapy: ​ ​ Similar to psychoanalysis but focuses on present issues instead of childhood. ​ ​ Longer lasting than other therapies. Interpersonal Psychotherapy (IPT): ​ ​ Addresses relationship issues, communication, grief, and role transitions. ​ ​ Premise: Mental health disorders stem from interpersonal stressors. Cognitive Therapy: ​ ​ Based on cognitive models that focus on changing thoughts before feelings. ​ ​ Effective for depression, anxiety, and trauma. Behavioral Therapy: ​ ​ Rooted in behaviorism (Pavlov, Watson, Skinner). Belief: Behavior is learned and can be unlearned. ​ ​ Used for phobias, substance abuse, and anxiety disorders. Eye Movement Desensitization and Reprocessing (EMDR): ​ ​ Encourages clients to process traumatic memories in a safe, structured environment. ​ ​ Effective for PTSD and anxiety. Cognitive-Behavioral Therapy (CBT): ​ ​ Combination of cognitive & behavioral therapy. ​ ​ Focuses on how thoughts influence feelings and behaviors. ​ ​ Used for anxiety, depression, and stress management. ​ ​ Dialectical Behavior Therapy (DBT): ​ ​ A subset of CBT for personality disorders & self-harm. ​ ​ Focuses on gradual behavior changes, validation, and emotional regulation. Use of Cognitive Therapy Cognitive Reframing: ​ ​ Helps clients identify negative thoughts, challenge them, and develop healthier thinking. ​ ​ Example: A client who believes they are a bad person can learn to reframe their thoughts. Priority Restructuring: Helps clients focus on healthy, enjoyable activities. Journal Keeping: Encourages self-reflection & emotional processing. Monitoring Thoughts: Teaches clients to recognize and challenge negative thinking patterns. Types and Uses of Behavioral Therapy Modeling: ​ ​ Therapists or peers model positive behaviors for clients to imitate. ​ ​ Used in acute care to improve social skills. Operant Conditioning: ​ ​ Positive reinforcement rewards good behavior. ​ ​ Example: Token economy (clients earn tokens for good behavior). ​ 3.​ Systematic Desensitization: ​ ​ Gradual exposure to anxiety-provoking stimuli while using relaxation techniques. ​ ​ Helps clients manage phobias and anxiety. ​ Aversion Therapy: ​ ​ Pairing maladaptive behavior with punishment. ​ ​ Example: Using bitter-tasting substance for alcohol aversion. ​ 5.​ Meditation, Guided Imagery, Muscle Relaxation, Biofeedback: ​ ​ Helps with pain, tension, and anxiety management. Other Behavioral Techniques Flooding: ​ ​ Exposing a client to high levels of an anxiety trigger to reduce fear quickly. Response Prevention: ​ ​ Preventing clients from performing compulsive behaviors to break the anxiety cycle. Thought Stopping: ​ ​ Teaching clients to interrupt negative thoughts with a verbal or mental “STOP.” Trauma-Focused CBT: ​ ​ Uses psychoeducation about trauma and coping mechanisms. ​ ​ Helps clients process and reframe traumatic memories. Validation Therapy: ​ ​ Used for neurocognitive disorders (e.g., dementia). ​ ​ Encourages validating client emotions even if they are in an altered reality. Virtual Reality Exposure Therapy: ​ ​ Places clients in controlled virtual environments to help treat phobias, PTSD, and anxiety disorders. Key Takeaways ​ ​ Psychoanalysis focuses on unconscious conflicts & childhood experiences. ​ ​ Psychotherapy is interactive and builds client-therapist trust. ​ ​ CBT & DBT help reframe negative thoughts & behaviors. ​ ​ Behavioral therapy uses learning principles to change maladaptive behavior. ​ ​ Exposure & aversion techniques help with phobias & addictions. ​ ​ Newer methods like EMDR & Virtual Reality Therapy are effective for trauma & anxiety. Chapter 7: Group and Family Therapy Overview ​ ​ Group and family therapy involve open therapeutic communication among participants. ​ ​ Although individual therapy is important, group and family therapy are also vital treatment components in mental health settings. ​ ​ Leaders guide the therapy and use different leadership styles: Democratic leadership: Encourages group interaction and decision-making. Laissez-faire leadership: Promotes autonomy, with minimal leader involvement. Autocratic leadership: The leader controls the structure and direction without allowing much group input. Examples of group therapy include: ​ ​ Stress management ​ ​ Substance use disorder recovery ​ ​ Medication education ​ ​ Understanding mental illness ​ ​ Dual diagnosis support groups Group Therapy Key Concepts Group Process: ​ ​ Verbal & nonverbal communication between members during group sessions. ​ ​ Includes how work progresses and how members interact. Group Norms: ​ ​ Expected behaviors within the group. ​ ​ Example: Raising hands before speaking or sitting in assigned seats. ​ Hidden Agenda: ​ ​ Unstated personal goals that disrupt group process. ​ ​ Example: A group member embarrassing another rather than focusing on therapy. Group Dynamics: ​ ​ Groups can be open (new members join) or closed (fixed membership). Group Membership Homogeneous groups: ​ ​ Members share a specific characteristic (diagnosis, gender). Heterogeneous groups: ​ ​ Members differ in various characteristics (e.g., mixed gender in a mental health unit). Subgroups: ​ ​ Smaller groups within a larger one that work separately. Components of Therapy Sessions ​ ​ Use of open and clear communication. ​ ​ Cohesion & guidelines for group sessions. ​ ​ Direction toward therapeutic goals. ​ ​ Development of interpersonal skills. ​ ​ Resolution of issues related to family & personal challenges. Focus & Goals for Therapy Types Therapy Type​ Focus​ Goals Individual Therapy​Client’s needs & problems​ - Improve decision-making - Develop self-awareness - Strengthen sense of self Family Therapy​ Family dynamics & functioning​- Learn coping strategies - Improve understanding among members - Promote positive family interaction Group Therapy​ Helping members develop support systems​- Improve relationships - Share common experiences - Encourage behavioral changes Group Therapy Goals ​ ​ Encourage sharing of emotions & concerns. ​ ​ Decrease feelings of isolation. ​ ​ Create a healing community. ​ ​ Provide cost-effective treatment compared to individual therapy. Concerns in Group Therapy ​ ​ Privacy issues. ​ ​ Unequal attention among members. ​ ​ Disruptive members affecting group cohesion. Phases of Group Development ​ 1.​ Planning Phase: ​ ​ Define group characteristics, such as membership and meeting structure. ​ ​ Consider group composition (e.g., a withdrawn client may not interact well with an overly talkative member). ​ ​ Choose a leadership style ​ Orientation Phase: ​ ​ Define goals & purpose. ​ ​ Establish trust, respect, and structure. ​ ​ Discuss termination policies. Working Phase: ​ ​ Promote problem-solving and behavioral changes. ​ ​ Power struggles may arise. ​ ​ The leader guides communication toward solutions. Termination Phase: ​ ​ Members reflect on progress. ​ ​ The leader summarizes group growth. ​ ​ Group members provide feedback. Roles in Group Therapy Maintenance Roles: ​ ​ Keep the group focused on its goals. ​ ​ Example: A harmonizer prevents conflicts. Task Roles: ​ ​ Help organize group activities. ​ ​ Example: A recorder keeps track of discussions. Individual Roles: ​ ​ Can disrupt group process by prioritizing personal agendas. Examples: ​ ​ Dominator tries to control others. ​ ​ Recognition seeker boasts about achievements. Types of Group Therapy Settings Acute Mental Health Setting: ​ ​ Daily meetings focused on immediate relief. ​ ​ Leader provides structure. Outpatient Setting: ​ ​ Long-term therapy with consistent attendance. ​ ​ Members help shape the group. ​ Virtual Groups: ​ ​ Used for remote therapy sessions. Challenges include: ​ ​ Limited access to technology. ​ ​ Difficulty with nonverbal cues. ​ ​ Lack of presence in discussions. Families & Family Therapy Types of Families ​ ​ Nuclear: Children living with married parents. ​ ​ Single-Parent: Children living with one adult. ​ ​ Adoptive: Children living with adoptive parents. ​ ​ Blended: Children living with a biological & stepparent. ​ ​ Cohabitating: Children living with unmarried adults. ​ ​ Extended: Children living with grandparents, aunts, uncles, etc.. Family Functions Healthy Families: ​ ​ Encourage clear communication. ​ ​ Support role flexibility. ​ ​ Promote emotional support. Dysfunctional Families: ​ ​ Have poor communication. ​ ​ Show rigid or enmeshed boundaries. ​ ​ Use negative coping patterns (e.g., blaming, manipulating). Family Boundaries Healthy: ​ ​ Defined roles with mutual understanding. Dysfunctional: ​ ​ Enmeshed Boundaries: Members lose individuality. ​ ​ Rigid Boundaries: Strict & inflexible roles, leading to isolation. Family Dysfunction Concepts Scapegoating: ​ ​ One member takes the blame for family problems. ​ ​ Example: A child blamed for the family missing an outing. Triangulation: ​ ​ One member is drawn into a conflict between two others. ​ ​ Example: A child caught in parents’ arguments. Multigenerational Issues: ​ ​ Patterns of dysfunction repeating over generations. ​ ​ Example: Substance abuse & trauma cycles. Discipline in Families Healthy discipline: ​ ​ Maintains child safety & security. ​ ​ Is consistent, timely, and age-appropriate. ​ ​ Should be administered calmly & privately. Family Therapy ​ ​ Defines family as a system of reciprocal relationships. ​ ​ Focuses on the family unit rather than individuals. ​ ​ Uses various assessment tools to evaluate communication, structure, and boundaries. Nurses’ Role in Family Therapy: ​ ​ Educate families on mental health management. ​ ​ Provide medication administration guidance. ​ ​ Improve communication & resource access. Multi-Family Therapy: ​ ​ Two or more families with similar experiences work together. ​ ​ Example: Families with members diagnosed with schizophrenia share coping strategies. Key Takeaways ​ ​ Group therapy improves interpersonal skills, emotional support, and problem-solving. ​ ​ Group dynamics include roles, norms, and leadership styles. ​ ​ Family therapy focuses on improving relationships & communication. ​ ​ Healthy families have clear roles, boundaries, and emotional support. ​ ​ Dysfunctional families struggle with poor communication, rigid roles, and unhealthy coping. Chapter 8 Brain Stimulation Therapies Overview ​ ​ Brain stimulation therapies are nonpharmacological treatments for mental health disorders. Types include: ​ ​ Electroconvulsive therapy (ECT) ​ ​ Repetitive transcranial magnetic stimulation (rTMS) ​ ​ Vagus nerve stimulation (VNS) ​ ​ Deep brain stimulation (DBS) Electroconvulsive Therapy (ECT) ​ ​ Uses electrical currents to induce brief seizure activity while the client is under anesthesia. ​ ​ Exact mechanism is unknown, but it is believed to enhance neurotransmitters (serotonin, dopamine, norepinephrine). Indications (Potential Diagnoses) Major Depressive Disorder: ​ ​ When symptoms do not respond to medication. ​ ​ When suicidal or homicidal tendencies require rapid treatment. ​ ​ When the client has psychotic features. Schizophrenia Spectrum Disorders: ​ ​ Effective for catatonic schizophrenia. ​ ​ Used for schizoaffective disorder. Acute Manic Episodes: ​ ​ For bipolar disorder with rapid cycling (≥4 episodes of mania in 1 year). ​ ​ For clients unresponsive to lithium & antipsychotics. Contraindications ​ ​ No absolute contraindications, but caution is needed for: Cardiovascular disorders: ​ ​ Recent heart attack, heart failure, arrhythmias, hypertension. ​ ​ ECT increases cardiac stress. Cerebrovascular disorders: ​ ​ History of stroke, brain tumors, subdural hematomas. ​ ​ ECT increases blood flow & intracranial pressure. ​ ​ Ineffective for: ​ ​ Substance use disorders. ​ ​ Personality disorders. ​ ​ Dysphoric disorder. Considerations & Procedural Care Treatment Schedule: ​ ​ 2–3 sessions per week for 6–12 total treatments. ​ ​ Informed consent is required. Pre-ECT care: ​ ​ Chest X-ray, blood work, ECG. ​ ​ Discontinue benzodiazepines (they interfere with seizures). Medication Management: ​ ​ 30 minutes before ECT: Injection of atropine sulfate to reduce secretions & prevent bradycardia. During ECT: ​ ​ Short-acting anesthetic (e.g., propofol). ​ ​ Muscle relaxant (succinylcholine) to prevent injuries. Monitoring: ​ ​ Blood pressure, oxygen levels, cardiac rhythm. ​ ​ 100% oxygen given during & after ECT. Complications Memory Loss & Confusion: ​ ​ Short-term memory loss, disorientation, and confusion are common. ​ ​ Retrograde amnesia (loss of memory before procedure) can occur. ​ ​ Memory typically improves within weeks. Nursing Actions: ​ ​ Frequent orientation & safety measures. ​ ​ Encourage good hygiene & nutrition. Reactions to Anesthesia: ​ ​ Continuous monitoring is required. Cardiovascular Effects: ​ ​ Monitor for hypertension or dysrhythmias. Relapse of Depression: ​ ​ ECT is not a permanent cure; maintenance sessions may be required. Repetitive Transcranial Magnetic Stimulation (rTMS) ​ ​ Noninvasive therapy using magnetic pulsations to stimulate the cerebral cortex. ​ ​ Does not cause seizures. Indications ​ ​ Approved for major depressive disorder when medication is ineffective. ​ ​ Similar to ECT but with fewer risks. Considerations ​ ​ Prescribed for 4–6 weeks. ​ ​ Outpatient procedure lasting 30–40 minutes. ​ ​ Electromagnet placed on the scalp. ​ ​ Client remains alert. ​ ​ Sensation of tapping or contraction may be felt. Complications ​ ​ Mild tingling or headache is common. ​ ​ Seizures are rare but possible. ​ ​ Not associated with systemic side effects. Vagus Nerve Stimulation (VNS) ​ ​ Implanted device that provides electrical stimulation to the vagus nerve. ​ ​ Increases neurotransmitter levels, similar to antidepressants. Indications ​ ​ Used for treatment-resistant depression. ​ ​ FDA-approved for depression unresponsive to medications or ECT. ​ ​ Being studied for anxiety, obesity, and pain. Considerations ​ ​ Outpatient surgical procedure. ​ ​ Device sends electrical pulses every 5 minutes. ​ ​ Effects take weeks to develop. ​ ​ Client can deactivate the device using an external magnet. Complications ​ ​ Hoarseness, throat pain, voice changes. ​ ​ Possible dyspnea with physical exertion. Deep Brain Stimulation (DBS) ​ ​ Surgical implantation of electrodes into the brain. ​ ​ Used to stimulate underactive regions. ​ ​ More invasive than VNS. Indications ​ ​ FDA-approved for Parkinson’s disease & treatment-resistant OCD. Considerations ​ ​ Outpatient procedure. ​ ​ Continuous electrical pulses delivered. ​ ​ Antidepressant effects take weeks. ​ ​ Client can deactivate with an external magnet. Complications ​ ​ Infection risk from implanted device. ​ ​ Possible hypomania episodes. ​ ​ Headaches, seizures, stroke, confusion. Key Takeaways ​ ​ ECT is effective for severe depression, schizophrenia, and acute mania. ​ ​ rTMS is a noninvasive alternative to ECT. ​ ​ VNS & DBS are surgical procedures for treatment-resistant conditions. ​ ​ Memory loss is a common ECT side effect but is usually temporary. ​ ​ Proper pre/post-procedure care is essential to ensure safety. Chapter 9 Communication & Therapeutic Relationships I. Therapeutic Relationship Client-Centered Care ​ ​ Client Participation: Active involvement in treatment plan & goals. ​ ​ Nurse Role: Empathetic listening, fostering a supportive environment, holistic approach. Therapeutic Communication Techniques ​ ​ Open-ended questions (Encourage discussion) ​ ​ Clarification (Ensuring understanding) ​ ​ Closed-ended questions (For specific information) ​ ​ Summarizing (Confirming information) II. Assessment & Recognizing Cues Assessment Steps Recognizing Cues ​ ​ Identify symptoms & patterns ​ ​ Determine what is concerning ​ ​ Assess additional needed information Prioritizing Problems ​ ​ Cluster & analyze information ​ ​ Determine risk (safety, self-harm, harm to others) ​ 3.​ Client History Assessment ​ ​ Physiological: Ability to participate ​ ​ Co-occurring Conditions: Demographics, history, coping ability, cultural/spiritual beliefs Psychosocial Assessment ​ ​ Mental Status Exam (MSE) ​ ​ Risk for violence, suicide, aggression ​ ​ Work, education, family history ​ ​ Dementia care & validation therapy III. Nursing Process Planning & Implementation ​ ​ Generating Solutions: Prioritizing nursing care, adjusting to condition changes, team collaboration. ​ ​ Goals & Outcomes: Client-focused, facilitated by nurse, safety first. ​ ​ Discharge Planning: Starts at diagnosis, involves interdisciplinary communication. Implementation ​ ​ Client & Family Teaching ​ ​ Condition, medications, relapse warning signs, follow-ups. ​ ​ Evaluation of Outcomes ​ ​ Review effectiveness of care plan, revise as needed, ensure appropriateness. IV. Treatments & Therapies Cognitive Therapy Techniques ​ ​ Priority Restructuring: Focus on priorities ​ ​ Journal Keeping: Expressing stressful thoughts ​ ​ Assertiveness Training: Expressing emotions non-aggressively ​ ​ Thought Monitoring: Identifying negative thoughts Behavioral Therapy Techniques ​ ​ Modeling: Improving social skills ​ ​ Operant Conditioning: Reward-based behavior reinforcement ​ ​ Systematic Desensitization: Exposure therapy ​ ​ Aversion Therapy: Unpleasant stimuli to deter behaviors Other Psychological Techniques ​ ​ Flooding: Treating phobias & PTSD by direct exposure ​ ​ Response Prevention: Prevents compulsive behaviors (OCD) ​ ​ Thought Stopping: Stopping intrusive thoughts ​ ​ TF-CBT (Trauma-Focused Cognitive Behavioral Therapy): Used for PTSD & abuse survivors ​ ​ Validation Therapy: Respecting emotions (Dementia care, schizophrenia) ​ ​ VRET (Virtual Reality Exposure Therapy): Anxiety-provoking situations (PTSD, phobias) V. Phases of the Nurse-Client Relationship ​ 1.​ Orientation Phase: Establish trust, set boundaries. ​ 2.​ Identification Phase: Identify unmet client needs. ​ 3.​ Exploitation Phase: Collaborate on goals. ​ 4.​ Resolution Phase: Evaluate progress, set new goals. VI. Professionalism & Communication Strategies Building Trust & Rapport ​ ​ Qualities that build trust: Honesty, transparency, respect, understanding. ​ ​ Barriers to trust: Gender, education, language, culture, socioeconomic status. Maintaining Professional Boundaries ​ ​ Avoid boundary blurring. Stay professional & therapeutic. ​ ​ Transference: Client shifts feelings onto the nurse. ​ ​ Countertransference: Nurse shifts feelings onto the client. VII. Nonverbal Communication Strategies ​ ​ S.O.L.E.R. Technique ​ ​ S – Sit squarely to client ​ ​ O – Open posture ​ ​ L – Lean forward ​ ​ E – Eye contact ​ ​ R – Relax ​ ​ Adjusting for Comfort: Some clients may find direct sitting confrontational. ​ ​ Recognizing Nonverbal Cues from Clients ​ ​ Affect: Frowning, grimacing, lip-licking, biting. ​ ​ Appearance: Disheveled, inappropriate clothing. ​ ​ Autonomic Signs: Sweating, flushed face, dilated pupils. ​ ​ Body Language: Rocking, clenched hands. ​ ​ Eye Contact: Squinting, minimal blinking. VIII. Wellness & Health Promotion ​ 1.​ Primary Prevention: Preventing mental illness before symptoms arise. ​ 2.​ Secondary Prevention: Early detection, screening, education. ​ 3.​ Tertiary Prevention: Supporting well-being & quality of life. Mental Health Nursing (Chapters 11 and 12) Chapter 4 – Stress and Defense Mechanisms Defense Mechanisms: Adaptive vs. Maladaptive Use 1. Altruism ​ ​ Definition: Helping others to reduce personal anxiety. ​ ​ Adaptive Example: A nurse volunteers after losing a family member in a fire. ​ ​ Maladaptive Example: N/A (Always adaptive). 2. Sublimation ​ ​ Definition: Replacing unacceptable impulses with acceptable ones. ​ ​ Adaptive Example: A person channels anger into exercise. ​ ​ Maladaptive Example: N/A (Always adaptive). 3. Suppression ​ ​ Definition: Voluntarily pushing away unpleasant thoughts. ​ ​ Adaptive Example: A student ignores a breakup to focus on a test. ​ ​ Maladaptive Example: A person avoids worrying about losing their job. 4. Repression ​ ​ Definition: Unconsciously forgetting distressing thoughts. ​ ​ Adaptive Example: A person forgets about a childhood bullying incident before a speech. ​ ​ Maladaptive Example: A person continually avoids going to the dentist due to past trauma. 5. Regression ​ ​ Definition: Returning to childlike behaviors. ​ ​ Adaptive Example: A child temporarily wets the bed after losing a pet. ​ ​ Maladaptive Example: An adult throws things when upset at work. 6. Displacement ​ ​ Definition: Redirecting emotions toward something else. ​ ​ Adaptive Example: A teenager punches a pillow after an argument. ​ ​ Maladaptive Example: A parent destroys their child’s toy after losing a job. 7. Reaction Formation ​ ​ Definition: Overcompensating by behaving in the opposite way of one’s true feelings. ​ ​ Adaptive Example: A person trying to quit smoking warns others about its dangers. ​ ​ Maladaptive Example: A resentful caregiver becomes overprotective of an aging parent. 8. Undoing ​ ​ Definition: Making up for an unacceptable action. ​ ​ Adaptive Example: A teenager does chores after arguing with a parent. ​ ​ Maladaptive Example: A partner buys flowers after an abusive incident. 9. Rationalization ​ ​ Definition: Justifying behaviors with logical-sounding reasons. ​ ​ Adaptive Example: A rejected adolescent assumes their crush must be taken. ​ ​ Maladaptive Example: A drunk driver claims they only drove to avoid inconvenience. 10. Dissociation ​ ​ Definition: Disconnecting from reality to avoid stress. ​ ​ Adaptive Example: A parent tunes out distractions while driving. ​ ​ Maladaptive Example: A sexual assault victim forgets who they are. 11. Denial ​ ​ Definition: Refusing to accept reality. ​ ​ Adaptive Example: A person reacts with disbelief to a cancer diagnosis. ​ ​ Maladaptive Example: A grieving parent insists their deceased child is still alive. 12. Compensation ​ ​ Definition: Strengthening a skill to make up for a weakness. ​ ​ Adaptive Example: A student who struggles academically excels in sports. ​ ​ Maladaptive Example: A shy person avoids social interactions by focusing on computers. 13. Identification ​ ​ Definition: Adopting traits of another person or group. ​ ​ Adaptive Example: A sick child pretends to be a nurse for their dolls. ​ ​ Maladaptive Example: A child of abusive parents becomes a bully. 14. Intellectualization ​ ​ Definition: Using logic instead of emotions to cope. ​ ​ Adaptive Example: A detective focuses on facts rather than emotions. ​ ​ Maladaptive Example: A terminally ill person focuses only on finances instead of grief. 15. Conversion ​ ​ Definition: Stress manifests as physical symptoms. ​ ​ Adaptive Example: N/A ​ ​ Maladaptive Example: A person experiences blindness after receiving bad news. 16. Splitting ​ ​ Definition: Viewing things as entirely good or bad. ​ ​ Adaptive Example: N/A ​ ​ Maladaptive Example: A patient praises a nurse one day and ignores them the next. 17. Projection ​ ​ Definition: Attributing one’s own negative thoughts onto others. ​ ​ Adaptive Example: N/A ​ ​ Maladaptive Example: A cheating spouse accuses their partner of cheating. 3. Anxiety Levels and Nursing Interventions 1. Mild Anxiety ​ ​ Symptoms: ​ ​ Normal anxiety level ​ ​ Enhances perception ​ ​ Mild tension (e.g., fidgeting, lip-chewing) ​ ​ Nursing Interventions: ​ ​ Use active listening ​ ​ Ask open-ended questions 2. Moderate Anxiety ​ ​ Symptoms: ​ ​ Reduced perception ​ ​ Increased heart rate ​ ​ Headaches ​ ​ Urinary urgency ​ ​ Nursing Interventions: ​ ​ Stay calm ​ ​ Use clear communication ​ ​ Encourage problem-solving 3. Severe Anxiety ​ ​ Symptoms: ​ ​ Distorted perception ​ ​ Confusion ​ ​ Rapid speech ​ ​ Hyperventilation ​ ​ Nursing Interventions: ​ ​ Provide a quiet environment ​ ​ Set limits ​ ​ Focus on reality 4. Panic Anxiety ​ ​ Symptoms: ​ ​ Extreme fright ​ ​ Hallucinations ​ ​ Immobility ​ ​ Disorganized speech ​ ​ Nursing Interventions: ​ ​ Stay with the patient ​ ​ Speak in a calm voice ​ ​ Use simple directions Chapter 9 – Stress Management 1. Understanding Stress ​ ​ Stress: The brain’s response to demands. ​ ​ Types of Responses: ​ ​ Fight: Facing the stressor head-on. ​ ​ Flight: Avoiding the stressor. ​ ​ Freeze: Feeling stuck or unable to act. ​ ​ Fawn: Submissively trying to please others. 2. Effects of Stress Type​ Effects Acute Stress (Short-term): Increased heart rate, insomnia, decreased appetite, suppressed immunity. Chronic Stress (Long-term): Anxiety, weight changes, hypertension, fatigue, risk for infections. 3. Nursing Care: Stress Management Techniques Cognitive Techniques ​ ​ Cognitive Reframing: Restructuring negative thoughts into positive ones. ​ ​ Example: A parent thinks, “I’m a terrible parent” → “I’ve made mistakes but learned from them.” ​ ​ Priority Restructuring: Adjusting priorities to reduce stress. ​ ​ Example: A busy person delegates tasks instead of handling everything alone. Primary Techniques: ​ 1.​ Meditation – Focuses the mind for relaxation. ​ 2.​ Guided Imagery – Uses visualization to create a sense of calm. ​ 3.​ Breathing Exercises – Controls breathing to lower stress. ​ 4.​ Progressive Muscle Relaxation – Involves tensing and relaxing muscles to reduce tension. ​ 5.​ Physical Exercise – Releases endorphins, reducing anxiety and stress. Additional Techniques: ​ 1.​ Biofeedback – Uses devices to monitor physiological responses to stress. ​ 2.​ Mindfulness – Encourages staying present and aware. ​ 3.​ Assertiveness Training – Helps individuals express needs and set boundaries. ​ 4.​ Journal Writing – A therapeutic way to process stress. Other Individual Stress-Reduction Strategies ​ ​ Engaging in hobbies (e.g., music, fishing, pet therapy). ​ ​ Getting enough sleep and massage therapy. 4. Nursing Assessment for Stress ​ ​ Protective Factors: ​ ​ Strong social support ​ ​ Religious/spiritual beliefs ​ ​ Optimism and humor ​ ​ Standardized Stress Screening Tools: ​ ​ Holmes and Rahe Stress Scale (Measures life stressors) ​ ​ Perceived Stress Scale ​ ​ Lazarus’s Cognitive Appraisal (Assesses coping) Key Takeaways for the Exam ​ 1.​ Defense Mechanisms: Understand which are adaptive, which are maladaptive, and how they function. ​ 2.​ Anxiety Levels: Recognize symptoms and appropriate nursing interventions for mild to panic-level anxiety. ​ 3.​ Stress Management: Know various cognitive and behavioral stress-reduction techniques. ​ 4.​ Nursing Interventions: Focus on effective communication, calming techniques, and patient education