Psych HESI Hints

Psych HESI Hints 1. The purpose of therapeutic interaction with clients is to allow them the autonomy to make choices when appropriate. Keep statements value-free, advice-free, and reassurance-free. Remember, just the facts! No opinions! 2. What action should the nurse take in a psychiatric situation when the client describes a physical problem? Assess, assess, assess! If a client in the psychiatric unit with paranoid schizophrenia complains of chest pain, take his or her BP. If the obstetrical client who has delivered a dead fetus complains of perineal pain, look at the perineal area (she may have a hematoma). Just because the focus of the client’s situation is on his or her psychological needs, it does not mean that the nurse can ignore physiologic needs. 3. Basic communication principles can be applied to all clients:  Establish trust.  Demonstrate a nonjudgmental attitude.  Offer self; be empathetic, not sympathetic.  Use active listening.  Accept and support client’s feelings.  Clarify and validate client’s statements.  Use matter-of-fact approach. 4. Remember, a nurse’s nonverbal communication may be more important than the verbal communication. 5. A question concerning nurse–client confidentiality appears often on the NCLEX-RN. For the nurse to tell a client that he or she will not tell anyone about their discussion puts the nurse in a difficult position. Some information must be shared with other team members for the client’s safety (e.g., suicide plan) and optimal therapy. 6. Nausea is a common complaint after ECT. Vomiting by an unconscious client can lead to aspiration. Because post-ECT clients are unconscious, the nurse must observe closely for the possibility of aspiration: maintain a patent airway! 7. Common physiologic responses to anxiety include increased heart rate and blood pressure; rapid, shallow respirations; dry mouth and tight feeling in throat; tremors and muscle tension; anorexia; urinary frequency; and palmar sweating. 8. Anxiety is very contagious and is easily transferred from client to nurse and from nurse to client. First, the nurse must assess his or her own level of anxiety and remain calm. A calm nurse helps the client to gain control, decrease anxiety, and increase feelings of security. 9. When a client describes a phobia or expresses an unreasonable fear, the nurse should acknowledge the feeling (fear) and refrain from exposing the client to the identified fear. After trust is established, a desensitization process may be prescribed. Desensitization is the nursing intervention for phobia disorders. The nurse should:  Assist client to recognize the factors associated with feared stimuli that precipitate a phobic response.  Teach and practice with client alternative adaptive coping strategies, such as the use of thought substitution (replacing a fearful thought with a pleasant thought) and relaxation techniques. (Role-playing is useful when the client is in a calm state.)  Expose client progressively to feared stimuli, offering support with the nurse’s presence.  Provide positive reinforcement whenever a decrease in phobic reaction occurs.  Note: In all likelihood, the desensitization process will be overseen by a mental health practitioner (nurse practitioner), or psychologist. 10. The nurse should place an anxious client where there are reduced environmental stimuli (a quiet area of the unit, away from the nurses’ station). 11. The best time for interaction with a client is at the completion of the performed ritual. The client’s anxiety is lowest at this time; therefore, it is an optimal time for learning. 12. Compulsive acts are used in response to anxiety, which may or may not be related to the obsession. It is the nurse’s responsibility to help alleviate anxiety.  Interfering will increase anxiety. These acts should be allowed as long as the client’s acts are free of violence. The nurse should: o Actively listen to the client’s obsessive themes. o Acknowledge the effects that ritualistic acts have on the client. o Demonstrate empathy. o Avoid being judgmental. 13. For clients with posttraumatic stress disorder, the nurse should:  Actively listen to client’s stories of experiences surrounding the traumatic event.  Assess suicide risk.  Assist client to develop objectivity about the event and problem-solve regarding possible means of controlling anxiety related to the event.  Encourage group therapy with other clients who have experienced the same or related traumatic events. 14. Be aware of your own feelings when dealing with this type of client. It is a challenge to be nonjudgmental. The pain is real to the person experiencing it. These disorders cannot be explained medically; they result from internal conflict. The nurse should:  Acknowledge the symptom or complaint.  Reaffirm that diagnostic test results reveal no organic pathology.  Determine the secondary gains acquired by the client. 15. The nurse should be aware that all behavior has meaning. 16. Avoid giving clients with dissociative disorders too much information about past events at one time. The various types of amnesia that accompany dissociative disorders provide protection from pain. Too much, too soon may cause decompensation. 17. Personality disorders are long-standing behavioral traits that are maladaptive responses to anxiety and that cause difficulty in relating to and working with other individuals. NCLEX-RN® questions sometimes test personality disorder content by describing management situations. 18. Persons with personality disorders are usually comfortable with their disorders and believe that they are right and the world is wrong. These individuals usually have very little motivation to change. Think of them as a challenge! 19. People with anorexia gain pleasure from providing others with food and watching them eat. These behaviors reinforce their perception of self-control. Do not allow these clients to plan or prepare food for unit-based activities. 20. Individuals with bulimia often use syrup of ipecac to induce vomiting. If ipecac is not vomited and is absorbed, cardiotoxicity may occur and can cause conduction disturbances, cardiac dysrhythmias, fatal myocarditis, and circulatory failure. Because heart failure is not usually seen in this age group, it is often overlooked. Assess for edema and listen to breath sounds. 21. Physical assessment and nutritional support are a priority; the physiologic implications are great. Nursing interventions should increase self-esteem and develop a positive body image. Behavior modification is useful and effective. Family therapy is most effective because issues of control are common in these disorders. (Therapy is usually long term.) 22. The most important signs and symptoms of depression are a depressed mood with a loss of interest in the pleasures in life. The client has sustained a loss. Other symptoms include: 23. Significant change in appetite, often accompanied by a change in weight, either weight loss or gain  Insomnia or hypersomnia (usually sleeping during the day, often because the client is not sleeping at night due to anxiety)  Fatigue or lack of energy  Feelings of hopelessness, worthlessness, guilt, or overresponsibility  Loss of ability to concentrate or think clearly  Preoccupation with death or suicide 24. Depressed clients have difficulty hearing and accepting compliments because of their lowered self-concept. Comment on signs of improvement by noting the behavior (e.g., “I notice you combed your hair today” not, “You look nice today”). 25. The nurse knows depressed clients are improving when they begin to take an interest in their appearance or begin to perform self-care activities that were previously of little or no interest to them. 26. The nurse should suspect an imminent suicide attempt if a depressed client becomes “better” (i.e., happy or even elated). Be aware: a happy affect may signify that the client feels relieved that a plan has been made and is prepared for the suicide attempt. 27. When dealing with a depressed client, the nurse should assist with personal hygiene tasks and encourage the client to initiate grooming activities even when he or she does not feel like doing so. This helps promote self-esteem and a sense of control. 28. An important nursing intervention for the depressed client is to sit quietly with the client. When answering NCLEX-RN questions, remember that you are working at Utopia General and there is plenty of time and staff to provide ideal nursing care. Do not let the realities of clinical situations deter you from choosing the best nursing intervention,. The best intervention is to sit quietly with the client, offering support with your presence. 29. There are always questions about drugs on the NCLEX-RN. Here are some tips:  Know the common side effects of drug groups. o For example:  Antianxiety drugs: sedation, drowsiness  Antidepressant drugs: anticholinergic effects, postural hypotension  MAO inhibitors: hypertensive crisis  Know specific problems and concerns in drug therapy. o For example:  Lithium requires renal function assessment and monitoring.  Phenothiazines cause extrapyramidal effects (EPS); tardive dyskinesia can be permanent if client is not assessed regularly for signs of tardive dyskinesia!  Know specific client teachings about drug therapy. o For example:  Phenothiazines cause photosensitivity, so client must wear protective clothing and sunglasses.  MAO inhibitors require dietary restrictions to prevent hypertensive crisis. 30. Monitor serum lithium levels carefully. The therapeutic and toxic levels are very close to each other on the readings. Signs of toxicity are evident when lithium levels are more than 1.5 mEq/L. Blood levels should be drawn 12 hours after last dose. 31. Manic clients can be very caustic toward authority figures. Be prepared for personal putdowns. Avoid arguing or becoming defensive. 32. What activities are appropriate for a manic client? Noncompetitive physical activities that require the use of large muscle groups. 33. Where a manic client should be placed on the unit?  Make every attempt to reduce stimuli in the environment. Place the client in a quiet part of the unit. 34. What interventions should the nurse use if a client becomes abusive?  Redirect negative behavior or verbal abuse in a calm, firm, nonjudgmental, nondefensive manner.  Suggest a walk or other physical activity.  Set limits on intrusive behavior. For example, “When you interrupt, I cannot explain the procedure to the others; please wait your turn.”  If necessary, seclude or administer medication if client becomes totally out of control. Always remember to use compassion because nurses are “nice” people. 35. When evaluating client behaviors, consider the medications the client is receiving. Exhibited behaviors may be manifestations of schizophrenia or a drug reaction. 36. There are five types of schizophrenia specified in the DSM-IV-TR, which is a diagnostic manual prepared by the American Psychiatric Association that provides diagnostic criteria for all psychiatric disorders. 37. Use Bleuler’s four A’s to help remember the important characteristics of schizophrenia:  Autism (preoccupied with self)  Affect (flat)  Associations (loose)  Ambivalence (difficulty making decisions) 38. Know the side effects of drugs commonly used to treat schizophrenia because client behavioral changes may be due to drug reactions instead of schizophrenia. 39. Observe for increased motor activity and/or erratic response to staff and other clients. The client may be experiencing an increase in command hallucinations. When this occurs, there is an increased potential for aggressive behavior. 40. Do not argue with a client about the delusions. Logic does not work; it only increases the client’s anxiety. Be matter-of-fact and divert delusional thought to reality. Trust is the basis for all interactions with these clients. Be supportive and nonjudgmental. Stress increases anxiety and the need for delusions and hallucinations. Do not agree that you hear voices (you should be the client’s contact with reality), but acknowledge your observation of the client; for example, “You look like you’re listening to something.” 41. What medications can the nurse expect to administer to chemically dependent clients? In treating alcohol withdrawal, Librium or Ativan are commonly used. Antabuse is often used as a deterrent to drinking alcohol. Client teaching should include the effects of consuming any alcohol while on Antabuse. Encourage client to read all labels of overthe-counter medications and food products that may contain small amounts of alcohol. 42. What type of therapy is used with chemically dependent clients? Group therapy is effective, as are support groups such as Alcoholics Anonymous and Narcotics Anonymous. 43. Harm reduction is a community health strategy designed to reduce the harm of substance abuse to families, individuals, community, and society. Examples: More compassionate drug treatment options, including abstinence and drug-substitution models; HIV-related interventions such as needle exchanges; directed drug-use management should the client wish to continue use; changes in laws concerning possession of paraphernalia and drug use. 44. Know what defense mechanisms are used by chemically dependent clients. Denial and rationalization are the two most common coping styles used. Their use must be confronted so the client’s accountability for his or her own behavior can be developed. 45. What basic needs take priority when working with chemically dependent clients? Nutrition is a priority. Alcohol and drug intake has superseded the intake of food for these clients. 46. What behaviors are expected during withdrawal? In the alcoholic, DTs occurs 12 to 36 hours after the last intake of alcohol. Know the symptoms. In drug abuse, withdrawal symptoms are specific to the type of drug. 47. Select only one nurse to care for an abused child. Abused children have difficulty establishing trust. The child will be less anxious with one consistent caregiver. 48. Women who are abused may rationalize the spouse’s behavior and unnecessarily accept blame for his actions. The woman may or may not choose to press charges. Be sure to give her the number of a shelter or help line for future occurrences and help her to develop a safety plan. 49. It is difficult for an elderly person to admit abuse for fear of being placed in a nursing home or being abandoned. Therefore, it is imperative to establish a trusting relationship with the elderly client. 50. Rape victims are at high risk for posttraumatic stress disorder (PTSD). Immediate intervention to diminish distress is vital. The nurse should also assess for and intervene for sequelae such as unwanted pregnancy, sexually transmitted diseases, and HIV risk. 51. Questions on the NCLEX-RN exam regarding physical and sexual abuse usually focus on three aspects:  Physical manifestations of abuse  Client safety  Legal responsibilities of the nurse. For children, the nurse is legally responsible for reporting all suspected cases of abuse. In intimate-partner abuse, it is the adult’s decision; the nurse should be supportive of the decision. Remember to document objective factual assessment data and the client’s exact words in cases of sexual abuse and rape. 52. The basic difference between delirium and dementia is that delirium is acute and reversible, whereas dementia is gradual and permanent. 53. Confusion in older adults is often accepted as being part of growing old. However, the confusion may be due to dehydration with resulting electrolyte imbalance. Think “sudden change” when obtaining a history. Such changes are usually due to a specific stressor, and treatment of the causative stressor will usually result in correcting the confusion. 54. Confabulation is not lying. It is used by the client to decrease anxiety and protect the ego. 55. Nursing interventions for the confused older adult should focus on:  Maintaining the client’s health and safety  Encouraging self-care  Reinforcing reality orientation (e.g., saying, “Today is Monday,” and calling the client by name)  Providing a consistent, safe environment; engaging client in simple tasks and activities to build self-esteem 56. Providing a consistent caregiver is a priority in planning nursing care for the confused older client. Change increases anxiety and confusion. 57. Children also experience depression, which often presents as headaches, stomachaches, and other somatic complaints. Be sure to assess suicide risk, especially in the adolescent. 58. The client’s lack of remorse or guilt about the antisocial behavior represents a malfunction of the superego, or conscience. The id functions on the basic instinct level and strives to meet immediate needs. The ego is in touch with external reality and is the part of the personality that makes decisions. 59. Important points to remember when answering NCLEX-RN questions:    A child in this situation may be involved in a self-fulfilling prophecy (e.g., “Mom says that I’m a troublemaker; therefore, I must live up to Mom’s expectations”). Confront the client with his or her behavior (e.g., lying). This gives the client a sense of security. Provide consistent interventions; this helps to prevent manipulation. Inconsistency does not help the client develop self-control.