Presentation on theme: "NCLEX-RN PREPARATION PROGRAM"— Presentation transcript:
1NCLEX-RN PREPARATION PROGRAM MENTAL HEALTHDISORDERSModule 6, Part 1 of 3
2Module DescriptionThis module will prepare the graduate nurse to pass the NCLEX exam in the area of mental health. Included in this module is a review of the following areas:Therapeutic communication and milieu therapyNursing processMental illnesses and disordersPsychopharmacologyLife span development issues
3IntroductionThe nurse must be aware of the therapeutic or nontherapeutic value of the communication techniques used with the client—they are the “tools” of psychosocial intervention.
4What is Communication? Interpersonal communication is a transaction between the sender andthe receiver. Both persons participatesimultaneously.In the transactional model, both participants perceive each other, listen to each other and simultaneously engage in the process of creating meaning in a relationship.
5CommunicationIncludes: dominant language, dialects, contextual use of language;Paralanguage variations such as voice volume, tone, inflections and willingness to share thoughts and feelings;Nonverbal communications such as eye contact, gesturing and facial expressions, use of touch, body language, spatial distancing practices and acceptable greetings;.
6Communication Communication is: Temporary in terms of past, present and future orientation of worldview;Clock versus social time, and the amount of formality in use of names
7CommunicationTherapeutic communication techniques encourage the client or other individual with whom the nurse is communicating to express their thoughts and feelings.
8Communication Technique Description Active Listening Broad OpeningsDescriptionCarefully noting whatthe client is saying andobserving the client’snonverbal behaviorEncouraging the clientto select topics fordiscussionThere are many therapeutic communication techniques that can be used to promote verbalization.
9Communication Technique: Description: Clarifying FocusingDescription:Making the message clearer, to correct any misunderstanding, and to promote mutual understandingDirecting the conversation onto the topic being discussed
10Communication Technique: Description: Informing Open-endedquestionsDescription:Giving information to the clientEncourage conversation because questions require more than just one-word answers
11Communication Technique: Description: Paraphrasing Reflecting Silence Restating in different words what the client saidDirecting the client’s question or statement or feelings back to the clientAllowing time for formulating thoughtsValidating - Verifying that both the nurse and the client are interpreting the topic or message in the same way
12Communication Non-therapeutic Communication Techniques Approval/DisapprovalAsking excessive questionsChanging the subjectClose-ended questionsGiving adviceFalse reassuranceValue judgmentsWhy questionsMinimizing the client’s feelingsNon therapeutic communication techniques impair or block the flow of a conversation. These techniques are barriers to an effective communication process. There are many non-therapeutic communication techniques
13NCLEX Communication Question Guidelines Look for the option that indicates the use of a therapeutic communication technique.Eliminate non-therapeutic communication techniques.Look for the option that focuses on feelings, concerns, anxieties or fears.Consider cultural differences as you answer the questions.Therapeutic communication techniques are used to answer communication questions because of their effectiveness.You need to think about specific cultural characteristics to answer the question correctly. Remember that each culture is unique with regard to the characteristics related to the process of communication.
14Impact of Preexisting Conditions Both sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted.Values, attitudes, and beliefs.Attitudes of prejudice are expressedthrough negative stereotyping.Culture or religion.Cultural mores, norms, ideas and customsprovide the basis for ways of thinking. Howdo these affect the relationship?
15Impact of Preexisting Conditions Social status. High-status persons often convey their high-power position with gestures of hands on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status.Gender. Masculine and femininegestures influence messages conveyedin communication with others.
16Impact of Preexisting Conditions Age or developmental level. The influence of developmental level on communication is especially evident during adolescence, with words such as “cool,” “awesome” and others.
17Impact of Preexisting Conditions The environment in which the transaction takes place. Territoriality, density, and distance are aspects of environment that communicate messages.Territoriality – the innatetendency to own spaceDensity – the number ofpeople within a givenenvironmental spaceDistance – the means by which various culturesuse space to communicate
18Communication Cultural Considerations With regard to communication, there are three cultural characteristics to consider:Communication styleUse of eye contactThe meaning of touchThe goal is to promote cultural sensitivity and culturally competent care that respects each person’s right to be understood and treated as a unique individual.Questions on the NCLEX-RN examination may address the concept of communication with a client from a specific cultural group.
19Communication Cultural Consideration Communication StyleAfrican AmericansPersonal questions asked on initial contact may be viewed as intrusiveBackground information to consider when developing your communication style with specific cultural groups.
20Communication Cultural Consideration Communication StyleAsian culturesOpen expression of emotions not valuedSilence is valuedCriticism or disagreement not expressedHead nodding does not necessarily mean agreementMay interpret the word “no” as disrespect for othersDo not use hand gestures
21Communication Cultural Consideration Communication StyleAmericans of Northern European descentSilence can be used to show respect or disrespect, depending on situationMay show little facial emotion because they value concept of self-control
22Communication Cultural Consideration Communication StyleFrench and Italian AmericansMay use expressive hand gestures and animated facial expressions
23Communication Cultural Consideration Communication StyleHispanic AmericansMay use dramatic body language such as gestures or facial expressions to express emotion or painConfidentiality importantDirect confrontation disrespectful, and expression of negative feelings impolite
24Communication Cultural Consideration Communication StyleNative AmericansSilence indicates respect for the speakerSpeak in a low tone of voice and expects others to be attentiveBody language is importantObtaining input from extended family important
25Communication Cultural Consideration Use Of Eye ContactAsian CulturesEye contact is limited and may be considered inappropriate or disrespectful
26Communication Cultural Consideration Use Of Eye ContactEuropean (White) AmericansEye contact viewed as indicating trustworthinessNative AmericansEye contact may be viewed as a sign of disrespectClient may be attentive even when eye contact is absent
27Communication Cultural Consideration Use Of Eye ContactHispanic AmericansAvoiding eye contact with a person in authority indicates respect and attentiveness
28Communication Cultural Consideration Meaning of TouchAfrican AmericansComfortable with close personal space when interacting with family and friendsEuropean (White) AmericansTend to avoid close physical contactRespect personal space
29Communication Cultural Consideration Meaning of TouchAsian CulturesPrefer formal personal space except with family & close friendsUsually do not touch others during conversationTouching unacceptable with members of the opposite sex; if possible, a female client prefers a female health care providerThe head is considered to be sacred; touching someone on the head may be considered disrespectfulAvoid physical closeness and excessive touching and only touch a client’s head when necessary, informing before doing so
30Communication Cultural Consideration Meaning of TouchHispanic AmericansComfortable with close proximity with family, friends and acquaintancesProtect privacyTactile and sensory are important - use embraces and handshakesAsk if it would be all right to touch a child before examining him or her
31Practice Question - Communication While communicating with a client, a nurse decides to provide the client with feedback. The primary reason for this is that giving appropriate feedback makes it possible for the nurse to:A. Present adviceB. Explore feelingsC. Provide informationD. Explain behaviorC. Provide information
32Overview of Psychiatric Mental Health Nursing The ability to see oneself as others doFit into one’s culture and societyIndicators of mental healthPositive attitudes toward self, growth, development, self actualization, integration, autonomy, reality perception and environmental mastery.Mental health is not a concrete goal to be achieved; rather, it is lifelong process.
33Overview of Psychiatric Mental Health Nursing Mental IllnessInability to see as others doNot having the ability to conform to the norms of the culture and societyMental health and mental illness can be viewed as end points on a continuum, with movement back and forth throughout life. The mental health-mental illness continuum cuts across physical, personal, interpersonal, and societal levels. On the mental health-mental illness continuum, each level is so intertwined with the others that it is often difficult to pinpoint the original source of the distress.
34Overview of Psychiatric Mental Health Nursing Medical Diagnosis of Mental IllnessClassified according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), of the American Psychiatric Association.The DSM-IV uses a multi-axial system that gives attention to various mental disorders, general medical conditions, aspects of the environment, and areas of functioning that might be overlooked if the focus were exclusively on assessing a single mental illness.
35Overview of Psychiatric Mental Health Nursing The DSM-IV Classification system uses five axes for diagnostic purposes:Axis I: Adult and child clinical disordersAxis II: Personality disorders; mental retardationAxis III: General medical conditionsAxis IV: Psychosocial and environmental problemsAxis V: Global assessment of functioning (0-100)
36Mental Health Nurses Need both general and specific cultural knowledge If above absent, nurses won’t know what questions to askGeneralizations made are almost certain to be oversimplifications
37Mental Health NursesMust first address their own personal and professional knowledge, values, beliefs, ethics and life experiences in a manner that optimizes assessment of and interactions with culturally diverse clients
38Mental Health NursesSelf awareness includes a deliberate process of getting to know oneself; one’s own personality, values, beliefs, professional knowledge, standards, ethics and the impact of the various roles one plays when interacting with individuals who are different from oneself.
39Overview of PMHN Duties/Responsibilities Psychiatric Mental Health Nurses (PMHNs):Assess, formulate nursing interventions, and implement individualized treatment plans with culturally competent interventions.Document progress.Document changes.Attend interdisciplinary meetings to discuss progress, issues and treatment updates.Complete assault prevention training and other required trainings.Nurses’ conduct should be a model for adaptive behavior.
40Overview of PMHN Duties/Responsibilities Uphold professional standards of behavior, appearance, language, dress and demeanor.As a member of an integrated treatment team, assist families, agency representatives and other staff.Understand the legal framework for the delivery of mental health services.
41Nursing Process Assessment Nsg Dx Outcome ID Planning Implementation EvaluationGathering and organizing dataIdentify (ID) areas for interventionSetting outcome criteriaPlanning action to meet the goalsCarrying out actionsEvaluating if goals (outcomes) are met
42Mental Health Assessment INTERVIEWDuring the interview, the nurse uses verbal and nonverbal therapeutic communication techniques to collect subjective and objective data about the client.These data include the client’s current mental health problem; past medical, social, family, academic/vocational, psychiatric, and substance abuse histories; medications and allergies; health habits; interests; strengths and weaknesses; behavior; cultural beliefs and practices; and mental status.
43Mental Health Assessment PurposeEstablish rapportDetermine reason client is seeking helpObtain an understanding of current illness (via client, family, chart review and interdisciplinary team)Understand how this illness has affected client’s lifeIdentify client’s recent life changes or stressors
44Mental Health Assessment Gather current life style informationSocial patternsInterests and abilitiesRelationship issuesSubstance use and abuse
45Mental Health Assessment Assess for risk factorsSuicide or self-harmAssault or violencePhysiological instability
46Mental Health Assessment Appraisal of health and illnessInfo on previous psychiatric problems or or disordersCurrent and past medicationsPhysiological coping responsesPsychological coping responsesResources
47Nursing Conditions During Assessment Self-awarenessAccurate observationsTherapeutic communicationEstablish nursing contractObtain informationOrganize data
48Analyze Data/Norms Formulate Nursing Diagnoses Identify patterns in dataCompare with normsAnalyze and synthesize dataIdentify problems and strengthsValidate problems with clientFormulate nursing diagnosesSet priorities of problems
49Outcome Identification (Goals) Identify expected outcomes individualized to clientPlanningInterventions to attain outcomesNursing ConditionsApplication of theoryNursing BehaviorsPrioritize goalsIdentify nursing activitiesValidate plan with client/familyKey ElementsIndividualized, collaborative, documented
50Implementation Implements interventions identified in the plan of care ExperienceEvidence-based practiceNursing behaviorsKnow available resources, implement, generate alternatives, coordinate with other team members
51Evaluation Evaluation of progress in attaining expected outcomes An ongoing processClient and family participation essentialGoal achievement should be documentedRevisions in the plan of care PRN
52Levels of Intervention CounselingMilieu therapySelf-care activitiesPsychobiological interventionsHealth teachingCase managementHealth maintenance and promotionBased on Nurse Practice Act
53Nursing Interventions Form a trusting one-on-one relationship with the clientMutual learning experience for both the nurse and clientCorrective emotional experience for the clientExplore stressorsGive constructive feedbackPromote development of insight and constructive copingOvercome resistance behaviorForming a one-on-one relationship with the client will help the client to enhance communication, problem-solving, and social skills. Coping skills and trust in relationship may be learned or enhanced.
54Nursing Interventions Behavioral change is the focusEmphasize positive resultsProvide an environment that is safe and private with decreased stimuli as neededEnsure physical and psychosocial needs are metEncourage client participation in treatment planningAdminister medications as ordered and assess resultsEducate client and familyAnd finally: Discharge planning
55Specific Nursing Interventions Active listeningAnger controlAssertiveness trainingBehavior managementBody image enhancementDelusion managementEating disorders managementGrief work facilitationHallucination managementImpulse control trainingMilieu therapyMood managementRole enhancementSleep enhancementSpiritual supportSubstance abuse TxSuicide preventionTeaching (meds…)
56Legal and Ethical Issues DefinitionsVoluntary admission:Client consents to confinement in the hospital and signs a document indicating as much.Client autonomy and liberty must be ensured by giving treatment in the least restrictive setting and by active client participation in treatment
57Legal and Ethical Issues DefinitionsMental Health 72-hour Hold (“5150”):May be implemented on the basis that client poses a danger to self or others or is gravely disabled due to mental illness. Some states also have the criterion of prevention of significant physical or mental deterioration for involuntary admission. Police, doctors, psychologists, county-approved mental health professionals, nurses may initiate.
58Criteria for Involuntary Confinement DANGER TO SELFDANGER TO OTHERSGRAVELY DISABLED(Due to mental illness)72-hour hold (5150)72-hour hold14-day certification (5250)14-day certificationCertification ReviewHearingWrit of Habeas Corpus14-day Extension90-day ExtensionTemporary conservatorship (30-day-6 months)1 year conservatorshipRehearingReappointmentThe following chart shows the three (3) categories that are legal for holding a person in psychiatric treatment against their will.
59Involuntary Confinement (continued) DANGER TO SELF ASSESSMENTDANGER TO OTHERS ASSESSMENTGRAVELY DISABLED ASSESSMENTSuicidal ideationHomicidal ideationsInability to provide food,clothing, shelter for self.Delusions or hallucinations which increase potential ofsuicide.Delusions or hallucinations which increase potential for harm to others.Amount of income, how it is spentLethality Medical, psychological, educational, social and legal situationAssessment for involuntary commitment
60Legal and Ethical Issues DefinitionsCompetency: A legal determination that a client can make reasonable judgments and decisions about treatment and other significant areas of personal life.An adult is considered competent unless a court rules the client incompetent; in such cases, a guardian is appointed to make decisions on the person’s behalf. Clients who are committed are still capable of participating in healthcare decisions
61Legal and Ethical Issues Informed consent: Client’s right to be given enough info to:Make a decisionUnderstand the informationCommunicate his or her decision to othersReceive explanation of client rights and unit policiesReceive signed statement of understanding/refusal to receive TxReceive explanation of insurance benefits or paymentoptions/third-party reimbursementIn an emergency situation, where there is not time to obtain consent without endangering health or safety a client may be treated without legal liability.All patients, voluntary or involuntary, have the right to what is called “informed consent” relative to the right to refuse treatment/medication. This means the physician must inform the resident of the benefits and side effects of each medication ordered. The medication consent must be signed by the conservator if there is a conservator, and by the resident, if voluntary.
62Client Rights/Nursing Responsibility Right to appropriate treatmentRight to know qualifications of those involved in treatment processRight to receive explanations of treatmentRight to be involved in planning of own careRight to refuse to be a part of experimental treatment methodsRight to understand the effects of prescribed medicationRight to treatment in least restrictive environmentRight to refuse treatment - decide which treatment option is best for them
63Legal and Ethical Issues Principle of ConfidentialityFederal laws regarding chemical dependence confidentiality; staff members are not allowed to disclose any admission or discharge information.States have laws regarding when HIV test results or the diagnosis of acquired immunodeficiency syndrome (AIDS) may be disclosed.The healthcare professional has an obligation to warn identified individuals if a client has made a credible threat to harm someone
64Legal and Ethical Issues Principles of ConfidentialityClient’s rightPrevent written or verbal communications from being disclosed to outside parties without authorizationRequired by Nurse Practice ActHIPAA (Health Insurance Portability and Accountability Act of 1996 (2003)Ensures that security procedures protect the privacy and confidentiality of informationClient has right to know what information is disclosed, to whom and for what purpose
65Legal and Ethical Issues Required disclosureIntent to commit a crimeDuty to warn endangered personsEvidence of child, elder, vulnerable adult abuseInitiation of involuntary hospitalization
66An adult client says, “No, I don’t want that medicine. I won’t take it An adult client says, “No, I don’t want that medicine. I won’t take it.” The nurse says, “Take it. It’s good medicine.” The nurse then places the cup in front of the client’s mouth and forcefully presses it against the client’s lips. In counseling this nurse, what important legal principle(s) can be applied to the nurse’s action? Select all that apply.A. If a client does not object a second time, a nurse can administer the medication.B. If treatment is given without consent, legal charges of battery can be filed.C. Clients have the right to be treated in the least restrictive manner possible.D. Clients, unless declared legally incompetent, have the right to refuse medication.E. Clients who wish to do so may establish psychiatric advance directives.B. If treatment is given without consent, legal charges of battery can be filed.D. Clients, unless declared legally incompetent, have the right to refuse medication.
67A. Clarify the intention of the client. A client has purposefully attempted to embarrass a nurse by making a sexually explicit comment. The best response by the nurse is to:A. Clarify the intention of the client.B. Leave the situation altogether.C. Refuse to talk with the client any further.D. Continue to interact as if the comments did not cause embarrassment.A. Clarify the intention of the client.
68CrisisDefinition of CrisisBeing confronted by a stress with which the individual is unable to cope/problem-solveThreatens the individual’s equilibriumGenerally time limited, lasting from 4 to 6 weeksPotential for increased psychological vulnerability or personal growthAnxiety and tension accompany the experience. Hopelessness and/or helplessness results in a state of disorganization
69Crisis Interventions Establish a relationship Identify the problem Identify and reduce perceptual distortionsEnhance self-esteemAlleviate anxietyPromote engagement of support systemsReinforce healthy copingValidate client’s ability to problem-solve.Keep safe if at risk for suicideCrisis is not a psychiatric illness, nor a prolonged condition; therefore pharmacologic interventions are not the intervention of choice.
70A client seeks assistance at a crisis center A client seeks assistance at a crisis center. The client describes being intensely anxious and sleepless since assisting with cleanup activities at a school where a student fatally shot a classmate. To assist the client to cope more effectively, what should be the first intervention of the nurse?Arrange for a member of the clergy to visit the clientAdvise the client to avoid going near the school for at least 6 weeksSend the client to the Emergency Department for further evaluationAllow ventilation of feelingsD.Allow ventilation of feelings
71When the nurse is working with a client in crisis, which nursing action is most important? A. Obtaining a complete assessment of the client’s past historyB. Remaining focused on the client’s immediate problemC. Determining the relationship of early life experiences and the crisis stateD. Developing an action plan for the clientB. Remaining focused on the client’s immediate problem
72Suicide Prevention Assessment Determine suicidal ideation Evaluate how client sought helpSuicide plan?Mental statusAvailable support systemsLifestyleMove from general to specific questions like: Have you had any ideas about killing yourself? If the client answers yes, ask the client: Have you thought of/or made any plans on how you might harm or kill yourself? Further assessment includes asking about access to means of self-harm, (i.e., do you have a gun in your home?) and evaluation of the lethality of the means (e.g., guns vs. pills).
73Suicide Prevention Interventions Inpatient interventions Providing a safe milieu in which the client’s ability to act out on suicidal ideations is minimizedInpatient treatment is indicated if the client is felt to be at a high risk for self-directed violence.
74Suicide Prevention Safe Milieu (continued) Depending on the degree of suicidal ideation and lethality assessedConstant observation for 24 hours or until the degree of suicidal risk is lessened15-minute checks thereafterMaintain awareness of the client’s whereabouts constantlyWhile the client may be admitted to the milieu voluntarily, the unit is self-contained and doors are commonly locked; nursing staff regulate the flow of traffic on and off the unit.
75Suicide Prevention Safe Milieu (continued) Upon admission to the unit: Assess personal belongings and remove any items that could be used to harm client (drugs, potentially sharp objects, cords and neck ties) and keep them in a safe place.
76Suicide Prevention Safe Milieu (continued) Keep the unit free of materials that can be used by clients to harm themselves.For example, metal or glass objects that may be altered to create a sharp edge, light fixture or call bell cordsKeep windows locked, count silverware, and check the client’s belongings when returning from a pass.Check gifts and other items brought in by visitors for safety before being given to the client.
77Suicide Prevention Safe Milieu (continued) Develop a safety plan and assess frequentlyOral check for hoarding medications for a later overdoseAssign a roommate to reduce the opportunity for solitudeWork with the client to identify an aftercare plan that includes:A commitment to attend aftercare appointmentsAn agreement to maintain contact with social support systemsIdentification of a safety plan with emergency contact numbersAn action plan should suicidal ideations return
78Psychopharmacology Prevent Suicide Pharmacologic interventionsPharmacologic interventions aimed at treating:Underlying mood disorderOther psychiatric disordersCo-existing psychiatric disordersDepressive disorders treated with antidepressantsSSRIs relatively low risk of lethal overdoseTricyclic antidepressants can be highly lethal in overdoseQuantity of prescribed/dispensed kept at a minimum and may need to be managed by a family member
79A. Clients with personality disorders rarely kill themselves. For the third time within a month, a client with borderline personality disorder took a handful of pills, called 911, and was admitted to the Emergency Department. The nurse overhears an unlicensed staff member say, “Here she comes again. If she was serious about committing suicide, she’d have done it by now.” The nurse determines there is a need to teach the staff member which of the following?A. Clients with personality disorders rarely kill themselves.B. Each suicide attempt should be taken seriously.C. Exploration of suicidal ideas and intent should be avoided.D. The nurse should prepare the client for direct inpatient admission.B. Each suicide attempt should be taken seriously.
80A. Explore current life events that led to the suicide attempt. A client has been treated in the surgical intensive care unit after sustaining a self-inflicted gunshot wound. The client is now admitted to a psychiatric unit. The nurse schedules time to meet with the client on a one-to-one basis with the goals that the client will: (Select all that apply.)A. Explore current life events that led to the suicide attempt.B. Initiate contact with the nurse spontaneously.C. Discuss past suicidal ideations and behavior.D. Enter into a contract for safety with the nurse.E. Identify post-discharge living arrangements.Explore current life events that led to the suicide attempt.C. Discuss past suicidal ideations and behavior.D. Enter into a contract for safety with the nurse.
81Mental Health Therapies Inpatient HospitalizationConditions for hospitalization:Dangerous to oneself or othersIncapable of providing for one’s basic physical needs; gravely disabledIn need of care or treatment in the hospital (voluntary)
82Mental Health Therapies Milieu TherapyAn environment designed to promote healing experiences and to provide a corrective setting for the enhancement of the client’s coping abilities. Includes:Correcting perceptions of stressorsChanging coping mechanisms from maladaptive to adaptiveImproving interpersonal relationship skillsLearning effective stress management strategies
83Mental Health Therapies Critical IssuesBoundaries define functions in the therapeutic relationship and imply responsibility.The nurse must clarify/maintain boundaries to make the client more at ease in the new relationship and environment.Boundaries provide structure for individual work by defining the work, its goals, and the time frame.
84What Is Child Abuse? Definition Child abuse: Any act of omission or commission that endangers or impairs child’s physical or emotional health and development.Sexual Abuse: Victimizer uses victim for sexual gratification & victim incapable of consenting to this sexual activity or of resisting when it occurs.Physical Abuse: Deliberate violent actions that inflict pain and/or non-accidental injury.Physical abuse and corporal punishment resulting in an injury, Emotional abuse, Emotional deprivation, Physical neglect and/or inadequate supervision, Sexual abuse and exploitation. Nurses are mandated reporters
85What Is Child Abuse? Child Abuse Physical neglect - Deprivation or non-provision of necessary & socially-available resourcesPsychological abuse - Deliberate destruction of a person’s sense of competence
86Elder Abuse Elder abuse Mistreatment or neglect of an elderly person Most victims are women 75 years of age or olderVictims usually physically, emotionally or financially dependent on their abusersTypes:Psychological abusePhysical abuseNeglect (intentional or unintentional)Financial or material abuseElder abuse most often is inflicted by family membersElder abuse may include verbal harassment, threats, withholding companionship, or isolating him or her. Intimidation can be used as a form of behavior modification. Confining older people against their will, forcing older people out of their homes, or controlling their behavior not only constitutes psychological abuse, but also may violate their civil rights.
87Mandated Reporters: Abuse Nurses who suspect abuse of children, dependent adults or elders must report it.You must immediately call and report the suspected abuse.A follow-up written report is required within two working days.Failure to report abuse is a misdemeanor.Every hospital is required to have report forms available for your use.
88A. Obtain a urine sample to confirm a UTI. A 5-year-old girl is brought to the clinic for symptoms of a urinary tract infection (UTI). The nurse’s assessment reveals bruises in the child’s genital and rectal areas. The mother reports that she left the little girl with her boyfriend the night before. The nurse’s first priority with this client is to take what action?A. Obtain a urine sample to confirm a UTI.B. Teach the mother about symptoms of UTI.C. Report suspected sexual abuse to protective services.D. Assess the child for other health problems.C. Report suspected sexual abuse to protective services.
89An 85-year-old client is brought into the Emergency Department after a fall at home. The client appears confused and malnourished and is severely dehydrated. The client can speak but appears reluctant to explain how the fall happened. The client’s 62-year-old daughter frequently interrupts the client and does not allow the client to answer questions. Which of the following nursing interventions is a priority?A. Take the history from the daughter because the client is confused.B. Provide the daughter with nutritional teaching.C. Request a psychiatric evaluation for the client.D. Interview the client alone first and assess for abuse.D. Interview the client alone first and assess for abuse.
90Protection in the Mental Health Setting - Restraints Seclusion – placement of client in controlled environment to treat a clinical emergencyPhysical restraint – use of mechanical devices to provide limited movement by clientChemical restraint – use of medication to calm client and prevent need for physical restraint
91Protection in the Mental Health Setting- Restraints Physical restraint appropriate after all other types of interventions are used to assist the client to control his/her behavior and remain safeDocumentation of all interventions and results are critical
92Protection in the Mental Health Setting- Restraints Legal ImplicationsPhysician’s order is a necessityFacility rules and state lawsLiability for false imprisonmentLiability for assault and batteryKNOW LIMITATIONS OF THE LAW!
93Protection in the Mental Health Setting - Restraints Documentation should include:Description of a clear process from less restrictive interventionsCriteria for a removal of restraintsCare and observation during the use of restraintsRegular assessment of the client and potential complications of restraintsReasons for removal of restraintsFollow-up interventions, including processing with client, event leading to restraint.
94Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the Microsoft Office Clip Art Gallery.