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Presentation on theme: "NCLEX-RN PREPARATION PROGRAM"— Presentation transcript:


2 Module Description This 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 therapy Nursing process Mental illnesses and disorders Psychopharmacology Life span development issues

3 Introduction The 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.

4 What is Communication? Interpersonal communication is a
transaction between the sender and the receiver. Both persons participate simultaneously. 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.

5 Communication Includes: 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;.

6 Communication 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

7 Communication Therapeutic communication techniques encourage the client or other individual with whom the nurse is communicating to express their thoughts and feelings.

8 Communication Technique Description Active Listening
Broad Openings Description Carefully noting what the client is saying and observing the client’s nonverbal behavior Encouraging the client to select topics for discussion There are many therapeutic communication techniques that can be used to promote verbalization.

9 Communication Technique: Description: Clarifying
Focusing Description: Making the message clearer, to correct any misunderstanding, and to promote mutual understanding Directing the conversation onto the topic being discussed

10 Communication Technique: Description: Informing
Open-ended questions Description: Giving information to the client Encourage conversation because questions require more than just one-word answers

11 Communication Technique: Description: Paraphrasing Reflecting Silence
Restating in different words what the client said Directing the client’s question or statement or feelings back to the client Allowing time for formulating thoughts Validating - Verifying that both the nurse and the client are interpreting the topic or message in the same way

12 Communication Non-therapeutic Communication Techniques
Approval/Disapproval Asking excessive questions Changing the subject Close-ended questions Giving advice False reassurance Value judgments Why questions Minimizing the client’s feelings Non 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

13 NCLEX 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.

14 Impact 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 expressed through negative stereotyping. Culture or religion. Cultural mores, norms, ideas and customs provide the basis for ways of thinking. How do these affect the relationship?

15 Impact 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 feminine gestures influence messages conveyed in communication with others.

16 Impact 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.

17 Impact of Preexisting Conditions
The environment in which the transaction takes place. Territoriality, density, and distance are aspects of environment that communicate messages. Territoriality – the innate tendency to own space Density – the number of people within a given environmental space Distance – the means by which various cultures use space to communicate

18 Communication Cultural Considerations
With regard to communication, there are three cultural characteristics to consider: Communication style Use of eye contact The meaning of touch The 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.

19 Communication Cultural Consideration
Communication Style African Americans Personal questions asked on initial contact may be viewed as intrusive Background information to consider when developing your communication style with specific cultural groups.

20 Communication Cultural Consideration
Communication Style Asian cultures Open expression of emotions not valued Silence is valued Criticism or disagreement not expressed Head nodding does not necessarily mean agreement May interpret the word “no” as disrespect for others Do not use hand gestures

21 Communication Cultural Consideration
Communication Style Americans of Northern European descent Silence can be used to show respect or disrespect, depending on situation May show little facial emotion because they value concept of self-control

22 Communication Cultural Consideration
Communication Style French and Italian Americans May use expressive hand gestures and animated facial expressions

23 Communication Cultural Consideration
Communication Style Hispanic Americans May use dramatic body language such as gestures or facial expressions to express emotion or pain Confidentiality important Direct confrontation disrespectful, and expression of negative feelings impolite

24 Communication Cultural Consideration
Communication Style Native Americans Silence indicates respect for the speaker Speak in a low tone of voice and expects others to be attentive Body language is important Obtaining input from extended family important

25 Communication Cultural Consideration
Use Of Eye Contact Asian Cultures Eye contact is limited and may be considered inappropriate or disrespectful

26 Communication Cultural Consideration
Use Of Eye Contact European (White) Americans Eye contact viewed as indicating trustworthiness Native Americans Eye contact may be viewed as a sign of disrespect Client may be attentive even when eye contact is absent

27 Communication Cultural Consideration
Use Of Eye Contact Hispanic Americans Avoiding eye contact with a person in authority indicates respect and attentiveness

28 Communication Cultural Consideration
Meaning of Touch African Americans Comfortable with close personal space when interacting with family and friends European (White) Americans Tend to avoid close physical contact Respect personal space

29 Communication Cultural Consideration
Meaning of Touch Asian Cultures Prefer formal personal space except with family & close friends Usually do not touch others during conversation Touching unacceptable with members of the opposite sex; if possible, a female client prefers a female health care provider The head is considered to be sacred; touching someone on the head may be considered disrespectful Avoid physical closeness and excessive touching and only touch a client’s head when necessary, informing before doing so

30 Communication Cultural Consideration
Meaning of Touch Hispanic Americans Comfortable with close proximity with family, friends and acquaintances Protect privacy Tactile and sensory are important - use embraces and handshakes Ask if it would be all right to touch a child before examining him or her

31 Practice 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 advice B. Explore feelings C. Provide information D. Explain behavior C. Provide information

32 Overview of Psychiatric Mental Health Nursing
The ability to see oneself as others do Fit into one’s culture and society Indicators of mental health Positive 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.

33 Overview of Psychiatric Mental Health Nursing
Mental Illness Inability to see as others do Not having the ability to conform to the norms of the culture and society Mental 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.

34 Overview of Psychiatric Mental Health Nursing
Medical Diagnosis of Mental Illness Classified 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.

35 Overview of Psychiatric Mental Health Nursing
The DSM-IV Classification system uses five axes for diagnostic purposes: Axis I: Adult and child clinical disorders Axis II: Personality disorders; mental retardation Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning (0-100)

36 Mental Health Nurses Need both general and specific cultural knowledge
If above absent, nurses won’t know what questions to ask Generalizations made are almost certain to be oversimplifications

37 Mental Health Nurses Must 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

38 Mental Health Nurses Self 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.

39 Overview 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.

40 Overview 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.

41 Nursing Process Assessment Nsg Dx Outcome ID Planning Implementation
Evaluation Gathering and organizing data Identify (ID) areas for intervention Setting outcome criteria Planning action to meet the goals Carrying out actions Evaluating if goals (outcomes) are met

42 Mental Health Assessment
INTERVIEW During 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.

43 Mental Health Assessment
Purpose Establish rapport Determine reason client is seeking help Obtain an understanding of current illness (via client, family, chart review and interdisciplinary team) Understand how this illness has affected client’s life Identify client’s recent life changes or stressors

44 Mental Health Assessment
Gather current life style information Social patterns Interests and abilities Relationship issues Substance use and abuse

45 Mental Health Assessment
Assess for risk factors Suicide or self-harm Assault or violence Physiological instability

46 Mental Health Assessment
Appraisal of health and illness Info on previous psychiatric problems or or disorders Current and past medications Physiological coping responses Psychological coping responses Resources

47 Nursing Conditions During Assessment
Self-awareness Accurate observations Therapeutic communication Establish nursing contract Obtain information Organize data

48 Analyze Data/Norms Formulate Nursing Diagnoses
Identify patterns in data Compare with norms Analyze and synthesize data Identify problems and strengths Validate problems with client Formulate nursing diagnoses Set priorities of problems

49 Outcome Identification (Goals)
Identify expected outcomes individualized to client Planning Interventions to attain outcomes Nursing Conditions Application of theory Nursing Behaviors Prioritize goals Identify nursing activities Validate plan with client/family Key Elements Individualized, collaborative, documented

50 Implementation Implements interventions identified in the plan of care
Experience Evidence-based practice Nursing behaviors Know available resources, implement, generate alternatives, coordinate with other team members

51 Evaluation Evaluation of progress in attaining expected outcomes
An ongoing process Client and family participation essential Goal achievement should be documented Revisions in the plan of care PRN

52 Levels of Intervention
Counseling Milieu therapy Self-care activities Psychobiological interventions Health teaching Case management Health maintenance and promotion Based on Nurse Practice Act

53 Nursing Interventions
Form a trusting one-on-one relationship with the client Mutual learning experience for both the nurse and client Corrective emotional experience for the client Explore stressors Give constructive feedback Promote development of insight and constructive coping Overcome resistance behavior Forming 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.

54 Nursing Interventions
Behavioral change is the focus Emphasize positive results Provide an environment that is safe and private with decreased stimuli as needed Ensure physical and psychosocial needs are met Encourage client participation in treatment planning Administer medications as ordered and assess results Educate client and family And finally: Discharge planning

55 Specific Nursing Interventions
Active listening Anger control Assertiveness training Behavior management Body image enhancement Delusion management Eating disorders management Grief work facilitation Hallucination management Impulse control training Milieu therapy Mood management Role enhancement Sleep enhancement Spiritual support Substance abuse Tx Suicide prevention Teaching (meds…)

56 Legal and Ethical Issues
Definitions Voluntary 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

57 Legal and Ethical Issues
Definitions Mental 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.

58 Criteria for Involuntary Confinement
DANGER TO SELF DANGER TO OTHERS GRAVELY DISABLED (Due to mental illness) 72-hour hold (5150) 72-hour hold 14-day certification (5250) 14-day certification Certification Review Hearing Writ of Habeas Corpus 14-day Extension 90-day Extension Temporary conservatorship (30-day-6 months) 1 year conservatorship Rehearing Reappointment The following chart shows the three (3) categories that are legal for holding a person in psychiatric treatment against their will.

59 Involuntary Confinement (continued)
DANGER TO SELF ASSESSMENT DANGER TO OTHERS ASSESSMENT GRAVELY DISABLED ASSESSMENT Suicidal ideation Homicidal ideations Inability to provide food, clothing, shelter for self. Delusions or hallucinations which increase potential of suicide. Delusions or hallucinations which increase potential for harm to others. Amount of income, how it is spent Lethality  Medical, psychological, educational, social and legal situation Assessment for involuntary commitment

60 Legal and Ethical Issues
Definitions Competency: 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

61 Legal and Ethical Issues
Informed consent: Client’s right to be given enough info to: Make a decision Understand the information Communicate his or her decision to others Receive explanation of client rights and unit policies Receive signed statement of understanding/refusal to receive Tx Receive explanation of insurance benefits or payment options/third-party reimbursement In 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.

62 Client Rights/Nursing Responsibility
Right to appropriate treatment Right to know qualifications of those involved in treatment process Right to receive explanations of treatment Right to be involved in planning of own care Right to refuse to be a part of experimental treatment methods Right to understand the effects of prescribed medication Right to treatment in least restrictive environment Right to refuse treatment - decide which treatment option is best for them

63 Legal and Ethical Issues
Principle of Confidentiality Federal 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

64 Legal and Ethical Issues
Principles of Confidentiality Client’s right Prevent written or verbal communications from being disclosed to outside parties without authorization Required by Nurse Practice Act HIPAA (Health Insurance Portability and Accountability Act of 1996 (2003) Ensures that security procedures protect the privacy and confidentiality of information Client has right to know what information is disclosed, to whom and for what purpose

65 Legal and Ethical Issues
Required disclosure Intent to commit a crime Duty to warn endangered persons Evidence of child, elder, vulnerable adult abuse Initiation of involuntary hospitalization

66 An 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.

67 A. 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.

68 Crisis Definition of Crisis Being confronted by a stress with which the individual is unable to cope/problem-solve Threatens the individual’s equilibrium Generally time limited, lasting from 4 to 6 weeks Potential for increased psychological vulnerability or personal growth Anxiety and tension accompany the experience. Hopelessness and/or helplessness results in a state of disorganization

69 Crisis Interventions Establish a relationship Identify the problem
Identify and reduce perceptual distortions Enhance self-esteem Alleviate anxiety Promote engagement of support systems Reinforce healthy coping Validate client’s ability to problem-solve. Keep safe if at risk for suicide Crisis is not a psychiatric illness, nor a prolonged condition; therefore pharmacologic interventions are not the intervention of choice.

70 A 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 client Advise the client to avoid going near the school for at least 6 weeks Send the client to the Emergency Department for further evaluation Allow ventilation of feelings D.Allow ventilation of feelings

71 When 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 history B. Remaining focused on the client’s immediate problem C. Determining the relationship of early life experiences and the crisis state D. Developing an action plan for the client B. Remaining focused on the client’s immediate problem

72 Suicide Prevention Assessment Determine suicidal ideation
Evaluate how client sought help Suicide plan? Mental status Available support systems Lifestyle Move 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).

73 Suicide Prevention Interventions Inpatient interventions
Providing a safe milieu in which the client’s ability to act out on suicidal ideations is minimized Inpatient treatment is indicated if the client is felt to be at a high risk for self-directed violence.

74 Suicide Prevention Safe Milieu (continued)
Depending on the degree of suicidal ideation and lethality assessed Constant observation for 24 hours or until the degree of suicidal risk is lessened 15-minute checks thereafter Maintain awareness of the client’s whereabouts constantly While 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.

75 Suicide 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.

76 Suicide 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 cords Keep 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.

77 Suicide Prevention Safe Milieu (continued)
Develop a safety plan and assess frequently Oral check for hoarding medications for a later overdose Assign a roommate to reduce the opportunity for solitude Work with the client to identify an aftercare plan that includes: A commitment to attend aftercare appointments An agreement to maintain contact with social support systems Identification of a safety plan with emergency contact numbers An action plan should suicidal ideations return

78 Psychopharmacology Prevent Suicide
Pharmacologic interventions Pharmacologic interventions aimed at treating: Underlying mood disorder Other psychiatric disorders Co-existing psychiatric disorders Depressive disorders treated with antidepressants SSRIs relatively low risk of lethal overdose Tricyclic antidepressants can be highly lethal in overdose Quantity of prescribed/dispensed kept at a minimum and may need to be managed by a family member

79 A. 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.

80 A. 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.

81 Mental Health Therapies
Inpatient Hospitalization Conditions for hospitalization: Dangerous to oneself or others Incapable of providing for one’s basic physical needs; gravely disabled In need of care or treatment in the hospital (voluntary)

82 Mental Health Therapies
Milieu Therapy An 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 stressors Changing coping mechanisms from maladaptive to adaptive Improving interpersonal relationship skills Learning effective stress management strategies

83 Mental Health Therapies
Critical Issues Boundaries 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.

84 What 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

85 What Is Child Abuse? Child Abuse
Physical neglect - Deprivation or non-provision of necessary & socially-available resources Psychological abuse - Deliberate destruction of a person’s sense of competence

86 Elder Abuse Elder abuse Mistreatment or neglect of an elderly person
Most victims are women 75 years of age or older Victims usually physically, emotionally or financially dependent on their abusers Types: Psychological abuse Physical abuse Neglect (intentional or unintentional) Financial or material abuse Elder abuse most often is inflicted by family members Elder 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.

87 Mandated 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.

88 A. 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.

89 An 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.

90 Protection in the Mental Health Setting - Restraints
Seclusion – placement of client in controlled environment to treat a clinical emergency Physical restraint – use of mechanical devices to provide limited movement by client Chemical restraint – use of medication to calm client and prevent need for physical restraint

91 Protection 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 safe Documentation of all interventions and results are critical

92 Protection in the Mental Health Setting- Restraints
Legal Implications Physician’s order is a necessity Facility rules and state laws Liability for false imprisonment Liability for assault and battery KNOW LIMITATIONS OF THE LAW!

93 Protection in the Mental Health Setting - Restraints
Documentation should include: Description of a clear process from less restrictive interventions Criteria for a removal of restraints Care and observation during the use of restraints Regular assessment of the client and potential complications of restraints Reasons for removal of restraints Follow-up interventions, including processing with client, event leading to restraint.

94 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the Microsoft Office Clip Art Gallery.


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