Psychosocial Integrity

Coping Mechanisms (also called defense mechanisms)
A. Definition: psychological techniques that the personality develops to manage anxiety,

aggression, hostility, etc.
B. Coping mechanisms represent conflicts between the id and superego
C. Used by both mentally healthy and ill individuals
D. May be used consciously, but are usually unconscious
E. Types of coping mechanisms
Types of Coping Mechanisms
1. Compensation - extra effort in one area to offset real or imagined lack in another area
o Example: Short man becomes assertively verbal and excels in business.
2. Conversion - A mental conflict is expressed through physical symptoms
o Example: Woman becomes blind after seeing her husband with another woman.
3. Denial - treating obvious reality factors as though they do not exist because they are consciously
intolerable
o Example: Mother refuses to believe her child has been diagnosed with leukemia. "She just has
the flu."
4. Displacement - transferring unacceptable feelings aroused by one object to another, more acceptable
substitute
o Example: Adolescent lashes out at parents after not being invited to party.
5. Dissociation - walling off specific areas of the personality from consciousness
o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about
them.
6. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction
o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a
cardiac arrest.
7. Fixation - becoming stagnated in a level of emotional development in which one is comfortable
o Example: A sixty year old man who dresses and acts as if he were still in the 1960's.
8. Identification - subconsciously attributing to oneself qualities of others
o Example: Elvis impersonators.
9. Intellectualization - use of thinking, ideas, or intellect to avoid emotions
o Example: Parent becomes extremely knowledgeable about child's diabetes.
10. Introjection - incorporating the traits of others
o Example: Husband's symptoms mimic wife's before she died.
11. Projection - unconsciously projecting one's own unacceptable qualities or feelings onto others
o Example: Woman who is jealous of another woman's wealth accuses her of being a gold-digger.
12. Rationalization - justifying behaviors, emotions, motives, considered intolerable through acceptable
excuses
o Example: "I didn't get chosen for the team because the coach plays favorites."
13. Reaction Formation - expressing unacceptable wishes or behavior by opposite overt behavior
o Example: Recovered smoker preaches about the dangers of second hand smoke.
14. Regression - retreating to an earlier and more comfortable emotional level of development
o Example: Four year old insists on climbing into crib with younger sibling.
15. Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses, feelings
or acts
o Example: Adolescent "forgets" appointment with counselor to discuss final grades.
16. Sublimation - diversion of unacceptable instinctual drives into personally and socially acceptable areas.
o Example: Young woman who hated school becomes a teacher.
17. Therapeutic Communication - Characterizes the Nurse-Client Relationship
o Nurse-client relationship: a therapeutic professional relationship in which two people interact
1. The nurse who possesses the skills and ability to provide counseling, crisis
intervention, health teaching, etc. and
2. The client who seeks help for some problem
o Phases of the nurse-client relationship
PHASES OF THE THERAPEUTIC NURSE-CLIENT RELATIONSHIP
A. Initiating or orientation
1. Sets time, place and duration of sessions
2. Establishes boundaries of the relationship
3. Identifies the problem and expectations-that is, goal setting
4. Usually an anxious time for both client and nurse
a. Client may be late for the session
b. Client may exhibit anxious mannerisms
c. Nurse's own anxiety may prompt nurse to use techniques that block communication
B. Working
1. Boundaries of the relationship are accepted by the client and the nurse and a therapeutic
relationship is established
2. Nurse uses interpersonal skills to communicate with the client
3. Client identifies problems, develops insights to the problems
4. Client learns adaptive coping skills and problem solving
C. Termination
1. Actually begins with the first session and ends when identified treatment goals are met
2. Anticipate problems of termination
a. Client may become too dependent on nurse
b. Client may recall previous separation experiences, and feelings of rejection,
depression, and/or abandonment
3. Client and nurse summarize and evaluate work
4. Client and nurse express thoughts and feelings about termination
THERAPEUTIC COMMUNICATION TECHNIQUES
Not Necessarily Verbal
1. Acceptance - Recognizing the other person without inserting your own values or judgments. May be
verbal or nonverbal; with or without understanding
2. Listening - Consciously receiving the client's message. Includes listening actively, responsibly, and
seriously
3. Empathy - Experiencing another's feeling temporarily; truly being with and understanding another
through active listening
4. Silence - Suspending talk for a therapeutic reason
5. Neutral response - Showing interest and involvement without saying anything else
6. Eye contact - As appropriate to the client's culture
Verbal
7. Self-disclosure - Sharing personal information at an opportune moment to convey understanding or to
role model behavior
8. Clarification - Putting into words vague ideas or unclear thoughts of the client. Purpose is to help nurse
understand, or invite the client to explain
9. Restating - Repeating to the client the main thought he has expressed to indicate the nurse is listening
and interested. May encourage the client to elaborate
10. Refocusing - Picking up on central topics or "cues" given by the client
11. Open-ended questions - Asking questions that cannot be answered "yes" or "no." Used to broaden
conversational opportunities and to enable the client to communicate.
12. Incomplete sentences - Encouraging the client to continue with phrases such as "Go on"
13. Focusing - Helping the client to explore a specific topic
1. Five characteristics of nurse-client relationship
1. Mutual definition: together, nurse and client define relationship
2. Goal direction: purpose, time, and place are specific
3. Specified boundaries: in time, space, content, and confidentiality
4. Therapeutic communication: nurse eases trust and open communication by these
interpersonal techniques
5. Nurse helps client toward resolution
6. Therapeutic communication
1. Consider the developmental level, culture, and physical condition of the
client
2. Focus not on subjective inferences but on actual objective behaviors
3. Focus not on judgment but on description
4. Instead of offering advice and solutions, share information and explore
alternatives
5. Focus not on "why" but on how and what
6. For confused or disoriented clients, focus on reality orientation
7. Ask open-ended questions and seek information
8. Focus on nursing interventions
9. To ease this process, use specific techniques
10. Certain techniques block therapeutic communication
7. Other types of therapeutic interventions
1. Group therapy
2. Family therapy
3. Milieu therapy
THERAPEUTIC COMMUNICATION TECHNIQUES
Not Necessarily Verbal
1. Acceptance - Recognizing the other person without inserting your own values or judgments. May be
verbal or nonverbal; with or without understanding
2. Listening - Consciously receiving the client's message. Includes listening actively, responsibly, and
seriously
3. Empathy - Experiencing another's feeling temporarily; truly being with and understanding another
through active listening
4. Silence - Suspending talk for a therapeutic reason
5. Neutral response - Showing interest and involvement without saying anything else
6. Eye contact - As appropriate to the client's culture
Verbal
7. Self-disclosure - Sharing personal information at an opportune moment to convey understanding or to
role model behavior
8. Clarification - Putting into words vague ideas or unclear thoughts of the client. Purpose is to help nurse
understand, or invite the client to explain
9. Restating - Repeating to the client the main thought he has expressed to indicate the nurse is listening
and interested. May encourage the client to elaborate
10. Refocusing - Picking up on central topics or "cues" given by the client
11. Open-ended questions - Asking questions that cannot be answered "yes" or "no." Used to broaden
conversational opportunities and to enable the client to communicate.
12. Incomplete sentences - Encouraging the client to continue with phrases such as "Go on"
13. Focusing - Helping the client to explore a specific topic
NINE INEFFECTIVE COMMUNICATION TECHNIQUES
1. Giving advice - Telling the client what to do. Giving an opinion or making decisions for the client. Implies
the client cannot handle life decisions and that the nurse is accepting responsibility for client.
2. False reassurance - Using clichs, pat answers, cheery words and comforting statements as an attempt to
reassure client.
3. Changing the Subject - Introducing new topics inappropriately. May result from poor listening skills
4. Social Response - Responding in a way that either focuses attention on the nurse instead of the client, or
is not goal-directed on behalf of the client.
5. Invalidation - Ignoring or denying the client's thoughts or feelings.

6. Overloading - Talking rapidly, changing subjects or asking for more information than can be absorbed at
one time; for example, asking two questions at once.
7. Underloading - Remaining silent and unresponsive, not picking up cues and failing to give feedback.
8. Incongruence - Sending verbal and nonverbal messages that contradict one another; often called a
double message.
9. Value Judgments - Giving one's own opinion, evaluating , moralizing or implying one's own values by
using words such as "should," "ought," Read the body or 'stem' of the question carefully. Pay special
attention to words such as BEST, MOST, and FIRST when reading the questions."good," or "bad."
Read the body or 'stem' of the question carefully. Pay special attention to words such as BESTMOSTand FIRST when
reading the questions.
III. Grief
A. Loss
1. A universal phenomenon; it occurs across the lifespan
2. There are many types of loss
a. loss of external objects
b. loss of significant other: through death, divorce
c. loss of environment: by moving, taking a new job, hospitalization
d. loss of an aspect of self: may include a body part, physiologic or psychologic
function
3. Response to loss depends on
a. one's personality
b. culture
c. previous experience with loss
d. one's values
e. perceived value of loss
f. support system
4. Types of Grief
a. Anticipatory grief: person learns of impending loss and responds with
processes of mourning, coping, interaction, planning, and psychosocial
reorganization
b. Disenfranchised grief: person experiences a loss that is not or cannot be
openly acknowledged, publicly mourned, or socially supported
c. Mourning: process used to resolve grief
d. Tasks of mourning (common to the models of grief) spell R-E-A-L
I. Real: accept that the loss is real
II. Experience the emotions associated with the loss
III. Adjust or re-adjust to life and activities
IV. Let go: move on with one's own life
e. Grief theory models
FOUR THEORETIC MODELS OF GRIEF
A. Elizabeth Kubler-Ross: Five Stages

1. Denial
a. Unconscious avoidance which varies from a brief period to the remainder of life
b. Allows one to mobilize defenses to cope
c. Positive adaptive responses - verbal denial; crying
d. Maladaptive responses - no crying, no acknowledgement of loss
2. Anger
a. Expresses the realization of loss
b. May be overt or covert
c. Positive adaptive responses - verbal expressions of anger
d. Maladaptive responses - persistent guilt or low self esteem, aggression, self
destructive ideation or behavior
3. Bargaining
a. An attempt to change reality of loss; person bargains for treatment control, expresses
wish to be alive for specific events in near future
b. Maladaptive responses - bargains for unrealistic activities or events in distant future
4. Depression and Withdrawal
a. Sadness resulting from actual and/or anticipated loss
b. Positive adaptive response - crying, social withdrawal
c. Maladaptive responses - self-destructive actions, despair
5. Acceptance
a. Resolution of feelings about death or other loss, resulting in peaceful feelings
b. Positive adaptive behaviors - may wish to be alone, limit social contacts, complete
personal business
B. John Bowlby: Four Stages of Separation and Loss
1. Shock
2. Despair
3. Detachment
4. Resolution
C. E. Lindemann
1. Shock
2. Acute mourning
3. Resolution of grief
D. J.W. Wooden
1. Accepting the reality
2. Experiencing the pain
3. Adjusting to the changed environment
4. Withdrawing and reinvesting emotional energy
a. Nursing care in grief
A. Support client's effective coping mechanisms
B. Don't take client's responses personally
C. Listen attentively
D. Help client with problem solving and decision making as indicated
E. Encourage the client and/or significant others to ventilate
F. Utilize therapeutic touch as appropriate
G. Assist in discussions of future plans as appropriate
E. Stress Management
1. Stress: a universal phenomenon, stress requires change or adaptation so that the person can
maintain equilibrium
2. Stress can be internal or external
3. Nature of stressor involves:
a. Intensity
b. Scope
c. Duration
d. Other stressors: their number and nature
4. Categories of stressors - and examples
a. Physical - drugs or alcohol
b. Psychological - such as adolescent emotional upheaval, or unexpressed anger
c. Social - isolation, interpersonal loss
d. Cultural - ideal body image
e. Microbiologic - infection
5. The greater the stressor as preceived by the client, the greater the stress response
6. Stress response involves both localized and general adaptation
STRESS RESPONSE
A. Local responses to stress: Local Adaptation Syndrome (LAS):

1. Examples
a. Blood clotting
b. Wound healing
c. Reflex pain response
d. Inflammatory response
2. Characteristics
a. Localized response
b. Adaptive (that is, requires a stressor)
c. Short-term
d. Restorative
(Illustration )
B. Whole-body response to stress: General Adaptation Syndrome (GAS)

1. Involves primarily nervous and endocrine systems, in 3 stages
2. Stage 1: Alarm reaction - exposure to adverse stimulus; body mobilized to resist in form of
compensatory behavior
a. Fight or flight response
A. Increased cardiac output
B. Increased heart rate
C. Increased respiratory rate
D. Pupils dilate
E. Increased mental alertness
b. Sympathetic Nervous System response
A. Increased epinephrine
A. Increased heart rate
B. Increased oxygen intake
C. Increased blood sugar
B. Increased norepinephrine
A. Increased blood flow to skeletal muscle
B. Involves increased arterial blood pressure
c. Posterior Pituitary: Increased ADH
A. Increased water reabsorption
B. Decreased urine output
d. Anterior Pituitary: Increased ACTH
A. Increased cortisol secretion

A. Body turns fat and proteins into glycogen
B. Increased protein catabolism
C. Increased fat catabolism
B. Increased aldosterone secretion:
A. Body reabsorbs more sodium, more water
B. Kidneys produce less urine
C. Kidneys secrete more potassium
3. Stage 2: Resistance - When stimulus is excessive or prolonged, alarm and mobilization give way
to resistance
a. Stabilization
b. Hormonal levels return to normal
c. Parasympathetic nervous system activates
d. Body adapts to stressors
4. Stage 3: Exhaustion - If stressor continues, energy wanes and body weakens
a. Physiological response as noted in alarm reaction
b. Decreased energy levels
c. Decreased physiologic adaptation
d. Death
Arrive at the testing center with enough time to allow yourself to relax before taking your examination.
G. Factors affecting stress response
1. Personal: heredity, gender, race, age personality, cognitive ability
2. Sociocultural: finances, support systems
3. Interpersonal: self-esteem, prior coping mechanisms
4. Spiritual: belief system
5. Environmental: crowding, pollution, climate
6. Occupational: work overload, conflict, risk
H. Physiologic indicators of stress

I. Emotional/behavioral indicators of stress
J. Stress can cause a variety of emotional and physical disorders
K. Stress management strategies
L. The non-compliant client does not cooperate with the treatment plan
1. Behavior characteristics
a. does not take prescrived medication
b. continues activities restricted by provider of care, such as smoking
c. does not follow prescribed activities, such as exercise
2. Nursing interventions
a. explore the reasons for non-compliance
i. lack of understanding - reinforce teaching
ii. lack of family support - involve family and support groups
iii. side effects - refer to provider of care
iv. finances and access - refer to Social Services
v. negative attitude toward treatment - encourage expression
b. express genuine concern for client
c. discuss imporvement potential
PHYSIOLOGIC INDICATORS OF STRESS

1. Increased Blood Pressure
2. Tachycardia
3. Tachypnea
4. Sweaty palms
5. Cold Hands and Feet
6. Decreased urine output
7. Dilated Pupils
8. Change in appetite
9. Gastrointestinal changes: nausea, vomiting, diarrhea
10. Headache
11. Restlessness
12. Insomnia
13. Muscle tension
EMOTIONAL/BEHAVIORAL INDICATORS OF STRESS

A. Behavior Patterns
1. Substance use/abuse
2. Changes in eating habits
3. Changes in activity
B. Mood
4. Loss of self esteem

5. Feelings of inadequacy
6. Increased irritability
7. Crying
B. Cognitive
8. Lack of motivation
9. Forgetfulness
10. Tendency to make mistakes
11. Decreased productivity
12. Poor judgment
13. Inability to concentrate
14. Preoccupation
STRESS-RELATED DISORDERS
1. Hypertension
2. Ulcers
3. Skin Disorders
4. Cardiovascular disorders
5. Increased cholesterol
6. Migraines
7. Eating Disorders
8. Depression
9. Substance Abuse
10. Asthma
11. Cancer
12. Rheumatoid Arthritis
13. Anxiety disorders
14. Dysrhythmias
15. Muscle tension/aches
16. Sleeping disorders
17. Gastrointestinal upset/disorders
18. Endocrine disorders
STRESS MANAGEMENT STRATEGIES

1. Balanced diet
2. Adequate rest
3. Regular physical exercise
4. Relaxation techniques such as
a. Breathing exercises
b. Meditation
c. Progressive relaxation
d. Prayer
e. Guided imagery
f. Relaxation response
g. Yoga
h. Biofeedback
5. Hypnosis or self-hypnosis
6. Humor
7. Therapeutic touch or massage
8. Social support
9. Spirituality
10. Crisis intervention
11. Cognitive restructuring: Nurse and client analyze client's appraisal of stressors.
Emphasis is on restructuring client's unrealistic or negative thinking.
V. Schizophrenia
A. Definition: a multifaceted psychosis with early onset; criteria from DSM IV as follows:
1. When disease is in active phase, client shows psychotic behaviors. (Psychosis is
severe ego dysfunction. Psychosis is also part of other DSM-IV diagnoses of
dysfunctions of thought and sensorium.)
2. Findings involve many psychological processes
3. Previously, client had functioned at a higher level
4. Schizophrenia normally sets in before 30 years of age
5. Findings last six months or more
6. Not caused by affective or organic mental disorder
7. Involves hallucinations and/or delusions
B. General characteristics of schizophrenia - six losses: S-S-O-B-E-R
1. Self-care often fails
2. Social adjustment is impaired
3. Orientation to the environment is lost
4. Boundaries between self/others dissolve
5. External/internal stimuli are confused (delusions/hallucinations)
6. Reality testing fails
C. Etiologies of Schizophrenia
1. Biogenetic (possible hereditary factor)
2. Biochemical
a. dopamine hydrochloride - too much neurotransmitter for neural activity
b. research has suggested abnormalities of neurotransmitters norepinephrine,
serotonin, acetylcholine and GABA (gamma aminobutyric acid).
TYPES OF SCHIZOPHRENIA
1. Paranoid
a. Dominant: hallucinations and delusions.
b. No disorganized speach
2. Disorganized
a. Dominant: disorganized speech and behavior and inappropriate affect
3. Catatonic
a. Motor immobility
b. Excessive, purposeless motor activity
4. Residual
a. No longer has active phase symptoms
b. Negative symptoms
5. Undifferentiated
a. Has active phase symptoms
b. No one clinical presentation dominates
3. Contributing factors
a. poor relationships with primary caretaker
b. dysfunctional family systems
c. double-bind communication
d. stressful life events
e. decreased socio-economic status (SES)
D. Findings of schizophrenia
3. Positive findings
a. hallucinations
b. delusions
c. looseness of associations
d. agitated or bizarre behaviors
4. Negative findings
a. apathy
b. poverty of speech or content of speech
c. poor social functioning
d. anhedonia
e. Social withdrawal
E. Positive findings
3. Acute onset
4. Normal premorbid functioning
5. Normal social functioning during remission
6. Normal CT scan
7. Normal neuropsychological test results
8. Favorable response to antipsychotic meds
9. Appear early in illness
10. Often precipitate hospitalization
11. Alterations in thinking, perceiving and behavior
F. Negative findings
3. Insidious onset
4. Premorbid history of emotional problems
5. Chronic deterioration
6. Demonstration of atrophy on CT scan
7. Abnormalities on neuro-psychological testing
8. Poor response to antipsychotic meds
9. Interferes with person's ability to:
a. initiate and maintain relationships
b. initiate and maintain conversations
c. hold a job
d. make decisions
e. maintain adequate hygiene and grooming
G. Alterations in thinking
3. Types of delusions
a. ideas of reference
b. persecution
c. grandeur
d. somatic delusions
e. jealousy
f. control/being controlled
g. thought-broadcasting
h. thought insertion
i. thought withdrawal
4. Associative looseness
5. Neologisms
6. Concrete thinking
7. Echolalia
8. Clang association
9. Word salad
H. Alterations in perceiving
3. Hallucinations
a. auditory
b. visual
c. olfactory
d. gustatory
e. tactile
4. Loss of ego boundaries
I. Alterations in behavior
3. Bizarre behavior
a. extreme motor agitation
b. stereotyped behaviors
c. automatic obedience
d. waxy flexibility
4. Stupor
5. Negativism
6. Agitated behavior
J. Associated findings
3. Depression/suicide
4. Water intoxication
5. Substance abuse
6. Violent behavior
K. Treatments in schizophrenia
1. Psychopharmacology
a. antipsychotic agents and neuroleptics
i. decrease psychotic symptoms
ii. decrease agitation
iii. less effective with negative symptoms
iv. decrease dopamine - dependent neural activity in the brain and

other parts of the body (causing extrapyramidal symptoms)
b. antiparkinsonian agents: used to counteract these extrapyramidal symptoms
2. Individual psychotherapy
a. long-term therapy
b. difficult because schizophrenia impairs interpersonal functioning
c. focused, supportive problem-solving is most useful
3. Group therapy in schizophrenia
a. oriented toward providing support, an environment in which the client can
develop social skills, and a format that allows friendships to begin
b. some success with long-term work
c. less success if client actively delusional and/or psychotic
4. Social skills training
a. role play to simulate anticipated interactions
b. teach eye contact, interpersonal skills, voice, posture
5. Vocational/rehabilitation often succeeds
a. long-term treatment
b. includes job training
c. promotes semi-independent daily activities
d. raises self esteem
6. Family therapy
a. to help families cope with psychotic and residual symptoms of schizophrenia
b. to help reduce relapse rate
ANTIPSYCHOTICS / NEUROLEPTICS
1. Types
A. Phenothiazines
B. Thioxanthenes
C. Butyrophenones
D. Dibenzoxazepines
E. Dibenzodiazepines
F. Indolenes
2. Physiology: Blocks postsynaptic dopamine hydrochloride receptors in the brain that cause psychotic
symptoms: hallucinations, delusions, disorganized thought patterns and paranoia
3. Used for schizophrenia, paranoia, mania
4. Side effects: extrapyramidal symptoms
5. Contraindications: liver damage, severe hypertension, coronary disease, arteriosclerosis , dyscrasias ,
Parkinson's disease , narrow-angle glaucoma , severe depression
6. May cause orthostatic hypotension and drowsiness
7. Advise client to rise slowly from sitting or lying position
8. To prevent hypotension, teach client to avoid hot baths, showers, hot tubs
9. Teach client the hazards of driving and operating machinery while taking antipsychotics or neuroleptics
A. Nursing care in schizophrenia
1. Protect client and others from harm, including suicide precautions as indicated
2. Administer medications as ordered
3. Monitor for extrapyramidal symptoms
4. Establish trust, decrease anxiety
5. Encourage or reinforce:
1. client's sense of control
2. reality orientation
3. self-care
6. Help client set realistic goals
7. Provide safe and successful experiences
8. Assist with hygiene and/or feeding as indicated
9. Teach client
1. importance of medication compliance
2. medications and side effects
SUICIDE PRECAUTIONS
1. Remove all harmful objects from the environment
2. One to one monitoring of the client day and night, having the client in view at all times even during
toileting, gradually progress to 15 minute and then hourly checks
3. Ask client exactly how she/he would commit suicide. Assess how lethal the attempt would be, and how
quickly it could be carried out.
4. Keep client within one arm's length distance or less at all times
5. Use plastic utensils
6. Keep electrical cords to a minimum length
7. Take all potentially harmful gifts from visitors
8. Keep all windows locked and if possible keep client in room with unbreakable glass in windows
9. Do not assign a private room
10. Mood Disorders (Affective Disorders)
1. Definition:
1. Elevated or depressed mood, with disturbances in behavioral response
2. Divided into bipolar and depressive disorders
2. Bipolar disorders: mood disorders that include one or more manic or hypomanic episodes and
usually one or more depressive episodes
3. Mania:
1. Person's elevated mood described as euphoric
2. Inflated self-esteem
3. Impaired judgment
4. Constant physical activity
5. Pressured speech
6. Racing thought patterns
7. Requires hospitalization
4. Hypomania:
1. Findings less severe
2. Does not impair social, occupational or interpersonal functioning
3. Treated in outpatient setting
5. The seven traits typical of mood disorders
1. Impair job functioning
2. Impair social activities
3. Impair relationships
4. Necessitate hospitalization (in most cases)
5. No time longer than two weeks has client had delusions or hallucinations without the
mood disturbance
6. Findings are not superimposed on
1. schizophrenia
2. delusional disorder
3. psychotic disorder
7. Findings are not caused by organic disease
6. Etiology - unknown; possible genetic, biochemical predisposition
1. Psychosocial theories of depression
1. Freud: anger internalized and directed against ego
2. Seligman: depression results from learned helplessness: individual who fails
over time learns to expect poor outcomes and eventually gives up
3. Beck: cognitive theory: over time, cognition is altered, resulting in negative
attitudes; events can trigger depression
2. Biological cycles affect mood (via Circadian rhythm)
1. light affects mood by increasing melatonin
2. melatonin is a mood modulator which decreases in depression
3. Seasonal Affective Disorder (SAD)
3. Biochemical theories of mood disorders

a. mania
i. probably a genetic factor
ii. biochemical influences
possible deficiency of neurotransmitter GABA (gamma
aminobutyric acid)
possible excess of norepinephrine and dopamine
hydrochloride
possible increase in electrolytes: sodium and calcium

b. depression
i. possible deficit of serotonin, dopamine, norepinephrine
ii. possible deficit of TSH (thyroid-stimulating hormone) and/or other
neuroendocrine disturbances
iii. depression is more common in viral infections (AIDS,
mononucleosis, hepatitis)
iv. possible deficit in vitamin intake or metabolism: (vitamin B
complex, folic acid)
v. genetics may be involved
G. Types of mood disorders: mania, bipolar, depression
3. Mania - DSM IV criteria for mania

a. period of abnormally/persistently elevated mood or irritability
b. at least three of these six signs
i. grandiosity
ii. decreased sleep
iii. hypertalkative, with pressured speech and flight of ideas or racing
thoughts
iv. highly goal-directed activity (sexual, work)
v. highly distractible
vi. pursues pleasure, but overestimates own skill and luck
3. Biochemical theories of mood disorders

a. mania
i. probably a genetic factor
ii. biochemical influences
possible deficiency of neurotransmitter GABA (gamma
aminobutyric acid)
possible excess of norepinephrine and dopamine
hydrochloride
possible increase in electrolytes: sodium and calcium

b. depression
i. possible deficit of serotonin, dopamine, norepinephrine
ii. possible deficit of TSH (thyroid-stimulating hormone) and/or other
neuroendocrine disturbances
iii. depression is more common in viral infections (AIDS,
mononucleosis, hepatitis)
iv. possible deficit in vitamin intake or metabolism: (vitamin B
complex, folic acid)
v. genetics may be involved
G. Types of mood disorders: mania, bipolar, depression
3. Mania - DSM IV criteria for mania

a. period of abnormally/persistently elevated mood or irritability
b. at least three of these six signs
i. grandiosity
ii. decreased sleep
iii. hypertalkative, with pressured speech and flight of ideas or racing
thoughts
iv. highly goal-directed activity (sexual, work)
v. highly distractible
vi. pursues pleasure, but overestimates own skill and luck
2. Bipolar disorders onset usually before age 30

a. bipolar disorder, mixed: both manic and depressive episodes present
i. bipolar I
consists of one or more periods of major depression plus
one or more periods of clear-cut mania
findings as in Definition of mood disorder (on page 15 of
this lesson)
no marked drop in social and job functioning
manic episode requires hospitalization
ii. bipolar II
consists of one or more periods of major depression plus
periods of hypomania
includes all symptoms in Definition of mood disorder (on
page 15 of this lesson) and does not require
hospitalization
b. bipolar disorder, manic: fulfills criteria for manic episode (see Findings
below)
c. bipolar disorder, depressed: major depressive episode and at least one
manic episode, current or past
d. cyclothymic mood disorder:
i. many milder findings of mania and depression
ii. periods of normal mood are short
iii. usually does not require hospitalization
3. Depression
a. includes all 7 typical traits of mood disorders
b. specific criteria for depression (see Findings below)
I. Findings
2. Mania
a. elation, euphoria; inappropriate laughter; very talkative
b. irritable, hostile, aggressive
c. flight of ideas, delusions of grandeur, exhibitionism, sexual acting-out
d. reduced sleep
e. unlimited energy; no time for food or drink
f. impulsive, easily distracted
g. manipulative behavior
The 7 Traits of Typical Mood Disorders
1. Impaired job functioning
2. Impaired social activities
3. Impaired relationships
4. Necessitate hospitalization (in most cases)
5. No time longer than two weeks has client had delusions or hallucinations without the mood disturbance
6. Symptoms are not superimposed on
a. Schizophrenia
b. Delusional disorder
c. Psychotic disorder
7. Symptoms are not caused by organic disease
2. Depression
a. melancholia, crying, absence of pleasure; slumped posture
b. apathy; loss of desire for food and/or sex
c. slower reactions
d. low self-confidence; inhibition, introversion
e. ruminating, decreased communication, social isolation
f. fatigue and/or insomnia
g. decreased concentration
h. poor hygiene
i. hopelessness, pessimism
j. self-destructiveness
J. Treatments
2. Treatments for mania
a. pharmacologic
i. lithium carbonate (Lithane), carbamazapine (Carbatrol), valproic
acid (Depakene)
ii. antipsychotics: chlorpromazine (Thorazine), haloperidol (Haldol)
b. occupational therapy
c. recreational therapy
2. Depression
a. pharmacologic antidepressants
i. tricyclic antidepressants - amitriptyline HCl (Elavil), doxepin
(Sinequan), imipramine (Tofranil)
ii. monoamine oxidase inhibitors - phenelzine (Nardil),
tranylcypromine (Parnate)
iii. selective serotonin reuptake inhibitors (SSRI) - fluoxetine
(Prozac), sertraline (Zoloft)
b. ECT: electroconvulsive therapy
c. psychotherapy
d. occupational therapy
e. recreational therapy
f. cognitive therapy
K. Nursing care in mood disorders
2. Mania
a. protect client and others from harm
b. provide quiet environment with few stimuli
c. give medications as ordered; be sure client swallows meds
d. establish trust relationship
e. do not argue with client or provoke hostility
f. redirect client to task at hand
g. set firm, consistent limits; explain them simply
h. allow client to express anger in positive ways
i. offer finger foods
j. increase client's fluid intake to at least 1000cc/day
k. allow client to pace
l. teach client
i. acceptable ways to release anger
ii. medications and side effects
iii. importance of taking medication
Don't pay attention to how quickly others complete their examination. The time taken by a candidate to complete
the examination is not a predictor of passing or failing.
ANTI DEPRESSANTS
1. Types
A. Tricyclics and tetracyclic antidepressants
1. Prevent nerve endings from taking up norepinephrine and serotonin
2. Increase the action of norepinephrine and serotonin in nerve cells
B. MAO Inhibitors (Monoamine oxidase inhibitors)
1. Lower the production of monoamine oxidase
2. Thus the central nervous system stores more endogenous epinephrine,
norepinephrine, serotonin, and dopamine
2. Contraindications: convulsive disorders, prostatic hypertrophy, severe renal, cardiac or hepatic disease
3. Administer with food to prevent GI disturbance
4. Therapeutic effect may take up to three weeks
5. Teach client about potential for drowsiness or dizziness
6. Teach client to avoid drinking alcohol
7. Do not stop taking antidepressants suddenly
1. Depression
1. monitor suicidal thoughts
2. take suicide precautions as indicated and observe for suicide warning
signs
3. build trust with client
4. speak slowly and clearly in simple sentences
5. administer medications as ordered
6. encourage client to ventilate
7. provide relaxation exercises
8. help with hygiene and feeding as indicated
9. help client assess negative thoughts more objectively
10. divert client from morose thoughts
11. encourage client to focus on positive attributes
12. teach client
1. medications and side effects
2. importance of taking medication
3. problem-solving techniques
SUICIDE PRECAUTIONS
1. Remove all harmful objects from the environment
2. One to one monitoring of the client day and night, having the client in view at all times even during
toileting, gradually progress to 15 minute and then hourly checks
3. Ask client exactly how she/he would commit suicide. Assess how lethal the attempt would be, and how
quickly it could be carried out.
4. Keep client within one arm's length distance or less at all times
5. Use plastic utensils
6. Keep electrical cords to a minimum length
7. Take all potentially harmful gifts from visitors
8. Keep all windows locked and if possible keep client in room with unbreakable glass in windows
9. Do not assign a private room
WARNING OF SUICIDAL THOUGHTS OR PLANS

1. Previous suicide attempt
2. Threatening to commit suicide
3. Giving away prized possessions
4. Collecting and discussing information on suicide methods
5. Expressing hopelessness, helplessness, and anger at self or world
6. Death or depression in talk, writing, or artwork
7. Client states or suggests he/she would not be missed
8. Client expresses no hope for the future
9. Self-mutilation
10. Recent loss of friend or family member through natural death, accident or suicide; other major loss such
as job or divorce
11. Acute personality changes such as unusual withdrawal or aggressiveness, moodiness, or taking risks
12. Sudden change in academic performance, truancy, or running away
13. Physical symptoms such as insomnia or excessive sleeping, headaches, stomach aches
14. Use or increased use of potentially addictive substances
15. Low self esteem; feeling worthless, ashamed, guilty, self-hating
VII. Anxiety Disorders

A. Definition: group of disorders in which anxiety is predominant symptom. Degrees range from
mild anxiety to severe (panic attack)
1. Seven types
a. GAD: generalized anxiety disorder
b. phobic disorders
c. panic disorder
d. dissociative disorder
e. somatoform disorder
f. obsessive-compulsive disorder (OCD)
g. PTSD: Post-traumatic stress disorder
B. Etiology
1. Found equally in men and women
2. Hereditary predisposition
3. Biochemical factors: neurotransmitters may play a role
4. Psychologic and interpersonal factors
a. early psychic trauma,
b. pathogenic parent-child relationship,
c. pathogenic family patterns
d. loss of social supports
C. Findings
1. Fear, dread, or apprehension
2. Feeling powerless
3. Crying
4. Irritability
5. Scattered thoughts, inability to concentrate or solve problems
6. Preoccupation with self
7. Rapid speech, hyperventilation, tachycardia
8. Palpitations, chest pains, jittery behavior
9. Diaphoresis
10. Insomnia
11. Diarrhea and/or urinary urgency and frequency
D. Treatments for anxiety disorders
1. Pharmacologic: anxiolytics (antianxiety drugs) such as alprazolam (Xanax) and
diazepam (Valium)
2. Psychotherapy
3. Occupational therapy
4. Recreational therapy
E. Nursing care
1. Provide a nondemanding environment; stay with client if indicated
2. Acknowledge client's feelings of fear, worry, helplessness
3. Do not force contact with feared item or situation
4. If client demonstrates compulsive behavior, allow the compulsion but set reasonable
limits
5. Provide distracting activities
6. Allow temporary dependence
7. Speak calmly, slowly and clearly
8. Assist client in ADL as indicated
9. Encourage relaxation techniques and regular physical exercise
11. Limit caffeine intake
12. Teach client
a. medications and side effects
b. relaxation techniques
VIII. Borderline Personality Disorder

A. Definition
1. Client shows personality traits that are long-lasting, inflexible and maladaptive.
2. Client may appear to function normally until stressed
3. Generally begins in childhood or adolescence
4. More common in women
B. Etiology
1. Impaired development of object relations; separation-individuation process is
arrested
2. Issues of dependence, independence, and control are mixed with fear of
abandonment, loss of love, or engulfment by mother
C. Findings
1. Personal relationships are unstable; lonely; emotions shallow
2. Images of self and others are primarily bad; feels inadequate
3. Anger, hostility
4. Projection of hostility onto others
5. Acts out and denies responsibility for actions
6. Poor judgment
7. Impaired problem solving
8. Very "black or white" thinking
9. Regression
10. Marked mood swings
11. Demanding
12. Sarcastic
13. Manipulative
14. Behaves self-destructively
15. Splitting
D. Treatment
1. Pharmacologic
a. antianxiety agents: oxazepam (Serax)
b. antidepressants: carbamazapine (Carbatrol)
2. Psychotherapy
E. Nursing care in borderline personality disorder
1. Protect client and others from harm

3. Establish a trusting relationship
4. Set limits, and provide a structured environment
5. Use a calm, controlled approach; see that other staff stay consistent
6. Do not argue with client
7. Encourage client to evaluate consequences of actions
8. Divert anger, or let client ventilate it in positive ways
9. Set limits on manipulative behaviors by communicating expected behaviors

10. Teach client
a. medications and their side effects
b. anger-control strategies
c. relaxation strategies
F. Nursing care in borderline personality disorder
1. Protect client and others from harm
3. Establish a trusting relationship
4. Set limits, and provide a structured environment
5. Use a calm, controlled approach; see that other staff stay consistent
6. Do not argue with client
7. Encourage client to evaluate consequences of actions
8. Divert anger, or let client ventilate it in positive ways
9. Set limits on manipulative behaviors by communicating expected behaviors

10. Teach client
a. medications and their side effects
b. anger-control strategies
c. relaxation strategies
Remain focused on every question and every set of options. Do not allow distractions at the testing site to distract
you nor the noises in your head distract you
IX. Suicide Prevention

A. Definitions:
1. Suicide is a self-harming act intended to produce death
2. Degrees
a. completed suicide: life ends
b. attempted suicide: failed self-destructive act
c. suicide ideation: thoughts of ending one's life
B. Epidemiology
1. Women attempt more than men
2. Men are more often successful
3. Second leading cause of death in adolescence
4. Black males have higher incidence
C. Etiology
1. Depression
2. Delusions/hallucinations in psychotic clients
3. Hopelessness
4. Environmental factors: work or school performance, loss of job, death of loved one,
unsatisfying interpersonal relationships
D. Findings
1. Statements about suicide
2. Anger, sadness, hopelessness, negative view of future
3. Recent loss of job, loved one
4. Perceived lack of support system
5. Self-mutilation
WARNING OF SUICIDAL THOUGHTS OR PLANS

1. Previous suicide attempt
2. Threatening to commit suicide
3. Giving away prized possessions
4. Collecting and discussing information on suicide methods
5. Expressing hopelessness, helplessness, and anger at self or world
6. Death or depression in talk, writing, or artwork
7. Client states or suggests he/she would not be missed
8. Client expresses no hope for the future
9. Self-mutilation
10. Recent loss of friend or family member through natural death, accident or suicide; other major loss such
as job or divorce
11. Acute personality changes such as unusual withdrawal or aggressiveness, moodiness, or taking risks
12. Sudden change in academic performance, truancy, or running away
13. Physical symptoms such as insomnia or excessive sleeping, headaches, stomach aches
14. Use or increased use of potentially addictive substances
15. Low self esteem; feeling worthless, ashamed, guilty, self-hating
1. Treatment for suicidal condition
1. Objective: to treat the condition that underlies the suicidal thoughts
2. Medications: amitriptyline (Elavil), chlorpromazine (Thorazine)
3. Suicide precautions
2.Nursing care
2. Institute suicide precautions
3. Encourage relaxation strategies
16. Crisis Intervention
1. Definition - crisis: temporary personality disorganization with an acute emotional state. Crisis
is a normal response to threatening environment.
2. Types and phases of crisis response
1. Panic state: acute crisis where client temporarily loses control
1. emotional reactions are overwhelming
2. decision making and problem solving abilities are inoperative
3. thinking is scattered
4. social isolation
5. immobilization (unable to act)
2. Exhaustion crisis
1. under emergency conditions
2. person has lost effective coping
3. cannot continue to function
3. Shock crisis
1. sudden external change
2. causes release of emotions
3. overwhelms client
4. Four phases of crisis (average crisis four to six weeks but may vary widely)
1. vulnerable state
2. precipitating event
1. developmental change (maturational crisis)
2. a life change (situational crisis)
3. loss of loved one or job (situational crisis)
4. environmental disaster or war (adventitious crisis)
3. acute crisis
4. reorganization
3. Findings of crisis
1. Mild to severe anxiety
2. Anger
3. Crying, social isolation, helplessness
4. Impaired cognitive processes; inability to concentrate; confusion
5. Insomnia
6. Regression
7. Nausea and vomiting
4. Treatment: crisis intervention
1. Objective: to help the client through the current crisis
2. Brief supportive interventions focused on the phase of crisis
3. Allow free discharge of emotions
4. Enhance client's cognitive processes
5. Pharmacologic: trazodone (Desyrel), alprazolam (Xanax)
5. Nursing care in crisis
1. Provide a quiet, restful environment
2. Help the client solve problems
3. Let the client ventilate
4. Correct any misperceptions about the crisis that the client may have
5. Help the client to identify support systems, alternative solutions
6. Help the client to deal with long term impact of crisis
7. Encourage relaxation strategies
8. Assist the client in the development of new coping skills
9. Give medications as ordered
17. Substance Abuse
1. Definitions
1. Maladaptive behaviors resulting from the regular intake of large amounts of addictive
chemicals
2. Addictive chemicals include alcohol, stimulants, depressants, hallucinogens,
narcotics.
3. Levels of substance abuse
1. abuse is pathologic use of mood-altering chemicals that continues for at
least 1 month, which impairs social or occupational functioning
2. dependence is a more severe level of abuse that involves impaired ability to
control use of substance and results in withdrawal (adverse consequences)
when substance is discontinued or reduced. There are three types of
dependence
1. psychologic dependence: pleasure that intensifies craving for
substance; often begins in teens and twenties.
2. physiologic dependence: after repeated use, physiology changes;
and after substance is reduced or removed, withdrawal symptoms
appear
3. tolerance: drug dosage must keep increasing to
achieve same effect
Get regular physical exercise at least three times a week for a minimum of 20 minutes to enhance your body mind
connection.
B. Alcohol
Although alcohol is a legal substance, problem drinking has detrimental physiologic and social
effects.
1. Dependence
a. daily intake of large quantities, or
b. excessive drinking limited to weekends; or
c. periods of abstinence with binges lasting for weeks or longer
2. Etiology unknown
a. stress has been implicated
b. some research suggests a familial tendency
3. Produces withdrawal symptoms
4. Findings of chronic alcohol use
a. anemia
b. hypertension
c. tachycardia
d. hepatomegaly
e. ascites
f. cirrhosis
g. gastritis
h. esophagitis
i. malabsorption syndrome
j. fatigue
k. depression
l. impaired judgment; cognitive impairment
m. tremors
n. wernicke-Korsakoff syndrome
5. Treatment of alcohol dependence
a. antianxiety agents: chlordiazepoxide (Librium)
b. vitamin and nutritional therapy
c. disulfiram (Antabuse) - alcohol abuse deterrent
d. support groups (Alcoholics Anonymous)
WITHDRAWAL EFFECTS OF ABUSED SUBSTANCES
1. Narcotics
a. Runny nose, watery eyes
b. Severe anxiety to panic; irritability
c. Gooseflesh; tremors
d. Loss of appetite; nausea and vomiting
e. Muscle cramps
f. Tachycardia; Hypertension
g. Increased respirations
h. Increased temperature
i. Insomnia
2. Alcohol
a. Acute withdrawal symptoms
1. Tremors, Agitation, Tachycardia

2. Nausea and vomiting; abdominal cramps
3. Diaphoresis
4. Visual or tactile hallucinations
b. Severe Withdrawal - delirium tremens (DTs)
1. Confusion, Disorientation
2. Visual, tactile hallucinations
3. Diaphoresis, Fever
4. Tachycardia
5. Grand mal seizures
2. Sedatives/Hypnotics
a. Weakness, Nausea and vomiting
b. Hypertension, Tachycardia, Orthostatic hypotension
c. Gross tremors
d. Agitation , Anxiety
e. Disorientation
f. Hallucinations, Delirium
g. Convulsions
3. Stimulants
a. Fatigue
b. Depression
c. Disturbed sleep
d. Apathy
e. Cravings
4. Hallucinogens - No withdrawal symptoms reported but flashbacks can occur episodically after use
5. Marijuana
a. Irritability
b. Insomnia
c. Loss of appetite
d. Tremors
e. Perspiration
f. Nausea
1. Nursing care in alcohol dependence
1. during acute withdrawal
1. stay with client
2. provide quiet environment
3. administer medications as ordered
4. protect the client from harm
5. institute seizure precautions as indicated
6. maintain adequate fluid intake
2. during abstinence
1. provide emotional support
2. provide nutritious diet
3. encourage the development of new coping skills
4. provide relaxation exercises
5. inform client about support groups and rehab programs
g. Use of psychoactive drugs (prescription or "street"): stimulants, depressants, hallucinogens, and
narcotics
1. Stimulants
1. include cocaine, crack, amphetamines
2. effects of abuse of stimulants
1. psychomotor agitation
2. mood swings
3. tachycardia
4. hypertension
5. dilated pupils
6. perspiration and chills
7. insomnia
8. impaired cognitive function
9. seizures
10. if discontinued, withdrawal follows
3. overdose may cause lethal cardiac or respiratory arrest
4. emergency care of overdose on stimulants: cardiopulmonary support
2. Depressants
1. include barbiturates, tranquilizers, sedatives and hypnotics
2. findings of depressant use
1. slurred speech
2. impaired cognitive function; confusion
3. emotional lability
4. lack of coordination
5. cold and clammy skin
6. produce withdrawal symptoms
3. overdose can lead to respiratory depression, coma
4. emergency care of overdose
1. respiratory support
2. keep client awake and moving
3. Narcotics
1. include: heroin, morphine, meperidine, codeine, methadone
2. findings
1. euphoria
2. tranquility
3. drowsiness
4. constricted pupils
5. clouded sensorium
3. overdose threatens life: depresses respiratory function and alters level of
consciousness
4. emergency care includes cardiopulmonary support (illustration 1
illustration 2 illustration 3 )
4. Hallucinogens
1. include: LSD, PCP, marijuana, mescaline, psilocybin
2. findings
1. tachycardia
2. hypertension
3. dilated pupils
4. hallucinations
5. nausea
6. impaired attention and judgment
7. aggressive behavior
3. potentially life threatening
4. potentially psychotic long-term effects
h. Treatment: drug rehabilitation
E. Nursing care in substance abuse
1. Protect the client and others from harm
2. Help client through drug rehabilitation as indicated
3. Provide emotional support
4. Help the client develop a support system
5. Provide emergency care for overdose
IX. Autism
E. Definition: syndrome in which child does not relate to people
1. May become attached to objects
2. Develops before age three
F. Etiology unknown
G. Findings
1. Does not respond to human touch
2. Lack of eye contact
3. Talks poorly or not at all
4. Ritualistic behavior
5. Cannot deal with change
6. Emotional lability
7. May be self destructive (head-banging, hair pulling, finger/hand biting)
8. Failure to develop friendships or play with other children
9. Posture or gait abnormalities: poor coordination, tiptoe walking, peculiar hand
movements (flapping, clapping)
H. Treatment
1. Special education
2. May need full time care (institution)
I. Nursing care
1. Support parents emotionally
2. Protect the child from self harm
3. Help child with hygiene and feeding as indicated
4. Maintain consistency in schedule
5. Allow ritualistic behavior
X. Abuse Syndromes
E. Definition - abuse may be physical, sexual, psychological or physiological
1. Victims powerless to stop abuse
2. May be directed toward a child, a spouse, the elderly
3. Rape is a violent sexual abuse
4. Abusers
I. often blame victim
II. demonstrate poor impulse control
III. have frequently been victims of abuse themselves
F. Findings
1. Physical abuse
I. broken bones and/or dislocations
II. welts, and/or bruises
2. Sexual abuse
I. bruising or bleeding in genital or anal area,
II. pain or itching in genital area,
III. rape, evidence of sexual intercourse,
IV. genitourinary infections
3. General neglect
I. malnutrition
II. habitual behaviors: rocking, head banging
III. learning disorders
IV. social isolation
V. aggressive behavior
G. Treatment
1. In general, cases of abuse must be reported (refer to state statutes for variations)
2. Removal of victim from source of abuse
3. Protective services
4. Directing abuser to help or therapy
Upward Arm Stretch
Instructions
Sit up straight. This exercise may be done in a half lotus sitting position or in a chair.
Lift your arms up and bend your elbows, clasp your hands behind your head. Push your elbows back and
feel your shoulder muscles contracting and your chest expanding.
Now INHALE raise your arms as you clasp the fingers of both hands together, palms up. Hold for several
seconds. Then EXHALE release and return the hands back behind the head.
Repeat three times.
o Nursing care
Provide emotional support
Document all signs of abuse
File appropriate reports (report of suspected abuse is mandatory in most states)
Assist in placement for protection
Assist abuser in obtaining appropriate counseling
Eating Disorders
o A subcategory of disorders that includes multiple types of eating behavior disturbances
o Types of eating disorders
Anorexia nervosa
weight loss through restriction of food intake leading to emaciation
may involve purging behaviors
tend to reject mature-appearing body
tendency to asceticism
Bulimia nervosa
eating binges alternate with dieting or purging
purging behaviors may include self-induced vomiting, misuse of emetics and
cathartics or laxatives
more likely than those with anorexia to show impulsive or chaotic behavior
usually near normal weight
tend to be outgoing and sensitive to others
major issue: control self/environment through eating behaviors
drive for thinness
population at risk
adolescents and young adults
in industrialized countries
models, dancers and gymnasts at higher risk
potentially life threatening
o Etiology
Psychoanalytic theory
conflicts stem from oral phase of development
clients often have anxious, compulsive mothers
obsessive-compulsive control of body and life, via food
controlling bodily functions is critical to client's attempt at self-control
Interpersonal theory
results from dysfunctional family relationships
parents avoid their own conflicts by controlling child
child's self-identity becomes blurred
during adolescence parents become overcontrolling and demanding
demands thwart client's attempts at autonomy
adolescent attempts to control self through controlling food intake.
Cognitive theory
eating-disorder behaviors are learned
society glorifies thinness
for the adolescent or young adult, thinness equates with self-worth.
o Findings of eating disorder
Personal relationships become superficial and distant
Social contact avoided especially if food is involved
Preoccupation with food, meal planning, caloric intake and methods to avoid eating
Eats in private
Mood irritable and defiant
Exercises excessively
Physical findings
weight falls below 85% of normal
bradycardia
anemia
amenorrhea
decreased renal function
dental problems
fluid and electrolyte imbalances
delayed skeletal maturation
Use self recorded audiotapes or written index cards to review during available moments throughout the
day, such as in the car or waiting in line. However, if a computer is available to you, do test questions.
Have the goal of getting at least 80% of them correct.
E. Treatment of eating disorders

1. Objective: to correct underlying cause and prevent complications of weight loss
2. Client may require hospital care
3. Nutritional planning
4. Psychotherapy: individual and/or family
5. Group therapy
8. If underlying depression, treat with antidepressants
F. Nursing care
1. Monitor weight as prescribed
2. Monitor client's eating/record intake and output
3. Administer nasogastric feedings if ordered
4. Encourage oral hygiene
5. Set limits on eating including time allotted for meals
6. Stay with client during meals
7. Accompany client to bathroom after meals to prevent self-induced vomiting
8. Encourage client to express feelings
9. Encourage socialization
10. Monitor for findings of electrolyte imbalance or dehydration
11. Assist client to identify strengths
12. Teach client
a. relaxation techniques
b. alternative coping methods
c. assertiveness skills
Coping Mechanisms
People use coping mechanisms, also called ego defense mechanisms, to relieve anxiety.
They are usually unconscious; that is, the client is not aware of their use.
Watch for excessive use of these mechanisms.
Therapeutic Communication
Show positive regard for the client.

Give eye contact without staring.
Show empathy and genuine caring.
Show respect.
Use open-ended questions.
Be aware of your own body language. Appear relaxed. Use an open body posture. Do not cross your
arms.
Respect confidentiality.
Grief
The distinction between grieving and depression can be a matter of degree. Look for signs of clinical
depression.
Grieving takes time; the amount of time varies with individuals.
The stages of grief are not linear; they may come and go.
Grief follows death; but also follows divorce, loss of job, loss of financial status, loss of limb or other
physical disability, etc.
Chronic grief is an exaggerated, prolonged grief response characterized by efforts to keep the deceased
alive; chronic grief does not reach resolution. The mourner is unable to get on with life.
Pay attention to culturally diverse ways of responding to grief. This is important in assessment of grief
reaction and in respecting the customs and rituals of a cultural group.
Encourage client and family to talk about their feelings.
Beware of personal reaction to death and over identification with client. When necessary, seek
assistance to cope with personal issues.
Teach clients and their families about the up-and-down process of grieving.
Refer to appropriate support groups
Stress Management
Severity of reaction to a stressor depends on how it is interpreted/perceived by the individual, the

meaning or significance given to it.
Learn about support groups in your community for appropriate referral.
Stress is a normal part of life. People differ in how they cope with stressors.
Physical and emotional stressors trigger the same stress response; however the magnitude of the
response may vary.
There are individual differences in response to same stress.
Duration and intensity of physiologic indicators are directly related to the duration and intensity of the
stress.
Stress is classified as mild, moderate or severe.
Prolonged stress decreases the adaptive capacity of the body.
There are limits to a client's ability to handle stress.
Schizophrenia is the most common psychotic disorder. It originates from complex genetic, biological, and
psychosocial factors.
Extrapyramidal side effects of antipsychotic medications must be treated.
Depression can be mild, moderate, or severe.
Mild depression is often undiagnosed.
Antidepressants take 2 to 3 weeks to take effect.
Many people have fleeting thoughts of killing themselves at some point in their lives.
Cognitive Triad of Depression - negative view of self, negative view of the world, negative view of the
future.
Anorexia nervosa and bulimia are conditions that primarily occur among adolescent and young women.
The 3 phases of a therapeutic relationship are: (1) initial phase, (2) working phase and (3) termination
phase
Question Number 1 of 20
During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the
delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of
prejudice?
The correct response is "D".

A) "I wonder who is paying for this trip to the hospital?"
B) "I think she needs to go to the city hospital."
C) "I guess she doesnt understand how to use birth control."
D) "All those people indulge in large families!"

Your response was "B".
The correct answer is D: "All those people indulge in large families!"

Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to
have objectionable qualities. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual,
group, or culture that limit a full and accurate understanding of the individual, culture, gender, race, event, or
situation.
Leininger, M. & McFarland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice. New
York: McGraw Hill/ Appleton and Long.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.
An elderly client who lives in a retirement community is admitted with these findings as reported by the daughter:
absence at the daily senior group activity, missing the weekly card games, a change in calling the daughter from
daily to once a week, and allowing the client's tomato garden to become overgrown with weeds. The nurse should
assign this client to a room with which one of these clients?
The correct response is "B".

A) An adolescent who was admitted the day before with acute situational depression
B) A middle-aged person who has been on the unit for 72 hours with a dysthymia
C) An elderly person who was admitted 3 hours ago with cyclothymia
D) A young adult who was admitted 24 hours ago for detoxification

Your response was "A".
The correct answer is B: A middle-aged person who has been on the unit for 72 hours with a dysthymia
The findings suggest a client who is depressed. The most therapeutic milieu or environment for this client would
include clients with similar problems and those who might be more stable. A secondary consideration is matching
roommates ages as closely as possible, because they potentially would share similar developmental challenges
and needs. The client in option A has depression and would is more likely to be unstable since they have been in
the agency for only 24 hours. Dysthymia is defined as a mild depression with findings of trouble falling asleep or
no difficulty falling asleep but then wakes up in the middle of the night and with difficulty is able to fall back
asleep. Cyclothymia is the occurrence of behavioral periods that do not meet all of the criteria for manic or major
depressive episodes.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New
York: Delmar.
Altman, G. (2004). Delmars Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar
A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action
should the nurse take first?

A) Ask client if there are any old injuries also present
B) Interview the client without the persons who came with the client
C) Gain client's trust by not being hurried during the intake process
D) Photograph the specific injuries in question

Your response was "D".
The correct answer is B: Interview the client without the persons who came with the client
It is critical to separate the client from their partner or significant other. With the use of the nursing process the
nurses first action when a client is unstable or has potential problems is further assessment of the situation.
Condon, M.C. (2004). Women''s health, an integrated approach to wellness and illness. Upper Saddle River, New
Jersey: Prentice Hall.
Altman, G. (2004). Delmars Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.
An explosion has occurred at a high school for children with special needs and severe developmental delays. One
of the students, accompanied by a parent, is seen at a community health center a day later. After the initial
assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions,
based on crisis intervention principles, is appropriate to implement next?

A) Make the student identify a specific problem
B) Ask the parent to identify the major problem
C) Ask the student to think of different alternatives
D) Examine a variety of options with the parent

The correct answer is B: Ask the parent to identify the major problem
If a client is unable to participate in problem solving because of developmental delays or altered mental status,
then crisis intervention should not be attempted. However, the family can be approached using crisis intervention
methods. The crisis intervention method includes 5 steps: identify the problem and then the alternatives,
selection of an alternative, implementation, and evaluation.
York: Delmar.
Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?
The correct response is "A".

A) "You look upset. Would you like to talk about it?"
B) "I'd like to know more about your family. Tell me about them."
C) "I understand that you lost your partner. I don't think I could go on if that happened to me."
D) "You look very sad. How long have you been this way?"
The correct answer is A: "You look upset. Would you like to talk about it?"
Giving broad opening statements and making observations are examples of therapeutic communication. Option B is
not supported by any assessment data provided, and therefore would not be therapeutic in the absence of a
reason to inquire about the clients family. Option C is incorrect because it is an inappropriately personal remark
by the nurse. Option D is not as therapeutic as option B because it does not offer the client a broad opportunity to
talk about concerns and is vaguely critical of the client as phrased
York: Delmar.
A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the
client believes that suffering is part of life. The client states, Everyones life is in God's hands. The next action
for the nurse to take is to
The correct response is "C".

A) report the situation to the health care provider
B) discuss the situation with the client's family
C) ask the client if talking with a priest would be desired
D) document the situation on the notes

The correct answer is C: ask the client if talking with a priest would be desired
Beliefs regarding pain are one of the oldest culturally-related research areas in health care. Astute observations
and careful assessments must be completed to determine the level of pain a person can tolerate. Health care
practitioners must investigate the meaning of pain to each person within a cultural explanatory framework.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of
clinical problems. St. Louis: Mosby.
Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode?

A) "I think all children should have their heads shaved."
B) "I have been restricted in thought and harmed."
C) "I have powers to get you whatever you wish, no matter the cost."
D) "I think all of my contacts last week have attempted to poison me."
The correct answer is C: "I have powers to get you whatever you wish, no matter the cost."
Grandiosity is characteristic of a manic episode.
Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ: Prentice-Hall.
A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The
best response for the nurse to make is

A) "I apologize for the delay. I was involved in an emergency."
B) "Let's talk. Why are you upset about this?"
C) "I am surprised that you are upset. The request could have waited a few more minutes."
D) "I see this is frustrating for you. I have a few minutes so let's talk."
The correct answer is D: "I see this is frustrating for you. I have a few minutes so let''s talk."
This is the best response because it gives credence to the client''s feelings and then concerns. Option B does not
acknowledge or validate the client''s feelings.
Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical Approach (4th ed.). Philadelphia:
Saunders.
ach (4th ed.). Philadelphia: Saunders.
A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and
chanting. The attending nurse tells a colleague, "I wonder if he has any idea how ridiculous he looks -- he's a
grown man!" The nurse's response is an example of

A) discrimination
B) stereotyping
C) ethnocentrism
D) prejudice
The correct answer is D: prejudice

Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to
have objectionable qualities. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual,
group, or culture that limit a full and accurate understanding of the individual, culture, gender, race, event, or
situation.
Which statement by the client during the initial assessment in the emergency department is most indicative of
suspected domestic violence?

A) "I am determined to leave my house in a week."
B) "No one else in the family is as accident prone as I am."
C) "I have only been married for 2 months."
D) "I have tried leaving home, but have always gone back."
The correct answer is D: "I have tried leaving home, but have always gone back."
Victims develop a high tolerance for abuse. They blame themselves for being victimized. All members in the
family suffer from the effects of abuse, even if they are not the actual victims. For these reasons, victims often
have an extensive history of abuse and struggle for a long time before they can leave permanently.
Swearingen, P. (2004). All-in-One Care Planning Resource: Medical-surgical, Pediatric, Maternity, and Psychiatric
Nursing Care Plans. St. Louis: Mosby.
A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of
assorted pills in the clients drawer. The client tells the nurse that they are antacids for stomach pains. The best
verbal response by the nurse would be

A) "These pills arent antacids since they are all different."
B) "Some teenagers use pills to lose weight."
C) "Tell me about your week prior to being admitted."
D) "Are you taking pills to change your weight?."

The correct answer is C: "Tell me about your week prior to being admitted."
This is an open-ended question which is nonjudgmental and allows for further discussion. The topic is also
nonthreatening yet will give the nurse insight into the client''s view of events leading up to admission. It is the
only option that is client centered. The other options focus on the pills.
Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wongs Nursing Care of Infants and
Children, (7th ed). St. Louis: Mosby.
Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to
the working phase? The client

A) has revitalized a relationship with her family to help cope with the death of a daughter
B) had recognized regressive behavior as a defense mechanism
C) expresses a desire to be cared for and pampered
D) recognizes feelings and expresses them appropriately

The correct answer is D: recognizes feelings and expresses them appropriately

During the working phase, the client is able to focus on both pleasant and unpleasant feelings and express them
appropriately.
York: Delmar.
A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action?

After death a Hindu priest will pour water into the mouth of the client and tie a thread around the
A)
client's wrist
B) The elders may be with the client during the process of dying and no last rites are given
The family must be with the client during the process of dying and be the only ones to wash the body
C)
after death
D) The body is ritually cleansed and burial occurs as soon as possible after the death
Your response was "C".
The correct answer is A: After death a Hindu priest will pour water into the mouth of the client and tie a thread
around the client''s wrist
This action indicates a blessing in the practice of Hinduism. The family of a client whose belief system based in
Hinduism is particular about who touches the dead body, and cremation is preferred. In addition, last rites are
carefully prescribed. The actions in option B are expected with persons from the Church of Jesus Christ of Latter
Day Saints (also known as Mormons), and cremation is discouraged. Option C lists practices of the Islamic religion,
which specifies that only the family and friends may touch the body. Option D lists practices of Judaism, and some
Jewish groups also prohibit autopsy and require a rabbis pre-approval of organ donation or transplants .
York: Delmar.
A client who is thought to be homeless is brought to the emergency department (ED) by police. The client is
unkempt, has difficulty concentrating, is unable to sit still, and speaks in a loud tone of voice. Which of these
actions is the appropriate nursing intervention for the client at this time?

A) Allow the client to randomly move about the holding area until a hospital room is available
B) Engage the client in an activity that requires focus and individual effort
C) Isolate the client in a secure room until control is regained by the client
D) Locate a room that features minimal stimulation during the admission process
The correct answer is D: Locate a room that features minimal stimulation during the admission process
This intervention allows the client with moderate anxiety or agitation to have human contact in an environment
that does not exacerbate the condition. It also facilitates efficiency in the initial screening and admission process
to the ED, may prevent behavioral escalation, and thereby promotes safety for all involved .
Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis,
Missouri: Mosby.
A client diagnosed with anorexia nervosa states after lunch, "I shouldnt have eaten all of that sandwich, I dont
know why I ate it, I wasnt hungry." The clients comments indicate that the client is likely experiencing

A) Guilt
B) Bloating
C) Anxiety
D) Fear
The correct answer is A: Guilt

If people with anorexia lose control and eat more than they believe to be appropriate, they experience guilt.
Saunders.
A nurse states, "I dislike caring for African-American clients because they are all so hostile." The nurse's statement
is an example of

A) prejudice
B) discrimination
C) stereotyping
D) racism
The correct answer is C: stereotyping
Stereotyping refers to defining people and institutions, mentally or by attitudes, with narrow, fixed traits, rigid
patterns, or with inflexible "boxlike" profile characteristics. Stereotyping is one of the most common concerns of
nurses when they begin to study different cultures and learn about transcultural nursing.
Kozier, B., Erb, G., Berman, A. and Snyder, S. (2004). Fundamentals of Nursing. Upper Saddle River, N.J.: Pearson
Prentice Hall.
A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses
concern that the client seems depressed. The nurse should initially focus assessment by using which approach?

A) Administer a standardized tool that measures depression
B) Observe the clients affect and behavior
C) Inquire about use of alcohol
D) Obtain a family health history, including emotional problems or mental illness

The correct answer is B: Observe the clients affect and behavior

Although it is important to begin an assessment for depression immediately, the assessment should not be
aggressively intrusive unless the nurse has confirmed the observation of the family member or if there are
concerns about the risk of suicide.
Clark, M.J. (2003). Community Health Nursing: Caring for Populations. (4th edition). Prentice Hall: Upper Saddle
River, New Jersey.
Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis,
Missouri: Mosby.
A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out
of Ireland? I've never been to Ireland." The nurse would document this behavior as

A) perseveration
B) circumstantiality
C) neologisms
D) flight of ideas
The correct answer is D: flight of ideas

Flight of ideas is characterized by over productivity of talk and verbally skipping from one idea to another. It is
classic with clients diagnosed with bipolar disorder and occurs in the manic state of this disease. Flight of ideas
can also occur in schizophrenia and intoxication with psychoactive substances.
Saunders.
A 2 day-old child with spina bifida and meningomyelocele is in the intensive care unit after the initial surgery. As
the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the
grandparents?

A) Depression
B) Anger
C) Frustration
D) Disbelief
The correct answer is D: Disbelief

The first phase of the grieving process is shock, denial or disbelief. Then follows anger, bargaining, depression and
acceptance. Each stage can take any amount of time to work through. Clients often go back and forth the stages
before acceptance occurs. Some client get stuck in 1 or 2 of the stages.
Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wongs Nursing Care of Infants and
Children, (7th ed). St. Louis: Mosby.
Phipps, W., Monahan, F., Sands, J., Marke, J., Neighbors, N. (2003). Medical-Surgical Nursing: Health and Illness
Perspectives. (7th Edition). Mosby: St. Louis, Missouri.
A mother with a Roman Catholic belief system has given birth in an ambulance on the way to the hospital. The
neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these
requests should the nurse in the ambulance anticipate and be prepared to encounter?

A) The refusal of any treatment for the mother and the neonate until a reader is consulted.
The placement of a rosary necklace around the neonate's neck that is not to be removed unless
B)
absolutely necessary.
Arrange for a church elder to be at the emergency department when the ambulance arrives so a "laying
C)
on hands" can be done.
Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name
D)
of the father, the son and the holy spirit. Amen."
The correct answer is D: Pour fluid over the forehead backwards towards the back of the head and say "I baptize
you in the name of the father, the son and the holy spirit. Amen."
Infant baptism is mandatory according to Roman Catholic beliefs, especially if a neonate is not expected to live.
Anyone may perform this if an infant or child is gravely ill. Option A refers to the Christian Science belief system.
Option B is a belief of Russian Orthodoxy. Mormons believe in divine healing with the laying on of hands, as
represented in option C.
York: Delmar.

Psychosocial Integrity

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Coping Mechanisms (also called defense mechanisms)

A. Definition: psychological techniques that the personality develops to manage anxiety,

Types of Coping Mechanisms

THERAPEUTIC COMMUNICATION TECHNIQUES

Not Necessarily Verbal

THERAPEUTIC COMMUNICATION TECHNIQUES

Not Necessarily Verbal

NINE INEFFECTIVE COMMUNICATION TECHNIQUES

5. Invalidation - Ignoring or denying the client's thoughts or feelings.

FOUR THEORETIC MODELS OF GRIEF

A. Elizabeth Kubler-Ross: Five Stages

A. Local responses to stress: Local Adaptation Syndrome (LAS):

c. Reflex pain response

b. Adaptive (that is, requires a stressor)

B. Whole-body response to stress: General Adaptation Syndrome (GAS)

a. Fight or flight response

A. Increased cardiac output

B. Increased heart rate

C. Increased respiratory rate

E. Increased mental alertness

b. Sympathetic Nervous System response

A. Increased heart rate

B. Increased oxygen intake

C. Increased blood sugar

A. Increased blood flow to skeletal muscle

B. Involves increased arterial blood pressure

c. Posterior Pituitary: Increased ADH

A. Increased water reabsorption

B. Decreased urine output

d. Anterior Pituitary: Increased ACTH

A. Increased cortisol secretion

B. Increased protein catabolism

C. Increased fat catabolism

B. Increased aldosterone secretion:

A. Body reabsorbs more sodium, more water

B. Kidneys produce less urine

C. Kidneys secrete more potassium

b. Hormonal levels return to normal

c. Parasympathetic nervous system activates

d. Body adapts to stressors

4. Stage 3: Exhaustion - If stressor continues, energy wanes and body weakens

a. Physiological response as noted in alarm reaction

b. Decreased energy levels

c. Decreased physiologic adaptation

H. Physiologic indicators of stress

PHYSIOLOGIC INDICATORS OF STRESS

EMOTIONAL/BEHAVIORAL INDICATORS OF STRESS

4. Loss of self esteem

STRESS MANAGEMENT STRATEGIES

i. decrease psychotic symptoms

ii. decrease agitation

iii. less effective with negative symptoms

iv. decrease dopamine - dependent neural activity in the brain and

b. antiparkinsonian agents: used to counteract these extrapyramidal symptoms

3. Biochemical theories of mood disorders

possible increase in electrolytes: sodium and calcium

G. Types of mood disorders: mania, bipolar, depression

3. Mania - DSM IV criteria for mania

3. Biochemical theories of mood disorders

possible increase in electrolytes: sodium and calcium

G. Types of mood disorders: mania, bipolar, depression

3. Mania - DSM IV criteria for mania

2. Bipolar disorders onset usually before age 30

The 7 Traits of Typical Mood Disorders