Mental Health

Module 3 Mental Health Nursing FBNPC
Mental Health
Nursing (Module 3) for
the NCLEX. Tips
Strategies & MCQs
WWW.FBNPC.COM/306-316-0411
Anxiety WWW.FBNPC.COM/306-316-0411
Overview
1. A sense of worry or nervousness, typically about an upcoming event with an uncertain
outcome.
2. Anxiety is a normal part of life, we get concerned when it is persistent, chronic, and/or
is a response to normal life activities.
Nursing Points
General
1.
1. Types
1. Normal: healthy
2. Acute: sudden, related to an event/threat (also normal)
3. Chronic: consistent, related to normal daily activities

Assessment
1.
1. Levels
1. Mild: can be healthy, motivating, produce growth
2. Moderate: can still function and solve problems/issues
3. Severe: individual needs someone to refocus them
4. Panic: dread, impending doom, loss of rational thoughts and

can lead to exhaustion
Therapeutic Management
1. Therapeutic interventions
1. Ensure safety
2. Provide calming and safe environment
3. Establish trust / rapport
4. Acknowledge the anxiety
5. Encourage expression of thoughts, feelings, problem solving
6. Promote their coping mechanisms; do not critique / criticize
7. Provide gross motor activities

1. Definition: movement and coordination of arms, legs, and large
body parts
2. Examples: running, walking, jumping

8. Give anti-anxiety meds PRN
2. Interventions for an acute anxiety attack

1. Decrease stimuli, calm environment
1. Too many stimuli makes it worse
2. Encourage patient to identify and discuss feelings and their causes
1. Helps them see connection between the behaviors and their
resulting feelings
3. Listen/watch for indications of risk for self-harm like helplessness and
hopelessness
Nursing Concepts
1. Safety
2. Coping
3. Mood Affect
Patient Education
1. Identify and avoid triggers
2. Have an action plan
QUIZ
Question 1 of 10
The nurse is preparing a presentation on stress and anxiety. Which of the following is
included as part of this presentation? Select all that apply.
• Anxiety can be motivating and increase learning

• Stress can cause anxiety
• Severe anxiety does not lead to psychosis
• Prolonged anxiety can cause illness
• Severe anxiety can lead to suicidal thoughts
Question 2 of 10
A client is suffering from stress and anxiety and is being seen at a healthcare clinic for help
and management. Which best describes the initial physical effects of stress and anxiety in the
body? Select all that apply.
• Increased respiratory rate

• Vasodilation
• Changes in appetite
• Increased heart rate

• Pinpoint pupils
Question 3 of 10
A nurse is caring for a 20-year-old client with testicular cancer. The client has expressed
feelings of anxiety related to his diagnosis and appears restless and agitated every time the
nurse tries to talk with him. Which intervention would be the most appropriate for the nurse
to help this client with anxiety?
• Explain that the client most likely needs antidepressants to get him through this time
• Offer to have the provider talk with the client about his diagnosis
• Tell the client that he will feel better if he talks about it
• Offer information about support groups
Question 4 of 10
A 51-year-old client is getting ready to undergo a cardiac catheterization and is very anxious
about the procedure. Which intervention can the nurse provide that will most likely help this
client to remain calm?
• Explain what the client will see, hear, feel and experience during the procedure in terms
that he can understand
• Give the client literature about the procedure ahead of time so that he can read about
the process
• Tell the client that he will receive sedative medications so he will not be alert during the
procedure
• Have the client's family sit next to him during the procedure
Question 5 of 10
A client who has been diagnosed with anxiety tells the nurse that his thoughts contribute to
his problems. Which information can the nurse give the client that is true about automatic
negative thoughts?
• Persons with anxiety must accept that things are the way they are
• When you continue to struggle with anxiety, you are not putting enough effort into
changing
• Everything happens for a reason, and good will come out of the experience • How
you think about the world determines how you feel and behave
Question 6 of 10
A nurse is working with a client to use biofeedback as a method of controlling anxiety. Which
of the following outcomes would most likely result from correct use of this mechanism?
• A resolution of the client's anxiety symptoms

• A form of sedation that is calming when an anxiety attack occurs
• An ability to recognize and control the body's stress response
• The client being able to recognize that he suffers from anxiety
Question 7 of 10
An emergency department nurse is working with a client who sought care for a sudden panic
attack. The client tells the nurse that she feels like she is dying and is sweating and shaking.
Which statement by the nurse is best?
• You are not in a medical emergency, but you are having an abnormal fight-or-flight
response
• This is nothing serious and is related to stress
• It is time to calm down now because you are finally in the hospital
• I have panic attacks too, and they are terrible
Question 8 of 10
A client who is being prepared for surgery is experiencing severe anxiety about the
procedure. Which of the following interventions could the nurse employ to decrease this
client’s anxiety levels? Select all that apply.
• Ask the client to help with certain tasks, such as starting an IV

• Employ music therapy or aromatherapy if available
• Administer sedative medications to help the client sleep
• Encourage the client's own coping mechanisms
• Provide reassurance by answering the client's questions
Question 9 of 10
A nurse has given her client a nursing diagnosis of Anxiety because of her behavior when she
found out that she was pregnant. Which of the following interventions would be most
appropriate for this type of nursing diagnosis? Select all that apply.
• Assist with admitting the client to the psychiatric unit

• Assist the client with identifying coping mechanisms
• Reassure the client that she is safe
• Encourage the client to talk
• Maintain a calm demeanor
Question 10 of 10
A client is scheduled for surgery and admits that he has never been so anxious in his life.
Which of the following symptoms are common for a client in this situation? Select all that
apply.
• Blurry vision
• Headache
• Tachycardia
• Chest pain
• Nausea
Generalized Anxiety Disorder

Overview
1. Definition: Daily unrealistic, excessive, uncontrollable, persistent anxiety that manifests into
physical symptoms
Nursing Points
General
1. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
2. The symptoms can’t be explained by other physiological disorders

Assessment
1. Issues with sleeping
2. Irritability
3. Difficulty concentrating
4. Muscular tension
5. “On edge” all the time
6. Patient is hyper-focused on physical symptoms

1. Interventions if patient is experiencing a panic attack (sudden intense fear and
apprehension)
1. Determine what thoughts initiated/ triggered the attack
2. Reorient them or rationalize thoughts
3. Help to restructure distorted thoughts
4. Treat/medicate for anxiety first
5. Address physical symptoms

Nursing Concepts
1. Safety
2. Coping
3. Mood Affect
Patient Education
2. Have a resource for who to call or what to do when the anxiety gets too difficult to
handle
STUDY TOOLS:
Generalized Anxiety Disorder
Pathophysiology
While everyone worries about things from time to time, clients with Generalized Anxiety
Disorder worry about things more than what seems to be appropriate. Clients may have
anxiety or worry about situations or events, or even just day-to-day activities. The level of
worry may range from mild to severe and may make it difficult to carry out routine activities.
This condition is common in middle and high school aged children as well as adults and can
lead to physical manifestations such as abdominal pain and headaches. Clients may realize and
have probably been told by others that they worry too much, but they are unable to relax.
Etiology
Diagnostic Criteria:
• Excessive anxiety and worry, most days for at least 6 months
• Individual finds it difficult to control the worry
• Difficulty functioning in social or occupational areas
• Not caused by a substance (drug abuse, medication, alcohol) or some other medication
condition (hyperthyroidism)
• Cannot be more accurately diagnosed by another condition (ie., social phobia, PTSD, somatic
symptom disorder, etc.)
• Symptoms present most days in the past 6 months: (adult: 3+ symptoms; child: 1 symptom) o
Restlessness o Easily fatigued o Difficulty concentrating / mind goes blank o
Irritability o Muscle tension
o Sleep disturbance (too little or too much)
Desired Outcome
Client will be free from injury. Client will develop more effective coping techniques. Client will
learn how to manage worry and fears optimally. Subjective Data Outcome
• Persistent worry
• Overthinking plans and worst-case solutions
• Indecisiveness
• Difficulty sleeping
• Perceiving situations as threatening
• Inability to relax
• Difficulty concentrating
• Fatigue
• Abdominal pain
• Headaches
• Chest pain or tightness

• Shortness of breath
Objective Data
• Muscle tension
• Sweating
• Vomiting
• Diarrhea
Nursing Interventions
Assess vitals
RATIONALE
Determine baseline for effectiveness of interventions and to rule out other medical conditions
such as hypertension or fever.
Obtain 12-lead EKG

RATIONALE
Get an EKG to rule out cardiac etiology of symptoms. “Anxiety attacks” or “panic attacks” from
GAD may mimic the symptoms of a coronary event with chest pain or tightness and shortness of
breath.
Determine if client is having homicidal or suicidal ideations

RATIONALE
Maintain safety for client and others around them
Establish trust with the client

• Listen to their concerns
• Avoid giving immediate suggestions
• Be respectful of client’s space
RATIONALE
Especially when a client has a high level of anxiety, establishing trust can help the client calm
down and make treatment more effective.
Never say “calm down” or “just relax”, it’s not that easy.
Maintain a calm and comforting demeanor while working with client

RATIONALE
Clients often have the feeling of being out of control. Being around someone who is calm and in
control of the present situation may help the client feel safer and more at ease.
Be present
• Stay with the client during levels of high anxiety or “panic attacks”
RATIONALE
The presence of someone the client trusts provides positive encouragement to handle situations.
Being present also helps ensure the client’s safety.
Provide opportunities for client to assist with decision making, but avoid decisions that may
require concentrated thought or may be life-changing
RATIONALE
Allowing the client to help make minor decisions can help them regain control of their emotions.
For example, start with giving them a choice between music therapy or guided imagery.
Use desensitization approaches carefully

• Systematically expose client to small stressors to develop coping techniques
• Pair each situation with a positive or calming affect (relaxation or exercise)
RATIONALE
Desensitization helps the client take control of worry or fears. Start small with safe situations
and work up to those that cause higher anxiety.
Many times, this is coordinated by a psychiatric/mental health provider.
Administer medications appropriately (benzodiazepines)

RATIONALE
Medications can be a quick response to high stress or anxiety and help calm the client during
therapy or desensitization. Monitor for signs of addiction or withdrawal.
Avoid allowing personal thoughts, feelings, or anxiety to interfere with care

RATIONALE
Anxiety is somewhat contagious and contributing your own emotions can make a client’s
symptoms and worry more exacerbated.
References
https://DSM5_DiagnosticCriteria_GeneralizedAnxietyDisorder.pdf
https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad
Generalized Anxiety Disorder Pathochart
PATHOPHYSIOLOGY
While everyone worries about things from time to time, clients with Generalized Anxiety
Disorder worry about things more than what seems to be appropriate, including day-to-day
activities. The level of worry may range from mild to severe and may make it difficult to carry
out routine activities and can lead to physical manifestations such as abdominal pain and
headaches. Clients may realize and have probably been told by others that they worry too
much, but they are unable to relax.
ASSESSMENT FINDINGS
• Restlessness
• Easily fatigued
• Difficulty concentrating / mind goes blank
• Irritability
• Muscle tension
• Sleep disturbance (too little or too much)
DIAGNOSTICS
• Excessive anxiety and worry that is difficult to control
• Difficulty functioning in social or occupational areas

• Not caused by a substance or other medication condition
• Symptoms present most days in the past 6 months (Adult: 3+ symptoms; Child: 1
symptom)
NURSING PRIORITIES
• Maintain calm, supportive environment
• Promote adequate coping skills
• Maintain safety & prevent injury
THERAPEUTIC MANAGEMENT
• Rule out other sources of symptoms
• Assess for suicidal ideations
• Group or individual therapy/counseling
• Provide resources for coping strategies
• Identify and avoid triggers
MEDICATION THERAPY
• Benzodiazepines
• Some clients may bene-t from antidepressants as well
QUIZ
Question 1 of 7
A client is experiencing an anxiety attack. The nurse reviews the client’s home medications and notes
that they take an anti-anxiety medication. Which of the following medications is likely prescribed to
this client?
• Alprazolam
• Amiodarone
• Alendronate
• Amitriptyline
Question 2 of 7
A case management nurse is reviewing the chart for a client in a psychiatric hospital who has been
diagnosed with panic disorder. The client is anxious and irritable. The nurse has done teaching on
relaxation techniques, but the client requires close monitoring due to lack of adherence to the
regimen. Which action of the case manager will most likely support this client best?
• Arrange for the client to be committed to long-term inpatient care

• Help the client to learn about other complementary or alternative treatments available
• Plan for a home health nurse to visit the client daily to watch the client perform the relaxation
techniques
• Call to inform the provider that the client most likely needs surgery
Question 3 of 7
A nurse is working with a client who is having sleep difficulties at night. The nurse recommends that
the client keep a sleep diary and write down the times he goes to bed, the times he gets up and how
many times he awakens each night. The nurse can best describe the purpose of keeping a sleep diary
as which of the following?
• Determining the client's type of sleep disorder

• Assisting the client with making up all of his lost sleep
• Helping the client see how to improve his sleep
• Helping the client to discover if he is a morning person
Question 4 of 7
The nurse is caring for a client with generalized anxiety disorder requiring treatment. Which of the
following treatments does the nurse anticipate the client will need? Select all that apply.
• Cognitive behavioral therapy

• BuSpar (buspirone)
• SSRI medications
• Antipsychotic medications
• Psychoanalysis
Question 5 of 7
A client presents to the emergency department with an anxiety attack, stating that he has had
multiple attacks over the last six months. The client is hyperventilating, so the nurse administers a
benzodiazepine to help with the acute attack. The nurse anticipates that the client will begin to take
which of the following medications on a regular basis to help with the anxiety?
• Furosemide
• Famotidine
• Fentanyl
• Fluoxetine
Question 6 of 7
A nurse is caring for a client who is hospitalized in a very busy unit. The client complains to the nurse
that it is too noisy to sleep and that he is not getting rest. Which of the following nursing interventions
is most appropriate to better help this client sleep?
• Help the client to choose foods on the menu that promote sleep, such as broccoli
• Provide instructions to the client about the importance of going to bed and getting up at the
same time every day
• Encourage the client to verbalize his sleep difficulties
• Evaluate for the appropriate timing of client care tasks
Question 7 of 7
A client with anxiety disorder is in a state of panic after becoming injured while outside. The nurse
caring for this client would most likely observe which behaviors? Select all that apply.
• The client needs direction to focus

• The client has a loss of rational thought
• The client is moody
• The client demonstrates fear
• The client is disorganized
Posttraumatic Stress Disorder (PTSD)

Overview
1. A mental illness that results after someone experiences trauma.
Nursing Points
General
1. May relive the trauma, frequently dream about it, or have
flashbacks 2. Traumatic events can range widely:
1. Rape
2. Traumatic accidents
3. Wartime experiences
4. Natural disasters
5. Crime
6. Many more
3. Affects daily functioning
Assessment
1. Sleep issues: insomnia, nightmares
2. Other mental health issues: depression, anxiety
3. Avoidance of triggers
1. For example, if a woman was raped in a bar, she may avoid bars or that
bar
4. Flashbacks
5. Hypervigilance
6. Guilt related to the event

1. If they survived and others did not
2. If they would have done something differently

1. Validate feelings
2. Promote the coping mechanisms that work for them
3. Relaxation techniques
4. Encourage outpatient therapy, support groups
5. Therapy / service animals
6. Help patient to identify their own feelings, response, and the actual precipitating
event
Nursing Concepts
1. Safety
2. Coping
3. Mood Affect
Patient Education
2. Connect with community resources

STUDY TOOLS:
Post-Traumatic Stress Disorder (PTSD)
Pathophysiology
Post-traumatic stress disorder (PTSD) is a condition that develops when a person has been
exposed to a serious situation such as a natural disaster, serious accident, death of a loved one
or life-threatening event. This condition causes debilitating symptoms that, depending on the
severity, can negatively affect relationships, communication, and daily activities. PTSD affects all
ages from childhood to senior adult and symptoms may flare up without any known trigger.
Aside from emotional difficulty, clients may experience physical manifestations such as chronic
pain and headaches and can lead to drinking and drug addictions as well as physical abuse.
Etiology
• Exposure to death, threatened death, serious injury or actual or threatening sexual violence.
Direct exposure (personally witnessed), repeated exposure, or indirect exposure (i.e., first
responders, child victim advocates, law enforcement, etc.)
• Intrusion or persistently re-experienced stressors in at least one of the following ways: recurrent
memories, traumatic nightmares, flashbacks, prolonged distress following traumatic reminders,
significant physical symptoms after exposure to stressors
• Avoidance of distressing trauma-related stressors after the event in at least one way
• Negative alterations in mood and cognitions that began or got worse after the initial event. Must
include 2 of the following: Inability to recall key features of the event, persistent or negative
beliefs, persistent distorted blame, persistent negative emotions, significant lack of interest,
feeling of alienation, inability to experience positive emotions
• Alterations in reactivity since the traumatic event. Must include 2 of the following:
aggressiveness, self-destructive behavior, hypervigilance, exaggerated startle response, difficulty
concentrating, sleep problems
• Duration of symptoms must be greater than one month
• Functional impairment from symptoms
• Attribution – not related to medication, substance use or other medical illness Desired
Outcome
Client will be able to identify triggers. Client will learn and utilize positive coping strategies.
Client will demonstrate control of emotions and relaxation techniques. Client will be free from
injury.
Subjective Data Outcome
• Irritability, easily agitated
• Difficulty sleeping, nightmares
• Lack of interest or pleasure in activities
• Feeling emotionally numb
• Easily startled or frightened

• Mood swings, outbursts of anger
• Difficulty communicating with others
• Impaired relationships
• Loss of memory Objective Data
• Alcohol or drug use since event
• Suicidal or homicidal ideations
• Self-mutilation or self-destructive behavior Nursing Interventions
Assess vitals and perform nursing assessment
RATIONALE
Determine baseline for vitals and assess for underlying or accompanying medical conditions
Assess client for suicidal or homicidal ideations

RATIONALE
To ensure safety of the client and others.
Assess anxiety level

RATIONALE
Determine severity of condition and course of treatment or therapy
Establish trust with the client

• Listen to what the client is saying
• Behave in a calm manner
RATIONALE
Especially when a client has a high level of anxiety, establishing trust can help the client calm
down and make treatment more effective
Provide extra time for care and allow client extra time to respond to questions RATIONALE
Clients often have difficulty communicating due to racing thoughts or inability to concentrate.
Avoid rushing the client and allow them more time to answer or respond to promote security
and instill a sense of value.
Encourage client to express emotions in a safe environment

RATIONALE
Allows the client the freedom to acknowledge their feelings and release any repressed emotions
that may be exacerbating their distress. A safe environment should be free from actual or
perceived judgement and physical or perceived danger.
Encourage client to verbally identify current ineffective coping techniques

RATIONALE
Helps the client understand their current behaviors that may be preventing effective healing or
treatment.
Encourage client to write about the traumatic event

RATIONALE
Allows provider to better understand the nature of the client’s condition and anticipate triggers
that may cause symptoms. Also allows client and provider to periodically review evolution of
emotions toward the traumatic event
Encourage client to keep a journal of stressors and emotional reactions to those stressors
RATIONALE
Helps client identify triggers that prompt anxiety or symptoms and evaluate the outcomes of
those reactions.
Teach visualization and relaxation techniques such as deep breathing and imagery
RATIONALE
Helps client learn to manage anxiety that accompanies flashbacks or environmental stressors
and triggers
Administer medications appropriately and monitor for side effects or dependence

RATIONALE
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors

(SNRIs) are antidepressants that have proven to be effective for chronic management of
symptoms.
Provide calming and reassuring environment

RATIONALE
Clients with PTSD are often fearful. Providing a calm, relaxing environment can help lessen or
relieve anxiety and promote a feeling of safety.
Facilitate access to community resources using Case Manager or Social Worker

RATIONALE
Support groups and other community resources such as service animals, etc., can provide
support that the client needs to function in their daily lives.
References
https://www.professional-counselling.com/support-files/dsm5-ptsd-symptoms.pdf
https://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp
https://adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd
PTSD Pathochart
PATHOPHYSIOLOGY
Post-traumatic stress disorder (PTSD) is a condition that develops when a person has been
exposed to a serious situation such as a natural disaster, serious accident, death of a loved one
or life-threatening event. This condition causes debilitating symptoms that, depending on the
severity, can negatively affect relationships, communication, and daily activities. Clients may
also experience physical manifestations such as chronic pain and headaches.
ASSESSMENT FINDINGS
• Recurrent memories, flashbacks

• Traumatic nightmares
• Prolonged distress following traumatic reminders
• Inability to recall key features of the event
• Persistent distorted blame
• Persistent negative emotions
• Significant lack of interest
• Aggressiveness, self-destructive behavior
• Hypervigilance
• Difficulty concentrating
DIAGNOSTICS
• Exposure to trauma, directly or indirectly
• Intrusion of symptoms after exposure to stressors
• Avoidance of trauma-related stressors after the event
• Negative alterations in mood and cognition
• Alterations in reactivity since the traumatic event.
• Duration of symptoms greater than one month
• Functional impairment from symptoms
• Can’t be attributed to substance use or other illness
NURSING PRIORITIES
• Maintain safety and prevent injury
• Assess and monitor cognition
• Rule out other sources of symptoms
• Assess for suicidal/homicidal ideations

MEDICATION THERAPY
• Antidepressants - SSRI’s and SNRI’s
• Anxiolytics - Benzodiazepines
QUIZ
Question 1 of 7
A client is being seen for care at her primary care clinic. The client tells the nurse that she has difficulty
sleeping because of nightmares. Identify which description best explains the difference between night
terrors and nightmares.
• Night terrors result in the person waking up while nightmares result in the person staying asleep
• Night terrors are frightening but are not remembered by the client, while nightmares can be
easily remembered
• Night terrors cause a person to sleepwalk while nightmares usually result in thrashing in bed
• Night terrors are the sign of a more significant mental illness while nightmares are considered
benign
Question 2 of 7
A 46-year-old client is experiencing symptoms of post-traumatic stress disorder after being involved in
a traumatic accident. The client has symptoms of nightmares and flashbacks about the event. The
nurse knows that these symptoms most likely develop because of which of the following?
• The client may have a hyperactive amygdala that leads to an increase in feelings of fear
• The client is no longer able to regulate levels of serotonin
• The client's pituitary gland works in overdrive and consistently causes flashbacks
• The body secretes too much melatonin, which leads to an increase in nightmares
Question 3 of 7
A 29-year-old client suffered a subarachnoid hemorrhage 4 months ago and has now been diagnosed
with post-traumatic stress disorder (PTSD). Based on this diagnosis, the nurse knows that the client
would most likely demonstrate which of the following symptoms?
• Fatigue, increased sleep needs, and weight gain

• Upset stomach, constipation, and difficulties eating

• Increased sensory perceptions
• Nightmares, avoidance, and numbing
Question 4 of 7
A nurse is caring for a 40-year-old client with post-traumatic stress disorder following a severe injury
last year. The client requires a morning dose of an antidepressant medication and is scheduled for
EMDR therapy in 2 hours. The provider has been in to see the client for the day and has also left new
orders. Which task can the nurse delegate to the nursing assistant who is helping her?
• Administering the antidepressant

• Checking the provider's orders in the chart
• Serving the client breakfast to eat with the medication
• Performing the EMDR with the client
Question 5 of 7
A client was recently treated for sepsis and may have developed post-sepsis PTSD. Which information
is accurate for the nurse to give the client about how this condition is treated?
• Post-sepsis PTSD often goes away over time, so the client should wait for symptoms to resolve
• Post-sepsis PTSD can be managed through counseling or cognitive behavioral therapy
• Exposure therapy is the most reliable form of treatment for PTSD
• The client should utilize motivational interviewing to best manage his PTSD symptoms
Question 6 of 7
A client is experiencing stress response syndrome after losing his job where he had worked for 21
years. What describes the difference between stress response syndrome and clinical depression?
• Stress response syndrome typically lasts for months to years, while clinical depression may last
for several weeks
• Stress response syndrome often appears after a life-threatening event, while clinical depression
appears after a life-changing event
• Stress response syndrome involves an increase in pulse, blood pressure and breathing rate,
while clinical depression involves a decrease in these vital signs
• Stress response syndrome causes hopelessness and loss of interest in activities, but not suicidal
ideation such as with clinical depression
Question 7 of 7
A 6-year-old child has been brought in for care and treatment after suffering from physical abuse by
her father. The child is experiencing a post-traumatic fight-or-flight response. Which signs or
symptoms would the nurse most likely expect to initially see in this client?
• Stuttering and refusal to respond to caregivers

• Crying and screaming
• Somnolence
• Dissociation
Somatoform
Overview
1. Physical symptoms, worry, and complaints with no organic physiological explanation
2. Many patients will also have issues with anxiety
3. Secondary gain is noted from varying physical issues

Nursing Points
General
1. May use one of these disorders unconsciously for more attention and less
responsibilities
2. Somatoform disorders are closely related to anxiety

1. Example: anxiety is dealt with/expressed via one of these disorders
Assessment
1. Conversion disorder: serious neuro symptoms with no physical cause
1. Blindness
2. Hearing loss
3. Numbness or loss of sensation
4. Paralysis
2. Hypochondriasis: minor symptoms = major disease in their mind
1. Headache = brain tumor
2. Breast pain = breast cancer

3. Somatization disorder: many medical problems from various body systems at early age
1. Denial of possible psychological cause or emotional problems
2. Reports varying issues with pain

1. Acknowledge that symptoms/experiences are very real to the patient
2. Allow structured time to express physical problems but don’t continually talk about it.
3. Set boundaries and redirect when discussion becomes excessive.

1. However, don’t cut them off or stop them each time they talk about them
either
2. Find the balance between allowing them to feel like they’re being heard or
getting them too wrapped up in it
4. Try not to provide positive reinforcement when they are discussing their physiological
symptoms
Nursing Concepts
1. Mood Affect
2. Coping
STUDY TOOLS:
Somatic Symptom Disorder (SSD)
Pathophysiology
Somatic Symptom Disorder (SSD), previously known as somatoform disorder, is a mental illness
that causes unexplained physical symptoms such as pain that are distressing or disrupt the
client’s normal functioning. When no physical cause for their symptoms can be found, clients
often become upset and experience even more symptoms, or the symptoms may change. While
there may be no explanation for the symptoms, the distress that the client feels are very real.
These are the conditions that make up SSD:
• Somatization disorder – involves physical symptoms in multiple systems
• Conversion disorder – voluntary motor or sensory function symptoms
• Pain disorder – pain with a strong psychological involvement
• Body dysmorphic disorder -client is preoccupied with a real or imagined physical defect
• Hypochondriasis – fear of having a life-threatening illness
Etiology
The diagnosis is made based on the amount of distress the client experiences.
• Symptoms must be distressing or cause a disruption in the client’s daily life
• Excessive thoughts, feelings or behaviors are exhibited by at least one of the following:
• Disproportionate and ongoing thoughts about the seriousness of the symptoms
• Ongoing high level of anxiety about the client’s general health or their symptoms
• Excessive time and energy are spent on the symptoms or health concern
• At least one symptom is constantly present for more than six months; other symptoms may
come and go
Desired Outcome
Client’s pain will be managed; client will have optimal control of recognizing and
managing symptoms related to psychological factors; client will have improved
independence and functioning of daily activities Subjective Data Outcome
• Pain
• Fatigue
• Shortness of breath
• Nausea
• Chest pain
• Vision problems
• Amnesia
• Food intolerance
• Sexual dysfunction
• Headaches
• Anxiety
• Dysphagia Objective Data
• Unremarkable imaging (X-ray, CT, MRI, ultrasound)
• Lab tests are WNL
• Vomiting
• Paralysis
Perform complete nursing assessment with vital signs
RATIONALE
Get baseline information and determine if there is a physical or explained cause of symptoms.
Perform neurological assessment daily or per facility protocol

RATIONALE
Determine if client is having other neurological symptoms that may help determine treatment
options.
Assess if client is having suicidal or homicidal ideations or potential substance abuse

RATIONALE
Maintain client’s safety and the safety of others
Assess pain per appropriate scale

RATIONALE
Pain is subjective and must be managed according to what the client feels and reports.
Provide accommodation for client and make them more comfortable (ie., pillows, temperature,
positioning, etc.)
RATIONALE
This can help client feel accepted and develop rapport and trust. This can allow the client to feel
more comfortable and express their feelings and emotions more readily to the healthcare team.
Encourage behavior modification such as praising client and offering more attention when
symptoms improve
RATIONALE
Change the focus from what’s wrong to what’s right. Helps client feel accomplished and more
positive about improvements in health condition instead of focusing on the symptoms.
Provide teaching and demonstrations of relaxation techniques including progressive muscle

relaxation and deep breathing exercises
RATIONALE
This can help relieve acute pain and distress that the client may feel, but also helps them learn
to control many symptoms through focus and calming the mind.
Provide education about feared or actual medical condition

RATIONALE
Helps client understand the condition in a more realistic light and helps alleviate fear and
anxiety about a particular health concern.
Administer medications and decrease dosage as appropriate

• Pain relievers / analgesics
• Antidepressants
• Anti-anxiety medications
• Antiemetics
RATIONALE
Perceived pain and symptoms are to be treated appropriately, but as circumstance allows,
decrease medication, and continue offering praise for improvement of symptoms to encourage
continuing positivity.
Discuss symptoms with client and when they began, what makes them better or worse and how
they have been managing these symptoms
RATIONALE
This helps make a more definitive diagnosis and help determine how to best treat client. Helping
the client determine the etiology of symptoms helps them to recognize and avoid situations that
make symptoms worse.
Encourage client to keep a journal of symptoms and the events or factors that lead up to the
development of symptoms and their resolution
RATIONALE
This is a technique of cognitive behavior therapy that helps the client understand what factors
(usually stress) that prompt the onset of symptoms. It can also help the client determine a
pattern of emotions surrounding the symptoms.
Encourage client to involve family members in their care.

Discuss signs and symptoms and what triggers those symptoms
RATIONALE
Help the family to be aware and understand the reality of the client’s condition. This can be
helpful in long-term management if client’s family is willing to provide realistic feedback and
support.
References
https://www.aafp.org/afp/2007/1101/p1333.html
https://www.psychiatry.org/patients-families/somatic-symptom-disorder/what-is-somaticsymptom-disorder
https://medlineplus.gov/ency/article/000955.htm
QUIZ
Question 1 of 1
A client on the mental health unit has been diagnosed with cancer and is displaying a lack of healthy
coping mechanisms to deal with this diagnosis. The client is unable to make any decisions for herself
and has developed headaches and fatigue. Which of the following nursing interventions is most
appropriate for this client?
• Provide a book for the client that comprehensively describes ineffective coping
• Encourage the client to continue to make decisions, even when she is significantly stressed
• Help the client to get enough rest and to eat a healthy diet
• Point out the areas where the client is not taking care of herself
Dissociative Disorders
Overview
1. Disorders in which conscious awareness becomes separated from previous thoughts,
memories or feelings
1. There is an interruption in conscious awareness
2. Conscious awareness becomes disassociated from the past
3. Can result in sudden loss of memory or change in identity

Nursing Points
General
1. Extreme coping mechanism for an extremely traumatic event
2. We all experience a degree of this; like driving and forgetting how you got there – but
this is an extreme form of coping
3. RARE
Assessment
1. Types
1. Dissociative identity disorder (DID) – 2+ personalities
2. Dissociative amnesia – unable to remember important info due to anxiety
3. Dissociative fugue – entirely new identity
4. Depersonalization disorder – episodes of depersonalization

1. Feeling like outside of own body
2. Doesn’t recognize own reflection
3. Feeling like in a foggy, dreamlike world

1. Develop trust with patient
2. Ensure safety
3. Orient patient to reality
4. Explore feelings, concerns, painful experiences with patient and identify the conflict
5. Focus on their strengths and skills
6. Provide simple tasks that are easy to complete

7. Do not rush patient through process
8. Stress reduction techniques
9. Healthy coping mechanisms
10. Promote compliance and importance of continued therapy

Nursing Concepts
1. Safety
2. Mood Affect
3. Coping
Patient Education
1. Stress reduction techniques
3. Reality orientation strategies

STUDY TOOLS:
Dissociative Disorders
Pathophysiology
Dissociative disorders are the common result of many traumatic or stressful situations and
often develop as a way of avoiding difficult memories. Some clients report a feeling of being
outside of the body or watching their life from a distance. Others experience a memory gap and
present with various identities. People who have experienced physical, sexual, or emotional
abuse during childhood are at a higher risk of developing dissociative disorders.
Dissociative Dissociative Depersonalization Other Specified

Amnesia Identity Disorder – Derealization Dissociative Disorder
Disorder
(formerly DD-NOS)
• Localized/ • Two or • “Out of body

selective more experience e” • Recurrent
amnesia distinct • Surroundings episodes
• Significant identities may seem • Client
distress or • Recurrent foggy or experienced
functional gaps in dreamlike traumatic
impairment memory . coercive
• Bewildered • Behaviors • Reality testing persuasion
wandering are outside remains intact (brainwashing,
“normal” torture, long-
cultural or term
religious imprisonment)
practices
• Symptoms are
brief
• Trance-like
state or
unresponsive
to stimuli
These clients may also be more likely to attempt suicide or self-destructive behaviors.
Etiology
See chart below for specific diagnostic criteria for each disorder according to the DSM-V. These
symptoms are not due to substance use / abuse or another medical condition and cannot be
better explained by another mental disorder.
Desired Outcome
Client will remain safe; client will have optimal functioning during social and daily routine
activities; client will identify stressors and triggers for dissociative behaviors or reactions
• Memory loss
• Feeling of being detached
• Feeling of surroundings being foggy or dreamlike
• Inability to cope with emotional or social stress
• Suicidal thoughts
• Depression
Objective Data
• Anxiety
• Distant or reclusive behavior
• Erratic or chaotic behavior
• Unresponsiveness to environmental stimuli (sound, smell, temperature, etc.)
Perform complete nursing and neurological assessment. Note any signs of self-mutilation or
previous suicide attempts
RATIONALE
Get a baseline of data and help determine neurological status. Also rules out underlying
physiological cause of symptoms.
Assess for any suicidal or homicidal ideations

RATIONALE
To provide for client safety and the safety of others
Set limits for inappropriate behaviors

RATIONALE
Clients may act chaotic or erratic. Setting limits and consistently maintaining boundaries
reinforces routine and reality.
Provide care with calm and positive, respectful attitude

RATIONALE
Negativity or hostility can trigger hostile reactions or manipulative behaviors.
Gaining the client’s respect and trust helps facilitate care.
Encourage client to talk about their life, their past and their interests
RATIONALE
Helps identify specific areas of avoidance or infatuation that may pose as stress triggers for
behaviors
Provide support and encouragement during recollection of past traumatic experiences

RATIONALE
Build rapport and trust to help the client work through the difficult emotions and circumstances
that they may have been avoiding
Administer medications as needed appropriately

RATIONALE
While there are no medications for these specific disorders, many clients have other mental
illnesses or conditions that exacerbate symptoms such as depression and anxiety. Some
medications may be used for chaotic or erratic behaviors and are given on a PRN basis.
Provide teaching to family members and encourage their support in dealing with client’s
symptoms RATIONALE
Clients often feel isolated in regard to their past experiences. Incorporating a family support
system helps the progression and effectiveness of treatment
Provide appropriate, temporary use of restraints or lock-down facilities as necessary

RATIONALE
Keep clients safe from harm during gaps or changes in personalities. Prevent clients from
wandering into dangerous areas.
Monitor skin integrity when using restraints or for clients with suicidal ideations RATIONALE
Clients may develop self-destructive behaviors during treatment.
Improper or extended use of restraints can cause skin breakdown.
Provide resource information for continued long-term psychotherapy and counseling

RATIONALE
Help client with long-term treatment and give information to help client continue managing
symptoms.
References
https://information.pods-online.org.uk/what-are-the-diagnostic-criteria-for-the-dissociativedisorders/
https://psychcentral.com/disorders/dissociative-identity-disorder/in-depth/
https://www.psychiatry.org/patients-families/dissociative-disorders/what-are-dissociativedisorders
Dissociative Disorder Pathochart

PATHOPHYSIOLOGY
Dissociative disorders are the common result of many traumatic or stressful situations and
often develop as a way of avoiding difficult memories. Some clients report a feeling of being
outside of the body or watching their life from a distance. Others experience a memory gap and
present with various identities. People who have experienced physical, sexual, or emotional
abuse during childhood are at a higher risk of developing dissociative disorders.
These clients may also be more likely to attempt suicide or self-destructive behaviors.
ASSESSMENT FINDINGS
• Memory loss
• Feeling of being detached
• Surroundings feel foggy or dreamlike
• Distant or reclusive behavior
• Erratic or chaotic behavior
• Inability to cope with stress
• Suicidal thoughts
• Depression or Anxiety
DIAGNOSTICS
• Dissociative Identity Disorder
Two or more distinct identities
Recurrent gaps in memory
Behaviors are outside “normal” practices
• Depersonalization Disorder
“Out of body experience”
Surroundings may seem foggy or dreamlike.
Reality testing remains intact

NURSING PRIORITIES
• Set limits and boundaries
• Encourage expression
• Provide resources for coping strategies
MEDICATION THERAPY
• No routine medications
• PRN - antipsychotics, anxiolytics
QUIZ
Question 1 of 1
A nurse is caring for a client who is displaying symptoms of dissociative identity disorder (DID). Which
of the following is an appropriate intervention for DID? Select all that apply.
• Exploring methods of coping

• Focus on strengths and abilities
• Provide nondemanding, simple routines
• Plan for psychotherapy
• Encourage changes in lifestyle habits
Mood Disorders (Bipolar)

Overview
1. What’s a mood? Emotional states that are subjective and difficult to define / long term
emotional states
Nursing Points
General
1. Mood disorders: emotional extremes and challenges in regulating mood (think long-
term)
2. Bipolar disorder and depressive disorders

Assessment
1. Bipolar includes periods of mania and depression with normal periods in between
1. Extremely high highs
2. Extremely low lows
3. Inability to self-regulate
2. Mania definition: a mood disorder marked by hyperactive, wildly optimistic state
3. Depression: Module 02.07… 5+ depressive symptoms for 2+ weeks

1. Goals are to manage acute episodes, provide support and resources for long-term
management
2. Meds
1. Anti-anxiety meds used during manic episodes; use caution with patients
who
have a history of substance abuse
2. Antipsychotics: Zyprexa, Abilify, Risperdal (due to sedative and mood
stabilizing)
3. Mood stabilizer
1. Lithium
1. Regular labs to check therapeutic level
2. Toxicity can result if stable sodium intake and fluid

intake (2-3L/day) is not maintained
4. Depakote, Lamictal, Tegretol also given for patients with mood disorders
3. Interventions for Mania
1. Make sure environment is safe
2. Reorient as necessary
3. Promote appropriate sleep/wake cycles
4. Controlled, calm, focused interactions
5. Don’t argue!
6. High-calorie finger foods
7. Promote appropriate clothing choices
8. Set boundaries related to behaviors
9. Watch for dangerous hyperactivity
10. Ensure medication compliance
11. One on one, sedentary activity
12. Promote gross motor activities

Nursing Concepts
1. Safety
2. Mood Affect
3. Coping
Patient Education
1. Identify and avoid triggers for mania (there are not always triggers, sometimes it’s
spontaneous)
2. Report signs of hyperactivity / mania

STUDY TOOLS:
Mood Disorders (Major Depressive Disorder, Bipolar Disorder)
Pathophysiology
Mood disorders are a category of mental illnesses that affect a person’s emotional state over a
long period of time. Emotions, or moods, may fluctuate frequently and seemingly without any
reason. The most common of these are Major Depressive Disorder and Bipolar
Disorder. Depression may be a common feature of other mental illnesses but can occur
independently as well. Clients with mood disorders are at higher risk for substance abuse and
suicidal tendencies. Research has shown that there is a high incidence of depression among
clients that also have chronic medical conditions such as heart disease, cancer, Alzheimer’s
disease and hypertension. Treatment is geared toward managing symptoms using medications
and psychotherapy.
Etiology
Diagnoses do not include symptoms related to other medical conditions or substance use, does
not meet the criteria for another mental illness or psychotic disorder. Major Depressive
Disorder (MDD):
• Five or more of the following new symptoms present in the same 2-week period.
o Depressed mood, most days o Loss of interest or pleasure in
most activities’ o Significant weight loss or weight gain o
Insomnia or hypersomnia, most days o Slow or aggravated
psychomotor function o Fatigue or loss of energy, most days o
Feelings of worthlessness or inappropriate guilt, most days o
Inability to think or concentrate, indecisiveness, most days o
Recurrent thoughts of death, without a specific plan or attempt
• Symptoms significantly affect social or occupational functioning
• Never had a manic or hypomanic episode
Bipolar Disorder (BPD):

• One or more manic episodes; or one hypomanic and one major depressive episode
• Distinct period of abnormally elevated mood lasting more than 1 week
• More than 3 of the following occur during mood disturbance o Inflated self-esteem o
Decreased need for sleep o Racing thoughts o Easily distracted o Increased
activity o Excess risky or pleasurable activity
Desired Outcome
Client will remain safe. Client will not cause harm to self or others. Client will demonstrate
coping techniques. Client will identify appropriate actions for managing emotions. Subjective
Data Outcome
• Prolonged sadness
• Change in appetite
• Change in sleep patterns
• Irritability
• Feelings of guilt
• Inability to concentrate
• Inability to feel pleasure in former interests
• Suicidal ideations
• Grandiose delusions
• Unexplained aches and pains
• Increased fatigue (MDD)
• Decreased need for rest (BPD)
• Significant mood swings Objective Data
• Pessimism
• Reckless behavior
• Easily distracted
• Racing speech
• Tearfulness
• Restlessness
Assess for level of suicide precautions necessary
• Verbalizes desire to commit suicide
• Has a suicide plan
• Previous / recent suicide attempts
RATIONALE
Determine if client is an active risk to self or others and what safety precautions need to be
initiated. Always ask if there is a specific plan.
Initiate suicide precautions as necessary per facility protocol

• Do not leave client unattended
• Remove unnecessary items from room that may be used as a weapon (sharp instruments, belts,
etc.)
RATIONALE
Provide for the safety of client and others. Follow your facility’s specific protocol regarding
supervision and documentation.
Implement a written “no-suicide” contract with client

RATIONALE
Clients who agree to a written contract are often less likely to carry out a suicide plan. It shows
the client that they have value.
Obtain history from client or family members regarding any current or a history of substance
abuse. Labs may be necessary.
RATIONALE
Determine if client’s symptoms are caused by or exacerbated by use of drugs or alcohol.
Remove client valuables and send home with trusted family member or lock in facility safe.
RATIONALE
Clients experiencing suicidal behaviors or manic episodes may give away valuables or money
indiscriminately and may become victims of theft.
Encourage client to talk about feelings and emotions

RATIONALE
Helps client verbalize and identify the cause of their actions. Builds trust and rapport.
Provide activities that do not require concentration or competition (drawing, walking, exercise,
music, etc.)
RATIONALE
Clients who are depressed have difficulty concentrating. Allows client time to calm down.
Competition (games) can cause aggression – no card games except solitaire.
Provide calm, relaxing environment

RATIONALE
Overstimulation during manic episodes may cause an exacerbation of symptoms
Teach client visualization techniques that replace negative images with positive images
RATIONALE
Help improve client’s self-image and confidence
Minimize environmental stimuli

• Close blinds/curtains
• Keep door closed to reduce noise
• Limit visitors
• Cluster care
RATIONALE
Reduce chance of overstimulation to minimize aggression or agitation.
Observe for destructive or manipulative behaviors

RATIONALE
Clients experiencing mania often have poor impulse control and may become hostile.
Offer and arrange religious counseling as appropriate per client preference and facility protocol
RATIONALE
Religious services may be offered but are not required. Clients often have deep cultural or
religious views and may benefit from these services.
Encourage bedtime routine that may include warm bath, soothing music, and lack of
stimulation. Avoid caffeine.
RATIONALE
Promote healthy sleep hygiene and encourages rest and relaxation which can decrease mania
and improve mood.
Assist with ADLs by giving short, one-step instructions

RATIONALE
Promotes independence while minimizing the stress of complex instructions. Clients often have
difficulty concentrating, so using one-step directions is important.
Administer medications appropriately

RATIONALE
Antidepressants and antimanic medications may be given to improve client functioning and
effectiveness of interventions.
• Antidepressants – SSRI’s, SNRI’s, MAOI’s, TCA’s
• Anti-manic – Haloperidol, Benzodiazepines, Lithium
References
https://online.epocrates.com/diseases/48836/Bipolar-disorder-in-adults/Diagnostic-Criteria
https://images.pearsonclinical.com/images/assets/basc-
3/basc3resources/DSM5_DiagnosticCriteria_MajorDepressiveDisorder.pdf
http://www.mentalhealthamerica.net/conditions/mood-disorders
Manic Attack – Signs and Symptoms

DIG FAST
• D-Distractibility
• I-Indiscretion
• G-Grandiosity
• F-Flight of Ideas
• A-Activity Increase
• S-Sleep Deficit
• T-Talkative
The above signs would be indicative of a patient experiencing a manic episode. A manic episode
is a state in which the patient experiences abnormally elevated mood, typically lasting at least
one week. Think of a dog 'manically' digging for a bone.
Bipolar Disorder Pathochart

PATHOPHYSIOLOGY
Bipolar Disorder is classified as a Mood Disorder. Mood disorders are a category of mental
illnesses that affect a person’s emotional state over a long period of time. Emotions, or moods,
may fluctuate frequently and seemingly without any reason. Clients with mood disorders are at
higher risk for substance abuse and suicidal tendencies. Treatment is geared toward managing
symptoms using medications and psychotherapy.
ASSESSMENT FINDINGS
• Inflated self-esteem
• Decreased need for sleep
• Racing thoughts
• Easily distracted
• Increased activity
• Excess risky or pleasurable activity

DIAGNOSTICS
• One or more manic episodes
• One hypomanic and one major depressive episode
• Distinct period of abnormally elevated mood lasting more than 1 week
• More than 3 symptoms occur during this mood disturbance NURSING

PRIORITIES
• Assess and monitor emotional status

• Set limits and boundaries
• Encourage expression
• Provide non-competitive activities
• Minimize environmental stimuli

MEDICATION THERAPY
• Antidepressants - SSRI’s, SNRI’s, MAOI’s, TCA’s
• Anti-manic - Haloperidol, Benzodiazepines, Lithium
QUIZ
Question 1 of 10
A 44-year-old client is being seen for symptoms of bipolar disorder. After talking with the client, the
provider has determined that the client should start taking medication. The client says to the nurse,
“How do you know for sure? Isn’t there a lab test that will tell you if I have this condition?” Which
response from the nurse is accurate?
• There is no lab test that will identify whether you have bipolar disorder. The diagnosis is based
on the provider's assessment
• We could perform laboratory testing, but the provider has been able to diagnose you based on
your behavior
• The lab test you need will actually measure neurotransmitter levels in your blood, which will
help us pinpoint how much medication to prescribe
• You do not need lab testing. We can prescribe medication without an actual laboratory diagnosis
of bipolar disorder
Question 2 of 10
A nurse is caring for a client with bipolar disorder. The client has been taking antidepressants for
depression but is most recently in a manic state and for the past three days has not been sleeping or
eating. Which of the following questions from the nurse is correct in this assessment?
• Did you stop taking your antidepressants? If so, let's talk about why you did this.
• Have you been drinking alcohol?
• Are you still taking your mood stabilizing drugs?
• What non-prescription medications are you taking?
Question 3 of 10
A client with a history of bipolar disorder has been brought in to the hospital because the client was
running through a neighborhood without any clothes on. Which of the following is evidence that the
client is voluntarily willing to be admitted to the hospital? Select all that apply.
• The client is not a danger to himself or others

• The situation is an emergency
• The client agrees to follow orders
• The client states that he is willing to follow the regimen of the facility • The client has a court
order
Question 4 of 10
A nurse is caring for a client who has been diagnosed with bipolar disorder, type I. Which best
describes the difference between bipolar type I and type II?
• Bipolar I am associated with alternating mania and depression, while bipolar II is a continuous
state of hypomania
• Bipolar I lead to extreme depression, while bipolar II causes more subdued depression
• Bipolar I am associated with alternating mania and depression, while bipolar II is associated with
hypomania and depression
• Bipolar I describe mania or the high feeling of the disease, while bipolar II describes the
depressed state
Question 5 of 10
A public health nurse is caring for a client in a psychiatric facility who has a diagnosis of bipolar
disorder. Which best demonstrates that the nurse is acting as a liaison to coordinate this client’s plan
of care?
• The nurse asks the client's family if the client can stay with them after discharge
• The nurse contacts a social worker about follow-up care after the client is discharged
• The nurse tells the client to participate in group therapy while in the hospital
• The nurse arranges a payment plan for the client to cover the costs of medical care
Question 6 of 10
A client is undergoing behavioral therapy through counseling for manic behaviors exhibited during
episodes of bipolar disorder. Which best describes how cognitive-behavioral therapy is used as
treatment for a client with bipolar disorder?
• The client initiates a 12-step program to incorporate a change-through-leading approach

• The client studies a book about thoughts vs. behavior and implements the ideas
• The client meets with a group to discuss thoughts and feelings
• The client works at changing personal thoughts to impact actions
Question 7 of 10
A client is undergoing a clinical interview as part of diagnostic testing for bipolar disorder. Which best
describes why a clinical interview would be conducted?
• To measure the client's IQ level

• To test the client's memory function
• To assess the client's psychiatric and family background
• To determine how much the client perceives and cognitively understands
Question 8 of 10
A client who has been diagnosed with bipolar disorder is seeking treatment during the manic phase of
illness. Based on the nurse’s knowledge of this mental state, the nurse understands that which of the
following is likely during this phase?
• The client is at risk of suicide during the manic phase

• The client is more likely to develop chronic illnesses, including lung disease and obesity
• The client is at risk of destructive behaviors because of her manic mood • The client is not at
high risk and her safety is not threatened
Question 9 of 10
A nurse is caring for a client with bipolar disorder who is frequently manic. What describes the most
appropriate psychotherapy for a client with this condition? Select all that apply.
• Interpersonal and social rhythm therapy

• 12-step programs
• Electroconvulsive therapy
• Cognitive-behavior therapy
• Family focused therapy
Question 10 of 10
Which of the following are potential nursing interventions for a client with bipolar disorder? Select all
that apply.
• Put client valuables in a safe place

• Assess for suicide risk
• Give detailed step-by-step instructions for ADLs
• Encourage a daily routine
• Minimize environmental stimuli
Depression
Overview
1. Definition: state of low mood and aversion to activity that can affect a person’s
thoughts,
behaviors, feelings, and sense of wellbeing
Nursing Points
General
1. Can be mild, moderate, severe
1. Mild: 2 weeks or less
2. Moderate: more persistent, negative thinking and suicidal thoughts may

occur
3. Severe: intense and pervasive, may include delusions and hallucinations

Assessment
1. Some combination of the following symptoms may be present, especially in Major
Depressive Disorder
1. Depressed mood most of the day,
2. Diminished interest or pleasure in activities
3. Significant unintentional weight loss
4. Insomnia or hypersomnia
5. Psychomotor agitation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Difficulty concentrating or making decisions
9. Recurrent thoughts of death or suicide, with or without a plan
10. Low self-esteem
11. Feelings of hopelessness
12. Poor appetite or overeating

2. The symptoms cause clinically significant distress or impairment in social, occupational,
or
other important areas of functioning
1. #1 priority is assessing the risk for self-harm: “Have you had any thoughts of hurting
yourself?”
1. If they say yes, “Do you have a plan?”
2. One-on-one observation may be necessary

2. Ensure a safe environment
1. Removing anything from their room that they could potentially use to harm
themselves
3. Promote appropriate oral intake – focus on higher calorie foods frequently
1. They may go long periods without eating so maximize intake when they actually
do eat.
2. Hydrate!
4. May need reminding/encouragement to maintain basic personal
hygiene (ADL’s)
5. Encourage expression of feelings
6. Focus on their strengths
7. Validate their feelings of loss/frustration/sadness
8. Promote spending time with them to show them they are a priority
to you 9. Engage in activity
1. One-on-one situations, eventually progressing to group
discussions
2. Start with gross motor activities
3. Suggest activities that are easy to complete, non-competitive,

that offer a sense of accomplishment when complete (coloring,
drawing, playing cards, easy games)
10. Promote appropriate sleep-wake cycles
Nursing Concepts
1. Safety
2. Mood Affect
3. Coping
Patient Education
1. Patients should be encouraged to recognize their symptoms for what they
are – this helps
reduce feelings of guilt
2. Encourage the use of professional counseling or therapy

STUDY TOOLS:
Depression Assessment
SIGNS
• S-Sleep Disturbances
• I-Interest Decreased
• G-Guilty Feelings
• N-No Energy
• S-Sadness (Crying spells)
Monitor for these SIGNS in patients that may be at risk for depression.
QUIZ
Question 1 of 10
A 30-year-old client has been diagnosed with major depressive disorder. Which nutrition guideline
should the nurse give to this client that could help with some symptoms of depression?
• Some free radicals in the diet combat harmful antioxidants

• The client should increase carbohydrate intake and limit fats
• The best diet for depression is the Western diet
• Fluids such as water and sugar-free juice are preferred over caffeinated beverages
Question 2 of 10
A nurse is caring for a client who was diagnosed with depression and anxiety three years ago. The
client currently has prescriptions for four different medications for control of symptoms. Which
nursing intervention is most appropriate to reduce the risks associated with taking many different
medications in this situation?
• Have the client contact the provider and ask to be changed to an all-in-one drug instead of
taking 4 different kinds
• Tell the client that he should never take over-the-counter medications when using this many
prescriptions drugs
• Make an appointment for the client to meet with a dietitian to discuss the nutritional effects of
taking this many drugs
• Help the client to organize the medications and make a list of their uses and side effects
Question 3 of 10
A nurse is counseling a client who has been diagnosed with depression to attend a support group as
part of treatment. Which best describes how the nurse would explain what to expect for the client?
• A small group where the client will have to facilitate the discussion between members
• A large group of up to 50 people meeting and mingling together
• A presentation where group members watch an audiovisual demonstration
• A small group where the client may need to talk about his or her mental health issues
Question 4 of 10
A nurse is caring for a client has undergone ECT for the treatment of severe depression and has
developed some complications afterward. Which of the following is a physical side effect that has
been associated with ECT?
• Muscle soreness
• Bradycardia
• Peripheral edema
• Rash on the face and trunk
Question 5 of 10
A client in the psychiatric unit has been diagnosed with severe, intractable depression and is preparing
to undergo electroconvulsive therapy (ECT). Which best describes the role of the nurse during ECT?
Select all that apply.
• Prepare the client for applying EEG leads to the head

• Administer oxygen as needed
• Record the length of time of the client’s seizure
• Note the location of resuscitative equipment on the nursing unit in case of need
• Notify the provider immediately if the client is confused following the procedure
Question 6 of 10
A nurse is assisting a client who has undergone electroconvulsive therapy for treatment of severe
depression. Following the procedure, the client develops postictal agitation. Based on the nurse’s
knowledge of this condition, the nurse would expect to see which of the following?
• Limb contractures
• Incoherence, disorientation, and motor restlessness
• Hyperactivity and mania
• Coma
Question 7 of 10
A nurse is working with a client who suffers from depression. The client has started taking
medications and is engaged in group therapy, but still tells the nurse, “I do not like myself. I am
annoying, even to me.” Which activities can the nurse suggest that would most likely increase this
client’s self-concept? Select all that apply.
• Ask if the client has any friends

• Teach the client how to be mindful of negative thoughts
• Remind the client not to compare self to others
• Have the client recognize personal strengths
• List three things that the nurse likes about the client
Question 8 of 10
A client who has developed depression after experiencing chronic back pain is being seen at the acute
care clinic. Which best describes how the nurse would demonstrate psychoeducation when working
with this client?
• Helping the client to find a support group for people who suffer from back pain
• Providing information to the client about an upcoming research study based on the effects of
pain and depression
• Administering medications that will relieve some of the back pain
• Teaching the client about the effects of their mental health issue so it can be better managed
Question 9 of 10
An 11-year-old boy has been diagnosed with depression after his parents’ divorce. The nurse
understands that depression in children of this age most commonly manifests as:
• Whining
• Low self esteem
• Pouting
• Poor blood glucose control
Question 10 of 10
A nurse is performing depression screenings in the community. Which question would most likely be
included in this screening?
• Have you been having trouble sleeping?

• Are you trying to lose weight?
• Do you hear voices or have hallucinations?
• Do you believe that others are talking or thinking about you?
Schizophrenia
Overview
1. A long term mental disorder characterized by abnormal social behavior, disturbances in
mood, thought processes, behavior, affect.
Nursing Points
General
1. To be diagnosed, they need to have 2 of the following:
1. Negative symptoms: SUBTRACTS things.
1. Decrease in emotional range
2. Loss of interest/drive in life
3. Loss of inertia (tendency to do nothing or remain unchanged)

2. Positive symptoms: ADDS things.
1. Hallucinations
2. Delusions
3. Disorganized speech
4. Bizarre behavior
Assessment
1.
1. Delusions
1. Definition: false belief firmly held to be true, despite rational
argument. They are real to the patient, but they are not real.
2. Note: there are MANY more kinds, these are the ones you’re
most likely going to be tested on
1. Persecution: being singled out to be harmed by

others
2. Jealousy: belief that spouse or love interest is being
unfaithful despite being able to back up claims
3. Grandeur: belief that they are a very powerful or

important in the world
2. Hallucinations
1. Definition: patient is experiencing external stimuli, but they don’t

have an organic cause. They are real to the patient, but they are not
real.
2. One for each of the 5 senses:

1. Auditory
2. Olfactory
3. Tactile
4. Visual
5. Gustatory
1. Delusions
1. Ensure safety of the environment
2. Ask patient to describe the delusion so you know what they’re experiencing
1. Validate any real aspects of the delusion
3. Don’t argue
4. Reflect on how it makes them feel to make sure you connect with them
1. “Ok, so I hear that you’re feeling this way…”
5. Focus on the feelings the delusion creates, not the delusion itself
6. Focus on reality; don’t get stuck in talking about the delusion
7. Be upfront and honest with them so they don’t become paranoid or suspicious of you
8. Set limits if they are obsessing about it
2. Hallucinations
1. Ensure safety of environment
2. Monitor them so you are aware when they start experiencing hallucinations
3. Be direct about them, don’t tiptoe around the topic

1. “Are you experiencing a hallucination? What are you seeing?
hearing, feeling?”
2. Ensure safety by assessing if there is an auditory or visual hallucination telling patient to

harm self or others
4. Validate feelings but stay in reality
5. Don’t perpetuate the hallucinations
6. When patient does talk about real things, respond to those things
7. Don’t bring yourself or others into the hallucination

1. “Oh, you’re smelling burnt rubber? I do too, I wonder if others do,
too”
8. Try to engage in one-on-one interaction
9. Decrease stimuli
10. Don’t touch them or increase stimuli
11. Do not joke about the hallucinations
12. Monitor for worsening symptoms (increasing fear, anxiety)
13. Given PRN meds when appropriate

3. Other Interventions
1. Always ensure safety (monitor for self-harm/suicide)
2. Assess and address their physical needs
3. Be genuine; don’t be overly interested/warm or make promises you can’t follow through on
4. Communicate about basic things (when you don’t understand, when you need to end the
conversation, reorienting to reality). Silence may be required; be okay with just sitting and being
quiet.
5. Be present: don’t have calculated responses, try to read the scenario, and respond appropriately.
1. If they seem frightened, stay with them, and

reassure them that
they are safe.
2. If they need someone to be with them but don’t

want to talk, silently sit with them.
6. Make sure their behavior is appropriate before introducing them to group
activities or therapy
7. Start small, work to bigger things

1. Start with one-on-one interactions, progress

to group therapy
2. Start with small tasks, move to more complex
3. Start with direct tasks and no choices, move to

allowing choices
Nursing Concepts
1. Safety
2. Mood Affect
3. Cognition
Patient Education
1. Importance of medication compliance
2. Reality orientation strategies

STUDY TOOLS: Schizophrenia

Pathophysiology
Schizophrenia is a serious mental disorder that affects how a person thinks, feels and behaves.
Patients often have difficulty distinguishing between reality and imagination and have difficulty
communicating with others. Schizophrenia tends to run in families, but most frequently appears
to be related to an imbalance of neurotransmitters (dopamine, glutamate and serotonin) that
change the way the brain reacts to stimuli. Patients are not normally violent, but may react
defensively to even the most well-intended gestures or stimuli.
Etiology
The patient must have experienced at least two of the following symptoms, one of which must
be a positive symptom.
• Positive symptoms o Delusion’s o Hallucinations o Disorganized speech o
Disorganized (or catatonic) behavior
• Negative symptoms o Flat affect o Decrease in emotional range o Loss of interest in
activities o Reduced speaking
Symptoms must be present for at least 6 months with at least one month of active symptoms.
Symptoms are not related to substance use/abuse or any other medical condition.
Desired Outcome
Patient will communicate effectively. Patient will demonstrate reality-based thought processes.
Patient will demonstrate ability to distinguish between reality and hallucinations. Subjective
Data Outcome
• Hallucinations
• Feeling of being watched (paranoia)
• Change in personality
• Inability to sleep
• Inability to concentrate
• Feelings of indifference
Objective Data
• Awkward body positioning
• Decreased or impaired speech
• Decline in academic or work performance
• Inappropriate behavior
• Extreme preoccupation with religion or the occult
• Flat affect
• Unprovoked outbursts or uninhibited actions
• Tense, anxious or erratic movements
• Wandering
Obtain history and assess patient for hostile or self-destructive behaviors
RATIONALE
Determine risk of harm to patient or others and what precautions may be required. Stress
response often triggers hallucinations.
Provide encouragement in a non-judgemental, compassionate way, understanding that

symptoms are real to patient
RATIONALE
Develop trust between patient and nurse to improve effectiveness of interventions and
cooperation.
Encourage patient to communicate (verbal, drawing, written) how hallucinations make them
feel
RATIONALE
Helps understand and anticipate behaviors and help identify stressors such as fear or
helplessness. Reduce anxiety.
Ask if hallucinations are instructing them to harm themselves or others. Provide safety for
patient and others per facility protocol if needed.
RATIONALE
Patients may be inclined to obey commands given by hallucinations that instruct them to harm
themselves or others. Notify security or police if necessary.
Follow your facility’s specific protocol regarding supervision, restraint, and documentation.
Provide redirection for inappropriate behaviors, maintain boundaries and guidelines.

RATIONALE
Avoids need for intervention and exacerbated behaviors. Redirecting patient helps remove the
focus from the current perceived threat to a more positive activity.
Boundaries and guidelines should be held consistently among caregivers to prevent splitting
(turning one caregiver against another).
Encourage reality-based activities (music, art, playing cards, etc.)

RATIONALE
Help redirect patient to acceptable activities and behaviors and reduce the risk of hallucinatory
distractions.
Explain all procedures slowly and carefully before beginning

RATIONALE
Reduces paranoia and encourages cooperation. Patients are less likely to feel “tricked” if they
understand what is happening to them. Even taking a blood pressure can be frightening if not
fully explained first.
Avoid using large gestures or touching the patient except when necessary
RATIONALE
Patient’s distortion of reality may interpret the touch or gesture as an aggressive or threatening
action.
Gently reorient patient as necessary

RATIONALE
Reorienting patient helps them differentiate between reality and hallucination.
Avoid arguing with a patient regarding delusions or hallucinations

RATIONALE
If reorienting is initially ineffective, avoid persistent attempts or arguing as it can agitate the
patient or cause feelings of isolation.
Never confirm a delusion or hallucination (“I see Jesus, too!”) – this can exacerbate agitation or
confusion.
Teach patient coping skills to help manage hallucinations or delusions

• Exercise
• Singing / listening to music
• Writing
• Drawing
•Talking with someone they trust
RATIONALE
Help patient learn how to cope with and manage symptoms to improve daily functioning and
behaviors.
As symptoms improve, allow patient to make small decisions such as what to eat, wear or choice
of activities
RATIONALE
Allows patient to feel that they have more control of themself and their care. Promotes
independence.
Administer medication appropriately

RATIONALE
Routine medications may be given to help improve symptoms.
• Atypical antipsychotics
IM medications may be given PRN for acute exacerbations.
• Diphenhydramine
• Haloperidol
• Lorazepam
References
https://emedicine.medscape.com/article/288259-overview
http://www.mentalhealthamerica.net/conditions/schizophrenia
https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml
Schizophrenic Brain
QUIZ
Question 1
A 45-year-old client with schizophrenia has been brought to the hospital after trying to commit
suicide. The client tells the nurse that the voices he hears told him to do it. He is extremely anxious
and upset. Which assessment question would most likely help the nurse to assess the client’s
perception of this event?
• Have you had thoughts of hurting others?

• Who do you live with?
• Do you know what today's date is?
• What happened that has made you so upset?
Question 2
A nurse is working with a client who has schizoaffective disorder and believes that the hospital has
poisoned the food. Which response from the nurse is most appropriate?
• Why would the hospital want to hurt you?

• The hospital has not poisoned the food. Look at everyone else around you eating
• I do not think the hospital has poisoned the food, but would you like to tell me why you believe
this?
• What type of poison do you think the hospital has used?
Question 3
A client with catatonic schizophrenia is in the hospital on the mental health unit. The client has not
moved for three days. Which of the following nursing interventions best demonstrates that the nurse
is upholding the client’s safety in this situation?
• Administer methylphenidate to control behavior

• Perform range of motion exercises and apply sequential compression devices
• Place the client in seclusion until the catatonia has resolved
• Start an IV to administer a bolus of normal saline solution
Question 4
A client with schizoaffective disorder has been admitted to the inpatient mental health center of the
hospital. The client tells the nurse that he hears voices telling him to leave the hospital. Which
response from the nurse is best?
• You know that those voices aren't real, don't you?

• I do not hear anything, but I can see how you may feel worried about being in the hospital right
now
• Why don't we go to the game room and see what is happening there today?
• I do not hear anything, but you cannot leave the hospital
Question 5
A client is demonstrating catatonic schizophrenia. Which of the following characteristics would the
nurse most likely see with this condition?
• Incoherent speech
• Hallucinations
• Comatose appearance
• Violent behavior
Question 6
The nurse is working in the emergency department and receives an 18-year-old client with a
headache. While assessing the client, the nurse learns that this client’s headache worsens when the
client hears voices. When asked what the voices are saying, the client replies, “To kill everyone with a
knife.” Which of the following is the nurse’s priority?
• Confirm an exit and make sure the nurse's back is not to the client
• Check the client for weapons
• Ask the client if voices are telling her to harm herself as well
• Ask the client if they want to harm the nurse
Question 7
A nurse is working with a client who has schizophrenia. The client is demonstrating clang associations.
Which of the following statements by the client best displays this speech alteration?
• Bye, lie, die, sky, bye, bye, and rye

• Did you see where that blue salad orchid went?
• I want to see the bird jump in blue work by the ocean's pole
• I was just flippering and flitoning today
Question 8
A 50-year-old client with schizophrenia is being seen by the mental health nurse. The client is
demonstrating signs of altered thought processes. Which communication pattern would most be
associated with schizophrenia or psychosis? Select all that apply.
• Clanging
• Neologisms
• Flight of ideas
• Poverty of speech
• Word salad
Question 9
The nurse is caring for 4 clients and has determined that the client who will receive aripiprazole needs
to be seen first. For which of the client scenarios is this medication indicated?
• A client with multiple personality disorder

• A client with schizophrenia
• A client with anxiety
• A client with tardive dyskinesia
Question 10
A nurse is providing reality orientation to a client who has been experiencing auditory hallucinations.
Which of the following elements should the nurse consider when orienting this client to reality? Select
all that apply.
• Give the client frequent reassurances

• Ask questions that can be answered with a yes or no
• Do not discipline the client if he cannot remember something
• Ask the client to do two tasks at a time
• Respond verbally to reality-based things the client says
Question 11
The nurse is caring for a schizophrenic client who is talking to someone who is not there. The client
states, “I am talking to Cheryl. She’s right here.” No one is there. What is the most appropriate
response for the nurse?
• "Cheryl, go away and stop bothering him"

• "Hi Cheryl! How are you?"
• "Are you having a hallucination? Is this person telling you to hurt yourself or anyone else?" •
"You're having a hallucination. No one is there"
Question 12
A nurse is caring for a client with schizophrenia who tells her he believes that everyone else in the
inpatient unit is secretly laughing at him behind his back. Which response by the nurse is best?
• They are probably just laughing about someone else.

• Did you hear someone say something about you?
• There are some people here who are laughing but I do not think they are laughing at you.
• Do you think they do not like you?
Question 13
A 25-year-old client with mental illness is having delusions of grandeur. Which tasks would the nurse
utilize when orienting this client to reality? Select all that apply.
• Continue to talk about and discuss the fine points of the delusion
• Do not argue with the client about the delusions
• Be honest during interactions to reduce the client's suspiciousness
• Provide validation for the client if part of the delusion is real
• Ask the client to to describe the delusion
Question 14
A nurse is working with a client who is experiencing hallucinations of water running down the walls.
Which of the following intervention would be most helpful for the client?
• Frequently reassess whether the person is experiencing hallucinations

• Talk to the client in a loud, clear voice to minimize distractions
• Respond verbally to anything real the client talks about
• Explain that there is no water running down the walls and the client is seeing things
Question 15
A client with schizoaffective disorder is having hallucinations of hearing screaming voices. Which
action by the nurse should be done to provide a diversion for this client?
• Wait until the client shows signs of hearing something and then directly intervene
• Explain that the nurse does not hear the voices and try to discuss reality-based subjects
• Tell the client that the voices are not real and ask if they can talk about something else • Avoid
talking about the hallucinations and change the subject
Question 16
Which of the following are common findings in a client with schizophrenia? Select all that apply.
• Lack of guilt or remorse

• Disorganized speech
• Flat affect
• Delusions
• Loss of interest in activities
Question 17
A client with schizophrenia has become very angry and is throwing items at the nursing staff. The
nurses have tried other forms of calming the client, but nothing has worked. Which of the following
accurately describes the staff’s ability to use restraints in this situation?
• The staff may not use restraints because the client has a mental illness
• The staff may use restraints because the client is trying to hurt others
• The staff may not use restraints because they are not warranted in this situation
• The staff may only use chemical restraints for sedation and not physical restraints
Question 18
A client with schizophrenia has been non-compliant with taking his medications. The nurse
understands that the most likely reason for non-compliance with the treatment regimen for the client
is which of the following?
• Anger about the diagnosis of schizophrenia

• Lack of insight about the diagnosis of schizophrenia
• Irritation with the nurse for giving the medication
• The inability to remember to take the medication
Question 19
A client with schizoaffective disorder is being seen for recurrent swallowing issues as a result of
consuming non-food items. Which of the following would this client be at highest risk for?
• Injury to the muscles of the neck

• Choking from eating non-food items
• Breakdown of the oral mucosa
• Gastroesophageal reflux
Paranoid Disorders
Overview
1. This includes paranoid personality disorders (Cluster A), paranoia, paranoia-induced
state,
and paranoid schizophrenia
Nursing Points
General
1. Characterized by delusions, irrationality and closely related to anxiety and fear.
2. Patients typically mistrust others and are highly suspicious, while to others they seem
hostile, disturbed, and defensive.
3. Things that most would view as a coincidence, those suffering from paranoia would
view it as intentional
1. Attribution bias
Assessment
1. Some defining behaviors:
1. Low self-esteem
2. High value on being right/correct and find it difficult to admit they’re
wrong or incorrect
3. Very sensitive
4. Distorts reality
5. Attribution bias
1. Another’s accidental behavior is viewed as very
purposeful/intentional to hurt them/cause them harm
6. Very critical of others
7. Poor judgement
8. Hypervigilant
9. Very suspicious of others
10. Social anxiety
11. Typically, single or does not have many interpersonal relationships, as

maintaining friendships is difficult
1. Understand delusions
1. False belief firmly held to be true, despite the rational argument
2. For the patient suffering from paranoia, the delusions are part of who they are and
their self-esteem – VERY important
3. As they begin to trust and engage with others, the need for their delusion decreases
4. It is very real to them
2. Understand paranoia (as a stand-alone condition)

1. No symptoms of schizophrenia or hallucinations (important distinction!)
2. Delusions are organized
3. Prior to onset, they may be more sensitive or quiet

3. What to do
1. SAFETY is always the priority / reassure patient that they are safe
2. Start with a self-harm/suicide assessment
3. Be conscious of all your actions

1. Small and seemingly meaningless things may be perceived by a
patient suffering from paranoia as threatening or increase their
paranoia and/or delusions.
4. Start small and progress
1. 1:1 interaction, gradually progress to group interaction
2. Start with small, simple tasks/activities and progress to larger and

more complex
5. Always remain cool, calm, and collected in your actions
6. Establish rapport/trust
7. Consider decreasing or removing stimuli

1. For example, moving from a day room to a quieter/more private
area
8. Be honest and genuine
9. When the patient speaks in reality, use positive reinforcement

4. What NOT to do
1. Do NOT promote/play competitive activities
2. Do not play into the delusions; stay in reality and refocus when need
3. Do not speak in an accusatory manner
4. Do not hold direct eye contact
5. Do not whisper near them or touch them.

Nursing Concepts
1. Mood Affect
2. Safety
STUDY TOOLS:
Paranoid Disorders
Pathophysiology
Some paranoid disorders such as paranoid personality disorder and paranoid schizophrenia may
have more bizarre behavior and have intense feelings of distrust or fear. These clients will not
confide in others and may be difficult to talk to as they often misinterpret harmless
conversation or behavior.
Etiology
Criteria and symptoms must persist for one month or more, and cannot be attributed to
substance use or another medical or mental condition.
• Extreme distrust and suspiciousness of others, misinterpreting motives as malevolent, begins
early in adulthood
• Presents by at least four of the following:
o Suspects, without reason, that others are exploiting, harming or deceiving him
or her o Is preoccupied with unjustified doubts about the trustworthiness of
friends or associate’s o Is reluctant to confide in others because of fear that
information will be used against him or her
o Misinterprets threatening meanings into harmless remarks or events o Bears
grudges or is unforgiving of insults, injuries o Perceives attacks on his or her
character or reputation o Recurrent, unjustified suspicions about partner’s
fidelity
• Does not occur only during, but may be diagnosed prior to, schizophrenia
Desired Outcome
Client will be able to identify appropriate coping techniques. Client remains safe and free from
harm.
• Suspicion
• Fear of being deceived
• Feelings of being persecuted
• Poor self image
Objective Data
• Argumentative
• Hostility
• Detachment
• Social isolation
• Easily offended
• Self-righteous attitude
• Rigid behaviors and beliefs

• Perfectionism
Assess client’s neurological status
RATIONALE
To determine if there are other issues that may be causing symptoms or if disorder has
progressed to another serious conditions such as schizophrenia
Monitor behaviors and interactions with staff and other clients

RATIONALE
Determine how client interacts with others. Paranoid clients may exhibit aggressive behaviors
for no apparent reason.
Talk openly with client about their beliefs and thoughts, showing empathy and support
RATIONALE
Help build trust and rapport with clients. Paranoid clients may be more reluctant to trust
anyone, but open communication generally offers more cooperation
Explain all procedures clearly and carefully, and their purpose, before starting them
RATIONALE
Prevents aggressive behavior and suspicion. Promotes cooperation and compliance. Helps
develop trust.
Remain aware of client’s personal space.

Avoid startling the client, sudden movements or touching the client unnecessarily
RATIONALE
Even the best of intentions, such as a handshake, tidying the room, or body language may be
misinterpreted as threatening and may lead to aggressive behavior. Showing respect for
client’s space and possessions helps build trust.
Discuss feelings and help client identify behaviors that cause conflict or alienate others
RATIONALE
Helping clients see the reality of their own behaviors can help treatment progress and lead to
more appropriate behaviors and interactions.
Discuss and have client demonstrate (through role play if appropriate) more acceptable
responses and reactions to behaviors and stressors
RATIONALE
Helps client develop more positive coping skills for dealing with delusions, suspicions and fears
Minimize environmental stimuli

RATIONALE
Overstimulation from loud noises, excessive talking, television or radio may increase paranoia
and prompt erratic or aggressive behaviors.
Encourage socialization with others, but do not force participation in activities

RATIONALE
Help client develop relationships and more positive interactions with others. Helps reorient client
to reality. Forcing them to participate may trigger paranoia that you are trying to trick or trap
them.
Set behavior boundaries and enforce per facility protocols with medications or restraints as
necessary
RATIONALE
Promote the safety of client during agitated moments and the safety of others from aggressive
behaviors.
Administer medications appropriately and monitor for reactions to medications

RATIONALE
Antipsychotic medications may be given to manage delusions and behaviors. Monitor for
adverse reactions.
Offer praise and encouragement for accomplishments of tasks

RATIONALE
Promote a sense of self-worth and improves self-esteem
Consider any cultural concerns or impacts of treatment

RATIONALE
Depending on their culture, some behaviors and beliefs may be considered acceptable to the
client. Take these into consideration when implementing interventions.
Provide reorientation as appropriate, but avoid direct confrontation of the delusions

RATIONALE
Client may need to be refocused to reality at times, but avoid confrontation that may be
interpreted as argumentative to avoid noncompliance and uncooperative behaviors.
Provide education, resources and support for client’s family and loved ones
RATIONALE
Help family members understand the nature of the client’s illness and avoid conflict that could
exacerbate the client’s symptoms.
Encourages coping skills of family members through each other and support groups.
As client agrees, and per facility protocol, incorporate client’s family or loved ones in ongoing
treatment plan
RATIONALE
Help develop trust between client and loved ones and promotes positive management of illness
going forward. Help client and family members stay on track with treatment.
References
https://behavenet.com/diagnostic-criteria-3010-paranoid-personality-disorder
https://thriveworks.com/blog/delusional-disorder/
https://www.psychologytoday.com/us/conditions/paranoid-personality-disorder
QUIZ
Question 1 of 2
A nurse is working with a client who has paranoid thinking. The client believes that a secret chip has
been implanted under the client’s skin by the government. Which is the most appropriate first
approach from the nurse?
• Ask the client for more details about the secret chip
• Touch the client gently on the arm and guide him to a place to talk
• Divert the client's attention to activities in the game room
• Talk to the client about their feelings regarding the situation
Question 2 of 2
A client has been brought into the emergency department under the influence of illicit drugs. The
client is experiencing paranoia and yells at the nurse, “You can’t hurt me! I am more powerful than
you!” Which tactics would the nurse use that would help to orient this client to reality? Select all that
apply.
• Repeat to the client that no one will hurt him or her

• Leave the client alone until the client asks for help
• Place the client in restraints until the client has calmed down
• Remind the client that they are in the hospital
• Do not talk to the client until the client speaks normally
Personality Disorders
Overview
1. Definition: a group of maladaptive patterns of behavior, cognition, and inner culture
that
make maintaining relationships and functioning very difficult.

Nursing Points
General
1. Patients do NOT experience breaks in reality
2. Typically, unable to see the consequences of their behaviors.

1. VERY difficult to maintain positive relationships
3. Stress can make this worse
4. Can potentially progress to psychosis if it becomes severe.
5. Types
1. Cluster A / Odd + Eccentric
1. Schizoid
2. Schizotypal
3. Paranoid
2. Cluster B / Over-Emotional + Erratic
1. Histrionic
2. Narcissistic
3. Antisocial
4. Borderline
3. Cluster C / Anxious + Fearful
1. Obsessive-compulsive
2. Avoidant
3. Dependent
1. Very low self esteem and confidence
2. Cannot function independently
3. Tries to avoid making own decisions
4. Relies heavily on others

Assessment
1. Defining behaviors:
1. Preoccupation with sex, religion, or themselves
2. Impaired judgment, unable to see/predict consequences of actions
3. Unable to see how their actions (or lack of actions) affect others around
them
4. Difficulty maintaining relationships
5. Distortion of reality (but still in it)
6. Distorted view of themselves (love or hate themselves)
7. Manipulation
8. Unable to regulate stimuli

1. Excitable
2. Excessive response to light/sound
3. Unable to focus
9. Poor impulse control
1. Respond physically to deal with pain
1. Verbal and physical abuse/attacks
2. Self-harm
3. Suicide attempts
4. Promiscuity
1. General Interventions
1. Maintain safety of the patient and others – always!
1. Written contract for self-harm, suicide, and hurting others may be
necessary
2. Promote independence, when appropriate
3. Be consistent with your response regarding

inappropriate behavior
4. Limits, boundaries, communication about

expectations is essential
5. Be genuine in your responses
6. Praise when it is earned
7. Acknowledge splitting if it occurs

8. Promote discussing feelings rather than acting

Nursing Concepts
1. Safety
2. Mood Affect
3. Interpersonal Relationships
STUDY TOOLS:
Personality Disorders
Pathophysiology
Personality disorder is a term that covers several different types of mental disorders that cause
an unhealthy pattern of thinking, functioning, and behaving. Most clients with personality
disorders believe that their thought processes are normal, and everyone else is the problem;
therefore, many may never seek counseling or therapy and go untreated. Personality disorders
may develop from a history of childhood abuse or neglect, negative or traumatic experiences,
or dysfunctional family life. Personality disorders are categorized into three clusters according
to behavior: Cluster A disorders (Schizoid, Schizotypal) exhibit odd, or eccentric thinking and
behavior, Cluster B disorders (Antisocial, Borderline, Narcissistic) exhibit dramatic,
unpredictable and overly emotional behaviors, and Cluster C disorders (Obsessive-Compulsive,
Avoidant) exhibit anxiety and fear.
Etiology
The primary features of a personality disorder are self and interpersonal function and specific
personality traits. For each disorder, there must be stability in the expression of the personality
traits across a consistent period and situations. The client’s developmental stage,
socioeconomic status or culture do not explain the difficulty in functioning and the impairments
are not related to another mental or medical condition or substance use. Schizotypal
• Confused between self and others, views other people’s experiences as their own
• Difficulty understanding impact of own behaviors
• Psychoticism – odd, unusual behavior or thought processes
• Detachment – little reaction to emotional situations and wants to be alone
Antisocial
• Egocentric
• Lack of empathy or remorse for hurting or mistreating another, callousness
• Lack of mutually intimate relationships; exploitation, deceit and coercion used to
intimidate and control
• Frequently angry or irritable
• Disinhibition; irresponsible, impulsive and high-risk taker
Borderline
• Poor, unstable self-image, self-criticism, feelings of emptiness, often feels insulted
• Unstable goals or career plans
• Unstable and conflicted close relationships with mistrust and neediness

• Frequent mood changes, highly emotional, intense nervousness, or panic; hostility
• Fear of rejection or separation from others
• Impulsivity with risky, self-damaging activities
Narcissistic
• Compares self to others for self-definition with an exaggerated self-appraisal
• Goals are set based on gaining approval from others
• Recognizes others’ needs or feelings only if relevant to self
• Superficial relationships, need for personal gain
• Feelings of entitlement or self-centeredness, condescending toward others
• Excessive attempts to attract attention and admiration of others
Avoidant
• Low self-esteem, sensitivity to criticism or rejection
• Reluctant to pursue goals, take risks, or develop relationships for fear of shame or
ridicule
• Withdrawal from social contacts and activity, avoids intimacy
• Anhedonia: unable to feel pleasure or take interest in things
Obsessive- Compulsive
• Self identity derived from productivity; relationships are secondary to work
• Difficulty completing tasks due to unreasonably high standards
• Difficulty understanding others’ feelings
• Rigid perfectionism – persists at tasks or continues behavior despite repeated failures
Desired Outcome
Client will develop ability to set realistic goals. Client will identify realistic personal strengths.
Client will demonstrate a reduction in violent or manipulative behaviors. Client will
demonstrate coping skills for anxiety. Subjective Data Outcome
• Lack of interest in social activities or relationships
• Anxiety
• Feelings of emptiness
• Easily influenced by others
• Envy of others
• Low self-esteem or lack of self-confidence
• Difficulty disagreeing with others

• Desire to be in control of people Objective Data
• Odd or eccentric behavior
• Hostility, aggressive behavior
• Lying or stealing
• Lack of remorse
• Arrogance
• Shyness
• Clingy or submissive behavior
• Inability to discard broken or worthless objects / hoarding
• Poor control of money
Assess client’s neurological status
RATIONALE
Determine if there are other conditions present and get baseline
Observe and identify behaviors and set clear limits with consequences
RATIONALE
Helps to set and maintain structure and limits that develop feelings of security and safety
Be consistent when interacting with the client and in routine care

RATIONALE
Changes in consistency threaten the structure of care and open the opportunity for the client to
use manipulative behaviors or tactics. Client may be resistant to change, so consistency helps
encourage new thought processes.
Approach and interact with a calm, respectful, supportive, and stable attitude RATIONALE
Personal insecurities or emotions can cause tension or power struggles with client.
Professionalism helps improve client’s treatment and therapy and avoid negative behaviors.
Discuss with the client their plans and goals; help distinguish between positive, realistic goals
and unrealistic goals
RATIONALE
Help the client regain control of reality and become more focused. Helps the client understand
their personal capabilities
Set realistic, short-term goals for client and offer recognition for attaining those goals
RATIONALE
Helps client realize their abilities and limitations. Encouragement improves self-esteem and
cooperation.
Provide realistic feedback and evaluations

RATIONALE
Manipulative behavior may ensue without honest, realistic interpretations of behavior or
therapy progress and may negatively impact treatment.
Helps discern areas of improvement and areas that still need work
Enforce limits and consequences, and discourage hostile or aggressive behaviors

RATIONALE
Helps reinforce structure and discourage inappropriate behaviors. Maintains safety of client and
others.
Discuss alternative ideas or ways of thinking

RATIONALE
Helps client develop coping skills for emotions or feelings
Monitor and encourage positive social interaction with others in a safe environment
RATIONALE
Help clients develop positive social skills and healthy interactions. Offers an opportunity to learn
new ways of dealing with social situations.
Teach clients relaxation techniques and deep breathing exercises

RATIONALE
Help clients control anxiety and manage situations independently to reduce symptoms.
Provide resources and support for family members

RATIONALE
Help family members learn to cope with effects of client’s disorder and develop effective
communication skills.
References
https://www.psychologytoday.com/us/blog/hide-and-seek/201205/the-10-personalitydisorders
http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profes
ionales/820_clinica_tr_personalidad_psicosis/material/dsm.pdf
https://www.mayoclinic.org/diseases-conditions/personality-disorders/symptoms-causes/syc20354463
https://www.mentalhelp.net/articles/dsm-5-the-ten-personality-disorders-cluster-b/
Personality Disorder Pathochart
PATHOPHYSIOLOGY
Personality disorder is a term that covers several different types of mental disorders that cause
an unhealthy pattern of thinking, functioning and behaving. Most clients with personality
disorders believe that their thought processes are normal, and everyone else is the problem;
therefore, many may never seek counseling or therapy and go untreated. Personality disorders
may develop from a history of childhood abuse or neglect, negative or traumatic experiences,
or dysfunctional family life.
ASSESSMENT FINDINGS
• Lack of interest in social activities or relationships
• Low self-esteem or lack of self-confidence

• Desire to be in control of people
• Odd or eccentric behavior
• Hostility, aggressive behavior
• Lying or stealing, lack of remorse
• Inability to discard broken or worthless objects / hoarding
• Poor control of money
DIAGNOSTICS
• Cluster A (Schizoid) - odd or eccentric thinking and behavior
• Cluster B (Antisocial, Borderline, Narcissistic) - dramatic, unpredictable and overly
emotional behaviors
• Cluster C (Obsessive-Compulsive, Avoidant) - anxiety and fear.

NURSING PRIORITIES
• Set clear limits and boundaries
• Be consistent in interactions
• Set realistic short-term goals
• Group/individual therapy
• Encourage positive social interactions
• Provide resources for support for family members
MEDICATION THERAPY
• Antipsychotics
• Anxiolytics
QUIZ
Question 1 of 3
A 23-year-old client is being seen for treatment after purposely cutting the skin on her arm. The client
has impulsive behavior, is angry, and has been losing friends because of intense and needy behavior.
Which type of personality disorder does this best describe?
• Histrionic personality disorder

• Borderline personality disorder
• Schizotypal personality disorder
• Antisocial personality disorder
Question 2 of 3
A client has been diagnosed with antisocial personality disorder and becomes very angry with the
nurse and is starting to become aggressive. Which principle of management would most likely be
implemented in this situation?
• Promise the client that he will not be harmed if he cooperates

• Demonstrate to the client that the nurse is competent in self-defence
• Have the client stay in a private room that can be locked
• Remain calm and put space between the nurse and the client
Question 3 of 3
A client with obsessive-compulsive disorder (OCD) is in the hospital after having been diagnosed with
a chronic illness. Which best describes what the nurse would see in this client while trying to provide
care?
• Anxiety because they have no control over their illness

• Questioning so much that the nurse has difficulty leaving the room
• Refusing to trust the nurse and acting paranoid
• Requesting help with minor tasks and portraying a helpless role
Cognitive Impairment Disorders

Overview
1. Includes Autism-spectrum disorder (ASD), attention-deficit hyperactivity disorder
(ADHD),
Dementia, Alzheimer’s Disease
1. ASD and ADHD discussed in Peds course
Nursing Points
General
1. Dementia definition: a broad category of brain diseases that is gradual and long-term
that
results in self-care deficits, largely affecting their ability to function.
1. There are various types that can affect people of varying ages and it can
progress at different rates.
2. This results in judgement impairments, and issues problem solving and

behavior.
2. Alzheimer’s Disease definition: Alzheimer’s is a TYPE of dementia and is an irreversible form
caused by nerve cell deterioration.
1. There is a steady, progressive decline in functional capacity.
Assessment
1. Apraxia: difficulty performing motor tasks
2. Aphasia: difficulty progressing to inability to speak and understand what is being
said to them
3. Agnosia: doesn’t recognize familiar people or objects
4. Amnesia: memory loss

1. Always educate family as disease progresses on best ways to interact to maximize
time.
2. Caregiver stress
1. Role strain – i.e., childcaring for parent
2. Sadness due to loved one not recognizing them

3. SAFETY
1. Wandering can be an issue. Units should be locked/secured, patients should be
supervised.
2. Watch water temperature – may burn themselves
3. Remove anything toxic or hazardous from easy access
4. Watch for agitation

1. Remove things that increase agitation
5. Decrease stimuli/reassure patient
6. Never argue
7. Use a calm, reassuring voice with gentle touch (when appropriate)
8. Watch for sundowning (more issues at night)

4. Communicate
1. Needs will change as disease progresses
2. Maintain eye contact
3. Stand in front of them, be calm, firm, and direct with communication and
tasks
4. Simple one-step tasks/direction
5. Use short, simple words
6. Always identify them and yourself
7. Reorient as needed (this may be very frequent)

5. Promote their current abilities
1. Keep familiar things around them
2. Continually reinforce what they know and can do now
3. Promote independence, supervise to ensure ADL’s are taken care of
4. Utilize familiar simple games and activities they enjoy

1. Pay attention to their TV and music preferences
2. Coloring
3. Talk about their memories
4. Books they enjoy
5. Maintain routine
6. Pay attention for fatigue, memory strain, and agitation and

provide ample time for rest
7. Keep a calendar and clock on the wall and refer

to it when discussing the date/time
5. Provide positive reinforcement
Nursing Concepts
1. Mood Affect
2. Cognition
3. Safety
Patient Education
1. Educate family on their role in promoting independence and
safety
2. Provide resources for respite care

STUDY TOOLS:
Alzheimer’s Disease
Pathophysiology
Alzheimer’s disease, sometimes called Alzheimer’s Dementia, is a progressive and irreversible
neurological disorder that causes loss of memory and cognitive function. Symptoms begin
gradually, with signs that are easily attributed to other factors such as misplacing items,
forgetting appointments, or getting lost in a familiar area. The disease may begin occurring in
the fifties and sixties, but symptoms may not present until the client is in their eighties or
nineties. Studies have shown that clients who reside in smaller living spaces, avoid social
interaction, or rarely leave their homes are twice as likely to have Alzheimer’s disease. Since
Alzheimer’s is an irreversible disease, treatment is geared toward management of symptoms
and promoting support and the best quality of life possible.
Etiology
Diagnosis of Alzheimer’s disease should not be applied when symptoms began following a
stroke, traumatic brain injury (TBI), there is another known neurological disorder or when client
is being treated with medications for other neurological disorders that would produce similar
symptoms. The following characteristics must be met for diagnosis:
• Gradual onset (may take months or years)
• Clear observation of cognitive decline
• Decline in memory or learning and one other cognitive area (based on history of testing)
o Speech
o Visual-spatial (recognition of objects or faces) o Reasoning or
judgement
• Steady cognitive decline without periods of stability
Desired Outcome
Client will maintain optimal level of independent or assisted functioning. Client will remain free
from injury. Client will have minimal wandering behaviors. Client’s family will have adequate
resources and support for coping with client’s disease.
• Difficulty finding words during a conversation
• Difficulty remembering names
• Poor short-term memory
• Forgetting details of personal history (life events, phone number, etc.)
• Inability to recognize faces Objective Data
• Difficulty dressing or performing ADLs
• Loss of bladder and bowel control

• Personality changes
• Inappropriate behaviors (aggression, sexual gestures, etc.)
• Wandering or pacing
Perform complete nursing assessment
RATIONALE
Get a baseline for interventions and monitor progression of disease
Assess neurological status and level of confusion routinely, per facility protocols
RATIONALE
Help determine necessary interventions and progression of disease.
Assess for depression or reclusiveness

RATIONALE
Clients in the earlier stages who are still able to understand that they are losing their sense of
reality may become depressed and withdrawn.
Routinely assess client for organic contributors to behavior:

• Dehydration
• Poor nutrition
• Infection (systemic, urinary)
RATIONALE
Many organic factors may contribute to an increase in client’s confusion or changes in mental
status. It is important not to ignore them, since it could be related to infection or dehydration,
which is treatable.
Communicate effectively
• Speak in a slow and low, comforting voice
• Call client by name
• Speak face-to-face
RATIONALE
Helps increase the possibility of the client understanding what is being communicated.
Repeating the name helps the client maintain a sense of self-identity.
Limit choices for independent decisions appropriate to stage of disease progression

RATIONALE
Progressively reducing the client’s need for decision making helps reduce frustration and stress.
Avoid allowing client to watch television or violence on television

RATIONALE
Clients often have difficulty distinguishing fiction from reality and may cause aggressive or
violent behaviors or unwarranted fears.
Monitor for non-verbal cues and anticipate client’s needs

• Grimacing
• Crying
• Pointing
RATIONALE
As the disease progresses, clients have more difficulty communicating verbally. Anticipating
needs helps reduce stress and prevent frustration and anxiety.
Orient client to environment as often as needed

• Calendars
• Pictures
• Signs
RATIONALE
Helps client feel safer and reassured of their surroundings. Promotes awareness of environment.
Provide structured and guided activities that client can accomplish with minimal challenge
RATIONALE
This helps to keep the mind active and incorporate a sense of accomplishment. Make sure the
activity is not so challenging to cause frustration or stress.
Maintain schedule and routine

RATIONALE
Helps the client maintain an awareness of time of day and offers a sense of security and reality.
Assist with ADLs as needed

RATIONALE
Advanced stages of the disease may diminish the client’s ability to perform simple tasks like
dressing, bathing, combing hair and feeding. Provide whatever assistance the client needs to
maintain a sense of dignity.
Provide an opportunity for clients to interact with others, but avoid forcing interaction
RATIONALE
Helps prevent clients from feeling isolated or alone. Gives them an opportunity to share stories
or memories and maintain or develop social relationships. Forced interaction may cause
aggression or inappropriate behaviors.
Monitor client’s wandering habits and determine specific reasons, if any, for wandering
RATIONALE
Clients may wander because they are thirsty or hungry or are looking for a bathroom. Assess
needs and aid or direction within a safe environment.
Educate family about disease process and resources for coping

• Therapy or counseling for families
• Support groups for families or caregivers
• Respite care options
• Home modifications
RATIONALE
Help families cope and be prepared for the changes in their loved one.
Help families adapt to the needs of the clients.
Help reduce stress and anxiety that may be transferred to the client.
Administer medications appropriately and as needed

• Cholinesterase inhibitors (donepezil)
• NMDA receptor antagonist (memantine)
• Antipsychotics (olanzapine, quetiapine)
• Benzodiazepines (lorazepam, temazepam)
• SSRI antidepressants (citalopram, paroxetine)
RATIONALE
Some medications may be given regularly for management of memory loss and delay
progression of the disease.
Other medications may be given PRN to treat behaviors and symptoms such as depression,
anxiety or loss of appetite.
Minimize environmental hazards and make pathways clear and illuminated RATIONALE
Promote safety and prevent injury.
References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5619474/
https://www.theravive.com/therapedia/major-or-mild-neurocognitive-disorder-due-toalzheimers-disease-dsm--5-331.0-(g30.9)
https://www.alzheimers.net/stages-of-alzheimers-disease/
https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/symptoms-causes/syc-
20350447
Alzheimer – Diagnosis
The 5 A’s
• A-Amnesia – loss of memories

• A-Anomia – unable to recall names of everyday objects
• A-Apraxia – unable to perform tasks of movement
• A-Agnosia – inability to process sensory information
• A-Aphasia – disruption with ability to communicate
The 5 A's of Alzheimer’s Disease. These signs point to a diagnosis of Alzheimer's Type Dementia
Dementia
DEMENTIA
• DEMENTIA Make certain they don't have problems with:
• D-Drugs and alcohol
• E-Eyes and ears
• M-Metabolic and endocrine disorders
• E-Emotional disorders
• N-Neurologic disorders
• T-Tumors and trauma
• I-Infection
• A-Arteriovascular disease
When assessing a patient for dementia it is important to ensure that one of the following listed
conditions isn't an underlying cause for the dementia symptoms.
Senile Dementia – Assess for Changes

JAMCO
• J-Judgment • A-Affect
• M-Memory
• C-Cognition
• O-Orientation
These 5 things should be assessed in a patient with senile dementia. Judgment - can a patient
determine the outcome of a choice or assess risk? Affect - ability to express feeling or emotion.
Memory - assess short- and long-term memory. Cognition- ability to process and relate
information. Orientation - assess if a patient is oriented to person, place, time.
Alzheimer’s Disease Pathochart

PATHOPHYSIOLOGY
Alzheimer’s disease, sometimes called Alzheimer’s Dementia, is a progressive and irreversible
neurological disorder that causes loss of memory and cognitive function. Symptoms begin
gradually, with signs that are easily attributed to other factors such as misplacing items,
forgetting appointments, or getting lost in a familiar area. Since Alzheimer’s is an irreversible
disease, treatment is geared toward management of symptoms and promoting support and the
best quality of life possible.
ASSESSMENT FINDINGS
• Difficulty finding words or remembering names
• Poor short-term memory
• Forgetting details of personal history
• Inability to recognize faces
• Difficulty dressing or performing ADLs
• Loss of bladder and bowel control
• Personality changes & inappropriate behaviors
• Wandering or pacing DIAGNOSTICS

• Symptoms did not present following stroke or other brain injury
• Symptoms cannot be explained by medication or other illness
• Symptoms began gradually (months to years)
• Decline in memory or learning
• Steady cognitive decline without periods of stability

Speech
Visual-spatial
Reasoning or judgement
NURSING PRIORITIES
• Assess and monitor cognition

• Reorient as appropriate
• Maintain consistent schedule as able
• Provide structure and guided activities
• Rule out physiological causes of symptoms

MEDICATION THERAPY
• Cholinesterase inhibitors
• NMDA receptor antagonist
• SSRI antidepressants
Alzheimer’s Brain
Brain Atrophy in AD
QUIZ
Question 1
A nurse is caring for an older adult who is experiencing wasting and malnutrition as a result of
dementia. The client’s daughter asks the nurse about giving her mother a nutritional shake. Which
response from the nurse is accurate?
• You can supplement your mother's food intake with a nutritional shake to add after a meal
• Nutritional shakes are typically only used for weight loss, which does not apply in this situation
• You should not use nutritional shakes; they do not provide enough calories or nutrients
• You should substitute your mother's meals with a nutritional shake instead
Question 2
A nurse is preparing to move a 150-pound client with Alzheimer’s disease from a chair to a stretcher in
the emergency room. The client can help with the move but is uncooperative with the nurses. Which
best describes how the nurse should move this client?
• Using four people

• Using stand-by assist
• Using one other person and the nurse
• Using a full-body sling lift and two people
Question 3
A 65-year-old woman has been diagnosed with Alzheimer’s disease and is suffering from repeated
bouts of memory loss. The client asks the nurse, “How am I supposed to handle this? I do not think I
can cope with having this many memory problems.” Which response from the nurse is most
appropriate?
• Advise the client to perform tasks slowly to avoid being injured

• Explain to the client that she needs to ask for help from others
• Encourage the client to keep photos of loved ones and important events nearby
• Discuss the importance of taking several naps throughout the day
Question 4
A client with Alzheimer’s disease has had difficulties eating and is not getting enough nutrients in his
diet. The client’s daughter asks the nurse if there is anything that can be done to improve his nutrition
intake. Which recommendation should the nurse give?
• Limit calories to have better control of behavior

• Use more salt when cooking and serving food
• Help the client choose his own eating utensils
• Provide stand-by assistance when the client eats to offer support
Question 5
A nurse is working with the adult daughter of a client who has Alzheimer’s disease. The daughter cares
for her parent in her home but is becoming exhausted with meeting the demands of caregiving. Which
of the following actions could the nurse take that would help this caregiver to provide for her own
needs? Select all that apply.
• Teach the daughter relaxation techniques

• Encourage the father to join a support group
• Provide information about respite care to the daughter
• Provide information about a vacation that the daughter and her parent can take together •
Assess what means of support the family has
Question 6
A nurse is working with a family who home schools their three children and also cares for an aging
parent with Alzheimer’s in the home. Which statement by the family best indicates that they are
considering the needs of the older adult who is receiving care in the home?
• "We are going to have the children take care of their grandma to teach them life skills"
• "Grandma typically doesn't need much help from us so it should work out"
• "We will see how it goes; we may need to hire help"
• "We plan to have Grandma teach the children math"
Question 7
A 9-year-old child has been diagnosed with ADHD and is acting impulsively with hyperactivity. Which
developmental activity would most likely be difficult for this child to achieve?
• Talking to different groups of people

• Finding creative solutions to problems
• Social interaction and making friends
• Performing in gym classes and at sports
Question 8
A 14-year-old teen has been hospitalized for acute exacerbation of ADHD symptoms. The nurse tries
to help the client to engage with others on the unit. Which of the following interventions would be
most appropriate for supporting social interaction for this client?
• Bring the client to sit with another teen who is playing a video game
• Help the child join a structured game with other children
• Have the client sit and talk with another client in a one-to-one setting
• Avoid social interactions until the ADHD symptoms are under control
Question 9
A client is cognitively impaired. What techniques can the nurse use to facilitate communication?
• Using simple, direct wording

• Speaking very close to them
• Talking louder
• Maintaining eye contact
• Utilizing reassurance
Question 10
Which medical condition has been shown to cause dementia in some adults?
• Trichomonas
• Tuberculosis
• Varicella
• Lyme disease
Question 11
A nurse is caring for a client who has dementia and is in the hospital. Which of the following situations
would most likely result in a client suffering bed entrapment? Select all that apply.
• The client cannot move from the bed to the wheelchair

• The client can't find anything to watch on TV
• The client gets regular respiratory therapy treatments
• The client needs assistance with toileting
• The client has difficulty using the call light
Question 12
A nurse is helping a client who has been developing dementia. The client expresses fears about his
condition to the nurse. Which nursing interventions would be most appropriate in this case? Select all
that apply.
• Avoid activities that tax the client's memory

• Support and reassure the client
• Use simple, short words
• Help orient the client to reality
• Gently aid with communication when needed
Question 13
A nurse is helping a family in which the mother has Alzheimer’s disease and is being cared for in the
home by her son. Which of the following safety principles should the nurse teach the son to best keep
his mother safe?
• Do not allow the person with Alzheimer's to consume caffeine or alcohol

• Replace high-risk medications with vitamins to avoid accidental overdose by the client
• Store cleaning solutions and household products in a counter above the stove • Get rid of plants
or toxic items that could be mistaken for food
Question 14
A 70-year-old client is worried about developing dementia because his father had Alzheimer’s disease
at an early age. What lifestyle interventions would the nurse recommend that would potentially
reduce this client’s risk of dementia? Select all that apply.
• If drinking, only consume alcohol in moderation

• Participate in social activities
• Control blood pressure
• Control blood sugar if diabetic
• Play memory games
Question 15
A family whose father has Alzheimer’s disease is struggling with keeping their parent safe at home.
The nurse can suggest which of the following strategies?
• Try to help the person stay in one or two rooms of the house
• Leave the lights on in the house at night
• Keep a working fire extinguisher within close reach on a counter or table • Remove
dangerous items, such as guns or weapons
Question 16
The parents of a child with autism talk with a nurse about their feelings of being overwhelmed in
caring for their child. They state that they do not get a break from their child, the child’s needs are
almost more than they can handle, and they are considering divorce. Which of the following initial
responses from the nurse is most appropriate?
• You can look up several inpatient placement centers online for information about childcare
• Please do not get a divorce over this. There must be another solution
• You may want to consider taking a vacation away together without your child to help with your
stress levels
• You may want to talk with a respite provider who can occasionally care for your child
Question 17
A client with Alzheimer’s disease has been transferred to the medical unit accompanied by the
spouse. The client is cognitively impaired and confused. The nurse assigns the client a room with low
lighting near the nurse’s station. Which of the following best explains the reason for this room
assignment?
• The client is a fall risk and must be near the nurse's station for safety
• The client's treatments have most likely caused hearing loss
• The client's medications may cause photophobia
• The client benefits from the noise and camaraderie at the nurse's station
Question 18
A 68-year-old client is being seen because of problems with memory loss. Which best describes an
example of the difference between normal memory changes with aging versus dementia?
• Normal memory aging involves recollective memory decline while dementia involves
reconstructive memory decline
• Normal memory loss affects interpersonal skills while dementia affects social skills
• Normal memory loss involves forgetting short term memories while dementia involves
forgetting long term memories
• Normal memory changes may be noted as occasional forgetfulness while dementia results in
rapid loss of all things familiar
Eating Disorders (Anorexia Nervosa, Bulimia

Nervosa))
Overview
1. Broad definition: very disturbed eating habits that profoundly affect one’s mental and
physical health
2. These affect men and women

Nursing Points
General
1. Anorexia Nervosa
1. Preoccupation with food
2. Very distorted body image and low self esteem
3. Deathly afraid of becoming overweight or obese
4. May have actual phobias of various foods
5. This can result in death
6. They are typically an overachiever or perfectionist who exercises

compulsively
2. Bulimia Nervosa
1. Consumes food in binge-episodes, followed by purging
3. Binge-eating disorder
1. Recurrent and persistent episodes of binge eating
2. Absence of compensatory behaviors (such as purging or exercising).
3. May be a response to many feelings (depression, guilt, loneliness,

boredom, inadequacy)
1. Eating eases pain of above feelings but doesn’t provide pleasure,
happiness or euphoria
Assessment
1. Anorexia Nervosa
1. May completely refuse to eat and deny any appetite
2. Physical assessment findings:
1. Low body temp
2. Bradycardia
3. GI upset/issues
4. Hypotension
5. Electrolyte disturbances
1. Common
2. Life-threatening
6. Hormonal imbalances
7. Sleep disturbances
8. Cyanosis
9. Lanugo: fine, downy, soft, and white hair that grows on extremities.
10. Bone degeneration
11. Amenorrhea: 3+ months of no menstrual period
2. Bulimia Nervosa
1. Like above listed for anorexia nervosa
2. Labile moods
3. Dental issues or esophageal varices related to vomiting
4. Low libido
5. Desires to control their eating
6. Helplessness and hopelessness when eating/purging
7. May use enemas, diuretics, laxatives, cathartics (meds that

speed up defecation or induce purging), amphetamines
(like Adderall or Ritalin to aid in weight loss)
3. Compulsive Overeating
1. Binge-like eating without purging
1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of being embarrassed by how much one is eating
5. Feeling disgusted with oneself, depressed, or very guilty after overeating

a) Helplessness and hopelessness related to eating habits
b) Typically, overweight or obese

1. Addressing physiological medical issues is the priority
1. IE assessing and correcting electrolyte imbalances
2. Must stabilize medically FIRST

2. Ensure safety
1. Assess self-harm and suicide risk
2. Assess if there’s a plan
3. Establish a contract PRN

3. Establish rapport and trust
4. Validate feelings, do not judge
5. Promote exploring and establishing their own identity

based in reality
6. Attempt to explore any triggers or precipitants

1. Calorie counts on menus
2. Family members praising for weight loss
3. Receiving criticism
Nursing Concepts
1. Mood Affect
2. Nutrition
3. Coping
Patient Education
2. Explain to them the processes in the inpatient environment

3. Schedule
4. How mealtimes work
5. How intake and output is monitored
6. How weigh ins work (same time, in same clothes, on same scale)
7. Inform if any activity restrictions will be ordered
8. Discuss medication plan
9. Discuss therapy plan
10. Discuss family / support system, concerns, and their level of involvement if applicable
STUDY TOOLS:
Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-eating disorder)
Pathophysiology
Eating disorders are a serious, sometimes fatal illness that cause a significant change in a
client’s eating behaviors that most commonly occurs in young women (teens – 20s) but can
occur in clients of any gender or age. Early detection and treatment improve the likelihood of
recovery. Types of eating disorders include anorexia nervosa (voluntary starvation), bulimia
nervosa (binge-eating followed by purging) and binge-eating disorder (binge-eating without
purging). Inadequate nutrition can lead to serious medical complications and even death. These
conditions frequently coexist with other mood or personality disorders and substance abuse.
Etiology
Anorexia Nervosa
• Restriction of nutritional intake that leads to significant low body weight

• Intense fear of gaining weight or becoming fat
• Altered perception of body weight or shape
Bulimia Nervosa
• Recurrent episodes of binge-eating and BOTH:

o Eating a larger amount of food in a short period of time than normal o
Lack of control overeating
• Recurrent purging: self-induced vomiting, misuse of laxatives, diuretics, fasting or excessive
exercise
• Binge-eating and purging both occur at least once a week for 3 months
• Self perception is unreasonably influenced by body shape and weight
Binge-eating disorder
• Recurrent episodes of binge-eating and BOTH:

o Eating a larger amount of food in a short period of time than normal o
Lack of control overeating
• Binge-eating episodes are associated with 3 or more of the following:
o Eating quickly, until uncomfortably full, or alone due to
embarrassment o Eating large amounts of food when not
physically hungry o Feeling disgusted with oneself or guilty
afterward
o Marked distress regarding binge-eating
• Binge-eating occurs at least once/wk. for 3 months
• Binge-eating is not associated with purging

Desired Outcome
Client will verbalize understanding of nutritional needs. Client will improve weight toward
normal range. Client will establish more realistic body image. Client will demonstrate
compliance with therapy and treatment. Subjective Data Outcome
• Obsession with calories or fat content of foods
• Depression
• Fear of gaining weight
• Denial of low body weight
• Constipation
• Feeling cold most of the time
• Feeling tired
• Muscle weakness
• Chronic sore throat
• Abdominal pain
• Eating alone or in secret
• Frequent dieting
*Note – the presence of these symptoms individually do not indicate an eating disorder, assess
the full clinical picture.
Objective Data
• Restricted eating
• Emaciation
• Low blood pressure
• Infertility
• Lethargy
• Brittle hair and nails
• Dry, yellowing skin
• Muscle wasting
• Thinning bones
• Eating very fast
• Growth of hair all over the body (lanugo)
Perform complete nursing assessment noting skin, muscle tone and neurological status; include
weight (BMI) and vital sign assessment
RATIONALE
Get a baseline for effectiveness of interventions. Note any deficits or other issues that may
need to be prioritized.
Determine severity of condition.
Assess nutritional status and set a weight goal

RATIONALE
Determine if client is under or overweight and nutritional needs
Assess client for depression and suicide potential

RATIONALE
Clients with eating disorders often have accompanying depression with suicidal thoughts.
Monitor for safety.
Supervise client during meals and for at least one hour after eating (in inclined treatment)
RATIONALE
Determine client’s eating habits and prevent purging after meals.
Encourage liquid intake over solid foods

RATIONALE
Eliminates the need to choose foods, provides hydration and is more easily digested.
Provide small meals and snacks appropriately

RATIONALE
Prevents bloating and discomfort in clients following starvation and encourages eating more
appropriate portions.
Monitor for signs of food hoarding or disposing of food.

RATIONALE
Clients may try to hoard food for secretive eating or dispose of food to avoid calories.
Monitor exercise program and set limits and goals accordingly

RATIONALE
Moderate exercise helps maintain muscle strength and tone, but excessive exercise burns too
many calories and contributes to clients’ disorder.
Alternatively, lack of exercise can lead to depression, muscle wasting and increased weight and
a negative self image.
Administer TPN supplemental nutrition as appropriate

RATIONALE
In cases of severe malnourishment and life-threatening situations, TPN may be used to maintain
gastric function and provide nourishment.
Monitor fluid balance and administer oral and IV fluids as appropriate

RATIONALE
Failure to eat or drink and repeated purging through vomiting or excessive use of laxatives can
cause a fluid imbalance and lead to dehydration. Prevent electrolyte imbalances and cardiac
involvement by maintaining adequate hydration.
Record routine weights per facility protocol

RATIONALE
Monitor progress of interventions and incorporate routine accountability checks for clients.
Monitor skin for wounds, dryness, excoriation, or deep tissue injuries

RATIONALE
Lack of hydration and proper nutrition lead to decreased perfusion and poor circulation.
Dryness and itching are common. Wounds may develop over bony prominences.
Administer medications appropriately

• SSRI antidepressants
• Anti-anxiety medications
•Psychostimulants
RATIONALE
Medications may help relieve the underlying conditions that increase symptoms by improving
mood and thinking.
Psychostimulants have proven helpful in studies to help treat binge-eating disorder and
maintain weight.
Some medications may be given to curb appetite so that cognitive behavior therapy may be
more effective.
Provide education for clients and family members regarding disease, treatment and support
resources
RATIONALE
Help client and family members make informed decisions and reduce stress and anxiety about
treatments. Provide opportunity for continued support and therapy for optimal recovery.
References
https://www.opalfoodandbody.com/wp-content/uploads/2016/01/summary-of-dsm-5.pdf
https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml
https://npwomenshealthcare.com/continuing-education-practical-strategies-for-the-diagnosisand-management-of-binge-eating-disorder/
Anorexia – Signs and Symptoms

ANOREXIA
• A-Amenorrhea
• N-No organic factors account for weight loss
• O-Obviously thin but feels FAT
• R-Refusal to maintain normal body weight
• E-Epigastric discomfort is common
• X-X-symptoms (peculiar symptoms)

• I-Intense fears of gaining weight
• A-Always thinking of food
Anorexia nervosa is an eating disorder characterized by low body weight and periods of
starvation or binging and purging. The lack of adequate nutrition and fat stores can lead to
amenorrhea. Patients with anorexia will feel fat even if underweight, as anorexia is an
unhealthy way to cope with emotional problems. Binging and purging can lead to damage of
the GI tract and epigastric discomfort. Some peculiar symptoms may also be seen abnormal
blood counts, bluish discoloration of the fingers, hair that thins, breaks or falls out, or soft
downy hair covering the body.
Bulimia – Signs and Symptoms 1

BULIMIA
• B-Binge eating
• U-Under strict dieting
• L-Lacks control/over-eating Induced vomiting
• M-Minimum of two binge eating episodes
• I-Increase/Persistent concern of body size/shape
• A-Abuse of diuretics and laxatives
Bulimia is an eating disorder characterized by binging and purging. Patients may go through
periods of excessive eating and then try to purge be inducing vomiting, taking laxatives or
diuretics, or going through periods of fasting.
Bulimia – Signs and Symptoms 2

WASHED
• W-Weight loss of 15% of original body weight
• A-Amenorrhea
• S-Social withdrawal
• H-History of high activity and achievement
• E-Electrolyte imbalance
• D-Depression / Distorted Body Image
Bulimia is an eating disorder characterized by binging and purging. Patients may go through
periods of excessive eating and then try to purge be inducing vomiting, taking laxatives or
diuretics, or going through periods of fasting. Because they can be malnourished, they may look
"Washed out"
Bulimia Effects on Teeth
Bulimia Effects on Body

Anorexia
QUIZ
Question 1 of 5
The nurse is caring for a client with a poor appetite. The nurse notes that the client is consuming less
than 10% of meals and does not snack in between meals. Which of the following is NOT an
appropriate intervention? Select all that apply.
• Ask the client about food preferences and things the client dislikes
• Informing the client to call when hungry rather than continuing to waste food
• Requesting the nutrition staff to stop bringing trays
• Calorie counting
• Dietary supplements
Question 2 of 5
A nurse is assessing a client who is being seen for malnutrition associated with a history of anorexia.
Which of the following characteristics of the nervous system would the nurse expect to see in this
client?
• Peripheral neuropathy
• Hyperactive reflexes
• Confusion and stupor
• Dilated pupils
Question 3 of 5
A 21-year-old client with anorexia has been given the nursing diagnosis of Altered Nutrition: Less than
Body Requirements related to an unwillingness to eat and demonstrated by severe weight loss to less
than 100 lbs. Which nursing intervention is most appropriate that should be included as part of the
client’s ongoing assessment?
• Have the client document all food intake

• Encourage the client to participate in mild exercise
• Offer liquid nutrition supplements for added calories
• Consult a dietitian for nutrition recommendations
Question 4 of 5
A nurse is assigned to care for a client with bulimia nervosa and assists the client to order a meal.
Which of the following actions is important for the nurse to take regarding mealtime?
• Allowing the client privacy during mealtime

• Observing the client for 1-2 hours after the meal
• Emphasizing that it is the client's responsibility to re-establish trust in the nurse-client
relationship
• Allowing as much time as possible for the client to finish the meal
Question 5 of 5
A nurse is discussing inpatient treatment options for a client who has an eating disorder. The client
wants to try to manage the condition independently instead. Which response from the nurse is most
appropriate?
• Based on your condition, I think inpatient treatment is your best chance of recovery, but I will
respect your decision.
• Do you think that is a good idea?
• Ok, but you will not have a good outcome if you do that. I am only trying to help you
• I'm sorry to tell you, but because you are seeking treatment now, I am required by law to
commit you to a facility for eating disorders
Alcohol Withdrawal (Addiction)

Overview
1. Definition: a set of symptoms that result after one attempt to quit or abruptly stops
consuming alcohol for a long period of time.
1. The brain gets used to chronic regular alcohol (ETOH) consumption resulting in
changes in brain chemistry, so once it abruptly stops, it goes into
withdrawal.
Nursing Points
General
1. Most hospitals have a protocol: assessment screening and PRN
administration of a
benzodiazepine (Librium, Ativan)
1. MINDS
2. CIWAA
2. It’s important to assess when the last drink was and how much they drink
daily
1. Very early signs can begin within a few hours
2. Signs and symptoms typically peak around 48-72 hours and

then go away after
2-3 days…unless they go into delirium
3. Goal is to treat symptoms and prevent seizures, delirium

Assessment
1.
1. Minor Withdrawal (6+ hours after last drink)
1. Tremor
2. Anxiety
3. Nausea
4. Vomiting
5. Insomnia
6. Typically, they look malnourished
7. **Note – this feeling is what drives alcoholics to keep

drinking – to avoid feeling this way**
2. Major Withdrawal (10+ hours after last drink)

1. Above symptoms plus:
2. Whole body tremor
3. Seizures
4. Hypertension
5. Diaphoresis
6. Hallucinations
3. Withdrawal delirium (delirium tremens/DT’s) (3-10 days after
last drink)
1. Above symptoms plus:
2. Global confusion (hallmark)
3. High Fever
4. Autonomic Instability (Hypertension, Tachycardia)
5. Disorientation
6. Severe Hallucinations
7. Agitation
8. Severe Diaphoresis
1.
1. Monitor for withdrawal delirium – this is a medical emergency
1. People die from this from an MI, aspiration pneumonia,
fat
embolism.
2. Meds
1. Benzodiazepines for withdrawal
1. Usually utilize CIWAA scoring protocol to
drive
administration of meds
2. Vitamin replacement
1. Banana bag / rally pack / IV fluids with added vitamins
(Especially thiamine)
2. Vitamin B12 injection + PO for several days to attempt to prevent encephalopathy
3. Antabuse: deterrent for ETOH, produces an acute sensitivity to

ETOH.
1. Become violently ill within about 5 min and can last up
to 2 hours.
2. No alcohol 12 hours before first dose.
3. Educate patients about not consuming mouthwashes,
cold meds, various aftershaves, or anything else that
may contain alcohol, as it may elicit a reaction
4. Educate those effects of Antabuse may continue for

several days after they stop taking it
3. General interventions for the patient
experiencing alcohol withdrawal
1. Assess and monitor vitals and neuro
check frequently
2. Assess alcohol withdrawal protocol
and provide meds per protocol
3. Seizure and fall precautions
4. May need a sitter
5. Reorient as needed
6. May need to give antiemetics meds

before eating if they do eat
7. Maintain a safe, quiet, calm

environment
8. After acute withdrawal phase is over,

patient will need long term therapy
and support (Connect with Social
Work)
1. Alcoholics Anonymous
2. Halfway houses
3. Meds
4. Therapy (one-on-one or group)
5. Family support and therapy (support groups available for family members)
4. Interacting with a patient addicted to alcohol

1. Assess risk for self-harm and suicide
2. Try to identify what triggers alcohol

use
3. Promote boundaries and accountability
4. be consistent with rules and

consequences
5. Identify strengths, focus there
6. Promote various support groups,

therapy
Nursing Concepts
1. Mood Affect
2. Coping
3. Gastrointestinal/Liver Metabolism
Patient Education
2. Help them understand what to expect in the

coming days to ease anxiety
1. “You’re in a safe place”
2. “Things might get worse before they get

better, but we’re going to take good care of
you”
3. s/s to report to nurse or provider
STUDY TOOLS:
Alcohol Withdrawal Syndrome / Delirium Tremens
Pathophysiology
When a person regularly consumes large amounts of alcohol over a prolonged period of time
(usually years), the body becomes physically dependent upon that substance. Alcohol
withdrawal syndrome (AWS) is a set of symptoms that occur when a heavy drinker suddenly
stops or significantly reduces their consumption of alcohol. The neurological and physical
symptoms that ensue typically worsen over a period of 2-3 days before subsiding and mild
symptoms may continue for weeks. The most severe symptom of withdrawal is delirium
tremens (DT) which constitutes a medical emergency as it may be life-threatening. Treatment
for AWS and DT is geared toward initially managing symptoms and continuing with medications
and counseling or psychotherapy to treat the underlying cause of alcoholism.
Etiology
Symptoms are not caused by any other medical condition or mental illness, or withdrawal from
another substance.
• Cessation or significant reduction in alcohol intake
• Any of the 2 following symptoms developing over several hours to a few days:
o Autonomic hyperactivity o Worsening tremor o
Insomnia o Nausea and vomiting o Hallucinations o
Psychomotor agitation o Anxiety
o Generalized tonic-clonic seizures
• Symptoms cause significant distress or impairment in social or occupational functioning
Desired Outcome
Client will maintain or regain appropriate level of consciousness with absence of hallucinations.
Client will demonstrate ability to regain control of daily activities and functioning. Client will
remain free from injury. Client will have vital signs that are within normal limits for that client.
• Headaches
• Anxiety
• Confusion
• Heart palpitations
• Nausea
• Hallucinations
• Sensory perception disturbances (visual impairment, crawling sensation on skin, hearing
impairment)
• Inability to think clearly Objective Data
• Restlessness
• Confusion
• Seizures
• Tremors
• Vomiting
• Uncontrollable sweating
• Agitation
• Loss of or changes in level of consciousness
• Fever
• Cardiac dysrhythmias
• Hypertension
• Tachycardia
• Respiratory depression
Perform complete nursing assessment and assess vital signs
RATIONALE
Get baseline to determine effectiveness of interventions.
The sympathetic nervous system response may cause elevated temperature, high blood
pressure, tachycardia, and severe respiratory depression.
Determine stage of AWS

• Stage I – hyperactivity
• Stage II- hallucinations and seizure activity
• Stage III- DTs, confusion, fever, and anxiety
RATIONALE
Help determine appropriate interventions and prevent progression of symptoms
Perform 12-lead EKG per facility protocol

RATIONALE
Monitor for cardiac dysrhythmias and irregularities.
Monitor respiratory status and administer supplemental oxygen

RATIONALE
Severe respiratory depression may occur and requires immediate intervention.
Maintain patent airway and monitor for aspiration

RATIONALE
Clients with vomiting and respiratory depression are at risk for aspiration. Advanced airway may
be required.
Initiate IV access and administer fluids

RATIONALE
Vomiting may lead to dehydration and fluid imbalance. Maintain cardiac function and cardiac
output.
Monitor lab results and administer supplemental electrolytes as needed

RATIONALE
Dehydration, diaphoresis and vomiting may result in electrolyte imbalances that can cause
cardiac dysrhythmias.
Initiate seizure precautions per facility protocol

RATIONALE
Seizures are often contributed to low magnesium, hypoglycemia, or elevated blood alcohol
levels.
Antiepileptic drugs are not indicated for seizures associated with AWS as they typically resolve
spontaneously. Symptomatic treatment and safety are recommended.
Provide calm and safe environment, free from clutter, noise and shadows
RATIONALE
Sensory disturbances, hallucinations and confusion can lead to severe injury. Hallucinations
often occur more at night and clients in advanced stages may experience anxiety and fear.
Monitor client for signs of depression or suicidal ideation. Initiate suicide precautions as
necessary per facility protocol
RATIONALE
Confusion and anxiety may prompt client to attempt suicide or self-destruction.
Provide isolation or restraints as necessary per facility protocol

RATIONALE
During periods of excessive psychomotor activity, hallucinations and anxiety, restraints may be
required temporarily to prevent harm to client or others.
Reorient client to reality as often as needed in a calm and supportive manner

RATIONALE
Confusion, anxiety and hallucinations may cause periods of delirium. Reorientation helps calm
fears and relieve anxiety.
Administer medications as appropriate and required

RATIONALE
Anti-anxiety medications may be given to reduce hyperactivity and promote sleep.
• Benzodiazepines are also used to prevent seizures and manage severe tremors and withdrawal
symptoms.
• Specifically, lorazepam.
Antidepressants may be given to help client regain control of daily functioning and improve
ability to concentrate and participate in therapy or counseling.
Provide education and resources for client and family members

RATIONALE
Resources, support groups and counseling services may help client and family members manage
client’s needs going forward and help maintain relationships and daily functioning
References
https://online.epocrates.com/diseases/54936/Alcohol-withdrawal/Diagnostic-Criteria
https://www.healthline.com/health/alcoholism/withdrawal#diagnosis
https://www.therecoveryvillage.com/alcohol-abuse/withdrawal-detox/#gref
QUIZ
Question 1 of 10
The nurse is caring for a client who is an alcoholic with a history of seizures while going through
withdrawals. The nurse is setting up the room and implementing seizure precautions. Which of the
following does the nurse ensure is included in the client’s plan of care?
• PRN pain medication ordered

• Call light within reach
• Head of bed at 45 degrees
• Padded side rails
Question 2 of 10
The nurse is caring for a client who presents to the ER with complaints of a fall with a laceration to the
right arm. The client is slurring their speech. All vital signs are within normal limits. Which substance
should be suspected in this client?
• Methamphetamine
• Alcohol
• Cocaine
• Heroin
Question 3 of 10
The nurse is working in the emergency department caring for a client with delirium tremens and
severe alcohol withdrawal. Which question is the priority?
• When was your last drink and how much do you usually drink?
• Has this ever happened before when you tried to stop?
• Do you go to AA?
• Have you stopped for good?
Question 4 of 10
A client has orders for lorazepam administration, seizure precautions, and a banana bag. The nurse
recognizes that this client is at risk for which of the following conditions?
• Hypoactive delirium
• Epilepsy
• Alcohol withdrawal
• Sundowner's syndrome
Question 5 of 10
After being admitted as an inpatient for treatment of substance abuse, a client becomes confused and
disoriented and is demonstrating tachycardia, sweating, and tremor. Which nursing intervention is
most appropriate for management of this client?
• Provide warm blankets to promote client comfort

• Administer benzodiazepines to control symptoms
• Obtain an order to begin monitoring pulse oximetry
• Reduce fluid intake to prevent aspiration
Question 6 of 10
A client is admitted to the floor from the ER for Ulcerative Colitis complicated with infection. The
client is slurring their words and stumbling. The nurse notes empty mini vodka bottles in the client
belonging bag. The client reports that they drink every day and asks the nurse to get them more
vodka. What is the nurse’s priority at this time?
• Apply soft wrist restraints for safety

• Get a 12-lead EKG (ECG)
• Place client on a withdrawal protocol
• Administer IV antibiotics
Question 7 of 10
While working with a client who is experiencing acute alcohol withdrawal, a nurse performs an
assessment by asking the client to drink a glass of water. Which best explains the significance of this
test?
• To assess the client's cognitive ability

• To determine if the client can follow directions
• To see if the client has polydipsia
• To check for hand tremor in the client
Question 8 of 10
A client is undergoing acute alcohol withdrawal and is experiencing delirium tremens. Which nursing
diagnosis would most likely be associated with this condition?
• Readiness for Enhanced Nutrition

• Ineffective Thermoregulation
• Impaired Urinary Elimination
• Activity Intolerance
Question 9 of 10
A nurse arrives at work in the psychiatric unit and is given the assignments for the day. The nurse has
a client who is experiencing delirium tremens after alcohol withdrawal and needs medication, a client
who will be undergoing ECT later that day, a client with obsessive-compulsive disorder who has not
had breakfast yet, and a client who needs to go to eating disorder group therapy. Which client should
the nurse see first?
• The client who needs breakfast

• The client receiving ECT later
• The client going to group therapy
• The client with delirium tremens
Question 10 of 10
The nurse is caring for a client admitted for alcohol addiction. Which of the following questions is the
priority at this time?
• "Does anyone else in your family also suffer from alcohol addiction?"
• "Have you ever purposefully hurt yourself or tried to end your life?"
• "Have you ever been to treatment for this addiction?"
• "Have you had any legal consequences because of your addiction?"
Grief and Loss

Overview
1. Grief – The natural human response of deep sorrow after the loss (death, separation) of
someone important, and the attempt to deal with that loss
2. Loss – Definition: state or feeling of grief when deprived of someone or something of

value
1. The expression of mourning has cultural, spiritual, and/or religious

influences
on how this is expressed
Nursing Points
General
1. Grief
1. Grief in children depends on where they are developmentally
1. May not understand death as permanent until adolescent
years
2. May regress
2. The typical grief response occurs in 3 stages, but there is NO standardized grief
response or timeline
1. Shock and disbelief
1. Numbness
2. Labile emotions
3. Isolation
2. Experiencing the loss
1. Anger
2. Guilt
3. Bargaining
4. Depression
3. Reintegration
1. Reorganization of life
2. New relationships
Assessment
1. Types of grief
1. Normal
1. Can take months-years
2. Various reactions can occur

2. Anticipatory
1. Grief that occurs prior to the death because loved ones
know it is
eventual
2. For example, terminal illness

3. Disenfranchised
1. When a loved one cannot grief openly
2. May be due to strained relationship or cultural norms

4. Dysfunctional
1. A deviation from “normal” grieving
2. Unhealthy coping mechanisms
3. Lack of resolution
5. Complicated
1. An ongoing, heightened state of mourning that
prevents healing
and limits daily functioning
2. Think of it like a wound ‘complication’, but emotional
3. Extreme focus on their death or their memory
4. Problems accepting the loss
5. Wish they had died, too
6. And many more

2. Loss can be sudden or anticipated
1. Your role in supporting loved ones during grief and loss
1. Facilitate grief process, support emotionally
1. They may be upset, emotionally labile, crying, etc.
2. Assess religious, cultural, spiritual beliefs and influences; make
sure to follow
customs appropriately
3. Establish trust and rapport

4. Express empathy
5. Involve health care team

1. Child life specialists
2. Social workers
3. Palliative care
4. Chaplains or other religious leaders
5. Bereavement specialists
Nursing Concepts
1. Mood Affect
2. Grief
Patient Education
1. There is no right or wrong way to grieve
2. Feelings are valid
3. Healthy coping mechanisms
QUIZ
Question 1 of 10
Which of the following situations best describes acute grief?
• A client commits suicide because he can no longer handle the sadness of a break up
• A nurse sits with a client while he cries over the death of his father
• A person is suddenly overwhelmed and starts to cry when she sees a picture of her deceased
friend
• A client feels extreme pain over the death of a child four months earlier
Question 2 of 10
A client is suffering from feelings of loss after experiencing a miscarriage. Which action of the nurse
would best support this client in working through her grief?
• Explain that the client will have these feelings for a time, but she will eventually forget the
intense pain
• Remind the client that it is important for her to be strong for her family
• Help the client to see that hard feelings will go away sooner if she does not talk about it
• Tell the client that she will need time to mourn her loss, and eventually will learn to cope with it
Question 3 of 10
A nurse is caring for a woman whose mother died six months ago and who is grieving over the loss.
The nurse assesses the woman for any signs of complicated grief patterns. Based on the nurse’s
understanding of this condition, the nurse knows to look for what signs that indicate complicated
grief? Select all that apply.
• A complete focus on the deceased person

• Feelings of detachment from the world
• Lack of emotion such as crying or sorrow
• An increase in sexual activity
• A lack of trust in others
Question 4 of 10
A nurse is caring for a client who lost her father to cancer last year. The client is demonstrating
dysfunctional grief in that she has intense feelings of guilt over the situation. Which of the following
factors would increase a person’s risk of developing dysfunctional grief?
• Social isolation in the grieving person

• A prior experience with loss
• A lack of religious beliefs
• The age of the person when they died
Question 5 of 10
The parents of a 1-year-old child who has been adopted from Ethiopia ask the nurse about the child’s
feelings of grief. The mother tells the nurse, “I do not think the understands the loss at one year old.”
Which response from the nurse is correct?
• Even infants can feel grief and loss, even without conscious memory at this age
• The child will not remember this. I would not be concerned with grief
• A child does not start to feel grief until he is about 3 years old
• You should start counseling with the child now so that the child can talk about this grief later
Question 6 of 10
Which best describes disenfranchised grief?
• Grief over a loss that cannot be publicly shared

• Grieving in a manner that does not follow normal patterns
• Grieving over something that has yet to happen

• Grief that is accompanied with physical complaints
Question 7 of 10
The parents of a 2-year-old child who died of leukemia are experiencing intense grief in the months
following the death. Which of the following is a factor that would affect how these parents experience
grief?
• The personality of the grieving person

• The life history of the person who died
• The illness of the person who died
• The gender of the deceased person
Question 8 of 10
A 58-year-old client is feeling sadness and loss after his mother died. Which best describes the
difference between grief and depression?
• A grieving person may have feelings of hopelessness, but a depressed person would act on those
feelings
• A grieving person may suffer mild delusions in their grief, but a depressed person never has this
type of thought pattern
• A grieving person may have sadness but also sometimes of joy, while a depressed person's
feelings are constant
• A grieving person experiences sadness and loss but a depressed person experiences guilt and
anger
Question 9 of 10
A hospice nurse is helping a family whose loved one died thirty minutes ago. What kind of grief is the
family experiencing?
• Dysfunctional grief
• Anticipatory grief
• Acute grief
• Palliative grief
Question 10 of 10
A 35-year-old client is undergoing a lower limb amputation after a crushing injury. Which best
describes how the nurse can support the client’s anticipated grief during this time?
• Assist the client to verbalize feelings related to the loss of a body part
• Help the client to wrap the extremity to take care of it
• Have the client look at images of people who have lost a limb to get used to it
• Ask the provider for medications to manage anxiety
1. People with a previous history of suicide
2. Family history of suicide
3. Mental illness history: personality disorders, substance abuse, psychosis, people
with depression
4. People with terminal illnesses, people with disabilities
5. Elderly and adolescents
Suicidal Behavior
Overview
1. Patients with a consistent feeling of hopelessness, guilt, and worthlessness that are so
overwhelming that they don’t want to live anymore and attempt to end their life
Nursing Points
General
1. Most at risk:
Assessment
1. Things to watch for:
1. When they give away important, prized possessions
2. Creating a will or changing an existing one
3. Sleep disturbances
4. Difficulty concentrating, loss of interest in things
5. Appetite reduction
6. Asking about methods to end one’s life
7. Writing notes to loved ones
8. Sudden massive improvements in previously very depressed clients

1. Now be motivated/energy
2. Relief because they came up with a decided

1. Always assess patients with a history of depression for risk for suicide and self-harm
2. Safety is ESSENTIAL – inpatients admitted with suicide attempts are not to be left alone,
any items that could be used for self-harm are removed from their room
3. Things to do:
1. SAFETY
2. Follow your facility’s protocols

1. Suicide precautions (typically includes removing all objects that
could be used to harm self from room)
2. Sitter / 1:1 supervision
3. Never leave patient alone
4. Screen visitors (some facilities don’t allow any)

1. Assess room after to ensure nothing unsafe was left
3. Establish a suicide contract
4. Establish rapport and trust
5. Express empathy
6. Promote self-care / ADL’s
7. Focus on strengths
8. Suggest/encourage simple, achievable tasks
9. Provide positive reinforcement
10. Involve the support system the patient identifies
11. Encourage therapy (individual, group)

Nursing Concepts
1. Mood Affect
2. Coping
3. Safety
STUDY TOOLS:
Suicidal Behavior Disorder
Pathophysiology
Suicidal Behavior Disorder describes a client who has attempted suicide in the past two years
and includes unsuccessful attempts and completed suicides. Non suicidal self-injury is when a
client inflicts self-injury without the intention to result in death and may also be considered as a
precursor to suicidal behavior. While suicide is not a mental illness of itself, it usually stems
from another, underlying condition such as depression, bipolar disorder, PTSD or schizophrenia.
Studies indicate that clients who typically have completed suicides are primarily men, as men
tend to choose more lethal forms of injury (gun, jumping from heights, etc.) and women use
less lethal methods such as drug overdose. All suicide threats or attempts should be taken
seriously for all people, regardless of age or gender.
Etiology
Current disorder: the most recent suicide attempt has been within the past 24 months
Disorder in remission: the most recent suicide attempt was longer than 24 months ago
• The individual has attempted suicide in the past two years
• Criteria for “non-suicidal self-injurious behavior” was not met prior to previous suicide attempts
• The diagnosis does not apply to a person’s preparation for a suicide attempt, or suicidal ideation
• The suicide attempt was not done during an altered mental state (delirium, confusion, substance
use)
• The attempted suicide was not motivated by religious or political ideas
Desired Outcome
Client will not attempt suicide. Client will remain safe, without self-inflicted harm. Client will
identify alternative activities or support systems to prevent future suicide attempts. Subjective
Data Outcome
• Excessive sadness
• Sudden calmness following a deep sadness
• Feelings of hopelessness
• Changes in personality
• Sleep difficulty
• Moodiness
• Verbal or written threat of suicide
• Family history of suicide
• History of substance abuse
Objective Data
• Withdrawal from society
• Self-harmful behavior
• Recent trauma or crisis
• Giving away personal possessions
• Purchase of firearm or poisonous substance

• Recent release from prison or psychiatric institution
• Changes in personal appearance (lack of hygiene)
• High-risk behaviors
Perform neurological assessment
RATIONALE
Determine baseline and if there are other neurological conditions present that may cause
symptoms.
Initiate one-on-one monitoring at arm’s length per facility protocol. Avoid leaving client
unattended for any reason (including and especially bathroom or shower time) RATIONALE
Ensure client safety and remove opportunity to harm self.
Create a safe environment by removing potential weapons or objects that may inflict harm
(Weapons, utensils, sharp objects, belts, ties, etc.)
RATIONALE
Provide safety and remove items that may be used impulsively during actively suicidal phase.
When possible, remove monitor cables and electrical cables that are not being actively used.
Encourage client to discuss feelings, emotions, fears and anxieties and alternative ways to cope
with those feelings
RATIONALE
To determine the cause, if any, of client’s actions or thought processes.
Helps client gain a sense of control over actions and life in general
Emphasize resiliency with client to understand that

• The crisis is temporary, but their actions are permanent
• Help is available
• Pain can be overcome
RATIONALE
Help clients see that there are other ways of dealing with circumstances and give them
perspective and hope
Assess for signs that the client has a plan to commit suicide
• Ask if they have a specific plan
• Suddenly calm or appears happy or relieved
• Giving away personal possessions
RATIONALE
Ask specifically “do you have a plan?”. The client may even state “yes, I’m going to take that
cable and hang myself with it” – this allows you to remove these objects from their reach.
Clients who have made the decision to follow-through with a planned suicide attempt may
suddenly feel calm or relieved. This can be hard for caregivers or family members – they may
perceive it as the client getting better.
Obtain history from client and family members

RATIONALE
Determine if client has a personal or family history of suicide that would increase their risk, or
any recent catastrophic events that may have prompted such behaviors (death of a loved one,
loss of job, divorce, etc.)
Assist client in creating and sign a no-suicide contract

RATIONALE
Demonstrates an alternative plan for coping when they feel suicidal instead of acting on
impulses.
Allows client to feel more in-control of actions and promotes accountability
Identify situations or triggers and ineffective coping behaviors that may result in suicidal
thoughts or actions
RATIONALE
To determine most appropriate interventions and develop more positive coping techniques
Carefully and compassionately make client aware of unrealistic or destructive thinking and offer
alternative or more realistic ideas and explanations
RATIONALE
Constructive interaction helps client become more open to realistic and satisfying opportunities
for the future
Discuss and identify things that are important to or have meaning for the client (religious beliefs,
family, goals, and dreams)
RATIONALE
Helps refocus client’s thinking and priorities and renews potential for attaining goals. Provides
support and encouragement. Gives client something to hope for.
Teach positive problem-solving techniques

RATIONALE
Helps client identify and learn more creative and positive avenues for coping with stress
Enlist client’s family members or friends to be available for client to call on in cases of crisis
RATIONALE
Gives a sense of value to the client and reminds them that they are not alone. Provides a support
system for the client. Helps family and friends understand the struggles that the client is facing.
Administer medications carefully and appropriately

RATIONALE
Antidepressants and anti-anxiety medications may be given to improve client’s daily functioning
ability and provide relief during crisis situations.
Provide resource information for support groups, hotlines and counselors that are available
24/7
RATIONALE
Gives client support and more resources to help cope with emotions and underlying conditions
such as substance abuse
References
https://www.theravive.com/therapedia/suicidal-behavior-disorder-dsm--5
https://www.webmd.com/mental-health/recognizing-suicidal-behavior#1 https://www.merckmanuals.com/home/mental-health-
disorders/suicidal-behavior-and-selfinjury/suicidal-behavior
QUIZ
Question 1 of 10
A client with depression has been taken to the emergency department by a friend after making
statements that he was contemplating suicide. The provider has ordered that the client be admitted
for inpatient treatment but the client refuses. Which of the following best explains the client’s rights
in this situation?
• The client is not safe, and the nurse should fill out a petition to legally keep the client
• The client does not have the right to refuse treatment and should be placed in restraints
• The client may refuse inpatient treatment but must agree to outpatient therapy
• The client, if competent, has the right to refuse inpatient treatment
Question 2 of 10
A client reports feeling profoundly depressed and states that he came to the hospital because he feels
like he wants to end his life. Which medication is appropriate for this client?
• Phenazopyridine
• Propranolol
• Paroxetine
• Phenytoin
Question 3 of 10
A psych nurse is floated to the emergency room to help with the number of psych clients that are
being triaged. The psych nurse knows to see the client with which of the following first?
• ETOH of 200 mg/dl
• Depression with suicidal ideation
• State of mania, thinks bugs are crawling all over
• Severe depression and has not eaten for 2 days
Question 4 of 10
A client with a history of severe depression and anxiety is in the hospital after attempting suicide.
Which evidence would most likely be seen that indicates a crisis in a person with a mental illness?
• The client has increased interest in personal hygiene
• The client is socially withdrawn
• The client is crying
• The client is unable to concentrate
• The client has not slept for several nights in a row
Question 5 of 10
A client with post-traumatic stress disorder has been brought into the emergency department after
attempting suicide by carbon monoxide poisoning. The nurse assesses the client and finds that the
client is short of breath, with a respiratory rate of 30/min, HR 98 bpm, and a blood pressure 110/80
mmHg. The client is irritable and withdrawn and his wife is at his side. Which intervention is the
highest priority in this situation?
• Ask the client why he tried to end his life
• Help the client's spouse by making her comfortable and providing support
• Administer oxygen and connect the client to a hemodynamic monitor
• Contact the provider for a prescription for antidepressants
Question 6 of 10
The nurse is leading group therapy in a behavioral health unit. Which client concerns the nurse the
most?
• The client on lithium who has discussed the desire to get pregnant
• The client with a history of schizophrenia whose father passed last week, and who refuses to get
out of bed
• The client with anorexia meticulously arranging food on the tray, who has not eaten a bite
• The client with severe depression who reports a sudden and profound improvement in mood
Question 7 of 10
The provider has finished seeing four clients in the emergency room. The nurse should first assess the
client with which condition?
• Suicidal ideation
• Fishing hook lodged in his forehead
• Persistent back pain
• Injury to the right leg with obvious deformity
Question 8 of 10
Which of the following situations are risk factors for suicide? Select all that apply.
• The client is under 10 years of age
• The client is terminally ill
• The client has an adequate support system
• The client has a history of suicide attempts
• The client has been consistently rejected by peers
Question 9 of 10
A client with suicidal ideation is undergoing dialectical behavior therapy. The nurse should educate
the client to expect which type of treatment?
• Both individual and group counseling
• An inpatient, solitary program
• A 12-step program in the community
• ECT in conjunction with outpatient therapy
Question 10 of 10
Common symptoms of impending suicide include which of the following? Select all that apply.
• Changing a will
• Sudden improvement in a depressed client
• Interacting with peers
• Canceling social engagements
• Giving away belongings
References
https://www.mayoclinic.org/diseases-conditions/inflammatory-bowel-disease/diagnosis-treatment/drc-
20353320
https://www.cdc.gov/ibd/what-is-IBD.htm
Midwifery (2010) • A.C. Brathwaite et al. Childbirth experiences of professional Chinese Canadian women
Journal of Obstetric, Gynecologic & Neonatal Nursing (2004)
http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/
https://www.medicinenet.com/inflammatory_bowel_disease_intestinal_problems/article.htm
https://medlineplus.gov/ency/patientinstructions/000204.htm

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Module 3 Mental Health Nursing FBNPC

2. Acute: sudden, related to an event/threat (also normal)

3. Chronic: consistent, related to normal daily activities

2. Moderate: can still function and solve problems/issues

3. Severe: individual needs someone to refocus them

4. Panic: dread, impending doom, loss of rational thoughts and

2. Provide calming and safe environment

3. Establish trust / rapport

4. Acknowledge the anxiety

5. Encourage expression of thoughts, feelings, problem solving

6. Promote their coping mechanisms; do not critique / criticize

7. Provide gross motor activities

2. Examples: running, walking, jumping

2. Interventions for an acute anxiety attack

2. Have an action plan

• Anxiety can be motivating and increase learning

• Increased respiratory rate

• Increased heart rate

• A resolution of the client's anxiety symptoms

• Ask the client to help with certain tasks, such as starting an IV

• Assist with admitting the client to the psychiatric unit

• Maintain a calm demeanor

Generalized Anxiety Disorder

2. The symptoms can’t be explained by other physiological disorders

5. “On edge” all the time

6. Patient is hyper-focused on physical symptoms

1. Determine what thoughts initiated/ triggered the attack

2. Reorient them or rationalize thoughts

3. Help to restructure distorted thoughts

4. Treat/medicate for anxiety first

5. Address physical symptoms

• Chest pain or tightness

Obtain 12-lead EKG

Determine if client is having homicidal or suicidal ideations

Establish trust with the client

Maintain a calm and comforting demeanor while working with client

Use desensitization approaches carefully

Administer medications appropriately (benzodiazepines)

Avoid allowing personal thoughts, feelings, or anxiety to interfere with care

Generalized Anxiety Disorder Pathochart

• Difficulty functioning in social or occupational areas

• Arrange for the client to be committed to long-term inpatient care

• Determining the client's type of sleep disorder

• Cognitive behavioral therapy

• The client needs direction to focus

Posttraumatic Stress Disorder (PTSD)

2. Other mental health issues: depression, anxiety

6. Guilt related to the event

2. If they would have done something differently

2. Promote the coping mechanisms that work for them

5. Therapy / service animals

2. Connect with community resources

• Easily startled or frightened

Assess client for suicidal or homicidal ideations

Assess anxiety level

Establish trust with the client

Encourage client to express emotions in a safe environment

Encourage client to verbally identify current ineffective coping techniques

Encourage client to write about the traumatic event

Administer medications appropriately and monitor for side effects or dependence