NCLEX-RN PREPARATION
PROGRAM
MENTAL HEALTH
DISORDERS
Module 6, Part 1 of 3
Module Description

This module will prepare the graduate nurse
to pass the NCLEX exam in the area of
mental health. Included in this module is a
review of the following areas:
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Therapeutic communication and milieu
therapy
Nursing process
Mental illnesses and disorders
Psychopharmacology
Life span development issues
2
Introduction
The nurse must be aware of the therapeutic or
nontherapeutic value of the communication
techniques used with the client—they are the
“tools” of psychosocial intervention.
3
What is Communication?

Interpersonal communication is a
transaction between the sender and
the receiver. Both persons participate
simultaneously.

In the transactional model, both
participants perceive each other, listen to
each other and simultaneously engage in
the process of creating meaning in a
relationship.
4
Communication
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Includes: dominant language, dialects,
contextual use of language;
Paralanguage variations such as voice volume,
tone, inflections and willingness to share
thoughts and feelings;
Nonverbal communications such as eye contact,
gesturing and facial expressions, use of touch,
body language, spatial distancing practices and
acceptable greetings;.
5
Communication

Communication is:
Temporary in terms of past, present and
future orientation of worldview;
Clock versus social time, and the
amount of formality in use of names
6
Communication
Therapeutic communication techniques
encourage the client or other individual with
whom the nurse is communicating to express
their thoughts and feelings.
7
Communication
Technique
Description
Active Listening
Carefully noting what
the client is saying and
observing the client’s
nonverbal behavior
Broad Openings
Encouraging the client
to select topics for
discussion
8
Communication
Technique:
Description:
Clarifying
Making the message
clearer, to correct any
misunderstanding, and to
promote mutual
understanding
Focusing
Directing the conversation
onto the topic being
discussed
9
Communication
Technique:
Description:
Informing
Giving information to the
client
Open-ended
questions
Encourage conversation
because questions
require more than just
one-word answers
10
Communication
Technique:
Description:
Paraphrasing
Restating in different
words what the client said
Reflecting
Directing the client’s
question or statement or
feelings back to the client
Silence
Allowing time for
formulating thoughts
11
Communication
Non-therapeutic Communication Techniques
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Approval/Disapproval
Asking excessive
questions
Changing the subject
Close-ended questions
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Giving advice
False reassurance
Value judgments
Why questions
Minimizing the client’s
feelings
12
NCLEX Communication
Question Guidelines

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Look for the option that indicates the use of a
therapeutic communication technique.
Eliminate non-therapeutic communication
techniques.
Look for the option that focuses on feelings,
concerns, anxieties or fears.
Consider cultural differences as you answer
the questions.
13
Impact of Preexisting Conditions

Both sender and receiver bring certain preexisting
conditions to the exchange that influence both the intended
message and the way in which it is interpreted.

Values, attitudes, and beliefs.
Attitudes of prejudice are expressed
through negative stereotyping.

Culture or religion.
Cultural mores, norms, ideas and customs
provide the basis for ways of thinking. How
do these affect the relationship?
14
Impact of Preexisting Conditions

Social status. High-status persons often convey
their high-power position with gestures of hands on
hips, power dressing, greater height, and more
distance when communicating with individuals
considered to be of lower social status.

Gender. Masculine and feminine
gestures influence messages conveyed
in communication with others.
15
Impact of Preexisting Conditions

Age or developmental level. The influence
of developmental level on communication is
especially evident during adolescence, with
words such as “cool,” “awesome” and others.
16
Impact of Preexisting Conditions
The environment in which the transaction takes
place. Territoriality, density, and distance are aspects
of environment that communicate messages.
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Territoriality – the innate
tendency to own space
Density – the number of
people within a given
environmental space
Distance – the means by which various cultures
use space to communicate
17
Communication
Cultural Considerations
With regard to communication, there are three
cultural characteristics to consider:
Communication style
Use of eye contact
The meaning of touch
The goal is to promote cultural sensitivity and
culturally competent care that respects each
person’s right to be understood and treated as a
unique individual.
18
Communication
Cultural Consideration
Communication Style
African Americans
• Personal questions asked on initial contact
may be viewed as intrusive
19
Communication
Cultural Consideration
Communication Style
Asian cultures
 Open expression of emotions not valued
 Silence is valued
 Criticism or disagreement not expressed
 Head nodding does not necessarily mean agreement
 May interpret the word “no” as disrespect for others
 Do not use hand gestures
20
Communication
Cultural Consideration
Communication Style
Americans of Northern European descent
 Silence can be used to show respect or
disrespect, depending on situation
 May show little facial emotion because they
value concept of self-control
21
Communication
Cultural Consideration
Communication Style
French and Italian Americans
 May use expressive hand gestures and
animated facial expressions
22
Communication
Cultural Consideration
Communication Style
Hispanic Americans
 May use dramatic body language such as
gestures or facial expressions to express
emotion or pain
 Confidentiality important
 Direct confrontation disrespectful, and
expression of negative feelings impolite
23
Communication
Cultural Consideration
Communication Style
Native Americans
 Silence indicates respect for the speaker
 Speak in a low tone of voice and expects
others to be attentive
 Body language is important
 Obtaining input from extended family
important
24
Communication
Cultural Consideration
Use Of Eye Contact
Asian Cultures
 Eye contact is limited and may be
considered inappropriate or disrespectful
25
Communication
Cultural Consideration
Use Of Eye Contact
European (White) Americans
 Eye contact viewed as indicating trustworthiness
Native Americans
 Eye contact may be viewed as a sign of disrespect
 Client may be attentive even when eye contact is
absent
26
Communication
Cultural Consideration
Use Of Eye Contact
Hispanic Americans
 Avoiding eye contact with a person in
authority indicates respect and attentiveness
27
Communication
Cultural Consideration
Meaning of Touch
African Americans
• Comfortable with close personal space when
interacting with family and friends
European (White) Americans
 Tend to avoid close physical contact
 Respect personal space
28
Communication
Cultural Consideration
Meaning of Touch
Asian Cultures
 Prefer formal personal space except with family & close friends
 Usually do not touch others during conversation
 Touching unacceptable with members of the opposite sex; if
possible, a female client prefers a female health care provider
 The head is considered to be sacred; touching someone on the
head may be considered disrespectful
 Avoid physical closeness and excessive touching and only touch
a client’s head when necessary, informing before doing so
29
Communication
Cultural Consideration
Meaning of Touch
Hispanic Americans
 Comfortable with close proximity with family,
friends and acquaintances
 Protect privacy
 Tactile and sensory are important - use
embraces and handshakes
 Ask if it would be all right to touch a child
before examining him or her
30
Practice Question Communication
While communicating with a client, a nurse
decides to provide the client with feedback. The
primary reason for this is that giving appropriate
feedback makes it possible for the nurse to:
A.
B.
C.
D.
Present advice
Explore feelings
Provide information
Explain behavior
31
Overview of Psychiatric
Mental Health Nursing
Mental Health
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The ability to see oneself as others do
Fit into one’s culture and society
Indicators of mental health
 Positive attitudes toward self, growth,
development, self actualization, integration,
autonomy, reality perception and
environmental mastery.
32
Overview of Psychiatric
Mental Health Nursing
Mental Illness
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Inability to see as others do
Not having the ability to conform to the norms
of the culture and society
33
Overview of Psychiatric
Mental Health Nursing
Medical Diagnosis of Mental Illness
Classified according to the Diagnostic and
Statistical Manual of Mental Disorders, fourth
edition (DSM-IV), of the American Psychiatric
Association.
34
Overview of Psychiatric
Mental Health Nursing
The DSM-IV Classification system uses five
axes for diagnostic purposes:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Adult and child clinical disorders
Personality disorders; mental retardation
General medical conditions
Psychosocial and environmental problems
Global assessment of functioning (0-100)
35
Mental Health Nurses
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Need both general and specific cultural
knowledge
If above absent, nurses won’t know what
questions to ask
Generalizations made are almost certain
to be oversimplifications
36
Mental Health Nurses

Must first address their own personal and
professional knowledge, values, beliefs,
ethics and life experiences in a manner that
optimizes assessment of and interactions
with culturally diverse clients
37
Mental Health Nurses

Self awareness includes a deliberate
process of getting to know oneself;
one’s own personality, values, beliefs,
professional knowledge, standards,
ethics and the impact of the various
roles one plays when interacting with
individuals who are different from
oneself.
38
Overview of PMHN
Duties/Responsibilities
Psychiatric Mental Health Nurses (PMHNs):

Assess, formulate nursing interventions, and
implement individualized treatment plans with
culturally competent interventions.
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Document progress.
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Document changes.
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Attend interdisciplinary meetings to discuss
progress, issues and treatment updates.
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Complete assault prevention training and other
required trainings.
39
Overview of PMHN
Duties/Responsibilities
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Uphold professional standards of behavior,
appearance, language, dress and
demeanor.
As a member of an integrated treatment
team, assist families, agency
representatives and other staff.
Understand the legal framework for the
delivery of mental health services.
40
Nursing Process

Assessment
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Gathering and organizing data
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Nsg Dx
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Outcome ID
Identify (ID) areas for
intervention
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Setting outcome criteria
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Planning action to meet the goals
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Carrying out actions
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Evaluating if goals (outcomes)
are met
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Planning
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Implementation
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Evaluation
41
Mental Health Assessment
INTERVIEW
During the interview, the nurse uses verbal and
nonverbal therapeutic communication techniques
to collect subjective and objective data about the
client.
42
Mental Health Assessment
Purpose
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Establish rapport
Determine reason client is seeking help
Obtain an understanding of current illness (via
client, family, chart review and interdisciplinary
team)
Understand how this illness has affected client’s
life
Identify client’s recent life changes or stressors
43
Mental Health Assessment
Gather current life style information
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Social patterns
Interests and abilities
Relationship issues
Substance use and abuse
44
Mental Health Assessment
Assess for risk factors
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Suicide or self-harm
Assault or violence
Physiological instability
45
Mental Health Assessment
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Appraisal of health and illness
Info on previous psychiatric problems or
or disorders
Current and past medications
Physiological coping responses
Psychological coping responses
Resources
46
Nursing Conditions During
Assessment
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Self-awareness
Accurate observations
Therapeutic communication
Establish nursing contract
Obtain information
Organize data
47
Analyze Data/Norms
Formulate Nursing Diagnoses
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Identify patterns in data
Compare with norms
Analyze and synthesize data
Identify problems and strengths
Validate problems with client
Formulate nursing diagnoses
Set priorities of problems
48
Outcome Identification (Goals)
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Identify expected outcomes individualized to client
Planning
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Nursing Conditions
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Application of theory
Nursing Behaviors
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Interventions to attain outcomes
Prioritize goals
Identify nursing activities
Validate plan with client/family
Key Elements
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Individualized, collaborative, documented
49
Implementation
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Implements interventions identified in the
plan of care
Experience
Evidence-based practice
Nursing behaviors
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Know available resources, implement,
generate alternatives, coordinate with other
team members
50
Evaluation
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Evaluation of progress in attaining
expected outcomes
An ongoing process
Client and family participation essential
Goal achievement should be documented
Revisions in the plan of care PRN
51
Levels of Intervention
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Counseling
Milieu therapy
Self-care activities
Psychobiological
interventions
Health teaching
Case management
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Health maintenance
and promotion
Based on Nurse
Practice Act
52
Nursing Interventions

Form a trusting one-on-one relationship with the
client
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Mutual learning experience for both the nurse and
client
Corrective emotional experience for the client
Explore stressors
Give constructive feedback
Promote development of insight and constructive
coping
Overcome resistance behavior
53
Nursing Interventions
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Behavioral change is the focus
Emphasize positive results
Provide an environment that is safe and private
with decreased stimuli as needed
Ensure physical and psychosocial needs are met
Encourage client participation in treatment
planning
Administer medications as ordered and assess
results
Educate client and family
54
Specific Nursing Interventions
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Active listening
Anger control
Assertiveness training
Behavior management
Body image enhancement
Delusion management
Eating disorders
management
Grief work facilitation
Hallucination management
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Impulse control training
Milieu therapy
Mood management
Role enhancement
Sleep enhancement
Spiritual support
Substance abuse Tx
Suicide prevention
Teaching (meds…)
55
Legal and Ethical Issues
Definitions
Voluntary admission:
Client consents to confinement in the hospital
and signs a document indicating as much.
56
Legal and Ethical Issues
Definitions
Mental Health 72-hour Hold (“5150”):
May be implemented on the basis that client poses a
danger to self or others or is gravely disabled due to
mental illness. Some states also have the criterion of
prevention of significant physical or mental
deterioration for involuntary admission. Police, doctors,
psychologists, county-approved mental health
professionals, nurses may initiate.
57
Criteria for Involuntary
Confinement
DANGER TO SELF
DANGER TO OTHERS
GRAVELY DISABLED
(Due to mental illness)
72-hour hold (5150)
72-hour hold
72-hour hold
14-day certification
(5250)
14-day certification
14-day certification
Certification Review
Certification Review
Certification Review
Hearing
Hearing
Hearing
Writ of Habeas Corpus
Writ of Habeas Corpus
Writ of Habeas Corpus
14-day Extension
90-day Extension
Temporary
conservatorship (30day-6 months)
1 year conservatorship
Rehearing
Reappointment
58
Involuntary Confinement
(continued)
DANGER TO SELF
ASSESSMENT
DANGER TO OTHERS
ASSESSMENT
GRAVELY DISABLED
ASSESSMENT
Inability to provide food,
clothing, shelter for self.
Suicidal ideation
Homicidal ideations
Delusions or hallucinations
which increase potential of
suicide.
Delusions or hallucinations Amount of income, how
which increase potential for it is spent
harm to others.
Lethality
Lethality
Medical, psychological,
educational, social and
legal situation
59
Legal and Ethical Issues
Definitions
Competency: A legal determination that a client
can make reasonable judgments and decisions
about treatment and other significant areas of
personal life.
60
Legal and Ethical Issues
Informed consent: Client’s right to be given enough info to:
Make a decision
 Understand the information
 Communicate his or her decision to others
 Receive explanation of client rights and unit policies
 Receive signed statement of understanding/refusal to receive Tx
 Receive explanation of insurance benefits or payment
options/third-party reimbursement

In an emergency situation, where there is not time to obtain consent
without endangering health or safety a client may be treated without legal
liability.
61
Client Rights/Nursing Responsibility
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Right to appropriate treatment
Right to know qualifications of those involved in
treatment process
Right to receive explanations of treatment
Right to be involved in planning of own care
Right to refuse to be a part of experimental treatment
methods
Right to understand the effects of prescribed
medication
Right to treatment in least restrictive environment
Right to refuse treatment - decide which treatment
option is best for them
62
Legal and Ethical Issues

Principle of Confidentiality
Federal laws regarding chemical dependence
confidentiality; staff members are not allowed to
disclose any admission or discharge information.
States have laws regarding when HIV test results or
the diagnosis of acquired immunodeficiency syndrome
(AIDS) may be disclosed.
63
Legal and Ethical Issues

Principles of Confidentiality

Client’s right

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Prevent written or verbal communications from being
disclosed to outside parties without authorization
Required by Nurse Practice Act
HIPAA (Health Insurance Portability and Accountability
Act of 1996 (2003)

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Ensures that security procedures protect the privacy and
confidentiality of information
Client has right to know what information is disclosed, to
whom and for what purpose
64
Legal and Ethical Issues

Required disclosure
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Intent to commit a crime
Duty to warn endangered persons
Evidence of child, elder, vulnerable adult
abuse
Initiation of involuntary hospitalization
65
An adult client says, “No, I don’t want that medicine.
I won’t take it.” The nurse says, “Take it. It’s good
medicine.” The nurse then places the cup in front of
the client’s mouth and forcefully presses it against
the client’s lips. In counseling this nurse, what
important legal principle(s) can be applied to the
nurse’s action? Select all that apply.
A. If a client does not object a second time, a nurse can
administer the medication.
B. If treatment is given without consent, legal charges of battery
can be filed.
C. Clients have the right to be treated in the least restrictive
manner possible.
D. Clients, unless declared legally incompetent, have the right to
refuse medication.
E. Clients who wish to do so may establish psychiatric advance
66
directives.
A client has purposefully attempted to
embarrass a nurse by making a sexually
explicit comment. The best response by the
nurse is to:
A. Clarify the intention of the client.
B. Leave the situation altogether.
C. Refuse to talk with the client any further.
D. Continue to interact as if the comments
did not cause embarrassment.
67
Crisis
Definition of Crisis
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Being confronted by a stress with which the
individual is unable to cope/problem-solve
Threatens the individual’s equilibrium
Generally time limited, lasting from 4 to 6 weeks
Potential for increased psychological vulnerability
or personal growth
68
Crisis
Interventions
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Establish a relationship
Identify the problem
Identify and reduce perceptual distortions
Enhance self-esteem
Alleviate anxiety
Promote engagement of support systems
Reinforce healthy coping
Validate client’s ability to problem-solve.
Keep safe if at risk for suicide
69
A client seeks assistance at a crisis center.
The client describes being intensely anxious
and sleepless since assisting with cleanup
activities at a school where a student fatally
shot a classmate. To assist the client to cope
more effectively, what should be the first
intervention of the nurse?
A. Arrange for a member of the clergy to visit the client
B. Advise the client to avoid going near the school for at
least 6 weeks
C. Send the client to the Emergency Department for
further evaluation
D. Allow ventilation of feelings
70
When the nurse is working with a client
in crisis, which nursing action is most
important?
A. Obtaining a complete assessment of the
client’s past history
B. Remaining focused on the client’s immediate
problem
C. Determining the relationship of early life
experiences and the crisis state
D. Developing an action plan for the client
71
Suicide Prevention
Assessment

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Determine suicidal ideation
Evaluate how client sought help
Suicide plan?
Mental status
Available support systems
Lifestyle
72
Suicide Prevention
Interventions
Inpatient interventions

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Providing a safe milieu in which the client’s
ability to act out on suicidal ideations is
minimized
73
Suicide Prevention
Safe Milieu (continued)
Depending on the degree of suicidal ideation and
lethality assessed
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Constant observation for 24 hours or until
the degree of suicidal risk is lessened
15-minute checks thereafter
Maintain awareness of the client’s
whereabouts constantly
74
Suicide Prevention
Safe Milieu (continued)
Upon admission to the unit:

Assess personal belongings and remove any
items that could be used to harm client
(drugs, potentially sharp objects, cords and
neck ties) and keep them in a safe place.
75
Suicide Prevention
Safe Milieu (continued)
 Keep the unit free of materials that can be used
by clients to harm themselves.
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For example, metal or glass objects that may be altered
to create a sharp edge, light fixture or call bell cords
Keep windows locked, count silverware, and
check the client’s belongings when returning from
a pass.
Check gifts and other items brought in by visitors
for safety before being given to the client.
76
Suicide Prevention
Safe Milieu (continued)
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Develop a safety plan and assess frequently
Oral check for hoarding medications for a later overdose
Assign a roommate to reduce the opportunity for solitude
Work with the client to identify an aftercare plan that includes:
 A commitment to attend aftercare appointments
 An agreement to maintain contact with social support systems
 Identification of a safety plan with emergency contact
numbers
 An action plan should suicidal ideations return
77
Psychopharmacology Prevent Suicide
Pharmacologic interventions
 Pharmacologic interventions aimed at treating:
 Underlying mood disorder
 Other psychiatric disorders
 Co-existing psychiatric disorders
 Depressive disorders treated with antidepressants
 SSRIs relatively low risk of lethal overdose
 Tricyclic antidepressants can be highly lethal in
overdose
 Quantity of prescribed/dispensed kept at a minimum and
may need to be managed by a family member
78
For the third time within a month, a client with
borderline personality disorder took a handful of
pills, called 911, and was admitted to the Emergency
Department. The nurse overhears an unlicensed staff
member say, “Here she comes again. If she was
serious about committing suicide, she’d have done it
by now.” The nurse determines there is a need to
teach the staff member which of the following?
A. Clients with personality disorders rarely kill themselves.
B. Each suicide attempt should be taken seriously.
C. Exploration of suicidal ideas and intent should be
avoided.
D. The nurse should prepare the client for direct inpatient
admission.
79
A client has been treated in the surgical intensive
care unit after sustaining a self-inflicted gunshot
wound. The client is now admitted to a psychiatric
unit. The nurse schedules time to meet with the
client on a one-to-one basis with the goals that the
client will: (Select all that apply.)
A. Explore current life events that led to the suicide
attempt.
B. Initiate contact with the nurse spontaneously.
C. Discuss past suicidal ideations and behavior.
D. Enter into a contract for safety with the nurse.
E. Identify post-discharge living arrangements.
80
Mental Health Therapies
Inpatient Hospitalization
Conditions for hospitalization:
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Dangerous to oneself or others
Incapable of providing for one’s basic physical
needs; gravely disabled
In need of care or treatment in the hospital
(voluntary)
81
Mental Health Therapies
Milieu Therapy

An environment designed to promote healing
experiences and to provide a corrective setting for
the enhancement of the client’s coping abilities.
Includes:

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Correcting perceptions of stressors
Changing coping mechanisms from maladaptive to
adaptive
Improving interpersonal relationship skills
Learning effective stress management strategies
82
Mental Health Therapies
Critical Issues


Boundaries define functions in the therapeutic
relationship and imply responsibility.
The nurse must clarify/maintain boundaries to
make the client more at ease in the new
relationship and environment.
83
What Is Child Abuse?
Definition

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
Child abuse: Any act of omission or commission
that endangers or impairs child’s physical or
emotional health and development.
Sexual Abuse: Victimizer uses victim for sexual
gratification & victim incapable of consenting to
this sexual activity or of resisting when it occurs.
Physical Abuse: Deliberate violent actions that
inflict pain and/or non-accidental injury.
84
What Is Child Abuse?
Child Abuse
 Physical neglect - Deprivation or non-provision
of necessary & socially-available resources
 Psychological abuse - Deliberate destruction of
a person’s sense of competence
85
Elder Abuse
Elder abuse


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
Mistreatment or neglect of an elderly person
Most victims are women 75 years of age or older
Victims usually physically, emotionally or
financially dependent on their abusers
Types:
 Psychological abuse
 Physical abuse
 Neglect (intentional or unintentional)
 Financial or material abuse
86
Mandated Reporters: Abuse
Mandated Reporters
 Nurses who suspect abuse of children,
dependent adults or elders must report it.
 You must immediately call and report the
suspected abuse.
 A follow-up written report is required within two
working days.
 Failure to report abuse is a misdemeanor.
87
A 5-year-old girl is brought to the clinic for
symptoms of a urinary tract infection (UTI).
The nurse’s assessment reveals bruises in
the child’s genital and rectal areas. The
mother reports that she left the little girl with
her boyfriend the night before. The nurse’s
first priority with this client is to take what
action?
A. Obtain a urine sample to confirm a UTI.
B. Teach the mother about symptoms of UTI.
C. Report suspected sexual abuse to protective
services.
D. Assess the child for other health problems.
88
An 85-year-old client is brought into the
Emergency Department after a fall at home. The
client appears confused and malnourished and is
severely dehydrated. The client can speak but
appears reluctant to explain how the fall
happened. The client’s 62-year-old daughter
frequently interrupts the client and does not
allow the client to answer questions. Which of
the following nursing interventions is a priority?
A. Take the history from the daughter because the client
is confused.
B. Provide the daughter with nutritional teaching.
C. Request a psychiatric evaluation for the client.
D. Interview the client alone first and assess for abuse.
89
Protection in the Mental Health
Setting - Restraints
Restraints



Seclusion – placement of client in controlled
environment to treat a clinical emergency
Physical restraint – use of mechanical
devices to provide limited movement by client
Chemical restraint – use of medication to
calm client and prevent need for physical
restraint
90
Protection in the Mental
Health Setting- Restraints
Restraints

Physical restraint appropriate after all other
types of interventions are used to assist the
client to control his/her behavior and remain
safe

Documentation of all interventions and results
are critical
91
Protection in the Mental Health
Setting- Restraints
Restraints






Legal Implications
Physician’s order is a necessity
Facility rules and state laws
Liability for false imprisonment
Liability for assault and battery
KNOW LIMITATIONS OF THE LAW!
92
Protection in the Mental
Health Setting - Restraints

Documentation should include:






Description of a clear process from less restrictive
interventions
Criteria for a removal of restraints
Care and observation during the use of restraints
Regular assessment of the client and potential
complications of restraints
Reasons for removal of restraints
Follow-up interventions, including processing with client,
event leading to restraint.
93
Photo Acknowledgement:
All unmarked photos and clip art
contained in this module
were obtained from the
2003 Microsoft Office Clip Art
Gallery.
94
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NCLEX PREPARATION PROGRAM MODULE 7