FINAL EXAM REVIEWBEHAVIORAL HEALTHNUR 2740DATE:08/24/14By Prof: I. Salvador
NURSING DOCUMENTATION OF OBSERVATIONS1.The documentation states specific observations of the patient’s appearance and the exact statements made. If pt states “I need protection from evil germs trying to slice my skin”
CULTURAL HERITAGE2.Cultural heritage is expressed through language, works of art, music, dance, customs, traditions, diet, and expressions of spirituality. Patient’s prominent placement of the picture is an example of expression of cultural heritage and spirituality. The nurse should not move it unless the patient’s safety is jeopardized.
SELF HARM3.The patient has responded appropriately to the urge to harm herself by calling a helping individual. The nurse can assist the patient to choose an alternative to self-injury. Except when the patient is judged to be at risk of suicide as well, hospital or crisis center admissions are generally discouraged in favor of guiding the patient to use internal controls to manage urges to self-injure. This is designed to minimize dependence on hospitalization for safety and promote independence and adaptive coping.
ELECTROCONVULSIVE TREATMENT4.Electroconvulsive treatment may cause memory loss; such loss is usually transient and improves after treatments are completed. Most patients respond to a course of treatment involving 12 to 15 sessions of ECT. Restraint is not part of pretreatment protocol. ECT improves depression and can interrupt an episode of depression, but its effects are not lasting and may not improve the depression completely.
DEFINE DSM-IV-TR5. The medical diagnosis is concerned with the patient’s disease state, causes, and cures, whereas the nursing diagnosis focuses on the patient’s response to stress and possible caring interventions. Both tools consider culture. The DSM-IV-TRis multi-axial. Nursing diagnoses also consider potential problems.
PART OF GRIEVING6.Nurses are encouraged to tell bereaved patients that telling the personal story of loss as many times as needed is acceptable and healthy because repetition is a helpful and necessary part of grieving.
PARANOID PATIENT WITH LIMIT SETTING7.In urging a paranoid patient to strike anyone who stares at him, the patient is being manipulative, trying to get another patient to act violently while staying “innocent” of actual violence herself. Because manipulation violates the rights of others, limit setting is absolutely necessary. It would be appropriate to set limits relative to any significantly inappropriate behavior, but the highest priority here would be behavior which endangers others, such as enticing the paranoid person to strike anyone who stares at him.