VATI Mental Health

Provide the client with plastic eating utensils. -The client can use glass dishes and metal silverware to cause self harm, therefore, the nurse should arrange for the client to have only plastic products on their meal tray.

Inform the client that this admission is confidential. -According to evidence-based practice, the nurse should first inform the client about confidentiality during the orientation phase of the nurse client relationship. This action establishes trust between the client and the nurse, which in turn decreases the client's anxiety level.

You're afraid you have caused physical injury to yourself? -Repeating the main idea of what the client has said, which will allow for clarification of any misunderstanding on the part of the client or the nurse.

Have you thought of harming yourself? -The greatest risk to this client is self harm due to the loss of her child and home, therefore, the first question the nurse should ask a client who is having a personal crisis is to determine if the client has suicidal ideation. If so, the nurse should take action to protect the client from self harm.

Serum creatinine 2.1 mg/dL -Reference range of 0.5-1.2 mg/dL. The greatest risk to this client is decreased kidney function, which can cause an increase in the client's lithium level; therefore, this value is the priority for the nurse to report to the provider. The clients lithium dosage might need to be modified based on this lab value. The cause of increased serum creatinine include dehydration as well as renal disorders. Lithium is contraindicated for clients who have severe renal disease, cardiac disease, or severe dehydration.

You will still need to give informed consent for treatment after admission. -A client who seeks voluntary admission to a mental health facility has the same rights as clients receiving any other kind of health care. The client will still need to give informed consent for treatment and therapies, such as electroconvulsive therapy.

Initiate a behavioral contract with the client. -A client who has conduct disorder can demonstrate patterns of behavior that are aggressive, disrespectful of others rights, and can lead to injury of others. A behavioral contract helps to develop trust between the client and the nurse and emphasizes the client's responsibility to commit to work on changes in behavior.

Displacement -When this family member uses displacement, they are transferring their feelings of anger to the provider so they do not have to cope with their own feelings of sadness and loss.

I expect that my father will no longer be confused when he is discharged.

Encourage the client to rest each hour. -The greatest risk to this client is injury from exhaustion due to the manic phase, therefore, the priority action the nurse should take is to encourage the client to rest for 3-5mins every hour.

Move others away from the client. Offer the client a PRN dose of lorazepam. Ask the client open ended questions about the behavior. -A large personal space should be maintained around the client who is angry. If the client's behavior continues to escalate, the nurse should move others away from the client for their safety. -Antianxiety medication can be used in conjunction with de-escalation techniques to prevent a violent episode. -Communication technique is nonthreatening and encourages the client to express their feelings.

Record the client's behavior every 15mins while in restraints. -Complete a written record of the client's behavior every 15mins in the client's medical record while in restraints. The client should be considered for reintegration when they are able to follow commands and exhibit self-control of behavior.

Dental caries -Have dental caries and tooth erosion due to excessive exposure to stomach acid from frequent vomiting.

Limit outdoor exercise during hot weather. -Spending time outdoors during hot weather, especially if exercising, promoting dehydration and sodium loss through diuresis, which can increase lithium levels. Whenever the client exercises, develops diarrhea, vomits, or has any circumstance that can cause dehydration, fluids and electrolytes must be replaced promptly.

I've noticed you have become quiets. Please share with me what you are thinking. -Making observation about the clients feelings, which encourages the client to discuss their thoughts, and facilitates further communication with the nurse.

It must be hard for you to have to pace the floor. Let's talk about your feelings. -Making observations and offering a general lead, which allows clients to notice their behavior and discuss their feelings with the nurse. The client is displaying obsessive-compulsive behavior. Clients who have this disorder are aware that their behavior is excessive but are unable to stop the behavior.

And after that? -Give this example as the technique of offering a general lead. This therapeutic communication technique offers the client encouragement to continue the conversation with the nurse.

Coordinating community resources for a hospitalized client. -Secondary prevention strategies include intervening for a client who is currently experiencing partner violence, counseling the client, and arranging a move to a safe house.

I cannot discuss your spouse's health information with you without his consent. -HIPAA protects a client privacy regardless of admission status. The client can approve individuals with whom the nurse can share information. Releasing protected health information without permission from the client is an invasion of privacy and a HIPAA violation.

Role Playing. -The nurse can assign specific roles to clients and develop scripts for them to use when acting out different situations. This allows clients to see how their behavior affects others and gives them an opportunity to practice new behaviors.

Assist the client with completing the Hoarding Scale Self Report. -Asking the client to complete the report provides data about the severity of the clients hoarding behavior.

Check the client's physical needs every 15mins while in seclusion. -Assess and document the client's physical, comfort, and safety needs every 15mins. Assessing and documenting at such frequent intervals minimizes the risk of injury to the client and provides a legal record of the care the client is receiving.

Ensure the client signs the form voluntarily. -The nurse acts a client advocate by ensuring that the client gives consent voluntarily, appears competent to provide consent, and has received information about the purpose, alternatives, risks, and benefits of the procedure.

Hyperpyrexia -The nurse should initiate the use of cooling blankets or other means to lower body temperature.

A 7-year-old child has a variety of old and new bruises on his back and posterior thighs. A 2-year-old child has a spiral fracture of his arm, which the parent states happened when he fell from a swing. An 80-year-old client who has dementia and lives in a group home has bruises in the perineal area. -A variety of bruises in different stages of healing and in an area unlikely to be bruised on a school aged child is suspicious and must be reported to the appropriate agency. -Explanations regarding injuries that do not match the presentation of an injury are suspicious and must be reported to the appropriate agency. A spiral fracture is most likely to be caused by an adult twisting a child's limb with their hands, rather than by a fall from a swing. -The nurse must report suspicious assessment data in vulnerable older adults as well as children. Perineal bruising is not expected in an older adult who has dementia and should be reported.

Avocados -High tyramine content, which promotes the release of norepinephrine from sympathetic neurons. Consuming avocados while taking tranylcypromine can result in a hypertensive crisis due to massive vasoconstriction and excessive stimulation of the heart. Tyramine levels are highest in very ripe avocados.

Tachycardia -At risk for palpitations and tachycardia caused by anticholinergic toxicity. Common adverse effects associated with anticholinergic medications include dry mouth, blurred vision, urinary retention, constipation, photophobia, and tachycardia. Benztropine is commonly prescribed for clients who take antipsychotic agents and who are experiencing extrapyramidal effects, such as Pseudoparkinsonism with tremors, shuffling gait, and drooling or dystonia with painful contractions of the jaw or neck.

Avoids self responsibility. -Has a great need to be taken care of, which leads to fears of separation, difficulty making decisions, and avoidance of taking responsibility for most aspects of life.

Diazepam -Benzodiazepine, to client during acute alcohol withdrawal to raise the seizure threshold and prevent seizures, decrease agitation, stabilized vital signs, decrease the intensity of withdrawal manifestations, and prevent delirium tremens.

A child who was born with cleft lip and palate. -Having a congenital abnormality, such as cleft lip and palate, increases a child's risk for bring maltreated. The nurse should also teach the group of nurses that children who are younger than 3 years of age and children from an unwanted pregnancy are at risk for maltreatment.

Walk with the client while setting physical limits on her behavior. - The client is experiencing panic level anxiety and might display unsafe behavior during this time. The nurse should stay with the client and allow her to walk around to decrease tension and anxiety.

Request that the provider see the client within 1hr. -Notify the clients provider of the need for restraints and request that the provider assess the client within 1hr.

Uses profanity to express emotions. Clenches and unclenches the jaw. Maintains intense eye contact. Paces the floor. -Increase in profanity can be a manifestation of escalating behavior, which can signal a violent episode. Some clients speak more loudly when they become angry, while others become very quiet or speak more softly. -As behavior escalates toward violence, the nurse might observe the client clenching and unclenching the jaw or fist, or standing with a rigid posture. -Maintaining intense eye contact or suddenly avoiding eye contact are manifestations associated with imminent violence. -Client who becomes more active or restless and paces often around the unit is at a high risk for becoming violent.

Remain with a client who has anorexia nervosa following a meal. -At risk for purging following a meal. It is within the range of function of the AP to remain with the client following the meal to ensure the client complies with the plan of care and does not purge.

15 mL

A residential rehabilitation program. -These programs have a 24hr medical staff and provides specialized care for clients who have comorbid conditions.

Genogram -Assess the current and past functioning of a family unit of several generations. The nurse should collect information about where the family lives, educational level of the members, and occupations, as well as information about medical, emotional, and behavioral status.

It does not cause physical dependence. -Unlike other antianxiety agents, buspirone is not a CNS depressant. It does not cause physical or psychological dependence and does not produce tolerance. Buspirone might also be prescribed for clients who have other types of anxiety disorders, such as obsessive-compulsive disorder.

Assign the same staff to care for the client. -Client who has PTSD can be suspicious of others in their environment and assigning the same staff will facilitate a trusting relationship.

Case Manager -A case manager or social worker coordinates care for a client who has a mental health disorder, including sources of financial aid. They can provide care in the client's home, school, or place of employment. This care can include medication monitoring and guidance with community services.

Fasting blood glucose 140 mg/dL. -Olanzapine is an atypical antipsychotic medication prescribed for the treatment of schizophrenia. An adverse effect is hyperglycemia. The expected reference range for fasting glucose is 74-106 mg/dL.

If a client threatens to seriously harm someone, the provider should notify that person of the threat. -Nurses should report a client's threat to the provider, and the provider has a legal obligation to notify third parties when a client threatens serious harm. If the risk for violence exists, the provider should notify the person, the person's family, or local law enforcement.

Make appropriate referrals. -During the termination phase of the nurse-client relationship, the nurse should make referrals to appropriate agencies for the client to contact if they need help in the future. It is also necessary for the nurse to collaborate with the client's case manager prior to making referrals to ensure continuity of care for the client.

Limit fluid intake after the client's evening meal. -Educate the family to limit the client's fluid intake after the evening meal around 1800. The family should offer the client fluids every 2hrs during the day to prevent dehydration, but to minimize nighttime incontinence, they should limit or restrict fluid intake after 1800.

The client refuses to drink fluids. -Severe dehydration can cause cardiac arrhythmias due to fluid and electrolyte imbalances. The nurse should continue to offer the client fluids at least once per hour, and encourage the client to drink the fluids using a clean and calm tone.

Ataxia -CNS adverse effects are common during the first few weeks when beginning to take carbamazepine. These adverse effects include vertigo, ataxia, and downiness.

Your child will be privately interviewed about the incident. -To allow the child the opportunity to discuss the situation accurately in his own words. The presence of a parent during the interview can influence the child's responses.

Outpatient treatment program. -When using the least restrictive framework, the nurse should identify that an outpatient treatment program provides the least restrictive alcohol use disorder treatment. This form of treatment is nonresidential and includes treatment groups an individual therapy of no more than 5hrs per week.

Limit the client's choices. -Asking the client to choose between three or four options can lead to anxiety and agitation; Therefore, if the client is capable of making choices, the nurse should limit choices to no more than two at a time, such as making decisions about eating and getting dressed.

Identify the client's feelings underlying the delusions. -The nurse should focus on the client's underlying feelings, rather than on the illogical aspects of the delusion. The nurse should encourage the client to talk about their fears and anxieties that relate to the delusion without any assumptions and statements about the delusion being real or false.

Chronic grief -Occurs when there is a prolonged emotional instability, a withdrawal from usual tasks or activities, and lack of progression to successful coping with loss.

Bupropion -An atypical antidepressant, to a client undergoing nicotine withdrawal. Bupropion reduces the addictive action of nicotine and can minimize the manifestations of withdrawal.

Patient-centered medical home (PCMH) -Provides behavioral health and medical services. It offers extended hours of service 7 days a week with comprehensive patient-centered care. Clients participating in the patient-centered medical home receive comprehensive care as well as supportive community and social services. Services such as email and phone support to clients are a part of the patient-centered medical home.

Command hallucinations -The greatest risk to this client is injury to self or others due to command hallucinations. Command hallucinations occur when the client hears inner voices that tell them to take an action, such as self harm or harm to others. The nurse should ask the client what the voices are telling them to do.

This therapy will help me recognize changes in my blood pressure. -Uses a monitoring machine, to identify changes in body function. The purpose of biofeedback therapy is to enable the client to learn to consciously control body processes.

Sharpened perceptions. -Mild anxiety occurs daily during normal experiences and allows and individual to grasp more information and problem-solve more effectively. As stress increases, the client's perceptual field narrows and they are able to focus only on the source of the anxiety.

What did you have for dinner last night? -The nurse can assess the client's cognitive status by asking questions that test the client's recent and immediate memory, such as what they had for dinner.

Weigh the client daily after first voiding. -Weigh the client each morning after waking and following their first voiding. The client should have nothing by mouth, including water, before obtaining the clients weight. The nurse should also assess the clients skin turgor and oral mucus membranes to ensure the client is hydrated.

Heroin -Manifestations of opioid withdrawal can include severe muscle cramps, yawning, rhinorrhea, and pupillary dilation. A client who is withdrawing from heroin can start to experience manifestations within 6-8hrs after the last dose following a period of at least 1 week of use.

Change in LOC Decreased attention span Hallucinations -Change in LOC is an indication that the client is experiencing delirium, which the nurse should observe as a decreased awareness of surroundings. -Delirium usually shows a disturbance in ability to focus and maintain attention as well as memory impairment and poor judgement. -Hallucinations can indicate that the client is experiencing delirium. Hallucinations are false sensory perceptions that can increase the clients fear and anxiety.

Older adults who are dependent on a caregiver might be at an increased risk for abuse. -Caregiver strain can increase the risk for elder abuse. An older adult who is dependent on others for care due to poor physical health, or a chronic disease such as Alzheimer's disease, is at an increased risk for abuse.

I'm sorry but I do not see anything on the ceiling. -Use therapeutic communication to address the client's hallucinations and delusions. The nurse should offer their own perception of what the client is seeing or hearing without negating the client's experience.

Tachypnea -Other manifestations of withdrawal include hyperreflexia, enlarged pupils, muscle spasms, lacrimation, yawning, and rhinorrhea.

Lorazepam -Lorazepam is a benzodiazepine that helps to alleviate the clients craving for alcohol.

A client who recently lost their home in a fire. -An adventitious crisis is caused by an unplanned event, such as a fire, earthquake, riot, plan crash, or violent crime.

Fear of being abandoned by others. -Other manifestations include submissiveness and a desire to be cared for.

Biofeedback teaches you to control physical reactions to stress, such as your heart rate. -Biofeedback uses sensitive instrument that detect changes in muscle activity, heart rate, respiratory rate, and skin temperature. Stress causes an increase in theses autonomic responses. Allows clients to learn how to gain voluntary control over theses responses, thereby decreasing feelings of stress.

Moderate anxiety causes HA and insomnia. -Somatic manifestations begin during moderate anxiety. Clients can experience urinary frequency, muscle tension, HA and insomnia. If anxiety progresses to severe levels, somatic manifestations worsen and can include chest pain, dizziness, and diaphoresis.

Allow the client to experience and express grief in personally unique ways. -Encourage the client to verbalize their feelings and express them in ways that assist them in coping with the loss.

Loss of self-esteem due to feelings of worthlessness. -Expected grief responses include an intact self-esteem, a focus on the deceased, and feelings of sadness that decrease over time.

Redirect the client attention using reality based conversation. -Using a calm voice, the nurse should provide a diversion from the hallucinations by engaging the client with simple conversation. The nurse can also encourage the client to use other diversions such as listening to music or watching television.

Consider using respite care services. -These services allow time to rest and strengthen the ability to be a caregiver. Long term illness affects the caregiver's mental, physical, emotional, and spiritual health.

What are some ways you can deal with the job loss? -The nurse can then encourage the client to identify a plan of action for addressing the situation.

Decrease the volume of the television in the dayroom. -The nurse should also dim bright lights and avoid placing the client in a group of people.

A bereavement support group helps clients who are experiencing loss. -Bereavement support group teaches participants how to deal with significant emotional stressors, such as loss and grief. One of the most important aspects of the group is the commonality of the shared experience between members. This commonality provides support and comfort to participants.

Decrease in facial muscle spasms. -Benztropine is an antiparkinsonian medication used to treat acute dystonic reactions, which can be an adverse effect of antipsychotic medications such as fluphenazine. An acute dystonic reaction causes painful contractions of the face, tongue, jaw, neck, and back. Benztropine reduces muscle spasms and rigidity.

Hold the dose of escitalopram and consult the provider. - St. John's wort can increase the risk of serotonin syndrome when combined with escitalopram, a selective serotonin reuptake inhibitor (SSRI).

Haloperidol -The nurse should identify that these findings indicate tardive dyskinesia, which is a potential adverse effect of antipsychotic medications such as haloperidol. Tardive dyskinesia usually persists even after discontinuation of the medication.