NUR 2459 / NUR2459 Exam 1 (Latest 2024 / 2025): Mental And Behavioral Health Nursing – Rasmussen

NUR 2459 Mental & Behavioral Health Nursing
Mental Health Exam 1
Question:
Application of the Nursing Process
Answer:

1. Nursing Diagnosis
2. Outcome considerations
3. Planning and implementation
4. Evaluation
   Question:
   Spiritual concepts nursing diagnoses includes:
   Answer:
5. Risk for spiritual distress
6. Spiritual distress
7. Readiness for enhanced spiritual well-being
8. Risk for impaired religiosity
9. Impaired religiosity
10. Readiness for enhanced religiosity

Question:
Spiritual concepts outcome identification means the patient:
Answer:

1. Identifies meaning and purpose in their life that reinforce hope, peace,
   and contentment
2. Verbalizes acceptance of self as a worthwhile human being
3. Accepts and incorporates change into life in a healthy manner
4. Expresses understanding of difficulties between current life situation and
   interruption in previous religious beliefs and activities
   Question:
   Spiritual concepts for planning and implementation means:
   Answer:
   Susceptible to an impaired ability to experience and integrate meaning and
   purpose in life through connectedness within self, literature, nature, or a
   power greater than oneself that may compromise health
   Risk factors include: physical, psychosocial, developmental, and
   environmental
   Question:
   Spiritual concepts evaluation is:
   Answer:
5. Directed at achievement of established outcomes
6. Includes continuous reassessment
7. Includes family and extended support systems
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Ethical codes serve two purposes
-act as guidelines for standards of practice

-let the public know what behaviors can be expected from their health care providers

Autonomy
respecting the rights of others to make their own decisions

Beneficence
Doing the greatest good for the client

Nonmaleficence
Do no harm

Justice
Justice as fairness

Veracity
Truthfulness

4 Patient Rights

1. Refuse treatment
2. Withhold consent
3. Withdraw consent any time
4. Retract consent; must be honored, whether verbal or written

Confidentiality and right to privacy means what?
Duty to respect private information

Health Insurance Portability and Accountability Act (HIPAA)
Right to receive treatment and to have confidential medical records. Can only be breech when there is a duty to warn a client’s potential victim of harm.

A duty to warn (protection of a third party)
A client’s potential victim of potential harm

Suspected child or elder abuse
Mandated reporter, know your state laws

Informed consent
If a clinician approached the client with medication in hand and the client indicates a willingness to receive the medication, then informed consent has occurred. Although consent was given, they can change their mind

Restraints and seclusion

1. Only use after all other interventions have been tried and failed
2. Shortest duration is always the rule of thumb
3. Should never be used as a form of punishment
4. Must be trained

False imprisonment

1. Intent to confine to a specific area
2. Indefensible use of seclusion or restraints
3. Detain voluntarily admitted client with no agency or legal policies to support detaining

When a client initiates the request for mental health services, it is considered a voluntary admission. Can patients discharge at any time?
Voluntary admission clients may legally discharge themselves at any time

Involuntary commitment is a process for institutionalization initiated by someone other than the client and include what? (5)

1. Restriction of client’s rights
2. Clients may stay for days to years
3. Client is imminently dangerous to self
4. Client is a danger to others
5. Client unable to take care of their basic needs

Reasonable and prudent person theory involve what two nursing liabilities?
Negligence and malpractice

Negligence
Omission (or commission) of an act that a reasonable and prudent person would (or would not) do

Examples: when a nurse fails to act in a manner that a reasonable prudent nurse would act under the same circumstances, a nurse who fails to assess for suicide potential in a client who has threatened suicide in the past, Certain conditions must be met to determine negligence and hold the nurse responsible

Malpractice
Failure to exercise an accepted degree of professional skill that results in injury, loss, or damage

Examples: Suicidal client to be continuously observed (duty). Staff goes to lunch, leaving the client alone (breech of duty). During this time, client commits suicide (proximate cause) and dies (damage). The staff is guilty of malpractice because no reasonable and prudent caregiver would leave a client unattended in a similar circumstance.

Crisis
A sudden event in one’s life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem

Crisis Intervention (3):

1. Any stressful situation can precipitate a crisis
2. Crisis intervention and resolution requires problem-solving skills
3. Assistance with problem solving during the crisis period preserves self-esteem and promotes growth with resolution

Phases in development of crisis

1. exposed to precipitating stressor
2. when problem solving techniques do not relieve the stressor, anxiety increases further
3. All possible resources called on to relieve the discomfort
4. If resolution does not occur in previous phases, tension mounts beyond a further threshold or it’s burned increases to breaking point- major disorganization of the individual occurs, often with a drastic results

Whether individuals experience a crisis in response to a stressful situation depends on three factors:

1. Individuals perception of the event
2. Availability of situational supports
3. Availability of adequate coping mechanisms

Dispositional crisis
an acute response to an external situational stressor

Crisis of anticipated life transitions
Normal life-cycle transition that may be anticipated but over which the individual may feel a lack of control

Crisis of resulting from traumatic stress
Precipitated by an unexpected, external stressor over which the individual has little or no control and from which he or she feels emotionally overwhelmed and defeated

Maturational/Developmental crisis
Occurs in response to a situation that triggers emotions related to unresolved conflicts in one’s life

Crisis reflecting psychopathology
An emotional crisis in which preexisting psychopathology has been instrumental in precipitating the crisis or in which psychopathology significantly impairs or complicates adaptive resolution

Psychiatric emergency
A crisis situation in which general functioning has been severely impaired and the individual rendered incompetent or unable to assume personal responsibility

Phases of crisis intervention
Phase 1: Assessment
Phase 2: Planning of therapeutic intervention
Phase 3: Intervention
Phase 4: Evaluation of crisis resolution and anticipatory planning

Providing healthcare in an environment of cultural awareness and sensitivity is essential to:

1. Accomplish client-centered care
2. Ensure that all clients receive adequate resources
3. Ensure that all clients have access to treatment

Spirituality
The human quality that gives meaning and sense of purpose to an individual’s existence

Religion
A set of beliefs, values, rites, and rituals adopted by a group of people. The practices are usually grounded in the teachings of a spiritual leader

Assessment strategies for cultures:

1. Ask preferred name
2. What language do you speak at home?
3. Are you able to read and write English if not, what language?
4. Are you comfortable?
5. Do you have any concerns you would like to discuss?

With assessment be sure to:

1. Ensure comfort prior to interview
2. Maintain safe distance and observe cues from patient
3. Be aware of cultural differences
4. Be aware of objects that create barriers to comfort
5. Ensure the physical environment is arranged to ensure safety, security, and familiarity

When to use interpreters?
When the patient does not speak English

Application of the Nursing Process

1. Nursing Diagnosis
2. Outcome considerations
3. Planning and implementation
4. Evaluation

Spiritual concepts nursing diagnoses includes:

1. Risk for spiritual distress
2. Spiritual distress
3. Readiness for enhanced spiritual well-being
4. Risk for impaired religiosity
5. Impaired religiosity
6. Readiness for enhanced religiosity

Spiritual concepts outcome identification means the patient:

1. Identifies meaning and purpose in their life that reinforce hope, peace, and contentment
2. Verbalizes acceptance of self as a worthwhile human being
3. Accepts and incorporates change into life in a healthy manner
4. Expresses understanding of difficulties between current life situation and interruption in previous religious beliefs and activities

Spiritual concepts for planning and implementation means:
Susceptible to an impaired ability to experience and integrate meaning and purpose in life through connectedness within self, literature, nature, or a power greater than oneself that may compromise health

Risk factors include: physical, psychosocial, developmental, and environmental

Spiritual concepts evaluation is:

1. Directed at achievement of established outcomes
2. Includes continuous reassessment
3. Includes family and extended support systems

What percentage of people with bipolar disorder have religious delusions?
15% of people

Definition of Rights of a patient
Described as a power or privilege or existence to which one has a just claim