HESI Study Guide Psychiatric Nursing
HESI Study Guide Psychiatric Nursing
HESI Study Guide Psychiatric Nursing
Eating disorder
anorexia 10
bulimia 11
Mood disorder………………………………………………………12
Depression, 13
Bipolar disorder, or manic depressive illness, 14
Thought disorders
Schizophrenia, 16
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Therapeutic Communication
The goal of therapeutic communication is to allow the client the autonomy to make choices
when appropriate
Keep statements value free, advice free, and false reassurance free (i.e. Everything is going
to be okay)
Just remember the facts not opinions
The nurses nonverbal communication may be more important than the verbal
Nurse-Patient Confidentiality
The patient should always be aware some information discusses (suicide plan) with the
nurse must be shared with other team members for the patient safety or optimal therapy.
As a result the nurse can never tell a client that she will not tell anyone about the discussion
What is the most important nursing intervention when the psychiatric client describes a physical
problem?
1. Assessment (ASSESS, ASSESS, ASSESS!)- never ignore the psychiatric patient physical needs.
a. If a paranoid schizophrenia is complaining of chest paint, then check their blood pressure
b. If OB client who has delivered a dead fetus complains of perineal pain- look at the perineal
area (she may have hematoma)
c. Just because the focus of the client’s situation is on his/her psychological needs, it does not
mean that the nurse can ignore physiological needs
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***FIVE TOP INTERVENTIONS FOR PSYCH PATIENTS***
Safety
Setting limits
Establishing trusting relationship
Meds
Least restrictive methods, and environment are always attempted first (offering an oral med,
injecting an IM med, then lastly placing the client in seclusion)
Levels of Anxiety
1. Mild Anxiety
a. Is associated with daily life and motivate learning
b. Produces increased levels of sensory awareness and alertness
c. Allows for logical thinking and problem solving
d. Client appears calm and in control
2. Moderate Anxiety
a. Continues to motivate learning with assistance from others
b. Allows for attentive focus and problem-solving but not at an optimal level
c. Does increase the perception of sensory stimuli; client become hesitant
d. Client speech rate and volume increases; patient becomes wordy
e. Client becomes restless with frequent body movement and gestures
f. May be converted into physical symptoms such as
i. Headaches, nausea, diarrhea and tachycardia
3. Severe Anxiety
a. Simulates fight or flight response
b. Cause sensory stimuli input to be disorganized
c. Causes distorted perceptions and decrease concentration and problem-solving
ability
d. Results in selective attention, focusing only on one detail at a time
e. Causes tremors, increase motor activity such as pacing or wringing hands
NEW:
Physical symptoms appear: headaches, palpitations, insomnia, trembling, diarrhea, urinary frequency,
tachycardia, and nausea.-Emotional symptoms appear: confusion, dread, horror…may be evident
oIntense need to relieve the anxiety
-Basically all overt behavior is aimed at relieving the anxiety.
-Neurosis: excessive anxiety that is either expressed as is or as a defense mechanism
oCommon symptoms: phobias, sexual dysfunction, compulsion/obsession
oCharacteristics: person is aware of maladaptive behaviors and distress, feel helpless, don’t lose contact w/
reality, BUT unaware of possible psychological causes of distress
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4. Panic
a. Causes perceptions to be grossly distorted; client can’t differentiate real from
unreal
b. Causes client to be unable to concentrate or problem solve, loss of rational
logical thinking and hallucinations may occur
c. Causes the client to feel overwhelm and helpless
NEW:
Misperceptions are common, and a loss of contact with reality may occuro
Person may experience hallucinations or delusions-Human functioning and communication with others is
ineffective
Person may feel terror and individuals may be convinced that they have a life-threatening illness or fear
that they are “going crazy,” are losing control, or are emotionally weak.
O May exhibit bizarre behaviors like: shouting, screaming, running around wildly, clinging to
anyone/thing that provides sense of safety and/or extreme withdrawal.
Can eventually lead to psychosis.
-Physical and emotional exhaustion and can be a life-threatening situation if a person is in this state for a
prolonged amount of time
-Physical characteristics:dilated pupils, labored breathing, severe trembling, diaphoresis/pallor, muscular
incoordination, incoherence/unable to verbalize
-Psychosis: characterized by impaired reality via hallucinations, delusions, disorganized, catatonic behavior
oPt. is unaware of maladaptive behavior/psychological problem, exhibit minimal distress (ex. flat
tone/inappropriate), attempting to mentally escape stressful world into a less stressful world in
which they are trying to adapt
Anxiety Disorders
1. Generalized Anxiety Disorder
a. Unrealistic, excessive or persistent (lasting six months or longer) anxiety and worry
about two or more life circumstances
2. Panic Disorders and Phobias
a. Is characterized by an irrational fear of an external object, activity, situation and
feelings impeding doom
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b. It’s a chronic condition that has exacerbations and remissions
Common Phobias
1. Acrophobia- fear of heights
2. Agoraphobia- fear of crowds and open places
3. Claustrophobia- fear of closed in spaces
4. Hydrophobia- fear of water
5. Nyctophobia- fear of the dark
6. Thanatophobia- fear of death
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Anti-Anxiety Medications
BENZODIAZEPINES
Drugs Indications Reactions Nursing Implications
Chlodiazepoxise Reduces anxiety Sedation and Administer at bedtime
HCL (Librium) Induce sdation, relax Drowsiness are the most to alleviate daytime
Diazepam (Valium) muscles, inhibit common side effects for sedation
Alprazolam ( convulsions antianxiety Greatest harm occurs
Xanax) Treat alcohol and drug medications*** when combined with
Clorazepate withdrawal symptoms Ataxia (uncontrolled alcohol or other CNS
Dispotassium More safe than the movements) depressants
(Tranxene) sedative- hypontics Irratibility Instruct to avoid
Lorazepam (Ativan) Blood dyscrasias driving or working
(abnormal blood cellular around equipment
elelments) Gradually taper drug
Habituations and theraphy due to
increases tolerance withdrawal effects do
Can cause respiratory not stop suddenly
depression if mixed with Used only as short-
another depressant such term drug and has
as alcohol supplemented other
medications
★Flumazenil
(Romazicon)- is used to
treat Benzodiazepine
Toxicity (Overdose)
NON- BENZODIAZEPINES
Drugs Indications Reactions Nursing Implications
Buspirone (BuSpar) Reduces anxiety dizziness contradicated for
Help to control concurrent use with
symptoms such as MAOI antidepressant, or
insomnia, sweating, and for 14 days after MAOIs
palpitations associated are D/C
with anxiety it takes several weeks
for the anti-anxiety
effects to become
apparent
intended for short-term
use only
Zolpidem (Ambien) Used for short-term Daytime drowsiness Give with food 1- 1 ½
treatment of insomnia hours before bedtime
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Ramelteon (Rozerem) approved for long- dizziness appropriate for clients
term treatment of with the late sleep onset
insomnia
selectively binds to
belatonin receptors
Selective serotonin inhibitiors (SSRIs)- used for the treatment of Anxiety
DisordersThe first choice medication for anxiety disorders because they have less side effects but a longer
half-life so that it will take longer time for them to work
Drug Name Indications Therapeutic Uses Complication Nursing Implications
1.Paroxetine 1.Allow more 1.generalized 1.Serotonin 1.SSRIs are
(Paxil) serotonin to stay at anxiety disorder syndrome: contradicated in
the junction site of (GAD) *** client that have taken
2.Sertraline the neurons MAOIs or Tricyclic
(Zoloft) 2. Depression 2. Sexual antidepressants
2.it does not block Disorders ** 2 dysfunction
3.Escitalopram reuptake of major uses for 2. Use SSRIs
(Lexapro) dopamine or SSRIs 3.Weight Gain cautiously in clients
norepinephrine with liver and renal
4.Fluoxetine 3.Panic Disorder dysfunction, seizure
(Prozac) 3.causes CNS disorders, or history of
stimulations, which 4.OCD HI bleeding
5. Fluvoxamine causes insomia
(Luvox) 5.PTSD 3.Use SSRIs
4.has an extensively cautiously in clients
6.Duloxetine long half-life, about 6.Anorexia who have bipolar
(Cymbalta) 5 weeks are disorder d/t risk for
necessary to 7.Aggression mania
7.Citalopram produce therapeutic
(Celexa) medication levels 4. taken with food in
the morning to
8.Vilazodone minimize sleep
(Viibryd distubrances
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Obsessive-Compulsive Disorder (OCD)
Anxiety Associated with
o Obsessions ( repetitive thoughts)
o Compulsions (perform an action)
PTSD
For clients with postraumatic stress disorder, the nurse should:
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Somatoform Disorders
A group of disorders characterized by the expression of unexplained physical symptoms that have
no physical basis.
Somatoform disorders occur more often in females and came before age 30
Secondary Gain occurs when a child may learn physical complains are acceptable coping strategies
and are rewarded by receiving attention for this behavior
these clients may abuse analgesics without relief from pain or discomfort
Nursing Interventions (not treated with drugs long term because the illness is a cognitive
impairment not a physical, a one time dose of Benzo can be given IV or PO in the ED for acute sedation)
Always acknowledges the symptom or complaint as real
Re-affirm that diagnostic tests results reveal no organic pathology
Determine any secondary gains acquire by the clinet (i.e reqard obtained from the “sick role”)
Determine the primary gains ( i.e decrease in anxiety resulting from the ability to deal with the
stressful situation)
Treatment is aimed at cognitive behavioral therapy or ECT
Disassociative Disorders
these disorders involve alteration in the function of consciousness, personality, memory or
identity.
They can be sudden and temporary or gradual and chronic
Person affected by these disorders handle social situations by “splitting” from the situation and
going into a fantasy state
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a. Its usually occurs after dramatic event such as a threat of death or injury, an intolerable life
situation or natural disaster
2. Psychogenic Fugue
a. Is characterized by a person suddenly leaving home or work with inability to recall his or
her identiy, they may even assume a new identity
3. Dissassociative identiy disorder
a. Is a presenc eof two or more distinct personalities with an individual, is believed to be
caused by child abuse
4. Depersonalization
a. Is characterized by temporary loss of one’s reality, inability to feel and expression of
motions, patient describes a sense of “strangeness” about the surrounding environment
Nursing Interventions
Reduce environmental stimuli to decrease anxiety
Stay with the client during periods of depersonilization
Encourages client to identify stressfull situations that can cause a transiition from one personality to
another
Help the client identify ffective coping pattenrs
AVOID giving client with dissociative disorders too much information about past events at one
time.
o The various types of amnesia, which accompany dissociative disorders, provide protection
form pain. Too much, too sun, may cause decompensation.
Personality Disorders
Cluster A: Paranoid, Schizoid, Schizotypal (Odd or Eccentric) PSS
Cluster B: Antisocial, Borderline, Histrionic, Narcissistic (Dramatic and emotional) ABHN
Cluster C: Avoidant, Dependent, Obsessive-Compulsive (Anxious, fearful) ADO
Personality disorders are long-standing behavioral traits that are maladaptive responses to anxiety
and cause difficulty in relating and working with other individuals. NCLEX-RN questions test
personality disorder content by describing management situations.
Persons with a personality disorder are usually comfortable with their disorder and believe that they
are right and the world is wrong. These individuals usually have very little motivation to change.
Think of them as a CHALLENGE.
Eating Disorders
1. Anorexia Nervosa
a. Voluntary refusal to ear (w/ excessive exercise) & maintian a minimum weight for height &
age
b. Deals with issues of control (of their bodies & own weight) and struggle between
dependence and independents
c. People with Anorexia gain pleasure from providing others with food and watching them eat.
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These behaviors reinforce their perception of self-control. Do not allow these clients to plan
or prepare food for unit-based activities
Signs &symptoms
Weight loss of at least 15% of ideal or original body weight
Excessive exercise
Hair loss and dry skin
Hypothermia (cool extremeities
Edema (peripheral)
Muscle weakness
Vital signs: irregular heartbeat, decrease pulse and blood presssure (orthostatic hypotension)
resulting from decreased fluid volume could lead to heart failure
Amenorrhea for at least three months
Dehydration and electrolyte imbalance (decreased potassium, sodium and chloride) from:
o Diet pill abuse, enema and laxative abuse, diuretic abuse or self-induced vomiting
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History and Physical: initial treatment for a new patient admitted to the hospital with a diagnosis
of bulimia
1. Blood word (number 1 intervention, to evaluate electrolyte status)
2. Cardiac monitoring
3. Replenish electrolytes and fluid as indicated
4. Careful monitoring for evidence of vomiting
Remember: with anyone with an eating disorder such as anorexia or bulimia have increased
risk for cardiac dysrhythmias and heart failure due to low potassium and electrolytes.
Nursing Interventions: People with Bulimia often use syrup of ipecac to induce vomiting
which may cause cardiovascular problems such as congestive heart failure (CHF). Because
CHF is not usually seen in young people, it is often overlooked. Assess for edema and listen
to breath sounds carefully
Treatment for eating disorders: Physical assessment and nutritional support are a priority; the
physiological implications are great. Nursing interventions should increase self-esteem and develop
a positive body image. Behavior modification is useful and effective. Family therapy is most
effective since issues of control are common in these disorders. (Therapy is usually long term).
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Mood Disorders
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Abnormal Lab Test for Depression
Cortisol >5 mg/dL
Decreased serotonin
A decrease in norepinephrine
Nursing Interventions:
*** Assess for sudden elevation in mood and energy: this may indicate increased risk for
suicide
o directly asked the client about feelings and plans of suicide or hamring themself
o initiate suicide precaution if neccesary
insist the patient participate in ADLs, do not give the pt a choice about patitipation (e.g it’s
time to go to the gym for basketball)
administer antidepressant medications
Tricyclic
MAOI
o Easy way to remmebr MAOI’S! Think of PANAMA!
PA- parnate
NA- naradil
MA- marplan
SSRI
Atypical
o Trazodon (Desryl)
SNRIs
o Bupropion (Wlbutrin)- only antidepressant that does NOT cause weight gain
o All the other info is the same as SSRI
*****Remember: when aswering HESI/NCLES questions you are at Utopia general and
there’s plenty of time & staff to provide ideal nursing care. DO not let the realities of
clinical situations to tear you from choosing th best nursing intervention
o ****the best intervention for depressed patient is to sit quietly with the client,
offering support with your presence.
o Spend time with client to return when promised
o Depressed clients have difficulty hearing and accepting complements because of
their lowered self-concept
Comment on signs of improvedment by noting the behavior (i.e I noticed
you comb your hair today, NOT you look nice today because the client can
also intepret that as them not looking nice other days.)
o The nurse knows depressed clients are improving when they begin to take an
interest in their parents or begins to perform self-care activities that were previously
of little or no interest
Suicide Precautions
o Obtain a history: a previous suicide attempt is the msot significant risk factor
o Always stay with the client: never leave a suicida patient alone
Warning signs of impeding suicide attempt
a client begins giving away his or he rpossesions
a previously depressed client becomes happy. This indicated here that he or she
has made the decision to commit suicide, is no longer debating the possibility
and has figured out how to accomplish the suicide
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2. Bipolar Disorder, or Manic-Depressive Ilness
a. Is an affective disorder manifested by mood swings including euphoria, grandiosity, and an
inflated snese of self-worth
b. To be diagnosed with bipolar disorder, the patient must have at least one episode of major
depression. A client may cycle. Going from elevation to depression, with periods of normal
activity in between.
Treatments:
Number 1 Med of choice for Bipolar Disorder is Lithium
Lithium Carbonate #1 med use to treat bipolar especially during the manic phase
Normal Lithium level is between 0.8-1.2 mEq****
a. ***Nursing interventions monito serium lithium levels carefully *****
b. the thearpeutic and toxic levels are very close to each other on the readings. Signs of toxicity
are evident when lithium levels are mroe than 1.5 mEq/L
c. blood levels should be drawn 12 hours after the last dose was given.
d. While on Lithium the patient requires renal function asessment and monitoring
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Tricyclics Antidepressant (cause anticholinergeic Effects)*** Treat DEPRESSION
Drugs Indications Adverse Reactions Nursing Intervention
1.Amitriptyline (Elavil) 1.Depressions 1.Anticholinergic side 1.Given at bedtime
2.Desipramine effects (DRY 2.take 2-6 weeks to
(Norpramin) EVERYTHING) obtain therapeutic levels
3.Imipramine (Tofranil) dry mouth 3.1-3 weeks should
4.Nortriptyline (Aventyl) blurred vision elaspe between DC
5. Protriptyline photophobia tricyclics and beginning
(Vivavtil) urinary hesistancy or MAOIs
Maprotiline retention 4.Avoid the use of
(Lumdiomil) constipation antihypertensive drugs
2.Cannot be taken with 5.Can be lethal in OD
MAOIs due to
development of a
hypertensive crisis
3. postural hypertension
4.tachycardia
5. GI: Nausea and
vomitting
***LITHIUM Mnemonic
L- level of therapeutic affect is 0.5-1.5 ******
I- indicate mania
T- toxic level level 2-3 but S&S can begin at 1.5 mEq/L- N/V, diarrhea, tremors
H- hydrate 2-3 L of water/day
I-increase UO and dry mouth
U-uh oh; give Mannitol and Diamox if toxic s/s are present
M- maintain Na intake of 2-3 g/day
NSAIDs- (ibuprofen (Motrin) Celebrex)- concurrent use will increase renal reabsorption of lithium, leading
to TOXICITY
Anticholinergics (antihistamines, tricyclic antidepressant) abdominal discomfort and can result from
anticholinergic-induce urinary retention and polyuria
Mood stabiizing antiepileptic (anticonvulsants) drugs (AEDs) used to treat bipolar
1. Carbamazepine (Tegretol)- used as an ALTERNATIVE to lithium
2. Valproic Acid (Depakote)- used alone r with lithium
3. Lamotrigine (Lamictal) used or alone with others
o Benzos (Ativan, Lorazepam, etc) good for Alcohol withdrawal and Status Epilepticus
o Antabuse for Alcohol deterrence- makes you sick with OH intake
o Alcohol withdrawal= delerium tremens- tachycardia, tachypnea, anxiety, nausea, shakes
halluincations, paranoia… (DTs start 12-36 hrs after last drink)
o Opiate (heroin, morphine, etc) Withdrawal= watery eyes, runny nose, dilated pupils, NVD, cramps
o Stimulant Withdrawal= depression, fatique, anxiety, disturbed sleep
Non- Phenothiazines 1. used to control psychiatric 1.Severe extrapyramidal 1.Teach the patient to avoid
(are typicals but have behavior reactions alcohol
different structure) - less sedated than 2.Leukocytosis 2.Orap is used only for
Phenothaiazines 3.Blurred Vision Tourette syndrome
1. Haliperidol (Haldol) 4.Dry mouth
2. Thiothixene HCL 5.Urinary retention
(Navane)
3.Pimozide (Orap)
Long-acting Meds
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Haldol Deconate &
Fluphenazine Deconate
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ATYPICAL ANTIPYCHOTIC DRUGS
Drugs Indications Adverse Reactions Nursing Intervention
1.Risperidone (Risperdal) 1.Treat positive and negative 1.Risperdal- neuropleptic 1. Monitor WBC weekly for
2.Olanzapine (Zyprexa) symptoms of schizophrenia malignant syndrom (NMS) the first six months then
3.Quetiapin (Seroquel) without significant EPS ,EPS, dizziness, G.I biweekly
4.Aripirazole (Abilify) 2. Use for clients who do not symptoms (nausea and 2.Teach patient to change
5.Ziprasidone (Geodon) resond well to tyical constipation) and anxiety position slowly
6.Clozapine (Clozaril) antipsychotics 2.Zyprexa- drowsiness, 3.Seroquel- monitor lipids,
3.Clozapine has superior dizziness, EPS, agitation especially for obese, diabetic,
efficacy inclined to have been 3.Seroquel-drowsiness, or hypertensive clients.
treatment resistant dizziness, headache, EPS,
weight gain & anticholinergic
effects
4. Clozapine- agranulocytosis
is major concern.
Substance Abuse
Alcohol withdrawal symptoms
o Begin shortly after drinking stops, as early as 4 to 6 hours after
o Nausea, anxiety, insomnia, tremors, hyperalertness, & restlessness
o Sudden or gradual increase in all vital signs (autonomic hyperactivity)
o Use of denial and rationalization as coping mechanisms- their use must be confronted so the client
accountability for his or her own behavior can be developed
o Nutrition is a priority***
*** Delirium Tremens: (DTs) may appear 12 to 36 hours after the last drink, signs and symptoms include:
1. Tachycardia, tachypnea, diaphoresis
2. Anxiety
3. Nausea
4. Shakes
5. Marked tremors
6. Hallunications
7. Paranoia
8. Confusion
Child Abuse
Most important indicators of child abuse include
o Injuries not congruent with the child’s developmental age or skills
o Injuries are not correlated with the stated cause
o A delay in seeking medicla care
Bruises or fractures in unusual places and in various stages of healing
Whipleash injuries caused by being shaken
Bald patches were here and has been pulled out
Parent seeing child as “different” from other children
The child appears frightened and withdrawn in the presenc eof the parents or other adult
Family history of frequent moves, unstable employment, family violence
One parent answring all the questions
Nursing Interventions
Nurses are legally required to report all cases of suspected child abuse to the appropriate local or
state agency
Nurses take color photographs of the injuries
Document the factual objective statments, Philly interaction interview
Establish trust with the child
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o Establish only one nurse to care for the abuse child: abuse children have difficulty
establishing trust. The child will be less anxious with one constant care giver.
HESI HINT for Child Abuse : during an exam if it’s an option then:
***** It is always the correct answer to report suspected cases of child abuse*****
HESI HINTS: reguarding physicla and sexual abuse, usually focuses on three aspects
1. Physical manifestation of abuse
2. Client safety
3. Legal responsibilities of the nurse:
a. For children, the nurse legally responsible for reporting all suspected cases of abuse.
b. In intimate partner abuse it is the adult decision to report the abuse: the nurse should be
supportive of the court’s decisions
c. Remedy document objective factual assessment data and the client exact words in cases of
sexual abuse or rape
Organic Disorders
abnormal psychological or behavioral signs and symptoms that occur as a result of cerebral diseases
systemic dysfunction, or use of or exposure to exogenous substances
Hesi Hints:
Confusion in the elderly is often “accepted” as part of growing old. This confusion may be due to
dehydration with resulting electrolyte imbalance. Think “sudden change” when obtaining a
history. Such changes are usually due to a specific stressor, and treatment for the causative
stressor will usually result in correcting the confusion.
Confabulation is not lying. It is used by the client to decrease anxiety and protect the ego.
Nursing interventions for the confused elderly should focus on:
- Maintaining the client’s health and safety
- Encouraging self care
- Reinforcing reality orientation (e.g., “Today is Monday,” and
call the client by name).
- Providing a consistent, safe environment – engage client in
simple tasks, activities to
build self-esteem
• Providing consistent caregiver is a priority in planning nursing care for the confused older client.
Change increases anxiety and confusion.
• May also use atypical antipsychotics such as resperidine, quetiapine, olanzapine, Clozaril is not a front-
line agent due to side-effects. May also give mood stabilizers and antianxiety medications as
indicated.
****Difference between Delirium & Dementia- the basic difference between delirium and dementia is
that delirium is acute and reversible (think of a sudden change), whereas dementia is gradual impermanent.
o Children also experience depression, which often presents as headaches, stomachaches, and other
somatic complaints. Be sure to assess suicidal risks, especially in the adolescent.
o The client’s lack of remorse or guilt about their antisocial behavior represents a malfunction of the
superego or conscience. The id functions on the basic instinct level and strive to meet immediate
needs. The ego is in touch with
external reality and is the part of the personality that makes
decisions.
o Important points to remember when answering NCLEX-RN questions:
- These children may be involved in self-fulfilling prophecy (e.g., “Mom says that he/she is a
trouble-maker, therefore, he/she must live up to Mom’s expectations”).
- Confront the client with his/her behavior, e.g., lying. This gives the client a sense of
security.
- Provide consistent interventions – helps to prevent manipulation. Inconsistency does not
help the client develop self-control.
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