Psych Concept

Defense Mechanisms
Defense Mechanism Definition Example
Rationalization Using excuses to explain away I did poorly on the test
threatening circumstances because the questions were
so tricky
Displacement Transferring thoughts and A person who is angry with a
feelings toward one person or boss comes home and yells at
object onto another person or his wife
object
Regression Returning to a previous level An adult has a “temper
of development tantrum” when stuck in traffic
Introjection Taking on the qualities or A person may take on the
attitudes of others without political views of a famous,
thoughts or examination admired actor
Reaction formation Behaving in a manner or A parent who is resentful of
expressing a feeling opposite an “unplanned” child
of one’s true feelings becomes overprotective of
that child
Repression Keeping unacceptable A person who was raped
thoughts or traumatic events cannot recall the event
buried in the unconscious
Sublimation Transforming unacceptable A person may turn to boxing
thoughts or needs into to deal with aggression
acceptable action

 Research shows that identical twins have about 50% change of developing schizophrenia if
one twin develops the disease. This points to a genetic component, but schizophrenia is not
entirely a genetic disease. The exact cause is unknown, it most likely results from the
interaction and combination of number of different risk factors which includes:
o Biochem theories- abnormalities affecting the neurotransmitters dopamine,
serotonin, norep, and glutamate.
o Structural brain abn- reduced size of certain brain areas
o Developmental factors- prenatal factors such as faulty neuronal connections
o MSC factors- birth trauma, epilepsy, maternal influenza during pregnancy.
 Dementia pt wanders and becomes lost during any stage of the disease. Strategies to
prevent wandering include:
o Placing lock above or below eye level (lose peripheral vision, cannot see objects
unless in front of them or move their heads)
o Adding motion sensors or alarms
o Placing large stop signs on exits
o Disguising a door with curtain or wall hanging
o Child proof doorknob covers
 o Black mat or black trip by the exit (impassable black hole d/t changes in perception)
 Pt with PTSD have periods of extreme anxiety and emotional arousal during which they can
be danger to themselves or others.
 Activities for children with intellectual disabilities (low IQ) should be based on
developmental consideration given to the child’s size, coordination, physical fitness,
maturity, likes and dislikes, and health status.
 Factors for delirium development in hospitalized pt include:
o Advanced age
o Underlying neurodegenerative disease (stroke, dementia)
o Polypharmacy
o Coexisting medical conditions (infection)
o Acid-base/ABG imbalance (acidosis, hypercarbia, hypoxemia)
o Metabolic and electrolyte disturbances
o Impaired mobility (early ambulation prevents delirium)
o Surgery (postop)
o Untreated pain and inadequate analgesia
 Pt with mental illness have the right to refuse tx, including inpatient hospitalization. Pt can
be involuntarily committed for psychiatric treatment if they pose an imminent danger to self
or other or if they are gravely disabled and cannot take care of self.
 Pt with major depressive disorder does not have energy to carry out daily activities including
grooming. They need assistance and direction to perform basic ADLs, and initiating social
interaction with others.
 During the end-of-life process, the pt and family typically go through several emotional
stages, each requiring therapeutic communication techniques by the nurse. The nurse can
help the client and family by providing a few minutes of time and attention. The nurse
should validate the family’s needs by providing emotional support.
 The most important intervention for ADHD child is providing structured, consistent, and
organized environment. A written sched of activities will remind the child what to expect at
any given time.
 Exploring auditory hallucination is important to assess for risk for harm or injury and
determine appropriate interventions. The nurse can say the voices are real to pt but are not
heard by the nurse. Pt with hallucinations should be directed to reality-oriented activities
rather than to further discussion of the content of the hallucinations.
 Pt with antisocial personality disorder often disregard the rules, have hx of irresponsible
behavior, and blame others for their behavior. Nursing interventions include setting firm
limits and making clients aware of the rules and acceptable behaviors.
 Pt with dependent personality disorder have an extreme need to be taken care of by
another person, cannot make decisions on their own, and have intense fear of separation
and being left alone. The ability to make decision and act on one’s own means progress
toward a therapeutic outcome.
 Any client who expresses ambivalence (not sure, whatever) about being suicidal should be
treated as a “yes”. The pt must be in a safe environment with hospital supervision and
should not be left alone.
 Functional disorders (e.g. migraines) are currently undiagnosable medical issues and should
not be confused with psychosomatic illness, attention-seeking behavior, or malingering.
 Alcohol can cause hypoglycemia, but intoxication can make it difficult to differentiate
between the effects of alcohol and hypoglycemia. Clients with acute alcohol intoxication
especially those who have diabetes mellitus, should have their blood glucose levels
monitored.
 Types of impaired thought processes in schizophrenia pt include:
o Neologisms- made-up words
o Concrete thinking- literal interpretation
o Loose associations- rapid shifting from one idea to another, with little to no
connection
o Echolalia- “echoing” of what is heard
o Tangentiality- going from one topic to the next without getting to the point of the
original idea
o Word salad- mix of words without meaning
o Clang association- meaningless rhyming words
o Perseveration- repeating the same words or phrases in response to different
questions.
 Acknowledge how pt feels and reinforce reality when dealing with pt experiencing
hallucination.
 Tx for pt requiring hospitalization for anorexia nervosa should focus on the short-term
outcomes of increasing caloric intake, promoting gradual weight gain and addressing
medical conditions caused by starvation.
 Codependency is when the partner gains self-esteem for doing something for the other
partner(im such a good wife, I did this for him). Examples are making excuses for pt’s
substance use, putting pt’s needs before one’s own, and not allowing pt to suffer the
consequences of actions.
 Memantine is a med used to treat moderate to severe Alzheimer disease. It slows
progression of symptoms, and improvement may be seen in the behavior, cognitive
functioning and ability to perform activities of daily living.
 Pt who suffer from PTSD often experience feelings of guilt and shame; they believe that they
are responsible for what happened and that, somehow, they could have prevented the
traumatic event. Using therapeutic communication, the nurse need to convey that what
happened was not their fault.
 Social isolation and impaired social interaction are common negative symptoms of
schizophrenia. The client will seek to be alone to relieve anxiety associated with being
around others. the nurse needs to be accepting of the client’s behavior and continue
attempts at brief contact until the client is comfortable.
 Caring for a client with complex needs at home can be an overwhelming and intimidating
experience for a family member and can lead to caregiver strain.
 Delusions are positive symptoms of schizophrenia. Delusions of reference cause clients to
feel as if songs, newspaper articles, and other events are personal to them.
 Two common misunderstandings about ADHD are that children outgrow it as they become
adults, and that dietary modifications (restricting additives/sugar) will improve or ‘cure’ the
symptoms. Neither statement is true. These individuals learn to cope with and manage their
symptoms as they grow older, but they do not outgrow ADHD.
 Communication with a client experiencing a hallucination should first focus on the nature of
the hallucination so that the nurse can assess for suicidal or homicidal themes.
 A suicide risk assessment is the priority nursing action for a client who expresses thoughts
about “not wanting to go on” or “wishing for death” or engages in potential suicidal
indicators such as giving away possessions. Asking the client directly about thoughts of
hurting or killing oneself is the therapeutic approach and an essential component of the risk
assessment.
 For people who are anxious or overwhelmed, a ‘why’ question asked by the nurse is often
interpreted as being critical, judgmental and intrusive. These feelings are damaging to the
development of the nurse-client relationship and therapeutic communication. Voicing doubt
is a therapeutic communication technique that allows the nurse to dispel misconceptions or
delusions without directly confronting the client’s beliefs.
 Typical characteristics of perpetrators of child abuse include:
o Unrealistic expectations of the child’s performance, behavior, and/or
accomplishments; overly critical of the child.
o Confusion between punishment and discipline; having a stern, authoritative
approach to discipline
o Having to cope with ongoing stress and crises such as poverty, violence, illness, lack
of social support, and isolation.
o Low self-esteem- a sense of incompetence or unworthiness as a parent
o A hx of substance abuse, alcohol or drugs at the time the abuse occurs
o Punitive tx and/or abuse as a child
o Lack of parenting skills, inexperience, minimal knowledge about child care and child
development, and young parental age.
o Resentment or rejection of the child.
o Low tolerance for frustration and poor impulse control
o Attempts to conceal the child’s injury or being evasive about an injury; shows little
concern about the child’s injury.
 A person suffering from PTSD experiences 3 categories of symptoms: re-experiencing the
traumatic event (flashbacks, recurring nightmares, strong physical reactions to event
reminders), avoiding reminders of the trauma (feeling detached and emotionally numb, loss
of interest in life, inability to set goals and amnesia), and hyperarousal (insomnia, irritability,
outburst of rage, persistent anger and/or fear, difficulty concentrating).
 Clients with social anxiety disorder have an excessive, persistent fear of social or
performance situations involving strangers and the possibility of criticism, embarrassment,
humiliation and rejection. The fear of the situation(s) causes severe anxiety and avoidance.
 Clients with anorexia nervosa have disturbed body image and see themselves as being fat or
overweight even when they are severely underweight or even at a normal body weight. The
nurse can help the client develop a more realistic self-image by presenting the situation
realistically and discussing weight in terms of client’s health.
 Safety is a high priority for clients with delirium. Disorientation, confusion, agitation, and
difficulty interpreting reality all increase the risk for physical injury. Close observation,
including one-on-one supervision, is essential to ensure client safety.
 Caregivers of pt with Alzheimer disease and other types of dementia often experience
burnout due to stress and exhaustion. They need information on community resources that
can provide assistance with the pt care, referring to social worker for adult day care, in-
home assistance, visiting nurse services, and home-delivered meals.
 Nursing intervention for a depressed client who expresses feelings for worthlessness and
guilt and has a distorted sense of reality include listening attentively, encouraging the client
to verbalize feelings about what has happened, and helping the client view the situation in a
more realistic way.
 Alcohol dependency is frequently missed during the admission process. Client should always
be screened for heavy use of alcohol or benzodiazepines as withdrawal is potentially life-
threatening and avoidable. Signs of delirium tremens include agitation, fever, tachycardia,
hypertension and diaphoresis. This can be prevented with benzodiazepine admin during
hospitalization.

Manifestation s/s Onset since last

drink (h)
Mild Anxiety, insomnia, tremors, diaphoresis, 6-24
palpitations, GI upset, intact orientation
Seizures Single or multiple gen tonic-clonic 12-48
Alcoholic Visual, auditory or tactile; intact orientation; 12-48
hallucinations stable vitals
Delirium Confusion, agitation, fever, tachycardia, HTN, 48-96
tremens diaphoresis, hallucinations
 The priority intervention for a child with ADHD who is engaging in aggressive behavior is to
assist the child in calming down and gaining control. Deep breathing exercises such as
blowing a balloon are an easy and efficient approach to help the body and mind slow down
and relax. After the child is calm, the nurse and the child can further discuss the disruptive
behavior.
 Alcoholism affects the whole family. AA provides help to the individual who has alcoholism.
ALATEEN provides support to teenagers whose lives have been affected by someone else’s
drinking. AL-ANON provides help for spouses and significant others of alcoholics.
 Spiritual, cultural and religious needs are important part of the nursing assessment and plan
of care. Clients have the right to verbalize and practice their beliefs; the nurse should
 include these in the plan of care. Asking the client if a spiritual advisor or clergy member
knows about the surgery opens up a nonthreatening dialogue and shows respect for the
client’s feelings and belief.
 Strategies for improving sleep hygiene include the following:
o Staying up during the day and avoiding naps
o Engaging in physical activity or exercise during the day, pref atleast 5h before
bedtime
o Receiving atleast 20mins of natural sunlight each day, ideally in the morning
(improves sleep patterns)
o Avoiding coffee or other caffeinated beverages after noon
o Avoiding alcohol/smoking at bedtime
o Dealing with or thinking about one’s concerns or issues prior to bedtime, letting go
of one’s worries before going to bed.
o Participating in a relaxing activity such as warm bath, reading, or listening to soft
music, prior to bedtime.
o Decreasing environmental stimuli in the bedroom; making sure the room is dark,
cool and quiet
o Avoiding heavy meals or large amounts of fluid at bedtime
o Drinking a cup of warm milk or eating a small amount of carbs before bedtime (milk
has tryptophan, promotes sleepiness; carbs aid in the release of serotonin, which
promotes relaxation.
 When talking with a delusional client, the nurse must focus on the client’s feelings and
reinforce reality rather than argue or present evidence that the delusion is false or
irrational.
 School phobia (aka school refusal or school avoidance) is a childhood anxiety disorder in
which the child experiences an irrational and persistent fear of going to school. A child with
school phobia needs to return to the classroom immediately. Insisting on school attendance,
along with other supportive interventions, will help the child make a faster adjustment. If
the child is allowed to remain out of school, the problem will only worsen, with potential
deterioration of academic performance and social relationships.
 Clients with schizophrenia often become anxious when around other individuals and will
seek to be alone to relieve anxiety. Impaired social interpersonal functioning (social
withdrawal, poor social interaction skills) are common negative symptoms of schizophrenia.
These are more difficult to treat than the positive symptoms (hallucinations, delusions) and
contribute to a poor quality of life. The nurse needs to be accepting of the client’s behavior
and continue attempts at brief contact until the client is comfortable. Nursing interventions
directed at improving the social interaction skills of a client with schizo include:
o Making brief, frequent contacts.
o Accepting the client unconditionally by minimizing expectations and demands
o Assessing the client’s readiness for longer contacts with the nurse and/or other staff
and clients.
 o Being with or close by the client during group activities
o Offering positive reinforcement when the client interacts with others
 A person with OCD is typically rigid and inflexible and has a need to control both internal
and external experiences. A change in sched that is outside of the client’s control could
cause significant distress.
 The nursing plan for clients with acute mania includes providing a quiet, structured, non-
stimulating environment; engaging the client in one-on-one activities and physical activity;
limiting contact with other people; and providing foods of high nutritional value that are
easy to eat. Acute manic episode is characterized by excessive psychomotor activity,
euphoric mood, poor impulse control, flight of ideas, non-stop talking, poor attention span,
distractibility, hallucinations and delusions, insomnia, wearing bizarre or inappropriate
clothing, jewelry and makeup, neglected hygiene and inadequate nutritional intake.
 ECT is an effective tx for major depression with psychotic features or for a client who is
highly suicidal. ECT is used when it is unsafe to wait for medication tx to become effective. It
is also used in clients who do not respond to or cannot tolerate psychotropic medications.
The best response to the family about ECT is to ask about their concerns, allows assessment
of knowledge and implement educational interventions to answer any misinformation or
knowledge gaps.
o During ECT, electrodes are applied to the scalp. Electrical stimulus is enough to
cause brief convulsion. General anesthesia and a skeletal muscle relaxer are given to
minimize the motor seizure and prevent musculoskeletal injury. Pt will not feel
anything from the procedure, but confusion and memory loss are common side
effects.
 Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid
and food intake and are at high risk for dehydration and malnutrition. The priority nursing
action is to anticipate the client’s needs and to ensure that the client is well hydrated and
has adequate nourishment. Some clients will need total care.
 Clients with borderline personality disorder, in an attempt to prevent abandonment and
control their environment, may flatter and cling to one staff member while making
derogatory remarks about others. The best nursing action is to rotate staff members
assigned to care for the client.
 Clients with borderline personality disorder are at very high risk for suicide. Suicidal gestures
and attempts must be taken seriously and evaluated for suicidal intent.
 Risk for suicide related to depression is a priority ND for a client with previous suicide
attempts.
 Agoraphobia is intense anxiety about being in a situation from which there maybe difficulty
escaping in the event of a panic attack. A person with agoraphobia may avoid open spaces,
closed spaces, riding in a public or private transportation, going outside the home,
bridges/tunnels, and crowds.
 The priority nursing action for the client experiencing symptoms of a panic attack is for the
nurse to stay with the client in a clam environment and offer support and reassurance that
the client is safe and secure.
 Clients who abuse alcohol often have low magnesium levels as ventricular arrhythmias
and/or neuromuscular excitability (similar to hypocalcemia), which includes tremors,
positive Chvostek and Trousseau signs, hyperactive reflexes and seizures. Normal Mag is 1.5-
2.5meq/L.
 Clinical manifestations of anorexia nervosa include extreme weight loss, amenorrhea,
bradycardia, cold intolerance, dry skin, and lanugo. Life-threatening complications, such as
cardiac arrhythmias associated with hypokalemia, may develop.
 Increasing external auditory stimulation can help distract the client from internal voices and
focus on reality for pt with auditory hallucinations.
 The best approach for a suicide risk pt is one-on-one observation.
 The first step to resolve PTSD is to encourage the pt to talk about the experience at their
own pace, listen actively to build trust, and allow clients to vent. This will assist in decreasing
their feelings of isolation.
 Clients with OCD engages in rituals and activities that help reduce the anxiety associated
with unacceptable thoughts, images and impulses. Therapeutic approaches to a client with
OCD include pointing out the amount of time the client has spent performing an activity and
redirecting the client to another activity.
 Cognitive behavioral tx (CBT) teaches clients to reframe their thought processes and develop
new adaptive approaches for coping with anxiety, stress and conflict. CBT requires that the
client learn about the disorder and engage in self-observation and monitoring, relaxation
techniques, desensitization activities and changing negative thoughts.
 Elderly white men, severe depression, living alone, prior of family hx of suicide attempt,
substance abuse, rational thinking loss, organized plan, unemployed or unskilled and
terminal illness are the risk factors for suicide. Social support/family connectedness,
pregnancy, parenthood and religion and participating in religious activities are protective
factors against suicide. SADPERSONS for high risk of committing suicide.
o S-sex (men kill themselves more often than women; women make more attempts)
o A-age (teenagers/young adults, age >45)
o D-Depression (and hopelessness)
o P-Prior hx of suicide attempt
o E-Ethanol and/or drug abuse
o R-rational thinking loss (hearing voices to harm self)
o S-support system loss (living alone)
o O-organized plan; having a method in mind (with lethality and availability)
o N-no significant other
o S-sickness (terminal)
 Among the components necessary for recovery are self-direction and responsibility, holistic
care, and hope. When all the components are reasonably represented, recovery is
 demonstrated by client’s ability to function in all aspects of living to the highest level of
capacity.
 The clinical characteristic of narcissistic personality disorder can be best explained as an
attempt to maintain a fragile self-esteem that was damaged during childhood due to an
environment that was highly critical, demanding, and fostered a sense of inferiority. Clients
with NPD may project a picture of superiority, uniqueness, and independence that hides
their true sense of emptiness. Narcissistic characteristics develop as a way to regulate self-
esteem and protect the ego from further psychic injury.
 Fear of dying is common concern for many clients with terminal disease. The nurse should
acknowledge these feelings and use open-ended statements and active listening to invite
clients to talk about death.
 Clients showing altered mental status should be assessed for intoxication and medical
causes of delirium (electrolyte/glucose imbalance, PNA, sepsis, malnutrition) prior to
involving a mental health care professional.
 Histrionic personality disorder is characterized by persistent attention-seeking behavior and
exaggerated emotionality. The client with this disorder demands immediate gratification
and has little tolerance for frustration.
 Paranoid personality disorder shows distrust and suspicion of others. They do not trust
other people; they have intense need to control them and their environment.
 Pt with borderline personality disorder, in attempt to prevent abandonment and control
their environment, may flatter and cling to one staff member while making derogatory
remarks about others. The best nursing action is to rotate staff members assigned to care
for the client.
 The diagnosis of ADHD includes the presence of hyperactivity, impulsiveness, and
inattention. The negative consequences of the core manifestations include impaired social
skills, poor self-esteem, academic or work failure, increased risk for depression and anxiety,
and increased risk for substance abuse.
 Psychomotor retardation is clinical symptom of major depressive disorder. Manifestations of
psychomotor retardation include slowed speech, decreased movement, and impaired
cognitive function. The individual may not have the energy or ability to perform activities of
daily living or to interact with others. psychomotor retardation may range from severe (total
immobility and speechlessness—catatonia) or mild (slowing of speech and behavior).
Specific findings include:
o Movement impairment- body immobility, slumping posture, slowed movement,
delay in motor activity, slow gait
o Lack of facial expression
o Downcast gaze
o Speech impairment-reduced voice volume, slurring of speech, delayed verbal
responses, short responses
o Social interaction-reduced or non-interaction
 A client at high risk for violence, self-directed or other-directed may need to be placed in
restraints as a last resort. Frequent monitoring and assessment through observation and use
of therapeutic communication techniques will help determine if the client is ready to have
restraints removed.
 The mental health continuum uses a continuous line to represent the transition from mental
health to mental illness. This passage varies from person to person and within an individual
over time but is demonstrated by the ability to cope and function effectively with routine
stress and anxiety.
 Assessment of client’s physiologic status and needs is priority nursing action when he client
is suffering from amnesia with no recollection of where he has been or what he has been
doing for a period of time. interventions need to be implemented to stabilize the client
physically before psychosocial needs are addressed.
 Clients who need to gain power or control over a situation or desire material gratification
may use manipulative behaviors such as staff splitting to get what they want. Appropriate
nursing interventions include setting behavioral limits; using neutral, matter of fact tone
when discussing rules and the consequences of unacceptable behavior; and consistency
from staff members in following the client’s nursing care plan.
 Strategies to improve nutritional intake and promote weight gain in a client with anorexia
nervosa include setting goals for daily caloric intake and weekly gain, allowing the client to
make food choices, monitoring intake, setting limits on physical activity and exercise, basing
privileges on treatment adherence, maintaining a matter-of-fact, nonjudgmental approach
toward weight and food-related behaviors.
 Manifestations of heroin withdrawal include myalgias, arthralgias, abdominal cramps,
diarrhea, piloerection (goose bumps) and pupillary dilation. When you are on a downer and
on withdrawal, you will experience the signs and symptoms of upper overdose.
 Signs and symptoms of major depression (SIGECAPS): Sleep (inc or dec); Interest deficit
(anhedonia); guilt (worthless,hopeless); energy deficit; concentration deficit; appetite (inc or
dec); psychomotor retardation or agitation; suicidality. The 2 key clinical features of major
depressive disorder (unipolar depression are depressed mood and loss of interest or
pressure. One of these must be present daily for at least 2 weeks for the diagnosis of major
depressive disorder to be made.
 Resilience plays a primary role in individual’s ability to prevent and recover from mental
illness and to manage daily stressors. Resilience is strengthened by the practice of
appropriate coping skills.
 Parents of newborns diagnosed with Down syndrome or other developmental disability may
experience shock or disbelief along with a wide array of emotions. Nurses should be
supportive by using therapeutic communication techniques that encourage the family to
talk about what they are experiencing and/or feeling.
 Clients with bulimia nervosa should be monitored for signs of hidden binging or purging
activity particularly for 1 to 2 h after meals. Excessive vomiting may result in electrolyte
imbalances, including hypokalemia ,which may lead to cardiac arrhythmias. They are
normally in normal weight, which contributes to the hidden nature of this disorder.
 Cutting in adolescence is usually a coping mechanism used when a client is emotionally
overwhelmed. Although not technically a suicide attempt, it is a clear indication that this
client is unable to process current stressors in life and needs formal assessment by a mental
health care provider with experience in adolescent psychiatry. The best therapeutic
communication at the this time is to inform the parents about the physical condition of their
child and reassure them that this client is stable. These are the most immediate concerns of
the family. Providing relevant information is a therapeutic communication technique. It
helps clients make decisions and feel safer and less anxious.
 Initial reactions to a crisis even may include shock, disbelief, denial, helplessness, and
confusion. Nursing actions are directed at providing support to the client. Acknowledging
the impact of the event and encouraging the client to ventilate are therapeutic
interventions.