Editing Mental Health and Psychosocial Nursing – LPN Flashcards (section)

== Recognizing and Responding to Symptoms ==

;How should the nurse respond to a delusion?
:Do not agree with it and do not argue against it. Respond to the underlying feeling: "It must be frightening to feel that you are being watched." Arguing with logic increases defensiveness and damages trust.

;How should the nurse respond to a hallucination?
:Present reality once without arguing and validate the client's experience: "I do not hear a voice, but I understand that you do." Then ask what the voices are saying, because voices commanding harm to self or others are an emergency to report at once.

;A client is trembling, breathing rapidly, and says "I can't breathe, I am dying," and cannot follow directions. What does the LPN do?
:Stay with the client, use a calm voice with short simple repeated sentences, and move to a quiet low-stimulation area. Never leave a panicked client alone and do not ask for decisions or explanations. Report to the registered nurse, who evaluates the need for a PRN medication.

;A client with obsessive-compulsive disorder must complete a handwashing ritual before meals. What does the LPN do?
:Allow extra time for the ritual early in treatment. Abruptly stopping it causes a sharp rise in anxiety. Limits are reduced gradually as part of the plan of care. Also check the hands for skin breakdown.

;What is sundowning, and what helps?
:Increased confusion, restlessness, and agitation in the late afternoon and evening in clients with dementia. Increase lighting, reduce noise and clutter, keep a predictable routine, and redirect with a calm familiar activity such as walking and talking about family. Avoid arguing or correcting in advanced dementia, and never lie by promising that someone is coming to take the client home.

;What are the early signs of escalation and the basic de-escalation steps?
:Early signs: louder voice, pacing, clenched fists or jaw, invading others' space, staring, and refusing redirection. Speak calmly and quietly, keep at least two arm-lengths of space, do not block the exit or corner the client, avoid sustained direct eye contact and touch, remove other clients, offer simple choices, state a clear limit, and summon additional staff before force is needed.