HESI PN MENTAL HEALTH PROCTORED EXAM
VERSION 9
1) Findings to share w/ treatment team
a) Pt at risk for suicide (especially w/ personal & family history)
b) Comorbid anxiety disorder or panic attacks
2) Anorexia Nervosa S&S
a) Pt. preoccupied w/ food & rituals of eating
b) Refusal to eat
c) Most often in females around adolescence to young adulthood
d) Stress can cause an onset such as college
3) Applying restraints
a) Must obtain order within 15 to 30 min of ER situation
b) D/C when pt. is calmer, safer, & quieter
c) Document every 15 to 30 min include: time Tx. begin, med admin., starting
events & behaviors, alternative actions taken to avoid seclusion, pt.behavior, foods offered, needs provided, vital signs 4) Sexual assault
a) Priority interventions
i) Perform self-assessment
ii) Provide pt. safety and ensure they know they are safe iii) Assess for suicidal ideation iv) Perform an initial & ongoing assessment of the client’s level of anxiety, coping mechanisms, & support system
v) Assess for emotional and/or physical trauma
vi) Give the pt. a private environment for the exam vii) Provide a SANE & specially trained nurse-advocate viii) Provide nonjudgmental & empathetic care ix) Treat injuries & document care given
x) Give prophylactic tx for STIs
xi) Provide D/C care (1) Therapy referral (2) Hotline numbers 5) Maladaptive (chronic or prolonged) grief response
a) Can last for varying lengths of time requiring the pt. to work through the
stages/tasks of grief
b) Pt. can remain in denial stage & unable to accept reality of the loss
c) Can results in the pt. being unable to perform ADLs
6) Deep breathing teaching
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