Flashcards.

WHAT IS IT?

Menopause is a drop in reproductive hormones that ends the reproductive period. It is diagnosed after 12 months of amenorrhea (no menstrual periods). The average age is around 50 years old.

ASSESSMENT

Symptoms can start up to 6 years before the final period and continue for a variable number of years after:

• •Hot flashes (most common)
• •Insomnia (trouble sleeping)
• •Weight gain, bloating
• •Mood changes, depression
• •Breast pain, headaches
• •Osteoporosis (weak, brittle bones)
• •Irregular menses (periods)
• •Vaginal dryness, painful intercourse
• •Prolapse of reproductive and urinary structures (organs dropping out of place)

Lab testing (endocrine changes):

• •Increased FSH (Follicle-Stimulating Hormone) indicates that menopause has occurred
• •Decreased estrogen and inhibin

MANAGEMENT

• •Hormone replacement therapy for severe cases
• •Symptom management

WHAT IS IT?

Disseminated intravascular coagulation (DIC) is widespread activation of the clotting cascade. The body clots and bleeds at the same time. The normal clotting cascade is disrupted and the clotting factors are used up. This causes severe bleeding and massive hemorrhage.

RISK FACTORS

• •Anything that triggers the clotting cascade, which then overreacts
• •The leading cause of DIC is infection

ASSESSMENT

• •Pallor, dyspnea, chest pain, anxiety, confusion
• •Ecchymosis: petechiae, purpura, and hematomas
• •Bleeding from every orifice
• •Abnormal labs: prolonged PTT, PT, and thrombin time, and decreased platelets
• •Tachycardia and hypotension

MANAGEMENT

• •Determine and treat the underlying cause immediately
• •Replace clotting factors: fresh frozen plasma, vitamin K, factor VII
• •Administer a heparin drip if excessive clotting, which stops the consumption of clotting factors

WHAT IS IT?

This card continues care strategies for clients with cognitive impairment (problems with memory and thinking). The focus is on familiar, calming activities and a steady routine.

MANAGEMENT

• •Use familiar, simple games and activities they enjoy (coloring, reading books they enjoy)
• •Talk about their memories
• •Maintain a routine
• •Pay attention to fatigue, memory strain, and agitation, and provide ample time for rest
• •Keep a calendar and clock on the wall and refer to it when discussing the date or time

WHAT IS IT?

Mood disorders involve emotional extremes and trouble regulating moods over the long term. Mood (emotional states) is subjective and hard to define. Examples include bipolar disorder and depressive disorders.

ASSESSMENT

• •Bipolar includes periods of mania and depression with normal periods in between (extremely high highs, extremely low lows, inability to self-regulate)
• •Mania: a mood disorder marked by a hyperactive, wildly optimistic state
• •Depression: 5 or more depressive symptoms for 2 or more weeks

MANAGEMENT

Goals:

• •Manage acute episodes
• •Provide support and resources for long-term management

Medications:

• •Anti-anxiety medication can be used during manic episodes. Use caution with clients who have a history of substance abuse.
• •Antipsychotics: olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal)
• •Mood stabilizer: Lithium. Clients need regular labs to check the therapeutic level. Toxicity can result if stable sodium intake and fluid intake (2-3L/day) are not maintained.
• •Also given: sodium valproate (Depakote), lamotrigine (Lamictal), carbamazepine (Tegretol)

Interventions for mania:

• •Make sure the environment is safe; watch for dangerous hyperactivity
• •Reorient as necessary
• •Promote appropriate sleep/wake cycles
• •Use controlled, calm, focused interactions
• •Offer high-calorie finger foods because the client is manic and hyperactive
• •Set boundaries related to behaviors
• •Ensure medication compliance

WHAT IS IT?

Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviors, feelings, and sense of wellbeing.

SEVERITY

• •Mild: lasts 2 weeks or less
• •Moderate: more persistent, with negative thinking and possible suicidal thoughts
• •Severe: intense and pervasive, may include delusions and hallucinations

ASSESSMENT

Some combination of these symptoms may be present, especially in major depressive disorder:

• •Depressed mood most of the day
• •Diminished interest or pleasure in activities
• •Significant unintentional weight loss
• •Insomnia or hypersomnia
• •Psychomotor agitation
• •Fatigue or loss of energy
• •Feelings of worthlessness, or excessive or inappropriate guilt
• •Difficulty concentrating or making decisions
• •Recurrent thoughts of death or suicide, with or without a plan
• •Low self-esteem
• •Feelings of hopelessness
• •Poor appetite or overeating
• •Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

MANAGEMENT

• •The number one priority is assessing the risk for self-harm: "Have you had any thoughts of hurting yourself?" If they say yes, then ask, "Do you have a plan?"
• •Ensure a safe environment: remove anything from their room that they could use to harm themselves
• •Promote appropriate intake; focus on higher-calorie foods frequently, since they may go long periods without eating, so maximize intake when they do eat
• •May need reminding or encouragement to maintain basic personal hygiene (ADLs)
• •Encourage expression of feelings and focus on their strengths
• •Validate their feelings of loss, frustration, and sadness
• •Spend time with them to show they are a priority to you
• •Engage the client in activity toward progress: one-on-one situations, eventually progressing to group discussions; start with gross motor activities; suggest activities that are easy to complete, non-competitive, and offer a sense of accomplishment (coloring, drawing, playing cards, easy games)
• •Promote appropriate sleep-wake cycles

WHAT IS IT?

Suicidal behavior occurs in clients with a consistent feeling of hopelessness, guilt, and worthlessness so overwhelming that they do not want to live anymore and attempt to end their life.

At-risk clients (previous personal or family history of suicide, or mental illness history):

• •Personality disorders
• •Substance abuse
• •Psychosis
• •People with depression
• •People with terminal illness
• •People with disabilities
• •Elderly and adolescents

ASSESSMENT

Objective information:

• •Giving away important, prized possessions
• •Creating a will or changing an existing one
• •Sleep disturbances
• •Difficulty concentrating, loss of interest in things
• •Asking about methods to end one's life
• •Writing notes to loved ones
• •Sudden massive improvement in a previously very depressed client: they may have new energy or relief because they made a plan or a decision, so observe more closely for an increased chance of carrying out the plan

MANAGEMENT

• •Assess clients with a history of depression for risk of suicide and self-harm

Safety is essential:

• •Inpatients admitted with suicide attempts are not to be left alone
• •Remove any items that could be used for self-harm from their room
• •Initiate suicide precautions
• •Begin sitter or 1:1 supervision and never leave the client alone

Other therapeutic management:

• •Establish a suicide contract
• •Establish rapport and trust
• •Provide positive reinforcement
• •Involve the support system the client identifies
• •Encourage therapy (individual, group)

WHAT IS IT?

PTSD is a mental illness that results after someone experiences trauma. The client might relive the trauma, frequently dream about it, or have flashbacks. Traumatic events that cause PTSD include anything traumatic to the client, such as rape, accidents, wartime experiences, or natural disasters.

ASSESSMENT

• •Sleep issues such as insomnia, nightmares, and flashbacks
• •Mental health issues such as depression or anxiety
• •Avoiding triggers: a trigger is a situational, audible, or visual experience that invokes an anxiety-driven or fear response, similar to the original cause of the PTSD. For example, if a client experienced violence at a location, they may avoid that location or similar ones.
• •Guilt related to the event. For example, if they survived and others did not, the client might think they could have done something differently.

MANAGEMENT

• •Validate the client's feelings and promote coping mechanisms that work for them
• •Offer relaxation techniques
• •Encourage outpatient therapy and support groups
• •Therapy/service animals may help clients

WHAT IS IT?

Anxiety is a sense of worry or nervousness, usually about an upcoming event with an uncertain outcome. It is a normal part of life. It becomes concerning when it is persistent, chronic, or a response to normal daily activities.

Types:

• •Normal: healthy
• •Acute: sudden, related to an event or threat (also normal)
• •Chronic: consistent, related to normal daily activities

ASSESSMENT

Levels of anxiety:

• •Mild: can be healthy, motivating, and produce growth
• •Moderate: can still function and solve problems
• •Severe: the individual needs someone to refocus them
• •Panic: dread, impending doom, and lack of rational thoughts; this can lead to exhaustion

MANAGEMENT

Therapeutic interventions:

• •Ensure safety
• •Provide a calming and safe environment
• •Establish trust and acknowledge the anxiety
• •Encourage expression of thoughts, feelings, and problem-solving
• •Promote their coping mechanisms; do not criticize
• •Provide gross motor activities to reduce stress (movement and coordination of arms, legs, and large body parts, such as running, walking, jumping)
• •Give anti-anxiety medications PRN (as needed)

For an acute anxiety attack:

• •Decrease stimuli and maintain a calm environment (overstimulation makes it worse)
• •Encourage the client to identify and discuss feelings and their causes, which helps them see connections between behaviors and feelings
• •Listen and watch for signs of risk for self-harm such as helplessness and hopelessness; safety is the priority

WHAT IS IT?

This card lists common health and cultural considerations for several groups in the United States to help guide care. These are general patterns, not rules for every individual.

CULTURAL CONSIDERATIONS

African Americans:

• •Higher incidence of high blood pressure and obesity
• •High incidence of lactose intolerance

Arab Americans:

• •May remain silent about STIs (sexually transmitted infections), substance abuse, and mental illness
• •After death, the family may want to prepare the body; autopsy is discouraged unless required by law
• •Use same-sex family members as interpreters

Asian Americans:

• •Believe in the yin/yang "hot-cold" theory of illness
• •Sodium intake is generally high because of salted and dried foods
• •Usually refuse organ donation
• •May nod without necessarily understanding

Latino Americans:

• •Family members are typically involved in all aspects of decision making, such as terminal illness
• •May see no reason to submit to mammograms or vaccinations

Native Americans:

• •Diet may be deficient in vitamin D and calcium because many have lactose intolerance or don't drink milk
• •Obesity and diabetes are major health concerns

WHAT IS IT?

This card is a memory aid for the common side effects of anticholinergic medications.

KEY SIDE EFFECTS (mnemonic: ABCD'S)

• •Anorexia (loss of appetite)
• •Blurry vision
• •Constipation / Confusion
• •Dry Mouth
• •Sedation / Stasis of urine (urine not draining)

WHAT IS IT?

A left cerebrovascular accident (CVA, stroke) affects the left side of the brain. This card lists the typical findings.

ASSESSMENT

• •Paralyzed right side (right-sided hemiplegia)
• •Impaired speech and language
• •Slow performance
• •Visual field deficits
• •Aware of deficits: depression, anxiety
• •Impaired comprehension

WHAT IS IT?

This card uses two memory aids to separate left-sided heart failure signs (FORCED) from right-sided heart failure signs (BACONED).

ASSESSMENT

Left side (FORCED):

• •Fatigue
• •Orthopnea (trouble breathing while lying flat)
• •Rales / Restlessness
• •Cyanosis / Confusion
• •Extreme weakness
• •Dyspnea (trouble breathing)

Right side (BACONED):

• •Bloating
• •Anorexia
• •Cyanosis / Cool legs
• •Oliguria (low urine output)
• •Nausea
• •Edema
• •Distended neck veins

WHAT IS IT?

These are skills nurses use to build trust and help the client express feelings. The goal is to keep the focus on the client. Good technique invites the client to keep talking.

TECHNIQUES

• •Open-ended questions: "Tell me how you are feeling today."
• •Reflection: turn the question back to the client. Client: "Should I take the medicine?" Nurse: "What are your thoughts about taking it?"
• •Restating: repeat the client's main idea. Client: "I did not sleep at all." Nurse: "You did not sleep at all last night?"
• •Silence: stay quiet to give the client time to think and speak.
• •Offering self: "I will sit here with you for a while."
• •Clarifying: "I am not sure I understand. Can you explain what you mean?"

Quick Concept: Good technique keeps the focus on the client, not the nurse.

WHAT IS IT?

These are responses that block communication. They shut down the client's feelings or shift focus away from the client. On the NCLEX, these answers are almost always wrong.

BARRIERS

• •False reassurance: "Do not worry, everything will be fine." This dismisses real fear.
• •"Why" questions: "Why did you do that?" This sounds like blame and makes the client defensive.
• •Changing the subject: client talks about dying, nurse talks about the weather.
• •Giving advice: "If I were you, I would get a divorce." This takes away the client's choice.
• •Closed-ended questions during emotional moments: "Are you okay?" gets a yes or no and stops talking.

Quick Concept: If a response stops the client from sharing feelings, it is a barrier.

WHAT IS IT?

Active listening means giving the client your full attention. Your body language shows you care. Words are only part of the message. How you sit and look matters too.

KEY POINTS

• •Sit at eye level and lean slightly toward the client.
• •Keep an open posture. Do not cross your arms.
• •Make comfortable eye contact, but respect cultural differences.
• •Use SOLER: Sit squarely, Open posture, Lean in, Eye contact, Relax.
• •Watch the client's nonverbal cues, such as a tense face or shaking hands.
• •Match your tone and face to the client's emotion.

Quick Concept: Most of a message is nonverbal, so watch what the body says.

WHAT IS IT?

Defense mechanisms are unconscious ways the mind protects itself from stress and anxiety. Everyone uses them. They become a problem only when used too much.

MECHANISMS

• •Denial: refusing to accept reality. A client with new cancer says, "The lab made a mistake. I am fine."
• •Projection: blaming your own feelings on someone else. An angry client says, "You are the one who is angry, not me."
• •Rationalization: making excuses to justify behavior. A student who fails says, "The test was unfair."

Quick Concept: Denial rejects reality, projection blames others, rationalization makes excuses.

WHAT IS IT?

These defense mechanisms redirect strong feelings to safer outlets. Sublimation and compensation can be healthy. Displacement is usually less healthy.

MECHANISMS

• •Displacement: moving feelings from the real target to a safer one. A man yelled at by his boss goes home and yells at his child.
• •Sublimation: channeling unacceptable urges into acceptable action. A person with anger takes up boxing as a sport.
• •Compensation: making up for a weakness by excelling in another area. A short teen becomes a star at chess.

Quick Concept: Displacement misdirects anger, sublimation channels it usefully, compensation covers a weak spot with a strength.

WHAT IS IT?

These defense mechanisms involve going backward in behavior, blocking memories, or acting the opposite of how you feel. They help the mind avoid painful feelings.

MECHANISMS

• •Regression: returning to an earlier stage of behavior under stress. A toilet-trained child starts bedwetting after a new baby arrives.
• •Repression: unconsciously blocking painful memories or thoughts. A trauma survivor cannot recall the event.
• •Reaction formation: acting the opposite of true feelings. A person who dislikes a coworker acts overly kind and friendly.

Quick Concept: Regression goes backward, repression buries memories, reaction formation flips the feeling.

WHAT IS IT?

Kubler-Ross described five stages people may pass through when facing loss or death. The stages do not always happen in order. A person can skip stages or move back and forth.

KEY POINTS

• •Denial: "This is not happening to me."
• •Anger: "Why me? This is not fair."
• •Bargaining: "If I get better, I will change my life."
• •Depression: deep sadness, withdrawal, crying.
• •Acceptance: coming to peace with the loss.
• •Stay with the client at each stage. Do not rush them to acceptance.

Quick Concept: Stages are not a straight line. Meet the client where they are.

WHAT IS IT?

Normal grief is a healthy response to loss that eases over time. Complicated grief (also called dysfunctional or prolonged grief) is intense and does not improve. It can block daily life.

NORMAL GRIEF

• •Sadness, crying, and missing the person.
• •The client can still function and slowly heals.
• •Feelings come in waves and lessen over months.

COMPLICATED GRIEF

• •Severe grief that lasts a long time, often beyond 12 months in adults (verify at source).
• •Cannot accept the loss or carry out daily tasks.
• •May include thoughts of suicide, which need immediate action.

Quick Concept: Time helps normal grief. Complicated grief stays stuck and disrupts life.

WHAT IS IT?

Major depressive disorder is a mood disorder with deep, lasting sadness or loss of interest. It lasts at least two weeks. Safety is the top concern because of suicide risk.

ASSESSMENT

• •Sad mood, loss of interest or pleasure (anhedonia).
• •Sleep changes, appetite or weight changes, low energy.
• •Poor focus, guilt, feeling worthless.
• •Slow movement and speech, or agitation.
• •Thoughts of death or suicide.

NURSING CONSIDERATIONS

• •Always assess for suicidal thoughts and a plan first.
• •Watch closely when energy returns, as risk for acting on suicide can rise.
• •Encourage small, simple activities and basic self-care.

Quick Concept: Safety first. Rising energy in depression can mean rising suicide risk.

WHAT IS IT?

Bipolar disorder causes mood swings between mania (very high energy) and depression. Mania is a period of high or irritable mood with risky behavior. It can harm health and safety.

ASSESSMENT

• •Elevated, expansive, or irritable mood.
• •Less need for sleep, but high energy.
• •Rapid speech (pressured speech) and racing thoughts (flight of ideas).
• •Grandiosity, feeling powerful or special.
• •Risky acts: overspending, risky sex, reckless driving.
• •Poor eating because the client is too busy to eat.

NURSING CONSIDERATIONS

• •Offer finger foods and high-calorie drinks the client can eat while moving.
• •Reduce stimulation. Use a calm, low-noise area.
• •Set firm, simple limits and keep the client safe.

Quick Concept: In mania, the client may not stop to eat or sleep, so meet basic needs creatively.

WHAT IS IT?

Schizophrenia is a disorder that affects thinking, feeling, and behavior. Symptoms are grouped as positive or negative. Positive means added experiences. Negative means lost normal functions.

POSITIVE SYMPTOMS (added, not normal)

• •Hallucinations: seeing or hearing things that are not there.
• •Delusions: fixed false beliefs.
• •Disorganized speech and thinking.
• •Agitation and bizarre behavior.

NEGATIVE SYMPTOMS (lost, taken away)

• •Flat affect: little facial expression.
• •Lack of motivation (avolition).
• •Withdrawal from people.
• •Poor speech (alogia) and lack of pleasure (anhedonia).

Quick Concept: Positive = added (hallucinations). Negative = subtracted (flat, withdrawn).

WHAT IS IT?

Hallucinations are false sensory experiences, most often hearing voices. The nurse must keep the client safe and stay honest. Never argue about whether the voices are real.

KEY POINTS

• •Ask directly what the voices are saying to check for command hallucinations.
• •Command hallucinations that tell the client to harm self or others are an emergency.
• •Do not agree the hallucination is real and do not argue it is fake.
• •Say, "I do not hear the voices, but I believe you do hear them."
• •Use simple, clear, calm statements.
• •Redirect the client to real activities and people.

Quick Concept: Acknowledge the client's experience, present your reality, and check for danger.

WHAT IS IT?

Generalized anxiety disorder (GAD) is constant, excessive worry that is hard to control. The worry covers many areas of life. It lasts for months, often six months or more (verify at source).

ASSESSMENT

• •Worry that does not match the real situation.
• •Restlessness and feeling on edge.
• •Muscle tension, fatigue, trouble sleeping.
• •Trouble concentrating and feeling irritable.

NURSING CONSIDERATIONS

• •Stay calm and use a quiet, simple voice.
• •Teach relaxation: slow deep breathing and grounding.
• •Help the client name the feeling and find triggers.

Quick Concept: GAD is too much worry, too often, about too many things.

WHAT IS IT?

A panic attack is a sudden burst of intense fear that peaks within minutes. The body reacts as if in danger. Panic disorder is when these attacks happen again and again.

ASSESSMENT

• •Pounding heart, chest pain, shortness of breath.
• •Sweating, shaking, dizziness, numbness.
• •Fear of dying or losing control.
• •The attack often peaks in about 10 minutes.

NURSING CONSIDERATIONS

• •Stay with the client. Do not leave them alone.
• •Use short, simple words in a calm voice.
• •Guide slow breathing and move to a quiet space.
• •Severe panic blocks learning, so wait until it passes to teach.

Quick Concept: During panic, do not teach or reason. Stay, stay calm, and slow the breathing.

WHAT IS IT?

A phobia is a strong, lasting fear of a specific thing or situation. The fear is much larger than the real danger. The client avoids the feared object or place.

KEY POINTS

• •Specific phobia: fear of one thing, such as spiders or heights.
• •Social phobia (social anxiety): fear of being judged by others.
• •Agoraphobia: fear of places that are hard to escape, such as crowds.
• •Avoidance can shrink the client's daily life.
• •Treatment often uses gradual exposure and relaxation.

NURSING CONSIDERATIONS

• •Do not force the client to face the fear all at once.
• •Accept the fear as real to the client.
• •Support slow, planned exposure with the care team.

Quick Concept: A phobia is an outsized fear that drives avoidance.

WHAT IS IT?

Obsessive-compulsive disorder (OCD) has two parts. Obsessions are unwanted, repeated thoughts. Compulsions are repeated actions done to ease the anxiety from those thoughts.

ASSESSMENT

• •Obsessions: fear of germs, fear of harm, need for order.
• •Compulsions: handwashing, checking, counting, arranging.
• •The rituals take a lot of time and cause distress.
• •Stopping the ritual raises anxiety.

NURSING CONSIDERATIONS

• •Allow time for rituals at first. Do not stop them abruptly.
• •Set a schedule and slowly limit ritual time with the team.
• •Do not shame the client for the behavior.
• •Reduce stress, since stress makes rituals worse.

Quick Concept: Obsessions are the thoughts. Compulsions are the acts that quiet them.

WHAT IS IT?

Post-traumatic stress disorder (PTSD) develops after a person lives through or witnesses a terrifying event. The brain keeps reliving the trauma. Symptoms last more than one month.

ASSESSMENT

• •Flashbacks and nightmares that replay the event.
• •Avoiding reminders of the trauma.
• •Hypervigilance: always on guard, easy to startle.
• •Numb feelings and trouble sleeping.
• •Guilt or shame about the event.

NURSING CONSIDERATIONS

• •Build trust and offer a safe, predictable space.
• •Do not force the client to talk about the trauma.
• •Teach grounding skills to manage flashbacks.
• •Screen for substance use and suicide risk.

Quick Concept: PTSD is the trauma that will not stay in the past.

WHAT IS IT?

Alcohol withdrawal starts after the last drink as the body misses the alcohol. Symptoms get worse over the first days. Early treatment prevents serious harm.

ASSESSMENT

• •6 to 12 hours: tremors, sweating, nausea, anxiety, fast heart rate.
• •12 to 24 hours: possible hallucinations (often visual).
• •24 to 48 hours: risk of withdrawal seizures.
• •48 to 72 hours and beyond: risk of delirium tremens (DTs).
• •Note: exact hours vary by person (verify at source).

NURSING CONSIDERATIONS

• •Use a withdrawal scale such as CIWA to guide care.
• •Benzodiazepines are commonly given to ease withdrawal.
• •Monitor vital signs closely and keep the client safe.

Quick Concept: Symptoms climb over the first 72 hours, with DTs the most dangerous.

WHAT IS IT?

Delirium tremens (DTs) is the most severe form of alcohol withdrawal. It usually starts 48 to 72 hours after the last drink. It is a medical emergency and can be deadly.

ASSESSMENT

• •Severe confusion and disorientation.
• •Agitation and vivid hallucinations.
• •High blood pressure, fast heart rate, fever.
• •Heavy sweating and tremors.
• •Possible seizures.

NURSING CONSIDERATIONS

• •This is an emergency. Notify the provider right away.
• •Keep the client safe and prevent falls.
• •Give benzodiazepines and fluids as ordered.
• •Provide a calm, quiet, well-lit room.
• •Monitor vital signs and airway closely.

Quick Concept: DTs is life-threatening. Watch for confusion, fever, and unstable vital signs.

WHAT IS IT?

Opioid withdrawal happens when a person stops opioids after regular use. It is very uncomfortable but is usually not life-threatening on its own. It can look like a bad flu.

ASSESSMENT

• •Runny nose, watery eyes, yawning.
• •Muscle aches, joint pain, abdominal cramps.
• •Nausea, vomiting, diarrhea.
• •Sweating, goosebumps, dilated (large) pupils.
• •Anxiety, restlessness, trouble sleeping.

NURSING CONSIDERATIONS

• •Treat symptoms and keep the client hydrated.
• •Watch for dehydration from vomiting and diarrhea.
• •Medications such as methadone or buprenorphine may be ordered.
• •Stay nonjudgmental and supportive.

Quick Concept: Opioid withdrawal feels awful but is rarely deadly, unlike severe alcohol withdrawal.

WHAT IS IT?

Wernicke-Korsakoff syndrome is brain damage from a lack of thiamine (vitamin B1). It is common in long-term heavy alcohol use. It has two parts that often come together.

KEY POINTS

• •Wernicke encephalopathy: confusion, eye movement problems, and unsteady walking. It may be reversible with early thiamine.
• •Korsakoff psychosis: severe, often permanent memory loss with confabulation (making up stories to fill memory gaps).
• •Cause: thiamine deficiency, often from alcohol use disorder.

NURSING CONSIDERATIONS

• •Give thiamine before or with glucose, since giving glucose first can worsen damage.
• •Keep the client safe due to confusion and poor balance.
• •Support nutrition and a steady routine.

Quick Concept: Give thiamine first. Wernicke can be reversed, but Korsakoff memory loss often is not.

WHAT IS IT?

Suicide risk factors are things that raise the chance a person may attempt suicide. The nurse assesses these to plan safety. The more factors present, the higher the risk.

ASSESSMENT

• •Past suicide attempt (a strong risk factor).
• •A specific plan and the means to carry it out.
• •Depression, hopelessness, recent major loss.
• •Substance use and social isolation.
• •Giving away prized items or saying goodbye.
• •A sudden calm after deep depression can be a warning sign.

NURSING CONSIDERATIONS

• •Ask directly about suicide. Asking does not plant the idea.
• •A client with a clear plan and means is at high risk.
• •Take all threats seriously and act on them.

Quick Concept: Direct questions save lives. A specific plan plus means equals high risk.

WHAT IS IT?

When a client is at high risk for suicide, safety becomes the first priority. The nurse removes danger and watches the client closely. One-to-one observation means constant, direct supervision.

KEY POINTS

• •Remove harmful items: belts, cords, sharp objects, glass, medications.
• •One-to-one observation: a staff member stays within arm's reach at all times.
• •Keep the client in view, including in the bathroom, per policy.
• •Make a no-harm or safety plan with the client.
• •Document mood, statements, and behavior often.

NURSING CONSIDERATIONS

• •Never leave a high-risk client alone, even briefly.
• •Check the environment for hidden hazards.
• •Maintain a calm, caring, nonjudgmental presence.

Quick Concept: High risk means constant one-to-one watch and a hazard-free space.

WHAT IS IT?

A crisis is a stressful event that overwhelms a person's usual coping. Crisis intervention is short-term help focused on the here and now. The goal is safety and return to baseline.

KEY POINTS

• •A crisis is time-limited, often lasting a few weeks.
• •Safety is always the first concern.
• •Focus on the present problem, not the distant past.
• •Use a direct, active, problem-solving approach.
• •Help the client use support systems and coping skills.

NURSING CONSIDERATIONS

• •Stay calm and clear. Give simple directions.
• •Help the client name the problem and next small step.
• •Connect the client to follow-up resources.

Quick Concept: Crisis care is short, focused on now, and aimed at restoring coping.

WHAT IS IT?

Elder abuse is harm to an older adult by a caregiver or other person. It can be physical, emotional, sexual, financial, or neglect. The nurse must recognize the signs and report them.

ASSESSMENT

• •Unexplained bruises, burns, or injuries in different healing stages.
• •Poor hygiene, dehydration, weight loss, untreated sores (neglect).
• •Fear of a caregiver or being left alone with them.
• •Missing money or sudden financial changes.
• •The caregiver answers for the client and will not leave the room.

NURSING CONSIDERATIONS

• •Interview the older adult alone, away from the caregiver.
• •Report suspected abuse per state law and facility policy.
• •Document findings clearly using the client's own words.

Quick Concept: Injuries that do not match the story and a controlling caregiver are red flags.

WHAT IS IT?

Child abuse is harm to a child by physical, emotional, sexual means, or neglect. Nurses are mandatory reporters. They must report suspected abuse even without proof.

ASSESSMENT

• •Injuries that do not match the child's age or the story given.
• •Bruises in unusual spots or in the shape of an object.
• •Burns with clear patterns, such as a cigarette or immersion line.
• •Fear of adults, very watchful behavior, or flinching.
• •Delay in seeking care for an injury.

NURSING CONSIDERATIONS

• •Nurses must report suspected abuse, not prove it.
• •Report to child protective services per state law.
• •Keep the child safe and document objective findings.
• •Use a calm, nonthreatening approach with the child.

Quick Concept: When abuse is suspected, the nurse reports it. Proof is not required.

WHAT IS IT?

Intimate partner violence (IPV) is abuse by a current or former partner. It often follows a repeating cycle. The cycle tends to get worse over time.

KEY POINTS

• •Tension-building phase: stress and minor conflicts grow.
• •Acute battering phase: the violent incident occurs.
• •Honeymoon phase: the abuser is sorry, kind, and promises to change.
• •The cycle repeats and the violence often becomes more severe.

NURSING CONSIDERATIONS

• •Interview the client alone in a private, safe space.
• •Be nonjudgmental. Do not pressure the client to leave.
• •Help create a safety plan and offer resources.
• •Leaving is the most dangerous time, so respect the client's choice.

Quick Concept: Tension, then battering, then honeymoon, then it repeats and worsens.

WHAT IS IT?

Both hospice and palliative care focus on comfort and quality of life. They are not the same. The main difference is timing and whether the client still seeks a cure.

PALLIATIVE CARE

• •Can start at any stage of a serious illness.
• •Can be given along with curative treatment.
• •Focuses on comfort and symptom relief.

HOSPICE CARE

• •For clients near the end of life, often with a prognosis of about six months or less (verify at source).
• •The client is no longer seeking a cure.
• •Focuses fully on comfort, dignity, and family support.

Quick Concept: Palliative can come with cure attempts. Hospice is comfort care when cure stops.

WHAT IS IT?

Comfort measures keep a dying client peaceful and free of pain. The goal shifts from cure to comfort. The nurse cares for the body and the spirit.

KEY POINTS

• •Treat pain promptly. Do not under-treat for fear of addiction at end of life.
• •Give mouth care often, since the mouth dries out.
• •Reposition gently to prevent skin breakdown.
• •Manage shortness of breath, nausea, and restlessness.
• •Hearing is often the last sense to go, so keep speaking kindly.

NURSING CONSIDERATIONS

• •Honor the client's wishes and advance directives.
• •Provide a calm, quiet space.
• •Support spiritual and cultural needs.

Quick Concept: The goal is comfort and dignity, not cure. Keep speaking, since hearing remains.

WHAT IS IT?

The family also needs care when a loved one is dying. The nurse supports them through fear, grief, and decisions. Good family support eases the dying process.

KEY POINTS

• •Allow family to stay with the client as much as possible.
• •Explain what to expect as death nears, in simple terms.
• •Encourage them to talk to and touch the client.
• •Allow them to take part in care, such as mouth care, if they wish.
• •Respect their cultural and religious practices.

NURSING CONSIDERATIONS

• •Give honest, gentle answers to their questions.
• •Offer privacy and quiet time together.
• •Connect them to chaplain, social work, and bereavement support.

Quick Concept: Care for the family too. Presence, honesty, and respect comfort them.

WHAT IS IT?

Many cultures and religions have food rules. The nurse must ask about and respect these when planning meals. Honoring diet shows respect and builds trust.

KEY POINTS

• •Some Jewish clients keep kosher: no pork, no shellfish, no mixing meat and dairy.
• •Some Muslim clients eat halal food and avoid pork and alcohol.
• •Many Hindu clients avoid beef, and some are vegetarian.
• •Some Buddhist clients are vegetarian.
• •Fasting may occur during certain religious periods.

NURSING CONSIDERATIONS

• •Always ask the client about food preferences and rules.
• •Do not assume based on appearance or background.
• •Involve the dietitian to meet both diet and culture needs.

Quick Concept: Ask, do not assume. Respecting food rules respects the person.

WHAT IS IT?

Cultures differ in how people communicate. Eye contact, personal space, and touch carry different meanings. The nurse adjusts to the client's comfort.

KEY POINTS

• •In some cultures, direct eye contact is rude or a challenge.
• •Personal space needs vary by culture.
• •A family elder or male head may speak for the client in some cultures.
• •Touch may be welcome or unwelcome depending on culture and gender.
• •Use a trained medical interpreter, not a family member, for limited English.

NURSING CONSIDERATIONS

• •Watch the client's cues and follow their lead.
• •Do not take limited eye contact as dishonesty.
• •Speak to the client directly even when an interpreter helps.

Quick Concept: Use a trained interpreter, and let the client's comfort guide eye contact and touch.

WHAT IS IT?

People show pain in different ways based on culture. Some are loud and open. Others stay quiet and stoic. The nurse must not judge pain by how loud a client is.

KEY POINTS

• •Some cultures express pain openly with crying or moaning.
• •Other cultures value being quiet and bearing pain silently.
• •A quiet client may still have severe pain.
• •Pain is what the client says it is.
• •Always use a pain scale, not assumptions.

NURSING CONSIDERATIONS

• •Believe the client's report of pain.
• •Use a pain scale suited to the client's age and language.
• •Respect cultural views on medication and treatment.

Quick Concept: Pain is what the client says it is. Quiet does not mean pain-free.

WHAT IS IT?

Both are eating disorders with a distorted body image and intense fear of weight gain. They differ in body weight and behavior. Both can be life-threatening.

ANOREXIA NERVOSA

• •Severe food restriction and very low body weight.
• •Intense fear of gaining weight even when underweight.
• •Sees self as fat despite being thin.
• •May over-exercise.

BULIMIA NERVOSA

• •Cycles of binge eating then purging (vomiting, laxatives).
• •Body weight is often normal or near normal.
• •Feels out of control during a binge.
• •Often hides the behavior with shame.

Quick Concept: Anorexia restricts and is underweight. Bulimia binges then purges, often at normal weight.

WHAT IS IT?

Eating disorders harm the whole body, not just weight. Starvation and purging cause dangerous changes. Some complications can be deadly.

ASSESSMENT

• •Anorexia: low heart rate, low blood pressure, low body temperature.
• •Anorexia: loss of menstrual periods (amenorrhea) and thinning hair.
• •Anorexia: fine body hair (lanugo) and weak bones.
• •Bulimia: low potassium from vomiting, which can cause heart rhythm problems.
• •Bulimia: tooth enamel erosion and swollen salivary glands.
• •Bulimia: sore throat and calluses on knuckles (Russell's sign).

NURSING CONSIDERATIONS

• •Monitor electrolytes, especially potassium, and heart rhythm.
• •Watch for cardiac problems, the most dangerous complication.
• •Track weight, intake, and vital signs carefully.

Quick Concept: Low potassium from purging can stop the heart. Electrolytes are key.

WHAT IS IT?

Refeeding syndrome happens when a starved client is fed too fast. The body shifts fluids and electrolytes in a dangerous way. It can cause heart and breathing failure.

ASSESSMENT

• •Low phosphate (the key marker), low potassium, low magnesium.
• •Fluid overload and swelling (edema).
• •Confusion, weakness, muscle cramps.
• •Heart rhythm problems and possible heart failure.

NURSING CONSIDERATIONS

• •Reintroduce food slowly and increase calories gradually.
• •Monitor phosphate, potassium, and magnesium closely.
• •Watch heart rhythm and fluid status.
• •Replace electrolytes as ordered.

Quick Concept: Feed slowly. Watch phosphate. Too-fast refeeding can be deadly.

WHAT IS IT?

Silence is a powerful tool, not an empty pause. It gives the client time to think and feel. Presence means simply being there with the client.

KEY POINTS

• •Silence lets the client gather thoughts and find words.
• •It shows the nurse is patient and not rushing.
• •Do not fill every quiet moment with talk.
• •Presence: "I will stay here with you," even without words.
• •Sit quietly with a grieving or anxious client.

NURSING CONSIDERATIONS

• •Allow comfortable silence after a hard question.
• •Watch the client's face during silence for cues.
• •Use silence with new clients carefully, as it can feel awkward at first.

Quick Concept: Silence is care, not absence. Being present can comfort more than words.

WHAT IS IT?

Anxiety comes in levels from mild to panic. As anxiety rises, the ability to think and learn drops. The nurse matches care to the level.

KEY POINTS

• •Mild anxiety: alert, focused, can solve problems. Learning is best here.
• •Moderate anxiety: narrowed focus, can still follow direction with help.
• •Severe anxiety: very narrow focus, hard to think clearly.
• •Panic: loss of control, cannot focus, may need protection from harm.

NURSING CONSIDERATIONS

• •Teach only at mild to moderate levels, not during severe or panic.
• •Stay with the client at high levels and use a calm voice.
• •Use short, simple words as anxiety rises.
• •Keep the client safe during panic.

Quick Concept: The higher the anxiety, the simpler your words and the less you teach.

WHAT IS IT?

A therapeutic milieu is a safe, structured environment that supports healing. Limit setting means giving clear, firm, and consistent rules. Both help clients feel safe.

KEY POINTS

• •The milieu provides routine, safety, and a sense of community.
• •Clear rules reduce confusion and anxiety.
• •Limits must be firm, consistent, and the same from all staff.
• •Set limits on behavior, not on the person's worth.
• •State the limit calmly and explain the reason simply.

NURSING CONSIDERATIONS

• •All staff must enforce the same limits to avoid manipulation.
• •Do not argue or bargain over a set limit.
• •Offer choices within the limit when possible.

Quick Concept: Firm, fair, and consistent limits create safety. Limit the behavior, not the person.

WHAT IS IT?

Agitation can build toward aggression. De-escalation uses calm words and actions to lower tension. The goal is safety for everyone without force when possible.

KEY POINTS

• •Watch for early signs: pacing, clenched fists, loud voice, glaring.
• •Stay calm and keep your own voice low and steady.
• •Give the client space. Do not crowd or corner them.
• •Keep an open exit for yourself and the client.
• •Set clear, simple limits and offer choices.

NURSING CONSIDERATIONS

• •Call for help early and ensure staff safety.
• •Use restraints only as a last resort, per policy and orders.
• •Restraints need a provider order and frequent monitoring.

Quick Concept: De-escalate first. Calm voice, space, and choices come before any restraint.