All 99 of your review questions for modules 11–13, grouped into 7 topics: somatic disorders, autism, ADHD, tics, communication disorders, disruptive behaviour, delirium and dementia. Tap a question to check yourself.
Assess safety
Provide emotional support
Do NOT accuse patient of pretending
Those are somatic symptoms
True
Real to the patient
Not intentionally produced
Not "faking it"
Somatic Symptom Disorder
Ex: abdominal pain, fatigue, headaches, nausea
Never tell the patient, "nothing is wrong." Instead, use "I understand that your pain is real."
Illness Anxiety Disorder
Example: "My headache means I have a brain tumor."
Clue: Patient repeatedly seeks reassurance but never feels reassured.
Conversion Disorder
Examples:
Sudden blindness, paralysis, inability to speak, seizures, numbness
No neurological explanation exists.
It's a common finding with Conversion Disorders. It is when the patient seems strangely unconcerned about severe symptoms.
Example: Patient becomes blind…but calmly asks:
"So when can I go home?"
Pain disorder
Often labeled as "idiopathic pain" or pain with an unidentified source.
Factitious disorder
Goal:
Example: Injects bacteria into IV site. Alters lab specimens.
Munchausen by proxy (type of factitious disorder)
Often a mom to child.
It's the production of intentional symptoms for EXTERNAL GAIN.
External gains could include: avoiding jail, getting disability, avoiding military service, obtaining narcotics.
If there is an obvious external reward = malingering
Factitious disorder and malingering
Primary gain is the internal psychological relief a person receives from developing symptoms. The symptoms reduce emotional conflict or anxiety without the person consciously intending them.
Primary = Psychological relief
This is seen in Somatic Symptom D/O, Illness Anxiety D/O, and Conversion D/O.
Secondary gain is any external benefit that occurs because the illness exists.
Think: Secondary = Outside reward
"Other people treat me differently because I'm sick."
Examples: attention, sympathy, financial help, avoiding work, avoiding responsibilities
The person is not intentionally creating symptoms to receive these benefits.
Her unconscious mind converts emotional stress into paralysis.
The paralysis removes the anxiety of going to clinical.
That relief is primary gain.
These are secondary gains.
She didn't purposely invent symptoms to obtain them.
"Other people treat me differently because I'm sick."
Factitious disorder
Symptoms are intentional. The person knows they are making themselves sick. "I WANT to be sick."
Why? Not for money. Not to avoid work.
They simply want to be cared for & be the patient.
This is NOT Primary Gain b/c that requires unconscious symptom formation.
Malingering
Not primary or secondary gain b/c symptoms are intentional.
"I WANT something."
Never argue.
Never challenge symptoms.
Never reinforce illness behavior.
Instead:
Good: "I believe you're experiencing pain." "I'd like to help you find ways to manage stress."
Trick question - NONE
Treat associated anxiety or depression - usually SSRIs
Fluoxetine, sertraline, paroxetine, escitalopram
Rule out real illness FIRST.
Never assume symptoms are psychiatric.
Always complete appropriate medical evaluation.
Treatment is more focused on teaching them how to better manage those symptoms so that they can live an improved quality of life. Not "curing" them.
Physical symptoms are real to the patient but lack sufficient medical explanation.
Illness anxiety disorder.
la belle indifférence
CBT
D) Acknowledging the patient's symptoms as real and offering support for their distress while addressing underlying psychological factors.
C. "I should expect my symptoms to go away once the doctors find the cause."
Because simply knowing what the problem is isn't going to make them go away. Need to work on the trigger behind the somatic response.
A person with an IQ < 70, family genetic history of Tay-Sachs, and significant limitations in areas of adaptive functioning, such as communication skills, the ability to care for themselves, life skills, and interpersonal skills.
Impaired: Social interaction, Communication
Restricted interests
Repetitive behaviors
Usually before age 3
Poor eye contact
No pretend play
No pointing
Delayed speech
Little interest in peers
Doesn't respond to own name
Repetitive movements: rocking, hand flapping, toe walking
Before age 3
Maintain routine
Prepare for transitions
Decrease environmental stimulation
Use short simple instructions
Reward desired behaviors
Avoid overwhelming sensory input
Maintain routine
Short, Concrete, Simple directions
Give one instruction at a time.
No meds treat autism itself; treat associated symptoms
risperidone or aripiprazole for aggression/self injury.
B. Implement a consistent routine and minimize changes to the child's environment.
With ASD, they need that consistent routine and the minimizing of changes because that can cause a lot of emotional distress.
A. Limited eye contact during interaction with the nurse.
B. Uses single words rather than sentences to communicate needs.
C. Displays repetitive hand flapping movements.
E. Shows a strong attachment to a specific toy or object.
C. We should encourage eye contact by forcing our child to look at us when speaking.
ADHD
Typical behaviors: blurting out answers, interrupting, losing homework, forgetfulness, poor organization, difficulty finishing tasks (like most nursing students about semester 4!!!)
Excess talking, cannot stay seated
Stimulants:
Methylphenidate (Ritalin)
Dexmethylphenidate
Amphetamine salts (Adderall)
Lisdexamfetamine (Vyvanse)
Non-Stims:
Atomoxetine - SNRI
Atomoxetine
False, it is an SNRI used to treat ADHD - NOT a stimulant.
CNS stimulant for ADHD
Causes appetite suppression
Loss of appetite (give to kids AFTER a big breakfast)
Weight loss
Insomnia
Tachycardia
Elevated BP
Growth suppression (monitor)
Admin after breakfast
Height & Weight
Pulse
Blood pressure
Avoid evening doses.
Never stop medication suddenly without provider direction.
Store medication safely.
Watch for decreased appetite.
Encourage high-calorie evening meal.
Safety
A. Frequently interrupts others during conversations.
B. Easily distracted by external stimuli.
D. Often fidgets or squirms in seat.
"Punishing our child for every instance of inattention will help improve focus."
Structure, positive reinforcement, and breaking tasks into smaller steps are the correct approaches.
C. If our child has trouble sleeping, we can give the medication at bedtime.
This is a stimulant and will keep them awake.
Tic
Several motor and at least one vocal tic over a year = Tourette syndrome
Tourette syndrome
Motor Tics
Vocal tics
Blinking, head bobbing
Grimacing
Throat clearing
Grunting
Coprolalia (rare)
These are sudden, repetitive movements.
Examples:
Excessive blinking
Eye rolling
Shoulder shrugging
Facial grimacing
Head jerking, Neck twisting
Arm movements, Jumping
Touching objects
Examples:
Throat clearing ⭐
Grunting
Sniffing
Barking sounds
Coughing
Humming
Clicking noises
Less common:
Echolalia (repeating others' words)
Palilalia (repeating own words)
Coprolalia (swearing)
Tourette syndrome is a neurodevelopmental disorder characterized by multiple motor tics and at least one vocal tic that persist for more than 1 year, with onset before age 18.
Begin before age 18
Last longer than 1 year
Wax and wane in frequency
Not be caused by medications or another medical condition
Risperidone
Olanzapine
Risperidone
Child has average intelligence
BUT
Difficulty in: Reading, Writing, Math
Early intervention improves outcomes.
Early intervention improves outcomes.
Language disorder
Speech sound disorder
Stuttering
Social communication disorder
Difficulty understanding and/or using language that is below what is expected for the child's age.
The child has trouble with:
Vocabulary
Sentence structure
Conversation
Following directions
The problem is with language itself—not speech.
** These kids are not intellectually disabled nor do they have hearing loss
The child knows what they want to say, but cannot correctly produce speech sounds.
Think: Pronunciation problem
Rabbit = Wabbit
Manifestations:
Stuttering = Disruption in the flow of speech.
Long pauses
Difficulty getting words out
Visible frustration
Eye blinking
Facial tension
Foot tapping
Stress
Excitement
Fatigue
Speaking in public
Talking on the phone
Never say "Slow down." or "Take a deep breath."
Instead:
Parents should never finish the child's sentences.
Difficulty using language appropriately in social situations.
The child understands language. The child can speak.
But they don't understand:
(Can be confused with autism)
SCD does NOT include repetitive behaviors. SCD patients typically don't have the sensory issues found with autism.
Language D/O
Speech Sound D/O
Stuttering
Social Communication D/O
Difficulty with writing, buttoning, sports, and balance.
Enuresis (Bed wetting)
Encopresis
Often associated with constipation
These disorders are characterized by persistent patterns of behavior that involve anger, hostility, and/or aggression towards both other people and towards other people's property.
These disorders include ODD (oppositional defiant disorder), conduct disorder, and intermittent explosive disorder. Also kleptomania (thieving), pyromania (fire obsession)
True
Lower self-concept, lack of confidence in social situations. They don't do well in social situations, with other kids, peers, or adults either. They become very awkward in social settings; social interactions are difficult.
Limited ability to make associations between their behavior and the consequences of their behavior, so they have difficulty understanding cause and effect.
Oppositional Defiant Disorder
Not motivated by reward or punishment
Also: impaired problem-solving abilities, deficiencies in their ability to pay attention, deficiencies in their flexibility of thinking, and poor decision-making.
False, meds generally are not a TX option for ODD. If they have ADHD and that is treated, it can help ODD.
Use role modeling - therapeutic interventions and role modeling, rewarding good behavior, demonstrating the types of behaviors and responses that we want to see.
Conduct disorder can develop from untreated or unsuccessfully treated ODD.
Persistent behaviors that violate society's norms, rules and laws and the rights of others. These kids have significantly impaired abilities to function in social, academic, and occupational areas.
It is extremely difficult to treat… treatment is very unsuccessful. Start young!
Treat ODD before it becomes CD
Safety first
We don't want to jump to medication first, and we don't want to jump to seclusion first. We want to try other things, but we do want the child to be able to be removed from the group so that it doesn't disturb the group.
"I didn't hit Johnny, can I have my Tootsie roll?"
Cognitive disorder
Delirium
Ex: Elderly patient with UTI = delirium
Treat underlying cause, keep them safe
Almost always transient - goes away.
Generally don't give them a med for the delirium, we medicate underlying cause.
Starts with forgetfulness, progresses to the 3 A's:
Aphasia - impairment in language function
Apraxia - impairment of motor functions, despite motor abilities intact
Agnosia - can't recognize or name objects despite intact sensory abilities
Moves to disturbances in executive functioning (thinking):
True
Three stages: Mild (forgetfulness, loss of words, lost objects, anxiety/shame/fear), moderate (confusion is apparent, memory loss), severe (can't do ADLs, personality changes)
When a person will make up a story or a lie, because they don't know the answer to a question, but they know that they should.
Mild or moderate dementia.
Cholinesterase inhibitors slow progression: Donepezil, rivastigmine, galantamine - SSX: drowsy, dizzy
Antipsychotics control symptoms: haloperidol, olanzapine, risperidone, quetiapine
Memantine - NMDA receptor antagonist - SSX: HTN, pain, H/A, vomiting, constipation, fatigue.
2, 3 and 4 are dementia, not delirium
Under normal circumstances, you'd get the supervisor, but since they are delirious, it's better to stay with them and help settle them down.