NSG3450/ NSG 3450 Exam 1 (NEW 2026/ 2027 Update) Nursing Practice – Mental Health Guide| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Galen

NSG3450/ NSG 3450 Exam 1 (NEW 2026/ 2027 Update) Nursing Practice – Mental Health Guide| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Galen Q. Define mental health ANSWER - A person's condition with regard to their psychological and emotional well-being. - A wide range of conditions that affect mood, thinking, and behavior Q. Factors that affect mental health ANSWER Genes, trauma, family, lifestyle, stressors, biological factors, childhood abuse, neglect, social isolation, racism, losing someone close to you, severe long-term stress Q. What are the 3 general adaptation syndrome ANSWER Alarm Reaction Stage, Stage of Resistance, Stage of Exhaustion Q. What is the alarm reaction stage ANSWER The initial reaction stage your body experiences when under stress. Prepapres you for the flight or fight response. Heart rate and the adrenal gland releases cortisol (stress hormone) and a boost of adrenaline. Q. What is the Stage of Resistance ANSWER The body begins to repair itself. Releases a lower amount of cortisol and heart rate and blood pressure are stabilized. Remains on high alert. Signs of resistance are irritability, frustration, and poor concentration. Q. What is the Stage of Exhaustion ANSWER The stage that results after prolonged stress. Signs are fatigue, burnout, depression, anxiety, decreased stress tolerance. Q. What are the 4 levels of anxiety ANSWER Mild - Anxious throughout the day, but not all day. Some changes in concentration and sleep. Stomach-ache and muscle tension Moderate - Anxious most of the day. Changes in sleep appetite, and concentration. Avoidance. Feeling panicky, headaches, and fatigue. Severe - Anxiety all day. Feeling breathless, chest tightness, digestive issues, unable to focus, and sensory overload. Isolation. Panic - Sever anxiety all day. Panic attack, can't function. Obsessive thoughts. Q. What are the 5 stages of grief? ANSWER Denial - Denying the situation. Usually, to numb the intensity of the situation. Anger - Anger is hiding many of the emotions and pain that you carry Bargaining - You may find yourself creating a lot of "what if" and "only if" statements Depression - Where you isolate yourself from the others in order to fully cope with the loss Acceptance - Accepted the situation. You understand what it meant in your life Q. What is the DSM5? ANSWER The diagnostic and statistical manual of mental disorders, DSM-5 is the current official guidebook for categorizing and diagnosing psychiatric mental health disorders in the United States. Q. What are ways to check for mental status? ANSWER Level of Consciousness - refers to the state of wakefulness of the patient and depends both on brainstem and cortical components. Altered & Oriented, Comatose. Physical appearance - Manner of dress, level of cleanliness, appearance Behavior - Level of eye contact, restless/anxious, withdrawn, disinhibited behavior, rapport, level of motor activity Cognitive and intellectual abilities - Patients level of orientation, attention, memory, alertness and visuospatial functioning. The cognition section assesses their awareness of itself, their environment, higher cortical functioning, frontal functioning, language, mental calculation, drawing and copying. Q. What is a HEADSS assessment? ANSWER Home, Education, Activities, Drugs, Sex, Suicide. Assessment is a psychosocial screening tool designed for the adolescent population. The American Academy of Pediatrics (AAP) and other organizaitons recommend using this assessment in order to address risk behaviors. Q. What is the MMSE ANSWER The mini mental state exam, or MMSE, is a simple pen and paper test of cognitive function based on a total possible score of 30 points; it includes tests of orientation, concentration, attention, verbal memory, naming and visuospatial skills. Q. Therapeutic strategies: What is counseling? ANSWER Process of meeting with a therapist to resolve problematic behaviors, beliefs, feelings, relationship issues, and/or somatic responses. Q. Therapeutic strategies: What is milieu therapy? ANSWER Safe, structured, group treatment method for mental health issues. Interaction in a community setting. Q. Therapeutic strategies: What is promotion of self-care activites? ANSWER Meditation, exercise, get sleep, good hygiene, practice gratitude, focus on positivity, eating healthy, socializing Q. Therapeutic strategies: What is psychobiological interventions? ANSWER Another psychobiological intervention is electrical stimulation or neuromuscular electrical stimulation (NMES) Q. Therapeutic strategies: What is Cognitive and behavioral therapies? ANSWER Identifying specific problems or issues in your daily life. Becoming aware of unproductive thought patterns and how they can impact your life. Identifying negative thinking and reshaping it in a way that changes how you feel. Learning new behaviors and putting them into practice. Q. Therapeutic strategies: What is health teaching? ANSWER Teaching the patient medication awareness, intervention purposes, and coping strategies. Q. Therapeutic strategies: What is health promotion? ANSWER Process of enabling people to increase control over or improve their health Q. Therapeutic strategies: What is case management? ANSWER Case management is the coordination of community-based services by a professional or team to provide quality mental health care customized accordingly to individual patient' setbacks or persistent challenges and aim them to their recovery. Q. Neurons are comprised of? ANSWER Cell body - Where you will find the nucleus or the brain of the cell. Axon - what transmits the nerve impulses away from the cell body. A for away. Also called the pre-synaptic cleft. Dendrites - Move nerve impulses towards the brain. Also known as post-synaptic cleft. Q. What is a synapse? ANSWER The space in between the axon and the dendrite. These two do not touch. Axons bring neurotransmitter to the end of the axon where it will travel to the the synapse. Q. What is a neurotransmitter? ANSWER Neurotransmitters are chemical messengers. The receptors of the dendrite will grab the neurotransmitter and action the next cell. Neurotransmitters can travel back to the axon in a process called "re-uptake" which can then be used on a later time. Q. A 23-year-old male was brought to the emergency department by ambulance after a suicide attempt. He has been extremely depressed since the death of his girlfriend 5 months previously in a motor vehicle accident in which he was the driver. Since the accident, he has not been attending college although he was an honor student. He has also not shown up for his tutoring job. The patient's existing seizure disorder has worsened since the accident, but he refuses treatment. He states he deserves to be punished for "killing my girlfriend." a. What evidence can you identify indicating a decline in the patient's level of functioning? b. Using the mental health continuum, would you rate this patient's symptoms as mild, moderate or severe? Why? ANSWER a) Not attending class or tutoring job, seizure disorder worsen and refused treatment, guilt b) Severe due to suiide attempt Q. Which is the goal of cognitive-behavioral therapy? a. Developing satisfactory relationships, maturity and relative freedom from anxiety b. Substituting rational for irrational beliefs and eliminating self-defeating behaviors c. Facing reality and developing standards for behaving responsibly d. Reducing bodily tensions and managing stress by biofeedback and relaxation training ANSWER B Q. How is the DSM-5 helpful to mental health providers? Select all that apply. a. The DSM-5 provides a common language related to the diagnoses of mental illness b. The DSM-5 lists medications that are appropriate for the treatment of mental disorders c. The DSM-5 presents standard criteria for the classification of mental disorders d. The DSM-5 presents a comprehensive list of community resources. ANSWER A and C Q. How can you use your knowledge of normal brain function to better understand how a patient can be affected by psychotropic drugs or psychiatric illness? ANSWER Neurotransmitters impact the brain as they activate a neuron to excite or function Q. Which of the following are true statements about neurotransmitters? Select all that apply. a. Neurotransmitters are responsible for essential functions in human emotions and behaviors b. Neurotransmitters are targets for the mechanism of action for many psychotropic medications c. Neurotransmitters are only studied for their effect related to psychiatric disease processes d. Neurotransmitters are nerve cells that generate and transmit the body's electrochemical impulses e. Neurotransmitters are cholinergic such as serotonin, norepinephrine, dopamine and histamine ANSWER A and B Q. What is displacement ANSWER Shifting feelings related to an object, person or situation to another less threatening object person or situation. Displacement What is undoing? Performing an act to make up for prior behavior. Undoing What is isolation? Separating a thought or a memory from the feeling, tone or emotions associated with it. Isolation What is denial? Pretending the truth is not reality to manage the anxiety of acknowledging what real is. Denial What is introjection? Internalization of the beliefs and values of another individual, which symbolically became a part of the self, to the extent that the feeling of separateness or distinctness is lost. Introjection What is identification? Conscious or unconscious assumption of the characteristics of another individual or group. Identification What is regression? Sudden use of childlike or primitive behaviors that do not correlate with the person's current developmental level. Regression What is compensation? Emphasizing strengths to make up for weakness. Compensation What is repression? Unconsciously putting unacceptable ideas, thoughts and emotions out of awareness. Repression What is projection? Attributing one's unacceptable thoughts and feelings onto another who does not have them. Projection What is suppression? Voluntarily denying unpleasant thoughts and feelings. Suppression What is rationalization? Creating reasonable and acceptable explanations for unacceptable behavior. Rationalization What are ethics? Moral behavior. Helps us guide our own principle of what we think is right and wrong. Our ethical beliefs vary from person to person What are bioethics? Specifically related to health care. What are moral behavior? How individuals should treat each other What is beneficence? To promote good of others. What is autonomy? ability to make our own decisions What is justice? equal resources and holding someone to the law What is fidelity? has to do with maintaining loyalty and faithfulness What is veracity? honesty, telling the truth, not sugar-coating things What are values? what we feel is important What is a right? an entitlement to a benefit or service What is a legal right? a right that society has formed into a law. Ex: patient rights What is utilitarianism? Most common perspective in healthcare. Producing the most good for the most amount of people. Decision is based on best outcome. Ex: kids being vaccinated before school What is kantianism? Based on motivation behind the issue rather than the end result. What is driving the issue vs what is the end result What is Christian ethics? following the values of Christianity to make an ethical decision What is natural law ethics? the decision is self-evident. Natural. Human nature will determine the right outcome or the right decision. What is ethical egoism? decision is best for the decision maker. Desire of the person making the decision for the outcome. Doesn't matter how it will impact other people. What is voluntary admission? Person comes and wants to be admitted on their own free will. They can leave when they want to as long as they are not a harm to themselves or others. What is involunary admission (commitment)? Against the patients will. Doctor will decide if the pt needs to be in-patient. Ex: suicidal or they can't meet their basic needs. Determined to be incompetent. A&O x0. IOT to have this, there needs to be two doctors that need to sign off. Limited to 60 days. After this time, it has to go through a legal review. What is a temporary emergency hospitalization? When someone is presenting dangerous behavior. No time to get the doctors written order or agreement. This tends to happen when a police officer respond to a suicidal ideation or someone who is harmful to themselves or others. They will bring them to the ER and then they will make that temporary emergency hospitalization. After, they will switch to involuntary admission or voluntary depends on the patient status. What is involuntary outpatient commitment? Usually for patients that are in jail or house arrest. Court orders them to do out-patient therapy. What is long term or formal commitment? someone who is not able to live on their own. They need to be committed for an infinite amount of time. What is a conditional release? they are released from in-patient to out-patient care. What is unconditional release? do not have to go to out-patient care. Usually just follows up with PCM What is release AMA? if they are voluntarily admitted, they can leave AMA as long as they are determined to be safe and can meet basic needs and understand what can happen if they leave AMA. What rights do clients have? The right to treatment The right to refuse treatment The right to least restrictive treatment The right to informed consent What are the 4 types of law? Statutory law - a law that is enacted by a legislative body Common law - a law that is based on a decision from a previous case. Civil law - protects individuals and businesses Criminal law - to protect the public as a whole What are the exceptions to keeping a patients file confidential? Duty to warn Suspected elder or child abuse What do yu know about restraints and seclusions? - Must use least restrictive measures. Last resort would be restraints and seclusions - If you don't follow least restrictive measures, you will get in trouble - D/C as soon as behavior changes - Adults order has to be renewed every 24 hours. Less frequently with children. Assess every 15 mins. They are on 24-hour VSM or a sitter What is malpractice vs negligence? - Malpractice - The incompetence part of a professional - Negligence - Failure to exercise the standard of care How do you avoid liabilities? - Respond to the client - Educate the client - Comply with the standard of ccare - Supervise care - Adhere to the nursing process - Document carefully - Follow up as required - Develop and maintain a good interpersonal relationship with client and family What are types of lawsuits? Breach of confidentiality - Anything that has PII we want to make sure it remains confidential. Defamation of character - Talking bad about someone Invasion of privacy - In an in-patient during admission, their person belongings will be gone through and anything posing of threat will be taken away. Assault and battery - Assault is the threat of harming someone and battery is physical False imprisonment - secluding someone when they shouldn't be secluded What is culture? societies way of living. Shared pattern of beliefs and feeling and knowledge. Passed down trhough generations. What is ethnicity? people who identify with each other and often have a shared heritage How do cultures differ? Communication - can vary between verbal and nonverbal beahavior, language, eye movement, gestures Space - distance between people. Some like space some are okay with being close Social organization - How families interact, family dynamics, different religious groups Time - some cultures are very focused on the past, some are focused on present, and some are focused on the future. Timeliness and promptness Environmental Control - Things they can control in their environment. When they are sick, and they want warm soup. Biological Variations - Responses to medication. Some cultural groups respond different to medications than other cultural groups What are culture bound syndroms? symptoms associated with specific cultures that may be expressed differently from the American culture. Most are considered "illnesses" and most have local names What is spirituality? refers to the human quality that gives meaning and sense of purpose to an individual's existence. Exists with each individual regardless of belief system and serves as a force for interconnectedness between the self and others, the environment and a higher power. What are types of spiritual needs? Faith - Acceptance of a belief without physical evidence. EX: Believing in God Hope - Finding the positive, focusing on the positive in bad situations Love - Good feeling for others Forgiveness - being able to release past hurts that someone has done to you What is religion? part of spirituality. Practices are usually grounded in the teaching of a spiritual leader What is the nursing process? Assessment - mental status exam, focused assessment on the brain Diagnosis - Focusing more on nursing problems that we can focus on and help pt Outcome Identification - what do we want to see as a result Planning - Develop plans and interventions that nurses can do Implementation - Carrying out those interventions Evaluation - Assessing the situation What is case management? Goal of case management is to make sure the patient is getting what they need and not getting unnecessary procedures What is managed care? has to do with insurance. They work together to determine what the reimbursement will be for different procedures What is a case manager? the one who does the case management. Could be a nurse, social worker, various other people can take this role What is a critical pathways of care? interdisciplinary care plan. What is the role of the nurse? To assist with the client's successful adaptation. Goals are directed toward change in thoughts, feelings and behaviors that are age appropriate. The nurse is a valuable member of the interdisciplinary team What is problem-oriented recording? onger type of note. SOAPIE (subjective, objective, assessment, plan, intervention, evaluation) What is focus charting? Quick to the point. Could be helpful when talking to a provider. DAR (data, action, patients response)Assessment, problem, intervention, evaluation What is APIE? Assessment, problem, intervention, evaluation 1In which situation does a health care worker have a duty to warn a potential victim? a. When clients manipulate and split staff and are a danger to self. b. When clients curse at family members during visiting hours c. When clients exhibit paranoid delusions and auditory or visual hallucinations d. When clients make specific threats toward someone who is identifiable D A client has been placed in seclusion because the client has been deemed a danger to others. What is the priority nursing intervention for this client? a. Have little contact with the client to decrease stimulation b. Provide the client with privacy to maintain confidentiality c. Maintain contact and assure the client that seclusion will maintain the client's safety d. Teach the client relaxation techniques and effective coping strategies to deal with anger C Which of the following clients does not have the ability to refuse medications or treatments? Select all that apply a. An involuntary committed client b. A voluntary committed client c. A client who has been deemed incompetent by the court d. A client who has a diagnosis of antisocial personality disorder e. A client who is an imminent danger to him or herself C and E When a client makes a written application to be admitted to a psychiatric facility, which statement about this client applies? a. The client may retain none, or all civil rights depending on state law b. The client cannot make discharge decisions. These are initiated by the hospital or court or both c. The client has been determined to be a danger to self or others d. The client makes decisions about discharge, unless he or she is determined to be a danger to self or others D On an inpatient locked psychiatric unit, a newly admitted client requests to leave against medical advice. What should be the initial nursing action for this client? a. Tell the client, that because he or she is on a locked unit, he or she cannot leave AMA b. Check the client's admission status ad discuss the client's reasons for wanting to leave c. In a matter of fact way, initiate room restrictions d. Place the client on one-to-one observation B What are the steps of communication? Stimulus - What is initiating the communication or conversation. We have something we want to share, tell, speak, communicate to someone else Sender - person who is sending the message Message - the information we are trying to give to the receiver Media - The means we are giving the message. Ex: verbally, writing, email, texting, etc Receiver - Person who is getting the message Feedback - What the receiver is giving back to the sender What are the levels of communication? Intrapersonal - Self talk. All the convo's you have in your head. Just personal talking to yourself Interpersonal - One on one conversation. Talking to a friend, or another person Small group - Conversation with two or more people Public - A larger group of people conversing Transpersonal - Spiritual needs. Example would be prayer What is rapport? Building trust What is trust? having someone comfortable around us What is respect? not judging others What is genuineness? Being real, not changing yourself because of who you're helping What is empathy? Trying to udnerstand what it's like to be in the patient's shoes What are the phases of a relationship? Pre-interaction phase - When we haven't even met the client yet. Gathering all of the information we can before having that meeting. Looking at past medical history. Set aside biases at this point as it could be a barrier to therapeutic relationship. Orientation phase - This is the introduction part of the relationship. Building rapport and trust. Setting goals and exploring ideas to meet goals. Setting limits. Working phase - This is where we continue and maintain the relationship. Encourage problem solving. Promote self-esteem and help the patient use new coping skills they've learned. Termination phase - This is where we want to disucss thoughts and feelings about terminating the relationship. Therapeutic relationships don't last forever. What is transference? When the client sees a member of the healthcare team that is having characteristics of someone that is significant to them. A nurse reminds them of their mother, child, sister, etc. The client then displays behavior according to the person they remember. It can be a good thing or a bad thing. It becomes a barrier to meeting those goals. When we have transference, we need to set back and establish the boundaries to help them get back on goals. If this doesn't work, a new health care provider will need to be given to the patient. What is countertransferene? When the client reminds the healthcare provider of someone they know. It's the opposite of transference. If the healthcare provider can't get past that, then that person needs to be switched with a new person. What are professional boundary concerns? Self-disclosure - Don't ever tell personal information to a client. Gift giving - We don't give gifts to clients; we don't accept gifts from clients. Touch - should only be for care. Nothing else. Need to have consent. Friendship or romantic association - not sharing personal phone numbers, being friends on social media, or starting a relationship with your patient. What is focusing? Taking notice of a single idea or even a single word works especially well with clients who are moving rapidly from one thought to another, This technique is nor therapeutic, however, with dients who are very anxious. Focusing should not be pursued until the anxiety level subsides, What is reflecting? Questions and feelings are referred back to client so that they may be recognized and accepted and so that the client may recognize that his or her point of view has value— a good technique to use when client asks the nurse for advice, What is restating? Repeating the main idea of what the client has said What is giving recognition? Acknowledging and indicating awareness is better than complimenting, which reflects the nurse' s judgment What is giving reassurance? False reassurance indicates to client that there is no cause for anxiety, thereby devaluing client's feelings; may discourage client from further expression of feelings if he or she believes the feelings will be downplayed or ridiculed. What is giving broad opening? Broad openings allow client to take the initiative in introducing the topic; emphasizes the importance of client's role in the interaction What is verbalizing the implied? Putting into words what client has only implied implied or said indirectly is a technique that can also be used with clients who are mute or are otherwise experiencing impaired verbal communication. This technique clarifies that which is implicit rather than explicit What is indicating an external source of power Justifying that the cause is due to external sources of power What is voicing a doubt? Expressing uncertainty as to the reality of dients perceptions is a technique often used with clients experiencing delusional thinking. What is exploring? Delving further into a subject, idea, experience, or relationship is especially helpful with dients who tend to remain on a superficial level of communication, However, if client chooses not to disclose further information, the nurse should refrain from pushing or probing in an area that obviously creates discomfort, What is requesting an explanation? Striving to explain that which is vague or incomprehensible and searching for mutual understanding facilitates and increases understanding for both dient and nurse, What is giving advice? Giving biased opinion What is belittling feelings? Making the patient feel that their feelings are not valid What is rejecting? Not understanding or giving the patients thoughts or feelings any thought What is defending? Going against what the patient said by defending your reason A depressed client discussing marital problems with the nurse says "What will I do if my husband asks me for a divorce?" Which response by the nurse would be an example of therapeutic communication? a. "Why do you think your husband will ask you for a divorce?" b. "You seem to be worrying over nothing. I'm sure everything will be fine." c. "What has happened to make you think that your husband will ask for a divorce?" d. "Talking about this will only make you more anxious and increase your depression." C Which of the following are examples of nontherapeutic communication blocks? Select all that apply. a. "You acted out in group. It made the other clients uncomfortable." b. "Why did you refuse your medication this afternoon?" c. "I'm sorry you feel this way. It is a feeling of typical hospitalized clients." d. "You just think that you are not getting better. You'll see. Everything will work out." e. "What I am hearing you say is that everyone is out to get you." B C D Which nurse-client communication centered skill implies respect? a. The nurse communicates regard for the client as a person of worth who is valued and accecpted without qualification. b. The nurse communicates an understanding of the client's world from the client's internal frame of reference with sensitivity to the client's feelings c. The nurse communicates that the nurse is an open person who is self-congruent, authentic and transparent. d. The nurse communicates specific terminology rather than abstractions in the discussion of the client's feelings, experiences and behaviors A A nurse is communicating with a client on the in-patient psychiatric unit. The client moves closer and invades the nurse's personal space, making the nurse uncomfortable. Which is an appropriate intervention? a. The nurse ignores the behavior because it shows the client is progressing b. The nurse expresses a sense of discomfort and limits behaviors c. The nurse understands that clients require various amounts of personal space and accepts the behavior d. The nurse confronts the client and states that he or she will be secluded if this behavior continues B Which is the overall, priority goal of in-patient psychiatric treatment? a. Maintenance of stability in the community b. Medication adherence c. Stabilization and return to the community d. Beter communication skills C What are types of intervention groups? Task groups - Where we are accomplishing a specific task Teaching groups - Teaching about medication, parenting skills, symptoms, etc Supportive/therapeutic groups - Teach participants how to deal with situations, or coping skills Self-help groups - Typically run by other members of the community. Ex: AA, NA What are physical conditions that influence group dynamics? Seating - Everyone is in a circle, no table. This promotes no barrier with everyone. Everyone can see each other. Size - Research shows size of 7-8 is best for a therapeutic number. Groups that are too small we might see patients that are less willing to participate and talk. Not enough support. Or Vice Versa in a big group. Someone talks too much, and a non-talkative person might not talk. Membership - Closed or open memberships What are phases of a group development? Phase 1 - Initial Orientation Phase This is where we establish rules, and goals. Leader of the group would orient the members. Phase 2 - Middle or working phase This is where the cohesiveness of the group develops. They work towards the goals. The leader starts to step back and becomes more of a facilitator Phase 3 - Final or termination phase Everyone reviews everything and provides feedback. How to use skills in the future What are 3 types of leadership styles? Autocratic - Focus is on the leader. Leader is making the decision Democratic - Focus on the group members Laissez-faire - There's no goals, no one knows what's going on. No leadership. Avoid this What are the 4 developmental phases of a crisis? Phase 1 - When we are exposed to the stressor. We used problem solving techniques Phase 2 - When our anxiety is increasing. Coping mechanism and problem-solving techniques are failing Phase 3 - We try new problem-solving techniques and coping techniques Phase 4 - We are still panicking. Can result in panic, ptsd, psychosis What is the difference between anger and aggression? Anger - Secondary emotion Aggression - Outward expression (clinching fist, facial expression, verbal/nonverbal communication) What are the 4 phases of crisis intervention? Phase 1 - Assessment Gather all the information during the incident. What precipitated the event? Figure out what coping skills they tried to use. Determine nursing problem Phase 2 - Plan Therapeutic Intervention Plan what you will do. Establish goals and intervention Phase 3 - Intervention Implement interventions. Bring patient back to reality. Set limits Phase 4 - Evaluation of crisis resolutions and anticipatory guidance Identify alternatives in case this incident happens again Mental Health defined by the World Health Organization is a state in which a person realizes their potential, can cope with stress, work and contribute to society. Mental Illness interferes developmentally, biologically, or psychologically. Impairs ability to think, regulate emotions and manage behaviors. Definable diagnoses. DSM-V Diagnostic and Statistical Manual of Mental Disorder, 5th edition What are personal factors that contribute to mental health and well being? genetics, biological, ability to perspective take, response to social cues, involvement in activities, capacity to be resilient. What are social & economic factors that contribute to mental health and well being? availability of resources/ basic needs, access to health care, family relationships and family response to stress. What are environmental factors that contribute to mental health and well being? cultural beliefs, accessibility of places to access resources. Protective factors enhance the likelihood of positive outcomes and lessen the likelihood of negative consequences from exposure to risk. Risk Factors lower likelihood of positive outcomes and increase the likelihood of negative outcomes. Resilience the ability and capacity for people to secure the resources they need to support their well being. What is the most common factor for children who develop resilience? they have at least one stable and committed relationship with a supportive parent, caregiver, or other adult. Resiliency skills can be strengthened at any age but they are easier developed in childhood. Surgeon General's Report Importance of mental health in relationship to over all health. Supported that there are effective treatments for mental illness. Human Genome Project identify genes in human DNA and the combinations created by DNA pairs. improve databases where the info is stored and address legal issues that may arise from the work. The work is associated with this project supports theories that mental illness is biologically and genetically linked. National Alliance on Mental Illness (NAMI) patient involvement in treatment decisions, focus on recovery. Substance Abuse and Mental Health Services Administration (SAMSHSA) recovery is process towards reaching full potential What are goals for transforming the mental health system in the U.S. 1. Americans understand that mental health is essential to overall health. 2. mental healthcare is consumer- and family-driven. 3. disparities in mental health services are eliminated. 4. early mental health screening, assessment, and referral to services are common practice. 5. excellent mental healthcare is delivered, and research is accelerated. 6. technology is used to access mental healthcare and information. Institute of Medicine Report focus on safe and effective care nursing education Legislation changes & goals Affordable Care Act 2020 improved healthcare coverage for uninsured and underinsured improved mental health coverage What is used when classifying mental disorders? 1. DSM-V guidelines- of the American Psychiatric Association for diagnosing psychiatric disorder. 2. ICD-10-CM- international guidelines Basic Level nursing intervention- Coordination of Care coordinates implementation of the nursing care plan and documents coordination of care. Basic level nursing intervention- Health and teaching and health maintenance individualized anticipatory guidance to prevent or reduce mental illness or enhance mental health. Basic level nursing intervention- Milieu Therapy provides, structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other healthcare clinicians. Basic level nursing interventions- pharmacological, biological, and integrative therapies applies current knowledge to assessing patient's response to medication, provides medication teaching, and communicates observations to other members of the healthcare team. Advance practice interventions- medication prescription and treatment prescription of psychotropic medications with appropriate use of diagnostic tests; hospitals admitting privileges advances practice intervention- psychotherapy individual, couple, group, or family therapy using evidence-based therapeutic framework and nurse-patient relationship advanced practice interventions- consultation sharing of clinical expertise with nurses or those in other disciplines to enhance their treatment of the patients or address systems issues. What is the scope of practice for mental health nursing? to promote mental health and well being through assessment, diagnosis, and interventions related to mental health and psychiatric illness. What are some future issues in mental health nursing? 1. education- availability of clinical sites 2. aging population- increasing, increased Alzheimer's, increased need for services. 3. cultural diversity- nursing will need to adjust to provide care 4. Science, technology, and electronic healthcare What advocacy and legislative involvement does mental health nursing have? 1. advocates for patient 2. reports abuse 3. protects confidentiality 4. supports patient's rights to make decisions regarding care. Freud & Psychoanalytic Theory- three levels of consciousness 1. Conscious 2. Preconscious 3. Unconscious Conscious level of freud & psychoanalytic theory current thoughts, perception, feelings, sensations. aware of this information at any time. Preconscious level of freud & psychoanalytic theory yesterday's experiences, unprotected information, this morning's experiences, last week's feelings, idea. easily accessible information in the back of the mind but not currently aware of it. Unconscious level of freud and psychoanalytic theory embarrassing fears, unacceptable feelings, protected information, traumatic events, emotionally harmful thoughts, unfulfilled wishes, desires, impulses. hidden and not immediately available. Personality Structure- ID primitive part of personality present at birth, impulsive. Personality Structure- EGO part has been modified by external influences, mediates, decision maker. Personality Structure- SUPER EGO develops around ages 3-5, moral aspect of the personality, controls id's impulses. Classical Psychoanalysis seldom used today, expensive and time consuming. Goal is to uncover unconscious conflicts. Transference unconscious feelings a patient has towards a healthcare worker connected to a significant relationship in childhood. Countertransference unconscious feelings healthcare provider has towards patient connected to a significant relationship. Be aware of strong reactions to patients. What does the psychoanalytic theory do for nursing? 1. creates an understanding of personality development. 2. encourages the consideration of both conscious and unconscious influences. 3. highlights the importance of attentive listening and spending time talking with someone. Defense Mechanisms 1. unconscious responses developed by the ego to prevent awareness of feelings that threaten the stability of the ego. 2. They block feelings, conflicts, and memories. 3. Distort reality. Theory of Psychosocial Development- ERIKSON 1. personality is not set by age 2. influenced not only by parents but society and culture. 3. 8 life stages with certain crisis to overcome. What does Erikson's theory have to do with nursing? 1. development is part of nursing assessment. 2. helps determine what types of interventions are more likely to be effective. Trust vs. Mistrust 1. Infancy (0-1 1/2) 2. Task- Attachment with mother, building foundation for trust in the future. 3. successful- Relates to others, hopeful about the future 4. unsuccessful- Difficulty relating to and trusting others. No one has ever been there Autonomy vs. shame and doubt 1. Early childhood (1 1/2- 3) 2. Task: Develop control of self and environment / toilet training. 3. Successful Resolution of Crisis: Self-control, will power 4. Unsuccessful Resolution of Crisis: Fear of conflict, self doubt Initiative vs. guilt 1. Preschool (3-6 yr) 2. Task: Becoming purposeful and self-directive 3. Successful Resolution of Crisis: Make decisions about what they will do ; sense of purpose. Examples include selecting what wear or play, helping others with tasks. 4. Unsuccessful Resolution of Crisis: Aggression/fear conflict; guilt. Taking something they want. Industry vs. Inferiority 1. School age (6-12) 2. Task: Develops social, physical, and academic skills 3. Successful Resolution : Competent , completes work 4. Unsuccessful Resolution : Academic challenges, feeling inferior to others, low self esteem. Identity vs. Role Confusion 1. Adolescence (12-20) 2. Task: Transition from childhood to adulthood. Develop their own personal identity. 3. Successful Resolution : Sense of identity 4. Unsuccessful Resolution : Confusion about identity, weak sense of self, Example gang involvement.. Intimacy vs. Isolation 1. Adulthood (20-35) 2. Task- Developing loving relationships and friendships 3. Successful Resolution: Deep love and commitment. Example marriage. 4. Unsuccessful Resolution: Emotional isolation; egocentricity Generativity vs. Self-Absorption 1. middle adulthood (35-65) 2. Task: Fulfilling life goals family, career, and society; concern for future generations 3. Successful Resolution : Giving of oneself. 4. Unsuccessful Resolution : Self-absorption Integrity vs. Despair 1. Later years (65- death) 2. Task: Viewing one's life as meaningful. 3. Successful Resolution : Integrity willingness to accept death. 4. Unsuccessful Resolution : Feeling that life has been a waste, fear of dying alone. Interpersonal theories and therapies- SULLIVAN 1. driven to have interaction. 2. purpose of behaviors is to get needs met. 3. effective therapy- grief and loss, interpersonal disputes, role transition Peplau's Theory of interpersonal relationships 1. foundation for the practice of psychiatric nursing. 2. focuses on not what we do to the patient but with the patient. 3. illness offers opportunities for experiential learning, personal growth, and to improve coping strategies. Peplau first nurse theorists to identify the nurse-patient relationship as the foundation of nursing practice. Phases of Peplau's model- Pre orientation phase patient assignment and review of the medical record. Phases of Peplau's model- Orientation phase interview, expression of feelings, determine goals. phases of Peplau's model- Working phase gather more data, work on problem solving, manage symptoms, education, and evaluation of progress. phases of Peplau's model- Termination phase the client is able to to self-manage their initial issues of concern. The nurse releases the client from their care. Classical conditioning- PAVLOV Experiment with the dogs responding responding to a neutral stimulus versus the actual reward had the same response. •This response is unconscious. Behaviorism- JOHN WATSON Response were adaptive or maladaptive. Responses can be socially conditioned and therefore molded. Operant Conditioning- B.F. SKINNER Worked with mice. Voluntary behavior was rewarded or punished. Reinforcement caused increased frequency of behaviors. Positive and negative reinforcement. Extinction by removing reinforcement (example planned ignoring) Behavior Therapy successful when focused on specific problems/ behaviors. Modeling therapist, videos , another person to demonstrate desired response. Role play is another form of modeling. Operant Conditioning Helpful with mutism, autism, developmental disabilities. Reinforces desired behaviors with tokens that can be utilized to obtain small desired item(token economy). systemic desensitization Involves Identifying patients fears and teaching relaxation exercises to gradual decrease response. Aversion Therapy Pairing a negative stimulus with target behavior. Helpful with alcoholism, shoplifting, aggression, paraphilic disorders. •Is it in the best interest of the patient •Is it a violation of patient's rights •Is it in the best interest of society Rational Emotive Therapy- ALBERT ELLIS Remove irrational beliefs. How you perceive something influences thinking which influence response. It's how you look at things. Cognitive Behavioral Therapy Structured time limited therapy. Challenges thought distortions called schemas (automatic thoughts). Taught to challenge automatic thoughts Utilize homework as part of the process. Humanistic Theory Human motivation is based on people seeking fulfillment and change through personal growth. Self-actualized people are those who were fulfilled and doing all they were capable of . Priority nursing actions are based in therapeutic relationships. when lower needs are met. Biological Therapy Follows medical model where abnormal behavior has a physiologic cause. Pharmacologic. ECT Care Continuum 1. Movement between care services is fluid. 2. Referral to least restrictive environment 3. Decision is based on current psychiatric state with goal to prevent decompensation or remain stable. Levels of care- OUTPATIENT 1. primary care 2. specialty care- psychiatry 3. patient centered medical homes 4. community health centers 5. psychiatric home care 6. assertive community treatment 7. intensive outpatient Outpatient Interventions 1. intermittent supervision 2. patient cares for themselves in some capacity/be stable 3. safety risks 4. therapeutic relationship is more long term. 5. encourages medication compliance 6. patient education regarding self-care, nutrition, and rest 7. refer patient to activities to increase social contact 8. assist patient to be able to manage in the community. Nursing role in outpatient 1. problem solving and flexibility 2. clinical skills/ assessment 3. cultural competence 4. knowledge of community resources 5. autonomy 6. promote recovery and ongoing treatment Prevention in outpatient setting- Primary 1.Reduce the incidents of new cases of illness 2. Providing psychosocial support 3. Teaching coping skills Prevention in outpatient settings- Secondary 1. Reducing Prevalence of Psychiatric illness 2. Problem identification, screening, and referrals to effective treatment delays progression. prevention in outpatient settings- Tertiary 1. Delays progression• 2. Rehabilitation that supports maintaining function Emergency services 1. For triage and stabilization 2. Provides a bridge from the community to more intensive inpatient services. 3. Emergency services may be accessed voluntarily or involuntarily INPATIENT- crisis stabilization or observation units Typically for close observation 72 hours or less. INPATIENT- general or private hospitalization Use Clinical Pathways which are standardized treatment evidence-based treatment courses that are problem based. They result in decreased cost, length of stay and complications. INPATIENT- state hospitals Treat the most seriously mentally ill. Nursing role in inpatient settings 1. Assessment Data Collection 2. Developing and Implementing Plans of Care 3. Coordinating care 4. Supervising and assisting Mental Health Workers 5. Maintaining Safety of The Milieu 6. Health promotion and Education 6. Model De Escalation and oversee safe and valid use of seclusion and restraint when there is eminent risk. evaluation and treatment 1.Psychiatric Assessment 2.Consults 3. Lab Work 4. Medication 5. Individual , Group and Family Therapy Integrative Care 6. Chaplain Team Roles- Psychiatric RN Assesses the patients coordinates care, counsels, administers medications, evaluates responses to treatment, and educates. Team Roles- Psychiatric APRN Diagnoses, prescribes medication, psychotherapy. Team Roles- Psychiatrist Diagnoses, prescribes medications, and psychotherapy. Team roles- Psychologist Completes psychological testing, and provides individual, family, and marital counseling. team roles- Mental health specialists Supervised under of the direction of RN, assist with patient needs, Assist in milieu. team roles- social worker Assists in strengthening support systems, may facilitate transfer to another level of care, assist with getting financial assistance, facilitate groups. team roles- occupational therapist, speech therapist, art therapist, music therapist Assist in the development of coping skills or life skills. team roles- pharmacist Provides consultation regarding medications. team roles- medical team members consult when indicated Therapeutic Milieu 1. The environment and the interactions that take place within that environment. 2. The people (patients and staff), the setting, the structure, and the emotional climate are important to healing. 3. A well-managed milieu offers patients a sense of security and promotes healing. Behavioral Crisis & safety 1. Staff train in de-escalation techniques and as a last resort hands on interventions. 2. Competency is assessed at minimum of once a year. 3. Specially trained teams that respond to behavioral crises called "codes.". 4. Seclusion, Restraint, and Emergency medications are utilized when every other intervention is exhausted. examples of unit safety features 1. Doors that open out 2. Continuous hinges on doors 3. Floor anchored furniture 4. Boxed in plumbing fixtures 5. Blinds are behind glass Culture 1. Shared beliefs, values, and practices that result in patterned ways of thinking and acting. 2. Made up of religious, geographic, socioeconomic, occupational, ability or disability-related, and sexual orientation-beliefs and behaviors. Enculturation Process of transmitting worldview, beliefs, values, and practices to members. Ethnocentrism Thinking our way of thinking and behaving is the correct and natural way (Nurses beware: can interfere with therapeutic relationship). Cultural heritage and influence 1. Defines what is important to a group of people. 2. Avoid making assumptions about your patient's cultural heritage. Western Culture 1. disease has a cause and treatment is aimed at the cause. Mind and body are treated separate. 2. science based 3. right to decide, right to be informed, open communication, and truthfulness is valued Eastern Culture 1. Disease is caused by fluctuations in opposing forces (ying and yang) 2. ethical decisions are based on promoting positive relationships. 3. duty to comply 4. sympathy, compassion, fidelity, discernement, action on behalf of others is values; the vulnerable and require protection Indigenous Culture 1. disease is a lack of harmony between individual and environment and is a lack of personal, interpersonal, environmental, or spiritual harmony. 2. ethical decisions are based on the needs of the community. Non-verbal communication for other cultures- EYE CONTACT rude, challenging, arrogant Non-verbal communication for other cultures- PERSONAL SPACE Asian cultures are more distant. Non-verbal communication for other cultures- TOUCH varies and is described in terms of high touch cultures and low touch cultures Non-verbal communication for other cultures- FACIAL EXPRESSIONS AND GESTURES smiling may indicate respect, thumbs up may be viewed as disrespectful or obscene, pointing ones foot at another is an insult. What populations are at risk for mental illness and inadequate care? immigrants, refugees, cultural "minorities" cultural skill the ability to perform a cultural assessment in a sensitive way spirituality Recognizing a patients emotional and mental distress has an effect their view of the purpose and meaning of their life. Stigma causes individuals with mental illness unnecessary shame and results in avoidance of help seeking behaviors. Patient's Rights 1. receive treatment 2. Refuse treatment 3. Receive Informed Consent 4. Receive access to civil rights such as right to vote even when admitted involuntarily. The right to refuse treatment includes: 1. freedom from excessive or unnecessary medication. 2. privacy and dignity 3. least restrictive environment 4. informed consent Exception to the right to refuse treatment: in an emergency situation to prevent a person from causing serious and imminent harm to self or others a person can be medicated w/o a court hearing. Exception to the right to refuse treatment: after court hearing a person can continue to be medicated if the following criteria are met: 1. serious mental illness 2. function is deteriorating 3. exhibiting threatening behaviors 4. benefits of treatment outweigh the harm 5. lacks capacity to make a reasoned decision about the treatment 6. less-restrictive services have been found inappropriate. Tort a wrongful act or an infringement of a right (other than under contract) leading to civil legal liability. Assault an intentional attempt or threat to inflict injury that places another person in fear of imminent bodily harm. Battery intentional touching of another person in a harmful authority. It is an act punishable under criminal law. False Imprisonment being imprisoned w/o legal authority. It is an act punishable under criminal law. Basic Civil Rights vote, civil service ranking, press charges against another, humane care & treatment, religious freedom & practice, social interaction, receive, forfeit, or be denies a driver's license, make purchases & contractual relationships, exercise &join recreational opportunities. exceptions to HIPPA exceptions to the rule- 1. duty to warn and protect third parties 2. child and elder abuse reporting statutes. Duty to warn Protecting others includes: 1. assess and predict whether a patient's being a danger of violence toward another. 2. identifying individuals being threatened 3. identifying appropriate actions to protect victims. Admissions- to be admitted 1. illness must be present and pose an immediate crisis 2. voluntary admission 3. Involuntary admission (judicial determination) 4. Intensive outpatient (court ordered treatment) Restraint 1. Any mechanical, physical device, equipment, or material that prevents or restricts movement. 2. It is not the device alone it is the intent. Chemical Restraints medications that when administered are used to control a patient which is separate from treating their psychiatric illness Restraints should only be used by? trained and qualified staff as A LAST RESORT for safety. Review and Implement the following before using seclusion or restraint 1. awareness of any physiologic condition 2. verbally intervening (asking the pt cooperation) 3. reducing stimulation 4. actively listening 5. providing diversion 6. offering PRN medications General Requirements for seclusion and restraints utilized in a crisis situation where imminent risk of physical harm to the individual and all other lesser restrictive means have been exhausted or considered. When should restraints not be used? be used a s behavior management technique, to punishment or to manage the milieu when short staffed. 2. destruction of property is not considered reason to restrain a patient. Positioning in physical or mechanical restraints 1. should allow airway access and does not compromise breathing. 2. never restrain someone prone. 3. transitional holds are limited to the minimum amount of time necessary to safely bring the person under control. Orders for Restraints 1. In an emergency, a nurse may place a patient in seclusion or restraint and obtain a written or verbal as soon as possible. 2. never written as a PRN or as a standing order 3. orders must be renewed every 25 hours with limits depending on pt's age 4. adults 18 yr or older are limited to 4 hrs 5. children and adolescents 9 to 17 yrs old are limited to 2 hours 6. children under 9yrs old have a 1-hr limit 7. after 24 hrs, a physician or other licences person responsible for the patient's care must personally assess the patient. When should a restraint be discontinued? as soon as safer behavior begins. a new order is required if behavior indicates imminent risk. What to Document- restraints 1. the specific behaviors leading to restraint or seclusion. 2. the time the pt is placed in and released from restraint. 3. observations while in restraints Observing while pt is in restraints 1. pt in restraints must have continuous observation 2. assess the pt restraint at regular and frequent intervals such as every 15-30 minutes for physical needs, safety, and comfort. 3. While in restraints the pt must be protected from all sources of harm. Mental Health, Advance Directives & Hippa 1. If your pt has a Mental Health Advanced Directive copy should be placed in chart. Ethics what is considered right or wrong in a society Bioethics ethical dilemmas related to health care Ethical dilemmas two or more courses of action, each with favorable and unfavorable consequences that are in conflict with each other. Nursing Care Standards 1. state boards of nursing 2. professional organizations 3. institutional policies and procedures 4. custom as a standard of care Professional duty r/t to practice standards report negligence, irresponsibility, impairment nursing duty to intervene and duty to report 1. incompetence, impairment, or criminal activity. 2. bodies to whom the nurse must report vary from state to state. Beneficence promotion of good autonomy right to make independent decisions Justice resources or care given equally Fidelity (nonmaleficence) loyalty and commitment; doing no wrong to a patient Veracity duty to be truthful Admission of mental health pt- 1. illness must be present and pose an immediate crisis. Discharges 1. conditional release 2. unconditional release 3. against medical advice Medical record 1. record of care 2. utilized for quality improvement 3. legal document Electronic Medical Record protected (password), provided real time charting, reduces errors, facilitates decision making, allows for monitoring privacy protection. Function of the brain Maintains homeostasis and responds to the internal and external changes ANS (autonomic nervous system 1. controls cardiac muscle contraction, visceral activities, and glandular functions of the body. 2. unconscious function 3. regulates HR, BP, RR, body temp, sweating, GI motility and secretion. ANS: Sympathetic 1. prepares body for response requiring energy 2. flight or fight 3. norepinephrine is released 4. pupil dilation, bronchiole dilation, blood vessel constriction, sweat secretion, inhibits peristalsis, increases renin secretion by the kidneys. Link with mental health problem- anxiety can trigger responses ANS: Parasympathetic 1. restores the body after stressful event 2. releases acetylcholine 3. decreases HR, constricts pupils, increases peristalsis, increases secretion of salivary and pancreatic glands, and constricts bronchioles Sleep 1. needed to be physiologically and psychologically stable 2. disturbances in sleep is a symptom in most psychiatric disorders 3. many pharmacologic interventions impact sleep Circadian Rhythms 1. fluctuations behavioral and physiologic patterns in a 24 hour time frame. 2. includes sleep, temp, hormones and neurotransmitter secretion cycles. Brainstem function HR, breathing, digestion, and sleeping. Limbic system- emotional regulation (norepinephrine, serotonin, and dopamine) Cerebellum function voluntary muscle control, equilibrium, and balance Cerebrum function consciousness, emotions, memory, control of skeletal muscles and movement, language and communication Disturbance of mental function result from? drugs, infection, hormones, trauma, genetics, alterations in neurotransmitter function. Pharmacodynamics the action of a drug on the body and hot it carries out the action- dose related Pharmacokinetics movement through the body- ADME Pharmacogenetics genetics and response to drug responses Benzodiazepines 1. enhance the activity of GABA 2. create a calming effect. 3. decreases anxiety w/o causing sedation in lower doses 4. used for seizure emergencies 5. useful for alcohol withdrawal 6. in high doses causes sedation 7. interferes with attention, motor ability and judgement 8. avoid combining with alcohol, opiates and tricyclic antidepressants r/t risk of severe CNS depression 9. increase risk for falls and fractures in older adults. Example of Benzos diazepam, clonazepam, alprazolam, lorazepam Benzos- sleep inducing effects flurazepam, temazepam, triazolam, estazolam, quazepam Short- acting sedative hypnotic agents 1. fast acting 2. amnesia 3. ataxia 4. patient should be ready to go to bed r/t to quick action Examples of short acting sedative hypnotics Zolpidem (ambien) Zaleplon Eszopiclone Melatonin Receptor agonists 1. mimic naturally occurring melatonin which regulates sleep wake cycles 2. low abuse potential 3. side effects include headaches and dizziness 4. long term use with above recommended doses can cause elevated prolactin levels. example of melatonin receptor agonist Ramelteon Doxepin reformulated TCA- for maintaining sleep Buspirone reduces anxiety w/o a strong sedative effect Subvariants blocks neurotransmitter in the hypothalamus that promoted wakefulness to produce sleep Subvariants precautions daytime sleepiness, CNS depression when combines with other depressants, behavior changes, sleep paralysis, depression and suicidal ideation Antidepressants and anxiety the neurotransmitter pathways associated with anxiety disorders are connected to those associates with depression. antidepressant medications have been effective in the treatment of anxiety. SSRI (Selective Serotonin Reuptake Inhibitor) Drugs block the re-uptake of serotonin making more of the neurotransmitter available. examples of SSRIs etine (prozac) 2. sertraline (zoloft)- anti anxiety and antipsychotic effects 3. paroxetine (paxil)- has anticholinergic contraindicated for ppl with narrow angle glaucoma 4. citalopram (celexa) 5. escitalopram (lexapro) 6. fluvoxamine- anitanxiety and antipsychotic effects SSRI- target symptoms sleep, appetite (decrease or increased), fatigue, decreased sex drive, psychomotor retardation or agitation, poor concentration or forgetfulness, anhedonia/ loss of pleasure SSRI- common side effects agitation, insomnia, headache, nausea and vomiting, sexual dysfunction, hyponatremia SSRI- education points 1. improvement in mood may take 3 weeks or longer. adequate trial is 3 months. 2. recommend that medication be taken for at least 6-9 mons. 3. Taper medications slowly 4. Discontinuation syndrome 5. Black Box warning Discontinuation syndrome dizziness, insomnia, nervousness, irritability, nausea, and agitation. This may occur with abrupt withdrawal. Black box warning increased risk of suicide or suicidal behaviors in children and young adults. SSRI toxic effects- SEROTONIN SYNDROME caused by over activation of serotonin receptors, dose is to high, or interaction with other medications. Serotonin syndrome symptoms abdominal pain, diarrhea, sweating, FEVER, tachycardia, elevated BP, ALTERED MENTAL STATE (DELIRIUM), myoclonus (muscle spasms, increased motor activity, irritability, hostility, and mood change Serotonin Syndrome- severe manifestations HYPERPYREXIA , cardiovascular shock, or death Mir