I have given you all the resoures to do this assignment, question, article, textbook, powerpoint of chapters 8 & 9 so, please use only what’s given. Also, the professors grading scale. 

Forum Post #4 – Research Designs

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Read “Chemotherapy Use and Patient Treatment Preferences in Advanced Colorectal Cancer.” Is this quantitative research design appropriate for the research problem and question? Support your answer with rationale. How might you change the study if you were to use a qualitative design?

Chapters 8 & 9  to be reviewed.

Required Texts

Boswell, C. & Cannon, S. (2013). Introduction to nursing research: Incorporating evidence

based practice (3rd  ed.). Sudbury, MA: Jones and Bartlett.  ISBN: 1-4496-9507-8

Dear H 365 student: Do use an APA reference for postings and try to connect your point to the chapter(s) we are studying. Do try to tie your “post” to a particular concept in the text/chapter and do consider asking a question that clarifies or probes a classmate (in your reply post).  Chemotherapy Use and Patient Treatment Preferences in Advanced Colorectal Cancer

I have listed the point guide here below. We are off to a good start – thank you, Dr Cullen

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10 points: Demonstrates excellence in grasping key concepts; critiques work of others, stimulates discussion; provides citations for support of opinions. Ideas are expressed clearly and concisely. Uses appropriate vocabulary. Student makes a thoughtful an initial post and makes a thoughtful comment on a classmates post.
8 points: Shows evidence of understanding major concepts; offers an occasional divergent viewpoint or challenge; show some skill in supporting ideas. Expression of ideas somewhat disorganized. Student makes an initial post and a thoughtful response to a peer.  
5 points: Shows evidence of understanding most major concepts, offers an occasional divergent viewpoint or challenge; lacks skill supporting ideas. Some signs of disorganization with expression; transition wording may be faulty. Student makes an initial post and/or doesn’t give much of a response to group members post
3 point: Has mostly shallow grasp of material; rarely takes a stand on issues; offers inadequate support. Poor language use garbles much of the message and expression seems disjointed. Overuse of simple sentence and comments are redundant without commentary. Paragraphs appear unrelated. Student does not respond to a peer. Chemotherapy Use and Patient Treatment Preferences in Advanced Colorectal Cancer

Respiratory  disorders such as pneumonia and asthma are among the leading causes of hospitalization in pediatric patients (U.S. Department of Health and Human Services, 2011). With such severe implications associated with many respiratory disorders, advanced practice nurses (FAMILY NURSE PRACTITIONER) must be able to quickly identify symptoms, diagnose patients, and recommend appropriate treatment. For this Discussion, consider potential diagnoses and treatments for the patients in the following three case studies.

Case Study 1:

 A 14-month-old female presents with a 4-day history of nasal congestion and congested cough. This morning, the mother noted that her daughter was breathing quickly and “it sounds like she has rice cereal popping in her throat.” Oral intake is decreased. Physical examination reveals the following: respiratory rate is 58, lung sounds are diminished in the bases, she has pronounced intercostal and subcostal retractions, expiratory wheezes are heard in all lung fields, and her tympanic membranes are normal. There is moderate, thick, clear rhinorrhea and postnasal drip. Her capillary refill is less than 3 seconds, and she is alert and smiling. Her RSV rapid antigen test is positive. Diagnosis and Management of Respiratory, Cardiovascular, and Genetic Disorders

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POST I TO 2 PAGES DISCUSSION PAPER ON:  An explanation of the differential diagnosis for the patient in the case study you selected.

Explain which is the most likely diagnosis for the patient and why.

Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis.

Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments.

Finally, explain strategies for educating patients and families on the treatment and management of the respiratory, cardiovascular, and/or genetic disorder.

Reference

Readings

•Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier.

◦Chapter 31, “Respiratory Disorders” (pp. 708–738)

•Chapter 40, “Genetic Disorders” (pp. 1032–1054)

National Heart, Lung, and Blood Institute. (2007). Expert panel report 3 (EPR3): Guidelines for the diagnosis and management of asthma. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm Diagnosis and Management of Respiratory, Cardiovascular, and Genetic Disorders

.

•Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis by  Ralston, S.L., Lieberthal ,A.S., Meissner, H.C., Alverson, B.K., Baley, J.E., Gadomski ,A.M., Johnson, D.W., Light, M.J., Maraqa, N.F., Mendonca ,E.A., Phelan, K.J., Zorc ,J.J., Stanko-Lopp, D., Brown, M.A., Nathanson ,I., Rosenblum, E., Sayles, S. 3rd, & Hernandez-Cancio, S. in Pediatrics, 134(5), 1474-1502.

Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis by Keeney, G.E., Gray, M.P., Morrison, A.K., Levas, M.N., Kessler, E.A., Hill, G.D., Gorelick, M.H., & Jackson J.L. in Pediatrics, 133(3): 493–499. Diagnosis and Management of Respiratory, Cardiovascular, and Genetic Disorders

Discussion: Determining Workflow Issues

Workflow is a term used to describe the interconnected steps and processes that nurses and other health care professionals complete on a day-to-day basis (McGonigle & Mastrian, 2012, p. 226). Many existing workflows contain inefficiencies and areas that could be improved using new technologies or evidence-based practice. Workflow issues are often referred to as “gaps” because they indicate a disparity between the current state and the optimal, future state. Many gaps in health care exist related to the implementation and optimization of electronic health records (EHRs). The Health Information Technology for Economic and Clinical Health (HITECH) Act was passed in 2009 to assist organizations in identifying these gaps and encouraging the “meaningful use” of EHRs. The meaningful use objectives seek to fulfill the IOM six aims of patient care (patient-centered, timely, effective, efficient, equitable, and safe). interconnected steps and processes for nurses 

In this Discussion, you examine scenarios that feature workflow issues related to the HITECH Act and its meaningful use objectives. You identify specific workflow gaps and consider how you would conduct a gap analysis to gather more information about the gaps. This Discussion allows you to explore workflow gaps and meaningful use objectives to prepare you for completing the Course Project, which is also centered on workflow gaps and their relevance to meaningful use objectives

Scenario

General Health Hospital is implementing new outreach programs and preventive care support groups for patients with certain conditions or health risks such as diabetes, smoking, and obesity. Philip, a nurse leader, is the manager of a team of nurses who have been asked to organize these programs and groups and to identify patients who would be eligible for and interested in being involved in these opportunities. However, Philip and his team have run into a variety of challenges and problems as they attempt to complete these tasks. In identifying patients to contact about the outreach programs and support groups, Philip’s team has had to browse the hospital’s EHR system. The team has also run across significant holes in the EHR system as they try to contact patients; many patients’ contact information is inaccurate or out of date. Furthermore, Philip’s team has partnered with the hospital’s Appointments Desk personnel in sending reminders about meeting dates and times to patients who express interest. However, the Appointments Desk often either neglects to send out these reminders or sends duplicate reminders to only a few patients because the personnel do not have a way of tracking who should be contacted and when. interconnected steps and processes for nurses 

To prepare

Your Instructor will have assigned you to respond to a specific scenario. Review this week’s Learning Resources on workflow, gap analysis, and meaningful use, and consider how they connect to the scenario you were assigned.

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• Determine the most prominent workflow gap you see in the scenario you were assigned. Where does the gap lie, what factors contribute to the gap, and what are the consequences of the gap?
• Explore how this gap relates to one meaningful use objective. Refer to the articles in this week’s Learning Resources for more information on meaningful use.
• If you were involved in the scenario, consider how you would go about conducting a gap analysis to gather more information about the gap you identified, and determine possible strategies for addressing the gap. How would you gather data? Who would you contact, interview, and/or observe? How would you determine strategies for addressing the gap?

Post by tomorrow Tuesday 9/13/16, 550 words essay in APA format with a minimum of 3 references from the list provided below. Include the level 1 headings as numbered below:

1) An explanation of the most prominent workflow gap in the scenario you were assigned, including who is responsible for the gap and the outcomes or consequences.

2) Identify the meaningful use objective to which the gap relates, citing specific points in the Brown article. (See Attached File)

3) Explain how you would conduct a gap analysis to gather further information and determine strategies for addressing the gap.

Required Readings

Dennis, A., Wixom, B. H., & Roth, R. M. (2015). Systems analysis and design (6th ed.). Hoboken, NJ: Wiley.

• Chapter 2, “Project Selection and Management” (pp. 35–80)

 This chapter describes the organizational steps involved in selecting an appropriate IT project, creating a viable project plan, and finally, managing and controlling the project once it is implemented.

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

• Chapter 14, “Nursing Informatics: Improving Workflow and meaningful Use” interconnected steps and processes for nurses 

Better clinical outcomes, increased efficiency and improved care coordination are a few of the benefits afforded by the use of electronic medical records. In this chapter, the authors illustrate how nurses are actively supporting, developing and utilizing informatics to improve patient care and fulfill meaningful use standards by improving workflow in their respective health care organizations.

Brown, B. (2010). 25 steps to meaningful use. Journal of Health Care Compliance, 12(3), 33–34, 68–69.

Retrieved from the Walden Library databases.

 As part of the implementation of the HITECH initiative, three different stages of implementation have been outlined. This article dissects the first phase and describes the different steps health care organizations must achieve to be in compliant with the meaningful use standards.

Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. The New England Journal of Medicine, 363(6), 501–504.

Retrieved from the Walden Library databases.

 The authors explain HITECH’s objective in creating the meaningful use policies in order to help create a consistently high quality nationwide system of EHRs. The article reviews the key regulations that are tied to meaningful use and what they mean to health care organizations.

Centers for Disease Control and Prevention. (2011). Meaningful use: Introduction. Retrieved from http://www.cdc.gov/ehrmeaningfuluse/introduction.html

This page offers an overview of meaningful use as outlined in the HITECH initiative. It highlights the rationale behind the meaningful use standards and how they relate to health outcomes policy priorities.

Healthcare Financial Management Association. (2008). Gap analysis helps nurses become better leaders. Retrieved from http://www.hfma.org/Content.aspx?id=3398

 This article presents how gap analysis aids in optimizing unit performance and management. By examining a real-life example of how gap analysis was employed in this study, the authors demonstrate its real-world applications and benefits.

HealthIT.gov. (n.d.). Meaningful use. Retrieved January 2, 2014, from http://www.healthit.gov/policy-researchers-implementers/meaningful-use

 The meaningful use initiative is part of the governmental agenda to further advance the use of electronic health records in the health care community. This article outlines the conditions and projected timeline of meaningful use’s national implementation.

Required Media

Laureate Education, Inc. (Executive Producer). (2012a). A discussion on meaningful use. Baltimore, MD: Author.

 Note: The approximate length of this media piece is 7 minutes.

 This audio interview provides an overview of the meaningful use component of the HITECH law and how it affects the use of electronic health records. interconnected steps and processes for nurses 

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors. Discussion: Assessing Neurological Symptoms

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

Case 1: Headaches

A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.

Case 2: Numbness and Pain

A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools.

Case 3: Drooping of Face

A 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well.

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To prepare:

With regard to the case study you were assigned:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• Consider what history would be necessary to collect from the patient in the case study you were assigned.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? Discussion: Assessing Neurological Symptoms
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Note: Before you submit your initial post, replace the subject line (“Discussion – Week 9”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.

By Day 3

Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 9 Discussion Rubric

Post by Day 3 and Respond by Day 6

To participate in this Discussion:

Week 9 Discussion Discussion: Assessing Neurological Symptoms

The Assignment

Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

Week 8: Therapy for Clients With Impulsivity, Compulsivity, and Addiction

Impulsivity and compulsivity have a wide range of clinical presentations and often overlap with many other psychiatric disorders. Some individuals act without forethought and have difficulty saying “no” to certain things such as using illicit drugs or spending money, whereas other individuals engage in compulsive behaviors with undesirable consequences. In some cases, these impulsive and compulsive behaviors also fuel issues with addiction. To effectively assess and treat clients, you must understand how these disorders differ, as well as how their symptoms impact clients and their families. Therapy for Clients With Impulsivity, Compulsivity, and Addiction

This week, as you examine therapies for individuals with impulsivity, compulsivity, and addiction, you explore the assessment and treatment of clients with these disorders. You also consider ethical and legal implications of these therapies.

Photo Credit: [Apolinar B. Fonseca]/[Moment]/Getty Images

Assignment: Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction

Impulsivity, compulsivity, and addiction are challenging disorders for clients across the lifespan. These disorders often manifest as negative behaviors, resulting in adverse outcomes for clients. In your role as the psychiatric mental health nurse practitioner, you have the opportunity to help clients address underlying causes of the disorders and overcome these behaviors. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with impulsivity, compulsivity, and addiction.

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Learning Objectives

Students will:

· Assess client factors and history to develop personalized therapy plans for clients with impulsivity, compulsivity, and addiction

· Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for impulsivity, compulsivity, and addiction

· Evaluate efficacy of treatment plans

· Analyze ethical and legal implications related to prescribing therapy for clients with impulsivity, compulsivity, and addiction

Learning Resources

Note:  To access this week’s required library resources, please click on the link to the Course Readings List, found in the  Course Materials  section of your Syllabus. Therapy for Clients With Impulsivity, Compulsivity, and Addiction

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

· Chapter 14, “Impulsivity, Compulsivity, and Addiction”

Stahl, S. M., & Grady, M. (2012). Stahl’s illustrated substance use and impulsive disorder New York, NY: Cambridge University Press.

To access the following chapter, click on the Illustrated Guides tab and then the Substance Use and Impulsive Disorders tab.

· Chapter 10, “Disorders of Impulsivity and Compulsivity”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication. Therapy for Clients With Impulsivity, Compulsivity, and Addiction

Review the following medications:

For insomnia

For obsessive-compulsive disorder

· Citalopram

· clomipramine

· escitalopram

· fluoxetine

· fluvoxamine

· paroxetine

· sertraline

· venlafaxine

· vilazodone

For alcohol withdrawal

· chlordiazepoxide

· clonidine

· clorazepate

· diazepam

· lorazepam

· oxazepam

For bulimia nervosa and binge eating

· fluoxetine

· topiramate

· zonisamide

For alcohol abstinence

· acamprosate

· disulfiram

For alcohol dependence

· nalmefene

· naltrexone

For opioid dependence

· buprenorphine

· naltrexone

For nicotine addiction

· bupropion

· varenicline

Book Excerpt: Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders. Treatment Improvement Protocol Series, No. 32. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64350/

· Chapter 1, “Substance Use Among Adolescents”

· Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”

· Chapter 7, “Youths with Distinctive Treatment Needs”

University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control in adulthood, study finds. Retrieved from https://www.sciencedaily.com/releases/2016/01/160120201324.htm

Note: Retrieved from Walden Library databases. Therapy for Clients With Impulsivity, Compulsivity, and Addiction

Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375–381. doi:10.1111/j.1365-2125.2012.04457.x

Note: Retrieved from Walden Library databases.

Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing, 42(4), 10–15. doi:10.3928/00989134-20160314-04

Note: Retrieved from Walden Library databases.

Salmon, J. M., & Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in older adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis, 8(1), 74–84. doi:10.1080/15504263.2012.648439

Note: Retrieved from Walden Library databases.

Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., & … Soares, J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry, 55(6), 1337–1341. doi:10.1016/j.comppsych.2014.04.018

Note: Retrieved from Walden Library databases.

Required Media

Laureate Education (2016c). Case study: A Puerto Rican woman with comorbid addiction [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this week’s Assignment.

To prepare for this Assignment:

· Review this week’s Learning Resources. Consider how to assess and treat adolescent clients requiring therapy for impulsivity, compulsivity, and addiction.

The Assignment

Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

· Decision #1

· Which decision did you select?

· Why did you select this decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

· Decision #2

· Why did you select this decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Therapy for Clients With Impulsivity, Compulsivity, and Addiction

· Decision #3

· Why did you select this decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

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· Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Note:  Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Co-morbid Addiction (ETOH and Gambling)  53-year-old Puerto Rican Female

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”

SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health.

She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

Diagnosis: Gambling disorder, alcohol use disorder

Decision Point One

Select what the PMHNP should do:

Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeksAntabuse (Disulfiram) 250 mg orally dailyCampral (Acamprosate) 666 mg orally three times/dayCo-morbid Addiction (ETOH and Gambling)  53-year-old Puerto Rican Female Decision Point OneNaltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeksRESULTS OF DECISION POINT ONE·  Client returns to clinic in four weeks·  Mrs. Perez said that she felt “wonderful” as she has not “touched a drop” to drink since receiving the injection·  Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)·  Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also have her concernedDecision Point TwoRefer to a counselor to address gambling issuesRESULTS OF DECISION POINT TWO·  Client returns to clinic in four weeks·  Client reports that the anxiety that she had been experiencing is gone·  Client reports that she has met with the counselor, but did not really like her. She did start going to a local meeting gamblers anonymous. She stated that last week, for the first time, she spoke during the meeting. She reports feeling supported in this groupDecision Point ThreeExplore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetingsGuidance to StudentAlthough controversy exists in the literature regarding how long to maintain a client on Vivitrol, four weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As you will learn in future courses, ruptures and the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA approved treatments for gambling addiction, and the mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the gamblers anonymous meetings, she should be encouraged to continue her participation with this group.The PMHNP needs to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health. Therapy for Clients With Impulsivity, Compulsivity, and Addiction