21. Psychiatric Mental Health Problem

A well-known celebrity is admitted to your psychiatric unit. Several RNs from other units drop by and express an interest in seeing the patient. What is the best response?

Answer: "How did you find out that the patient was admitted to this unit?" Rationale: First try to determine how the nurses found out about the patient's admission. This is a serious Health Insurance Portability and Accountability Act (HIPAA) violation, and information disclosure must be immediately stopped.

You arrive home and find that the house of your neighbor (Jane) is on fire. A fireman is physically restraining her from running back into the house. What is the best response?

Answer: "Jane, look at me and hold my hand." Rationale: Jane is experiencing a panic level of anxiety and initially she needs very simple and direct instructions. Instruct her to look at you first, to make a connection and to get her attention, then you can continue with your instructions. Telling her to calm down is not useful at this point, and she may or may not be able to articulate why she is trying to go back into the house. Regardless of her reason, she cannot be allowed to run back into the house.

You are interviewing a patient with suicidal ideations and a history of major depression. Which comment concerns you the most?

Answer: "My father and my brother both committed suicide." Rationale: The patient has a strong family history of completed suicide, which is an increased risk factor. The patient may believe that other family members have successfully used suicide to solve their problems. A long history of depression suggests that the problem is chronic; assess for treatment history, risk factors, and coping strategies.

An adolescent girl (Ms. C) is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium level is 3.5 mEq/L, and she has experienced weight loss of more than 25% within the past 3 months. You find Ms. C in her room jogging in place and doing jumping jacks "for about the last 20 minutes." What is the best response to give at this time?

Answer: "We have talked about exercise, and you agreed to reach your target weight goal first." Rationale: Reminding the patient of a previous contractual agreement and her responsibility in meeting treatment goals is the best response. (For certain patients, allowing limited times for exercise may be part of the contract in the early phase, if the patient has been compulsively exercising.) Avoid opening opportunities for manipulation by allowing "a few more minutes" of exercise.

The emergency department (ED) is calling report on a patient who will be admitted to your acute psychiatric unit. He has a history of bipolar disorder and was in an altercation that resulted in the death of another. He has contusions, abrasions, and minor lacerations. What is the priority question that you should ask?

Answer: "What is the patient's current mood and behavior?" Rationale: Current mood and behavior is the priority so that you will be able to make preparations for physical or chemical restraints, isolation or a private room, and staffing.

A patient diagnosed with paranoid schizophrenia tells you that, "Dr. Smith has killed several other patients and now he is trying to kill me." What is the best response?

Answer: "Whenever you are concerned or nervous, talk to me or any of the nurses." Rationale: You can acknowledge the patient's fears without agreeing or disagreeing with his accusation toward Dr. Smith, and by directing him to talk to the nursing staff you are giving him emotional support and an action that he can use to decrease his anxiety.

An elderly man was admitted for palliative care of terminal pancreatic cancer. The wife stated, "We don't want hospice; he wants treatment." The patient requested discharge and home health visits. Several hours after discharge, the man committed suicide with a gun. Which people should participate in a root cause analysis of this sentinel event? (Select all that apply.)

Answer: - Any nurse who cared for the patient during hospitalization - The case manager who arranged home visits for the patient - Any physician who was involved in the care of the patient Rationale: Anyone who was involved in the direct care of the patient should be invited to participate. The purpose of this root cause analysis is to review the event to identify behaviors, signs, or signals of risk for suicide. This information would be used to increase the staff's awareness to prevent future similar events.

A patient needs Klonopin 1 mg by mouth. The pharmacy delivers clonidine 0.1-mg tablets. A nursing student asks you if Klonopin and clonidine are two different names for the same drug. Place the following steps in the correct sequence so that you can teach the nursing student how to prevent medication errors.

Answer: 1. Recognize that "look-alike, sound-alike" drugs increase the chances of error. 2. Check the original medication order to verify what was prescribed. 3. Consult a medication book to verify the purpose of the drugs and generic and brand names. 4. Call the physician for clarification of the order as appropriate. 5. Advise the pharmacy of any corrections as appropriate. 6. Write an incident report, as appropriate, if you believe that a system error is occurring. Rationale: The first step is to maintain an awareness of the ways that medication errors can occur. Check the original order for legibility and clarification. Consult a drug reference to determine if the patient's condition warrants the type of medication ordered and to see if Klonopin and clonidine are different names for the same drug. Klonopin: It can treat seizures, panic disorder, and anxiety. Clonidine: It can treat high blood pressure. Certain formulations can also treat Attention deficit hyperactivity disorder (ADHD) and cancer pain.

A nursing student reports to you that he has observed several types of behavior among the patients. Which patient needs priority assessment?

Answer: A patient who is having command hallucinations Rationale: Assess the content of command hallucinations, because the patient may be getting a command to harm self or others. Ideas of reference occur when an ordinary thing or event (e.g., a song on the radio) has personal significance (e.g., belief that the lyrics were written for him or her). Ideas of reference could escalate into aggression, especially if delusions of persecution are present, so the nurse would check on this patient next. Clang association is a meaningless rhyming of words, and neologisms are new words created by patients. These communication patterns create frustration for staff and patients, but there is no need for immediate intervention.

Mr. J. has a panic disorder and it appears that he is having some problems controlling his anxiety. Which symptoms concern you the most?

Answer: He is pacing to and fro and pounding his fists together. Rationale: All of these symptoms signal an increase of anxiety; however, physically aggressive behavior signals a danger to others and to self. Verbal intervention is still possible, but the pacing and fist pounding are a step above the other symptoms.

Which behavior would be the most problematic and require vigilance to prevent danger to self or others?

Answer: Motor agitation Rationale: Although all unusual behavior requires ongoing assessment, intervention, and documentation, motor agitation presents the greatest safety issue because excessive physical activity such as running about or flailing the arms and legs creates a risk for injury to self and others and/or exhaustion (to the point of death).

An adolescent girl (Ms. C) is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium level is 3.5 mEq/L, and she has experienced weight loss of more than 25% within the past 3 months. For Ms. C, which route for delivery of nutrition and fluids will the health care team try first?

Answer: Oral Rationale: The oral route is the least intrusive. In addition, the patient and family can participate in determining the food plan and food choices. The nasogastric and IV routes are options for patients who are in life-threatening situations.

Which patient should be assigned to a newly-graduated nurse who has just started on the acute psychiatric unit?

Answer: Patient newly diagnosed with major depression and rumination about loss and suicide Rationale: Although the patient is ruminating (To think carefully and deeply) about suicide, major depression usually leaves the patient with minimal energy to act. The danger for suicide will increase as the medication and therapy begin to help. A new nurse is more likely to be manipulated by a borderline patient. Psychotic patients can seem very threatening to new nurses. Depression, dementia, and delirium have some behavior and symptom overlap; this patient is best assigned to an experienced nurse until delirium is treated or ruled out.

A patient comes in to the clinic with nausea, constipation, and "excruciating stomach pain." Over a period of several years, this patient has come in two or three times a month with the same report, but multiple diagnostic tests have consistently yielded negative results for physical disorders. What is the priority nursing intervention for this patient? (AKA. Patiente na may Somatoform Disorder)

Answer: Perform a physical assessment to identify any physical abnormalities. Rationale:The health care team must always be vigilant for actual physical disease; however, the patient most likely has an undiagnosed somatoform disorder, which is a chronic and severe psychological condition in which the patient experiences physical symptoms but without apparent organic cause. Depression and anxiety are common among patients with somatoform disorders. Once physical disease has been ruled out, having emotional support from a consistent health care provider is often the most effective approach for somatoform disorders.

A patient with a diagnosis of hypochondriasis has made multiple clinic visits and undergone diagnostic tests for "cancer," with no evidence of organic disease. Today he declares, "I have a brain tumor. I can feel it growing. My appointment is tomorrow, but I can't wait!" What is the most therapeutic response?

Answer: Set boundaries: "Sir, I will take your vital signs, but then I am going to call your case manager so that you can discuss the scheduled appointment." Rationale: The case manager has a relationship with the patient, knows the specific details of agreements made with the patient, and is the most capable of helping him to decrease anxiety and preoccupation with physical symptoms.

You are caring for a patient in whom a conversion disorder was recently diagnosed. She is experiencing a sudden loss of vision after witnessing a violent fight between her husband and adult-aged son. What is the priority therapeutic approach to use with this patient?

Answer: Teach ways to cope with blindness, such as methodically arranging personal items (AKA. CONVERSION DISORDER) Rationale: Patients with conversion disorders are experiencing symptoms, even though there is no identifiable organic cause; therefore, they should be assisted in learning ways to cope and live with the disability.

An LPN/LVN complains to you (charge nurse) that she is always assigned to the same patient with chronic depression. What should you do?

Answer: Tell her to care for the patient today, but that you will remember the request for future assignments. Rationale: Switching the assignments at shift change or mid-shift creates delays for everyone, so politely ask her to continue for the day. However, her request is not unreasonable; dealing with depressed patients can be very tiring, so consider her request for future assignments.

A patient comes into the walk-in clinic and tells you that he wants to be admitted to an alcohol rehabilitation program. Which question is the most important to ask?

Answer: When was the last time you had a drink? Rationale: Before someone enters an alcohol rehabilitation program, there should be a medically-supervised detoxification. This patient has walked in off the street; therefore, you must determine whether he is at risk for withdrawal symptoms. The other questions are relevant and are likely to be included in the interview.

A patient on the acute psychiatric unit develops neuroleptic malignant syndrome. Which task should be delegated to the mental health assistant?

Answer: Wiping the patient's body with cool moist towels Rationale: The mental health assistant can initiate this simple cooling measure with minimal instruction. Neuroleptic malignant syndrome is a rare but potentially fatal reaction to antipsychotic medication. Symptoms include fever, altered mental status, muscle rigidity, and autonomic instability.

Which task can be assigned to a medical-surgical UAP who has been temporarily floated to the acute psychiatric unit to help out?

Answer: Accompanying an elderly patient who wanders on a walk outside Rationale: Medical-surgical UAPs frequently assist patients to ambulate and can redirect the patient if he wanders off. Performing one-to-one suicide watch requires experience, because the observer may have to immediately intervene while calling out for help.

The team has to apply restraints to a combative patient in order to prevent harm to others or to self. Which action requires your intervention?

Answer: Physician secures the restraint to the side rail

A patient is displaying muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He has been prescribed haloperidol (Haldol). What is the priority action?

Answer: Obtain an order for intramuscular or IV diphenhydramine (Benadryl). Rationale:The patient is experiencing medication side effects. This condition is frightening and uncomfortable for the patient, but it is not usually harmful. Initiating swallow precautions or waiting for the spasms to pass delays the most appropriate intervention; intramuscular or IV administration of diphenhydramine will rapidly alleviate the symptoms.

Hypochondriasis

Obsession with the idea of having a serious but undiagnosed medical condition.

Somatoform Disorder

People with somatoform disorder have a number of different symptoms that typically last for several years. Their symptoms can't be traced to a specific physical cause. In people with somatoform disorder, medical test results are either normal or don't explain the person's symptoms. People who have somatoform disorder often become very worried about their health because they don't know what is causing their health problems. The symptoms of somatoform disorder are similar to the symptoms of other illnesses. People with this disorder may have several medical evaluations and tests to be sure that they don't have another illness.

You are reviewing the principle of "least restrictive" interventions with the staff. Place the following interventions in the correct ascending order from the least restrictive to the most restrictive.

Verbally instruct the patient to stop the unacceptable behavior (i.e., yelling, arguing) and move to another part of the day room. Accompany the patient out into the garden courtyard. Escort the patient to a quiet room for a time out. Place the patient in an isolation room with a mental health assistant observing. Restrain the patient's upper extremities with wrist restraints. Restrain the patient's arms and legs with soft cloth restraints. Rationale: The least restrictive method is verbal intervention. The patient should be allowed to stay in public areas if possible, and then moved to isolated spaces. Finally, if nothing else works, the patient can be physically restrained for safety purposes.