Emergency Nursing Orientation 3.0: Behavioral Health Emergencies

Which disorder is least likely to cause death related to bulimia? A. Neuroleptic malignant syndrome B. Cardiac dysrhythmias C. Esophageal rupture D. Electrolyte imbalances

A. Neuroleptic malignant syndrome Death related to bulimia can result from cardiac dysrhythmias, esophageal rupture, or emetic-related electrolyte imbalances. Cardiac dysrhythmias are related to electrolyte imbalances. Esophageal rupture can result from persistent vomiting. Neuroleptic malignant syndrome is a life-threatening adverse effect of antipsychotic medications—not bulimia.

Which medication is used to calm an agitated patient without causing sedation? A. Olanzapine (Zyprexa) B. Haloperidol (Haldol) C. Ziprasidone (Geodon) D. Clonazepam (Klonopin)

A. Olanzapine (Zyprexa) Olanzapine (Zyprexa), an antipsychotic, produces a calming effect without sedating the patient. Haloperidol (Haldol) and ziprasidone (Geodon) are second-line medications for agitation that can produce sedation. Clonazepam (Klonopin) is a benzodiazepine with sedative effects.

In a patient who presents to the emergency department, signs and symptoms of which problem warrant emergency psychiatric consultation? A. Acute psychosis B. Anxiety C. Depression D. Anorexia nervosa

A. Acute psychosis Any patient with signs and symptoms of acute psychosis requires an immediate psychiatric evaluation. Patients with anxiety, depression, and anorexia nervosa need evaluation, but not on an emergent basis.

During the euphoric phase of bipolar disorder, a patient is likely to have which sign or symptom? A. Auditory hallucinations B. Psychomotor retardation C. Preoccupation D. Tearfulness

A. Auditory hallucinations During the euphoric phase of bipolar disorder, the patient experiences auditory hallucinations. Psychomotor retardation, preoccupation, and tearfulness occur during the depressive phase of bipolar disorder.

Which neurochemical dysfunction is associated with panic disorder? A. Disturbances in serotonin B. Decreased adenosine receptor function C. Decreased cortisol D. Increased benzodiazepine receptor function

A. Disturbances in serotonin Panic disorder may be associated with disturbances in serotonin. The disorder appears to be a genetically inherited neurochemical dysfunction that involves increased (not decreased) adenosine receptor function, increased (not decreased) cortisol, and decreased (not increased) benzodiazepine receptor function.

Which finding is expected in a patient with bulimia nervosa? A. Electrolyte imbalances B. Metabolic acidosis C. Significant weight loss D. Bradycardia

A. Electrolyte imbalances In a patient with bulimia nervosa, electrolyte imbalances commonly result from self-induced vomiting and laxative and diuretic use. Frequent vomiting may cause metabolic alkalosis, not metabolic acidosis. Significant weight loss is associated with anorexia nervosa, not bulimia nervosa. Most bulimic patients are of normal weight or overweight. Patients with bulimia nervosa are more likely to develop tachycardia (not bradycardia) or to have an irregular rhythm due to stimulant use or electrolyte disturbances.

Which statement accurately reflects the guidelines for behavioral restraint and seclusion of adults? A. Ensure continuous face-to-face observation for the first hour of restraint or seclusion. B. Assess patient safety and well-being every 30 minutes after the first hour of restraint or seclusion. C. Use a remote camera to avoid being in the same room as the patient during restraint or seclusion. D. Expect the order to state, "Restrain as needed."

A. Ensure continuous face-to-face observation for the first hour of restraint or seclusion. The patient requires continuous face-to-face observation during the first hour of behavioral restraint or seclusion. Use of a remote camera is not acceptable as a sole means of monitoring because the nurse needs some face-to-face contact with the patient. Assess and document the patient's safety and well-being every 15 minutes. Expect time-specific orders. "Restrain as needed" is not acceptable because it is not time specific.

For a patient with bipolar disorder, treatment commonly calls for which medication? A. Lithium (Lithobid) B. Fluoxetine (Prozac) C. Citalopram (Celexa) D. Paroxetine (Paxil)

A. Lithium (Lithobid) Medications commonly used to treat bipolar disorder include lithium (Lithobid); carbamazepine (Tegretol), valproic acid (Depakote), or other anticonvulsant agents; olanzapine (Zyprexa) or other antipsychotic agents; and clonazepam (Klonopin) or other antianxiety agents. Fluoxetine (Prozac), citalopram (Celexa), and paroxetine (Paxil) are antidepressants used to treat depression.

Which medication most effectively treats an acute panic attack? A. Lorazepam (Ativan) B. Haloperidol (Haldol) C. Ziprasidone (Geodon) D. Quetiapine (Seroquel)

A. Lorazepam (Ativan) Lorazepam (Ativan), a benzodiazepine, is optimal for emergency and outpatient abortive therapy of panic disorder because of its anti-panic effects. Haloperidol (Haldol), ziprasidone (Geodon), and quetiapine (Seroquel) are antipsychotic medications.

For a patient who presents with mental status changes, what is the most important reason an emergency nurse should conduct a complete medication history? A. Many commonly prescribed medications can cause mental status changes. B. Regulatory agencies require a medication history for all emergency patients. C. A determination of patient compliance with the medication plan is needed. D. A determination of the patient's ability to afford prescribed medications is needed.

A. Many commonly prescribed medications can cause mental status changes. Many commonly prescribed medications can cause mental status changes. Although obtaining a medication history and determining the patient's medication compliance and ability to afford medications are all important to know, mental status changes take precedence in this patient's treatment plan.

A patient admits to causing herself to vomit after eating. Which imbalance is a complication of this eating disorder? A. Metabolic alkalosis B. Metabolic acidosis C. Hyperkalemia D. Hypermagnesemia

A. Metabolic alkalosis Excessive vomiting of acidic gastric contents causes metabolic alkalosis. Metabolic acidosis is a complication of excessive laxative use because a large amount of bicarbonate exists in the rectal area and is lost during diarrhea. Other complications of excessive vomiting include hypokalemia and hypomagnesemia, rather than hyperkalemia and hypermagnesemia.

Which statement accurately characterizes eating disorders? A. Patients with anorexia nervosa have excessive dependency needs. B. Patients with eating disorders usually present with a life-threatening behavioral emergency. C. Patients with eating disorders usually present with diarrhea. D. Patients with bulimia nervosa typically present with weight loss of 25 percent from their baseline.

A. Patients with anorexia nervosa have excessive dependency needs. Patients with anorexia nervosa have excessive dependency needs, developmental immaturity, obsessive-compulsive behavior, and social isolation. Patients with eating disorders do not commonly present with life-threatening psychiatric conditions, but the effects of eating disorders (such as starvation, self-mutilation, suicide attempt, and binging and purging) can lead to life-threatening emergencies. Patients with eating disorders typically present with amenorrhea, muscle weakness, constipation (not diarrhea), and dehydration. Patients with bulimia nervosa usually exhibit a normal weight or are overweight.

Which statement accurately characterizes bulimia nervosa? A. Patients with bulimia nervosa have poor impulse control. B. Calorie loss is achieved through the use of laxatives and diuretics. C. Patients with bulimia nervosa eat very small portions of food. D. Self-loathing is less severe in bulimia nervosa than in anorexia nervosa.

A. Patients with bulimia nervosa have poor impulse control. Conditions associated with bulimia nervosa include affective disorders, personality disorders, anxiety disorders, substance abuse, and adverse events related to poor impulse control. Laxative or diuretic use is common in bulimia nervosa, but almost exclusively causes fluid and electrolyte loss rather than calorie loss. Patients with bulimia nervosa eat, in a discrete period of time, an amount of food that is larger than most would eat during a similar time. They feel a lack of control over eating during that period. Self-loathing and disgust with the body image are even more severe in bulimia nervosa than in anorexia nervosa.

Which finding places a patient at the highest risk of suicide? A. Recent discharge from a psychiatric inpatient unit B. Suicidal ideation with some level of suicide intent, but no current means to act on the plan C. A confirmed, current and active therapeutic alliance with a mental health professional D. Some mild or passive suicidal ideation with no intent or plan

A. Recent discharge from a psychiatric inpatient unit A patient at high risk of suicide is one who was recently discharged from a psychiatric inpatient unit, has made a serious or nearly lethal suicide attempt, has persistent suicidal ideation (or intermittent ideation with intent, planning, or both) and an operational plan. The patient also often has psychosis (including command hallucinations), exhibits other signs of acute risk, or reports a recent onset of major psychiatric syndromes (especially depression). A patient at moderate risk is one who has suicidal ideation with some level of suicide intent but no action on the plan or has a confirmed, current and active therapeutic alliance with a mental health professional. A patient at low risk is one who has some mild or passive suicidal ideation with no intent or plan.

Which problem can precede the onset of schizophrenia? A. Substance abuse B. Head trauma C. Depression D. Anxiety disorder

A. Substance abuse Substance abuse has been implicated as a cause of schizophrenia as well as a result. Abuse of a substance, particularly a sympathomimetic or hallucinogenic drug, can precede the onset of schizophrenia. Head trauma, depression, and an anxiety disorder do not precede the onset of schizophrenia.

Which statement correctly applies to behavioral health emergencies? A. Their severity is related to the patient's ability to function and adapt. B. They result from coping with normal developmental challenges. C. Mental health manifestations rarely result from organic causes in geriatric patients. D. Pediatric patients rarely have symptoms of mental impairment.

A. Their severity is related to the patient's ability to function and adapt. Severity is related to the patient's ability to function and adapt and to the patient's support systems. Behavioral health disorders must be differentiated from normal developmental challenges. Pediatric mental health emergencies may not be recognized as such, presenting initially as trauma or somatic complaints sometimes due to domestic violence or child abuse, violence in the school or community, mass casualty incidents, or disasters. One in ten children suffer from a mental disorder that causes some degree of impairment. Geriatric, not pediatric, patients commonly present with somatic complaints that may have an organic cause or result from a mental health disorder. Geriatric patients require thorough assessment for an underlying medical cause of behaviors, such as depression, anxiety, and sleep disturbances.

Which medication is a tricyclic antidepressant? A. Citalopram (Celexa) B. Doxepin (Sinequan) C. Venlafaxine (Effexor) D. Phenelzine (Nardil)

B. Doxepin (Sinequan) Doxepin (Sinequan) is a tricyclic antidepressant, which works by blocking the reuptake of norepinephrine and serotonin into nerve endings and increasing the action of norepinephrine and serotonin in nerve cells. Citalopram (Celexa) and venlafaxine (Effexor) are selective serotonin reuptake inhibitors. Phenelzine (Nardil) is a monoamine oxidase inhibitor.

How frequently must a licensed independent practitioner reorder behavioral restraints for an adolescent, age 13? A. Every hour B. Every 2 hour C. Every 4 hour D. Every 24 hour

B. Every 2 hour A licensed independent practitioner must reorder behavioral restraints for adolescents, ages 9 to 17, every 2 hours. The time limits vary with the patient's age. For pediatric patients under age 9, behavioral restraints must be reordered every hour. For adults age 18 or older, behavioral restraints must be reordered every 4 hours.

A cachectic female patient, age 16, is admitted to the emergency department. Which assessment finding should cause you to suspect anorexia nervosa? A. Hypoactivity B. Flat affect C. Excessive hair growth D. Periorbital edema

B. Flat affect Patients with anorexia nervosa are likely to display a flat affect, decreased hair growth, hyperactivity, and peripheral (not periorbital) edema related to the effects of starvation.

Which finding is associated with anorexia nervosa? A. Heartburn B. Menstrual irregularity C. Carpopedal spasm D. Mallory-Weiss tear

B. Menstrual irregularity Anorexia nervosa and bulimia nervosa can cause menstrual irregularity. Heartburn, carpopedal spasm, and Mallory-Weiss tears are associated with bulimia nervosa, but not anorexia nervosa.

Which finding is expected in a patient with anorexia nervosa? A. Sinus tachycardia B. Metabolic acidosis C. Increased gastric emptying D. Hypertension

B. Metabolic acidosis Anorexia nervosa is associated with metabolic acidosis due to hypokalemia and laxative use. Cardiovascular effects of anorexia include atrial and ventricular tachydysrhythmias, nodal rhythms or heart block, prolonged QTc interval, or bradycardia. The patient typically has delayed gastric emptying and may have orthostatic hypotension and signs of shock.

During the depressive phase of bipolar disorder, a patient is likely to have which symptom? A. Flight of ideas B. Poor abstract reasoning C. Disorganized thoughts D. Grandiosity

B. Poor abstract reasoning During the depressive phase of bipolar disorder, the patient experiences poor abstract reasoning, memory loss, and poor concentration. Flight of ideas, disorganized thoughts, and grandiosity occur during the euphoric phase of bipolar disorder.

Which class of drugs is most effective for initial treatment of anxiety or panic? A. Beta-blockers B. Short-acting benzodiazepines C. Antipsychotics D. Antidepressants

B. Short-acting benzodiazepines Short-acting benzodiazepines are most effective for initial treatment of anxiety and panic. Beta-blockers, antipsychotics, and antidepressants are not indicated for the initial treatment of anxiety or panic.

In a patient with anorexia nervosa, which laboratory finding is expected? A. Increased glomerular filtration rate B. Hyperglycemia C. Increased blood urea nitrogen level D. Hypernatremia

C. Increased blood urea nitrogen level For a patient with anorexia nervosa, common laboratory test results include an increased blood urea nitrogen level, decreased glomerular filtration rate, hypoglycemia, hyponatremia, hypocalcemia, hypokalemia, hypochloremic alkalosis, thyroid disturbances, and protein deficiency.

Which statement accurately applies to agitation? A. The initial management goal is to identify triggers that precipitated the agitation. B. Treatment of agitation should primarily focus on de-escalation of the symptoms. C. Agitation is the most common psychiatric disorder. D. Agitation appears to be a genetically inherited neurochemical dysfunction.

B. Treatment of agitation should primarily focus on de-escalation of the symptoms. Agitation treatment should primarily focus on de-escalation of the symptoms. If de-escalation techniques do not control the agitation, physical or chemical restraint is required. Identifying triggers that precipitate agitation helps prevent future episodes, but the initial priority of care is de-escalation of the presenting symptoms. The most common psychiatric disorders are anxiety disorders, not agitation. Panic disorder may be a genetically inherited neurochemical dysfunction. Agitation may have organic causes, such as anoxia and medication adverse effects, or may be triggered by a specific event.

For a patient in the throes of a panic attack, which response by the emergency nurse is the most appropriate? A. "Don't worry. It's nothing serious." B. "Calm down. This is only related to stress." C. "When you are able, tell me what happened before the symptoms began." D. "Everything will be OK if you take a deep breath and relax."

C. "When you are able, tell me what happened before the symptoms began." "When you are able, tell me what happened before the symptoms began" expresses empathy and is not argumentative. The patient may interpret the other statements as dismissive or showing a lack of understanding or concern.

Which disorder characteristically causes unpredictable euphoric or depressed periods of varied duration? A. Anxiety B. Panic disorder C. Bipolar disorder D. Schizophrenia

C. Bipolar disorder Bipolar disorder (manic-depressive illness or bipolar affective disorder) is characterized by unpredictable euphoric or depressed periods of varied duration, possibly with long periods of stability between episodes. Anxiety is a normal response to threatening sensations. It is also a complex feeling of apprehension, fear, and worry often accompanied by pulmonary, cardiac, and other physical sensations. Panic disorder may be a genetically inherited neurochemical dysfunction in which bouts of panic can occur in any setting. Schizophrenia causes fluctuating, gradually deteriorating, or relatively unstable disturbances in thinking, behavior, and perception.

A patient diagnosed with schizophrenia is likely to receive which medication? A. Lithium (Lithobid) B. Fluoxetine (Prozac) C. Clozapine (Clozaril) D. Citalopram (Celexa)

C. Clozapine (Clozaril) Antipsychotic medications used to treat schizophrenia include clozapine (Clozaril), fluphenazine (Prolixin), chlorpromazine (Thorazine), thioridazine (Mellaril), haloperidol (Haldol), olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal). Lithium (Lithobid) is commonly administered to treat bipolar disorder. Fluoxetine (Prozac) and citalopram (Celexa) are antidepressants, which are used to treat depression.

Which finding is expected in a patient with an acute panic attack? A. Increased blood pressure B. Decreased temperature C. Increased heart rate D. Decreased pulse oximetry reading

C. Increased heart rate An acute panic attack commonly causes the urge to flee or escape, a strong sense of impending doom, an increased heart rate and respiratory rate. The patient's blood pressure and temperature typically remain at the baseline. Pulse oximetry usually is normal to high normal.

Which finding is associated with bulimia nervosa? A. It predominantly occurs in middle and upper class families. B. It predominantly occurs in individuals with academic success. C. It may affect males engaged in sports that require a specific weight and body fat. D. It has no specific pharmacologic therapy.

C. It may affect males engaged in sports that require a specific weight and body fat. Although bulimia nervosa usually affects females, it may occur in males who participate in sports that require a specific weight and body fat, such as wrestling. Unlike patients with bulimia nervosa, those with anorexia nervosa are predominantly from middle and upper class families and have achieved academic success. Antidepressant and vitamin therapy is useful in treating bulimia nervosa. No specific medication is useful in treating anorexia nervosa

Which medication most effectively treats acute anxiety? A. Haloperidol (Haldol) B. Ziprasidone (Geodon) C. Lorazepam (Ativan) D. Amitriptyline (Elavil)

C. Lorazepam (Ativan) Acute anxiety is effectively treated with a short course of a fast-acting anxiolytic, preferably a benzodiazepine, such as lorazepam (Ativan). Haloperidol (Haldol) and ziprasidone (Geodon) are antipsychotics that are used to treat such disorders as schizophrenia. Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression.

Which statement accurately describes a restraint principle? A. A physician can write an order to "Restrain or seclude a patient as needed." B. Remote observation by camera is an acceptable method of observing restrained patients. C. Restraint or seclusion should be used when an immediate threat to life exists. D. The patient's safety and well-being must be assessed and documented every 30 minutes.

C. Restraint or seclusion should be used when an immediate threat to life exists. Restraint or seclusion should only be used when other alternative means have been exhausted or an immediate threat to life exists. Orders must be time specific. "Restrain as needed" or "restrain for duration of the visit" are not acceptable orders. Continuous face-to-face observation is required for the first hour of behavioral restraint or seclusion. Remote observation by camera is not acceptable. The patient's safety and well-being must be assessed and documented every 15 minutes.

When caring for a patient in a bipolar state, which action is the priority? A. Administer medication. B. Obtain specimens for drug screening. C. Arrange for psychiatric consultation. D. Ensure patient and staff safety.

D. Ensure patient and staff safety. Although the patient may require medication administration, drug screening, and psychiatric consultation, the priority is the safety of the patient and healthcare staff members.

Your patient states that she takes a serotonin-reuptake inhibitor to treat depression. Which medication would you expect her to take? A. Trazodone (Desyrel) B. Imipramine (Tofranil) C. Amitriptyline (Elavil) D. Fluoxetine (Prozac)

D. Fluoxetine (Prozac) Fluoxetine, a serotonin-reuptake inhibitor, works to treat depression by inhibiting serotonin uptake, enhancing serotonergic function, and relieving the symptoms of depression. The other medications are classified as tricyclic antidepressants.

Which medication is a selective serotonin reuptake inhibitor? A. Mirtazapine (Remeron) B. Tranylcypromine (Parnate) C. Amitriptyline (Elavil) D. Fluoxetine (Prozac)

D. Fluoxetine (Prozac) Selective serotonin reuptake inhibitors include fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), venlafaxine (Effexor), bupropion (Wellbutrin), and nefazodone (Serzone). Mirtazapine (Remeron) is a cyclic antidepressant. Tranylcypromine (Parnate) is a monoamine oxidase inhibitor. Amitriptyline (Elavil) is a tricyclic antidepressant.

When caring for a patient exhibiting violent behavior, which intervention is the priority? A. Treat and assess injuries and medical conditions. B. Administer medications as indicated. C. Refer the patient for treatment or legal disposition. D. Restrain or seclude the patient, according to facility policy.

D. Restrain or seclude the patient, according to facility policy. Initial interventions include ensuring hemodynamic stability; removing any firearms, weapons, or objects that may cause physical harm to the patient or staff; and restraining or secluding the patient according to facility policy. Once the area has been secured, perform all the other interventions.

Which of these antipsychotic medications is least likely to produce dystonia? A. Haloperidol (Haldol) B. Fluphenazine (Prolixin) C. Chlorpromazine (Thorazine) D. Risperidone (Risperdal)

D. Risperidone (Risperdal) Compared to traditional antipsychotics, the newer antipsychotics, such as risperidone (Risperdal), are less likely to produce dystonia and tardive dyskinesia and more likely to improve negative symptoms, such as poverty of speech, flat affect, and social withdrawal. However, most newer antipsychotics are no more effective than traditional agents, such as haloperidol, (Haldol), fluphenazine (Prolixin), and chlorpromazine (Thorazine) in treatment-resistant patients.

When caring for a violent or homicidal patient in the emergency department, what is the nurse's most important priority? A. Psychiatric evaluation B. Law enforcement intervention C. Restraint of the patient D. Safety of the patient and staff

D. Safety of the patient and staff The safety of the patient and staff is the most important priority when caring for a violent or homicidal patient. Psychiatric evaluation and patient restraint do not take priority over safety. Intervention by hospital security, not law enforcement, may be warranted in the emergency department.

The emergency nurse can use the Manchester Self-Harm Rule to assess for which condition? A. Depression B. Eating disorder C. Schizophrenia D. Suicide

D. Suicide According to ENA, use a standard tool, such as the Ask Suicide-Screening Questions, the Manchester Self-Harm Rule, the Risk of Suicide Questionnaire, ande Suicide Affect-Behavior-Cognition Scale or the Patient Safety Screener to evaluate the patient for the risk of suicide. Patients presenting with depression, an eating disorder, or schizophrenia should be tested to see if there is a suicide risk. The tool does not, however, test for depression, eating disorders or schizophrenia.

Which disorder is characterized by the acting out of emotions to achieve desired goals? A. Depression B. Anxiety C. Panic disorder D. Violence

D. Violence Violence is the acting out of emotions to achieve desired goals. It may result from organic disease, psychosis, antisocial behavior or the need to protect oneself or loved ones when a person is feeling attacked. Depression consists of specific alterations in mood often accompanied by a negative self-concept. Anxiety is a normal response to threatening sensations as well as a complex feeling of apprehension, fear, and worry often accompanied by pulmonary, cardiac, and other physical sensations. Panic disorder may be a genetically inherited neurochemical dysfunction in which bouts of panic can occur in any setting.