NURS 302 Mental Health 2: Exam 1

Treatment for depression: Meds

Atypical Antidepressants Other drugs used to treat depression include bupropion, mitazapine, and trazodone. Bupropion Bupropion (Aplenzin, Wellbutrin SR, Wellbutrin XL, Zyban) inhibits the reuptake of dopamine, norepinephrine, and sero-tonin. After an oral dose, peak plasma levels are reached in about 2 hours. The drug is metabolized in the liver and excreted primarily in the urine. Several metabolites are pharmacologi-cally active. Bupropion is useful in the treatment of depres-sion, seasonal affective disorder (SAD) (see Box 55.1), and smoking cessation. Prescribers often add it to a drug regimen when an SSRI does not provide a complete response. Acute episodes of depression usually require several months of drug therapy. It is necessary to reduce the dosage in patients with impaired hepatic or renal function Bupropion may have significant adverse effects. Seizures are likely to occur with doses above 450 mg/d and in patients known to have a seizure disorder. The drug has few adverse effects on cardiac function and does not cause orthostatic hypo-tension or sexual dysfunction. However, in addition to seizures, the drug has CNS stimulant effects (agitation, anxiety, excite-ment, increased motor activity, insomnia, restlessness) that may require a sedative during the first few days of administra-tion. These effects may increase the risk of abuse. Other com-mon adverse effects include dry mouth, headache, nausea and vomiting, and constipation. The FDA has issued a bLacK bOX Warning ♦ for bupropion, because serious neuropsychiatric reactions have been reported with the administration of the drug for smoking cessation. These reactions are more common with the discontinuation of the medication. Mirtazapine Mirtazapine (Remeron), another atypical antidepressant, blocks presynaptic alpha2-adrenergic receptors (which increase the release of norepinephrine), serotonin receptors, and histamine H1 receptors. Consequently, the drug decreases anxiety, agi-tation, insomnia, and migraine headaches as well as depres-sion. (Note that the drug is now classified as a tetracycline antidepressant.) Mirtazapine is well absorbed after oral administration, and it is metabolized in the liver, mainly to inactive metabo-lites. Common adverse effects include drowsiness (with accompanying cognitive and motor impairment), increased appetite, weight gain, dizziness, dry mouth, and constipa-tion. The drug does not cause sexual dysfunction. Mirtazapine should not be taken concurrently with other CNS depressants (e.g., alcohol, benzodiazepine, antianxiety, or hypnotic agents) because of additive sedation. In addition, it should not be taken concurrently with an MAO inhibitor. It is necessary to monitor patients for agranulocytosis or severe neutropenia. Patients should report sore throat, stomati-tis, or any signs of an infection to the prescriber. Trazodone Trazodone is used more often for sedation and sleep than for depression because high doses (greater than 300 mg/d) are required for antidepressant effects, and these amounts cause excessive sedation in many patients. The drug is often given concurrently with a stimulating antidepressant, such as bupro-pion, fluoxetine, sertraline, or venlafaxine. Trazodone should be administered with food for maximum absorption. The drug is metabolized in the liver and excreted primarily by the kidneys. Adverse effects include sedation, diz-ziness, edema, cardiac dysrhythmias, and priapism (prolonged and painful penile erection).

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? "The only disadvantage would be the exorbitant cost of the MAOI." "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." "That's a good idea. There have been good results with the combination of these two drugs." "This combination of drugs can lead to delirium tremens."

"A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis."

A patient diagnosed with depression is prescribed a monoamine oxidase inhibitor (MAOI). When teaching the patient about the medication, which statement made by the patient indicates the need for additional teaching? "I will miss putting soy sauce on my noodles." "I'm glad I can still eat hamburgers and french fries." "I can still eat out at restaurants as long as I'm careful." "I'm glad that I can have pepperoni on my pizza."

"I'm glad that I can have pepperoni on my pizza."

Pharmacotherapy for Opioids

Narcotic antagonists naltrexone (ReVia) naloxone (Narcan) nalmefene (Revex) Methadone: given on the first day in a dose sufficient to suppress withdrawal symptoms BBW: for methadone stipulates that monitoring for QT interval prolongation on an electrocardiogram is necessary Buprenorphine Clonidine

What parts of the brain impact/control mood and movement?

1. Pre-frontal Cortex - The gray matter of the anterior part of the frontal lobe that is highly developed in humans and pays a role in the regulation of complex cognitive, emotional and behavioral functioning 2. Frontal Lobes - Control voluntary body movement through impulses and play a role in emotional experiences 3. Temporal Lobes - Manage the auditory functions, smell and plays a role in the expression of emotion Limbic System (emotional brain) Cerebellum (involuntary movement) Hypothalamus (CNS) Neuronal pathways Neurotransmitters (Dopamine) Other: opioid, catecholamine (especially dopamine), and gamma-aminobutyric acid (GABA) systems

Delusional Disorder: Mixed Type

When the disorder is mixed, delusions are prominent, but no single theme is predominant.

Psychopharmacological Treatment: 2 Categories 1. Typical antipsychotic agents (first generation; conventional) 2. Atypical antipsychotic agents (second generation; novel)

1. zine, zide, idol, xene 2. done, pine, zole 1. Typical antipsychotic agents (first generation; conventional) Chlorpromazine Fluphenazine Haloperidol (Haldol) Loxapine ONLY PINE Perphenazine Pimozide (Orap) Prochlorperazine Thioridazine Thiothixene (Navane) Trifluoperazine 2. Atypical antipsychotic agents (second generation; novel) Aripiprazole (Abilify) Asenapine (Saphris) Brexpiprazole (Rexulti) Cariprazine (Vraylar) ONLY ZINE Clozapine (Clozaril) Iloperidone (Fanapt) Lurasidone (Latuda) Olanzapine (Zyprexa) Paliperidone (Invega) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)

Sedative/Hypnotic Use Disorder

1.Barbiturates 2.Nonbarbiturate hypnotics 3.Antianxiety agents Sedative/hypnotic/anxiolytic compounds are drugs of diverse chemical structures that are all capable of inducing varying degrees of CNS depression, from tranquilizing relief of anxiety to anesthesia, coma, and even death. They are generally categorized as barbiturates, nonbarbiturate hypnotics, and antianxiety agents.

Disturbances in Thought Processes Manifested in Speech

Neologisms Neologisms are newly invented words that are meaningless to others but have symbolic meaning to the individual (e.g., "She wanted to give me a ride in her new uniphorum").

Alcoholism: Alcoholic Myopathy

Acute condition The individual experiences a sudden onset of muscle pain, swelling, and weakness. These symptoms are usually generalized, but pain and swelling may selectively involve the calves or other muscle groups. Chronic Alcoholic myopathy includes a gradual wasting and weakness in skeletal muscles. Neither the pain and tenderness nor the elevated muscle enzymes seen in acute myopathy are evident in the chronic condition.

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? Liver function studies White blood cell count Creatinine clearance Blood urea nitrogen

White blood cell count

Pharmacotherapy for alcoholism: Alcohol Withdraw Meds (Adjunct)

Adjunct Medications: Carbamazepine Clonidine Propranolol Atenolol Intended Effects: Decrease in seizures: Carbamazepine Depression of autonomic response (decrease in BP, HR): Clonidine, propranolol, atenolol Decrease in craving: Propranolol, atenolol Nursing Actions: Seizure precautions Obtain baseline vital signs, and continue to monitor Check HR prior to administration or propranolol, and withhold if less than 60/min

Psychopharmacological Treatment: 1. Typical antipsychotic agents (first generation; conventional)

Chlorpromazine (Thorazine) Use: The major clinical indication for chlorpromazine and other phenothiazine antipsychotics is schizophrenia. Other uses include treatment of psychotic symptoms associated with brain impairment induced by head injury, tumor, stroke, alcohol withdrawal, overdoses of CNS stimulants, and other disorders. It is necessary to individualize the dosage and route of administration of chlorpromazine according to the patient's condition and response; in some cases, prescribers may exceed the recommended maximum dosage approved by the U.S. Food and Drug Administration (FDA). Intended Effects: With acute psychotic episodes, the nurse observes for decreased agitation, combativeness, and psychomotor activity. The sedative effects of chlorpromazine, considered to be therapeutic, occur within 48 to 72 hours. With acute or chronic psychosis, the nurse observes for decreased psychotic behaviors, such as decreased hallucinations and delusions. Children: Chlorpromazine is administered for the treatment of psychosis. The drug is not routinely administered to children under the age of 6 months. It is also used preoperatively for the control of restlessness and apprehension. In addition, it is administered rectally or intramuscularly for the control of nausea and vomiting. Older Adults: Chlorpromazine should be administered cautiously to older adults. The dosage of chlorpromazine should be started at one fourth to one third of the level for younger adults. Older adults are more likely to have problems for which chlorpromazine and other antipsychotic agents are contraindicated (e.g., severe cardiovascular disease, liver damage, Parkinson's disease) or must be used very cautiously (diabetes mellitus, glaucoma, prostatic hypertrophy, peptic ulcer disease, chronic respiratory disorders). Home Care: People with chronic mental illness, such as schizophrenia, are among the most challenging in the caseload of the home care nurse. Major recurring problems include failure to take antipsychotic medications as prescribed and the concurrent use of alcohol and other drugs of abuse. Either problem is likely to lead to acute psychotic episodes and hospitalizations. The nurse must assist and support caregivers' efforts to administer medications and manage adverse effects, other aspects of daily care, and follow-up psychiatric care. In addition, the nurse may need to coordinate the efforts of several health and social service agencies or providers. Adverse Effects: ●● CNS effects: excessive sedation, with drowsiness, lethargy, fatigue, slurred speech, impaired mobility, and impaired mental processes. Extrapyramidal effects may also occur. Symptoms include movement disorders such as tar-dive dyskinesia, akathisia, dystonia, and drug-induced parkinsonism. ●● Tardive dyskinesia occurs as the result of long-term chlorpromazine use. Patients may experience lip smacking, tongue protrusion, and facial grimaces and may have choreic movements of trunk and limbs. This condition is usually irreversible, and there is no effective treatment. ●● Akathisia (motor restlessness and inability to be still), the most common extrapyramidal reaction, may occur about 5 to 60 days from the start of drug therapy. ●● Dystonias are uncoordinated bizarre movements of the neck, face, eyes, tongue, trunk, or extremities. These adverse effects may occur suddenly 1 to 5 days after drug therapy is started and may be misinterpreted as seizures or other disorders. ●● Drug-induced parkinsonism is loss of muscle movement (akinesia), muscular rigidity and tremors, shuffling gait, masked facies, and drooling. ●● Neuroleptic malignant syndrome is a rare but potentially fatal reaction, which may occur hours to months after initial drug use. Symptoms of fever, muscle rigidity, respiratory failure, and confusion develop rapidly. ●● Cardiovascular effects: prolonged QT and PR interval, T-wave blunting, and depression of the ST interval ●● Hematologic effects: agranulocytosis and pancytopenia ●● Other effects: antiadrenergic effects, such as hypotension, dizziness, fatigue, and faintness, as well as respiratory depres-sion, endocrine effects, photosensitivity, and difficulty with temperature regulation Assessing for Adverse Effects: The nurse assesses the fluid and electrolyte status for a possible fluid volume deficit. It is also necessary to measure the patient's weight daily and assess for signs of dehydration. In addition, the nurse assesses for increased anticholinergic effects, such as diminished fluid status and urinary retention. The nurse assesses for aspiration related to depressed cough reflex. It is important to monitor renal and hepatic func-tion along with the complete blood count. A depression in white blood cell count requires discontinuation of the medication. The nurse monitors for increased CNS depression that could result in falls or altered safety. He or she assesses for extrapyramidal effects such as dystonia, tardive dyskinesia, and akathisia. Contraindictations: Because of wide-ranging adverse effects, chlorpromazine may cause or aggravate a number of conditions. Contraindications include liver damage, coronary artery disease, cerebrovascular disease, parkinsonism, bone marrow depression, severe hypo-tension or hypertension, coma, and severely depressed states. Caution is warranted in seizure disorders, diabetes mellitus, glaucoma, prostatic hypertrophy, peptic ulcer disease, and chronic respiratory disorders, as well as in pregnancy, especially during the first trimester.

Gastritis

Effects of alcohol on the stomach include inflammation of the stomach lining

Body Presentation

Posturing This symptom is manifested by the voluntary assumption of inappropriate or bizarre postures.

ACT Goals

The idea is to provide comprehensive treatment for the maximum level of effectiveness. The goal for ACT is to eliminate or reduce the symptoms of severe mental illness and to enhance the individual's quality of life.

Delusional Disorder: Erotomanic Type

With this type of delusion, the individual believes that someone, usually of a higher status, is in love with him or her. Famous persons are often the subjects of erotomanic delusions. Sometimes the delusion is kept secret, but some individuals may follow, contact, or otherwise try to pursue the object of their delusion.

Disturbances in Thought Processes Manifested in Speech

Word Salad A word salad is a group of words that appear to be put together randomly, without any logical connection (e.g., "Most forward action grows life double plays circle uniform").

Pancreatitis

categorized as acute or chronic. Acute pancreatitis usually occurs shortly after binge drinking. Symptoms include constant, severe epigastric pain, nausea and vomiting, and abdominal distention. Chronic condition leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus

Opioid withdrawal: Symptoms

dysphoric mood, nausea or vomiting, muscle aches, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, and insomnia.

Psychopharmacological Treatment: 2. Atypical antipsychotic agents (second generation; novel)

clozapine (Clozaril, Fazaclo ODT) Use: Clinicians consider clozapine and other "atypical" antipsychotics to be first-line therapy for schizophrenia. Prescribers use the drug to manage patients with severe schizophrenia who have not responded to standard antipsychotic medications. Other uses in psychosis include reducing the risk of recurrent suicidal behavior in patients with schizophrenia or with schizoaffective disorder. Clozapine is available only through a distribution system that ensures monitoring of white blood cell count and absolute neutrophil count. Table 56.3 presents route and dosage information for atypical antipsychotics, including clozapine. Children: Despite the wide range of benefits associated with clozapine treatment, use of this drug has been reserved for treatment resistant children and adolescents because of its greater propensity to cause serious hematologic adverse events (agranulocytosis) compared with other first- and second-generation antipsychotic medications. The safety and effectiveness of clozapine in chil-dren have not been established. Older Adults: BBW: related to the administration of clozapine to elderly patients with dementia. The risk of death is increased in these patients. The FDA has not approved the drug for use in dementia. Home Care: People with chronic mental illness, such as schizophrenia, are among the most challenging for the home care nurse. Major recurring problems include failure to take antipsychotic medi-cations as prescribed and the concurrent use of alcohol and other drugs of abuse. Either problem is likely to lead to acute psychotic episodes and hospitalizations. The nurse must assist and support caregivers' efforts to administer medications and manage adverse effects, other aspects of daily care, and follow-up psychiatric care. In addition, the nurse may need to coordi-nate the efforts of several health and social service agencies or providers. Adverse Effects: ●● Cardiovascular effects: orthostatic hypotension, tachy-cardia, ECG changes, and increased risk of myocarditis (greatest during the first month of treatment). The patient is also at risk for myocardial infarction, pericarditis, cardio-myopathy, mitral insufficiency, heart failure, and pericardial effusion. ●● CNS effects: increased risk of seizures in patients with a known seizure disorder. An FDA-issued BLAcK BOX WARNING ♦ alerts users of clozapine that the drug increases the risk of seizure activity as the dose increases. ●● Hematologic effects: agranulocytosis. Clozapine can decrease the number of neutrophils, a type of white blood cell, that function in the body to fight off infections. When neutro-phils are significantly decreased, severe neutropenia may result and the body may become prone to infections. Also, the FDA has issued a BLAcK BOX WARNING ♦ regarding the potential risk of fatal agranulocytosis in patients who take clozapine. ●● Metabolic effects: hyperglycemia and weight gain. The FDA has issued a BLAcK BOX WARNING ♦ regarding the risk of hyperglycemia in patients who take clozapine. (In some extreme cases, there have been reports of ketoacidosis, hyper-osmolar coma, and death.) Contraindictations: Contraindications to clozapine include a known allergy to the drug, a history of clozapine-induced agranulocytosis or severe granulocytopenia, CNS depression, and a history of seizure dis-orders. Caution is warranted in cardiovascular disease, narrow-angle glaucoma, diabetes mellitus, and/or pulmonary disease. Conditions that rule out drug use include pregnancy, especially the first trimester, immunosuppression, and coma Assessing for therapeutic effects: When clozapine is given for acute psychotic episodes, the nurse observes for sedation, decreased agitation, combativeness, and psychomotor activity. When the drug is given for acute or chronic psychosis, the nurse observes for decreased psychotic behaviors, such as decreased hallucinations and delusions Assessing for Adverse Effects: The nurse implements a thorough assessment of the cardio-vascular and cardiopulmonary status to check for orthostatic hypotension (sudden decrease in blood pressure, typically when standing too , heart failure, and cardiovascular adverse events. It is essential to monitor the complete blood count due to the risk of fatal agranulocytosis. Also, it is necessary to monitor the intraocular pressure for increased pressure and potential development of glaucoma.

Alcoholic cardiomyopathy

generally relates to congestive heart failure or arrhythmia. Symptoms include decreased exercise tolerance, tachycardia, dyspnea (trouble breathing), edema, palpitations, and nonproductive cough. Changes may be observed by electrocardiogram, and congestive heart failure may be evident on chest x-ray films. Treatment is total permanent abstinence from alcohol. Treatment of the congestive heart failure may include rest, oxygen, digitalization, sodium restriction, and diuretics. The death rate is high for individuals with advanced symptomatology.

Esophagitis

inflammation and pain in the esophagus—occurs because of the toxic effects of alcohol on the esophageal mucosa. It also occurs because of frequent vomiting associated with alcohol abuse. The effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention. Alcohol breaks down the stomach's protective mucosal barrier, allowing hydrochloric acid to erode the stomach wall. Damage to blood vessels may result in hemorrhage.

Pharmacotherapy for Opioids: Antidotes naloxone (Narcan)

naloxone (Narcan): a specific opioid antagonist, can be given IM, SQ, IV or via inhalation, to reverse respiratory depression, coma and other effects of opioid toxicity. In 2015 the FDA approved an intranasal form of naloxone hydrochloride under a fast-track approval process in response to the increase in deaths associated with drug overdose, particularly from respiratory depression and arrest. It is reported to work within 2 minutes but must be given quickly to prevent death. Naloxone nasal spray can cause severe withdrawal in patients who are opioid dependent

Complications of Cirrosis of the liver

•Portal Hypertension. Elevation of blood pressure through the portal circulation results from defective blood flow through the cirrhotic liver. • Ascites. A condition, in which an excessive amount of serous fluid accumulates in the abdominal cavity, occurs in response to portal hypertension. The increased pressure results in the seepage of fluid from the surface of the liver into the abdominal cavity. • Esophageal Varices. Veins in the esophagus that become distended because of excessive pressure from defective blood flow through the cirrhotic liver. As this pressure increases, these varicosities can rupture, resulting in hemorrhage and sometimes death. • Hepatic Encephalopathy. This serious complication occurs in response to the inability of the diseased liver to convert ammonia to urea for excretion. The continued rise in serum ammonia results in progressively impaired mental functioning, apathy, euphoria or depression, sleep disturbance, increasing confusion, and progression to coma and eventual death.

Opioid withdrawal

•Short-acting drugs (e.g., heroin) -Symptoms occur within 6 to 8 hours, peak within 1 to 3 days, and gradually subside in 5 to 10 days. •Long-acting drugs (e.g., methadone) -Symptoms occur within 1 to 3 days, peak between days 4 and 6, and subside in 14 to 21 days. •Ultra-short-acting (e.g., meperidine) -Symptoms begin quickly, peak in 8 to 12 hours, and subside in 4 to 5 days.

Opioid Intoxication

•Symptoms are consistent with the half-life of most opioid drugs and usually last for several hours. •Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment. •Severe opioid intoxication can lead to respiratory depression, coma, and death.

On the fifth day postpartum, a woman calls her healthcare provider and reports pronounced fatigue, sadness and tearfulness. She states, "I feel so overwhelmed, I don't know what to do!" Which of the following questions is most appropriate for the healthcare provider to ask? "Do you ever think about harming yourself or your baby?" "Is there a friend or relative that come and help you care for your baby?" "How much sleep do you get in a twenty-four hour period?" "Do you blame yourself for not being able to cope with motherhood?"

"Do you ever think about harming yourself or your baby?"

Which statement should indicate to a nurse that an individual is experiencing a delusion? "I'm not going to eat my food. It smells like brimstone." "There's an alien growing in my liver." "I see my dead husband everywhere I go." "The IRS may audit my taxes."

"There's an alien growing in my liver."

The healthcare provider is teaching a patient diagnosed with schizophrenia about the medication clozapine (Clozaril). Which of the following will be included in the teaching? Select all that apply. Select all that apply. "Call our office if you experience increased thirst and increased urination." "You'll need to come in periodically so your lipid profile can be monitored." "Remember that it's important that you avoid all citrus and citrus juices." "You should eat a healthy diet with plenty of fruits, vegetables, and fiber." "Remember to make position changes slowly until you get used to the medication." "Let us know if you experience symptoms of infection such as fever or fatigue."

"You'll need to come in periodically so your lipid profile can be monitored." "You should eat a healthy diet with plenty of fruits, vegetables, and fiber." "Remember to make position changes slowly until you get used to the medication." "Let us know if you experience symptoms of infection such as fever or fatigue."

Cirrhosis of the liver

-Cirrhosis is the end-stage of alcoholic liver disease and is believed to be caused by chronic heavy alcohol use. -There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue.

Opioid Use Disorder

-Obtained by prescription for relief of a medical problem -Use for recreational purposes and obtain by illegal sources -Opioids of natural origin -Opioid derivatives -Synthetic opiate-like drugs Opioids exert both a sedative and an analgesic (pain relief) effect, and their major medical uses are for the relief of pain, the treatment of diarrhea, and the relief of coughing.

Alcohol Intoxication

Alcohol intoxication -Occurs at blood alcohol levels between 100 and 200 mg/dL Symptoms: Disinhibition of sexual or aggressive impulses, mood lability, impaired judgment, impaired social or occupational functioning, slurred speech, incoordination, unsteady gait, nystagmus (crazy eye movements), and flushed face.

Dual Diagnosis

A client who has a coexisting substance disorder and mental illness may be assigned to a special program that targets both problems. Traditional counseling approaches use more confrontation than that which is considered appropriate for clients with dual diagnoses. Most dual diagnosis programs take a more supportive and less confrontational approach. Cognitive and behavioral therapies are helpful in training clients to monitor moods and thought patterns that lead to substance abuse. The individual who abuses or is dependent on substances undoubtedly has many unmet physical and emotional needs.

30. A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? Select all that apply. A. A diet rich in protein will promote hepatic healing. B. This condition leads to a rise in serum ammonia, resulting in impaired mental functioning. C. In this condition, blood accumulates in the abdominal cavity. D. Neomycin and lactulose are used in the treatment of this condition. E. This condition is caused by the inability of the liver to convert ammonia to urea.

A. A diet rich in protein will promote hepatic healing. C. In this condition, blood accumulates in the abdominal cavity. The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing or that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia by means of neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.

13. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this clients plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

A. A simple, structured daily schedule with limited choices of activities A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

7. A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

A. After discharge, the client will immediately attend 90 AA meetings in 90 days. The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

18. A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

A. Between 3 a.m. and 11 a.m. The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

24. A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

A. Encourage the client to bring into awareness underlying sources of guilt. A client raised in an environment that reinforces ones inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

21. A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

A. Gross tremors, delirium, hyperactivity, and hypertension Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

28. Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? Select all that apply. A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

A. Group therapy B. Medication management D. Supportive family therapy E. Social skills training The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.

21. A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

A. Sore throat, fever, and malaise The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.

29. Which of the following nursing statements exemplify important insights that will promote effective intervention with clients diagnosed with substance use disorders? Select all that apply. A. I am easily manipulated and need to work on this prior to caring for these clients. B. Because of my fathers alcoholism, I need to examine my attitude toward these clients. C. Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights. D. Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training. E. I can fix clients diagnosed with substance use disorders as long as I truly care about them.

A. I am easily manipulated and need to work on this prior to caring for these clients. B. Because of my fathers alcoholism, I need to examine my attitude toward these clients. D. Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training. The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurses ability to establish therapeutic relationships with these clients. A nurse who adopts the attitude that he or she can fix another person may be struggling with codependency issues.

23. A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis? A. I am sad most of the time and Ive felt this way for the last several years. B. I find myself preoccupied with death. C. Sometimes I hear voices telling me to kill myself. D. Im afraid to leave the house.

A. I am sad most of the time and Ive felt this way for the last several years. Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia.

30. A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? Select all that apply. A. Ill have to let my surgeon know about this medication before I have my cholecystectomy. B. Guess I will have to give up my glass of red wine with dinner. C. Ill have to be very careful about reading food and medication labels. D. Im going to miss my caffeinated coffee in the morning. E. Ill be sure not to stop this medication abruptly.

A. Ill have to let my surgeon know about this medication before I have my cholecystectomy. B. Guess I will have to give up my glass of red wine with dinner. C. Ill have to be very careful about reading food and medication labels. E. Ill be sure not to stop this medication abruptly. The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs because of the risk of drug interactions.

18. A client who is admitted to the inpatient psychiatric unit and is taking Thorazine presents to the nurse with severe muscle rigidity, tachycardia, and a temperature of 105F (40.5C). The nurse identifies these symptoms as which of the following conditions? A. Neuroleptic malignant syndrome B. Tardive dyskinesia C. Acute dystonia D. Agranulocytosis

A. Neuroleptic malignant syndrome Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability.

11. A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

A. Pepperoni pizza and red wine The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.

1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

A. Risk for injury R/T central nervous system stimulation The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

19. A client diagnosed with depression and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

29. A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? Select all that apply. A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations

A. Somatic delusions C. Gustatory hallucinations E. Clang associations The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.

28. A 20-year-old female has a diagnosis of premenstrual dysphoric disorder. Which of the following should a nurse identify as consistent with this diagnosis? Select all that apply. A. Symptoms are causing significant interference with work, school, and social relationships. B. Patient-rated mood is 2/10 for the past 6 months C. Mood swings occur the week before onset of menses D. Patient reports subjective difficulty concentrating E. Patient manifests pressured speech when communicating

A. Symptoms are causing significant interference with work, school, and social relationships. C. Mood swings occur the week before onset of menses D. Patient reports subjective difficulty concentrating Diagnostic criteria for a premenstrual dysphoric disorder include that symptoms must be associated with significant distress, occur in the week before onset of menses, and improve or disappear in the week post-menses

5. A lonely, depressed divorce has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individuals situation? A. The individual is experiencing psychological addiction. B. The individual is experiencing physical addiction. C. The individual is experiencing substance addiction. D. The individual is experiencing social addiction.

A. The individual is experiencing psychological addiction. The nurse should use the term psychological addiction to best describe this clients situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.

13. Which statement should indicate to a nurse that an individual is experiencing a delusion? A. Theres an alien growing in my liver. B. I see my dead husband everywhere I go. C. The IRS may audit my taxes. D. Im not going to eat my food. It smells like brimstone.

A. Theres an alien growing in my liver. The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the persons intelligence or cultural background.

23. A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. This medication will help you maintain your abstinence. B. This medication will cause uncomfortable symptoms if you combine it with alcohol. C. This medication will decrease the effect alcohol has on your body. D. This medication will lower your risk of experiencing a complicated withdrawal.

A. This medication will help you maintain your abstinence. Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.

4. A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the clients laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms.

22. If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

A. White blood cell count The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considered as a treatment option. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur.

3. A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse, Where do the voices come from? Which is the appropriate nursing reply? A. Your child has a chemical imbalance of the brain, which leads to altered thoughts. B. Your childs hallucinations are caused by medication interactions. C. Your child has too little serotonin in the brain, causing delusions and hallucinations. D. Your childs abnormal hormonal changes have precipitated auditory hallucinations.

A. Your child has a chemical imbalance of the brain, which leads to altered thoughts. The nurse should explain that a chemical imbalance of the brain leads to altered thought processes. Hallucinations, or false sensory perceptions, may occur in all five senses. The client who hears voices is experiencing an auditory hallucination.

Effects of alcohol on the body

Alcohol can interfere with the normal production and maintenance of female and male hormones. For women, this can mean changes in the menstrual cycles and a decreased or loss of ability to become pregnant. For men, the altered hormone levels result in a diminished libido, decreased sexual performance, impaired fertility, and gynecomastia may develop secondary to testicular atrophy.

Alcohol Anonymous (AA)

AA provides a Twelve Step process to achieving and maintaining sobriety. These steps include: 1. Admitting powerlessness over alcohol 2. Believing that a greater power could restore sanity 3. Make a decision to turn lives over to the care of God 4. Making a moral inventory 5. Admitting wrongs 6. Become ready to have God remove defects of character 7. Ask God to remove shortcomings 8. Make a list of all persons harmed 9. Made direct amends to such people wherever possible except when to do so would injure them or others 10. Continued to take personal inventory admit wrongdoing 11. Seek to improve conscious contact with God 12. Carry the message to other alcoholics

Alcoholism: CNS

Alcohol exerts a depressant effect on the CNS, resulting in behavioral and mood changes. The effects of alcohol on the CNS are proportional to the alcoholic concentration in the blood. Alcohol can be harmless and enjoyable if used in moderation, but like any other mind-altering drug, has the potential for abuse.

Alcohol withdrawal

Alcohol Withdraw -Occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use Symptoms: Disinhibition of sexual or aggressive impulses, mood lability, impaired judgment, impaired social or occupational functioning, slurred speech, incoordination, unsteady gait, nystagmus (crazy eye movements), and flushed face.

Anhedonia

Anhedonia is the inability to experience pleasure. This is a particularly distressing symptom that compels some clients to attempt suicide. Lack of Abstract Thinking Ability Concrete thinking, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development. Abstract thinking becomes impaired in some individuals with schizophrenia. For example, the client with schizophrenia would have great difficulty describing the abstract meaning of sayings such as "I'm climbing the walls" or "It's raining cats and dogs."

Indications (Uses)

Antipsychotic medications are used in the treatment of schizophrenia and other psychotic disorders. Selected agents are used in the treatment of bipolar mania (olanzapine, aripiprazole, chlorpromazine, quetiapine, risperidone, asenapine, ziprasidone, cariprazine).

While talking to a female client diagnosed with schizophrenia, the nurse notices the client looks away from the nurse and stares at the wall while making facial grimaces. What is the most appropriate action by the nurse? Ask the client if she is seeing something in the wall. Tell the patient that you will be back when she is ready to listen. Administer the ordered PRN trihexyphenidyl (Artane). Redirect the patient to the conversation.

Ask the client if she is seeing something in the wall.

Treatment: Assertive Community Treatment

Assertive community treatment (ACT) is an evidence- based program of case management that takes a team approach in providing comprehensive, community- based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness such as schizophrenia. Some states use other terms for this type of treatment, such as mobile treatment teams and community support programs. Assertive programs of treatment are individually tailored for each client, intended to be proactive, and include teaching basic living skills, helping clients work with community agencies, and assisting clients to develop a social support network. Vocational expectations are emphasized, and supported work settings (i.e., sheltered workshops) are an important part of the treatment program. Other services include substance abuse treatment, psychoeducational programs, family support and education, mobile crisis intervention, and attention to health-care needs.

Treatment

Atypical antipsychotics have been advanced as more effective in treating negative symptoms, but researchers continue to search for medications that will specifically treat the several cognitive deficits that are most problematic for patients with schizophrenia. These deficits include memory, attention, language, and executive functions, and they can dramatically impact an individual's overall functional ability

17. A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

B. 100 mg/dL The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

10. A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, I heard about something called a monoamine oxidase inhibitor (MAOI). Cant my doctor add that to my medications? Which is an appropriate nursing reply? A. This combination of drugs can lead to delirium tremens. B. A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis. C. Thats a good idea. There have been good results with the combination of these two drugs. D. The only disadvantage would be the exorbitant cost of the MAOI.

B. A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis. The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.

25. Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body.

B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.

18. A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, Im feeling a lot better, so you can stop watching me. I have taken up too much of your time already. Which is the best nursing reply? A. I really appreciate your concern but I have been ordered to continue to watch you. B. Because we are concerned about your safety, we will continue to observe you. C. I am glad you are feeling better. The treatment team will consider your request. D. I will forward you request to your psychiatrist because it is his decision.

B. Because we are concerned about your safety, we will continue to observe you. Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

11. Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia? A. Establishing personal contact with family members. B. Being reliable, honest, and consistent during interactions. C. Sharing limited personal information. D. Sitting close to the client to establish rapport.

B. Being reliable, honest, and consistent during interactions. The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the clients needs and maintain a calm attitude when dealing with agitated behavior.

8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician? A. Antecubital bruising B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

B. Blood pressure of 180/100 mm Hg The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

27. A newly admitted client diagnosed with major depressive disorder states, I have never considered suicide. Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. There is nothing to worry about. We will handle it together. B. Bringing this up is a very positive action on your part. C. We need to talk about the things you have to live for. D. I think you should consider all your options prior to taking this action.

B. Bringing this up is a very positive action on your part. By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

19. A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

2. A nurse evaluates a clients patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance use disorder? A. Narcotic pain medication is contraindicated for all clients with active substance-use problems. B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance use disorder. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. The nurse should assess the client for substance use disorder because clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessens the clients response to another drug.

7. During an admission assessment, a nurse asks a client diagnosed with schizophrenia, Have you ever felt that certain objects or persons have control over your behavior? The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

B. Delusions of influence The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the clients behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

6. What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

B. Depression is a symptom of several medical conditions. Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs.

27. In assessing a client with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)

B. Diazepam (Valium) If large doses of a central nervous system (CNS) depressant (such as Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.

29. An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the clients symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

25. A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the clients focus on delusional thinking? A. Present evidence that supports the reality of the situation B. Focus on feelings suggested by the delusion C. Address the delusion with logical explanations D. Explore reasons why the client has the delusion

B. Focus on feelings suggested by the delusion The nurse should focus on the clients feelings rather than attempt to change the clients delusional thinking by the use of evidence or logical explanations. Delusional thinking is usually fixed, and clients will continue to have the belief in spite of obvious proof that the belief is false or irrational.

12. A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient drug rehabilitation program. Which client statement should a nurse associate with a positive prognosis for this client? A. Im not going to use heroin ever again. I know Ive got the willpower to do it this time. B. I cannot control my use of heroin. Its stronger than I am. C. Im going to get all my children back. They need their mother. D. Once I deal with my childhood physical abuse, recovery should be easy.

B. I cannot control my use of heroin. Its stronger than I am. A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in the 12-step model for treatment is for the client to admit powerlessness over the substance.

14. An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. Well go to the day room when you are ready for group. B. Ill walk with you to the day room. Group is about to start. C. It must be difficult for you to attend group when you feel so bad. D. Let me tell you about the benefits of attending this group.

B. Ill walk with you to the day room. Group is about to start. A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

12. A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. I cannot drink any alcohol with this medication. B. It is going to take 2 to 3 weeks in order for me to begin to feel better. C. This drug causes physical dependence, and I need to strictly follow doctors orders. D. I cant take this medication with food. It needs to be taken on an empty stomach.

B. It is going to take 2 to 3 weeks in order for me to begin to feel better. BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

26. A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem

B. Lack of attention to grooming and hygiene Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene.

1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

B. Note escalating behaviors and intervene immediately The nurse should note escalating behaviors and intervene immediately to maintain this clients safety. Early intervention may prevent an aggressive response and keep the client and others safe.

16. A nurse is caring for a client who is experiencing a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the clients positive and negative symptoms of schizophrenia? A. Paranoia, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoia, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoia, flat affect, and anhedonia are negative symptoms of schizophrenia.

B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia. The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions.

24. A college student has quit attending classes, isolates self because of hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood

B. Risk for other-directed violence R/T yelling accusations The nursing diagnosis that must be prioritized in this situation is risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicate a potential for violence, and this potential safety issue should be prioritized.

2. A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

B. Social isolation R/T poor self-esteem AEB secluding self in room A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

6. A client diagnosed with schizophrenia tells a nurse, The Shopatouliens took my shoes out of my room last night. Which is an appropriate charting entry to describe this clients statement? A. The client is experiencing command hallucinations. B. The client is expressing a neologism. C. The client is experiencing a paranoia. D. The client is verbalizing a word salad.

B. The client is expressing a neologism. The nurse should describe the clients statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly.

15. A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response? A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine. B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. C. Depression is a learned state of helplessness cause by ineffective parenting. D. Depression is caused by intrapersonal conflict between the id and the ego.

B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. Depression is likely an illness that has varied and multiple causative factors, but at present the exact cause of depressive disorders is not entirely understood.

Assessment Data

Background Assessment Data Symptomatology of depression can be viewed on a continuum from transient symptoms to severe depres- sion according to severity of the illness. All individuals become depressed from time to time in response to life's disappointments, and these symptoms tend to be transient. Severe depression, however, is marked by significant distress that interferes with social, occu- pational, cognitive, and emotional functioning. The individual who is severely depressed may also demonstrate a loss of contact with reality. This level is associated with a complete lack of pleasure in all activities, and ruminations about suicide are common. MDD is an example of severe depression. A contin- uum of depression is presented in Figure 25-3. A number of assessment rating scales are available for measuring severity of depressive symptoms. Some are meant to be clinician administered, whereas others may be self-administered. Examples of self-rating scales include the Zung Self-Rating Depression Scale and the Beck Depression Inventory. One of the most widely used clinician-administered scales is the Hamilton Depression Rating Scale (HDRS). It has been reviewed and revised over the years and exists today in several versions. The original version (see Box 25-5) contains 17 items and is designed to measure mood, guilty feelings, suicidal ideation, sleep disturbances, anxiety levels, and weight loss. Symptoms of depression can be described as alterations in four spheres of human functioning: (1) affective, (2) behavioral, (3) cognitive, and (4) physiological. Alterations within these spheres differ according to degree of severity of symptomatology.

Schizophrenia Phase 2: Prodromal Phase

Begins with a change from premorbid functioning and extends until the onset of frank psychotic symptoms. This phase can be as brief as a few weeks or months, but most studies indicate that the average length of the prodromal phase is between 2 and 5 years. During this phase, the individual begins to show signs of significant deterioration in function. Fifty percent complain of depressive symptoms. Social withdrawal is not uncommon, and signs of cognitive impairment may begin to emerge. In addition, some adolescent patients develop sudden onset of obsessive-compulsive behavior during the prodromal phase

Treatment: Behavior Therapy

Behavior modification has a history of qualified success in reducing the frequency of bizarre, disturbing, and deviant behaviors and increasing appropriate behaviors. Features that have led to the most positive results include the following: ■ Clearly defining goals and how they will be measured ■ Attaching positive, negative, and aversive reinforcements to adaptive and maladaptive behavior ■ Using simple, concrete instructions and prompts to elicit the desired behavior Behavior therapy can be a powerful treatment tool for helping clients change undesirable behaviors. In the treatment setting, the health-care provider can use praise and other positive reinforcements to help the client with schizophrenia reduce the frequency of maladaptive or deviant behaviors. A limitation of this type of therapy is the inability of some individuals with schizophrenia to generalize what they have learned from the treatment setting to the community setting.

Depression: Biochemical Influences

Biogenic Amines It has been hypothesized that depressive illness may be related to a deficiency of the neurotransmitters norepinephrine, serotonin, and dopamine at functionally important receptor sites in the brain. Historically, the biogenic amine hypothesis of mood disorders grew out of the observation that reserpine, an antihypertensive that depletes the brain of amines such as norepineph rine, was associated with the development of a depressive syndrome. The catecholamine norepinephrine has been identified as a key component in the mobilization of the body to deal with stressful situations. Neurons that contain serotonin are critically involved in the regulation of many psychobiological functions, such as mood, anxiety, arousal, vigilance, irritability, thinking, cognition, appetite, aggression, sleep-wake cycles, eating, and intestinal motility. Tryptophan, the amino acid precursor of serotonin, has been shown to enhance the efficacy of antidepressant medications and on occasion to be effective as an antidepressant itself. The level of dopamine in the mesolimbic system of the brain is thought to exert a strong influence over human mood and behavior. A diminished supply of these biogenic amines inhibits the transmission of impulses from one neuronal fiber to another, causing a failure of the cells to fire or become charged (see Figure 25-1). More recently, the biogenic amine hypothesis has been expanded to include another neurotransmitter, acetylcholine. Because cholinergic agents have pro- found effects on mood, electroencephalograms, sleep, and neuroendocrine function, it has been suggested that the problem in depression and mania may be an imbalance between the biogenic amines and acetyl- choline. Cholinergic transmission is thought to be excessive in depression and inadequate in mania (Sadock et al., 2015). The precise role that any neu- rotransmitters play in the etiology of depression is un- known because these chemicals cannot be measured in the brain. It has been theorized that since selective serotonin reuptake inhibitors (SSRIs) are drugs that elevate serotonin levels, low serotonin levels in the brain must be responsible for depression. However, SSRIs also seem to be beneficial in the treatment of anxiety, leading to the hypothesis that low serotonin levels are responsible for anxiety. Further, too much serotonin has also been implicated in anxiety states and in schizophrenia. All of this seemingly contradictory information has led many current researchers to believe that neurotransmitters such as serotonin might be better explained as modulators of intense emotional states rather than associated with any one particular emotion (Sadock et al., 2015). As the body of research grows, increased knowledge regarding the biogenic amines undoubtedly will contribute to a greater capacity for understanding and treating affec- tive illness.

22. A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

C. A reaction to disulfiram (Antabuse) Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.

Treatment for depression: Meds

CLINICAL PEARL As antidepressant drugs take effect and mood begins to lift, the individual may have increased energy with which to implement a suicide plan. Suicide potential often in- creases as level of depression decreases. The nurse should be particularly alert to sudden lifts in mood.

3. On the first day of a clients alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

28. The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client, using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

C. By using a screening tool such as the CAGE questionnaire The CAGE questionnaire is a screening tool used to determine whether the individual has a problem with alcohol. This questionnaire is composed of four simple questions. Scoring two or three yes answers strongly suggests a problem with alcohol.

When talking with a patient diagnosed with schizophrenia, the healthcare provider notes the patient continually states, "I'm the man with a plan, yes I am." The healthcare provider will document this behavior as which of the following? A. Tangentiality B. Word salad C. Clang associations D. Loosening of association

C. Clang associations

20. The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

C. Cognitive theory Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem.

12. A client diagnosed with schizophrenia states, My psychiatrist is out to get me. Im sad that the voice is telling me to stop him. What symptom is the client exhibiting, and what is the nurses legal responsibility related to this symptom? A. Magical thinking; administer an antipsychotic medication B. Persecutory delusions; orient the client to reality C. Command hallucinations; warn the psychiatrist D. Altered thought processes; call an emergency treatment team meeting

C. Command hallucinations; warn the psychiatrist The nurse should determine that the client is exhibiting command hallucinations. The nurses legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.

5. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this clients symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.

C. Depression is a result of repeated failures. Learning theory describes a model of learned helplessness in which multiple life failures cause the client to abandon future attempts to succeed.

20. A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium

C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

4. Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. Tell him to stop discussing the voices. B. Ignore what he is saying, while attempting to discover the underlying cause. C. Focus on the feelings generated by the hallucinations and present reality. D. Present objective evidence that the voices are not real.

C. Focus on the feelings generated by the hallucinations and present reality. The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

2. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

C. How to make eye contact when communicating The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness.

8. A client diagnosed with schizophrenia states, Cant you hear him? Its the devil. Hes telling me Im going to hell. Which is the most appropriate nursing reply? A. Did you take your medicine this morning? B. You are not going to hell. You are a good person. C. Im sure the voices sound scary. I dont hear any voices speaking. D. The devil only talks to people who are receptive to his influence.

C. Im sure the voices sound scary. I dont hear any voices speaking. The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination.

11. Upon admission for symptoms of alcohol withdrawal, a client states, I havent eaten in 3 days. Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping

C. Imbalanced nutrition: less than body requirements The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

A patient who overdosed on oxycodone is given naloxone. When assessing the patient, the healthcare provider would anticipate which of these clinical manifestations of opioid withdrawal? A. Hyperthermia and euphoria B. Depressed respirations and somnolence C. Irritability and nausea D. Bradycardia and hyporthermia

C. Irritability and nausea

15. A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

C. Restlessness and muscle rigidity The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

20. An elderly client diagnosed with schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, the nurse would most appropriately make which statement? A. Make sure you concentrate on taking slow, deep, cleansing breaths. B. Watch your diet and try to engage in some regular physical activity. C. Rise slowly when you change position from lying to sitting or sitting to standing. D. Wear sunscreen and try to avoid midday sun exposure.

C. Rise slowly when you change position from lying to sitting or sitting to standing. The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, this side effect places the client at risk for developing orthostatic hypotension.

22. A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

C. Risk for injury R/T orthostatic hypotension A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

9. A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client? A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury

C. Risk for violence: directed toward others The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

14. A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

C. Risperidone (Risperdal) to address the positive symptom The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).

19. A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the clients attending psychiatrist? A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation

C. Temperature of 104F (40C) When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome.

26. A client diagnosed with alcohol use disorder joins a community 12-step program and states, My life is unmanageable. How should the nurse interpret this clients statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

27. A newly admitted client has taken thioridazine (Mellaril) for 2 years, with good symptom control. Symptoms exhibited on admission included paranoia and hallucinations. The nurse should recognize which potential cause for the return of these symptoms? A. The client has developed tolerance to the antipsychotic medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.

C. The client has not taken the medication as prescribed. Altered thinking can affect a clients insight into the necessity for taking antipsychotic medications consistently. When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile.

15. During group therapy, a client diagnosed with alcohol use disorder states, I would not have boozed it up if my wife hadnt been nagging me all the time to get a job. She never did think that I was good enough for her. How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

C. The client is using rationalization to excuse his alcohol dependence. The nurse should interpret that the client is using rationalization to excuse his alcohol use disorder. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

26. A client states, I hear voices that tell me that I am evil. Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge? A. The client will verbalize the reason the voices make derogatory statements. B. The client will not hear auditory hallucinations. C. The client will identify events that increase anxiety and illicit hallucinations. D. The client will positively integrate the voices into the clients personality structure.

C. The client will identify events that increase anxiety and illicit hallucinations. It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills.

16. What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The clients understanding of the need for regular bloodwork B. The clients mood and affect score, according to the facilitys mood scale C. The clients cognitive ability to understand information about the medication D. The clients access to a support network willing to participate in treatment

C. The clients cognitive ability to understand information about the medication There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

8. A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder

C. To rule out neurocognitive disorder A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimers disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly.

13. A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she states, I just need to work harder to get him there on time. Which is the appropriate nursing response? A. Why do you assume responsibility for his behaviors? B. Codependency is a typical behavior of spouses of alcoholics. C. Your husband needs to deal with the consequences of his drinking. D. Do you understand what the term enabler means?

C. Your husband needs to deal with the consequences of his drinking. The appropriate nursing response is to use confrontation with caring. In Stage One (The Survival Stage) of recovery from codependency, the codependent person must begin to let go of the denial that problems exist or that his or her personal capabilities are unlimited.

Empathy

CLINICAL PEARL If the client is unable or unwilling to speak (mutism), using the technique of verbalizing the implied is therapeutic. For example, "That must have been very difficult for you when your mother left. You must have felt very alone." This approach conveys empathy, facilitates trust, and eventually may encourage the client to discuss painful issues.

Treatment for depression: Meds

CLINICAL PEARL All antidepressants carry an FDA black- box warning for increased risk of suicidality in children and adolescents.

Opioid Body Effects

CNS Euphoria, mood changes, mental clouding, drowsiness and pain reduction. The antitussive response is due to suppression of the cough center within the medulla. The nausea and vomiting commonly associated with opiate ingestion is related to the stimulation of the centers within the medulla that trigger this response. GI tract Stomach and intestinal tone are increased Peristaltic activity of the intestines is diminished These effects lead to a marked decrease in the movement of food through the GI tract. This is a notable therapeutic effect in the treatment of severe diarrhea. In fact, no drugs have yet been developed that are more effective than the opioids for this purpose. Morphine is used extensively to relieve pulmonary edema and the pain of myocardial infarction in cardiac clients. Cardiovascular Hypotension, which may be caused by direct action on the heart or by opioid-induced histamine release Decreased Sexual Functioning & Libido

Disturbances in Thought Processes Manifested in Speech

Circumstantiality With circumstantiality, the individual delays in reaching the point of a communication because of unnecessary and tedious details. The point or goal is usually met but only with numerous interruptions by the interviewer to keep the person on track.

Disturbances in Thought Processes Manifested in Speech

Clang Associations Choice of words is governed by sounds, often taking the form of rhyming, which forms a clang association. For instance, "It is very cold. I am cold and bold. The gold has been sold."

Treatment for depression

Cognitive Therapy In cognitive therapy, the individual is taught to con- trol thought distortions that are a factor in the devel- opment and maintenance of mood disorders. In the cognitive model, depression is characterized by a triad of negative distortions related to expectations of the environment, self, and future. The environment and activities within it are viewed as unsatisfying, the self is unrealistically devalued, and the future is perceived as hopeless. The general goals in cognitive therapy are to obtain symptom relief as quickly as possible, assist the client in identifying dysfunctional patterns of thinking and behaving, and guide the client to evidence and logic that effectively tests the validity of the dysfunctional thinking (see Chapter 19, Cognitive Therapy). Therapy focuses on changing "automatic thoughts" that occur spontaneously and contribute to the distorted affect. Following are examples of automatic thoughts that may be common cognitive distortions in depression: ■ Personalizing: "I'm the only one who failed." ■ All or nothing: "I'm a complete failure." ■ Mind reading: "He thinks I'm foolish." ■ Discounting positives: "The other questions were so easy. Any dummy could have gotten them right." The client is asked to describe evidence that both supports and disputes the automatic thought. The logic underlying the inferences is then reviewed with the client. Another technique involves evaluat- ing what would most likely happen if the client's automatic thoughts were true. Implications of the consequences are then discussed. Clients should not become discouraged if one technique seems not to be working. No single tech- nique works with all clients. He or she should be reassured that any of a number of techniques may be used, and both therapist and client may explore these possibilities.

client diagnosed with schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? Altered thought processes; call an emergency treatment team meeting Magical thinking; administer an antipsychotic medication Command hallucinations; warn the psychiatrist Persecutory delusions; orient the client to reality

Command hallucinations; warn the psychiatrist

10. Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the clients boundaries.

D. Provide personal space to respect the clients boundaries. The most appropriate nursing intervention is to provide personal space to respect the clients boundaries. Providing personal space may serve to reduce anxiety and thus reduce the clients risk for violence.

24. A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. Only oral ingestion of alcohol will cause a reaction when taking this drug. B. It is safe to drink beverages that have only 12% alcohol content. C. This medication will decrease your cravings for alcohol. D. Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug.

D. Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug. If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.

4. Which client statement indicates a knowledge deficit related to substance use? A. Although its legal, alcohol is one of the most widely abused drugs in our society. B. Tolerance to heroin develops quickly. C. Flashbacks from LSD use may reoccur spontaneously. D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.

D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless. The nurse should determine that the client has a knowledge deficit related to substance use when the client compares marijuana to smoking cigarettes and claims it to be harmless. Both of these substances have potentially harmful effects. Cannabis is the second most widely abused drug in the United States.

21. Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. Its just a matter of time and I will be well. B. If I ignore these feelings, they will go away. C. I can fight these feelings and overcome this disorder. D. Nothing will help me feel better.

D. Nothing will help me feel better. Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder.

25. A nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

D. Parnate Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content.

Which of the following assessment findings in a patient's health history supports a diagnosis of substance dependence? A. Patient has history of numerous legal problems and interpersonal conflicts. B. Patient has history of impaired judgment and risk-taking behaviors. C. Patient demonstrates continued tardiness and absenteeism from work. D. Patient experiences withdrawal symptoms when not using the substance.

D. Patient experiences withdrawal symptoms when not using the substance.

14. Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepam (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

D. Chlordiazepoxide (Librium) and phenytoin (Dilantin) The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.

5. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, Do you receive special messages from certain sources, such as the television or radio? Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference

D. Delusions of reference The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references.

7. A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

D. Fluoxetine (Prozac) Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

30. Laboratory results reveal elevated levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, the nurse should expect to observe which symptoms? Select all that apply. A. Apathy B. Social withdrawal C. Anhedonia D. Galactorrhea E. Gynecomastia

D. Galactorrhea E. Gynecomastia Dopamine blockage, an expected action of antipsychotic medications, also results in prolactin elevation. Galactorrhea and gynecomastia are symptoms of prolactin elevation.

1. A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

D. Gloomy and pessimistic outlook on life The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood.

17. A client diagnosed with major depressive disorder states, Ive been feeling down for 3 months. Will I ever feel like myself again? Which reply by the nurse will best assess this clients affective symptoms? A. Have you been diagnosed with any physical disorder within the last 3 months? B. Have you ever felt this way before? C. People who have mood changes often feel better when spring comes. D. Help me understand what you mean when you say, feeling down?

D. Help me understand what you mean when you say, feeling down? The nurse is using a clarifying statement in order to gather more details related to this clients mood.

9. A confused client has recently been prescribed sertraline (Zoloft). The clients spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect, and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

D. Serotonin syndrome caused by ingestion of two different SSRIs The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy

D. Substitution therapy A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system.

9. Which client statement demonstrates positive progress toward recovery from a substance use disorder? A. I have completed detox and therefore am in control of my drug use. B. I will faithfully attend Narcotic Anonymous (NA) when I cant control my cravings. C. As a church deacon, my focus will now be on spiritual renewal. D. Taking those pills got out of control. It cost me my job, marriage, and children.

D. Taking those pills got out of control. It cost me my job, marriage, and children. A client who takes responsibility for the consequences of substance use is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process, in which he or she accepts the fact that substance use causes problems.

17. A client diagnosed with schizophrenia, who has been taking antipsychotic medication for the last 5 months, presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications B. Agranulocytosis, treated by administration of clozapine (Clozaril) C. Extrapyramidal symptoms, treated by administration of benztropine (Cogentin) D. Tardive dyskinesia, treated by discontinuing antipsychotic medications

D. Tardive dyskinesia, treated by discontinuing antipsychotic medications The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.

3. A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

D. The client has maxed-out charge cards and exhibits promiscuous behaviors. The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder.

16. A nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use.

D. The client will correlate life problems with alcohol use. To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

23. During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. On the basis of this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.

10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

D. To assess for fine tremors The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.

Codependency

Defined by dysfunctional behaviors that are evident among members of the family of a chemically dependent person, or among family members who harbor secrets of physical or emotional abuse, other cruelties, or pathological condition •Codependent people sacrifice their own needs for the fulfillment of others to achieve a sense of control. •Derives self-worth from others •Feels responsible for the happiness of others •Commonly denies that problems exist •Codependent's home life is fraught with stress •Keeps feelings in control, and often releases anxiety in the form of stress-related illnesses, or compulsive behaviors, such as eating, spending, working, or use of substances •May have experienced abuse or emotional neglect as a child •Outwardly focused on others and know very little about how to direct their lives from their own sense of self

Delusional Disorder

Delusional disorder is characterized by the presence of delusions experienced for at least 1 month If present at all, hallucinations are not prominent, and behavior is not bizarre. The DSM-5 states that a specifier may be added to denote if the delusions are considered bizarre (i.e., if the thought is "clearly implausible, not understandable, and not derived from ordinary life experiences" Subtypes of delusional disorder include the following

Denial: Goals/Interventions

Denial is defined as a "conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety and/or fear, leading to the detriment of health." Goals should include focusing on behavioral outcomes associated with substance use and helping the client to verbalize acceptance of responsibility for their own behavior. Interventions include conveying an attitude of acceptance to the client, providing information to correct misconceptions, and encouraging participation in group activities.

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this client's symptoms? Depression is a result of negative thinking. Depression is a result of repeated failures. Depression is a result of abandonment. Depression is a result of anger turned inward.

Depression is a result of repeated failures.

Depression

Diagnosis/Behaviors Risk for suicide: Depressed mood; feelings of hopelessness and worthlessness; anger turned inward in the self; misinterpretations of reality; suicidal ideation, plan, and available means Complicated grieving: Depression, preoccupation with thoughts of loss, self-blame, grief avoidance, inappropriate expression of anger, decreased functioning in life roles Low self-esteem Expressions of helplessness, uselessness, guilt, and shame; hypersensitivity to slight or criticism; negative, pessimistic outlook; lack of eye contact; self-negating verbalizations Powerlessness Apathy, verbal expressions of having no control, dependence on others to fulfill needs Spiritual distress Expresses anger toward God, expresses lack of meaning in life, sudden changes in spiritual practices, refuses interactions with significant others or with spiritual leaders Social isolation/Impaired social interaction Withdrawn, uncommunicative, seeks to be alone, dysfunctional interaction with others, discomfort in social situations Disturbed thought processes Inappropriate thinking, confusion, difficulty concentrating, impaired problem- solving ability, inaccurate interpretation of environment, memory deficit Imbalanced nutrition: Less than body requirements Weight loss, poor muscle tone, pale conjunctiva and mucous membranes, poor skin turgor, weakness Insomnia Difficulty falling asleep, difficulty staying asleep, lack of energy, difficulty concentrating, verbal reports of not feeling well rested Self-care deficit (hygiene, grooming) Uncombed hair, disheveled clothing, offensive body odor

Pharmacotherapy for alcoholism: Abstinence Maintenance Following Withdraw Meds Disulfiram (Antabuse) Other: Naltrexone (ReVia) Nalmefene (Revex) Selective serotonin reuptake inhibitors (SSRIs) Acamprosate (Campral)

Disulfiram (Antabuse) Intended Effects: Daily oral med that is a type of aversion (behavioral) therapy Used concurrently with alcohol will cause acetaldehyde syndrome to occur. Acetaldehyde syndrome can progress to respiratory depression, cardiovascular supression, seizures and death Nursing Actions: Monitor liver function tests to detect hepatotoxity (chemical driven liver damage) Patient Teaching: Avoid use or contact with any products that contain alcohol (cough syrup, aftershave lotion, mouthwash, hand sanitizer) Wear a medical alert bracelet Medication effects (the potential for acetaldehyde syndrome with alcohol ingestion) persist for 2 weeks following discontinuation of disfulfiram Adverse Effects: The combination of disulfiram with alcohol may result in headaches, confusion, seizures, chest pain, flushing, palpitations, hypotension, sweating, blurred vision, nausea, vomiting, and a garlicike aftertaste. More severe effects (with alcohol): dysrhythmias, cardiovascular collapse, heart failure, myocardial infarction, and death. The nurse determines whether the patient has remained sober. In the event disulfiram is consumed with alcohol, the nurse assesses for cardiovascular effects. In a patient who presents with a severe reaction, it is essential to monitor for shock and hypokalemia. Contraindications: Contraindications to disulfiram include use with alcohol, metronidazole, or paraldehyde, as well as multiple drug dependence. BBW: states that the drug should not be given to a patient who has consumed alcohol in the past 12 hours or without his or her full knowledge. It is important that disulfiram never be administered to patients with myocardial disease, coronary occlusion, or psychosis. Also, patients who are known to be allergic to the drug should not take it. Home Care: ●● Take the medication daily—at bedtime if dizziness and drowsiness occur ●● Never consume alcohol in any form, including liniments (lotions), mouthwash, over-the-counter cough and cold aids, vinegars, sauces, and colognes ●● Not take the medication if alcohol has been consumed ●● Have periodic liver function tests ●● Wear a medical alert bracelet Adults: Initially, 500 mg/d PO once daily for 1-2 wk (maximum 500 mg daily) Maintenance, 125-500 mg PO daily (maximum 500 mg daily) Children: Safety and efficacy in patients younger than 18 y not established

Dysfunctional Family Process: Goals/Interventions

Dysfunctional family processes is defined as "psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized, which leads to conflict, denial of problems, resistance to change, ineffective problem solving, and a series of self-perpetuating crises." Goals should include helping family members participate in programs and support groups and take action to change self-destructive behaviors. Interventions include exploring the roles of family members, determining the extent of enabling behaviors, and involving the family in plans for discharge.

Moderate Depression

Dysthymia (also called persistent depressive disorder) is an example of moderate depression and represents a more problematic disturbance, which, according to the DSM-5, is characterized by symptoms that enduring for at least 2 years (APA, 2013). Symptoms associated with this disorder include the following: ■ Affective: Feelings of sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self-esteem; difficulty experiencing plea- sure in activities ■ Behavioral: Sluggish physical movements (i.e., psy- chomotor retardation); slumped posture; slowed speech; limited verbalizations, possibly consisting of ruminations about life's failures or regrets; social isolation with a focus on the self; increased use of substances possible; self-destructive behavior possi- ble; decreased interest in personal hygiene and grooming ■ Cognitive: Slowed thinking processes; difficulty concentrating and directing attention; obsessive and repetitive thoughts, generally portraying pes- simism and negativism; verbalizations and behavior reflecting suicidal ideation ■ Physiological: Anorexia or overeating; insomnia or hypersomnia; sleep disturbances; amenorrhea; decreased libido; headaches; backaches; chest pain; abdominal pain; low energy level; fatigue and listless- ness; feeling best early in the morning and continu- ally worse as the day progresses (possibly related to the diurnal variation in the level of neurotransmitters that affect mood and level of activity)

Empathy vs. Sympathy Example

EXAMPLE Situation: BJ is a client on the psychiatric unit with a diagnosisof persistent depressive disorder (dysthymia). Sheis 5'51⁄2" tall and weighs 295 pounds. BJ has been overweightall her life. She is single, has no close friends, andhas never had an intimate relationship with another person.It is her first day on the unit, and she is refusing tocome out of her room. When she appeared for lunch inthe dining room following admission, she was embarrassedwhen several of the other clients laughed out loudand called her "fatso." Sympathetic response: Nurse: "I can certainly identify withwhat you are feeling. I've been overweight most of mylife, too. I just get so angry when people act like that. Theyare so insensitive! It's just so typical of skinny people toact that way. You have a right to want to stay away fromthem. We'll just see how loud they laugh when you getto choose what movie is shown on the unit after dinnertonight." Empathetic response: Nurse: "You feel angry andembarrassedby what happened at lunch today." As tears fill BJ'seyes, the nurse encourages her to cry if she feels like itand to express her anger at the situation. She stays withBJ but does not dwell on her own feelings about whathappened. Instead, she focuses on BJ and what the clientperceives are her most immediate needs at this time.

Disturbances in Thought Processes Manifested in Speech

Echolalia Echolalia refers to repeating words or phrases spoken by another. In toddlers this is a normal phase in development, but in children with autism, echolalia may persist beyond the toddler years. In adulthood, echolalia is a significant neurological symptom of thought disturbance that occurs in schizophrenia, strokes, and other neurological disorders.

Treatment for depression

Electroconvulsive Therapy ECT is the induction of a grand mal (generalized) seizure through the application of electrical current to the brain. ECT is effective with clients who are acutely suicidal and in the treatment of severe depression, particularly in those clients who are also experiencing psychotic symptoms and those with psychomotor retardation and neurovegetative changes, such as dis- turbances in sleep, appetite, and energy. It is often considered for treatment only after a trial of therapy with antidepressant medication has proved ineffective. Major Depression ECT has been shown to be effective in the treatment of severe depression, particularly among depressed clients who are also experiencing psychotic symptoms, catatonia, psychomotor retardation, and neurovegeta-tive changes, such as disturbances in sleep, appetite, and energy. ECT is typically considered only after a trial of therapy with antidepressant medication has proved ineffective. It may be considered the treatment of choice when the need for treatment response is urgent, such as in patients who are extremely suicidal or are refusing food and are nutritionally compromised

Empathy

Empathy is the ability to see beyond outward behavior and understand the situation from the client's point of view. With empathy, the nurse can accurately perceive and comprehend the meaning and relevance of the client's thoughts and feelings. The nurse must also be able to communicate this perception to the client by attempting to translate words and behaviors into feelings. It is not uncommon for the concept of empathy to be confused with that of sympathy. The major difference is that with empathy the nurse "accurately perceives or understands" what the client is feeling and encourages the client to explore these feelings. With sympathy the nurse actually "shares" what the client is feeling and experiences a need to alleviate distress.

Body Presentation

Eye Movement Abnormalities Eye movement abnormalities may manifest in several ways including difficulty maintaining focus on a stationary object and difficulty with smooth pursuit of a moving object. Research (Benson et al., 2012) has found that simple eye movement tests can distinguish

A patient is being observed for extrapyramidal symptoms. Which of these symptoms would alert the nurse to the possible onset of this condition? Select all that apply. Inability to concentrate Facial grimacing Blurred vision Tremors at rest Restlessness Flaccid extremities

Facial grimacing Tremors at rest Restlessness

Treatment for depression

Family Therapy The ultimate objectives in working with families of clients with mood disorders are to resolve the symptoms and initiate or restore adaptive family functioning. Similar to group therapy, the most effective approach appears to be a combination of psychotherapeutic and pharmacotherapeutic treatments. Sadock and associates (2015) stated: Familytherapyisindicatedifthedisorderjeopardizes thepatient'smarriageorfamilyfunctioningorifthe mood disorder is promoted or maintained by the familysituation.Familytherapyexaminestheroleof themood-disorderedmemberintheoverallpsycho- logicalwell-beingofthewholefamily;italsoexam- inestheroleoftheentirefamilyinthemaintenance of the patient's symptoms.

Laboratory results reveal elevated levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, the nurse should expect to observe which symptoms? Select all that apply. Apathy Anhedonia Social withdrawal Galactorrhea Gynecomastia

Galactorrhea Gynecomastia

Alcoholism: Genetics

Genetics appear to be involved in the development of substance use disorders, especially alcoholism. Children of alcoholics are four times more likely than other children to become alcoholics. Studies with monozygotic and dizygotic twins have demonstrated that monozygotic twins have a higher rate for concordance of alcoholism than dizygotic twins.

A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? Social isolation with a focus on self Difficulty concentrating Low energy level Gloomy and pessimistic outlook on life

Gloomy and pessimistic outlook on life

Treatment for depression

Group Therapy Group therapy forms an important dimension of mul- timodal treatment for the depressed client. Once an acute phase of the illness has passed, groups can pro- vide an atmosphere in which individuals may discuss issues in their lives that cause, maintain, or arise from having a serious affective disorder. The element of peer support provides a feeling of security, as troublesome or embarrassing issues are discussed and resolved. Some groups have other specific purposes, such as helping to monitor medication-related issues or serv- ing as an avenue for promoting education related to the affective disorder and its treatment. Therapy

Treatment: Group Therapy

Group therapy Individuals with schizophrenia has been shown to be effective, particularly with outpatients and when combined with drug treatment. Sadock and associates Group therapy in inpatient settings is less productive. Inpatient treatment usually occurs when symptomatology and social disorganization are at their most intense. At this time, the least possible stimuli is most beneficial for the client. Because group therapy can be intensive and highly stimulating, it may be counterproductive early in treatment. Group therapy for schizophrenia has been most useful over the long-term course of the illness. The social interaction, sense of cohesiveness, identification, and reality testing achieved within the group setting have proven to be highly therapeutic processes for these clients. Groups that offer a supportive environment appear to be more helpful to clients with schizophrenia than those that follow a more confrontational approach.

Delusional Disorder: Persecutory Type

In persecutory delusions, the most common type, individuals believe they are being persecuted or malevolently treated in some way. Frequent themes include being plotted against, cheated or defrauded, followed and spied on, poisoned, or drugged. The individual may obsess about and exaggerate a slight rebuff (either real or imagined) until it becomes the focus of a delusional system. Repeated complaints may be directed at legal authorities, lack of satisfaction from which may result in violence toward the object of the delusion.

A depressed patient with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 week. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time? Give the client off-unit privileges as positive reinforcement. Increase frequency of client observation. Encourage the client to share mood improvement in group. Request that the psychiatrist reevaluate the current medication protocol.

Increase frequency of client observation.

Treatment: Individual Psychotherapy

Individual Psychotherapy Individual recovery-oriented psychotherapy and cognitive therapies are evidence-based interventions in the treatment of the client with schizophrenia, but these should be adjuncts to a multifaceted team approach. The primary focus in all cases must reflect efforts to decrease anxiety and increase trust. Establishing a relationship is often particularly difficult because the individual with schizophrenia is desperately lonely yet defends against closeness and trust. He or she is likely to respond to attempts at closeness with suspiciousness, anxiety, aggression, or regression. Successful intervention may be achieved with honesty, simple directness, and a manner that respects the client's privacy and human dignity. Exaggerated warmth and professions of friendship are likely to be met with confusion and suspicion.

Treatment for depression

Individual Psychotherapy Phase I During the first phase, the client is assessed to deter- mine the extent of the illness. Complete information is given to the individual regarding the nature of de- pression, symptom pattern, frequency, clinical course, and alternative treatments. If the level of depression is severe, interpersonal psychotherapy has been shown more effective if conducted in combination with anti- depressant medication. The client is encouraged to continue working and participating in regular activi- ties during therapy. A mutually agreeable therapeutic contract is negotiated. Phase II Treatment at this phase focuses on helping the client resolve complicated grief reactions. This may include resolving the ambivalence with a lost relationship and assistance with establishing new relationships. Other areas of treatment focus may include interpersonal disputes between the client and a significant other, difficult role transitions at various developmental life cycles, and correction of interpersonal deficits that may interfere with the client's ability to initiate or sustain interpersonal relationships. Phase III During the final phase of interpersonal psychotherapy, the therapeutic alliance is terminated. With emphasis on reassurance, clarification of emotional states, im- provement of interpersonal communication, testing of perceptions, and performance in interpersonal set- tings, interpersonal psychotherapy has been successful in helping depressed persons recover enhanced social functioning.

Delusional Disorder: Grandiose Type

Individuals with grandiose delusions have irrational ideas regarding their own worth, talent, knowledge, or power. They may believe that they have a special relationship with a famous person or even assume the identity of a famous person (believing that the actual person is an imposter). Grandiose delusions of a reli- gious nature may lead to assumption of the identity of a deity or religious leader.

Delusional Disorder: Somatic Type

Individuals with somatic delusions have fixed, false beliefs that they have some type of medical condition or that there has been an alteration in a body organ or its function.

Ineffective Coping: Goals/Interventions

Ineffective coping is defined as the "inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources." Goals should include helping the client express feelings about using substances as a method of coping with stress and the use of adaptive coping mechanisms. Interventions include setting limits on manipulative behavior, explaining the effects of substance abuse, and providing positive reinforcement.

alcoholic hepatitis (liver issue)

Inflammation of the liver caused by long-term heavy alcohol use. Symptoms include an enlarged and tender liver, nausea and vomiting, lethargy, anorexia, elevated white blood cell count, fever, and jaundice. Ascites and weight loss may be evident in more severe cases. With treatment—which includes strict abstinence from alcohol, proper nutrition, and rest—the individual can experience complete recovery. Severe cases can lead to cirrhosis or hepatic encephalopathy.

Buprenorphine

Intended Effects Agnoist-antagonist opiod use for both withdraw and maintenance Nursing Actions: Unlike methodone, PCP can prescribe Admin sublingually Buprenorphine opioid agonist- antagonist analgesic that is occasionally injected therapeutically to relieve moderate to severe pain. The drug is given sublingually (under tongue) to treat opioid dependence. It is essential that the pill be dissolved under the tongue and not swallowed. Serious and potentially deadly adverse effects may occur if a patient combines this drug with other CNS depressant medications. Suboxone, a buprenorphine-naloxone combination, is preferred therapy over buprenorphine alone for induction treatment and for maintenance therapy for short-acting opioid dependence. Physicians who prescribe the drug for out-patient use must meet several restrictions and are required to have special training. BBW: for buprenorphine because use of buccal and transdermal routes increases the risk of addiction, abuse, and misuse and the risk of life-threatening respiratory depression. In addition, there is a risk of fatal overdose with accidental exposure by children of buprenorphine administered by buccal film or a transdermal patch. In addition, prolonged use of the buccal or transdermal routes of buprenorphine during pregnancy has been known to cause neonatal opioid withdrawal syndrome.

Clonidine

Intended Effects: Clonidine withdraw effects related to autonomic hyperactivity (diarrhea, nausea, vomiting) Clonidine therapy does not reduce the craving for opioids Client Education: Avoid mental alertness activity until drowsiness subsides Chew sugarless gum hard candy, and sip small of water to treat dry mouth

Pharmacotherapy for alcoholism: Alcohol Withdraw Meds Benzodiazepines: chlordiazepoxide (Librium) oxazepam (Serax) lorazepam (Ativan) diazepam (Valium)

Intended Effects: Maintaenance of vital signs within expected reference ranges Decrease in the risk of seizures Decrease in the intensity of withdraw Substitution therapy during alcohol withdraw Nursing Actions: Administer around the clock or PRN Obtain baseline vital signs Monitor Vital Signs and Neurologic status on an ongoing basis Provide for seizure precautions

Methadone substitution

Intended Effects: Methadone sub is an oral opioid that replaces the opioid to which the client has a physical dependence Prevents abstinence syndrome Used for withdraw and long-term maintenance Nursing Actions: Must slowly taper Must be administered from an approved treatment center

Nalextrone

Intended Effects: Nalaxtrone is a pure opiod antagonist that suppresses the craving and pleasure effects of alcohol (also used for opioid withdraw) Nursing Actions: Access the client's history to determine whether the client is also dependant on opioids. Concurrent use increases the risk of opioid toxicity Suggest monthly IM injections of depot naltrexone for clients who have difficulty adhering to the medication regimen Patient Teaching: Take with meals to decrease gastrointestinal distress

Acamprosate

Intended Effects: Taken orally three times a day to reduce the unpleasant effects of abstinence (dysphoria, anxiety, restlessness) Patient teaching: Diarrhea can result. Maintain adequate fluid intake to prevent dehydration Avoid use in pregnancy

Interventions for aggressive/hostile behavior

Interventions ■ Observe the client for signs of hallucinations (lis- tening pose, laughing or talking to self, stopping in midsentence). Ask, "Are you hearing other voices?" "Are you able to distinguish those voices from my voice?" Early intervention may prevent aggressive responses to command hallucinations (such as voices telling the client to hurt or kill himself or her- self). ■ Avoid touching the client, or ask for permission before doing so. The client may perceive touch as threatening and respond in an aggressive or defen- sive manner.

Alcoholism: Korsakoff's psychosis

Korsakoff's psychosis is identified by a syndrome of confusion, loss of recent memory, and confabulation in alcoholics. It is frequently encountered in clients recovering from Wernicke's encephalopathy. In the United States, the two disorders are usually considered together and are called Wernicke-Korsakoff syndrome. Treatment is with parenteral or oral thiamine replacement.

Effects of alcohol on the blood

Leukopenia: Production, function, and movement of the white blood cells are impaired in chronic alcoholics. This condition, called leukopenia, places the individual at high risk for contracting infectious diseases as well as for complicated recovery. Thrombocytopenia: Platelet production and survival is impaired as a result of the toxic effects of alcohol. This places the alcoholic at risk for hemorrhage. Abstinence from alcohol rapidly reverses this deficiency.

Treatment for depression

Light Therapy The prevalence of depression with a seasonal pattern is reported to be up to 10 percent but varies on the basis of geographic location (Kurlansik & Ibay, 2013). The DSM-5 identifies this disorder as Major Depres- sive Disorder, Recurrent, With Seasonal Pattern. It has commonly been known as seasonal affective disorder (SAD). Theories suggest that SAD is related to the presence of the hormone melatonin (Cotterell, 2010), which is produced by the pineal gland. Melatonin plays a role in the regulation of biological rhythms for sleep and activation. It is produced during the cycle of darkness and shuts off in the light of day. During the months of longer darkness hours, there is increased production of melatonin, which seems to trigger the symptoms of SAD in susceptible people. Other research has pointed to seasonal serotonin transporter fluctuations associ- ated with variation in exposure to daylight (McMahon et al., 2016). Light therapy, or exposure to light, has been shown an effective treatment for SAD. The light therapy is administered by a 10,000-lux light box, whichcontainswhitefluorescentlighttubescovered with a plastic screen that blocks ultraviolet rays. Theindividualsitsinfrontoftheboxwitheyesopen (although one should not look directly into the light).Therapyusuallybeginswith10-to15-minute sessionsandgraduallyprogressesto30to45minutes. Themechanismofactionisbelievedtoberelat

Disturbances in Thought Processes Manifested in Speech

Loose association Thinking is characterized by speech in which ideas shift from one unrelated subject to another. Typically, the individual with loose associations is unaware that the topics are unconnected. When the condition is severe, speech may be incoherent (e.g., "We wanted to take the bus, but the airport took all the traffic. Driving is the ticket when you want to get somewhere. No one needs a ticket to heaven. We have it all in our pockets").

Alcoholism: Low/High dose effects

Low doses: Alcohol produces relaxation, loss of inhibitions, lack of concentration, drowsiness, slurred speech, and sleep. Chronic abuse: Results in multisystem physiological impairments.

Mesolimbic Pathway

Mesolimbic pathway: Originates in the ventral tegmentum area (VTA) and projects to areas of the limbic system, including the nucleus accumbens, amygdala, and hippocampus. The mesolimbic pathway is associated with functions of memory, emotion, arousal, and pleasure. Excess activity in the mesolimbic tract has been implicated in the positive symptoms of schizophrenia (e.g., hallucinations, delusions). Dopamine blockade in this pathway is the target of antipsychotic medication to reduce hallucinations and delusions.

Treatment for depression: Meds

Monoamine Oxidase Inhibitors MAO inhibitors are thirdline agents for the treatment of depression and are rarely used in clinical practice today, mainly because they may interact with some foods and drugs to pro-duce severe hypertension and possible heart attack or stroke. Prescribers are most likely to order MAO inhibitors when a patient does not respond to other antidepressant drugs or when electroconvulsive therapy is refused or contraindicated. The prototype MAO inhibitor is phenelzine (Nardil). Adverse Effects The most serious adverse effect associated with phenelzine is hypertensive crisis, which can be precipitated by intake of foods containing tyramine. Other reported effects include dysrhyth-mias, drowsiness, dizziness, sexual dysfunction, and orthostatic hypotension. Contraindications Contraindications to phenelzine include known sensitivity to the drug. Patients should not have elective surgery requiring general anesthesia or spinal anesthesia or use local anesthesia containing sympathomimetic vasoconstrictors. Patients who take other MAO inhibitors or weight-reduction and over-the-counter cold or hay fever preparations containing vasoconstric-tors should not take phenelzine. Use in Older Adults Phenelzine and other MAO inhibitors may be more likely to cause hypertensive crises in older adults because their cardio-vascular, renal, and hepatic functions are often diminished. Assessing for Therapeutic and Adverse Effects The nurse assesses for improvement in symptoms of depres-sion, including improvement in anxiety level, reduced agitation or irritability episodes, decreased number of panic attacks, and ability to sleep through the night. It is important to monitor the patient for severe headache, nausea, vomiting, neck stiffness, photophobia, and sweating. In addition, it is necessary to observe for blurred vision, constipation, dizziness, dry mouth, hypotension, urinary reten-tion, and hypoglycemia. If the patient eats any foods contain-ing tyramine, hypertensive crisis may occur. The treatment for hypertensive crisis is phentolamine.

naltrexone (ReVia)

Naltrexone A pure opioid antagonist that blocks opioids from occupying receptor sites, thereby preventing their physiologic effects. (This drug is also used to combat alcohol abuse.) Used to maintain opioid-free states in the opioid addict, it is recommended for use in conjunction with psychological counseling to promote patient motivation and adherence. If the patient taking naltrexone has mild or moderate pain, he or she should receive a nonopioid analgesic (e.g., acetaminophen or a nonsteroidal anti-inflammatory drug). If the patient has severe pain and requires an opioid, administration of the naltrexone should occur in a setting staffed and equipped for cardiopulmonary resuscitation because respiratory depression may be deeper and more prolonged than usual. BBW: about naltrexone and the risk of hepatocellular injury. It is necessary to obtain periodic liver function tests during therapy and discontinue the drug at signs of increasing hepatic impairment. Used for both Alcohol and Opioid Therapy

Depression: Neuroendocrine Disturbances

Neuroendocrine disturbances may play a role in the pathogenesis or persistence of depressive illness. This notion has arisen in view of the marked disturbances in mood observed with the administration of certain hormones or in the presence of spontaneously occur- ring endocrine disease. Hypothalamic-Pituitary-Adrenocortical Axis In clients who are depressed, the normal system of hormonal inhibition fails, resulting in a hypersecretion of cortisol. This elevated serum cortisol is the basis for the dexamethasone suppression test that is sometimes used to determine if an individual has somatically treatable depression. Hypothalamic-Pituitary-Thyroid Axis Thyrotropin-releasing factor (TRF) from the hypothalamus stimulates the release of thyroid-stimulating hormone (TSH) from the anterior pituitary gland. In turn, TSH stimulates the thyroid gland. Diminished TSH response to administered TRF is observed in approximately 25 percent of depressed persons and appears to be associated with increased risk for relapse despite treatment with antidepressants (Sadock et al.,

Reward System: Where in the brain?

Neuronal pathways that are responsible for sensing pleasure and reward, once activated, are believed to be responsible for pleasurable sensations associated with these drugs as well creating a "memory" that triggers desire for repeated use of the drug. These pathways are referred to as the brain-reward circuitry.

Fetal Alcohol Syndrom (FAS)

No amount of alcohol during pregnancy is considered safe, and alcohol can damage a fetus at any stage of pregnancy. Characteristics of FAS: •Abnormal facial features •Small head size •Shorter-than-average height •Low body weight •Poor coordination •Hyperactive behavior •Difficulty paying attention •Poor memory •Difficulty in school •Learning difficulties •Speech and language delays •Intellectual disability •Poor reasoning skills •Sleep and sucking problems as a baby •Vision or hearing problems •Problems with the heart, kidneys, or bones

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? Assess triggers for bizarre, inappropriate behaviors Note escalating behaviors and intervene immediately Interpret attempts at communication Assess for medication noncompliance

Note escalating behaviors and intervene immediately

How does the reward system respond to substances overtime?

Over time, the brain tries to compensate for this excessive activation by lowering levels of these neurotransmitters, resulting in the physical discomfort associated with drug withdrawal. At this point, the substance user may continue use of the substance simply to alleviate illness.

Body Presentation

Pacing and Rocking Pacing back and forth and body rocking (a slow, rhythmic, backward-and-forward swaying of thetrunk from the hips, usually while sitting) are common psychomotor behaviors of the client with schizophrenia

Alcoholism: Peripheral Neuropathy

Peripheral neuropathy results in pain, burning, tingling, or prickly sensations of the extremities. Researchers believe it is the direct result of deficiencies in the B vitamins, particularly thiamine. This is reversible with abstinence from alcohol and restoration of nutritional deficiencies, but permanent muscle wasting and paralysis can occur with continued use.

Opioid Use Behaviors

Perscription Abuse and addiction occur when the individual increases the amount and frequency of use, justifying the behavior as symptom treatment. Recreational purposes and obtain them from illegal sources

Disturbances in Thought Processes Manifested in Speech

Perseveration The individual who exhibits perseveration persistently repeats the same word or idea in response to different questions. It is the manifestation of a thought-processing disturbance in which the person gets stuck on a particular thought.

Alcoholism: Jellinek 4 Phases

Phase I: The Prealcoholic Phase. This phase is when alcohol is used to relieve the everyday stress and tensions of life. As a child, the individual may have observed parents or other adults drinking alcohol and enjoying the effects. Tolerance develops, and the amount required to achieve the desired effect increases steadily. Phase II: The Early Alcoholic Phase. This phase begins with blackouts, and alcohol stops being a source of pleasure or relief for the individual but rather a drug that is required. Common behaviors include sneaking drinks or secret drinking, preoccupation with drinking and maintaining the supply of alcohol, rapid gulping of drinks, and further blackouts. The individual feels enormous guilt and becomes very defensive about his or her drinking. Phase III: The Crucial Phase. In this phase, the individual has lost the inability to choose whether or not to drink, and addiction is clearly evident. Binge drinking is common. These episodes are characterized by sickness, loss of consciousness, squalor, and degradation. In this phase, the individual is extremely ill. Anger and aggression are common manifestations. By this phase of the illness, it is not uncommon for the individual to have experienced the loss of job, marriage, family, friends, and most especially, self-respect. Phase IV: The Chronic Phase. This phase is characterized by emotional and physical disintegration. Emotional disintegration is evidenced by profound helplessness and self-pity. Impairment may result in psychosis. Life-threatening physical manifestations may be evident in virtually every system of the body. Unmanaged withdrawal from alcohol results in a terrifying syndrome of symptoms that include hallucinations, tremors, convulsions, severe agitation, and panic. Depression and ideas of suicide are not uncommon. For long term, heavy drinkers, abrupt withdrawal of alcohol can be fatal.

Schizophrenia: Positive Symptoms

Positive symptoms are those present in a person with schizophrenia that would not be present in a person without the illness, sometimes described as features that are "added." Delusions (Fixed, False Beliefs) Persecutory—belief that one is going to be harmed by other(s) Referential—belief that cues in the environment are specifically referring to them Grandiose—belief that they have exceptional greatness Somatic—beliefs that center on one's body functioning Hallucinations (sensory perceptions without external stimuli) Auditory (most common in schizophrenia) Visual Tactile (touch) Olfactory (smell) Gustatory (taste) (Note: Hallucinations may be a normal part of religious experience in cultural contexts) Disorganized Thinking (Manifested in Speech) Loose association Tangentiality (irrelevant to questions) Circumstantiality (end at relevance) Incoherence (includes word salad) Neologisms (patients own words ex. "head shoe" for hat) Clang associations (using words that sound similar to each other) Echolalia (echoing what someone just said) Grossly Disorganized or Abnormal Motor Behavior (Including Catatonia) Hyperactivity Hypervigilance Hostility Agitation Childlike silliness Catatonia (ranging from rigid or bizarre posture and decreased responsivity to complete lack of verbal or behavioral response to the environment) Catatonic excitement (excessive and purposeless motor activity) Stereotyped, repetitive movements Unusual mannerisms or postures

Schizophrenia Phase 1: Premorbid Phase

Premorbid signs are those that occur before there is clear evidence of illness and may include distinctive personality traits or behaviors. Premorbid personality and behavioral indications may include being very shy and withdrawn, having poor peer relationships, doing poorly in school, and demonstrating antisocial behavior

Effects of Alcohol during pregnancy

Prenatal exposure to alcohol can result in a broad range of disorders to the fetus, known as fetal alcohol spectrum disorders (FASDs), the most common of which is fetal alcohol syndrome (FAS). Fetal alcohol syndrome includes physical, mental, behavioral, and/or learning disabilities with lifelong implications. Other FASDs include alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD).

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge? Provide a 1-week supply of Elavil with refills contingent on follow-up appointments. Provide education regarding the avoidance of foods containing tyramine. Provide a pill dispenser as a memory aid. Provide a 6-month supply of Elavil to ensure long-term compliance.

Provide a 1-week supply of Elavil with refills contingent on follow-up appointments.

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia? Use therapeutic touch to increase trust and rapport. Maintain continual eye contact throughout the interview. Provide neon lights and soft music. Provide personal space to respect the client's boundaries.

Provide personal space to respect the client's boundaries.

Regression

Regression is the retreat to an earlier level of development. This primary defense mechanism of schizophrenia may be a dysfunctional attempt to reduce anxiety. It provides the basis for many of the behaviors associated with schizophrenia

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? Tardive dyskinesia Reports of hearing disturbing voices Tactile hallucinations Restlessness and muscle rigidity

Restlessness and muscle rigidity

Risk for Injury: Goals/Interventions

Risk for injury is defined as "vulnerable to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources, which may compromise health." Goals should include stabilization of the client and avoiding physical injury. Interventions to achieve these goals include obtaining a drug history, observe the client's behaviors and vital signs, and frequently orient the client to reality and the surroundings.

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client? Risk for violence: directed toward others Altered thought processes Disturbed sensory perception Risk for injury

Risk for violence: directed toward others

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? Clonazepam (Klonopin) to address the positive symptom Risperidone (Risperdal) to address the positive symptom Clozapine (Clozaril) to address the negative symptom Haloperidol (Haldol) to address the negative symptom

Risperidone (Risperdal) to address the positive symptom

Schizophrenia as defined by DSM-5

Schizophrenia Disorder DSM-5 295.90 (F20.9) Schizophrenia is probably not a homogeneous disease entity. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), supports this concept by describing schizophrenia as one of the schizophrenia spectrum disorders

Schizophrenia Phase III: Active Psychotic Phase (Acute Schizophrenic Episode)

Schizophrenia is a chronic illness but is characterized by acute episodes in which symptoms are more pronounced. In the active phase of the disorder, psychotic symptoms are typically prominent.

Treatment: Family Therapy

Schizophrenia is an illness that can puzzle, disrupt, and sometimes destroy families. Even when families appear to cope well, there is a notable impact on the mental and physical health of relatives when a family member has this illness. The importance of the expanded role of family in the aftercare of those with schizophrenia has been recognized, thereby stimulating interest in family intervention programs designed to support the family system, prevent or delay relapse, and help to maintain the client in the community. These psychoeducational programs treat the family as a resource rather than a stressor, with the focus on concrete problem- solving and specific behaviors for coping with stress. These programs recognize the biological basis for schizophrenia and the impact that stress has on the client's ability to function. By providing the family with information about the illness and suggestions for effective coping, psychoeducational programs reduce the likelihood of the client's relapse and the possible emergence of mental illness in previously nonaffected relatives.

Schizophrenia Phase IV: Residual Phase

Schizophrenia is characterized by periods of remission and exacerbation and consequently is described as episodic despite being a chronic illness. A residual phase usually follows the active phase of the illness, during which symptoms of the active phase are either absent or no longer prominent. Negative symptoms may remain, and flat affect and impairment in role functioning are common during this phase. It has long been thought that these remaining symptoms are pervasive and stable, but current research has challenged that belief with evidence that negative symptoms can improve over time. Residual impairment often increases with additional episodes of active psychosis.

Treatment for depression: Meds

Selective Serotonin Reuptake Inhibitors (SSRIs) SSRIs, of which fluoxetine (Prozac, Sarafem) is the pro-totype, produce fewer serious adverse effects than the TCAs. (SSRIs are called "selective" because they seem to primarily affect serotonin and not other neurotransmitters.) The drugs of first choice in the treatment of depression, SSRIs are effective and usually produce fewer and milder adverse effects than other antidepressants. There are no guidelines for choosing one SSRI over another. Use in Children The FDA has issued a bLacK bOX Warning ♦ alerting health care providers to the increased risk of suicidal ideation in chil-dren, adolescents, and young adults 18 to 24 years of age when taking antidepressant medications, including fluoxetine. Use in Older Adults Fluoxetine and other SSRIs are the drugs of choice in older adults because they produce fewer sedative, anticholinergic, car-diotoxic, and psychomotor adverse effects than the TCAs and related antidepressants. Elimination may be slower, and smaller or less frequent doses may be prudent in older adults. Weight loss is often associated with SSRIs and may be undesirable in older adults. Use of maintenance antidepressant therapy is ben-eficial to prevent recurrence of depression in older adults. Adverse Effects Adverse effects of fluoxetine include a high incidence of GI symptoms (e.g., nausea, diarrhea, and weight loss) and sexual dysfunction (e.g., delayed ejaculation in men, impaired orgas-mic ability in women). Most SSRIs also cause some degree of CNS stimulation (e.g., anxiety, nervousness, insomnia), which is most prominent with fluoxetine. These drugs are also associated with increased risk of GI bleeding. For patients with diabetes mellitus, SSRIs may have a hypoglycemic effect. Serotonin syndrome , a serious and sometimes fatal reaction characterized by hypertensive crisis, hyperpyrexia, extreme agitation progressing to delirium and coma, muscle rigidity, and seizures, may occur due to combined therapy with an SSRI and an MAO inhibitor or another drug that potentiates serotonin neurotransmission. It is important not to take an SSRI or SNRI and an MAO inhibitor concurrently or within 2 weeks of each other. In most cases, if a patient taking an SSRI is transferred to an MAO inhibitor, it is necessary to discontinue the SSRI at least 14 days before starting the MAO inhibitor. However, the patient should discontinue fluoxetine at least 5 weeks before starting an MAO inhibitor due to the prolonged half-life. As previous discussed, antidepressant discontinuation syndrome can occur with sudden termination of the SSRIs. Withdrawal symptoms include dizziness, GI upset, lethargy or anxiety/hyperarousal, dysphoria, sleep problems, and head-ache, which can last from several days to several weeks. More serious symptoms may include aggression, hypomania, mood disturbances, and suicidal tendencies. Fluoxetine, with its long half-life, has not been associated with withdrawal symptoms. Contraindications Contraindications to fluoxetine include known sensitivity to the drug as well as the use of MAO inhibitors or thioridazine.

Severe Depression

Severe depression (also called major depressive disorder) is characterized by an intensification of the symptoms described for moderate depression (see Box 25-2). Symptoms at the severe level of depression include the following: ■ Affective: Feelings of total despair, hopelessness, and worthlessness; flat (unchanging) affect, appear- ing devoid of emotional tone; prevalent feelings of nothingness and emptiness; apathy; loneliness; sadness; inability to feel pleasure. ■ Behavioral: Psychomotor retardation so severe that physical movement may literally come to a standstill, or psychomotor behavior manifested by rapid, agitated, purposeless movements; slumped posture; sitting in a curled-up position; walking slowly and rigidly; virtually nonexistent communi- cation (when verbalizations do occur, they may reflect delusional thinking); no personal hygiene and grooming; social isolation is common, with vir- tually no inclination toward interaction with others ■ Cognitive: Prevalent delusional thinking, with delu- sions of persecution and somatic delusions being most common; confusion, indecisiveness, and an inability to concentrate; hallucinations reflecting misinterpretations of the environment; excessive self-deprecation, self-blame, and thoughts of suicide NOTE: Because of the low energy level and slow thought processes, the individual may be unable to follow through on suicidal ideas. However, the desire is strong at this level. ■ Physiological: A general slowdown of the entire body, reflected in sluggish digestion, constipation, and urinary retention; amenorrhea; impotence; diminished libido; anorexia; weight loss or weight gain associated with appetite changes; changes in sleep patterns, including difficulty falling asleep and awakening very early in the morning; feeling worse early in the morning and somewhat better as the day progresses (as with moderate depression, this may reflect the diurnal variation in the level of neurotransmitters that affect mood and activity)

Codependency Treatment Stages

Stage I: The Survival Stage. In this stage, codependent persons must begin to let go of the denial that problems exist. This initiation of abstinence from blanket denial may be a very emotional and painful period. Stage II: The Reidentification Stage. Reidentification occurs when the individuals are able to glimpse their true selves through a break in the denial system. They accept the label of codependent and take responsibility for their own dysfunctional behavior. They accept their limitations and are ready to face the issues of codependence. Stage III: The Core Issues Stage. In this stage, the recovering codependent must face the fact that relationships cannot be managed by force of will. Each partner must be independent and autonomous. The goal of this stage is to detach from the struggles of life that exist because of prideful and willful efforts to control those things that are beyond the individual's power to control. Stage IV: The Reintegration Stage. This is a stage of self-acceptance and willingness to change when codependents relinquish the power over others that was not rightfully theirs but reclaim the personal power that they do possess.

Sympothy

Sympathy The actual sharing of another's thoughts and behaviors. Differs from empathy in that with empathy one experiences an objective understanding of what another is feeling, rather than actually sharing those feelings. With empathy, while understanding the client's thoughts and feelings, the nurse is able to maintain sufficient objectivity to allow the client to achieve problem resolution with minimal assistance. With sympathy, the nurse actually feels what the client is feeling, objectivity is lost, and the nurse may become focused on relief of personal distress rather than on helping the client resolve the problem at hand. The

Mild Depression

Symptoms at the mild level of depression are like those associated with uncomplicated grieving. Alter- ations at the mild level include the following: ■ Affective: Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness, despondency ■ Behavioral: Tearfulness, regression, restlessness, agitation, withdrawal ■ Cognitive: Preoccupation with the loss, self-blame, ambivalence, blaming others ■ Physiological: Anorexia or overeating, insomnia or hypersomnia, headache, backache, chest pain, or other symptoms associated with the loss of a signif- icant other

Transient Depression

Symptoms at this level of the continuum are not nec- essarily dysfunctional; in fact, they may be considered part of the broad range of typical human emotional responses that accompany everyday disappointments in life. Transient depression subsides quickly, and the individual is able to refocus on other goals and achievements. Alterations include the following: ■ Affective: Sadness, dejection, feeling downhearted, having the blues ■ Behavioral: Some crying possible ■ Cognitive: Some difficulty getting mind off of one's disappointment ■ Physiological: Feeling tired and listless

Disturbances in Thought Processes Manifested in Speech

Tangentiality Tangentiality refers to a veering away from the topic of discussion and demonstrates difficulty in maintaining focus and attention.

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist? Weight gain of 8 pounds in 2 months Excessive salivation Temperature of 104°F (40°C) Respirations of 22 beats/minute

Temperature of 104°F (40°C)

Treatment: RAISE (Recovery After an Initial Schizophrenic Episode)

The RAISE approach incorporates many elements from other treatment approaches, including community treatment, recovery model approaches, family approaches, and comprehensive care models. It adds the dimension of early intervention at the first episode of psychosis. The research findings after 5 years of studying this approach are promising for improving care to this population when intervention begins at the earliest onset of psychotic symptoms. Positive outcomes have included greater adherence to treatment programs; greater improvement in symptoms, interpersonal relationships, and quality of life; more involvement in employment or educational pursuits; and less frequent hospitalizations than are seen for clients involved in more traditional treatment approaches (Insel, 2015). The hope for this approach to treatment is that through early and comprehensive intervention, the long-term debilitating consequences of schizophrenia can be averted or minimized.

Diagnostic Criteria for Catatonia Specifier

The clinical picture is dominated by three (or more) of the following symptoms: 1. Stupor (i.e., no psychomotor activity; not actively related to environment) 2. Catalepsy (i.e., passive induction of a posture held against gravity) 3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner) 4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]) 5. Negativism (i.e., opposition or no response to instructions or external stimuli) 6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity) 7. Mannerism (i.e., odd, circumstantial caricature of normal actions) 8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements) 9. Agitation, not influenced by external stimuli 10. Grimacing 11. Echolalia (i.e., mimicking another's speech) 12. Echopraxia (i.e., mimicking another's movements)

Delusional Disorder: Jealous Type

The content of jealous delusions centers on the idea that the person's sexual partner is unfaithful. The idea is irrational and without cause, but the individual with the delusion searches for evidence to justify the belief. The sexual partner is confronted (and some- times physically attacked) regarding the imagined infidelity. The imagined lover of the sexual partner may also be the object of the attack. Attempts to restrict the autonomy of the sexual partner in an effort to stop the imagined infidelity are common.

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. On the basis of this assessment data, which antipsychotic medication would be contraindicated? Risperidone (Risperdal), because it exacerbates symptoms of depression Haloperidol (Haldol), because it is used only in elderly patients Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines Clozapine (Clozaril), because of a cross-sensitivity to penicillin

Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

Side Effects

The effects of these medications are related to blockage of receptors for which they exhibit various degrees of affinity. Blockage of the dopamine receptors is thought to be responsible for controlling positive symptoms of schizophrenia. Dopamine blockage also results in extrapyramidal symptoms (EPS) and prolactin elevation (galactorrhea; gynecomastia). Cholinergic blockade causes anticholinergic side effects (dry mouth, blurred vision, constipation, urinary retention, tachycardia). Blockage of the alpha1-adrenergic receptors produces dizziness, orthostatic hypotension, tremors, and reflex tachycardia. Histamine blockade is associated with weight gain and sedation.

Schizophreniform Disorder

The essential features of this disorder are identical to those of schizophrenia except that the duration, including prodromal, active, and residual phases, is at least 1 month but less than 6 months (APA, 2013). If the diagnosis is made while the individual is still symptomatic but has been so for less than 6 months, it is qualified as "provisional." The diagnosis is changed to schizophrenia if the clinical picture persists be- yond 6 months. Schizophreniform disorder often has a good prognosis if the individual's affect is not blunted or flat, if there is a rapid onset of psychotic symptoms from the time the unusual behavior is noticed, or if premorbid social and occupational functioning was satisfactory (APA, 2013). Catatonic features may also be associated with this disorder

chlordiazepoxide (Librium) The prototype benzodiazepine for treatment of such substance abuse, provides adequate sedation and has a significant anticonvulsant effect. The drug may also make it easier for the patient to participate in rehabilitation programs and allow for the gradual reduction and discontinuation of the abused substance.

Therapeutic Effects: The nurse assesses the patient's vital signs; they should stabilize to within normal parameters. In addition, the nurse observes for the presence of cognitive impairment and/or thought disturbances and assesses for signs and symptoms of agitation and/or restlessness. The patient should not appear restless or confused and should not complain of thought disturbances. Adverse Effects: sedation, depression, lethargy, disorientation, and delirium. Patients taking high dosages may experience paradoxical excitatory reactions during the first few weeks of treatment. Other adverse effects include alterations in pulse and blood pressure, urticaria, constipation, diarrhea, dry mouth, jaundice, changes in libido, and blood dyscrasias The nurse assesses the patient for signs and symptoms of CNS depression. It is necessary to check the blood pressure for fluctuations from hypertension to hypotension. The nurse assesses the skin for redness, itching, and signs of bruising as well as the skin and sclera for jaundice. Interview the patient regarding the following: ●● Frequency and amount of bowel movements ●● Desire for sexual intercourse Contraindications: hypersensitivity to benzodiazepines, psychosis, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication with depression of vital signs, pregnancy, labor and delivery, and lactation. Home Care: Alcohol detoxification through pharmacologic means generally takes place in a hospital setting but may occur in the home. The home care nurse shares the responsibility for teaching patients how to use chlordiazepoxide effectively and how to recognize medication responses that should be reported to the health care provider. The nurse instructs the patient and/or caregivers to recognize signs and symptoms of alcohol withdrawal and reviews the pharmacologic treatment regimen with them. Also, the nurse monitors the patient's response to the drug. If the patient is unable to take the medication for any reason or is not responding to current dosage, it is essential to notify the health care provider. Adults: 50-100 mg PO followed by repeated doses up to 300 mg/d; subsequent doses reduced to lowest effective dose Children: Not recommended in children younger than 6 y ≥6 y, 5 mg PO two to four times daily; may be increased to 10 mg PO two to three times daily

Schizoaffective Disorder

This disorder is manifested by signs and symptoms of schizophrenia along with a strong element of symptomatology associated with the mood disorders (depression or mania). The client may appear depressed, with psychomotor retardation and suicidal ideation, or symptoms may include euphoria, grandiosity, and hyperactivity. The decisive factor in the diagnosis of schizoaffective disorder is the presence of hallucinations and/or delusions that occur for at least 2 weeks in the absence of a major mood episode (APA, 2013). However, prominent mood disorder symptoms must be evident for a majority of the time. The prognosis for schizoaffective disorder is generally better than that for other schizophrenic disorders but worse than that for mood disorders alone (Black & Andreasen, 2014). Catatonic features may also be associated with this disorder

A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? Thyroid-stimulating hormone (TSH) level of 6.2 U/mL (normal for this age group is 0.4 to 4.2 U/mL) Potassium (K+) level of 4.2 mEq/L (normal range is 3.5 to 5 mEq/L) Calcium (Ca2+) level of 9.5 mg/dL (normal range for this age group is 8 to 10 mEq/L) Sodium (Na+) level of 140 mEq/L (normal range for this age group is 135 to 145 mEq/L)

Thyroid-stimulating hormone (TSH) level of 6.2 U/mL (normal for this age group is 0.4 to 4.2 U/mL)

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? To rule out schizophrenia To rule out a personality disorder To rule out neurocognitive disorder To rule out bipolar disorder

To rule out neurocognitive disorder

Treatment for depression

Transcranial Magnetic Stimulation Transcranial magnetic stimulation (TMS) is a proce- dure that is used to treat depression by stimulating nerve cells in the brain. TMS involves the use of very short pulses of magnetic energy to stimulate nerve cells at localized areas in the cerebral cortex, similar to the electrical activity observed with ECT. However, unlike with ECT, the electrical waves generated by TMS do not result in generalized seizure activity (George, Taylor, & Short, 2013). The waves are passed through a coil placed on the scalp to areas of the brain involved in mood regulation. It is noninvasive and considered gen- erally safe. A typical course of treatment is 40-minute sessions, three to five times a week for 4 to 6 weeks (Raposelli, 2015). Some clinicians believe that TMS holds a great deal of promise in the treatment of depression, whereas others remain skeptical. In a study at King's College in London, researchers compared the efficacy of TMS with ECT in the treatment of severe depression (Eranti et al., 2007). They concluded that ECT is substantially more effective for the short-term treatment of depression and indicated the need for further intense clinical evaluation of TMS. In one study (Connolly et al., 2012), identified that 24.7 percent of patients receiving TMS were in remission at 6 weeks. Effectiveness ratings for ECT have varied from 17 to 70 percent. Although the effectiveness ratings may seem small or highly variable, both treatments provide an option for clients who are otherwise treatment-resistant. Magnezi and associates (2016) compared ECT to TMS and found that although ECT was more effective than TMS and additionally relieved anxiety symptoms, ECT had a much higher incidence (60%) of adverse effects, mostly related to memory loss. From the client's per- spective, TMS was still deemed preferable to ECT (if it was covered by insurance), which may be related to the stigma associated with ECT.

Treatment for depression: Meds

Tricyclics TCAs are the oldest antidepressants, although they are now sec-ond-line drugs for the treatment of depression. Imipramine(Tofranil) is the prototype. A patient's previous response or sus-ceptibility to adverse effects may be the basis for initial selection of TCAs. For example, if a patient (or a close family member) once responded well to a particular drug, that drug is proba-bly the drug of choice for repeated episodes of depression. The response of family members to individual drugs may be signifi-cant because there is a strong genetic component to depression and drug response. If therapeutic effects do not occur within 4 weeks, it is probably necessary to discontinue or change the TCA, because some patients tolerate or respond better to one TCA than to another. For patients with suicidal tendencies, beginning an SSRI or another newer drug is preferred over a TCA due to the safety profile. Use: Imipramine may be useful in the treatment of depression. Prescribers may order it for children and adolescents in the management of enuresis (bed wetting or involuntary urina-tion resulting from a physical or psychological disorder) after physical causes (e.g., urethral irritation, excessive intake of flu-ids) have been ruled out. Table 55.2 contains route and dosage information for imipramine and the other TCAs. Use in Children TCAs are more toxic in overdose than other antidepressants, and suicide is a leading cause of death in adolescents. The U.S. Food and Drug Administration (FDA) has issued a BLAcK BOX WARNING ♦ alerting health care providers to the increased risk of suicidal ideation in children, adolescents, and young adults 18 to 24 years of age who are taking antidepressants, including imipramine. However, in clinical trials, imipramine and other TCAs have not been shown to be superior to placebo for the treatment of depression in children and adolescents. TCAs are not recom-mended as first-line agents, although they may be beneficial in patients with attention deficit hyperactivity disorder or enuresis Use in Older Adults Imipramine may cause or aggravate conditions common in older adults (e.g., cardiac conduction abnormalities, urinary retention, narrow-angle glaucoma). In addition, impaired com-pensatory mechanisms make older adults more likely to experi-ence anticholinergic effects, confusion, orthostatic hypotension, and sedation. It is important to monitor vital signs, serum drug levels, and ECGs regularly. Adverse Effects Adverse effects of imipramine include sedation, orthostatic hypotension, cardiac dysrhythmias, anticholinergic symptoms (e.g., blurred vision, dry mouth, constipation, urinary reten-tion), and weight gain. Symptoms of TCA overdose occur 1 to 4 hours after drug ingestion. They consist primarily of CNS depression and cardiovascular effects (e.g., nystagmus, tremor, restlessness, seizures, hypotension, dysrhythmias, myocardial depression). Death usually results from cardiac, respiratory, and circulatory failure. TCAs are associated with clearly defined withdrawal syn-dromes, and these drugs also have strong anticholinergic effects. When they are abruptly discontinued, cholinergic rebound may occur. Symptoms include hypersalivation, diarrhea, urinary urgency, abdominal cramping, and sweating. Contraindications Contraindications to imipramine include known sensitivity to the drug and immediately postacute myocardial infarction. Other Meds: Amitriptyline Amoxapine Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin Imipramine (Tofranil) Nortriptyline (Aventyl; Pamelor) Protriptyline (Vivactil) Trimipramine (Surmontil)

Action

Typical antipsychotics work by blocking postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. They also demonstrate varying affinity for cholinergic, alpha1- adrenergic, and histaminic receptors. Antipsychotic effects may also be related to inhibition of dopamine- mediated transmission of neural impulses at the synapses.

Treatment for depression

Vagal Nerve Stimulation and Deep Brain Stimulation When studied in the treatment of epilepsy, vagal nerve stimulation (VNS) was found to improve the client's mood. This treatment involves implanting an electronic device in the skin to stimulate the vagus nerve. The mechanism of action is not known, but preliminary studies have shown that many clients with chronic recurrent depression improved when treated with VNS (Sadock et al., 2015). Trials are ongoing to determine its effectiveness. Another new approach is deep brain stimulation (DBS), a form of psychosurgery. In this procedure, as in VNS, an electrode is implanted with the intent of stimulating brain function. Unlike VNS, however, DBSinvolvesadeepimplantthatrequirescraniotomy. DBS has been well studied to determine its safety and effectiveness for other conditions, and controlled trialsareongoing.Currently,DBSisreservedforclients with severe, incapacitating depression or obsessive- compulsive disorder who have not responded toany moreconservativetreatments

Body Presentation

Waxy flexibility describes a condition in which the client with schizophrenia allows body parts to be placed in bizarre or uncomfortable positions. This symptom is associated with catatonia. Once placed in position, the arm, leg, or head remains in that position for long periods, regardless of how uncomfortable it is for the client. For example, the nurse may position the client's arm in an outward position to take a blood pressure measurement. When the cuff is removed, the client maintains the arm in the position in which it was placed to take the reading.

Alcoholism: Wernicke's encephalopathy

Wernicke's encephalopathy represents the most serious form of thiamine deficiency in alcoholics. Symptoms: paralysis of the ocular muscles, diplopia, ataxia, somnolence, and stupor. If thiamine replacement therapy is not undertaken quickly, death will ensue.

The healthcare provider is teaching a group of students about suicide assessment and prevention. Which of the following will be included in the teaching? Select all that apply. When medication improves a patient's mood, they may attempt suicide. It's important not to ask a patient whether they are having suicidal thoughts. If a patient is unsuccessful in a suicide attempt, another attempt is unlikely. A patient who talks about suicide may be signaling others for help. There are often no warning signs before a patient commits suicide.

When medication improves a patient's mood, they may attempt suicide. A patient who talks about suicide may be signaling others for help.

Schizophrenia: Negative Symptoms

negative symptoms are those that reflect a decrease in normal functions (functions that have been "taken away" by the illness). Most but not all clients exhibit a mixture of both types of symptoms. Lack of Emotional Expression Blunted affect Lack of movement in head and hands that add expression in communication Lack of intonation in speech (abnormal pitch level of words while talking) Decreased or Lack of Motivation to Complete Purposeful Activities (Avolition) Neglect of activities of daily living Decreased Verbal Communication (Alogia) Decreased Interest in Social Interaction and Relationship (Asociality) Withdrawal Poor rapport Diminished Ability for Abstract Thinking Concrete interpretation of events and communication from others