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Mental Health ATI Final - Review

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Observational commitment

(involuntary) Patient is in Need of observation, diagnosis, and treatment plan. May be imposed by family, legal guardian, PCP, or mental health.

What substances should a bipolar pt. avoid?

*AVOID* caffeine, alcohol, cocaine.

What are the s/sx of toxicity occurring with a serum lithium level of 2.0 to 2.5?

*Extreme polyuria of dilute urine*, tinnitus, blurred vision, *seizures*, *severe hypotension leading to coma*, *possible death from respiratory complications.* NC: administer emetic, gastric lavage, administer diuretic to increase lithium secretion (urea, mannitol, aminophylline).

What characterizes bipolar II disorder?

*Hypomania.*

What are the s/sx of toxicity for a lithium serum level of 1.5 to 2.0?

*Mental confusion, poor coordination, course tremors*, ongoing GI distress (n/v and diarrhea). Hold medication.

Define Suppression.

*Voluntarily* putting unpleasant thoughts and feelings out of mind. E.g. A person who lost his job states he will worry about paying the bills next week. ...Remember: Suppression = "supp"osed to forget, voluntarily

What are the TCA drugs for tx of depression?

- *Amitriptyline (Elavil)* - *Imipramine (Tofranil)* - *Doxepin (Sinequan)* - Nortiprtyline (Aventyl, Pamelor) - Amoxapine (Ascendin) - Trimipramine (Surmontil)

Adverse effects and teaching instruction for Carbamazepine (Tegretol) for bipolar disorder?

- *Blood dyscrasias*: leukopenia, anemia, thrombocytopenia (protect from infection, baseline) - Teratogenesis: do NOT use in pregnancy - Hypo-osmolairy: promotes secretion of aDH, which inhibits water excretion, places clients with heart failure at risk for fluid overload (monitor for HTN, edema, decreased urine output) - Skin disorders: dermatitis, rash (treat with anti-inflammatory or antihistamine medications; wear sunscreen). Administer in low doses initially. Effects will subside in a few weeks. Dose at bedtime.

Treatment of continuation phase of MDD?

- *Relapse prevention* through education, medication therapy, and psychotherapy.

Light therapy for SAD.

- 10000 lux light box 30 min a day, 2x a day

NC for mild/moderate anxiety.

- Active listening - Encourage client to express feelings - Calm presence - Evaluate past coping mechanisms - Explore alternative to problem situations - Encourage participation in activities such as exercise - Simple, clear statements

Describe the physical changes that may occur in a person with an eating disorder.

- Anorexia: fine, downy hair on face and back, yellow skin, mottled, cool extremities, poor skin turgor - Enlarged parotid glands - Dental erosion (with purging) - Dysrhythmias, heart failure, cardiomyopathy - Peripheral edema - Weakness - Constipation, self induced vomiting, diuretics/laxatives - Anorexia is often accompanied by amenorrhea for at least 3 consecutive cycles

What are the main SE to worry about in clients taking a conventional antipsycotic?

- Anticholinergic effects: (dry mouth, constipation, urinary hesitancy/retention) chew sugarless gum, sip water, high fiber foods, 2-3 L of fluid/day - Postural hypotension - EPS - Tardive dyskinesia

How often should lithium levels be monitored?

- At initiation of treatment, monitor lithium levels every 2-3 days until stable - Once medication reaches a therapeutic level, monitor blood lithium levels every 1-3 months.

SSRI's: what should the client avoid taking concurrently?

- Avoid use with MAOIs, TCAs, or St. John's Wort d/t risk of serotonin syndrome - Avoid concurrent use of warfarin - Avoid concurrent use with lithium - will result in ^ serum levels of SSRIs - Avoid use of NSAIDs and anticoagulants (increase risk for bleeding)

What is behavioral therapy?

- Believes changing behavior is key to treating problems such as anxiety/depression - Believes behavior is learned - Abnormal behavior is an attempt to avoid painful feelings - Teaches ways to decrease anxiety, avoidant behavior - Used for phobias, substance disorders, and other issues

What are the major medications used to treat anxiety disorders/trauma-related disorders?

- Benzodiazepines (Valium) - short term - Atypical anxiolytics (BuSpar) - long term, no dependency potential - SSRIs (Zoloft, Paxil) - SNRIs (Effexor) - TCAs (Elavil, Anafranil/comipramine) - concerned w/ sedation - Antihistamines - Beta blockers (Inderal) - decreases heightened vital signs that occur w/ anxiety - Anticonvulsants (Gabapentin/Neurotin)

What are adjunct medications that can be used to treat symptoms of bipolar?

- Benzodiazepines such as Ativan for impairment of sleep d/t mania. - Antidepressants such as fluoxetine (Prozac) for major depressive disorder.

What drugs are used for alcohol withdrawal?

- Benzodiazepines: Diazepam (Valium); Lorazepam (Ativan); cholordiazepoxide (Librium) - Carbamazepine (Tegretol) - decreases risk of seizures - Clonidine (Catapres) - helps with ^ BP

What is the action of TCAs? What are their uses?

- Block reuptake of norepinephrine and serotonin. - Mainly used for depression - Other uses: neuropathic pain, fibromyaliga, anxiety disorders, insomnia

What is used to tx nicotine withdrawal?

- Bupropion (Zyban) - Nicotine replacement therapy (Nicorette - gum; Nicotrol - patch)

What are the adverse SE of benzodiazepines?

- CNS depression: *sedation*, light headedness, ataxia, decreased cognitive function. - Anterograde amnesia: difficulty recalling events that occur after dosing. - Oral toxicity: drowsiness, lethargy, *confusion*. - IV toxicity: respiratory depression, severe hypotension, cardiac arrest. - Withdrawal effects: anxiety, insomnia, diaphoresis, tremors, light-headedness.

What are the SE of MAOI?

- CNS stimulation (anxiety, agitation, hypomania, mania) - Orthostatic hypotension - *HTN crisis d/t intake of tyramine. S/sx will include HA, nausea, ^ HR and BP.* - Local rash associated with transdermal preparation

Criteria to be admitted to an acute mental health facility.

- Clear risk of client as a danger to self/others - Failure of community-based tx - Dangerous decline in mental health status of client undergoing long term treatment - *Client having a medical need in addition to a mental illness*

Describe panic level anxiety.

- Client not in touch with reality. - Pt. experiences extreme fright/terror - Hyperactivity or flight - Immobility can occur - Dilated pupils, severe shakiness, inability to sleep, delusions, hallucinations

Depression in older adults may be confused as dementia. Explain.

- Clinical findings of depression such as memory loss, confusion, behavioral problems (social isolation or agitation) may mirror the s/sx of dementia.

Medication interactions w/ Lamictal?

- Contraceptives (decreased effectiveness of both medications) - Valproic acid (increases half-life of Lamictal)

Wellbutrin is contraindicated in clients taking what medications or with what disorders?

- Contraindicated in clients with a seizure disorder - *Concurrent use of an MAOI contraindicated.* - Contraindicated in clients w/ an eating disorder

Psychotherapy: what is it?

- Differs from psychoanalysis in that it involves more verbal therapist-to-client interactions. - Development of a trusting relationship - Psychodynamic psychotherapy employs the same tools as psychoanalysis. BUT, it focuses more on the client's *present* state than their early life. - Includes interpersonal psychotherapy. Can improve personal, social relationships, aid in bereavement, communication. - Includes cognitive therapy: based on the cognitive model, which focuses on individual thoughts and behaviors to solve current problems (used for tx of depression, eating disorders, anxiety)

Severe anxiety. Describe.

- Distorted perceptions - Learning/problem solving do NOT occur - Functioning is ineffective - Confusion, feelings of impending doom, hyperventilation, tachycardia, withdrawal, loud/rapid speech (yelling), aimless activity (psychomotor agitation)

What drugs are used for alcohol abstinence?

- Disulfiram (Antabuse) - Naltexone (Revia) - decreases cravings/rewarding effects of alcohol - Acamprosate (Campral)

BuSpar should not be used with what medications?

- Do not use with MAOIs. Wait 14 days until after last MAOI use before starting BuSpar. Interaction will cause HTN crisis. - Do not use with erythromycin, ketoconazole, St. John's wort, grapefruit juice > will ^ BuSpar's effects.

Medication interactions with atypical antipsycotics?

- Do not use with immunosuppressants, such as cancer drugs - Additive CNS depressants will cause further CNS depression - Do not use w/ barbiturates, phenytoin - Fluconazole (Diflucan)

What are the adverse effects of anxiety medications?

- Early adverse effects: nausea, diaphoresis, tremor, fatigue - Later adverse effects: sexual dysfunction, weight gain, HA - Weight gain (well balanced diet/exercise recommended) - GI bleed (use cautiously in clients with a bleeding disorder, ulcers, or coagulation disorders) - Hypoatremia in the elderly taking diuretics - Watch for serotonin syndrome - Bruxism (switch to an entirely different class of medications, treat with buspirone, use mouth guard) - Withdrawal syndrome (nausea, anxiety, tremor, unease; taper medication to avoid)

NC for pts. with eating disorders...

- Encourage client decision and participation in POC to allow for an ^ sense of control - Establish realistic goals for weight gain - Reward positive behaviors, such as completing meals or consuming a set number of calories (*NOT gaining weight*) - Closely monitor client during/after meals to prevent purging - Small frequent meals - High fiber diet - Diet low in sodium to prevent fluid retention - Limit high-fat, greasy food that prevent gas - Multivitamin - Avoid caffeine - One-to-one during meal times

Communication w/ pts. that have a personality disorder...

- Firm, yet supportive approach, consistent care - Offer realistic choices to help enhance client sense of control - Limit setting - Clients with *histrionic and dependent personality disorders often benefit from assertiveness training and modeling* - Clients who have schizoid or schizotypal personality disorders tend to isolate themselves and the nurse should respect this need

What are the five alterations in speech?

- Flight of ideas (associative looseness) - Neologisms - Echolalia - Clang association - Word salad (jumbling words together that have no relation to each other)

What can SSRI's be used for?

- GAD - Panic disorder: SSRIs will decrease the intensity and frequency of panic attacks; prevents panic attacks - OCD: reduces s/sx - Social anxiety disorder - Trauma-stessor related disorders - Depressive disorders

Adverse effects of AED: Valproic acid?

- GI (N/V) - *Hepatotoxicity* as evidenced by anorexia, N/V, fatigue, abdominal pain, jaundice (obtain baseline liver function, monitor regularly, avoid usei n children under 2 years old) - Monitor liver laps d/t hepatotoxicity, *AST/ALT* - Pancreatitis AEB N/V and abdominal pain (monitor client amylase levels) - Thrombocytopenia (observe for indications such as bruising; monitor platelet counts) - Teratogenesis

Characteristics of a therapeutic relationship.

- Goal directed - Behavioral change encouraged - Termination date established It is NOT a relationship in which both parties needs are met or there is an emotional commitment.

Treatment of maintenance phase of MDD?

- Goal is prevention of future depressive episodes - Phase may last for years

What are the s/sx of PTSD?

- Hallucinations - Recurring nightmares - Avoidance of stimuli associated with traumatic event - Inability to show/express emotions - Increased arousal

Common lab abnormalities associated with anorexia?

- Hypokalemia (especially for bulimia nervosa); expect K+ loss d/t purging; dehydration stimulates secretion of aldosterone > sodium and fluid retention - Anemia/leukopenia - ^ liver enzymes - ^ cholesterol - Abnormal thyroid function tests - Elevated carotene levels - which gives skin yellow appearance - Decreased bone density (osteoporosis) - ECG changes - Abnormal BG

What are risk factors for personality disorders?

- Pts. often have co-morbid substance use disorders; many have a history of violent/nonviolent crimes, includes sex offenses. - Psychosocial influences (childhood abuse/trauma) - Biological influences (genetic)

What is the criteria for acute care of eating disorders?

- Rapid weight loss of greater than 30% of body weight in 6 months - Vital signs: less than 40 bpm, systolic BP less than 70, body temperature less than 96.8 - ECG changes - Electrolyte disturbances - Psych criteria: depression, suicidal behavior, family crisis, psychosis

NC for panic/severe anxiety.

- Remain with the client. *Safety.* - Quiet environment, minimal stimuli - Encourage gross motor activities such as walking and other forms of exercise - Short, firm, simple statements; may need to repeat - Direct the client to reality - *Low pitched voice, speak slowly*

What are the adverse effects of SSRIs?

- Sexual dysfunction - CNS stimulation (insomnia, agitation, anxiety); avoid caffeinated beverages, take medication in morning - Weight loss initially; weight gain later in tx - Serotonin syndrome (mental confusion, hyperreflexia, hallucinations, sweating, tremors, fever, anxiety) - Withdrawal syndrome (HA, nausea, visual disturbances, anxiety, dizziness, tremors); taper dose slowly when d/c medications - Hypoatremia in older adults on diuretics - Rash - Sleepiness, faintness, lightheadedness - GI bleed - Bruxism

How does the DSM-5 define MDD?

- Single episode or recurrent episodes of unipolar depression (absence of manic-depressive disorder) - Results in a significant change in client's normal functioning - Accompanied by at least five of the following clinical findings for at least *two weeks for most of the day*: a. Depressed mood b. Difficulty sleeping/excessive sleeping c. Indecisiveness d. Decreased ability to concentrate e. Suicidal ideation f. Increase/decrease in motor activity g. Inability to feel pleasure h. Increase/decrease in weight of more than 5% of ideal body weight over 1 month

Describe moderate anxiety.

- Slightly reduced perception and processing of information - Ability to think clearly is hampered "I don't understand what you're trying to say?" - Visually anxious (pale, perspiring) - Concentration difficulties - Pacing, change in voice (tremors), shakiness, ^ HR - Somatic complaints: headache, backache, urinary urgency, insomnia

Lithium: teaching regarding SE. What are the SE?

- Teach the client that SE will resolve within a few weeks of starting the medication. - GI distress: nausea, diarrhea, abdominal pain; administer medication with meals/milk - Fine tremors: exacerbated by stress and caffeine - Polyuria, mild thirst: Use a potassium-sparing diuretic (Aldactone); instruct client to consume 2-3 L a day of fluid - Weight gain - Renal toxicity (monitor client I&O, lowest dosage necessary, assess baseline BUN, creatine) - Goiter and hypothyroidism w/ long term treatment (get baseline TSH, T3 and T4) - Bradydysrhythmias, hypotension, electrolyte imbalances (encourage pt. to maintain an adequate fluid intake - will help minimize these s/sx)

Personality disorders..

- The maladaptive behaviors of a personality disorder may not always be perceived as maladaptive by the individual. Some areas of personal functioning may be adequate.

What is wellbutrin also used for?

- Traditionally used for depression - Used as an alternative to SSRIs d/t intolerable sexual dysfunction, aid to quit smoking, prevention of SAD.

Requirements for seclusion/restraints?

- Treatment must be ordered by primary care provider in writing - Must specify duration and type of restraint - Must rewrite the order every 24 hours

Describe the therapeutic uses of conventional antipsycotics?

- Tx. of acute/chronic psychotic disorders - Schizophrenia spectrum disorders - Bipolar disorder - primarily manic phase - Tourette's disorder - Prevention of N/V d/t chemotherapy

What does the DSM-5 include?

- Used to identify mental health disorders - Established dx criteria - Assists in planning nursing care - Expected assessment findings - It does NOT recommend pharmacological treatment

What are other atypical antidepressants?

- Venlafaxine (Effexor) - Duloxetine (Cymbalta) - Desvenlafaxine (Pristiq) - Mirtazapine (Remeron) - Less sexual dysfunction, wel tolerated, ^ release of serotonin/norepinephrine - Reboxetine (Edronax) - No weight gain or sleepiness. - Tradazone (Desyrel) - Paprism is a serious SE; often used as an adjunct antidepressant medication.

What SE should be monitored for when giving an antidepressant?

- Watch for any increase in suicidal ideation (medication may ^ thoughts of self harm, especially when tx is initiated) - Advise client that abrupt cessation will cause withdrawal

What are the negative SE for atypicals?

- Weight gain: to minimize, have pt. follow a health, low calorie diet, engage in exercise, monitor weight - Fluctuations in BG - S/sx of agitation, dizziness, *sedation*, and sleep disruption may occur.

Severity scale for substance use disorder based on DSM-5 defining characteristics...

0-1 criteria = no dx 2-3 criteria = mild substance use disorder 4-5 criteria = moderate substance use disorder 6+ criteria = severe substance use disorder

How quickly will cocaine withdrawal effects occur?

1 hour to several days since cessation of drug use.

What are the mood stabilizing medications for bipolar?

1. *Lithium carbonate* or Lithobid. 2. Anticonvulsants that act as mood stabilizers including valproic acid (Depakote), clonazepam (Klonopin), lamotrigine (Lamictal), gabapentin (Neurotin), and topiramate (Topax).

What are the EPS to be concerned about when taking an antipsycotic?

1. Acute dystonia: severe spasm of tongue, head, and neck; will occur between 5 hours - 5 days of dose 2. Parkinsonism: bradykinesia, shuffling gait, rigidity, drooling, tremors 3. Akathisa: inability to sit/stand still; continual pacing/agitation 4. Tardive dyskinesia: late EPS; involuntary movements of tongue and face (lip smacking)

What are the SE associated with conventional antipsycotics?

1. Agranulocytosis - observe for s/sx of infection (fever, sore throat); notify doctor immediately if these occur 2. Anticholinergic effects - sip water, sugarless gum, avoid hazardous activities, sunglasses, ^ fiber/fluid/exercise 3. Neuroendocrine - gynecomastia, galactorrhea, menstrual irregularities 4. Orthostatic hypotension - client will develop tolerance in 2-3 months; change positions slowly 5. Sedation 6. Seizures 7. Severe dysrhythmias 8. Sexual dysfunction 9. Skin effects - photosensitivity that can cause severe sunburn, contact dermatitis handling conventional antipsycotic medications

What is an example of a TCA? Teaching points?

1. Amitriptyline (Elavil) Teaching: - Change positions slowly d/t orthostatic hypotension - Anticholinergic effects (chew gum, sip water, ^ fiber foods, ^ fluids to 2 -3 L a day) - Sedation

What are other classes of medications used for bipolar?

1. Atypical antipsycotics: useful in early treatment to promote sleep and decrease anxiety and agitation (i.e. Abilify, Risperdal) 2. Anxiolytics: Clonazepam (Klonopin) and Lorazepam (Ativan) to treat acute mania and mange psychomotor agitation that is often seen in mania 3. Antidepressants: medications such as bupropion (Wellbutrin) and sertaline (Zoloft) are useful during the depressive phase. Often prescribed in combination with a mood stabilizer to prevent mania.

What are the three mood stabilizing anti-epileptic drugs?

1. Carbamazepine (Tegretol, Equetro) 2. Valproic acid (Depakote) 3. Lamotrigine (Lamictal)

Describe the first generation antipsycotics. What drugs are used?

1. Chlorpromazine (Thorazine) - low potency 2. Loxapine - medium potency 3. Perphenazine - medium potency 4. Halodol - high potency 5. Fluphenazine - high potency 6. Thiothixene (Navane) - high potency 7. Trifluoperazine - high potency ...when you "zine" or "ene"... You n"eeeed" an antipsycotic....

What are the three SSRIs most used with MDD? What are educational points re. use of SSRIs?

1. Citalopram (Celexa) 2. Fluoxetine (Prozac) 3. Sertaline (Zoloft) Teaching: - SE: nausea, HA, CNS stimulation (agitation, insomnia, anxiety) - Sexual dysfunction - Watch for s/sx of serotonin syndrome - Avoid concurrent use of St. John's Wort - ^ risk of serotonin syndrome - Follow a healthy diet d/t risk of weight gain

What are the two examples of personal boundary difficulties?

1. Depersonalization: nonspecific feeling that a person has lost his/her identity; self is unreal 2. Derealization: the perception that the environment has changed

What medications interfere with lithium therapy?

1. Diuretics 2. NSAIDs 3. Anticholinergics

What are four of the conventional antipsycotics?

1. Haloperidol (Haldol) 2. Loxapine (Loxitane) 3. Chlorpromazine (Thorazine) 4. Fluphenazine (Prolixin)

What characterizes addiction?

1. Loss of control d/t addictive behavior 2. Participation continues despite associated problems 3. Tendency to relapse

Describe the behaviors involved with mania (4).

1. Mania: normally an elevated mood, which may be described as expansive or irritable. Usually requires hospitalization. 2. Hypomania: a less severe episode of mania; lasts at least 4 days with at least 3-4 findings associated with mania. Hospitalization not required. 3. Mixed episode: manic episode an an episode of major depression experienced by the client simultaneously. 4. Rapid cycling: four or more episodes of acute mania in 1 year.

What are five types of behavioral therapy?

1. Modeling: therapist serves as a role model for clients; client imitates this behavior 2. Operant conditioning: positive reinforcement 3. Systematic desensitization: planned, progressive, exposure to anxiety-provoking stimuli. Client uses relaxation techniques during exposure. 4. Aversion therapy - pairing of a maladaptive behavior with a punishment/unpleasant stimuli 5. Meditation, guided imagery, diaphragmatic breathing, muscle relaxation, biofeedback: all ways to control pain/anxiety

What are the two primary classes of medications are used with bipolar disorders?

1. Mood stabilizing medications - LIthium (Lithane, Lithobid) 2. Anti-epileptic medications - Depakote, carbmazepine (Tegretol), Lamotrigine (Lamictal)

What is an example of a MAOI? Teaching?

1. Phenelzine (Nardil) Teaching: - D/t risk for HTN crisis, advise clients to avoid intake of foods high in tyramine (ripe avocados, figs, fermented/smoked meats, liver, dried/cured fish, most cheeses, some beer and wine, protein supplements) - Avoid use of all medications, including OTC meds until talking with provider

What are the MAOIs given to treat depression?

1. Phenelzine (Nardil) - think "Na, na, na, I'm going to Maui!" 2. Isocarboxazid (Marplan) 3. Tranylcypromine (Parnate) 4. Selegiline (Emsam) - transdermal patch

What are the six atypical antipsychotics?

1. Risperidone (Risperdal) 2. Olanzapine (Zyprexa) - *weight gain* 3. Quetiapine (Seroquel) 4. Ziprasidone (Geodon) 5. Aripiprzole (Abilify) - *no weight gain* 6. Clozapine (Clozaril) - *agranulocytosis*

What are the types of psychotic disorders outlined in DSM-5?

1. Schizophrenia: psychotic thinking or behavior present for at least 6 months; functioning in all areas significantly impaired 2. Schizotypal personality disorder: client has impairments of personality; impairment not as severe as schizophrenia. 3. Delusional disorder: delusional thinking present for at least 1 month 4. Brief psychotic disorder: psychotic manifestations present for 1 day to 1 month 5. Schizophreniform disorder: client has manifestations similar to schizophrenia; duration from 1 month to 6 months 6. Schizoaffective: pts. disorder meets criteria for schizophrenia and depressive or bipolar disorder 7. Substance induced psychotic disorder: pt. experiences psychosis within 1 month of substance intoxication or withdrawal

What five classifications can be used to treat depression?

1. Selective Serotonin Reuptake Inhibitors 2. TCAs 3. MAOIs 4. Atypical antidepressants (Wellbutrin) 5. SNRI

Medications for depressive disorders: what are the four classes used?

1. TCAs 2. SSRIs 3. MAOI 4. Atypical antidepressants

What is an example of a serotonin norepinephrine reuptake inhibitor? Teaching?

1. Venlafaxine (Effexor) 2. Duloxetine (Cymbalta) Teaching: - Watch for adverse effects such as nausea, weight gain, and sexual dysfunction.

What is an example of atypical antidepressant? Teaching?

1. Wellbutrin (bupropion) Teaching: - Advise client to observe for HA, dry mouth, GI distress, constipation, ^ HR, nausea, restlessness, insomnia - Monitor client's food intake and weight d/t appetite suppression - Don't use with clients at risk for seizures

How long must the client wait before BuSpar kicks in?

3-6 weeks before full therapeutic benefit reached. Take on a regular basis (not as needed).

Group therapy: subgroup

A subgroup is a small number of people within a larger group who function separately from that group.

What is a tort?

A tort is a wrongful act or injury committed by an entity or person against another person or one's property.

Define long-term or formal involuntary commitment.

A type of commitment that is similar to temporary commitment but it must be imposed by the courts. Usually 60 - 180 days.

Define tort.

A wrongful act or injury committed by an entity or person against another person/another person's property.

What are two healthy defense mechanism?

A. Alturism B. Sublimation

A nurse is talking with a client who is at risk for suicide following the death of her spouse. Which of the following statements is appropriate?

A. I am sorry for the loneliness you are experiencing. - This is sympathetic rather than empathetic. NOT therapeutic. B. I know how difficult it is to lose a loved one. - This statement implies judgement and is therefore not therapeutic. C. Losing someone close to you must be very upsetting. C is the correct answer. It is an empathetic response that attempt to understand pt. feelings.

What are the effects of cocaine toxicity?

A. Mild toxicity: dizziness, irritability, tremor, blurred vision B. Severe: hallucinations, seizures, fever, tachycardia, HTN, chest pain, CV collapse, *death*.

What comorbidities are often associated with bipolar?

ADHD Anxiety ADHD

What is the purpose for anti-epileptic agents when treating bipolar?

AEDs help treat and manage bipolar disorder. Used to treat manic and depressive episodes of bipolar, as well as to prevent relapse of both mania/depression.

What is the intended effect of disulfiram (Antabuse)?

After the patient ingests alcohol, acetaldehyde syndrome will occur and includes perfuse vomiting, nausea, weakness, sweating, palpitations, and hypotension. Can progress to respiratory depression, seizures, and death.

What are tyramine-rich foods?

Aged cheese, smoked meats (pepperoni, salami), avocados, figs, bananas, smoked fish, protein, protein supplements, wine, beers.

What are symptoms of opioid withdrawal?

Agitation, insomnia, flulike manifestations, rhinorrhea, yawning, sweating, diarrhea. Suicidal ideation may occur.

What are the adverse effects of BuSpar?

Agitation, light headedness, headache, nausea, dizziness. Do not use with breast feeding women.

Buprenorphine (Subutex) intended effect?

Agonist-antagonist opioid use for detox and maintenance. Decreases feeling of craving.

What is alcohol withdrawal delirum and when can it occur?

Alcohol withdrawal delirium is a medical emergency and may occur 2-3 days after cessation and last the same (2-3 days). S/s include severe disorientation, hallucinations, severe HTN, cardiac dysrhythmias, delirium.

The procedure to obtain seclusion or restraint order from the physician?

All less restrictive means need to have been attempted and documented in the patient's chart. Treatment must be provided by PCP in WRITING. Must specify duration. Order needs to be rewritten q24 hours.

What are the withdrawal manifestations of sedatives/hypnotics?

Anxiety, insomnia, HTN, diaphoresis, hand tremors, N/V, hallucinations/illusions, psychomotor agitation, seizures.

Describe abstinence syndrome for opioids.

Begins with *sweating, rhinorrhea* progressing to *goosebumps*, tremors, irritability. Followed by severe weakness, *diarrhea, fever, insomnia, pupil dilation, N/V, pain, and muscle spasms.*

Define veracity:

Being honest when dealing with a client.

What are the 5 ethical principles?

Beneficence, autonomy, justice, fidelity, veracity.

How would you manage EPS akathisia best?

Benzodiazepines, beta-blockers, or anticholinergic medications. All slow the body's autonomic functions to reduce agitation and continual movement.

Early EPS: what medications can you give to control?

Beta-blockers, benzodiazepines, and anticholinergics.

DSM5 bipolar disorders definitions

Bipolar I- at least one episode of mania alternating with MDD. Bipolar II- at least one or more hypomanic episode alternating with MDD. Cyclothymia- 2 years of repeated hypomanic manifestations that do not meet criteria for hypomanic episodes alternating with minor depressive episodes.

What is bipolar disorder?

Bipolar disorder is a mood disorder with recurrent episodes of depression and mania.

Bad: Projection

Blaming others for unacceptable thoughts and feelings. E.g. a young adult blames his substance abuse on his parents' refusal to buy him a new car.

What is the atypical anxiolytic used for anxiety?

BuSpar (Buspirone). Unknown mechanism of aciton. Binds to serotonin and dopamine receptors.

Medications utilized to support withdrawal/abstinence from Nicotine?

Bupropion (Zyban), Nicotine replacement therapy (gum, patch, spray), varenicline (Chantix)

What are the 10 personality disorders and what how are they clustered? Explain cluster B.

Cluster B refers to dramatic, emotional, or erratic traits. 1. Antisocial: characterized by disregard for others with exploitation, repeated unlawful actions, deceit, failure to accept personal responsibility, *blame*, *e.g. convinces people to give them their belongings*, *no anxiety when in a social situation* (see avoidant) 2. Borderline: instability of affect, identify, and relationships; splitting behaviors, manipulation, impulsiveness, fear of abandonment; *self injury/suicidal* and *manipulative* 3. Histrionic: attention-seeking behavior; seductive, flirtatious (remember: they want to make "histor"y!) 4. Narcissistic: arrogance, grandiose views of self, *need for admiration*, lack of empathy; sensitive to criticism and therefore may be *indecisive*

What are the 10 personality disorders and what how are they clustered? Explain cluster C.

Cluster C refers to anxious, fearful traits, insecurity, or inadequacy. Avoidant: characterized by social inhibition and avoidance of all situations that require interpersonal contact, despite wanting close relationships d/t extreme *fear of rejection/abandonment* Dependent: extreme dependency Obsessive-compulsive: characterized by perfectionism, orderliness

If a client is prescribed an SSRI but is currently on an MAOI, how long should the client wait before initiating SSRI treatment?

D/c MAOI. Wait 14 days before initiating SSRI therapy.

Define Alturism.

Dealing with anxiety by reaching out to others. E.g. pt. who lost family member in a fire is now a volunteer fire fighter.

Define Sublimation.

Dealing with unacceptable feelings/impulses by consciously substituting acceptable forms of expression. E.g. feelings of anger and hostility sublimated by working out vigorously at the gym

What are each of the adjunct medications indicated for?

Decrease seizures (Carbamazepine) Decrease autonomic response (decrease BP, HR)- Clonidine and Propanolol Decrease craving- Propanolol

What are things to be aware of when attempting to decrease stimulation for a client in a manic episode?

Decrease stimulation without isolating client if possible. Be aware of noise, music, TV, and other clients - all of which may lead to an escalation of the client's behavior.

What is the concern when diuretics are combined with lithium therapy?

Decreased sodium levels will predispose the client to lithium toxicity.

Bupropion (Zyban) intended effect?

Decreases nicotine craving and manifestations of withdrawal. Anticholinergic effects (standard teaching to counteract). Avoid caffeine to and other CNS stimulants to control insomnia.

How does the DSM-5 characterize substance abuse?

Defined as the repeated use of chemical substances, leading to clinically *significant impairment during a 12 month period*, and at least two of the DSM-5 criteria, see pg. 149. (e.g. continued desire/unsuccessful attempts in controlling substance abuse, continues substance abuse regardless of social/interpersonal problems associated with use, develops a tolerance, strong urges...)

Bad: Splitting

Demonstrating an inability to reconcile negative and positive attributes of self or others. E.g. the client tells the nurse she loves her, yet the following day refuses to speak to her

What defense mechanism is commonly used in pts. with substance abuse disorders?

Denial. For example, pt. may say, "I can quit whenever I want to!"

Teaching points for acamprosate (Campral)

Diarrhea may occur while taking the medication. Increase fluids. Do not take while pregnant.

What drugs are included in the benzodiazepine sedative hypnotic anxiolytics? Onset?

Diazepam (Valium) Lorazepam (Ativan) Chlordiazepoxide (Librium) ...All three above are also used to treat alcohol withdrawal... Clorazepate (Tranxene) Oxazepam (Serax) Clonazepam (Klonopin) Rapid onset.

What kind of medications are indicated for abstinence maintenance of alcohol?

Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral)

What should be considered when a pt. is on an MAOI but has a cold?

Do not use OTC decongestants/cold remedies. These medications often contain medications w/ a sympathomimetic action and will result in a release of epinephrine > HTN crisis.

Contraindications for atypical antipsycotic therapy?

Do not use in pts. w/ dementia or use w/ alcohol. Use w/ caution in clients w/ CV disease, seizures, or DM.

Documentation of the patient prior to restraint or seclusion?

Document precipitating events, behavior of patient PRIOR to seclusion/restraint. Alternative actions to avoid seclusion or restraint. Time treatment began. Current behavior, foods and fluids offered and taken, needs provided for, vital signs, medication administration.

Adverse effects for Lamotrigine (Lamictal)?

Double or blurred vision, dizziness, N/V, serious skin rashes.

When should lithium blood levels be drawn?

Draw in the morning, 12 hours after last dose.

Blood level guidelines for lithium...

During initial tx of manic episode: 0.8 - 1.4 mEq/l During maintenance phase: 0.4 - 1.0 mEq/l *Toxicity begins to occur at plasma levels greater than 1.5 mEq/l.*

Different roles in group therapy: maintenance role

E.g. A member who praises input from others or follows the directions from other members

Different roles in group therapy: individual role

E.g. a member who brags about his/her accomplishments

Different roles in group therapy: task role

E.g. a member who evaluates the group's performance according to standard

When will the client see significant improvement in s/sx when using a conventional antipsycotic?

Effects noticeable in a few days; max therapeutic effect within 2-4 weeks. May take *several months.*

What are alcohol withdrawal manifestations? Timeframe?

Effects start within *4 to 12 hours of last drink*, peak after 24 - 48 hours, and then suddenly disappear. S/sx: cramping, vomiting, tremors, restlessness, inability to sleep, ^ HR, hallucinations/illusions, anxiety, ^ BP, RR and temperature, seizures

Inhalants: effects of intoxication? Withdrawal?

Effects: behavioral/psych changes, dizziness, uncoordinated movement, slurred speech, *hyporeflexia*, *muscle weakness*, diplopia, stupor or coma, respiratory depression, possible death. No withdrawal manifestations.

What therapy will be useful for patients with bipolar?

Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior.

Define involuntary commitment.

Enters facility against the patient's will. Commitment based on need for risk of harm to self or others, or inability to provide self care. Can be determined by judge or another agency.

Group therapy for adults: ?

Especially valuable, as this age group typically has strong peer relationships.

Your patient is scheduled for MRI, and reports utilizing the nicotine patch (Nicotrol) at home. What is the nurse's priority action?

Explain to the patient that this can cause burns, and ask the patient or as the nurse remove the patch.

What three things does the Glasgow coma scale evaluate?

Eye, verbal, and motor responses. Highest value is 15. Indicates client is awake and responds appropriately. A score less than 7 indicates coma. Less than 3 - severe coma.

Define justice:

Fair and equal treatment for all.

True or false: the nurse should argue with the pts. hallucination?

False. Do not argue with the client's delusions/hallucinations. *Focus on the client's feelings* and *offer reasonable explanations* such as, "I can't imagine that the president of the US would have a reason to kill a citizen, but it must be frightening for you to believe that."

SSRI's are the FIRST line treatment for what disorders?

First line treatment for trauma-stressor related disorders (GAD and PTSD).

What are characteristics of depression?

Flat, blunt affect. Tearful, crying. Lack of energy. Anhedonia (lack of pleasure in participating in activities, hobbies, sexual activity). Physical report of pain. Difficulty concentrating, focusing, problem solving. Self destructive. Decrease in personal hygeine. Loss of appetite, disturbed sleep.

Decorticate rigidity: define

Flexion and internal rotation of upper-extremitity joints and legs. Found in a pt. who is comatose.

Purpose of flooding for anxiety?

Flooding involves exposing the client to a great deal of undesirable stimulus in an attempt to turn off the anxiety response. *Most useful for client who has phobias.*

What is the antidote for benzodiazepine intoxication? Barbiturate?

Flumazenil (Romazicon) IV for benzodiazepine. No antidote for barbiturate toxicity.

What is the antidote for benzodiazepine overdose?

Flumazenil (Romazicon). Will reverse the sedation and adverse effects.

Describe SSRI use with depression. What drugs are used?

Fluoxetine (Prozac) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) Sertaline (Zoloft) Vilazodone (Viibryd)

What does the secondary level of prevention entail?

Focuses on early detection of mental illness. Example: Nurse screens parents of children who have developmental disorders.

What does the tertiary level of prevention entail?

Focuses on rehabilitation and prevention of further problems in clients previously diagnosed. Nurse leads support group for patients who have completed substance us disorder program.

Continuation phase of bipolar treatment?

Generally 4-9 months in duration. Relapse prevention through education, medication adherence, and psychotherapy is the goal of treatment.

What are risk factors for substance abuse disorders?

Genetics, lowered self-esteem, lowered tolerance for pain/frustration, few meaningful relationships, few life successes, risk-taking tendencies, ^ stressors, certain people groups.

Risk factors of bipolar disorder?

Genetics- immediate family member who has bipolar Psychological- stressful events, major life changes Physiological- neurobiological and neuroendocrine disorders Substance use disorders- alcohol and/or cocaine

What would be the medication given for HTN crisis d/t tyramine intake while on an MAOI?

Give phentolamine (Regitine) IV or nifedipine (Procardia).

What are the adverse effects of Wellbutrin?

HA, dry mouth, GI distress, constipation, ^ HR, nausea, restlessness, insomnia, suppression of appetite, seizures at high doses.

What happens if when there is a MAOI + TCA?

HTN crisis.

What will happen if you use a TCA with a MAOI?

HTN crisis.

MAOI + vasopressor?

HTN. Avoid caffeine, chocolate, fava beans, ginseng as all of these are vasopressors and will increase BP.

What are NC for clients taking a TCA for depression that are experiencing severe anticholinergic effects?

Have client sip water, sugarless gum, wear sunglasses when outdoors, eat ^ fiber foods, exercise regularly, ^ fluid intake, void before taking TCA medication.

Group therapy for older adults: ?

Helps with socialization and sharing of memories.

What drugs are considered opioids?

Heroin, morphine, hydromorphone (Dilaudid). Injected, smoked, inhaled.

Tabacco (a stimulant): what are the short term and long term effects of intoxication?

Highly toxic; acute toxicity seen only in children or when exposure is to nicotine in pesticides. Long term effects of smoking: CV disease (HTN, stroke), respiratory disease (emphysema, lung cancer). With "chew," irritation to oral mucous membranes and cancer.

Acute mania treatment?

Hospitalization may be required. Reduction of mania and patient safety are the main goals of treatment. Risk of harm to self or others is determined. Suicidal ideation/plans should be priority.

Emergency involuntary commitment (define):

Hospitalized to prevent harm to self or others. Temporary. May be imposed by PCP (primary care provider, mental health provider, or police officers)

What are the electrolyte disturbances associated with bulimia?

Hypokalemia, hypoatremia (decreased Na+), hypocholemia.

What happens when there is an MAOI + anti-HTN?

Hypotension.

What is the concern with NSAIDs + Lithium?

Ibprophen (Motrin) and Celebrex. These NSAIDs will increase renal reabsorption of lithium > *toxic accumulation* of lithium in blood. *Use aspirin instead.*

A nurse is conducting an interview. When the nurse is conducting an interview, which of the following is the highest priority action?

Identify the patient's perception of their mental health status. Assessment is the priority nursing action when taking the nursing health process approach to client care. Identifying pt. perception of health provides important information to the nurse about pt. psychosocial history.

What are the concerns with amphetamine intoxication?

Impaired judgement, psychomotor agitation, hypervigilence, extreme irritability, acute cardiovascular effects (^ HR, BP) that can cause *death*.

Describe treatment of maintenance phase of bipolar?

In the maintenance phase, there is an increased ability on the pts. part to function. Treatment will continue throughout the patient's lifetime. *Prevention of future manic episodes is the goal of treatment.*

Factors that will affect the future of mental health care include:

Increase in the aging population, increase in cultural diversity within US, expansion of technology which can provide new settings for client care.

Specific rights of the mental institution patient?

Informed consent, right to refuse treatment, confidentiality, written plan of care, communication with people outside of mental health facility, adequate interpretive services if needed, care provided with respect and dignity, freedom from harm, provision of care with LEAST restrictive method.

What is the acute care setting indicated for in mental health care?

Intensive treatment and supervision in locked units for patients with severe mental illness. These facilities stabilize mental illness symptoms and promotes patient return to the community.

What are the nurse tasks involved in the orientation phase?

Introduce self and state purpose. Set contract of relationship. Discuss confidentiality. Build trust. Set goals. Explore patient's ideas, issues, and needs. Explore meaning of testing behaviors. Enforce limits on testing or other inappropriate behaviors.

What are the withdrawal manifestations of cannabis?

Irritability, agression, anxiety, *insomnia*, *decreased appetite*, *depression*, abdominal pain, diaphoresis, fever, HA.

What are symptoms of tobacco (nicotine) withdrawal?

Irritability, nervousness, restlessness, insomnia, difficulty concentrating

Communication. What is the purpose of focusing?

It helps the client concentrate on what is important.

What is dysthymic disorder?

It is a milder form of depression that usually has an early onset, such as in childhood or adolescence. Lasts at least *two years* in length in adults. May later become MDD later in life.

What is avolition?

It is a negative s/sx of schizophrenia. It is a lack of motivation in activities and hygiene.

What is alogia?

It is a negative s/sx of schizophrenia. It is poverty of speech or thought. The client may sit with a visitor but only mumble or respond vaguely to questions.

What is the mini-mental state examination?

It is an examination done to assess a client's cognitive status by evaluating the following: a. Orientation to time and place b. Attention span and ability to calculate by counting backward by seven c. Registration and recalling of objects d. Language: including naming objects, following commands, and ability to write

There are various clarifying techniques that can be used to enhance communication. What is restating?

It is restating the client's exact words. E.g. The client says, "I can't sleep, I stay up all night." The nurse utilizes the restating technique and says, "You are having difficulty sleeping?"

What is cognitive-behavioral therapy?

It uses both cognitive and behavioral approach to assist a client with *anxiety* management. E.g. dialectical behavioral therapy is used. Focuses on gradual behavioral changes with affirmation and validation.

Define fidelity:

LOYALTY and faithfulness to client and to one's duty.

What are characteristics of mania?

Labile mood with euphoria, agitation, restlessness, dislike of interference and intolerance of criticism, increase in talking and activity, decreased sleep, poor judgement, demanding and manipulative in behavior, distractability and decreased attention span, neglect of ADLs, denial of illness or problems. Flight of ideas- rapid, continuous speech with sudden and frequent topic changes. Impulsive- spending money, giving away possessions.

When does bipolar disorder usually emerge?

Late adolescence/early adulthood.

What is age of onset for schizophrenia?

Late teens and 20s. Diagnosis of schizophrenia can not be made for children until age 7 to rule out ADHD with violent tendencies.

What medications may be seen for the patient who is diagnosed with bipolar?

Lithium carbonate (Lithobid), anticonvulsants such as valproic acid (Depakote), clonazepam (Klonopin), lamotrigine (Lamictal), gabapentin (Neurontin) and topiramate (Topax). Benzos like Ativan for patients experiencing sleep impairment r/t mania. Antidepressants like SSRIs for MDD episodes.

Why do they recommend lithium not be used with an anticholinegic?

Lithium causes polyuria. Anticholinergics cause urinary retention. This will cause a great deal of abdominal pain.

What does Lithium do?

Lithium is used in the treatment of bipolar disorders. It controls episodes of acute mania, helps prevent the return of mania or depression, and decreases incidence of suicide.

MAOIs can treat depression and what other disorder?

MAOIs also treat Bulimia Nervosa.

What are the nurse tasks involved in the working phase?

Maintain relationship according to contract. Perform ongoing assessment to plan and evaluate therapeutic measures. Facilitate client's expression of needs and issues. Encourage patient to problem self. Promote patient's self esteem. Foster positive behavioral change. Explore and deal with resistance and other defense mechanisms that the patient has developed. Support adaptive alternatives and use of new coping skills. Remind about date and time of termination.

What are the intended effects of the benzodiazepines for detoxification from alcohol?

Maintenance of patient's v/s, decrease risk of seizures, decrease intensity of withdrawal s/s.

What is management of the milieu? Who does it?

Management of the milieu refers to the management of the total environment of the mental health unit in order to provide the least amount of stress, while promoting the greatest benefit for all the clients. Nurses manage the milieu.

What is alcohol withdrawal delirium? When can it occur?

May occur 2-3 days after cessation of alcohol and may last 2 to 3 days. Considered a *medical emergency.* S/sx include severe disorientation, psychotic symptoms, severe HTN, cardiac dysrythmias, delirium > death.

Teaching for lithium administration.

May take 1-2 weeks for full therapeutic effect to take place. Med may be administered in 2-3 doses daily d/t short half life. Take lithium with food to minimize GI distress. Narrow therapeutic range. Be sure to attend lab appointments. Stress importance of adequate sodium and fluid intake.

When should antidepressant medications take effect?

May take 1-3 weeks for medication to take effect. 2-3 months for max therapeutic effect.

What medications can be used to support withdrawal/abstinence from opioids?

Methadone (Dolophine) substition, Clonidine (Catapres), Buprenorphine (Subutex)

Define modeling: What type of therapy is it?

Modeling is when a therapist or others serve as a role model for the client, who initiates modeling to improve behavior. Can occur in acute care milieu to help improve interpersonal skills of patient. It is behavioral therapy.

What personality disorder is splitting most associated with?

Most commonly seen with DID or borderline personality disorder. People with splitting tend to characterize people or things as all good or all bad at any particular time.

Does clonidine (Catapres) reduce the craving for opioids?

What is the antidote to opioid toxicity?

Narcan. IV.

What are symptoms of alcohol withdrawal?

Nausea, vomiting, tremors, restlessness, insomnia, depressed mood or irritability, tonic-clonic seizures, illusions.

Decerebrate rigidity: define

Neck and elbow extension, wrist, and finger flexion. Found in a pt. that is comatose.

Nicotine Replacement Therapy intended effects Nicotine gum (Nicorette) Nicotine patch (nicotrol) Nicotine nasal spray (nicotrol NS)

Cessation nearly doubled with use of these.

Teaching points for patients using the nicotine gum (Nicorette)

Chew gum slowly and intermittently over 30 minutes. Avoid eating or drinking 15 min before and while chewing gum.

What kind of medications would be expected to be prescribed for a patient who is detoxing from alcohol?

Chlordiazepoxide (Librium), Diazepam (Valium), Lorazepam (Ativan), Oxazepam (Serax)

What are the chronic effects of cannabis use? What occurs when cannabis is taken in ^ amounts?

Chronic use: lung cancer, chronic bronchitis, other respiratory effects. In high doses, occurrence of paranoia w/ delusions/hallucinations. Expect dry mouth, euphoria , tachycardia, and "munchies."

Criteria to justify admission into acute care facility:

Clear risk of harm/danger to self or others. Failure of community based treatment Dangerous decline in mental health status of patient undergoing long term treatment. Patient who has medical need + mental illness.

What is the benefit of BuSpar?

No sedation (but there is drowsiness as a SE). No abuse potential.

Are withdrawl manifstations of amphetamine life threatening?

No. Expect craving, depression, fatigue, sleeping (similar to cocaine withdrawal).

Is cocaine withdrawal life threatening?

No. It is uncomfortable. Will have depression, fatigue, craving, unpleasant dreams, and agitation.

"Why" questions: therapeutic or nontheraputic?

Nontheraputic. Do not ask "why" questions. E.g. "Why do you want to give your money to me?"

First generation antipsycotic medications (conventional) treat positive symptoms, negative symptoms, or both?

Only positive. Reserved for clients who are violent, particularly aggressive, or are able to tolerate the SE.

What can naltrexone (Vivitrol) also be utilized for?

Opioid withdrawal.

Intended effect of methadone (Dolophine)

Oral opioid agonist that replaces the opioid to which client addicted. Encourage participation in 12 step program. Inform that must be administered at an approved treatment center.

What are the three phases of the nurse-client relationship?

Orientation: introduce self to client, state purpose, set goals with client, build trust, enforce boundaries Working: ongoing assessment, encourage client to problems solve, promote client self-esteem, foster positive behavioral change, allow clients to test new behaviors/alternative solutions Termination: provide an opportunity for client to discuss thoughts/feelings re. termination and loss, *summarize goals and achievements*, maintain limits of final termination, discuss ways to use new behaviors

Reaction formation.

Overcompensating or demonstrating the opposite of what behavior is felt. E.g. a person who dislikes her sister's daughter offers to babysit so that her sister can go out of town.

Hallucinogens: what are some of these drugs?

PCP (phencyclidine piperidine), LSD (lysergic acid diethylamide), and peyote. Can be orally ingested, injected, or smoked.

What are overall nursing interventions and teaching points for patients who are experiencing detoxification?

Pad the side rails and include suction equipment at bedside (seizure precautions). Monitor vital signs and continue monitoring on ongoing basis.

What would be an example of an antidepressant used for a client with psychosis also suffering from depression?

Paroxetine (Paxil)

Describe the use of SSRI's for the treatment of anxiety.

Paroxetine (Paxil) Sertraline (Zoloft) Escitalopram (Lexopro) Fluoxetine (Prozac) Fluoxamine (Luvox)

What is a contraindication for Chantix?

Patients with suicidal thoughts, serious mental illnesses, or have suicidal ideation.

Undoing.

Performing an act to make up for a prior behavior.

Describe the positive s/sx of schizophrenia.

Positive s/sx are r/t behavior (echopraxia), thought (hallucinations/illusions), and speech (word salad).

Health teaching: when should the health care provider avoid teaching?

Postpone health teaching until after acute anxiety subsides. Clients experiencing a panic attack/severe anxiety are unable to concentrate or learn.

Bad: Denial

Pretending the truth is not reality to manage the anxiety of acknowledging what is real.

What is response prevention?

Preventing a client from performing a compulsive behavior with the intent that the anxiety will diminish (don't let OCD patient wash hands after touching "dirty" object).

What is the primary level of prevention entail?

Promotes health and prevents mental health problems from occurring. Example: nurse Leads a group for parents of toddlers discussing normal toddler behavior and ways to promote healthy development.

Varenicline (Chantix) intended effects

Promotes release of dopamine to stimulate pleasurable effects of Chantix.

What are therapeutic milieu treatments for the patient who is in an acute care mental health facility?

Provide *safe environment.* Assess regularly for suicidal thought, intention, escalating behavior. Decrease stimulation. Implement frequent rest periods. Provide outlets for physical activity. Maintain self care needs. Identify rules and boundaries.

What are the nurse tasks involved in the termination phase?

Provide opportunity for patient to discuss thoughts about feelings of termination and loss. Discuss patient's previous experiences with separation and loss. Elicit client's feelings about therapeutic work in the nurse-patient relationship. Summarize goals and achievements (of the patient) Review memories of work in the sessions. Express own feelings about sessions to validate the experience with the client. Discuss ways for client to incorporate new healthy behaviors. Maintain limits of final termination.

Teaching points for patients using the nicotine nasal spray (Nicotrol NS)

Provides pleasurable effects of smoking due to rapid rise of nicotine in blood level. One spray q nostril is one cigarette. Advise to follow instructions and prescription for frequency.

Emergency involuntary commitment.

Client is most often hospitalized to prevent harm to self or others. Emergency commitment usually only lasts 10 days.

Involuntary commitment: can they refuse treatment?

Clients admitted under involuntary commitment can still refuse treatment (they are considered competent unless judged otherwise by the court).

Define autonomy:

Clients rights to make her own decisions. Must accept consequences of their own decisions and respect others' decisions.

Primary care (community setting)

Clinics, schools, day care centers, partial hospitalization programs, drug and alcohol treatment facilities, forensic settings, psychosocial rehabilitation programs, telephone crisis counseling centers, and home health care.

What are the 10 personality disorders and what how are they clustered? Explain cluster A.

Cluster A refers to odd or eccentric disorders. 1. Paranoid: distrust, suspiciousness toward others on unfounded beliefs that others want to harm or deceive the person 2. Schizoid: characterized by *emotional detachment*, disinterest in close relationships, *indifference* to praise/criticism; often uncooperative 3. Schizotypal: characterized by *odd beliefs* leading to interpersonal difficulties, an *eccentric appearance*, and *magical thinking/perceptual distortions* (not full blown delusions/hallucinations)

What types of behavior are seen during mania?

Psychotic, paranoid, and/or bizarre behavior.

What is the weight requirement to dx anorexia?

Pt. must be less than 85% below normal body weight.

Substance disorder and bipolar?

Pts. that have a substance abuse disorder tend to experience more rapid cycling of mania than those who do not.

Naltrexone (Vivitrol) What is the indicated effect?

Pure opioid antagonist that supresses craving and pleasure of alcohol.

Define Repression.

Putting unacceptable ideas, thoughts, and emotions *out of conscious awareness.* E.g. a person who is scared of the dentist always forgets his appointments.

Define beneficence:

Quality of doing good and can be described as charity.

What are the s/sx of toxicity with a serum lithium level greater than 2.5 mEq/l?

Rapid progression of manifestations leading to *coma and death.* Hemodialysis may be indicated.

Re-feeding syndrome: a complication for malnourished clients

Re-feeding syndrome is a potentially fatal complication that can occur when fluids, electrolytes, and carbohydrates are introduced to a severely malnourished client.

Group therapy: hidden agenda

Refers to group members who have a different goal than the stated group goals. The hidden agenda is often disruptive to the effective functioning of group.

Medication interactions with carbamazepine (Tegretol)?

Remember: Tegretol causes blood dyscrasias, teratogenesis, hypo-osmolarity... Do not use oral contraceptives or warfarin. Use alternate form of birth control. Do not use grapefruit juice. Do not use with phenytoin or phenobarbital (will decrease the effects of Tegretol).

What are the defense mechanisms used by pts. who have personality disorders?

Repression, suppression, regression, undoing, and splitting. Of these, splitting is the inability to incorporate positive and negative aspects of oneself into a whole image and is frequently seen in the acute setting.

Psychoanalysis. What are its core principles?

Resolving conflict, unconscious thoughts, ego, id, superego, focus on childhood experiences, past relationships often a focus of therapy. Not often used d/t the long course of treatment required.

What is response prevention?

Response prevention focuses on preventing the pt. from performing a compulsive behavior with the intent that anxiety will diminish.

What are manifestations of GAD?

Restlessness, muscle tension, avoidance of stressful activities or events, increased time/effort required to prepare for stressful activities or events, procrastination in decision making, seeking repeated assurance.

Review ALL QUESTIONS, chapter 15, pg. 131.

What rights do patients who have been hospitalized or diagnosed with a mental disorder have?

Rights that any other citizen has. These include: right to humane treatment and care, such as medical and dental care. Right to vote, right to due process of law.

Describe serotonin syndrome and precipitating factors.

S/sx are agitation, *confusion and disorientation*, anxiety, *hallucinations*, *hyperreflexia*, fever, diaphoresis, incoordination, tremors. Will occur within 2 to 72 hours after initiation of tx or in response to using a concurrent SSRI, *MAOI, or TCA*.

What are the s/sx of an overdose of a sedative/hypnotic (such as a benzodiazepine or barbiturate)?

S/sx: ^ drowsiness, agitation, slurred speech, uncoordinated motor activity, disorientation, N/V. *Respiratory depression and decreased LOC - fatal.*

What medications would be considered for eating disorders?

SSRIs such as fluoxetine (Prozac). Instruct client may take 1-3 weeks to take effect and up to 2 months for max effect. Avoid hazardous activities such as driving until individual SE are known.

In an acute manic episode what is the focus of nursing care?

Safety and maintaining the patient's physical health.

What is thought stoping?

Teaching a client, when negative thoughts occur, to say or shout "stop!" and substitute a positive thought. Goal is that overtime the client will command silently.

A nurse hears two nurses talking about a client's hallucinations in the hallway. What should the nurse do first?

Tell the nurses to stop discussing the behavior in a public place. This is the priority action. THEN, she can notify nurse manager.

Bad: Dissociation

Temporarily blocking memories and perceptions out of consciousness. E.g. An adolescent witnesses a shooting and can't remember any details of the event.

Describe involuntary commitment.

The client enters the mental health facility against his/her will. Commitment based on client's need for psych treatment, the risk of harm to self/others, and inability to provide self-care. Need for commitment may be determined by a judge or another entity.

When assessing a stuporous client, what should the nurse expect?

The client will arouse briefly in response to a sternal rub. A client who is stuporous requires vigorous or painful stimuli to elicit a response.

What are the two trauma and stressor-related disorders?

a. Acute stress disorders: exposure to traumatic event causes numbing, detachment, and amnesia about the event for *AT LEAST 3 days but less than 1 month*; distress when reminded of event b. PTSD: exposure to a traumatic event that causes intense fear, flashbacks, feelings of detachment and foreboding, restricted affect, *impairment for longer than ONE MONTH after event. May last for years.*; recurrent, *intrusive* recollection of the event

What are the atypical antipsycotics?

a. Arpiprazole (Abilify) - no weight gain b. Asenapine (Saphris) c. Clozapine (Clozaril) - agranulocytosis d. Iloperidone (Fanapt) e. Lurasidone (Latuda) - watch for Parkinsonism, akathesia f. Olanzapine (Zyprexa) - weight gain g. Paliperidone (Invega) h. Quetiapine (Seroquel) - cataracts i. Ziprasidone (Geodon)

What are four therapeutic tools of psychoanalysis?

a. Free association: spontaneous, uncensored verbalization of whatever comes to a client's mind b. Dream analysis and interpretation c. Transference: includes feelings that the client has developed towards the therapist in relation to similar feelings toward significant persons in the client's ealy childhood d. Defense mechanisms

MDD may be further diagnosed in the DSM-5 with a more specific classifier (specifier) such as...

a. MDD with psychotic disorders (presence of auditory hallucinations or delusions) d. Postpartum onset c. Seasonal characteristics (SAD, occurs in winter, treat with light therapy)

What are various roles people can take on in a group?

a. Maintenance roles - members who take on these roles help maintain the purpose and process of the group b. Task roles - members take on various tasks within the group process. E.g. the recorder who takes notes and records the group sessions c. Individual roles - tend to prevent teamwork; individuals who take on these roles promote their own agenda