Psychosocial Exam 2

Personality disorders are most likely caused by

a combination of biological and psychosocial factors.

Guidelines for Counseling People With Depression

- help pt question underlying assumptions, consider alt. explanations to problems - identify cognitive distortions that result in a negative self perception - encourage exercise - encourage support systems - provide referrals

Auditory hallucinations

"hearing voices" Positive symptom of a serious mental illness May be critical, complementary, or neutral -Command hallucinations- may be disturbing and harmful May be male, female, without gender; child, adult; human, non-human Possible causes- -Physical or mental illness -Sleep deprivation -Grief or bereavement -Substance use -Bullying or abuse -Other traumatic experiences

Affect and Mood

- Affect is the emotional state as it appears to others. - Mood is the emotional state as described by the patient. - Observe the patient's facial expression. - No part of the body is as expressive as the face. - Feelings of joy, sadness, fear, surprise, anger, and disgust are conveyed by facial expression. - Facial expressions generally are not consciously controlled.

Cannabis - Treatment

-Abstinence and support are the main principles -Anti-anxiety meds can be used for short-term relief of withdrawal symptoms

Commonly Abused Substances - CNS Depressants

-Alcohol -Cannabinoids -Sedative/Hypnotic/Anxiolytic/Club drug

Schizophrenia - 2nd generation antipsychotics

-Atypical -Dopamine/serotonin antagonist -FIRST LINE MED Treat positive + & negative - symptoms -olanzapine (Zyprexa) -risperidone (Risperdal) -quetiapine (Seroquel) -ziprazidone (Geodon) -aripiprazole (Abilify) -clozapine (Clozaril)- not the 1st choice due to side effects Client and family education •Do not stop drug abruptly •Use sunscreens & protective clothing when outdoors •If receiving clozapine therapy- weekly blood levels drawn (to obtain a weekly supply of the drug) •Risks of taking antipsychotics during pregnancy •No drinking alcohol with antipsychotic therapy •Do not consume other medications (including over-the-counter drugs) without the healthcare provider's knowledge

Sedative, Hypnotic, Anti-Anxiety Meds

-CNS Depressant -Intended effect = decreased anxiety, sedation -All prescription sleeping meds --Benzodiazepines: diazepam --Benzodiazepine-like drugs --Carbamates --Barbiturates --Barbiturate-like hypnotics --Flunitrazepam "date rape"

Cannabis (Marijuana) - Cannabinoids

-CNS Depressant -Intended effect = euphoria, sedation, select medical conditions -Most widely used illegal drug in the world -Fourth most commonly used psychoactive drug in the United States after caffeine, alcohol, and nicotine -CBD does not cause intoxication, THC does

Opioids

-CNS Depressant -Intended effect = pain relief, euphoria -Heroin, Morphine, Fentanyl, others

Alcohol

-CNS Depressant -Intended effect = relaxation, reduced stress/anxiety levels -Sedative creating an initial feeling of euphoria -Decreased inhibitions -Binge-drinking versus heavy drinking -Intoxication and withdrawal -Alcohol-induced -Amnestic disorder - up and doing things then don't remember doing them a day or two later "blackouts" -Fetal alcohol syndrome: intellectual disability

Hallucinogens

-CNS Stimulant -Intended effect = altered perceptions, reality disturbances -PCP (phencyclidine), LSD (lysergic acid diethylamide), mescaline (peyote) -Cause a profound disturbance in reality -Natural or synthetic -Schedule 1 - have no medical use and have high abuse potential

Inhalants

-CNS Stimulant -Intended effect = euphoria -Nitrous oxide, paint thinner, aerosol sprays, solvents for glues and adhesives, propellants, fuels

Schizophrenia planning - acute phase of care

Hospitalization -Manage safety needs (perceived threats & agitation) -Structured milieu (physical & interpersonal) -Medication and response (dosing, route & "cheeking" pills)

Caffeine

-CNS Stimulant -Intended effect = increased alertness -Most widely used psychoactive substance in the world -Can result in intoxication, overdose, and withdrawal -Not an official use disorder Excessive use is associated with many psychiatric problems like bipolar, eating, and sleep disorders

Stimulants

-CNS Stimulant -Intended effect = pleasure, euphoria, increased energy -Amphetamine-type, cocaine, or other stimulant drugs -Second only to cannabis as the most widely used illicit substances in the United States -Disorder can occur in as little as a week of use!

Tobacco

-CNS Stimulant -Intended effect = relaxation, reduced anxiety -Cigarettes (most commonly used), tobacco, smokeless tobacco -Dependence happens quickly

Commonly Abused Substances - CNS Stimulants

-Caffeine -Cocaine -Amphetamines -Hallucinogens -Inhalants -Opioids -Tobacco

Schizophrenia outpt tx

-Community-based centers -Assertive community treatment -Support groups -Vocational -Housing services -Organizational resources (e.g., NAMI) Recovery model promotes empowerment and support Considerations -Stigmas -Social isolation -Victimization -Finances, access, and housing -Caregiver strain

Personality Disorders Clinical Picture

-Complex and challenging disorders to understand and treat -Must assess the individual's entire background -Problems are the result of others, or unaware problems exist Difficulty with: Self-identity Self-direction Lack of: Empathy Intimacy

Other treatment approaches

-Court involved intervention -Consumer-run programs -Peer support -Technology -Exercise

Substance abuse - nursing process

-Detoxification (detox) - (most intensive) -Rehabilitation -Halfway houses -Other housing -Partial hospitalization -Intensive outpatient (IOP) treatment -Outpatient treatment -Alcoholics Anonymous (AA) -Relapse prevention - (least intensive)

Schizophrenia - 1st generation anti-psychotics

-Dopamine antagonist Treat positive + symptoms -chlorpromazine (Thorazine)- low potency -haloperidol (Haldol)- high potency Client and family education •Do not stop drug abruptly •Use sunscreens & protective clothing when outdoors •If receiving clozapine therapy- weekly blood levels drawn (to obtain a weekly supply of the drug) •Risks of taking antipsychotics during pregnancy •No drinking alcohol with antipsychotic therapy •Do not consume other medications (including over-the-counter drugs) without the healthcare provider's knowledge

Consequences of sleep loss

-Excessive sleepiness: major consequence of acute or chronic sleep reduction -Sleep deprivation: accompanied by impaired functioning -Mental and physical problems -Psychomotor impairment: diminished safety, can look like alcohol intoxication -Increased risk for errors -Obesity, DM, increased appetite

Gambling Disorder Tx

-Gamblers Anonymous -Hospitalization may help remove pts from environments -SSRI's, bupropion, lithium, and anticonvulsants may be helpful -Severe: naltrexone

Sedative, Hypnotic, Anti-Anxiety, Club drugs - Overdose Tx

-Gastric lavage, activated charcoal, careful VS monitoring -Keep pts awake to prevent loss of consciousness -If unconscious, IV line should be established -ET tube may be required to maintain airway or mech vent may be needed

Caffeine - Treatment

-Hydration via oral or IV -Gastric lavage may be used to remove excess or activated charcoal -Beta Blockade for tachycardia -Vasodilators for BP maintenance w/o worsening tachycardia

Stimulant - Withdrawal Tx

-Inpt setting usually necessary -Antipsychotics may be prescribed for a few days -Diazepam for agitation and hyperactivity -Depression can be treated with bupropion once the pt has been withdrawn

Antipsychotics S/E

-Metabolic syndrome -Prolonged QT interval (get pre-EKG) Extrapyramidal effects -Abnormal Involuntary Movement Assessment (AIMS) -Treat with antiparkinsonian agents- trihexyphenidyl (Artane), benzotropine (Cogentin) Potentially fatal effects -Neuroleptic malignant syndrome -Agranulocytosis- neutropenia (clozapine) -Anticholinergic toxicity- bowel obstruction, altered mental status

Alcohol - Systemic effects

-Peripheral neuropathy -Alcoholic myopathy and cardiomyopathy -Esophagitis, gastritis, and pancreatitis -Alcoholic hepatitis -Cirrhosis of the liver -Leukopenia -Thrombocytopenia -Cancer (head and neck)

Hallucinogen - Intoxication Tx

-Talk the pt down, reassure that the symptoms are caused by the drug and they will go away -Physical restraint may be neccessary -Severe: haloperidol or benzos like diazepam can be used short term

Types of Grief

-Uncomplicated -Persistent Complex Bereavement Disorder -Disenfranchised -Anticipatory

Alcohol use assessment

-What substance? -What amount? (ounces and strength) -What timeframe? (use history/ per day/week) -When last use? (consider for withdrawal)

Treatment Modalities for Depression

-biological treatments: pharmacotherapy -brain stimulation therapies: electroconvulsive therapy, repetitive transcranial magnetic stimulation, vagus nerve stimulation, deep brain stimulation -other therapeutic modalities: light therapy, exercise -psychological therapies: individual therapy, group therapy

Depression

-can exist along or in conjunction w/other disorders or illnesses. -presents differently in different populations and in different age groups -consists on a continuum from mild to severe -has a neg impact on physical well-being and the course of other medical diagnoses

Epidemiology of Major Depressive Disorder

-leading cause of disability worldwide -about 17 million adults had at least one major depressive episode in 2017 -about 7% of all US adults -prevalence of depression was higher among adult females (8.7%) compared to males (5.3%) -young adults (18-25yrs) seem to be affected the most with a rate of 13.1% -having two or more races or being white results in higher rates of depression

Depressive Disorders: Older Adults

-not a typical sign of the aging process -bereavement overload -high percentage of suicides among older adults -symptoms of depression often confused with symptoms of a neurocognitive disorder

Developmental Landmarks and Task for the End of Life

-sense of completion with worldly affairs -Sense of completion in relationships with community -Sense of meaning about one's individual life -Experienced love of self -Experienced love of others -Sense of completion in relationships with family and friends -Acceptance of the finality of life and of one's existence as an individual -Sense of a new self (personhood) beyond personal loss -Sense of meaning about life in general -Surrender to the transcendent, to the unknown; "letting go"

Therapeutic Factors in Group Therapy

-universality -instillation of hope -imparting information -altruism -corrective recapitulation of the primary family group -development of socializing techniques -imitative behavior -interpersonal learning -group cohesiveness -catharisis -existential factors

Guidelines for Communication With Severely Withdrawn Persons

-when a pt is silent, use the technique of making observations -use simple, concrete words -allow time for the pt to respond -listen for covert messages, and ask about suicide plans -avoid platitudes such as "Things will look up" or "everyone gets down once in a while"

Tobacco - Withdrawal Tx

1) Nicotine Replacement - Gums, Patch, Spray 2) Buproprion (Welbutrin, Zyban) - Mild Stimulants, Blocking Uptake of NE and Dopamine, reduces cravings and s/s 3) Behavioral therapy - recognize cravings and how to respond to them correctly 4) Hypnosis 5) Varenicline - partial agonist that mimics effects of nicotine reducing cravings and withdrawal

Alcohol Tx

1. Alcoholics anonymous is best treatment 2. Disulfiram (antabuse)-good for short term, causes alcohol toxification when alcohol ingested 3. Naltrexone (Trexan) - improve abstinence, reduce cravings 4. Drugs for withdrawal- benzodiazepine (diazepam for long acting use) 5. Correct fluids, vitamin supplements (thiamine, folate, multivitamin) 6. Carbamazepine - for withdrawals, therapeutic level of 4-12 mg/L

Depression Implementation Phases

1. acute phase (6-12wks) directed at reduction of depressive symptoms and restoration of psychosocial and work function 2. continuation phase (4-9mos) directed at prevention of relapse through pharmacotherapy, education, and depression-specific psychotherapy 3. maintenance phase (1yr or more) of tx is directed at prevention of further episodes of depression.

Schizophrenia inpt tx

24-hour support -Acute setting for medical stabilization as needed -Inpatient mental health (voluntary or involuntary) Recovery model promotes empowerment and support Considerations -Stigmas -Social isolation -Victimization -Finances, access, and housing -Caregiver strain

Personality Clusters

Cluster A: Odd/Eccentric Behavior - Paranoid, Schizoid, Schizotypal Cluster B: Dramatic/Erratic Behavior - Histrionic, Narcissistic, Antisocial, Borderline Cluster C: Anxious/Fearful Behavior - Avoidant, Dependent, Obsessive-Compulsive

Hospice Care

offers compassionate care for those who are dying, generally during the last 6 months of life. It focuses on patients' physical and emotional comfort and offers holistic support for dying people and their families.

Schizophrenia

6 disorders on the schizophrenia spectrum -Serious mental illness -"fragmented pattern of thinking" Affects how an individual thinks, makes decisions, feels, behaves, and interact with others DSM-V criteria for diagnosis (p. 193) -At least 2 symptoms prominent in a 1-month period over the course of 6 months Treatable; can become disabling if left untreated Stigma is high which contributes to discrimination and violation of human rights is common in mental health institutions and in communities One of the top 15 leading causes of disability worldwide

Which statement made by the psychiatric nurse demonstrates an accurate understanding of the factors that affect an individual's personality? a. "Therapy will help her identify that her problems are personality related." b. "I'll need to learn more about this patient's cultural beliefs." c. "It's encouraging to know that personality disorders respond well to treatment." d. "A person's personality is fluid and adjusts to current social situations."

Answer: B

complementary and alternative medicine (CAM)

A diverse set of approaches and therapies for treating illness and promoting well-being that generally falls outside standard medical practices

d. She should experience a reduction in hallucinations.

A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms? a. Her memory problems will likely decrease. b. Depressive episodes should be less severe. c. She will probably enjoy social interactions more. d. She should experience a reduction in hallucinations.

Regulation of sleep

Complex interaction between two processes -Homeostatic process or sleep drive - promotes sleep -Circadian process or circadian drive - promotes wakefulness, near 24 hour cycles of behavior influenced by: --Endogenous factors --Exogenous factors The longer the period of wakefulness, the stronger the sleep drive

Ted, a former executive, is now unemployed due to manic episodes at work. He was diagnosed with bipolar I disorder 8 years ago. Ted has a history of IV drug use, which resulted in hepatitis C. He is taking his lithium exactly as scheduled, a fact that both Ted's wife and his blood tests confirm. To reduce Ted's mania, the psychiatric nurse practitioner recommends: a. Clonazepam (Klonopin) b. Fluoxetine (Prozac) c. Electroconvulsive therapy (ECT) d. Lurasidone (Latuda)

Answer: C

When a nurse uses therapeutic communication with a withdrawn patient who has major depressive disorder, an effective method of managing the silence is to: a. Meditate in the quiet environment b. Ask simple questions even if the patient will not answer c. Use the technique of making observations d. Simply sit quietly and leave when the patient falls asleep

Answer: C

b. Manage the patient's withdrawal symptoms well.

A patient diagnosed with opioid use disorder has expressed a desire to enter into a rehabilitation program. What initial nursing intervention during the early days after admission will help ensure the patient's success? a. Restrict visitors to family members only. b. Manage the patient's withdrawal symptoms well. c. Provide the patient a low-stimulus environment. d. Advocate for at least 3 months of treatment.

d. Encouraging the patient to use competing auditory stimuli, such as humming or listening to music.

A patient reports that "the voices are really bad today." Helpful nursing responses would include a. Giving an additional "as needed" dosage of his antipsychotic medication. b. Telling him that the voices are not real and that he should ignore them. c. Directing him to return to his room and try not to think about the voices. d. Encouraging the patient to use competing auditory stimuli, such as humming or listening to music.

Addiction

A term people commonly use to describe substance use disorders -chronic medical condition with roots in the env, neurotransmission, genetics, and life experiences -progressive and may end in disability or premature death -unable to abstain from the substance or activity Chronic, cycles of relapse and remission, progressive, without tx = disability or premature death

Which factor has the greatest influence on the hospice nurse's ability to provide respectful professional care? a. Acceptance that death is a natural part of life. b. Possession of excellent caregiving nursing skills. c. The existence of a healthy, well-balanced personal life. d. The desire to work with both the patient and the family.

Answer: C

Valproate (Depakote)

Anticonvulsant MOA: •Increases levels of GABA Therapeutic Uses: •Acute mania, prevention Side Effects: •N/V, GI concerns, dizziness, tremors, hepatotoxicity, pancreatitis, somnolence Education: •Monitor therapeutic levels, liver function and platelet counts

Iamotrigine (Lamictal)

Anticonvulsant MOA: •Modulates release of glutamate and aspartate Therapeutic Uses: •Maintenance therapy > 18 years old Side Effects: •N/V, headache, dizziness, double vision, ataxia, somnolence, rash •Stevens-Johnson syndrome, toxic epidermal necrolysis Education: •Not indicated for acute episodes of mania

Which nursing intervention focuses on managing a common characteristic of major depressive disorder associated with the older population? a. Conducting routine suicide screenings at a senior center. b. Identifying depression as a natural, but treatable result of aging. c. Identifying males as being at a greater risk for developing depression. d. Stressing that most individuals experience just a single episode of major depressive disorder in a lifetime.

Answer: A

Substance use problems or disorders are often present in people diagnosed with bipolar disorder. Laura, a 28-year-old with a diagnosis of bipolar disorder, drinks alcohol instead of taking her prescribed medications. The nurse caring for this patient recognizes that: a. Anxiety may be present. b. Alcohol ingestion is a form of self-medication. c. The patient is lacking a sufficient number of neurotransmitters. d. The patient is using alcohol because she is depressed.

Answer: B

Tatiana has been hospitalized for an acute manic episode. On admission, the nurse suspects lithium toxicity. What assessment findings would indicate the nurse's suspicion as correct? a. Shortness of breath, gastrointestinal distress, chronic cough b. Ataxia, severe hypotension, large volume of dilute urine c. Gastrointestinal distress, thirst, nystagmus d. Electroencephalographic changes, chest pain, dizziness

Answer: B

The biological approach to treating depression with electrodes surgically implanted into specific areas of the brain to stimulate the regions identified to be underactive in depression is: a. Transcranial magnetic stimulation b. Deep brain stimulation c. Vagus nerve stimulation d. Electroconvulsive therapy

Answer: B

What is the major reason for the hospitalization of a depressed client? A. Inability to go to work B. Suicidal ideation C. Psychomotor agitation D. Loss of appetite

Answer: B

Cognitive Enhancement Therapy

Also known as cognitive training, treatment that seeks to improve basic cognitive functions such as verbal learning ability in people with schizophrenia, meanwhile reducing symptoms as well. -computer based drills and group exercises

Assertive Community Treatment (ACT)

An intensive type of case management for people with serious, persistent psychiatric symptoms. Repeated hospitalizations are reduced through a multidisciplinary team that provides a comprehensive array of services.

Which statement made by a patient demonstrates acceptance of criteria required of hospice care? a. "I want my family to be with me." b. "There is no cure for my illness. I've accepted that." c. "It's important to me that I die in my own home." d. "I don't want my family to bear the burden of caring for me."

Answer: B

A bereavement group run by a local hospice includes a woman who is distraught over her supervisor's death. The woman appears severely distressed. She has trouble functioning with activities of daily living and making the simplest of decisions. The group facilitator recognizes that this woman is suffering from disenfranchised grief after learning: a. The woman was in love with her married supervisor. b. She has not taken enough time off work to grieve properly. c. The supervisor died over a year ago. d. Her family is not involved enough to support her.

Answer: A

Connor is a 28-year-old student, referred by his university for a psychiatric evaluation. He reports that he has no friends at the university and that people call him a loner. Connor has recently been "giving lectures" to pigeons at the university fountains. He is diagnosed as schizotypal, which differs from schizophrenia in that persons diagnosed as schizotypal a. Can be made aware of their delusions b. Are far more delusional than schizophrenics c. Have a greater need for socialization d. Do not usually respond to antipsychotic medications

Answer: A

Holly is a 53-year-old female with terminal breast cancer. Holly's nurse in the hospital brings up the subject of hospice care. Holly becomes upset and states, "I am not ready to give up and die." You respond that hospice is: a. A model of healthcare that emphasizes quality of life for you and your family. b. The end of curative treatments and pain management. c. A multidisciplinary team providing curative and therapeutic treatment. d. An aggressive medical plan to end suffering and hasten death.

Answer: A

Tammy, a 28-year-old with major depressive disorder and bulimia nervosa, is ready for discharge from the county hospital after 2 weeks of inpatient therapy. Tammy is taking citalopram (Celexa) and reports that it has made her feel more hopeful. With a secondary diagnosis of bulimia nervosa, what is an alternative antidepressant to consider? a. Fluoxetine (Prozac) b. Isocarboxazid (Marplan) c. Amitriptyline d. Duloxetine (Cymbalta)

Answer: A

Two months ago, Natasha's husband died suddenly and she has been overwhelmed with grief. When Natasha is subsequently diagnosed with major depressive disorder, her daughter, Nadia, makes which true statement? a. "Depression often begins after a major loss. Losing dad was a major loss." b. "Bereavement and depression are the same problem." c. "Mourning is pathological and not normal behavior." d. "Antidepressant medications will not help this type of depression."

Answer: A

What is the current accepted professional view of the effect of culture on the development of a personality disorder? a. There are not enough studies to confirm the role that ethnicity and race have on the prevalence of personality disorders. b. The North American and Australian cultures produce higher incidences of personality disorders within their populations. c. Neither culture nor ethnic background is generally considered in the development of personality disorders. d. Personality disorders have been found to be primarily the products of genetic factors, not cultural factors.

Answer: A

Which chronic medical condition is a common trigger for major depressive disorder? a. Pain b. Hypertension c. Hypothyroidism d. Crohn disease

Answer: A

Carbamazepine (Tegretol)

Anticonvulsant MOA: •Reduces sodium channel activity Therapeutic Uses: •Acute mania, mixed episodes Side Effects: •N/V, GI concerns, dizziness, somnolence, blurred vision, leukopenia, aplastic anemia •Stevens-Johnson syndrome, toxic epidermal necrolysis Education: •Monitor CBC, liver, platelet counts •Monitor blood count for first 8 weeks

The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include what characteristics? A. Socially anxious, rambling stories, peculiar ideas B. Arrogant, grandiose and a sense of self importance C. Impulsive, restless, socially aggressive behavior D. Attention seeking, melodramatic, and flirtatious

Answer: A Rationale: Individuals with schizotypal personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The other behaviors would characteristically be noted in narcissistic, histrionic, and antisocial personality disorder.

Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the best nursing response? A. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. B. Clients diagnosed with schizoid personality disorder exhibit delusions and hallucinations, while clients diagnosed with avoidant personality disorder do not. C. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant. D. Clients diagnosed with schizoid personality disorder have a history of psychosis, while clients diagnosed with avoidant personality disorder remain based in reality.

Answer: A Rationale: The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, while clients diagnosed with schizoid personality disorder prefer to be alone. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder may exhibit odd and eccentric behaviors.

Which personality disorders are generally associated with behaviors described as "odd or eccentric"? Select all that apply. a. Paranoid b. Schizoid c. Histrionic d. Obsessive-compulsive e. Avoidant

Answer: A, B

Which behaviors are examples of a primitive defense mechanism often relied upon by those diagnosed with a personality disorder? Select all that apply. a. Regularly attempts to split the staff b. Attempts to undo feelings of anger by offering to do favors c. Regresses to rocking and humming to sooth self when fearful d. Lashes out verbally when confronted with criticism e. Destroys another person's belongings when angry

Answer: A, B, C

Which statement made by a widow demonstrates that her grief work has been effective? Select all that apply. a. "I can remember how much my deceased husband loved chocolate chip ice cream." b. "Painting is my new passion, and I really enjoy learning the various strokes." c. "Jim could be very stubborn when he thought he was right." d. "I don't know why he had to die." e. "I just can't believe he's gone."

Answer: A, B, C

A client with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. A.Offer laxatives as needed. B.Monitor food and fluid intake. C.Provide a quiet sleep environment. D.Encourage physical activity during the day. E.Restrict intake of processed foods.

Answer: A, B, C, D

Which statement made by the patient demonstrates an understanding of the effective use of newly prescribed lithium to manage bipolar mania? Select all that apply. a. "I have to keep reminding myself to consistently drink six 12-ounce glasses of fluid every day." b. "I discussed the diuretic my cardiologist prescribed with my psychiatric care provider." c. "Lithium may help me lose the few extra pounds I tend to carry around." d. "I take my lithium on an empty stomach to help with absorption." e. "I've already made arrangements for outpatient lithium level monitoring."

Answer: A, B, E

Which intervention should the nurse implement when caring for a patient demonstrating manic behavior? Select all that apply. a. Monitor the patient's vital signs frequently. b. Keep the patient distracted with group-oriented activities. c. Provide the patient with frequent milkshakes and protein drinks. d. Reduce the volume on the television and dim bright lights in the environment. e. Use a firm but calm voice to give specific concise directions to the patient.

Answer: A, C, D, E

Which nursing response demonstrates accurate information that should be discussed with the female patient diagnosed with bipolar disorder and her support system? Select all that apply. a. "Remember that alcohol and caffeine can trigger a relapse of your symptoms." b. "Due to the risk of a manic episode, antidepressant therapy is never used with bipolar disorder." c. "It's critical to let your healthcare provider know immediately if you aren't sleeping well." d. "It will be helpful for your family to understand the management of this disorder." e. "The symptoms tend to come and go and so you need to be able to recognize the early signs."

Answer: A, C, D, E

A client prescribed fluoxetine demonstrates an understanding of the medication teaching when making which statement? A. "I will not take any over-the-counter medication while on the fluoxetine." B. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." C. "I will report increased thirst and urination to my provider." D. "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction."

Answer: B

A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially? a. Reinforce that the level is considered therapeutic. b. Instruct the patient to hold the next dose of medication and contact the prescriber. c. Have the patient go to the hospital emergency department immediately. d. Alert the patient to the possibility of seizures and appropriate precautions.

Answer: B

Josie, a 27-year-old patient, complains that most of the staff do not like her. She says she can tell whether you are a caring person. Josie is unsure of what she wants to do with her life and her "mixed-up feelings" about relationships. When you tell her that you will be on vacation next week, she becomes very angry. Two hours later, she is found using a curling iron to burn her underarms and explains that it "makes the numbness stop." Given this presentation, which personality disorder would you suspect? a. Obsessive-compulsive b. Borderline c. Antisocial d. Schizotypal

Answer: B

Personality disorders often co-occur with mood and eating disorders. A young woman is undergoing treatment at an eating disorders clinic and her nurse suspects that she may also have a cluster B personality disorder because of her a. Desire to avoid eating b. Dramatic response to frustration c. Excessive exercise routine d. Morose personality traits

Answer: B

A client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility and has a behavioral pattern of suffering in silence. Which statement best explains the etiology of this client's personality disorder? A. Childhood nurturance was provided from many sources, and independent behaviors were encouraged. B. Childhood nurturance was provided exclusively from one source, and independent behaviors were discouraged. C. Childhood nurturance was provided exclusively from one source, and independent behaviors were encouraged. D. Childhood nurturance was provided from many sources, and independent behaviors were discouraged.

Answer: B Rationale: The behaviors presented in the question represent symptoms of dependent personality disorder. Nurturance provided from one source & discouragement of independent behaviors can contribute to the development of this personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective & discourages autonomy.

When preparing to interview a client diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include which characteristics? A. Charm, drama, seductiveness, seeking admiration B. Grandiosity, self-importance, and a sense of entitlement C. Preoccupation with the minute details, perfectionist D. Difficulty being alone: indecisive, submissive

Answer: B Rationale: The characteristics of grandiosity, self-importance, and entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are seen in clients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Clients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

What personality traits are most likely to be documented by a client demonstrating characteristics of an obsessive-compulsive personality disorder (OCPD)? A. Suspicious, holds grudges B. Perfectionist, inflexible C. Affable, generous, dramatic speech, impulsive D. Dramatic speech, impulsive

Answer: B Rationale: The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD.

What is an appropriate initial outcome for a client diagnosed with a personality disorder who frequently manipulates others? A. The client will accept fulfillment of his or her requests within an hour rather than immediately. B. The client will acknowledge manipulative behavior when it is called to his or her attention. C. The client will identify when feeling angry. D. The client will use manipulation only to get legitimate needs met.

Answer: B Rationale: This is an early outcome that paves the way for later taking greater responsibility for controlling manipulative behavior. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The client would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control

A client says to the nurse, "My life does not have any happiness in it anymore. I once enjoyed holidays, but now they are just another day." The nurse documents this statement as an example of: A.dysthymia. B.anhedonia. C.euphoria. D.anergia.

Answer: B anhedonia

Which assessment question asked by the nurse demonstrates an understanding of comorbid mental health conditions associated with major depressive disorder? Select all that apply. a. "Do rules apply to you?" b. "What do you do to manage anxiety?" c. "Do you have a history of disordered eating?" d. "Do you think that you drink too much?" e. "Have you ever been arrested for committing a crime?"

Answer: B, C, D

Which characteristic identified during an assessment serves to support a diagnosis of disruptive mood dysregulation disorder? Select all that apply. a. Female b. 7 years old c. Comorbid autism diagnosis d. Outbursts occur at least once a week e. Temper tantrums occur at home and in school

Answer: B, C, E

A 33-year-old female diagnosed with bipolar I disorder has been functioning well on lithium for 11 months. At her most recent checkup, the psychiatric nurse practitioner states, "You are ready to enter the maintenance therapy stage, so at this time I am going to adjust your dosage by prescribing _______": a. A higher dosage b. Once a week dosing c. A lower dosage d. A different drug

Answer: C

A 38-year-old client is admitted with major depression. Which statement made by the client alerts the nurse to a common accompaniment to depression? A. "I still pray and read my Bible every day." B. "I've heard others say that depression is a sign of weakness." C. "I still feel bad about my sister dying of cancer. I should have done more for her!" D. "My mother wants to move in with me, but I want to independent."

Answer: C

A client admitted with major depression and suicidal ideation with a plan to overdose is preparing for discharge and asks you, "Why did I get a prescription for only 7 days of amitriptyline?" The nurse's response is based on what fact? A. Amitriptyline is very expensive, so the client may have to buy fewer at a time. B. The health care provider wants to see whether any side effects occur within the first week of administration. C. Amitriptyline is lethal in overdose. D. The goal is to see how the client responds to the first week of medication to evaluate its effectiveness.

Answer: C

A client is started on fluoxetine 20 mg by mouth every morning. Which client statement indicates that they understand the medication teaching the nurse provided? A."I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction." B."I will not take any over-the-counter medication while on the fluoxetine." C."I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." D."I will report increased thirst and urination to my provider."

Answer: C

Garret's wife of 8 years is divorcing him because their marriage never developed a warm or loving atmosphere. Garrett states in therapy, "I have always been a loner," and says that he was never concerned about what others think. The nurse practitioner suggests that Garrett try a trial of bupropion (Wellbutrin) to a. Improve his flat emotions b. Help him to get a good night's sleep c. Increase the pleasure of living d. Prepare Garrett for group therapy

Answer: C

Cabot has multiple symptoms of depression, including mood reactivity, social phobia, anxiety, and overeating. With a history of mild hypertension, which classification of antidepressants dispensed as a transdermal patch would be a safe medication? a. Tricyclic antidepressants b. Selective serotonin reuptake inhibitors c. Serotonin and norepinephrine reuptake inhibitors d. Monoamine oxidase inhibitor

Answer: D

Larry is from a small town and began displaying aggressive and manipulative traits while still a teenager. Now 40 years old, Larry is serving a life sentence for the murders of his wife and her brother. John, the prison psychiatric nurse practitioner, recognizes that Larry's treatment will most likely a. Transform Larry to a model prisoner b. Not improve Larry's coping skills c. Reaffirm Larry's high-risk behaviors d. Manifest as small incremental changes

Answer: D

Luc's family comes home one evening to find him extremely agitated and they suspect in a full manic episode. The family calls emergency medical services. While one medic is talking with Luc and his family, the other medic is counting something on his desk. What is the medic most likely counting? a. Hypodermic needles b. Fast food wrappers c. Empty soda cans d. Energy drink containers

Answer: D

When assessing a patient diagnosed with a borderline personality disorder, which statement by the patient warrants immediate attention? a. "My mother died ten years ago." b. "I haven't needed medication in weeks." c. "My dad never loved me." d. "I'd really like to hurt her for hurting me."

Answer: D

When the nurse asks whether a client is having any thoughts of suicide, the client becomes angry and defensive, shouting, "I'm sick of you people! All you ever do is ask me the same question over and over. Get out of here!" What fact concerning hostility should the nurse's response be based upon? A. The client is probably experiencing transference. B. The client may be angry at someone else and projecting that anger to staff. C. The client is getting better and is able to be assertive. D. The client may be at high risk for self-harm.

Answer: D

Which response by a 15-year-old demonstrates a common symptom observed in patients diagnosed with major depressive disorder? a. "I'm so restless. I can't seem to sit still." b. "I spend most of my time studying. I have to get into a good college." c. "I'm obsessed with counting telephone poles as I drive by them." d. "I go to sleep around 11 p.m. but I'm always up by 3 a.m. and can't go back to sleep."

Answer: D

What is the priority intervention for a nurse beginning to work with a client diagnosed with a schizotypal personality disorder? A. Engage the client in community activities B. Teach the client how to select clothing for outings C. Prevent the client from violating the nurse's rights D. Respect the client's need for periods of social isolation

Answer: D Rationale: Clients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the client to match clothing is not the priority intervention. Clients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse.

1. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings to address the client's needs and maintain a therapeutic milieu? A. Ability to achieve true intimacy B. Flexibility and adaptability to stress C. Inability to develop trusting relationships D. Ability to provoke interpersonal conflict

Answer: D Rationale: Frequent team meetings are held to counteract the effects of the client's attempts to split staff and set them against one another, causing interpersonal conflict (safety). Clients with personality disorders may be inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings for safety.

A nurse set limits while interacting with a client demonstrating behaviors associated with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be documented using what term? A. Reaction Formation B. Defensive C. Denial D. Splitting

Answer: D Rationale: Splitting involves loving a person, then hating the person because the client is unable to recognize that an individual can have both positive and negative qualities. Denial is unconsciously motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. The scenario does not indicate defensiveness.

As a nurse prepares to administer medication to a client diagnosed with a borderline personality disorder, the client says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? A. Ask the client, "Why don't you want to take your medication now?" B. Reinforce this assertive action by the client. Leave medication on the table as requested. C. Respond to the client, "I'm worried that you might not take it. I will come back later." D. Say to the client, "I must watch you. Please take it now."

Answer: D Rationale: The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital not only for the client's safety, but also to prevent splitting other staff. "Why" questions are not therapeutic.

The nurse is providing medication education to a patient who has been prescribed lithium to stabilize mood. Which early signs and symptoms of toxicity should the nurse stress to the patient? Select all that apply. a. Increased attentiveness b. Getting up at night to urinate c. Improved vision d. An upset stomach for no apparent reason e. Shaky hands that make holding a cup difficult

Answer: D, E

Additional Therapies in Bipolar Tx

Antianxiety medications (acute mania) •clonazepam (Klonopin) •lorazepam (Ativan) Second-generation antipsychotics (acute mania) •olanzapine (Zyprexa) •risperidone (Risperdal) •quetiapine (Seroquel) Integrative therapy •fish oil, cod liver oil (omega-3 fatty acids) Electroconvulsive therapy •Bipolar with severe depression •Post-procedure: monitor vital signs, level of consciousness

Avoidant Personality Disorder

Anxiety in society, hypersensitive to feedback, feelings of inadequacy, fears criticism Meets 4 of the following criteria: -Avoids occupational activities that involve significant interpersonal contact -Unwilling to get involved with people unless certain of being liked -Shows restraint within intimate relationships because of the fear of being shamed or ridiculed -Preoccupied with being criticized or rejected in social situations -Inhibited in new interpersonal situations -Views self inferior to others -Reluctant to take risks or engage in any new activities because of embarrassment

Histrionic Personality Disorder

Attention-seeking, excessive emotions, shallow Meets 5 of the following criteria: -Uncomfortable in situations in which he or she is not the center of attention -Interaction with others is characterized by inappropriate sexually seductive or provocative behavior -Rapidly shifting and shallow expression of emotions -Uses physical appearance to draw attention to self -Style of speech is excessively impressionistic and lacking in detail -Self-dramatization, theatricality, and exaggerated expression of emotion -Easily influenced by others -Considers relationships to be more intimate than they actually are

Borderline Personality Disorder

Behaviors of splitting, impulsivity, and difficulties with relationships Meets 5 of the following criteria: -Avoids real or imagined abandonment -Unstable and intense interpersonal relationships with alternating extremes of idealization and devaluation -Identity disturbance, unstable self-image or sense of self -Impulsivity in potentially self-damaging areas (e.g., spending, sex, substance use, reckless driving, binge eating) -Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior -Profound reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) -Chronic feelings of emptiness -Inappropriate anger that's difficult to control (e.g., frequent displays of temper, recurrent physical fights)

Schizophrenia risk factors

Believed to occur when multiple inherited genetic abnormalities combine with other factors - viral infections, birth injuries, env stressors, prenatal malnutrition, trauma, abnormal neural pruning Amphetamines and cocaine can induce psychosis -almost any drug of abuse (particularly marijuana) can increase risk Brain atrophy, toxins, etc

Personality Disorders Etiology

Biological Factors: -genetic: traits of anxious-dependent, psychopathy-antisocial, social withdrawal, compulsivity -neurobiological: neurotransmitter dysfunction, neurohormones (e.g. oxytocin, vasopressin); variations in brain structure and size Psychological Factors: -learning theories -cognitive theories -psychoanalytic theories Environmental Factors: -family -variations among siblings -adverse childhood experiences

Bipolar I vs Bipolar II

Bipolar I: presence or hx of at least one manic episode Bipolar II: presence or hx of at least one hypomanic episode

Mind and body approaches

Built on theories that focus on the continuous interaction between mind and body - the effects of illness on mental health -meditation and mindfulness -yoga -exercise -acupuncture -guided imagery

a. Heavy use of a substance known to cause withdrawal

Donald, a 49-year-old male, is admitted for inpatient alcohol detoxification. The rationale for admission into this program is due to: a. Heavy use of a substance known to cause withdrawal b. A need for rehabilitation c. The potential for relapse d. CNS hypoactivity following cessation of alcohol consumption

Bipolar Implementation

Communication: -Calm but firm approach -Remain neutral -Be consistent -Listen and act on legitimate complaints -Set boundaries and consequences -Concise, concrete statements and directions -Redirect energy into appropriate activities -Consistency among staff Safe Milieu: -Reduce amount of stimuli -Redirect aggressive behaviors -One-on-one observation -Monitor belongings Self-Care Needs: -Food, hygiene, toileting schedules -Ask for and offer finger foods -Nightly relaxation strategies -Increased monitoring of vital signs -Offer rest periods during the day

Gambling Disorder

a disorder marked by persistent and recurrent gambling behavior, leading to a range of life problems -otherwise honest people may commit illegal acts to finance their addiction -may be regular or episodic -stress and depression may increase this behavior

Depression Implementation/Take Action

Counseling and communication techniques -silence, allow time for a response -listen for covert messaging, offer meaningful conversation -support identifying distortions and negative perceptions Health teaching and health promotion -individual control of tx Promotion of self-care activies Teamwork and safety Evaluation of: -suicidal ideation -personal/sleep hygiene -self perception -social interaction

Major Depressive Disorder (MDD)

DSM-V criteria = persistently depressed mood lasting a minimum of 2 wks Symptoms include: -Affect/Mood -Behavioral changes -Cognitive/thoughts -Physiologic Depression is an alteration in mood that is expressed by feelings of sadness, despair, and pessimism

Mood Disorders

a disruption of the "general emotional state or mood...distorted or inconsistent with your circumstances" "...characterized by periods of depression, sometimes alternating with periods of elevated mood" affects children through older adults

Schizophrenia spectrum disorders

Disorders that share features with schizophrenia -characterized by psychosis (altered cognition, altered perception, and/or an impaired ability to determine what is or is not real) -Delusional disorder -Brief psychotic disorder -Schizophreniform disorder -Schizoaffective disorder -Substance-induced psychotic disorder and psychotic disorder due to another medical condition -Schizophrenia

Serious mental illness (SMI)

a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities

Pediatrics and Bipolar Disorders

Early onset symptoms: •An expansive or irritable mood •Separation anxiety •Defiance of authority •Hyperactivity •Extreme sadness •Lack of interest in play •Extreme rages •Increase in illness •Greater risk of suicide attempts

Issues related to serious mental health

Establishing a meaningful life Comorbid conditions -physical disorders: HTN, obesity, CV disease, DM -suicide: 12x's more freq -substance use Social problems -stigma -isolation and loneliness -victimization Economic challenges -unemployment and poverty -housing instability Caregiver burden Treatment issues -Anosognosia: inability to recognize one's illness due to illness itself -Nonadherence -Medication S/E -Tx inadequacy -Residual symptoms -Relapse, chronicity, and loss

Assessment: Mood, Behavior, Thoughts and Speech, Cognition

General guidelines: -Danger to self or to others -Fluid and nutrition -Need for boundaries/protection from dangerous activities -Overall health status/co-occurring disorders -Self-knowledge of bipolar disorder -Think "limit setting

Other complementary therapies

Homeopathy: example of western alternative medicine, small doses of prepared plant extracts and other materials are used to stimulate the body's defense mechanism and healing process Naturopathy: emphasizes health restoration rather than disease treatment combining many therapies Aromatherapy: use of essential oils for enhancing physical and mental well being and healing Music and art Energy therapies -Therapeutic touch -Healing touch: combined energy therapies -Reiki -Bioelectromagnetic based therapies and bright light therapy -Prayer and spirituality

Substance use disorder risk factors

Genetic: cannabis, cocaine, and opiates Neurobiological: neurotransmitters associated with substance use disorders - opioid, catecholamines (dopamine), and GABA Environmental Factors: poverty, lack of parental supervision, poor education, impaired support systems

Sedative, Hypnotic, Anti-Anxiety, Club drugs - Withdrawal Tx

Gradual reduction of benzodiazepines will prevent seizures and other s/s Phenobarbital can be used in barbiturate withdrawals

Narcissistic Personality Disorder

Grandiose, lack of empathy, need for admiration Meets 5 of the following criteria: -Sense of self-importance (e.g., exaggerates achievements and talents) -Preoccupied with fantasies of unlimited success, power, brilliance, beauty -Believes they are "special" and unique and can only be understood by, or should associate with, other special or high-status people -Requires excessive admiration -Sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations) -Is interpersonally exploitative (i.e., takes advantage of others) -Unwilling to recognize or identify with the feelings and needs of others -Envious of others or believes that others are envious of him or her -Demonstrates arrogant, haughty behaviors or attitudes

Health Teaching and Health Promotion

Health teaching points to pt: • Depression is an illness beyond a person's voluntary control. • Although it is beyond voluntary control, depression can be managed through medication and lifestyle. • Chronic illness management depends in large part on understanding personal signs and symptoms of relapse. • Illness management depends on understanding the role of medication and possible medication side effects. • Long-term management works best if the patient receives psychotherapy along with medication. • Identifying and coping with the stress of interpersonal relationships—whether they are familial, social, or occupational—are key to stable illness management. Including the family in discharge planning is also important. It helps the patient by: • Increasing the family's understanding and acceptance of the family member with depression during the aftercare period • Increasing the patient's use of aftercare facilities in the community • Contributing to higher overall adjustment in the patient after discharge

Natural products

Include herbal medicine (botanicals) and also vitamins, minerals, and probiotics -herbal therapy -diet and nutrition: pts with psychiatric disorders often have nutritional disturbances, eat too much or too little -vitamin D and depression -omega 3 fatty acids: tx of depression and bipolar disorder -microbiomes: depression and anxiety

Opioids - Withdrawal Tx

Methadone: decreases painful symptoms, blocks the euphoric effects, only dispensed through tx program, once a day dosing Buprenorphine: help reduce or quit, produces effects such as euphoria or respiratory depression Naltrexone

a, b

Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) a week ago. You find him sitting stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply. a. Hold his medication and contact his prescriber stat. b. Wipe him with a washcloth that has been wetted with cold water or alcohol. c. Administer an "as needed" medication such as benztropine intramuscularly to correct his dystonic reaction. d. Reassure him that no treatment is needed and that this reaction will pass. e. Hold his medication for now and consult his prescriber when he comes to the unit later today.

b. "Gambling activates the reward pathways in my brain."

Lester and Alene have always enjoyed gambling. Lately, Alene has discovered that their savings account is down by $50,000. Alene insists that Lester undergo therapy for his gambling behavior. The nurse recognizes that Lester is making progress when he states: a. "I understand that I am a bad person for depleting our savings." b. "Gambling activates the reward pathways in my brain." c. "Gambling is the only thing that makes me feel alive." d. "We have always enjoyed gaming. I do not know why Alene is so upset."

Lithium S/E Mnemonic

Level Incontinence Thirst, Thyroid Hand tremors Increase fluids Unsteady Manic, Morton's salt

First Line Medication Therapy: Selective Serotonin Reuptake Inhibitors

MOA: block uptake of serotonin Adverse Reactions: -agitation -anxiety -sleep disturbances -tremors, sexual dysfunction Potential Toxic Effects: -discontinuation syndrome -serotonin syndrom Patient Teaching: -1-3 weeks for effect -avoid abrupt discontinuation SSRIs: fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa) escitalopram (Lexapro) fluvoxamine (Luvox)

Third-Line Medication Therapy: Monoamine Oxidase Inhibitor

MOA: breaks down monoamine transmitters Food/Drug Interactions: -avoid tyramine-rich foods Contraindications: -CHF -pregnancy -children A hypertensive crisis is fatal! -anxiety -flushing -sweating -severe HA -gastric lavage -antihypertensives -benzodiazepines Patient Teachings: -wallet card -monitor BP MAOIs: isocarboxazid (Marplan) phenelzine (Nardil) selegiline (EMSAM) tranylcypromine (Parnate)

Second-Line Medication Therapy: Tricyclic Antidepressants

MOA: inhibit reuptake of norepinephrine and serotonin Adverse Effects: -anticholinergic (dry mouth) -urinary retention -orthostatic hypotension Toxic Effects: -cardiac abnormalities Contraindications: -older adult (CV effects) -pregnancy -not recommended for suicidal pts due to overdose effect Patient Teachings: -1-3 weeks for mood elevation -6-8 weeks for full effect -no alcohol TCAs: amitriptyline amoxapine desipramine (Norpramin) doxepin (Sinequan) imipramine (Tofranil) protriptyline (Vivactil) trimipramine (Surmontil)

Assessment of Cognition

Major depressive disorder usually results in a decreased ability to think or concentrate and indecisiveness. This set of symptoms may be the primary mediator of functional impairment. These changes include deficits in attention, short-term and working memory, verbal and nonverbal learning, problem solving, processing speed, and auditory and visual processing. Cognitive deficits may linger even after successful treatment for the disorder and result in continued functional impairment.

Antisocial Personality Disorder (sociopaths)

Manipulative, callous, disregards or violates the rights of others Meets 3 of the following criteria: -Fails to conform to social norms with respect to lawful behaviors -Deceitfulness (e.g., repeated lying, use of aliases, or conning others) for personal profit or pleasure -Impulsivity -Irritability and aggressiveness, repeated physical fights or assaults -Reckless disregard for safety of self or others -Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations -Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

b. Dehydration and caffeine overdose

Max is a 30-year-old male who arrives at the emergency department stating, "I feel like I am having a stroke." During the intake assessment, the nurse discovers that Max has been working for 36 hours straight without eating and has consumed 8 double espresso drinks and 12 caffeinated sodas. The nurse suspects: a. Fluid overload b. Dehydration and caffeine overdose c. Benzodiazepine overdose d. Sleep deprivation syndrome

Co-occurring disorder

May include any combination of two or more substance use disorders and psychiatric disorders

Schizophrenia - outcomes

Medication, treatment adherence, relationships, community-based services Acute Phase Client safety and medical stabilization Maintenance Phase Adherence to medical regimen Understanding schizophrenia Participation of client and family in psychoeducational activities Stabilization Phase Target negative symptoms Relapse prevention Pts progress should be re-evaluated regularly and treatment adjusted when needed

Depression is often overlooked in

children, adolescents, and older adults.

Mania Criteria

Must meet 3 of the following criteria: ◦Inflated self-esteem or grandiosity ◦Drastically decreased need for sleep ◦Excessive talking or pressured speech ◦Extreme drive and energy Racing thoughts Easy to distract Increased goal- or non-goal-directed activity Involvement in dangerous activities (extreme spending, reckless sexual activities, risky investments)

Opioid Overdose Tx

Naloxone (Narcan)

a, b, d, e

Natalya, a patient with a history of alcohol use disorder, has been prescribed disulfiram (Antabuse). Which physical effects support the suspicion that the patient has relapsed? Select all that apply. a. Intense nausea b. Diaphoresis c. Acute paranoia d. Confusion e. Dyspnea

Dependent Personality Disorder

Needy, submissive, fear of separation Meets 5 of the following criteria: -Difficulty making everyday decisions without an excessive amount of advice and reassurance from others -Needs others to assume responsibility for most major areas of life -Difficulty expressing disagreement because of fear of loss of approval -Difficulty doing things on their own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy) -Goes to excessive lengths to obtain nurturance and support from others -Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for themselves -Immediately seeks another relationship as a source of care and support when a close relationship ends -Unrealistically preoccupied with fears of being left to take care of themselves

Inhalants - Withdrawal S/S

No withdrawal s/s

Nursing Assessment - Schizophrenia

Observations of behavior -Safety - risk factors (medical, substances, suicide, history) -Content- intensity & emotion from the hallucinations or delusions? -Relationship to stress and anxiety -Coping strategies - music, substance use, etc. -Identifying underlying unmet needs present All dimensions affect the individuals ability to work, interpersonal relationships, self-care abilities, social functioning, and quality of life

Tolerance

Occurs when a person no longer responds to the drug in a way that the person initially responded -it takes a higher dose of the drug to achieve the same level of response achieved initially -cocaine is fast, pain meds take longer

Cluster A Disorders

Odd or eccentric traits Paranoid: characterized by distrust and suspiciousness toward others based on unfounded beliefs that others want to harm, exploit or deceive the person Schizoid: characterized by emotional detachment, disinterest in close relationships and indifference to praise or criticism; often uncooperative Schizotypal: characterized by odd beliefs lead to interpersonal difficulties, an eccentric appearance and magical thinking or perceptual distortions that are not clear delusions or hallucinations

c. Tolerance

Opioid use disorder is characterized by: a. Lack of withdrawal symptoms b. Intoxication symptoms of pupillary dilation, agitation, and insomnia c. Tolerance d. Requiring smaller amounts of the drug to achieve a high over time

Schizophrenia planning - stabilization & maintenance phase of care

Outpatient -Medication education and management -Treatment adherence strategies -Managing hallucinations and delusions /coping skills -Interpersonal social skills and family support -Focus on recovery-oriented whole-health care

Substance use disorder

Pathological use of a substance that leads to a disorder of use Symptoms fall into four major groups: -Impaired control -Social impairment -Risky use -Physical effects (intoxication, tolerance, and withdrawal)

Heavy drinking

chronic alcohol intake of more than two drinks per day for men and more than one drink per day for women, too often

Obsessive-Compulsive Personality Disorder

Perfectionist, preoccupation with orderliness, inflexible, interpersonal control Meets 4 of the following criteria: -Preoccupation with rules, lists, organization that interferes with activities -Perfectionism interferes with task completion -Excessively devoted to work and productivity -Overconscientious and inflexible about values and ethics -Unable to discard objects, even when they have no sentimental value -Reluctance in delegating tasks -Money is hoarded for future emergencies -Rigidity, stubbornness

Outpatient care settings

Primary care providers • Common • Lack of specialized training Specialty psychiatric care providers -experience in care of psychiatric problems and mental health Patient-centered health/medical homes -strong support from Affordable Care Act of 2010 -developed in response to fragmented care Community clinics Psychiatric home care Assertive community treatment (ACT) • Mobile teams provide care in homes or on out patient basis • Utilize creative problem solving and interventions • 24/7 accessibility Intensive outpatient programs (IOPs) and partial hospitalization programs (PHPs) • Bridge the gap between outpatient and inpatient care • Can be mandated as discharge criteria from inpatient Other outpatient venues for psychiatric care • Telephone crisis counseling • Telephone outreach • Internet • Tele psychiatry Nursing Role in Outpatient Care Settings • Strong problem-solving and clinical skills • Patient advocate • Cultural competence • Flexibility • Knowledge of community resources • Autonomy • Case Management • Situational Assistance • Promote recovery and continuation of treatment

Depression Outcomes and Planning

Recovery Model: -focus on client's strengths -tx goals mutually developed -based on client's personal needs and values Planning: is geared towards -client's phase of depression -particular symptoms -client's personal goals Depression is an illness beyond a person's voluntary control.

Assessment Thought Content and Process

Responses may be slow or absent. During a conversation, you may have to repeat questions or comments in order to prompt the patient for a response. In severe depression, a person may become mute.

Sleep pharmacological interventions

Sedative-hypnotics are used with caution -Benzos: estazolam, flurazepam, quazepam -Non-benzos: zolpidem (ambien)

Inhalants - Treatment

Usually does not require tx -may require haloperidol to manage severe agitation

Withdrawal

Set of physiological symptoms that occur when a person stops using a substance -specific to the substance being used -mild or life threatening

Schizotypal Personality Disorder

Socially inept, eccentric behaviors Meets 5 of the following criteria: -Ideas of reference (personal significance to trivial events) -Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g. "sixth sense") -Unusual perceptual experiences, including bodily illusions -Odd thinking and speech -Suspiciousness or paranoid ideation -Inappropriate or constricted affect -Behavior or appearance that is odd, eccentric, or peculiar -Lack of close friends or confidants other than first-degree relatives -Excessive social anxiety that does not diminish with familiarity, tends to be associated with paranoid fears

Cognitive symptoms of schizophrenia

Subtle or obvious impairment in memory, attention, thinking (e.g., disorganized or irrational thoughts); impaired executive functioning (e.g., impaired judgment, impulse control, prioritization, and problem solving)

Affective symptoms of schizophrenia

Symptoms involving emotions and their expression -dysphoria, suicidality, hopelessness

d. Not ready to change

Terry is a young male in a chemical dependency program. Recently, he has become increasingly distracted and disengaged. The nurse concludes that Terry is: a. Bored b. Depressed c. Bipolar d. Not ready to change

Negative symptoms of schizophrenia

The absence of qualities that should be present -include the inability to enjoy activities (anhedonia), social discomfort, or lack of goal-directed behavior, blunted affect, poverty of thought (alogia) Treatment of these s/s is more difficult than positive

b, c, d, e

The nursing diagnosis denial is especially useful when working with substance use disorders and gambling. Which statements describe this diagnosis? Select all that apply. a. Reports inability to cope b. Does not perceive the danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit the impact of disease on life pattern

Sleep Hygiene

The practice of following good sleep habits to sleep soundly and be alert during the day • Maintain a regular sleep-wake schedule. • Develop a presleep routine that signals the end of the day. • Reserve the bedroom for sleep and a place for intimacy. • Create an environment that is conducive to sleep (taking into consideration light, temperature, and clothing). • Avoid clock watching. • Limit caffeinated beverages to one or two a day and none in the evening. • Avoid heavy meals before bedtime. • Use alcohol cautiously and avoid use for several hours before bed. • Avoid daytime napping. • Exercise daily, but not right before bed.

Positive symptoms of schizophrenia

The presence of symptoms that should not be present -include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or speech such as clang association, neologisms, and echolalia Usually appear later after depressive symptoms, can be dramatic and are often what precipitates tx -what most people associated with "mental illness" One specific symptom -Reality testing: automatic and unconscious process by which we determine what is and is not real

e. Metabolic syndrome

To provide effective care for the patient who is taking a second-generation antipsychotic, the nurse should frequently assess for a. Alcohol use disorder b. Major depressive disorder c. Stomach cancer d. Polydipsia e. Metabolic syndrome

a, b

Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas's nurse recognizes that self-medicating with excessive alcohol is common in this disorder and can be an effort to: Select all that apply. a. Self-medicate for social discomfort. b. Cope with anxiety. c. Enhance mood. d. Enable Tomas to better express himself.

d. Confront her about your concerns and/or report your concerns to a supervisor immediately.

What action should you take when a female staff member is demonstrating behaviors associated with a substance use disorder? a. Accompany the staff member when she is giving patient care. b. Offer to attend rehabilitation counseling with her. c. Refer her to a peer assistance program. d. Confront her about your concerns and/or report your concerns to a supervisor immediately.

d. They are not actually ill.

When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that a. The medications provided are ineffective. b. Nurses are trying to control their minds. c. The medications will make them sick. d. They are not actually ill.

a, d

Which assessment data confirm the suspicion that a patient is experiencing opioid withdrawal? Select all that apply. a. Pupils are dilated b. Pulse rate is 62 beats/min c. Slow movements d. Extreme anxiety e. Sleepy

d. Paranoia

Which characteristic presents the greatest risk for injury to others by the patient diagnosed with schizophrenia? a. Depersonalization b. Pressured speech c. Negative symptoms d. Paranoia

a, b, c, d

Which characteristics suggest a man is experiencing the prodromal phase of schizophrenia? Select all that apply. a. Always afraid that others will steal his belongings. b. Displays unusual interest in numbers and specific topics. c. Has increasingly unusual thoughts and uses words oddly. d. Demonstrates increasing difficulty with concentration.

a, c, d

Which nursing interventions are particularly well chosen for addressing a population at high risk for developing schizophrenia? Select all that apply. a. Screening 15- to 25-year-olds for early symptoms. b. Forming a support group for females aged 25 to 35 who are diagnosed with substance use disorders. c. Teaching ways to cope and build resiliency. d. Educating about the risk of psychosis with marijuana use.

electroconvulsive therapy (ECT)

a biomedical therapy for severely depressed patients in which a brief electric current is sent through the brain of an anesthetized patient ECT has FDA approval for depressive symptoms associated with major depressive disorder or bipolar disorder in patients aged 13 years and older. Using ECT for depressive symptoms accounts for about 65% of the procedures. However, the FDA does not regulate the practice of medicine. Practitioners may use ECT for other conditions, such as schizophrenia, schizoaffective disorder, and mania

a, c

Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is hallucinations? Select all that apply. a. "I know you say you hear voices, but I cannot hear them." b. "Stop listening to the voices, they are NOT real." c. "Tell me more about what you hear." d. "Please tell the voices to leave you alone for now."

Cyclothymia

a bipolar-related disorder with symptoms of hypomania and symptoms of mild-moderate depression.

Cognitive Behavioral Therapy (CBT)

a popular integrative therapy that combines cognitive therapy (changing self-defeating thinking) with behavior therapy (changing behavior)

Anticipatory Grief

a syndrome characterized by the presence of grief in anticipation of death or loss; the actual death comes as a confirmation of knowledge of a life-limiting condition

Most anticonvulsant drugs are approved for

acute mania. Lamotrigine (Lamictal) is approved for maintenance.

Substances that lead to use disorders

alcohol, caffeine, cannabis, hallucinogen, inhalant, opioid, sedative-hypnotic, stimulant, tobacco other: process addiction - gambling

Grieving

also known as acute grieving, is the painful experiences after a loss

Nurses may experience intense emotional reactions to patients with personality disorders

and need to make use of clinical supervision to maintain objectivity.

Cluster C Disorders

anxious, apprehensive, fearful -avoidant -dependent -obsessive-compulsive

Therapeutic Group

any group of people who meet together for personal development and psychological growth

Mood stabilizers

are usually the first line of defense for bipolar disorder and include lithium and several anticonvulsants.

Manipulative practices

body based, relate to specific body systems and structures like bones, joints, circulation, soft tissue -spinal manipulation -massage therapy

Early detection of bipolar disorder

can help diminish comorbid substance use problems or disorders, suicide, and decline in social and personal relationships and may help promote more positive outcomes.

Dysphoric Mania

dark, depressive symptoms

Assessment of Behavior

data gathering about the behavior of the person as an adaptive system in each of the adaptive modes

Persistent Complex Bereavement Disorder

diagnostic category undergoing study; proposed disorder involves persistent sorrow or preoccupation continuing a year after the death of a loved one

Depressive Disorders: Children and Adolescents

disruptive mood dysregulation disorder (DMDD) -Age 6-18yrs -Typical onset prior to age 10yrs -Severe, chronic irritability (core feature) -Accompanied by verbal or behavioral outburst -Out of proportion to the situation and to the individual's development -had previously been diagnosed w/bipolar disorder -usually children grow up and are diagnosed w/major depressive disorder or an anxiety disorder. Interventions are focused on the symptoms and the problems.

Cluster B Disorders

dramatic, emotional, unpredictable -Histrionic -Narcissistic -Borderline -Antisocial

Binge drinking

drinking five or more alcoholic drinks at one sitting -drinking too much quickly

Patient and family teaching is most important in

encouraging adherence to the medication regimen and reducing the risk of relapse.

Types of Mania

euphoric and dysphoric

Social Skills Training

evidence-based practice that focuses on teaching a wide variety of social and ADL skills, largely with the focus of making progress in small increments

Euphoric Mania

feels wonderful in the beginning, but it turns scary and dark as it progresses toward loss of control and confusion

Persistent Depressive Disorder

formerly known as dysthymia (dys - bad + thymia - mood), is diagnosed when low-level depression occurs most of the day, for the majority of days. These depressive feelings last at least 2 years in adults and 1 year in children and adolescents. In addition to depressed mood, individuals with this disorder have at least two of the following: decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness.

Bipolar Disorder

formerly known as manic depression. chronic recurrent illnesses that require careful management throughout a person's life. The distinguishing symptoms of these disorder include unusual shifts from highs (mania and hypomania) to lows (depressive symptoms). Bipolar disorder frequently goes unrecognized, and people suffer for an average of 6 years before receiving a proper diagnosis and treatment

End of Life Care Models

hospice and palliative care

Bipolar II Disorder

hypomania with at least one major depressive episode •Hypomania lasts 4 consecutive days, meets 3 criteria for mania, meets 5 criteria for major depressive episode •Risk for suicide during depressive episodes •Increased functioning often observed during hypomania

Depression Interventions

include using specific principles of communication, planning activities of daily living, administering or participating in psychopharmacological therapy, maintaining a therapeutic environment, and teaching patients about the biochemical aspects of depression.

An individual who is grieving

is clinically different from a person who has major depressive disorder.

Bipolar Health Promotion

knowledge, adherence, support •In-depth understanding about bipolar disorders •Signs and symptoms of recurrence, lifelong maintenance •Medication adherence and side effects •Concurrent use of stimulants and/or depressants •Sleep hygiene and sleep schedules •Understanding of circadian rhythms •Strategies for stress reduction and relaxation •Therapy: individual, family, group •Insights, social support, role identification

Serotonin Syndrome

life threatening Symptoms: -HA -Agitation -Confusion -Mood changes agitation -Hyperthermia -Hypertension -Sweating -Tachycardia -avoid duplicate serotonin -St. John's wort (OTC) ↑ risk factor -teach client/caregiver to monitor for symptoms -report to mental health provider or ED if symptoms develop Dantrolene - prevent muscle stiffness and spasms caused and the rapid rise in body temp and severe muscle contractions

Hypomania

low-level and less dramatic mania

Lithium Carbonate

mood stabilizer MOA: •Inhibits release of norepinephrine, dopamine, glutamate •Alters sodium and potassium transport in nerve and muscle cells Therapeutic Uses: •Bipolar I (acute) •Recurrent manic/depressive episodes •Standard dose 300 mg-600 mg PO 2-3 times a day Side Effects: •N/V, diarrhea, thirst, polyuria, lethargy, sedation, fine tremors •Early toxicity (> 1.5 mEq/L)- GI concerns, confusion, slurred speech, muscle weakness, sedation, coarse tremors •Advanced toxicity (> 2.0 mEq/L)- blurred vision, clonic movements, seizures, ataxia •Severe toxicity (> 2.5 mEq/L)- convulsions, oliguria, death may occur Education: •12-hr trough level 0.8-1.2 mEq/L •Blood draws* •Treatment may last 9-12 months •Maintain salt and fluid intake •Hypothyroidism and impaired urine concentration from long-term use •Do not abruptly discontinue

Uncomplicated Grief

normal grief, natural response to a loss

Patients with personality disorders often enter psychiatric treatment because

of distress from a comorbid mental illness

All personality disorders share characteristics

of inflexibility and difficulties in interpersonal relationships that impair social or occupational functioning.

Bereavement

period of grieving following a death

During the acute phase of mania,

physical needs often take priority and demand nursing interventions.

Group Phases

planning, orientation, working, termination

Genetics

play a strong role in risk for bipolar disorders

Palliative Care

promotes comfort for the patient and the patient's family. Palliative care may begin at the time of diagnosis and continue throughout the course of the disease or disorder.

Screening (SBIRT)

quickly assesses the severity of substance use and identifies the appropriate level of treatment for early intervention Screening, Brief Intervention, and Referral to treatment

Schizoid Personality Disorder

reclusive, uncooperative, restricted expressive emotions Meets 4 of the following criteria: -Does not desire or enjoy close relationships -Almost always chooses solitary activities -Has little, if any, interest in having sexual experiences with another person -Takes pleasure in few, if any, activities -Lacks close friends or confidants other than first-degree relatives -Appears indifferent to the praise or criticism of others -Shows emotional coldness, detachment, or flattened affectivity

Premenstrual Dysphoric Disorder

refers to a cluster of symptoms that occur in the last week prior to the onset of a woman's period. Symptoms include physical discomfort and emotional symptoms similar to major depression that are severe enough to interfere with the ability of a woman to work or interact with others. Symptoms decrease significantly or disappear with the onset of menstruation. The prevalence for Premenstrual Dysphoric Disorder is 2% to 6%

Mourning

refers to things people do to cope with grief, including shared social expressions of grief such as viewing hours, funerals, and bereavement groups.

Despite the relatively fixed patterns of maladaptive behavior,

some patients with personality disorders are able to change their behavior over time as a result of treatment.

Bipolar Planning and Outcomes

stabilization, adherence, relapse prevention Acute: -safety -physiological and psychosocial stabilization -hospitalization likely Continuation: -relapse prevention -medication adherence -psychoeducation -therapeutic support -problem solving skill development Maintenance: -continued relapse prevention -limit future episodes -continued psychoeducation, therapeutic support

Disenfranchised Grief

the emotion surrounding a loss that others do not support, share, or understand ex: grief by healthcare worker over the loss of a pt

Orientation Phase

the group is forming. The group leader's role is active in structuring an atmosphere of respect, confidentiality, and trust. During the first session, the group leader begins by providing a personal introduction. The members are encouraged to get to know one another through their own introductions. The leader then describes the purpose of the group.

Termination Phase

the leader ensures that each member summarizes personal accomplishments, shares new insights, and identifies future goals. The leader encourages group members to provide both positive and negative feedback regarding the group experience.

Working Phase

the leader facilitates communication, the flow of group processes, and group conduct. The group leader's role is to encourage members to focus on problem solving consistent with the purpose of the group. As group members begin to feel safe within the group, conflicts may be expressed, which the group leader may view as a positive opportunity for group growth. It is important for the leader to guide and support conflict resolution.

Intoxication

the state in which a person's mental and physical abilities are impaired by alcohol or another substance

Lithium is approved for

treating acute mania and maintenance. Blood levels, kidney function, and thyroid function should be assessed regularly.

Complementary medicine

uses non-mainstream medicine in conjunction with standard medical care

Integrative medicine

uses non-mainstream medicine in conjunction with standard medical care in a coordinated way -places pt at the center of care, focuses on prevention and wellness, and attends to the pts holistic needs, including physical, mental, and spiritual

Alternative medicine

uses non-mainstream medicine instead of standard medical care

Nursing Care and Treatment: Avoidant Personality Disorder

•Help identify and address stressors •Therapeutic relationship can help with teaching assertive skills •Limits and boundaries •Therapy and CBT

Paranoid Personality Disorder

widespread mistrust, suspicious of others and their motives Meets 4 of the following criteria: -Suspects, without basis, that others are exploiting, harming, or deceiving -Preoccupied with unjustified doubts about loyalty or trustworthiness of others -Reluctant to confide in others because of unwarranted fear that the information will be used maliciously -Reads hidden demeaning or threatening meanings into remarks or events -Bears grudges (unforgiving of insults, injuries, or slights) -Perceives attacks on their character or reputation that are not apparent to others, quick to react angrily or counterattack -Recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

Nursing Care and Treatment: Dependent Personality Disorder

•Help identify current stressors •Therapeutic nurse relationship can help provide assertiveness •Be aware that they are needy and may require more time psychotherapy

Planning Phase

• The name of the group • Objectives of the group • Types of individuals (e.g., diagnoses, age, gender) for inclusion • Group schedule (frequency, times of meetings) • Physical setting • Seating configuration • Description of leader and member responsibilities • Methods or means of evaluating outcomes

Tobacco - Withdrawal S/S

•Abstinence syndrome •Mood alterations- irritability, anxiety, anger, depressed mood •Sleep disturbances (insomnia) •Cognition- difficult concentration •Restlessness •Cravings, hunger

Nursing Care and Treatment: Schizoid Personality Disorder

•Avoid being too "nice" or "friendly" •Avoid promoting socialization •Conduct thorough assessment and identify symptoms patient may be reluctant to discuss •Protect against ridicule or bullying from group members or others because of their distinct interests or ideas •Psychotherapy can be helpful in helping with social cues and sensitivities

Nursing Care and Treatment: Obsessive-Compulsive Personality Disorder

•Avoid power struggles and give choices their need for control is high •Know that they have difficulty with change •Provide structure and allow them extra time for their behaviors •Therapy and group therapy

Opioids - Intoxication S/S

•Changes in pupil size •Slurred speech •Mood alterations- euphoria to apathy/dysphoria •Cognition- impaired memory, judgment •Decreased vital signs- BP, HR, RR; respiratory depression; low body temperature

Nursing Care and Treatment: Paranoid Personality Disorder

•Consider degree of mistrust in these patients and adhere to appointments and schedules •Be clear and straightforward in explanations. Being too nice or too friendly may lead to more suspicion •Use simple language and project a neutral affect •Limits are essential

Schizophrenia - implementation/take action

•Develop trust (openness, transparency, follow-through) •Avoid conveying the belief the hallucinations or delusions are real •Focus on reality •Be non-threatening but direct, concrete, and specific with information •Provide space, avoid joking if paranoia is present •Offer hope and encouragement

Opioids - Withdrawal S/S

•Enlarged pupils •Abstinence syndrome •Mood alterations-dysphoria, anxiety •Nausea, vomiting, diarrhea •Sleep disturbance (insomnia) •Increased vital signs- BP, HR, RR; elevated body temperature •Hyperreflexia, muscle spasms •Lacrimation (tearing), yawning

Caffeine - Intoxication S/S

•Excess of 250 mg •Mood alterations- anxiety •Increased vital signs- HR •Arrhythmias •Flushing (vasodilation) •Sleep disturbances (insomnia) •Muscle hyperactivity •Restlessness, nervousness •Diuresis, Gastrointestinal disturbances

Stimulants - Withdrawal S/S

•Fatigue, sleep disturbances (vivid dreams, insomnia, excessive sleep) •Increased appetite •Increased or decreased psychomotor skills •Mood alterations- depression, suicidal thoughts

Cannabis - Intoxication S/S

•Increased appetite, dry mouth, increase HR •Dilated blood vessels (eyes) •Impaired motor skills •Delayed perception of time •Stimuli sensitivity •High doses- delusions, paranoia, hallucinations •Chronic use- respiratory injury including lung cancer

Sedative, Hypnotic, Anti-Anxiety, Club drugs - Intoxication S/S

•Increased drowsiness, sedation, respiratory depression, decreased LOC •Slurred speech •Nystagmus •Confusion, disorientation, impaired judgment and memory •Lack of coordination •Nausea, vomiting

Nursing Care and Treatment: Histrionic Personality Disorder

•Keep interactions and communication profession and be aware of seductive behavior •Help them clarify their feelings •Psychotherapy and group therapy helpful

Nursing Care and Treatment: Antisocial Personality Disorder

•Many times admitted involuntarily and may be angry, aggressive and manipulative •Try to prevent or reduce manipulation (flattery or guilt) •Set clear and realistic boundaries and consequences calmly and •Be aware that these patients manipulate with guilt •Teamwork and safety •Psychotherapy

Cyclothymic Disorder

•Mixed hypomania and mild-moderate depression for 1 year (children) or 2 years (adults) •Symptoms do not fully meet criteria for mania, hypomania, or depression •Common episodes of irritable hypomania •Difficulty with sleep, relationships and employment

Tobacco - Intoxication S/S

•Mood alterations- •Long-term effects- hypertension, stroke, emphysema, COPD, lung cancer; smokeless tobacco- oral mucous membrane irritation

Sedative, Hypnotic, Anti-Anxiety, Club drugs - Withdrawal S/S

•Mood alterations- anxiety •Sleep disturbances (insomnia) •Increased vital signs- BP •Nausea, vomiting •Restlessness without purpose, tremors •Potential hallucinations, seizures

Hallucinogens - Intoxication S/S

•Mood alterations- anxiety (panic attacks), depression •Paranoia, hallucinations •Cognition- impaired judgment •Increased vital signs- RR •Blurred vision, dilated pupils •Diaphoresis •Palpitations •Tremors, lack of coordination

Caffeine - Withdrawal S/S

•Mood alterations- depressed mood, irritability, agitation •Flu-like symptoms- headache, nausea, vomiting, muscle aches •Difficulty concentrating •Fatigue, drowsiness

Cannabis - Withdrawal S/S

•Mood alterations- irritability, anxiety, aggression, depression •Restlessness, sleep disturbances (insomnia, nightmares) •Decreased appetite •Sweating, chills, headache, fever

Stimulants - Intoxication S/S

•Mood alterations- irritability, anxiety, anger, hypervigilance •Vital signs- increased HR, BP, RR •Dilated pupils •Sweating or chills; nausea, vomiting, weight loss •Impaired motor skills- tremors, increased or decreased psychomotor skills •Cognition- impaired judgment, confusion •Seizures

Alcohol - Withdrawal S/S

•Mood alterations- irritability, hallucinations •Abdominal cramping, nausea/vomiting •Increased vital signs- BP, HR, RR •Restlessness, tremors, sleep disturbances •Seizures- grand mal, tonic-clonic •Delirium tremens- medical emergency

Bipolar I Disorder

•Most severe of all bipolar disorders •Minimum 1-week-long manic episode, occurs most of the day •May have a presence of psychosis (radical changes in personality) •Depressive episodes may precede or follow the manic episode •Difficulty in maintaining relationships, employment

General S/S of withdrawal

•Nausea, vomiting •Chills, sweating •Mood alterations (irritability, anxiety) •Restlessness •Sleep disturbances (insomnia, dreams)

Inhalants - Intoxication S/S

•Nystagmus, diplopia (2-image perception of 1 object) •Slurred speech •Impaired coordination- dizziness, unsteady gait •Lethargy, depressed reflexes, tremors •Mood alterations- euphoria

Hallucinogens - Withdrawal S/S

•Persisting perception disorder (long-term visual disturbances or hallucinations)

Nursing Care and Treatment: Borderline Personality Disorder

•Provide clear and consistent boundaries, boundaries, boundaries •Use straightforward communication •When behavioral issues emerge calmly review goals calmly be matter of fact •Communication and consistency between staff •Safety •Treatment with Cognitive behavioral therapy (CBT), Dialectical Behavioral Therapy (DBT), and Schema-focused therapy

Nursing Care and Treatment: Narcissistic Personality Disorder

•Remain neutral and recognize behavior comes from fear and abandonment •Avoid engaging in power struggle or becoming defensive •Don't challenge grandiose statements •Role model empathy •Individual and group therapy

Nursing Care and Treatment: Schizotypal Personality Disorder

•Respect their need for isolation and provide supportive care •Be aware of suspiciousness or psychotic symptoms with careful assessment •These patients often avoid treatment because of paranoia and anxiety

Alcohol - Intoxication S/S

•Slurred speech •Lack of coordination, unsteady gait •Nystagmus (uncontrolled eye movement) •Impaired attention, memory, judgment •Altered level of consciousness (stupor, coma) Respiratory arrest/death (large doses) •Chronic use- damage to cardiovascular, digestive (liver), gastrointestinal systems

General S/S of intoxication

•Variations in pupil size •Alterations in speech (slurring) •Impaired coordination (unsteady gait) •Cognition (lack of judgment, disorientation) •Mood alterations (irritability, anxiety) •Restlessness •Sleep disturbances (insomnia, dreams) •Slow reactions (depressants) or euphoria (stimulants)