HCCL 2 Exam 3 (Anxiety, Mood and Affect, Cognition, Psychosis, Vulnerability/Health Disparities, Grief and Loss, Palliation)

What are intrusions?

nightmares, Hallucinatory-like flashbacks

Additional side effects of 1st generation Anti-psychotics (*KNOW THESE*)

*Orthostatic hypotension*, sedation, sexual dysfunction, *agranulocytosis*, *severe dysrhythmias*

(Mood and Affect) *WHAT ARE THE SIGNS OF PPD?*

Clients who have postpartum depression are likely to experience trouble sleeping, loss of appetite and libido, and fear of not being able to adequately care for the baby.

*Most significant health disparity related to poor quality of care:*

"Health insurance is the most significant contributing factor to poor quality of care. . .Many racial/ethnic, low socioeconomic status (SES), and other minority groups lack adequate health insurance compared with their counterparts"

(Anxiety) When prescribed lorazepam (Ativan) 1 mg po qid for 1 week for generalized anxiety disorder, the nurse should

teach the client to limit caffeine intake. (Explanation: Caffeine is an antagonist of antianxiety medication.)

What is hyperarousal/hypervigilance?

Startles easily, insomnia, fear, anxiety, pain, irritability

(Psychosis) What are anticholinergic Agents?

• Benzotropine (Cogentin) • Bromocriptine (Parlodel) • Trihexyphenidyl (Artane) • Diphenhydramine (Benadryl)

(Psychosis) What are the Second-generation Antipsychotics?

*FIRST LINE CHOICE* • Clozapine (Clozaril) • Olanzapine (Zyprexa) • Risperidone (Risperdal) • Quetiapine (Seroquel) • Aripiprazole (Ability) • Paliperidone (Invega) • Ziprasidone (Geodon) • Asenapine (Saphris)

Place the stages of the grieving process according to Kubler-Ross in the correct order:

-Denial -Anger -Bargaining -Depression

Which side effect(s) are characteristic of atypical antipsychotics? (Select all that apply. One, some, or all options may be correct.)

-Increased Tardive Dyskinesia -FEWER extrapyramidal effects -Dry mouth (Explanation: Anticholinergic side effects such as dry mouth, blurred vision, urinary hesitancy and constipation are commonly experienced with atypical antipsychotics.)

What are the current leading causes of death in the US? (SATA):

-Strokes -Cancer -Accidents

Multiple studies have come to this conclusion over a wide range of health outcomes and indicators. Those who are poor (vulnerable) are more likely to suffer:

-diabetes morbidity and mortality -cancer mortality -suicide -respiratory dx

early signs of relapse in schizophrenia

-reduced sleep and confusion -troubling thoughts -hearing voices -restlessness -becoming more uncomfortable around others

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.)

1. Observe for incr. appetite. 2. Ask about epigastric pain. 3. Check for elevated blood glucose levels. (Explanation: The physiological changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in respiratory and heart rates.)

Which side effect would the nurse monitor for when administering SSRI's? (SATA)

Anxiety, nausea, sedation, restlessness, suicidal ideation, increased energy level

Which approach would the nurse use when managing the care of a client diagnosed with GAD?

Assisting the client with the development of healthy, adaptive coping mechanisms

Which adverse effect would the nurse anticipate in a client receiving lithium therapy for tx of depression?

Ataxia. (Explanation: Ataxia is the expected adverse effect in clients who are undergoing lithium therapy for the tx of depression. Confusion is one of the adverse effects of diazepam. )

The nurse recognizes which antidepressant is a second-generation medication?

Citalopram (Explanation: Citalopram is an example of a second-generation antidepressant medication. Doxepin, Protriptyline, and Trimipramine are all examples of first-generation antidepressant medication)

Which class of medications would the nurse identify as used to reduce tremors caused by lithium therapy?

Beta blockers

(Psychosis) What are NEGATIVE symptoms of Schizophrenia?

Blunted affect Alogia (Poverty of thought) Avolition (Loss of motivation) Anhedonia (Inability to experience pleasure or joy)

(Anxiety) A Gulf War veteran is entering treatment for post-traumatic stress disorder. What assessment is of importance to this particular client?

Determine the use of chemical substances for anxiety relief. (Explanation: Substance abuse often coexists with post-traumatic stress disorder. It is often the client's way of self-medicating to gain relief of symptoms)

Which medication worsens uncontrolled angle-closure glaucoma when used for the tx of generalized anxiety disorder?

Duloxetine

(Anxiety) Which medication is FDA approved for treatment of anxiety in children?

Duloxetine (Explanation: A few drugs are approved specifically for anxiety and obsessive-compulsive disorders in children and adolescents. The FDA approved the selective SNRI duloxetine (Cymbalta) in 2014 for children aged 7 to 17 years for generalized anxiety disorder. The FDA has approved four medications for use in children with obsessive-compulsive disorder. They are clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft).

(Anxiety) What medications would the nurse identify as used to treat generalized anxiety disorder (SATA):

Duloxetine, Venlafaxine, and Escitalopram. (Explanation: Duloxetine, Venlafaxine, and Escitalopram are antidepressants approved for the tx of GAD. Clonazepam and clomipramine are used to treat panic disorders.)

S/S of Lithium toxicity:

Early Signs of Toxicity: Blood level: 1.5 mEq/L Signs: Nausea Vomiting Diarrhea Thirst Polyuria Slurred speech Muscle weakness Fine hand tremors Lethargy Mild to Moderate Signs of Toxicity Blood level: 1.5 to 2.0 mEq/L Signs: Ataxia Tinnitus Coarse hand tremors Persistent gastrointestinal upset (Worsening N/V/D; also, gastritis, abdominal pain, flatulence, & indigestion) Salivation Gland Swelling w/ increased salivation Mental confusion Muscle hyperirritability Drowsiness Severe Toxicity Blood level: 2.0 to 2.5 mEq/L Signs: Increased Ataxia Worsening Tinnitus Severe diarrhea Blurred vision Clonic movements Large output of dilute urine Severe hypotension Arrhythmias/MI Seizures Stupor Coma Death

(Anxiety) Panic attacks in Latin American individuals often involve demonstration of which behavior?

Fear of dying (Explanation: Panic attacks in Latin Americans and Northern Europeans often involve sensations of choking, smothering, numbness or tingling, as well as fear of dying.)

(Psychosis) What are POSITIVE symptoms of Schizophrenia?

Hallucinations (Command) Delusions Associative Looseness (or disorganized speech) Bizarre behavior Paranoia

(Psychosis) What are the First-generation Antipsychotics?

Haloperidol (Haldol) • Fluphenazine (Prolixin) • Thiothixene (Navane) • Trifluoperazine (Stelazine) • Perphenazine (Trilofon) • Chlorpromazine (Thorazine) • Thioridazine (Mellaril) • Loxapine (Loxitane)

(Mood and Affect) *WHAT ARE THE SIGNS OF POSTPARTUM PSYCHOSIS?*

Harming the infant is a manifestation of postpartum psychosis.

What S/S should the nurse expect to assess if a client taking an MAO antidepressant ingests food ls containing tyramine?

Headache and Palpitations. Explosive headaches, palpitations, sudden elevations of BP, chest pain, nausea, and vomiting are some of the symptoms of a HTN CRISIS related to tyramine consumption

Advanced signs of Lithium toxicity *INTERVENTIONS* (2.0-2.5 mEq/L)

Hospitalization is indicated. The drug is stopped, and excretion is hastened. Whole bowel irrigation may be done to prevent further absorption of lithium.

A thyroid profile is important for several reasons. What role do thyroid levels play in depression?

Hypothyroidism can lead to feeling sluggish and depressed. Thyroid levels can help detect hypothyroidism, which can lead to depression .

What is avoidance, numbing?

Impairment of social fx is common for those suffering with PTSD.

Severe Lithium Toxicity *INTERVENTIONS* (>2.5 mEq/L)

In addition to the interventions above, hemodialysis may be used in severe cases.

(Mood and Affect) What are the symptoms of Bipolar 1?

Individuals may experience panic attack, specific phobias, and social anxiety disorder.

Laboratory reports reveal that the client's thyroxine levels are low. Which medication might have led to this condition?

Lithium. (Explanation: Lithium is used to treat bipolar disorder. Decreased levels of thyroxine and triiodothyronine may indicate hypothyroidism)

(M&A) Nurs. Interv. for Mania. Maintain a low stimuli environment. Why?

Loud music, loud people, bright lights and/ or loud television will agitate them more. Maintain low level of stimuli in p/t's environment. Escalation of anxiety can be decreased. Relaxation is promoted and manic behavior is minimized.

The nurse understands that a client with schizophrenia will experience which benefit from fluphenazine decanoate if it is administered intramuscularly (IM)?

Maintain long-term medication compliance. (Explanation:Fluphenazine decanoate is a long-acting medication that is administered as an injection every 1 to 3 weeks to promote compliance with the medication regimen.)

Early signs of lithium toxicity *INTERVENTIONS* (1.5-2.0 mEq/L)

Medication should be withheld, blood lithium levels measured, and dosage reevaluated

The nurse recognized which *atypical antipsychotics* as being approved for long-term use to prevent the recurrence of mood episodes in clients with bipolar disorder? (SATA)

Olanzapine, Ziprasidone, Aripiprazole.

(Anxiety)Inability to leave one's home because of avoidance of severe anxiety suggests the existence of which of anxiety disorder?

Panic attacks with agoraphobia. (Explanation: Panic disorder with agoraphobia is characterized by recurrent panic attacks combined with agoraphobia. Agoraphobia involves intense, excessive anxiety about being in places or situations from which escape might be difficulty or embarrassing or in which help might not be available if a panic attack occurred)

A client diagnosed with schizophrenia was prescribed antipsychotic medications and developed *extrapyramidal symptoms*. The nurse understands which medications might be responsible for these symptoms?

Perphenazine, Fluphenazine, Trifluoperazine. (Explanation: These are first-generation antipsychotic medications with a high risk of extrapyramidal symptoms. Second-generation antipsychotic medications such as Clozapine and Olanzapine have a lower risk of extrapyramidal symptoms.)

(M&A) Nurs. Interv. for Mania. Encourage napping during the day if the client feels tired. Why?

Prevent exhaustion. Lack of sleep can lead to exhaustion and increased mania.

(M&A) Nurs. Interv. for Mania. Weigh client daily and, offer finger foods to the client every two hours. Why?

Provide frequent high calorie fluids. Finger food allow for "eating on the run". Fluid and calorie replacement are needed. P/t may forget to eat and drink, so fluid and calorie replacement are needed. Ex. sandwiches, fruit, milkshakes.

Example of people who may experience PTSD?

Rape victim, watching someone be killed, assault survivor, war-time experiences

(Anxiety) A person who recently gave up smoking and now talks constantly about how smoking fouls the air, causes cancer, and "burns" money that could be better spent to feed the poor is demonstrating which ego defense mechanism?

Reaction formation (Explanation: Reaction formation keeps unacceptable feelings or behaviors out of awareness by developing the opposite behavior or emotion)

A client abruptly stops taking a barbiturate. Which withdrawal complication would the nurse anticipate that the client may experience?

Seizures.

Acute Dystonia (Extra Pyramidal Symptom)

Sudden, sustained contraction of one or several muscle groups, usually of the head and neck. Acute dystonias can be frightening and painful, but unless they involve muscles affecting the airway, which is rare, they are not dangerous. However, they cause significant anxiety and should be treated promptly. *Tx: Benztropine or Benadryl, usually given IV or IM in an acute episode*

(Anxiety)A cultural characteristic that may be observed in a teenage, female Hispanic client in times of stress would include what behavior?

Suddenly tremble severely. Ataque de nervios (attack of the nerves) is a culture-bound syndrome that is seen in undereducated, disadvantaged females of Hispanic ethnicity. *This is considered a cultural response to stress*

A client has been receiving lithium for the past two weeks for the tx of bipolar disorder, manic phase. Which information will the nurse include in the teaching plan for this client?

The blood level of lithium must be checked every month

Which statement about benzodiazepines requires correction?

These medications increase the activity of gamma-aminobutyric acid (GABA). (Explanation: Benzodiazepines act by DECREASING the activity of GABA, which is an inhibitory neurotransmitter. Benzo's act by depressing activity in the brainstem and limbic system)

(Mood and Affect) How do you take care of a client who is manic who is not eating or drinking?

They are at risk for fluid and electrolyte imbalance - so they're in need of *freq. snacks., encouragement to consume fluids, and frequent vital sign monitoring, as well as monitoring of intake and output*.

(Anxiety)Generally, which statement regarding ego defense mechanisms is true?

They often involve some degree of self-deception. (Explanation: Most ego defense mechanisms, with the exception of mature defenses, alter the individual's perception of reality to produce varying degree of self-deception

What is the focus of hospice care?

To ease the pain from illness.

(Anxiety) *How can we tell if relaxation techniques are working*?

We should see *improved ability to concentrate, decreased blood pressure and heart rate, a decrease in insomnia, and decreased muscle tension*.

(Mood and Affect) Who is at greatest risk for PPD?

Women with a previous hx of depression are at increased risk.

Lithium carbonate (Mood Stabilizing Drug)

controls mania, decreases incidence of suicide Blood levels should be obtained in the morning, usually 12 hours after last dose. Therapeutic blood level: 0.6-1.2 mEq/L Toxic blood level:1.5 mEq/L and above May cause nausea, give with meals to reduce nausea May take 1-3 weeks to reach RX effects

neuroliptic malignant syndrome

reaction to neuroleptic medications S/S: severe muscle rigidity, *elevated temp*, changes in LOC, *tachycardia*, *labile hypertension*, *tachycardia*, diaphoresis, drooling, leukocytosis, elevated liver enzymes, myoglobinuria, oculogyric crisis Nursing Interventions: •Stay with patient (who is unstable) and Notify HCP immediately for orders and prepare to transfer to ICU -Stop administration of antipsychotic meds -Continue to carefully monitor V/S -Reduce body temperature (cooling measures) -Supportive measures - Increase client's fluid intake (IV fluids!), continuous cardiac monitoring, *Dantrolene* (dopamine agonist that has muscle relaxant effects) -Monitor for complications such as DVT and rhabdomyolysis (protein in the blood from muscle breakdown which can cause organ failure)

*S/S of Serotonin Syndrome*

• Hyperactivity or restlessness • Tachycardia → cardiovascular shock • Fever → hyperpyrexia • Elevated blood pressure • Altered mental states (delirium) • Irrationality, mood swings, hostility • Seizures → status epilepticus • Myoclonus, incoordination, tonic rigidity • Abdominal pain, diarrhea, bloating • Apnea → death

*P/t and Family Teaching for Serotonin Syndrome*

• May cause sexual dysfunction or lack of sex drive. Inform nurse or primary care provider if this occurs. • May cause insomnia, anxiety, and nervousness. Inform nurse or primary care provider if this occurs. • May interact with other medications. Tell primary care provider about other medications patient is taking (e.g., digoxin, warfarin). SSRIs should not be taken within 14 days of the last dose of a monoamine oxidase inhibitor. • No over-the-counter drug should be taken without first notifying primary care provider. • Common side effects include fatigue, nausea, diarrhea, dry mouth, dizziness, tremor, and sexual dysfunction or lack of sex drive. • Because of the potential for drowsiness and dizziness, patient should not drive or operate machinery until these side effects are ruled out. • Alcohol should be avoided. • Liver and renal function tests should be performed and blood counts checked periodically. • Medication should not be discontinued abruptly. If side effects become bothersome, patient should ask primary care provider about changing to a different drug. Abrupt cessation can lead to serotonin withdrawal. • Any of the following symptoms should be reported to the primary care provider immediately: • Increase in depression or suicidal thoughts • Rash or hives • Rapid heartbeat • Sore throat • Difficulty urinating • Fever, malaise • Anorexia and weight loss • Unusual bleeding • Initiation of hyperactive behavior • Severe headache

*Interventions for Serotonin Syndrome*

• Remove offending agent(s) • Initiate symptomatic treatment: • Serotonin-receptor blockade with *cyproheptadine, methysergide, propranolol* • Cooling blankets, chlorpromazine for hyperthermia • Dantrolene, *diazepam* for muscle rigidity or rigors • Anticonvulsants • Artificial ventilation • Induction of paralysis

What are the effects of vulnerability?

•Poorer health outcomes: Vulnerable populations are more likely than others to suffer negative outcomes from health problems. •Cycle of vulnerability: •Without effective intervention, predisposing factors lead to poor health outcomes, which in turn worsen the predisposing factors. •This leads to a cycle of vulnerability that is difficult to break out of without assistance. •Vulnerability leads to the presence of chronic stress, adding yet another burden with which these groups must cope. •The chronic nature of these problems often leads to feelings of hopelessness. •Hopelessness results from an overwhelming sense of powerlessness and social isolation. •This is why it is very difficult for families facing severe vulnerability to simply "snap out of it," "just work harder," or "pull themselves up by their bootstraps!" Most of us cannot even imagine the obstacles these families are facing.