Mental Health Exam #2

S/S of lithium toxicity

*Hand tremors *N/V *Slurred speech *Unsteady gait

Side effects of MAOIs

- Common: hypotension, sedation/weakness/fatigue, muscle cramps, changes in cardiac rhythm, urinary hesitancy/constipation, weight gain, sexual dysfunction - Serious: hypertensive crisis (medical emergency, s/sx: severe occipital headache, marked increase in BP, palpitations/chest pain, nuchal rigidity, nausea/vomiting, fever/sweating

MAOIs (monoamine oxidase inhibitors)

-antidepressants that inhibit the action of an enzyme (monoamine oxidase) that is responsible for breakdown of NE and 5-HT -Depression with ATYPICAL features respond well to MAOIs

Normal lithium levels

0.6-1.4 mEq/L

How long after stopping an MAOI can you start taking lexapro (Prozac)?

2 weeks

Blood levels of carbamazepine

4-12 mcg/ml

How long does it take to see full effect of tricyclic antidepressants?

4-6 weeks

How do you diagnose major depressive disorder?

5 or more of the following symptoms in a two week period; weight loss/appetite changes, sleep disturbances, fatigue, worthlessness or guilt, loss of ability to concentrate, recurrent thoughts of death

Blood levels of divalproex

50-120mcg/ml

What is borderline personality disorder?

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.

A patient expresses interest in alternative treatment for depression with seasonal variations and asks the nurse about light therapy. Which of the following are evidence-based teaching points that the nurse may share with the patient? (SATA) a. Light therapy has demonstrated effectiveness that is comparable to anti-depressants. b. Light therapy should be used regularly until the season changes. c. Light therapy should only be used when ECT has proven to be ineffective. d. Side effects such as headache, nausea, or agitation, when they occur, are usually mild and transient. e. Light therapy can cause sedation so the best time to use it is before bedtime

A, B, D

Shondra is admitted to the hospital with Major Depressive Disorder and repeatedly makes negative statements about herself. Which of the following interventions is identified as an approach that promotes positive self-esteem in the patient? (SATA) a. teach more assertive communication skills b. Make observations to Shondra when she completes a goal or task c. Instruct Shondra that you will not talk with her unless she stops talking negatively about herself. d. Offer to spend time with Shondra using and nonjudgmental, accepting approach

A, B, D

Although historically lithium has been the medication of choice for mania, several others have been used with good results. Which of the following are used in the treatment of bipolar disorder? Select all that apply. A. Olanzepine (Zyprexa) B. Paroxetine (Paxil) C. Carbamazepine (Tegretol) D. Gabapentin (Neurontin) E. Tranylcypromine (Parnate)

A, C, D

Demetrius informs the nurse that his doctor is considering ECT and asks for some information about the procedure. Which of the following are accurate statements that the nurse can share with this patient? (SATA) a. ECT is typically used to treat patients who have not responded to antidepressant therapy b. A long-acting anesthetic agent is given to the patient the morning of the treatment c. One treatment is usually all that is needed to relieve depression d. Side effects may include headache and some confusion or memory loss

A, D

A patient has been admitted to a psychiatric unit with a diagnosis of Major Depressive Disorder. Which of the following manifestation may be apparent in a patient with this diagnosis? (SATA) a. slumped posture b. delusional thinking c. feelings of despair d. feels best early in the morning and worse as the day progresses e. anorexia

A,B,C,E

The physician orders lithium carbonate 600 mg tid for a client newly diagnosed with Bipolar I Disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. What is the therapeutic range for acute mania? a. 0.5-1.5 mEq/L b. 10-15 mEq/L c. 0.5-1 mEq/L d. 5-10 mEq/L

A. 0.5-1.5 mEq/L

A patient with depression asks the nurse, "Why would they check my thyroid function when I clearly have depression and I'm not overweight?" Which of these is an accurate response? a. an underactive thyroid gland can manifest as depression b. depression has been proven to be a hormonal illness c. thyroid hormone replacement is a first-line treatment for most people with depression. d. abnormal thyroid function predicts positive response to antidepressant medication

A. An underactive thyroid gland can manifest as depression

The goal of cognitive therapy with depressed clients is to: A. Identify and change dysfunctional patterns of thinking. B. Resolve the symptoms and initiate or restore adaptive family functioning. C. Alter the neurotransmitters that are creating the depressed mood. D. Provide feedback from peers who are having similar experiences

A. Identify and change dysfunctional patterns of thinking.

Jack is a new client on the psychiatric unit with a diagnosis of Antisocial Personality Disorder. Which of the following characteristics would you expect to assess in Jack? a. Lack of guilt for wrongdoing b. Insight into his own behavior c. Ability to learn from past experiences d. Compliance with authority

A. Lack of guilt for wrong doing

Perfectionism is a trait likely to be evident in a person with which personality disorder? A. OCD B. Narcissistic C. Antisocial D. Avoidant

A. OCD

Which of the following behavioral patterns is characteristic of individuals with narcissistic personality disorder? a. Overly self-centered and exploitative of others. b. Suspicious and mistrustful of others. c. Rule conscious and disapproving of change d. Anxious and socially isolated

A. Overly self-centered and exploitative of others

Kim, a patient diagnosed with BPD, manipulates staff in an effort to fulfill her own desires. All of the following may be examples of a manipulative behaviors in the borderline client, except: a. refusal to stay in room alone, stating "It's so lonely" b. Asking the nurse for cigarettes after 30 minutes, knowing that the assigned nurse has explained she must wait 1 hour. c. Stating to the nurse, "I really like having you for my nurse. You're the best one around here" d. Cutting arms with razor blade after discussing discharge plans with physician

A. Refusal to stay in room alone, stating "It's so lonely"

Jeff was just diagnosed with a major depressive disorder. Which medication is the health care provider most likely to start the patient on? A. SSRI B. SNRI C. Tricyclic antidepressant D. MAOI

A. SSRI; SSRI's are the first line of therapy

Tricyclic Antidepressants (TCAs)

Antidepressants that increase the action of neurotransimtters by blocking their removal (reuptake) from the synapses (spaces between nerve cells). Example: nortriptyline, and imipramine

What is the priority nursing assessment for a patient with BPD?

Assessing the patient for self-harm and a hx of anger and violence.

The nurse is prioritizing nursing diagnoses in the plan of care of a patient experiencing a manic episode. Number the diagnoses in order of appropriate priority. a. Disturbed sleep pattern b. Risk for injury c. Impaired social interaction d. Imbalanced nutrition

B, D, A, C

The physician orders sertraline (Zoloft) 50 mg PO bid for Margaret, a 68 year old woman with major depressive disorder. After 3 days of taking the medication, Margaret says to the nurse, "I don't think this medicine is doing any good. I don't feel a bit better". What is the most appropriate response by the nurse? A. "Cheer up Margaret. You have so much to be happy about" B. "Sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms" C. "I'll report that to the physician, Margaret. Maybe he will order something different." D. "Try not to dwell on your symptoms Margaret. Why don't you join the others down in the dayroom?"

B. " Sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms."

Which question would be a priority hen assessing for symptoms of major depression? A. "Tell me about any special powers you believe you have" B. "You look really sad. Have you ever though of harming yourself?" C. "Your family says you never stop. How much sleep do you get?" D. "Do you ever find that you don't remember where you've been or what you've done?"

B. "You look really sad. Have you ever thought of harming yourself?"

Which of the following behavioral patterns is characteristic of individuals with schizotypal personality disorder? a. Belittling themselves b. A lifelong pattern of social withdrawal c. Suspiciousness and mistrust of others d. Overreacting inappropriately to minor stimuli

B. A lifelong pattern of withdrawal

"Splitting" by the client with BPD denotes which of the following? a. Evidence of precocious development b. A primitive defense mechanism in which the client sees objects as all good or all bad. c. A brief psychotic episode in which the client loses contact with reality d. Two distinct personalities within the borderline client

B. A primitive defense mechanism in which the client sees objects as all good or all bad.

Use of splitting is most associated with which personality disorder? A. Antisocial B. Borderline C. Dependent D. Schizotypal

B. Borderline

Milieu therapy is a good choice for patients with antisocial personality disorder because it: a. Provides a system of punishment and rewards for behavior modification. b. Emulates a social community in which the patient may learn to live harmoniously with others c. Provides a mostly one-to-one interaction between the patient and therapist d. Provides a structured setting in which the patients have very little input into the planning of their care.

B. Emulates a social community in which the patient may learn to live harmoniously with others

Margaret, a 68-year-old widow experiencing a manic episode, is admitted to the psychiatric unit after being brought to the emergency department by her sister-in-law. Margaret yells, "My sister-in-law is just jealous of me! She's trying to make it look like I'm insane!" This behavior is an example of a delusion of.... a. grandeur b. persecution c. reference d. control

B. Persecution

Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sister-in-law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it anymore. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats little, is losing weight, and almost never sleeps: "I'm afraid she's going to just collapse!" Margaret is admitted to the psychiatric unit. The priority nursing diagnosis for Margaret is: a. Imbalance nutrition: less than body requirement related to not eating b. Risk for injury related to hyperactivity c. Disturbed sleep pattern related to agitation d. Ineffective coping related to denial of depression

B. Risk for injury related to hyperactivity

A nurse is educating a patient about his lithium therapy. She is explaining signs and symptoms of lithium toxicity. Which of the following would she instruct the patient to be on high alert for? a. Fever, sore throat, malaise b. Tinnitus, severe diarrhea, ataxia c. occipital headache, palpitations, chest pain d. skin rash, marked rise in blood pressure, bradycardia

B. Tinnitus, severe diarrhea, ataxia

Why are personality disorders not easily treated?

Because of the lack of a physiological source of symptoms and their ingrained nature. It is hard for them to change their behaviors and they do often do not stay in treatment.

What foods are high in tyramine?

Beer, ale, wine, aged cheese, sour cream, yogurt, avocados, bananas, fava bean, canned figs, bologna, salami, sausage, caffeinate coffee, cola, tea, chocolate, licorice, sauerkraut, soy sauce, and yeast

A patient whose husband died 6 months ago is diagnosed with major depressive disorder. She says to the nurse, "I start feeling angry that Harold died and left me all alone; he should have stopped smoking years ago! But then I start feeling guilty for feeling that way." What is an appropriate response by the nurse? a. "Yes he should have stopped smoking. Then he probably wouldn't have gotten lung cancer." b. "I can understand how you must feel." c. "Those feelings are a normal part of the grief response" d. "Just think about the good times that you had while he was alive"

C. "Those feelings are a normal part of the grief response"

A patient is taking amitriptyline 75 mg QHS for depression. He reports having a dry mouth, blurred vision, and constipation. What is causing these side effects? A. CNS effects B. Antiadrenergic effects C. Anticholinergic effects D. Cardiovascular effects

C. Anticholinergic effects

Which nursing action would the nurse do first when working with an individual with borderline personality disorder? A. Set limits B. Determine boundaries C. Assess for self harm D. Assess relationship system

C. Assess for self harm

In evaluating the progress of Jack, a client diagnosed with antisocial personality disorder, which of the following behaviors would be considered the most significant indication of positive change? a. Jack got angry only once in group this week b. Jack was able to wait a whole hour for a cigarette without verbally abusing the staff c. On his own initiative, Jack sent a note of apology to a man he had injured in a recent fight d. Jack stated that he would no longer start any more fights

C. On his own initiative, Jack sent a note of apology to a man he had injured in a recent fight.

Margaret, age 68, is diagnosed with Bipolar I Disorder, current episode manic. She is extremely hyperactive and has lost weight. One way to promote adequate nutritional intake for Margaret is to? a) sit with her during meals to ensure that she eats everything on her tray b) have her sister in law bring all her food from home because she knows Margaret's likes and dislikes c) provide high calorie, nutritious finger foods and snacks that Margaret can eat "on the run" d) tell Margaret that she will be on room restriction until she starts gaining weight

C. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run"

Katerina, who is experiencing a manic episode, enters the milieu area dressed in a provocative and physically revealing outfit. Which of the following is the most appropriate intervention by the nurse? a. Tell her, in front of the other patients that she cannot dress like a wh**e while she is in the hospital b. Do nothing and allow her to learn from the responses of her peers. c. Quietly walk with her back to her room and help her change into something more appropriate d. Explain to her that if she wears this outfit, she must remain in her room.

C. Quietly walk with her back to her room and help her change into something more appropriate.

Margaret, age 68, is a widow of 6 months. Since her husband died, her sister reports that Margaret has become socially withdrawn, has lost weight, and does little more each day than visit the cemetery where her husband was buried. She told her sister today that she "didn't have anything more to live for." She has been hospitalized with Major Depressive Disorder. The priority nursing diagnosis for Margaret would be: a. imbalanced nutrition; less than body requirements b. complicated grieving c. risk for suicide d. social isolation

C. Risk for suicide

A child with bipolar disorder also has attention-deficit/hyperactivity disorder (ADHD). How would these comorbid conditions most likely be treated? a. No medication would be given for either condition b. Medication would be given for both conditions simultaneously c. The bipolar condition would be stabilized first before medication for the ADHD would be given d. The ADHD would be treated before consideration of the bipolar disorder

C. The bipolar condition would be stabilized first before medication for the ADHD would be given.

Which behavior indicates that a patient diagnosed with borderline personality disorder is improving? A. The patient cries when her roommate refuses to go to the dining room with her. B. The patient yells at the group facilitator when he points out that she is monopolizing the group. C. The patient informs a staff member that she is having thoughts of harming herself. D. The patient tells the evening staff that the day staff excused her from group to smoke when she got upset.

C. The patient informs the staff member that she is having thoughts of harming herself.

What is persistent depressive disorder?

Chronic, milder form, symptoms last at least 1 yr

Which of the following is the most common comorbid condition in children with bipolar disorder? a. Schizophrenia b. Substance abuse disorder c. Oppositional Defiance Disorder d. ADHD

D. ADHD

Jeff's parents have described his lack of interest in the things he used to enjoy, like games with his friends, and his classes, which he used to like. Which term does the nurse use when documenting? A. Inappetance B. Impotence C. Indolence D. Anhedonia

D. Anhedonia

Antisocial, obsessive-compulsive, and schizotypal personality disorders occur most frequently in.... A. Adolescents B. Children C. Women D. Men

D. Men

According to Margaret Mahler, predisposition to borderline personality disorder occurs when developmental tasks go unfulfilled in which of the following phases? a. Autistic phase, during which the child's needs for security and comfort go unfulfilled b. Symbiotic phase, during which the child fails to bond with the mother c. Differentiation phase, during which the child fails to recognize a separateness between self and mother d. Rapprochement phase, during which the mother withdraws emotional support in response to the child's increasing independence

D. Rapprochement phase, during which the mother withdraws emotional support in response to the child's increasing independence

Kim has a diagnosis of BPD. She often exhibits alternating clinging and distancing behaviors. Which of the following is the most appropriate nursing intervention with this type of behavior? a. Encourage Kim to establish trust in one staff person with whom all therapeutic interaction should take place. b. Secure a verbal contract from Kim that she will discontinue these behaviors. c. Withdraw attention if these behaviors continue. d. Rotate staff members who work with Kim so that she will learn to relate to more than one person.

D. Rotate staff members who work with Kim so that she will learn to relate to more than one person

Jessica is a nurse who was floated to the psychiatric unit to cover for a staff nurse who called out sick. She encounters a patient who is diagnosed with BPD, and the patient states, "Thank goodness they sent you to the unit. No else here has taken the time to listen to my concerns. "This may be an example of which symptom common in BPD? a. Impulsivity b. Self-harming behaviors c. Dissociation d. Splitting

D. Splitting

Education for the patient who is taking MAOIs should include which of the following? A. Fluid and sodium replacement when appropriate, frequent blood levels, signs and symptoms of toxicity. B. Lifetime of continuous use, possible tardive dyskinesia, advantages of an injection every 2-4 weeks. C. short-term use, possible tolerance to beneficial effects, careful tapering of the drug at he end of treatment D. Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications without physician notification

D. Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications without physician notification

When does serotonin drop with seasonal depression?

Dec-Jan

What is a hypertensive crisis?

Extremely elevated blood pressure, tachycardia, palpitations, tightness in chest, stiff neck, throbbing radiating headache, sweating, dilated pupils

What should be avoided when taking MAOI's?

Foods high in tyramine (amino acid) can cause FATAL side effects

When does serotonin peak with seasonal depression?

In the fall

What is mania characterized by?

Intense elation or irritability Hyperactivity, talkativeness, distractibility, boundless energy, wild spending, foolish ventures, sexual indiscreet, manipulative, fault finding

What is important to remember about lithium?

It is a salt. If there is not enough sodium in the body the body will retain lithium which can lead to toxicity. Must maintain even level of water and salt to maintain lithium level.

Side effects of lithium

LMNOP: Lithium side effects - Movement (tremor) Nephrogenic diabetes insipidus (ADH antagonist) hypothyroidism Pregnancy problems

What medications should you not take when taking SSRIs?

MAOI inhibitors; allow 5-6 weeks of clearing before starting an MAOI

What antidepressant medications are typically not prescribed and why?

MAOI's because of fatal adverse reactions with foods high in tyramine.

When does serotonin begin to increase with seasonal depression?

March-May

What effects do SSRI's have on Lithium?

May increase or decrease lithium levels

Do medications treat personality disorders?

No, they treat the symptoms. SSRI's for impulsivity, depressed mood, anger, and feelings of loss control. Benzodiazepines and antipsychotics are used for aggressiveness, violence, or extreme impulsive behaviors.

What brain chemicals regulate mood?

Norepinephrine and serotonin increased=elevated mood decreased=depression

What does the recovery model focus on?

Patient strength, treatment goals that are mutually developed, the needs and values of the patient

What is disruptive mood dysregulation disorder?

Patients who have this disorder exhibit recurrent temper outbursts that are severe and do not correlate with the situation

____________ don't ___________to attacks and manipulation.

Respond;React (don't deny, defend, counterattack or withdraw)

What is the priority assessment for the nurse caring for a patient with depression?

Risk for suicide (SAFETY is always highest priority)

What antidepressant medications are the first line of therapy for depression and why?

SSRI's because they have less risks and side effects; take 2-4 weeks to reach therapeutic level

Side effects of tricyclic antidepressants

Sedation, blurred vision, orthostatic hypertension, cardiac dysthymias, tachycardia, constipation, weight gain, GI stress, sexual dysfunction

What is splitting?

Seeing the world in black and white, there is no gray area. Someone is good or bad and views can change quickly

What is premenstrual dysphoric disorder?

Symptoms of depression in the luteal phase

(T/F) Personality disorders can NOT be traced to a physiological source, substance use, medication, or medical condition.

True

What is the drug of choice for bipolar disorders?

Valproic acid

What is antisocial personality disorder?

a pervasive pattern of disregard for and violation of the rights of others

Traits of Antisocial Personality Disorder

aggressive, perceive the world as hostile and harmful, feel threatened, assertive, competitive, rigid

Cluster B (dramatic, emotional, and erratic)

antisocial, borderline, histrionic, narcissistic

An acutely depressed patient isolates herself in her room and just sits and stares into space. Which of these is the best example of an active communication approach with this patient? a. "Do you like to exercise?" b. "Come with me. I will go with you to group therapy" c. "Would you like to go to group therapy, stay in bed, or come out to the day lounge for some activities?" d. "Why do you stay in your room all the time?"

b. "Come with me. I will go with you to group therapy."

What is lithium used to treat?

bipolar disorders

What can increase risk of serotonin syndrome?

combining SSRIs with MAOI's, tryptophan, amphetamine, lithium, ecstasy, cocaine, venlafaxine, buspirone, and LSD

What is the most common symptom missed with antisocial personality disorder?

cunning, endearing tactics

Mood characteristics of bipolar disorder

euphoric, unstable, irritable, self-confident, grandiose

What is a patient diagnosed with bipolar disorder most likely to do to staff?

focus on their faults, make fun of them; it is important for the nurse to not feed into the behavior.

what are ruminations?

going over something over nd over again in your head and cannot get them out.

Side effects of SSRIs include

headaches nausea sedation increased anxiety sexual dysfunction INCREASED SUICIDE RISK IN CHILDREN BEERS LIST WARNING FOR OLDER ADULTS (due to sodium levels) hypotension/fall risk

What is anhedonia?

inability to experience pleasure

What is serotonin syndrome?

increased heart rate, sweating, dilated pupils, tremors, twitching, hyperthermia, agitation, confusion, disorientation, hallucinations Rare and life-threatening event

What are physiologic symptoms of depression?

insomnia, hypersomnia, weight change, constipation, decreased libido, somatic complaints

What is a hypomanic episode?

less severe than manic episode, at least 4 days duration, not severe enough for hospitalization, persistent elevated expansive or irritable mood

What is affect?

observable response a person has to his or her own feelings

Lithium blood levels should be monitored

once or twice a week until stable, then monthly during maintenance. Blood should be drawn 12 hours after last dose

What is substance induced depressive disorder?

one does NOT experience depressive symptoms with the abuse of drug or alcohol abuse or withdrawal

What is bipolar 2 disorder?

one or more major depressive episodes accompanied by at least one hypomanic episode

What is bipolar 1 disorder?

one or more manic or mixed episodes accompanied with at least one major depressive episodes

What is major depressive disorder?

people show persistent feelings of sadness and despair and a loss of interest in previous sources of pleasure

Common triggers of borderline personality disorder

perceiving abandonment, feeling invalidated, receiving criticism, being in situations where others have the spotlight, being labeled or stigmatized, being told to "snap out of it"

What is psychotic depression?

person loses touch with reality

What is a personality disorder?

personality traits become inflexible, maladaptive, and cause significant impairment or subjective distress

What should you avoid when dealing with a patient with a personality disorder?

power struggles: once in it is hard to get out of

Thought process of bipolar disorder

rapid speech, jokes/puns, vulgarity, flight of ideas, persecutory ideation, clang association, incoherent

How does self mutilation "help" the patient with BPD?

relieves tension and lets them know they are alive.

SSRIs (selective serotonin reuptake inhibitors)

selectively inhibits serotonin reuptake from synaptic gap and results in potentiation of serotonergic neurotransmissions. Examples: citalopram, paroxetine, lexapro, sertraline

What is seasonal depression?

serotonin levels decrease at the same time every year; the higher the latitude, the higher the incidence.

Interventions for manipulative behaviors include...

setting limits related to the behavior, be clear and communicate what is expected. BE CONSISTENT AND REALISTIC. Avoid threatening and making judgments. Focus on the patient's strengths. Teach the pt alternative behaviors to meet needs and expectations. Create opportunities, and tell the patient differences that you notice in behavior.

Common personality disorder behavior patterns include

splitting, projection, increased self esteem, passive aggression, acting out, narcissism, dependency, no-win relationship style

Measure your __________by things you can _____________.

success; control (this helps defuse anger and criticism from the nurse)

What is cyclothymic disorder?

swing between a hypomanic episode and depressive symptoms; symptoms occur for at lest 2 years and occur without remission for at least 2 months

What should be considered when choosing an antidepressant?

symptom profile of the patient, side effect profile, ease of administration, history of past response and history of family response, safety

What is mood?

the way a person feels

What is the definition of personality?

totality of thoughts, emotions, intentions, tendencies, and behaviors that a person exhibits consistently as he or she adapts to the environment

Treatment for seasonal depression

travel south, light box 30-60 minutes/day, visor, tanning booth (maybe)

What does labile mean?

unstable; mood changes quickly up and down

What is electroconvulsive therapy?

used for depressed patients --> may cause brain damage, but patients are much happier afterwards