MENTAL HEALTH EXAM 2: Mood disorders

SSRI'S client teaching:

1. May cause anxiety, insomnia, agitation, sexual dysfunction 2. Do not discontinue medication abruptly Medication interaction: 14-Day clearance from MAOI's; 4 weeks after Prozac 3. Many interactions, check with health care professionals before taking any drugs or OTC 4. Common side effects 5. Check Liver/Renal/Blood count periodically

Bipolar disorders: Client/Family Education

1. Nature of illness Causes of bipolar disorder Cyclic nature of the illness Symptoms of depression Symptoms of mania 2. Support services Crisis hotline Support groups Individual psychotherapy Legal/financial assistance

SUICIDE: Nursing interventions

1. One to One, Nurse-client relationship 2. Stay with the person 3. "No suicide" contract 4. Non- judgmental, accepting attitude 5. Listen and be attentive 6. Encourage to verbalize, provide hope 7. Safety in the environment 8. Assist in meeting basic needs 9. Provide activity

Predisposing Factors to Depression: Neuroendocrine Disturbances

1. Possible failure within the hypothalamic-pituitary-adrenocortical axis 2. Possible diminished release of thyroid-stimulating hormone

Substance-Induced Depressive Disorder

-The depression is considered to be the direct result of physiological effects of a substance.

Depression screen tool: Diagnosis criteria

*Five (or more)* of the following symptoms have been present *during the same 2-week period* and represent a change from previous functioning; at least *one of the symptoms *is either *(1) depressed mood, or (2) loss of interest or pleasure* 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way

Severe Depression

*Includes symptoms of major depressive disorder and bipolar depression* 1. Affective: *feelings of total despair, worthlessness, flat affect* 2. Behavioral: *psychomotor retardation, curled-up position, absence of communication* 3. Cognitive: *irrelevant delusional thinking with delusions of persecution and somatic delusions, confusion, suicidal thoughts* 4. Physiological: *a general slow-down of the entire body*

SUICIDE: theories

*Psychological theories* Anger Turned Inward Hopelessness Desperation and Guilt History of Aggression and Violence Shame and Humiliation Developmental Stressors 2. SOCIOLOGICAL 3. BIOLOGICAL -GENETICS -NEUROCHEMICAL

Moderate Depression

*Symptoms associated with dysthymia:* 1. Affective: *helpless, powerless* 2. Behavioral: *sluggish physical movements, slumped posture, limited verbalization* 3. Cognitive: *slow thinking processes, difficulty with concentration* 4. Physiological: *anorexia or overeating, sleep disturbance, headaches*

Mild Depression

*Symptoms of mild depression are identified by clinicians as those associated with normal grieving* 1. Affective: *anger, anxiety* 2. Behavioral: *tearful, regression* 3. Cognitive: *preoccupied with loss* 4. Physiological: *anorexia, insomnia*

Bipolar disorder Types: Cyclothymia

- Hypomanic episodes alternating with dysthemia.

Bipolar disorder psychopharmacology: Lithium carobonate

-*Class* MOOD STABILIZER -*Action* LEVELS OUT NEUROTRANSMITTERS -*Sid effects* METALLIC TASTE FINE HAND TREMORS WEIGHT GAIN NAUSEA POLYDIPSIA; POLYURIA EDEMA TOXICITY DROWSINESS SLURRED SPEECH ATAXIA, MUSCLE SPASMS DIZZINESS, STUPOR CONVULSIONS & DEATH

Bipolar: psychopharmacology

-ANTIPSYCHOTICS -BENZODIAZEPINES -MOOD STABILIZERS 1. *LITHIUM CARBONATE* Eskalith Lithane, Lithobid 2. ANTICONVULSANTS *Carbamazepine (Tegretol)* *Valproic acid (Depakote)* Lamotrigine (Lamictal) Gabapentin (Neurontin) Oxcarbazepine (Trileptal) Tiagabine (Gabitril) Topiramate (Topomax) 3. anticholinergic

Predisposing Factors to Depression: *developmental implications:* Senescence

-Bereavement overload -High percentage of suicides among elderly *Symptoms of depression often confused with symptoms of neurocognitive disorder.* -Treatment Antidepressant medication Electroconvulsive therapy Psychosocial therapies

Major Depressive Disorder (MDD)

-Characterized by depressed mood -Loss of interest or pleasure in usual activities *-Symptoms have been present for at least 2 weeks* -No history of manic behavior -Cannot be attributed to use of substances or another medical condition

Predisposing Factors to Depression: *developmental implications:* Postpartum Depression

-May last for a few weeks to several months. *Associated with hormonal changes, tryptophan metabolism, or cell alterations* -Symptoms include: Fatigue, irritability Loss of appetite Sleep disturbances Loss of libido Concern about inability to care for infant -Treatments Antidepressants and psychosocial therapies

Persistent Depressive Disorder (Dysthymia)

-Sad or "down in the dumps" -No evidence of psychotic symptoms -*Essential feature is a chronically depressed mood for:* 1. Most of the day 2. More days than not 3. For at least 2 years

Depression: Common Adverse Reactions to and Toxic Effects of Monoamine Oxidase Inhibitors

1. Adverse Reactions Hypotension Sedation, weakness, fatigue Insomnia Changes in cardiac rhythm Muscle cramps Anorgasmia or sexual impotence Urinary hesitancy or constipation Weight gain *Hypotension is the most critical side effect (10%); the elderly, especially, may sustain injuries from it.* 2. Toxic Effects *Hypertensive crisis* Severe headache Stiff, sore neck Flushing, cold, clammy skin Tachycardia Severe nosebleeds, dilated pupils Chest pains, stroke, coma, death Nausea and vomiting *Client should go to local emergency department immediately—blood pressure should be checked. One of the following may be given to lower blood pressure:* -5 mg intravenous phentolamine (Regitine) or -Oral chlorpromazine or -Nifedipine (Procardia) (calcium channel blocker), 10 mg sublingually

Levels of depression:

1. COMMON FEELING 2. BEREAVEMENT AND GRIEF 3. DYSTHYMIA 4. MAJOR DEPRESSION 5. SECONDARY TO A MEDICAL CONDITION 6. ACCOMPANING OTHER PSYCH ILLNESS

Premenstrual Dysphoric Disorder: Essential features:

1. Depressed mood 2. Anxiety 3. Mood swings 4. Decreased interest in activities 5. *Symptoms begin during week prior to menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses*

Mania

1. Labile moods 2. Inappropriate and intrusive behavior. 3. Speech profane and crude sexual remarks. 4. Flight of ideas; may have clan associations. 5. Good humor turns into rage and hostility specially when not getting his way, or controls are set. Quick shifts in moods, hostile to docility. 6. Grandiose delusions. 7. Judgment extremely poor. 8. Decreased attention span and distractibility intensify. 9. Restless, disorganized and chaotic. Behavior difficult to control, frequent outbursts and briefly assaultive when crossed. 10. Too busy for sex. 11. No time to eat or sleep. Too distracted and disorganized. 12. Severe hyperactive and restless. Can result in exhaustion and death. 13. Same as hypomanic with finances but extreme.

Bipolar disorders: NURSING INTERVENTIONS *20*

1. Firm and calm approach. 2 Short and concise explanations. 3. Remain neutral, avoid power struggles. 4. Be consistent in approach. 5. Have frequent staff meetings to plan consistent approach. 6. Set limits and tell in concrete terms consequences of inappropriate behavior. 7. Firmly redirect energy into appropriate channels. 8. Redirect violent behavior 9. Hear and act on legitimate complaints. 10. Low level of stimulation in environment. 11. Structured solitary activities with staff. 12. High- calorie protein "finger foods" snacks and drinks. Avoid caffeine. 13. Provide frequent rest periods. 14. Make sure patient takes prescribed meds. 15. When violent or extreme agitation use antipsychotics and seclusion. 16. Protect client from giving away money and possessions. 17. Monitor lithium levels and observe for signs of toxicity. 18. Supervise hygiene and choice of clothing. 19. Give simple step-by-step directions. 20. When able to learn teach about disorder, medication and community agencies.

Bipolar predisposing factors:

1. Genetics 2. Biochemical influences: *increased NE and DA* 3. Electrolytes: *inreased intracellular Na+ and Ca+* 4. Psychosocial theories

Predisposing Factors to Depression: Biological Theories

1. *Genetics* -Hereditary factor may be involved. 2. *Biochemical influences* Deficiency of norepinephrine, serotonin, and dopamine has been implicated. Excessive cholinergic transmission may also be a factor.

Depression: Client/Family Education

1. *Nature of the Illness* -Stages of grief and symptoms associated with each stage -What is depression? -Why do people get depressed? -What are the symptoms of depression? 2. Management of the Illness -Medication management -Assertive techniques -Stress-management techniques -Ways to increase self-esteem -Electroconvulsive therapy 3. Support Services -Suicide hotline -Support groups -Legal/financial assistance

hypomania assessment *14*

1. *Talks and jokes incessantly,* "life of the party" demands constant attention. 2. Treats everyone with familiarity; often crude. *Sexual talk often inappropriate and obscene, proposes to strangers.* 3. Talk is fresh; *flits from topic to topic.* 4. Full of pep and humor; euphoria and sociability. 5. *Inflated self-confidence and enthusiasm.* Many plans to become rich and famous. 6. *Poor judgment*; involved with schemes in which job, financial, or marriage is destroyed. 7. High degree of involvement with the rich and famous; world-wide phone calls. 8. *Decreased attention span, overactive.* 9. Busily preoccupied with *grandiose plans* (not delusions) goes from one action to the next. 10. *Increase sexual appetite;* sexually irresponsible and indiscreet, illegitimate pregnancies, increased incidences if venereal disease. Sex used for escape not for relating. 11. Voracious appetite, gobbles food, eats on the run. 12. *May go without sleeping, unaware of fatigue.* 13. Financially extravagant, buying sprees, gives money and gifts freely.* Goes into debt easily.* 14. *Wears extravagant often inappropriate clothes and jewelry.*

Lithium carobonate: Nursing implications

1. ADMINISTER WITH MEALS 2. SERUM LITHIUM LEVELS AT LEAST TWICE WEEKLY - THEN MONTHLY *THERAPEUTIC LEVELS - 0.5 - 1.5 mEq/L* 3. TEACH PATIENT TO MAINTAIN A NORMAL SALT INTAKE DRINK 8 GLASSES OF FLUIDS/DAY

SUICIDE: ASSESSMENT (potential) *8*

1. Admits to suicide thoughts? Clues? 2. Has a plan? Means? 3. Support systems 4. Past or family history of suicide? 5. Coping strategies? 6. Alcohol or drug abuse 7. Anxiety, agitation 8. Depression, hopelessness, isolation, withdrawal

Predisposing Factors to Depression: Psychosocial Theories

1. Psychoanalytical theory -A loss is internalized and becomes directed against the ego. 2. Learning theory -*Learned helplessness:* The individual who experiences numerous failures learns to give up trying. 3. Object loss -Experiences loss of significant other during first 6 months of life -Feelings of helplessness and despair -Early loss or trauma may predispose client to lifelong periods of depression. 4. Cognitive theory -Views primary disturbance in depression as cognitive rather than affective *Three cognitive distortions that serve as the basis for depression:* 1. Negative expectations of the environment 2. Negative expectations of the self 3. Negative expectations of the future

22. A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) 1. Sad mood on most days 2. Mood rating of 2 out of 10 for the past 6 months 3. Labile mood 4. Sad mood for the past 3 years after spouse's death 5. Pressured speech when communicating

ANS: 1, 4 Rationale: The nurse should anticipate that a client with a diagnosis of dysthymic disorder would experience a sad mood on most days for more than two years. The essential feature of dysthymia is a chronically depressed mood, which can have an early or late onset.

SUICIDE DEMOGRAPHICS

AGE- Adolescents and males older than 50 GENDER- Males ETHNICITY- #1 Caucasians, # 2 Native Americans, #3 African Americans MARITAL STATUS- Single, Divorced, Widow SOCIOECONOMIC STATUS- High & Low classes OCCUPATION- Healthcare professionals, Business exe. METHOD- Firearms RELIGION- Protestants highest FAMILY HISTORY- Highest with family History

9. A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis? 1. Thyroid-stimulating hormone (TSH) level of 25 U/mL 2. Potassium (K+) level of 4.2 mEq/L 3. Sodium (Na+) level of 140 mEq/L 4. Calcium (Ca2+) level of 9.5 mg/dL .

ANS: 1 Rationale: A diagnosis of major depressive episode may be ruled out if the client's lab results reveal a TSH level of 25 U/mL. *Normal levels of TSH range from 2 to 10 U/mL. High levels of TSH indicate low thyroid function. The client's high TSH value may indicate hypothyroidism, which can lead to depressive symptoms.* The DSM-5 criteria for the diagnosis of major depressive episode states that this diagnosis must not be attributable to the direct physiological effects of another medical condition

4. Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client? 1. On his or her side, to prevent aspiration 2. In high Fowler's position, to prevent increased intracranial pressure 3. In Trendelenburg's position, to promote blood flow to vital organs 4. In prone position, to prevent airway blockage

ANS: 1 Rationale: The nurse should place a client who has received ECT on his or her side, to prevent aspiration

11. A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate total parenteral nutrition to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.

ANS: 1 Rationale: The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 lb by the end of the week. Because of the hyperactive state, the client will have difficulty sitting still to consume large meals.

15. Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? (Select all that apply.) 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. Restrict sodium content. 5. Restrict fluids to 1,500 mL per day.

ANS: 1, 2, 3 Rationale: The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high because of the narrow margin between therapeutic doses and toxic levels. Fluid or sodium restriction can impact lithium levels.

24. A client is prescribed phenelzine (Nardil). Which of the following statements by the client should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.) 1. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." 2. "I guess I will have to give up my glass of red wine with dinner." 3. "I'll have to be very careful about reading food and medication labels." 4. "I'm going to miss my caffeinated coffee in the morning." 5. "I'll be sure not to stop this medication abruptly."

ANS: 1, 2, 3, 5 Rationale: The nurse should evaluate that teaching has been successful when the client states that phenelzine should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is an MAOI that can have negative interaction with other medications. The client needs to tell other physicians about taking MAOIs, because of the risk of drug interactions.

13. A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Increase the dosage of fluoxetine. 2. Discontinue the fluoxetine and rethink the client's diagnosis. 3. Order benztropine (Cogentin) to address extrapyramidal symptoms. 4. Order olanzapine (Zyprexa) to address altered thoughts. s

ANS: 2 Rationale: A full manic episode emerging during antidepressant treatment (medication, electroconvulsive therapy, etc.), but persisting beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a Bipolar I diagnosis

17. A number of assessment rating scales are available for measuring severity of depressive symptoms. Which scale would a nurse practitioner use to assess a depressed client? 1. Zung Depression Scale 2. Hamilton Depression Rating Scale 3. Beck Depression Inventory 4. AIMS Depression Rating Scale

ANS: 2 Rationale: A number of assessment rating scales are available for measuring severity of depressive symptoms. Some are meant to be clinician administered, whereas others may be self-administered. Examples of self-rating scales include the Zung Self-Rating Depression Scale and the Beck Depression Inventory. One of the most widely used clinician-administered scales is the Hamilton Depression Rating Scale. The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that measures involuntary movements associated with tardive dyskinesia.

5. A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder? 1. Altered communication R/T feelings of worthlessness AEB anhedonia 2. Social isolation R/T poor self-esteem AEB secluding self in room 3. Altered thought processes R/T hopelessness AEB persecutory delusions 4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

ANS: 2 Rationale: A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive episode. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, curled-up position, and no attention to personal hygiene and grooming.

21. After 6 months of taking imipramine (Tofranil) for depressive symptoms, a client complains that the medication doesn't seem as effective as before. Which question should the nurse ask to determine the cause of this problem? 1. "Are you consuming foods high in tyramine?" 2. "How many packs of cigarettes do you smoke daily?" 3. "Do you drink any alcohol?" 4. "Are you taking St. John's wort?"

ANS: 2 Rationale: Imipramine is a tricyclic antidepressant. Smoking should be avoided while receiving tricyclic therapy. Smoking increases the metabolism of tricyclics, requiring an adjustment in dosage to achieve the therapeutic effect. Alcohol potentiates the effects of antidepressants. Tyramine is only an issue when MAOI medications are prescribed. Concomitant use of St. John's wort and SSRIs, not tricyclics, increases, not decreases the effects of the drug.

14. Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships

ANS: 2 Rationale: The basic premise of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care and to enable a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

14. A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention, related to this medication, should be initiated to maintain this client's safety upon discharge? 1. Provide a 6-month supply of Elavil to ensure long-term compliance. 2. Provide a 1-week supply of Elavil, with refills contingent on follow-up appointments. 3. Provide pill dispenser as a memory aid. 4. Provide education regarding the avoidance of foods containing tyramine.

ANS: 2 Rationale: The health-care provider should provide no more than a 1-week supply of amitriptyline, with refills contingent on follow-up appointments, as an appropriate intervention to maintain the client's safety. Antidepressants, which are central nervous system depressants, can be used to commit suicide. Also these medications can precipitate suicidal thoughts during the initial use period. Limiting the amount of medication and monitoring the client weekly would be appropriate interventions to address the client's risk for suicide.

11. What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive episode? 1. The attention during the assessment is beneficial in decreasing social isolation. 2. Depression can generate somatic symptoms that can mask actual physical disorders. 3. Physical health complications are likely to arise from antidepressant therapy. 4. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: 2 Rationale: The nurse should determine that a client with a diagnosis of major depressive episode needs a full physical health assessment, because depression can generate somatic symptoms that can mask actual physical disorders.

16. A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing response? 1. "This combination of drugs can lead to delirium tremens." 2. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." 3. "That's a good idea. There have been good results with the combination of these two drugs." 4. "The only disadvantage would be the exorbitant cost of the MAOI."

ANS: 2 Rationale: The nurse should explain to the client that combining an MAOI and fluvoxamine, an SSRI, can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches, with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

9. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? 1. "Risky Activity" tool 2. "FIND" tool 3. "Consensus Committee" tool 4. "Monotherapy" tool

ANS: 2 Rationale: The nurse should use the "FIND" tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

18. The severity of depressive symptoms in the postpartum period varies from a feeling of the "blues," to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms? 1. Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions) 2. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby) 3. Postpartum melancholia (overprotection of infant, expresses concern about inability to care for baby, mysophobia) 4. Postpartum depressive psychosis (transient depressed mood, agitation, abnormal fear of child abduction, suicidal ideations)

ANS: 2 Rationale: The symptoms of the maternity blues include tearfulness, despondency, anxiety, and subjectively impaired concentration appearing in the early puerperium. Symptoms of postpartum depression are associated with fatigue, irritability, loss of appetite, sleep disturbances, loss of libido, and expressions of great concern about her inability to care for her baby. Both postpartum melancholia and postpartum depressive psychosis are characterized by a lack of interest in, or rejection of, the baby, or a morbid fear that the baby may be harmed. Other symptoms include depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions.

23. An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) 1. Gender differences in social opportunities that occur with age 2. Drastic temperature and barometric pressure changes 3. A seasonal increase in social interactions 4. Variations in serotonergic functioning 5. Inaccessibility of resources for dealing with life stressors

ANS: 2, 3, 4 Rationale: The nurse should identify drastic temperature and barometric pressure changes, a seasonal increase in social interactions, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

13. A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects a depressive disorder. What is the rationale for performing a mini-mental status exam? 1. To rule out bipolar disorder 2. To rule out schizophrenia 3. To rule out neurocognitive disorder 4. To rule out personality disorder

ANS: 3 Rationale: A mini-mental status exam should be performed to rule out neurocognitive disorder. The client may be experiencing reversible dementia, which can occur as a result of depression

3. A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure? 1. To prevent increased intracranial pressure resulting from anoxia. 2. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation. 3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles. 4. To prevent blocked airway, resulting from seizure activity.

ANS: 3 Rationale: The nurse administers 100% oxygen during and after ECT to prevent anoxia resulting from medication-induced paralysis of respiratory muscles.

10. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? 1. According to psychoanalytic theory, depression is a result of negative perceptions. 2. According to object-loss theory, depression is a result of overprotection. 3. According to learning theory, depression is a result of repeated failures. 4. According to cognitive theory, depression is a result of anger turned inward.

ANS: 3 Rationale: The nurse should assess that, according to learning theory, this client's depressive symptoms may have resulted from repeated failures. The learning theory is a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.

8. A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative. Which action should be the nurse's priority at this time? 1. Give the client off-unit privileges as positive reinforcement. 2. Encourage the client to share mood improvement in group. 3. Increase the level of this client's suicide precautions. 4. Request that the psychiatrist reevaluate the current medication protocol.

ANS: 3 Rationale: The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behavior.

6. A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time? 1. Obtaining an order for locked seclusion until client is no longer suicidal. 2. Conducting 15-minute checks to ensure safety. 3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations. 4. Encouraging client to express feelings related to suicide.

ANS: 3 Rationale: The nurse's priority intervention when a depressed client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideations. By providing one-to-one observation, the nurse will be able to interrupt any attempts at suicide.

1. A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why? 1. Administer lorazepam (Ativan) prn, because the client is angry about plan exposure. 2. Establish room restrictions, because the client's threat is an attempt to manipulate the staff. 3. Place client on one-to-one suicide precautions, because specific plans likely lead to attempts. 4. Call an emergency treatment team meeting, because the client's threat must be addressed.

ANS: 3 Rationale: The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide.

Avoid foods and medications high in tyramine when taking MAOIs. These include:

Aged cheese Caviar Wine; beer Raisins Chocolate; colas Pickled herring Coffee; tea Yeast products Sour cream; yogurt Broad beans Smoked and processed meats Soy sauce Beef or chicken liver Cold remedies Canned figs Diet pills

Mood:

Also called *affect.* Mood is a pervasive and sustained emotion that may have a major influence on a person's perception of the world. Examples of mood include *depression, joy, elation, anger, and anxiety.* Affect is described as the *emotional reaction associated with an experience.*

12. A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. 4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.

ANS: 3 Rationale: Three or more of the following symptoms may be experienced in both hypomanic and manic episodes: Inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep), more talkative than usual or pressure to keep talking, flight of ideas and racing thoughts, distractibility, increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments). If there are psychotic features, the episode is, by definition, manic.

19. A staff nurse is counseling a depressed client. The nurse determines that the client is using the cognitive distortion of "automatic thoughts." Which client statement is evidence of the "automatic thought" of discounting positives? 1. "It's all my fault for trusting him." 2. "I don't play games. I never win." 3. "She never visits because she thinks I don't care." 4. "I don't have a green thumb. Any old fool can grow a rose."

ANS: 4 Rationale: Examples of automatic thoughts in depression include: Personalizing: "I'm the only one who failed." All or nothing: "I'm a complete failure." Mind reading: "He thinks I'm foolish." Discounting positives: "The other questions were so easy. Any dummy could have gotten them right."

12. A nurse is planning care for a 13 -year-old who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in adolescents? 1. Paroxetine (Paxil) 2. Sertraline (Zoloft) 3. Citalopram (Celexa) 4. Escitalopram (Lexipro)

ANS: 4 Rationale: Fluoxetine (Prozac) has been approved by the FDA to treat depression in children and adolescents, and escitalopram was approved in 2009 for treatment of depression in adolescents aged 12 to 17 years. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

7. A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis? 1. The client is disheveled and malodorous. 2. The client refuses to interact with others and isolates self in room. 3. The client is unable to feel any pleasure. 4. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: 4 Rationale: The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior is exhibiting signs of mania. The DSM-5 criteria state that there must never have been a manic episode or a hypomanic episode to meet the criteria for the diagnosis of major depressive episode

1. A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

ANS: 4 Rationale: The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting mood swings from euphoria to irritability. Grandiosity refers to the attitude that one's abilities are better than everyone else's.

15. An older client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why? 1. Neuroleptic malignant syndrome; caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) 2. Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) 3. Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI 4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs

ANS: 4 Rationale: The nurse should suspect that the client is suffering from serotonin syndrome; possibly caused by ingesting two different SSRI's (sertraline and paroxetine). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

2. In planning care for a suicidal client, which correctly written outcome should be a nurse's first priority? 1. The client will not physically harm self. 2. The client will express hope for the future by day three. 3. The client will establish a trusting relationship with the nurse. 4. The client will remain safe during hospital stay.

ANS: 4 Rationale: The nurse's first priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse's first priority. Outcomes should be client-centered, specific, realistic, measureable, and must also include a time frame.

10. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. "Treatment is compromised when clients can't sleep." 2. "Treatment is compromised when irritability interferes with social interactions." 3. "Treatment is compromised when clients have no insight into their problems." 4. "Treatment is compromised when clients choose not to take their medications."

ANS: 4 Rationale: The nursing student is accurate when stating that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose not to take their medications. Clients diagnosed with bipolar disorder feel most productive and creative during manic episodes. This may lead to purposeful medication nonadherence. Symptoms of bipolar disorder will reemerge if medication is stopped.

16. A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.) 1. Symptoms lasting for a minimum of two years 2. Numerous periods with manic symptoms 3. Possible comorbid diagnosis of a delusional disorder 4. Symptoms cause clinically significant impairment in important areas of functioning 5. Depressive symptoms that do not meet the criteria for major depressive episode

ANS: 4, 5 Rationale: The following are selected criteria for the diagnosis of cyclothymic disorder. For at least one year in children and adolescents there have been numerous periods with hypomanic, not manic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. The symptoms are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not elsewhere classified. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

26. Order the depressive disorders and their predominant affective symptoms according to level of severity. ________ Dysthymic disorder (pessimistic outlook, low self-esteem) ________ Grief (feelings of anger, anxiety, guilt, helplessness) ________ Major depressive episode (despair, worthlessness, flat affect, apathy, anhedonia) ________ Transient depression (sadness, dejection, feeling downhearted, having "the blues")

ANS: The correct order is 3, 2, 4, 1 Rationale: Symptoms of transient depression are not necessarily dysfunctional. Affective symptoms include sadness, dejection, feeling downhearted, having the "blues." Symptoms at the mild level of depression are identified by those associated with uncomplicated grieving. Affective symptoms include denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness, despondency. Dysthymic disorder, which is an example of moderate depression, represents a more problematic disturbance. Affective symptoms include feelings of sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self-esteem; difficulty experiencing pleasure in activities. Severe depression is characterized by an intensification of the symptoms described for moderate depression. Examples of severe depression include major depressive episode. Affective symptoms include feelings of total despair, hopelessness, and worthlessness; flat (unchanging) affect, appearing devoid of emotional tone; prevalent feelings of nothingness and emptiness; apathy; loneliness; sadness; inability to feel pleasure. 1. Transient depression (sadness, dejection, feeling downhearted, having "the blues") 2. Grief (feelings of anger, anxiety, guilt, helplessness) 3. Dysthymic disorder (pessimistic outlook, low self-esteem) 4. Major depressive episode (despair, worthlessness, flat affect, apathy, anhedonia)

Depression

An alteration in mood that is expressed by feelings of sadness, despair, and pessimism. There is a loss of interest in usual activities, and somatic symptoms may be evident. *COMMON= CHANGES IN SLEEP PATTERN*

During a period of hyperactivity a client on the psychiatric unit demands to be allowed to go downtown to shop. The client does not currently have privileges. How should the nurse respond? 1 "You can't leave the unit, because you're too sick." 2 "You'll have to ask your primary healthcare provider for permission to go." 3 "You'll have to wait, because no staff member is available to go with you." 4 "You don't have privileges to leave, but we can look through this new catalog."

Clients who are hyperactive are easily diverted. It is best to use distraction rather than precipitate a confrontation. Telling the client that leaving will not be allowed ignores the client's wishes and offers no alternative behavior. Telling the client that the primary healthcare provider will have to be called shifts responsibility to the primary healthcare provider; the nurse should know that a shopping trip is unrealistic at this time. Telling the client that no one is available to accompany the client does not deal with reality and only postpones the need to address the problem directly.

When teaching about the tricyclic group of antidepressant medications, which information should the nurse include? A. Strong or aged cheese should not be eaten while taking this group of medications. B. The full therapeutic potential of tricyclics may not be reached for four weeks. C. Long-term use may result in physical dependence. D. Tricyclics should not be given with antianxiety agents.

Correct answer: B A client needs to be advised that it may take several weeks for tricyclic medications to reach their full therapeutic effect and for relief of symptoms to be noted.

A client has been diagnosed with major depression. The psychiatrist prescribes paroxetine (Paxil). Which of the following medication information should the nurse include in discharge teaching? A. Do not eat chocolate while taking this medication. B. The medication may cause priapism. C. The medication should not be discontinued abruptly. D. The medication may cause photosensitivity.

Correct answer: C Antidepressants such as paroxetine must be tapered and not stopped abruptly. All classifications of antidepressants have varying potentials to cause discontinuation syndromes. Abrupt withdrawal from SSRIs, such as paroxetine, may result in dizziness, lethargy, headache, and nausea.

Bipolar disorder types: criteria

Criteria also depends on intensity and duration

The Transactional Model

Depression is likely related to multiple factors, including genetic, biochemical and psychosocial

ELECTROCONVULSIVE THERAPY (ECT)

ECT- *used primarily for severely psychotic depressed patients* -90% remission rate -Side effects: Short term memory loss. -Confusion and disorientation may be present upon awakening after the treatment. -Medications used: Robinul, Diprivan, Anectine

SSRI's: Effective For Sadness, Panic, & Compulsions

Effective- *Escitalopram* For- *Fluoxetine* *Fluvoxamine* Sadness- *setroline* Panic- *Paroxetine* Compulsions- *Citalopram*

Bipolar disorder Types: Bipolar I

Full episodes of BOTH: (alternating) 1. depression 2. mania

Bipolar disorder Types: Bipolar II

Hypomanic episodes alternating with depression.

Depression: Treatment modalities *7*

Individual Psychotherapy Group Therapy Family Therapy Cognitive Therapy Electroconvulsive Therapy Transcranial Magnetic Stimulation Light Therapy

Depression: Planning/Implementation *7*

Nursing interventions are aimed at: 1. Maintaining client safety 2. Assisting client through grief process 3. Promoting increase in self-esteem 4. Encouraging client self-control and control over life situation 5. Helping client to reach out for spiritual support of choice 6. Assistance in confronting anger that has been turned inward on the self 7. Ensuring that needs related to nutrition, elimination, activity, rest, and personal hygiene are met

SUICIDE: TREATMENT MODALITIES

PSYCHOLOGICAL TREATMENTS Individual psychotherapy Group therapy Family therapy Cognitive therapy ORGANIC TREATMENTS ECT Psychopharmacology Alternative or Complementary therapy

Predisposing Factors to Depression: Physiological Influences *6*

Physiological Influences Medication side effects Neurological disorders Electrolyte disturbances Hormonal disorders Nutritional deficiencies Other physiological conditions

MANIC ATTACK S/S: (image)

QUALIFIERS: -3 + symptoms w/ one being *INCREASED ENERGY/ACTIVITY* -AT LEAST 1 wk *(BP1)* -AT LEAST 4 Days *(BP2)*

Bipolar disorder: Nursing Diagnosis *8*

Risk for other-directed violence Risk for self-directed violence Risk for injury Disturbed thought process Imbalanced nutrition, less than... Disturbed sleep pattern Self care deficit Impaired social interaction

Predisposing Factors to Depression: *developmental implications:* Childhood Depression

Symptoms 1. Younger than age 3: feeding problems, tantrums, lack of playfulness and emotional expressiveness 2. Ages 3 to 5: prone to accidents, phobias, excessive self-reproach 3. Ages 6 to 8: physical complaints, aggressive behavior, clinging behavior 4. Ages 9 to 12: morbid thoughts and excessive worrying -Precipitated by a loss *Focus of therapy: Alleviate symptoms and strengthen coping skills* -Parental and family therapy

Transient Depression

Symptoms at this level of the continuum not necessarily dysfunctional 1. Affective: the "blues" 2. Behavioral: some crying 3. Cognitive: some difficulty getting mind off of one's disappointment 4. Physiological: feeling tired and listless

Predisposing Factors to Depression: *developmental implications:* Adolescence

Symptoms include: 1. Anger, aggressiveness 2. Running away 3. Delinquency 4. Social withdrawal 5. Sexual acting out 6. Substance abuse 7. Restlessness, apathy -*Best clue that differentiates depression from normal, stormy adolescent behavior:* A visible manifestation of behavioral change that lasts for several weeks !!Most common precipitant to adolescent suicide: *Perception of abandonment by parents or close peer relationship* -Treatment with: Supportive psychosocial intervention Antidepressant medication *higher risk of suicide in child and adolescent*

Depression: Criteria for Measuring Outcomes *10*

The Client: 1. Has experienced no physical harm to self 2. Discusses the loss with staff and family members 3. No longer idealizes or obsesses about the lost entity 4. Sets realistic goals for self 5. Attempts new activities without fear of failure 6. Is able to identify aspects of self-control over life situation 7. Expresses personal satisfaction and support from spiritual practices 8. Interacts willingly and appropriately with others 9. Is able to maintain reality orientation 10. Is able to concentrate, reason, and solve problems

Bipolar disorders: GOALS

The client.. 1. Exhibits no evidence of physical injury 2. Has not harmed self or others 3. Is no longer exhibiting signs of physical agitation 4. Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status 5. Verbalizes an accurate interpretation of the environment 6. Accepts responsibility for own behaviors 7. Does not manipulate others for gratification of own needs 8. Interacts appropriately with others

Depressive Disorder Associated with Another Medical Condition

The depression is attributable to the direct physiological effects of a general medical condition.

Lithium carbonate toxicity

The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus.

Depression: Treatment modalities: Psychopharmacology *5*

Tricyclics (TCAs) SSRIs MAO inhibitors Heterocyclics SNRIs ACTION= 1. TCAs, heterocyclics, SSRIs, SNRIs *Block reuptake of norepinephrine, serotonin, and/or dopamine* 2. MAOIs *Inhibit monoamine oxidase, an enzyme known to inactivate norepinephrine, serotonin, and dopamine*

18. ___________________________ is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

mania