Exam 1 - Study Material

Question 1

What is Psychiatric nursing?

Answer 1

Nursing that focuses on the care and rehabilitation of people with identifiable mental illnesses or disorders

Question 2

What is Mental health nursing?

Answer 2

Nursing that focues on well and at risk patients to prevent mental illness or to provide immediate treatment for those with an early sign of a disorder.

Question 3

What is a Therapeutic Nurse-Patient Relationship?

Answer 3

It is a mutual learning experience and a corrective emotional experience for the patient. It is based on the humanity of the nurse and patient, mutual respect, and acceptance of sociocultural differences.

Question 4

What are the different phases of the Psychiatric Nurse-Patient relationship?

Answer 4

1. Preinteraction phase
2. Introductory or orientation phase
3. Working phase
4. Termination phase

Question 5

Describe the preinteraction phase of the Psychiatric Nurse-Patient relationship

Answer 5

• It is a time where the nurse explores his/her own professional strengths and limitations, explores thoughts and feelings about working in a psychiatric setting, gathers data about the patient and plans for the first interaction with the patient.
• Begins before the nurses 1st contact with the patient
• Involves self-analaysis on the nurses’s part

Question 6

Describe the Introductory or orientation phase of the Psychiatric Nurse-Patient relationship

Answer 6

You meet with the patient to:

• Determine why the patient sought help
• Establish mutual goals for their care with them
• Determine where you are going to meet and how often
• Discuss issues of confidentiality
• Establish a climate of trust and understanding
• To explore their perceptions, thoughts, and feelings
• To help the patient identify their problems

Question 7

Describe the working phase of the Psychiatric Nurse-Patient relationship

Answer 7

• The most therapeutic work is carried out during this phase
• The nurse and the patient explore stressors and promote the development of insight in the patient by linking perceptions, thoughts, feelings, and actions.
• This is the most difficult phase because patient do not want to change their behavior

Question 8

Describe the termination phase of the Psychiatric Nurse-Patient relationship

Answer 8

• This phase involves reviewing the progress of the therapy, exploring feelings of loss and rejection,
• It’s important to help the patient work and grow through the termination process, establish the reality of the separation.

Question 9

What are the different types of “space” a person has?

Answer 9

1. Intimate
2. Personal
3. Social-consultative
4. Public space

Question 10

Describe intimate space

Answer 10

• up to 18 inches
• This small degree of separation between people allows for maximal inter- personal sensory stimulation.

Question 11

Describe personal space

Answer 11

• 18 inches to 4 feet
• This zone is used for close relationships and when touching distance may be desired.

Question 12

Describe Social-consultative space

Answer 12

• 9 to 12 feet
• This zone is less personal; it requires that speech be louder

Question 13

Describe public space

Answer 13

• 12 feet and more
• This is used in speech giving and other large gatherings.

Question 14

What are 2 requirements for therapeutic communication?

Answer 14

1. All communication must preserve the self-respect of both individuals.
2. One should communicate understanding and acceptance before giving any suggestions or advice.

Question 15

What is the the first rule of a therapeutic relationship?

Answer 15

• Listen to the patient!
• It is the foundation on which all other therapeutic skills are built

Question 16

What are some therapeutic communication techniques?

Answer 16

1. Listening
2. Using Broad Openings
3. Broad Openings
4. Theme Identification
5. Restating
6. Silence
7. Clarification
8. Suggesting
9. Reflection
10. Humor
11. Informing
12. Sharing Perceptions
13. Focusing

Question 17

Define the “listening” therapeutic communication technique, give an example, and its value in practice.

Answer 17

• Definition: an active process of receiving information and examining reaction to the messages received
• Example: maintaining eye contact and receptive nonverbal communication
• Therapeutic value: nonverbally communicates to the patient the nurse’s interest and acceptance

Question 18

Define the “broad openings” therapeutic communication technique, give an example, and its value in practice.

Answer 18

• **Definition: **encouraging the patient to select topics for discussion
• Example: “What are you thinking about?”
• Therapeutic value: indicates acceptance by the nurse and the value of the patient’s initiative

Question 19

Define the “restating” therapeutic communication technique, give an example, and its value in practice.

Answer 19

• Definition: repeating the main thought the patient expressed
• Example: “You say that your mother left you when you were 5 years old.”
• Therapeutic value: indicates that the nurse is listening and validates, reinforces, or calls attention to something important that has been said

Question 20

Define the “clarification” therapeutic communication technique, give an example, and its value in practice.

Answer 20

• Definition: Attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding or asking the patient to explain what he means
• Example: “I’m not sure what you mean. Could you tell me about that again?”
• Therapeutic value: helps to clarify feelings, ideas, and perceptions of the patient and provides an explicit correlation between the nurse and the patient’s actions

Question 21

Define the “reflection” therapeutic communication technique, give an example, and its value in practice.

Answer 21

• Definition: directing back the patient’s ideas, feelings, questions or content
• Example: “You’re feeling tense and anxious, and it’s related to a conversation you had with your husband last night?”
• **Therapeutic value: **validates the nurse’s understanding of what the patient is saying and signifies empathy, interest and respect for the patient

Question 22

Define the “informing” therapeutic communication technique, give an example, and its value in practice.

Answer 22

• Definition: the skill of information giving
• Example:“I think you need to know more about how your medication works.”
• Therapeutic value: helpful in health teaching or patient education about relevant aspects of patient’s well-being and self-care

Question 23

Define the “focusing” therapeutic communication technique, give an example, and its value in practice.

Answer 23

• **Definition: **questions or statements that help the patient expand on a topic of importance
• Example: “I think that we should talk more about your relationship with your father.”
• **Therapeutic value: **allows the patient to discuss central issues and keeps the communication process goal directed

Question 24

Define the “sharing perceptions” therapeutic communication technique, give an example, and its value in practice.

Answer 24

• Definition: asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling
• Example: “You’re smiling, but I sense that you are really very angry with me.”
• Therapeutic value: conveys the nurse’s understanding to the patient and has the potential for clearing up confusing communication

Question 25

Define the “theme identification” therapeutic communication technique, give an example, and its value in practice.

Answer 25

• Definition: underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse-patient relationship
• Example: “I’ve noticed that in all of the relationships that you have described, you’ve been hurt or rejected by the man. Do you think this is an underlying issue?”
• Therapeutic value: allows the nurse to best promote the patient’s exploration and understanding of important problems

Question 26

Define the “silence” therapeutic communication technique, give an example, and its value in practice.

Answer 26

• Definition: lack of verbal communication for a therapeutic reason
• Example: sitting with a patient and nonverbally communicating interest and involvement
• Therapeutic value: allows the patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse’s support, understanding, and acceptance.

Question 27

Define the “Humor” therapeutic communication technique, give an example, and its value in practice.

Answer 27

• Definition: the discharge of energy through the comic enjoyment of the imperfect
• Example: “That gives a whole new meaning to the word nervous,” said with shared kidding between the nurse and patient.
• Therapeutic value: can promote insight by making conscious repressed material, resolving paradoxes, tempering aggression, and revealing new options; a socially acceptable form of sublimation

Question 28

Define the “suggesting” therapeutic communication technique, give an example, and its value in practice.

Answer 28

• Definition: presentation of alternative ideas for the patient’s consdieration relative to problem solving
• Example: “Have you thought about responding to your boss in a different way when he raises that issue with you? For example, you could ask him whether a specific problem has occurred.”
• Therapeutic value: increases the patient’s perceived options or choices

Question 29

What are responsive dimensions?

Answer 29

Characteristics crucial to establish trust and open communication in a relationship and help convey a sense of hope

Examples:

1. Genuineness
2. Respect
3. Empathic understanding
4. Concreteness

Question 30

What is genuineness?

Answer 30

To be an open, honest, sincere person who is actively involved in the relationship.

Question 31

What is respect?

Answer 31

Giving someone unconditional positive regard; the patient is regarded as a person of worth

Question 32

What is empathy?

Answer 32

The ability to enter into the life of another per- son, to accurately perceive the person’s current feelings and their meanings, and to communicate this understanding to the patient.

Question 33

What is concreteness?

Answer 33

• The use of specific terminology rather than abstractions when discussing the patient’s feelings, experiences, and behavior.
• It involves asking for examples and details rather than generalities.

Question 34

What is confrontation?

Answer 34

It is an expression by the nurse of perceived discrepancies in the patient’s behavior in which the nurse attempts to make the patient aware of incongruence in feelings, attitudes, beliefs, and behaviors.

Question 35

What is immediacy?

Answer 35

The process of focusing on the current interaction of the nurse and the patient in the relationship.

Question 36

What is self-disclosure?

Answer 36

• Subjectively true, personal statements about the self, intentionally revealed to another person.
• When self-disclosing, the nurse should have a par- ticular therapeutic goal in mind.

Question 37

What is Catharsis?

Answer 37

• A process that envolves encouraging a patient to talk about things that are most bothersome
• Catharsis brings fears, feelings, and experiences out into the open so that they can be examined and discussed with the nurse

Question 38

What is role playing?

Answer 38

• The process of acting out a particular situation
• It increases the patient’s insight into human relations and can deepen the ability to see the situation from another person’s point of view.
• it helps patients practice new and more adaptive behaviors.

Question 39

What are therapeutic impasses?

Answer 39

They are blocks in the progress of the nurse-patient relationship

Question 40

What are some examples of therapeutic impasses?

Answer 40

• Resistance
• Transference
• Countertransference
• Boundary violations

Question 41

What is resistance?

Answer 41

• the patient’s reluctance or avoidance of talking about or experiencing troubling aspects of oneself.
• Often caused by the patient’s unwillingness to change when the need for change is recognized (usually during the working phase)

Question 42

What is transference?

Answer 42

• An unconscious response in which patients experience feelings and attitudes toward the nurse that were originally associated with other significant figures in their life.
• It is characterized by the inappropriate intensity of the patient’s response.

Question 43

What is countertransference?

Answer 43

• A therapeutic impasse created by the nurse’s specific emotional response to the qualities of the patient.
• In such cases nurses identify the patient with individuals from their past, and personal needs interfere with their therapeutic effective- ness

Question 44

Describe boundary violations

Answer 44

• Occurs when a nurse goes outside the boundaries of the therapeutic relationship and establishes a social, economic, or personal relationship with a patient.
• As a general rule, whenever the nurse is doing or thinking of doing something special, different, or unusual for a patient, often a boundary violation is involved

Question 45

What were Hildegard Peplau’s contributions to nursing?

Answer 45

• She was Hildegard Peplau the mother of psych nursing; identified the heart of psych nursing as the role of counselor or psychotherapist
• Differentiated between general practice nurses who worked on a psych unit and psychiatric nurses who have graduate degrees and specialize in psych nursing
• Identified nursing as a significant therapeutic process

Question 46

What were Contributions of Linda Richards to nursing?

Answer 46

the first American psychiatric nurse; emphasized the physical AND emotional needs of the patient

Question 47

Describe Custodial care in 1800s

Answer 47

• Focused on the patient’s physical needs, such as medications, nutrition, hygiene, and ward activities
• Psych nurses had limited psych training and mostly used med-surg principles; their main qualification was being kind and more patient

Question 48

What are the functions of neurotransmitters?

Answer 48

• chemical “first” messengers
• Give rise to human activity, body functions, consciousness, intelligence, creativity, memory, dreams, and emotion
• Neurotransmission is a key factor in understanding how various regions of the brain function and how interventions, such as medications and other therapies, affect brain activity and human behavior

Question 49

What is the function of Dopamine?

Answer 49

• Involved in control of complex movements, motivation, and cognition and in regulating emotional responses
• Dopamine plats a role in the sensation of pleasure

Question 50

What is the function of Serotonin (5-HT)?

Answer 50

• Levels fluctuate with sleep and wakefulness, plats a role in arousal and modulation of general activity levels of CNS, particularly onset of sleep
• Involved in temperature regulation and pain-control system of body.

Question 51

What is the function of melatonin?

Answer 51

Induces pigment-lightening effects on skin cells and regulates reproductive and immune function.

Question 52

What is the function of acetylcholine?

Answer 52

• Plays a role in sleep-wakefulness cycle.
• Signals mus- cles to become active

Question 53

What is the function of Glutamate and where is it found?

Answer 53

• glutamate receptors control the opening of ion channels that allow calcium (essential to neurotransmission) to pass into nerve cells, propagating neuronal electrical impulses
• Found in all cells of body, where it is used to synthesize structural and functional proteins

Question 54

What are drugs that increase Gamma-aminobutyric acid (GABA) used for?

Answer 54

Drugs that increase GABA function, such as benzodiazepines, are used to treat anxiety and epilepsy and to induce sleep.

Question 55

What is the function of histamine and where is it located?

Answer 55

• May play a role in alertness and learning
• Located in diencephalon

Question 56

What are the functions of Endorphins, enkephalins, dynorphins, and endomorphins?

Answer 56

The opiates morphine and heroin bind to these endogenous opioid receptors on presynaptic neurons, blocking release of neurotransmitters and thus reducing pain

Question 57

What is the function of substance P?

Answer 57

Found in pain transmission pathway. Blocking release of substance P by morphine reduces pain.

Question 58

What are some changes seen in the brain with age?

Answer 58

• At birth, an infant’s brain is almost the same size as an adult’s brain and contains most of the brain cells for one’s entire life
• From birth, the brain matures from back to front. With aging, it degenerates in the opposite direction
• A newborn’s brain grows about three times its size in the first year
• The brains of 2-year-old children consume twice as much glucose as do adult brains
• Compared to an environment with little stimulation, a stimulating environment can give a child a 25% greater ability to learn
• By the age of 7 years, our brains are 95% their adult size
• It is a myth that we use only 10% of our brains. In fact, we use it all
• Your skin weights twice as much as your brain
• The brain can live for 4-6 minutes without oxygen, and then it begins to die. No oxygen for 5-10 minutes will result in permanent brain damage

Question 59

What is the function of the Cerebral cortex?

Answer 59

critical in decision making and higher order thinking, such as abstract reasoning

Question 60

What is the function of the limbic system?

Answer 60

involved in regulating emotional behavior, memory, and learning

Basal ganglia: coordinate involuntary movements and muscle tone

Question 61

What is the function of the Hypothalamus?

Answer 61

regulates pituitary hormones; temperature; and desires such as hunger, thirst, and sex drive

Question 62

What is the function of the Locus ceruleus?

Answer 62

makes NE, a neurotransmitter involved in the body’s response to stress

Question 63

What is the function of Raphe nuclei?

Answer 63

make serotonin, a neurotransmitter involved in the regulation of sleep, behavior, and mood

Question 64

What is the function of Substantia nigra?

Answer 64

makes dopamine, a neurotransmitter involved in complex movements, thinking, and emotions

Question 65

What is a Mental status exam?

Answer 65

Represents a cross section of the patient’s psychological life and the nurse’s observations and impressions at one point in time

Question 66

Describe the mental status exam

Answer 66

• The elements of the exam depend on the patient’s clinical presentation, as well as on the patient’s educational and sociocultural background
• Exam itself is usually divided into several parts; they can be arranged in different ways, as long as the nurse covers all the areas
• Some components of the exam are completed through simple observation of the patient, such as noting the patient’s clothing or facial expressions
• Other aspects require asking specific questions, such as those related to memory or attention span
• Most of all, the nurse should remember that the mental status exam does not reflect how the patient was in the past or will be in the future
• The mental status exam is an evaluation of the patient’s current state
• Info obtained during the exam is used along with other objective and subjective data

Question 67

What sections are on the mental status exam?

Answer 67

1. Appearance
2. Speech
3. Motor activity
4. Interaction during the interview
5. Affect
6. Perceptions
7. Thought content
8. Thought process
9. Level of consciousness
10. Level of concentration and calculation
11. Information and intelligence
12. Judgment
13. Insight

Question 68

In a mental status exam what would you observe for with appearance and what are its clinical implications?

Answer 68

Observe:

• apparent age, manner of dress, cleanliness, posture, gait, facial expressions, eye contact, pupil dilation or constriction, general state of health and nutrition

​​​Clinical implications:

• Dilated pupils are sometimes associated with drug intoxication
• Pupil constriction may indicate narcotic addiction
• Stooped posture is often seen in patients with depression
• Manic patients may dress in colorful or unusual attire

Question 69

In a mental status exam what would you observe for with speech and what are its clinical implications?

Answer 69

Observe for:

• Rate: rapid or slow
• Volume: loud or soft
• Amount: paucity, muteness, pressured speech
• Characteristics: stuttering, slurring of words, or unusual accents

Clinical implications:

• Speech disturbances are often caused by specific brain disturbances. For example, mumbling may occur in patients with Huntington chorea, and slurring of speech may occur in intoxicated patients

Question 70

In a mental status exam what would you observe for with motor activity and what are its clinical implications?

Answer 70

Observations:

• Level of activity: lethargic, tense, restless, or agitated
• Type of activity: tics, grimaces, or tremors
• Unusual gestures or mannerisms: compulsive behavior

Clinical implications:

• Excessive body movement may be associated with anxiety, mania, or stimulant abuse
• Little body activity may suggest depression, organic mental disorders, catatonic schizophrenia, or drug-induced stupor
• Tics and grimaces may suggest medication side effects
• Repeated motor movements or compulsive behavior may indicate OCD
• Repeated picking of lint or dirt off of clothing is sometimes associated with delirium or toxic conditiom

Question 71

In a mental status exam what would you observe for when
Interacting during the interview and what are its clinical implications?

Answer 71

Observations:

• is the patient hostile, uncooperative, irritable, guarded, apathetic, defensive, suspicious, or seductive? The nurse may explore the observed behavior by asking, “You seem irritated by something. Is that true?”

Clinical implications:

• Suspiciousness may be evident in patients with paranoia
• Irritability may suggest an anxiety disorder

Question 72

In a mental status exam what is “mood” and what would you observe for?

Answer 72

Mood is:

• a self-report of one’s emotional state and reflects the patient’s life situation

Observations:

• If the potential for suicide is suspected, the nurse should ask the patient directly about thoughts of self-harm. To judge a patient’s suicidal or homicidal risk, the nurse should assess the patients plans, the patient’s ability to carry out those plans, the patient’s attitude about death, and support systems available to the patient

Question 73

In a mental status exam what is “affect”, what would you observe for, and what are its clinical implications?

Answer 73

Affect is:

• the patient’s apparent emotional tone

Observations: affect can be described in terms of

• Range
• Duration
• Intensity
• Appropriateness
• Flat affect: the absence of emotional expression, as seen by a patient who reports significant life events without showing any emotional response
• Labile affect: expression by undergoing frequent changes from one affective response to another quickly in the same conversation
• The nurse should also assess whether the patient’s emotional response is congruent or in agreement with the speech content; for example, it would be incongruent if a patient reports being persecuted by the police and then laughs

Clinical observations:

• Labile affect is often seen in patients with mania
• Flat affect and incongruent affect are often evident in those with schizophrenia

Question 74

What are Hallucinations?

Answer 74

• A hallucination is a perception in the absence of a stimulus
• They are false sensory impressions or experiences
• These sensory impressions are generated by the mind rather than by any external stimuli, and may be seen, heard, felt, and even smelled or tasted by the patient

Question 75

What are Illusions?

Answer 75

false perceptions or false responses to a sensory stimulus

Question 76

What are Command hallucinations?

Answer 76

are those that tell the patient to do something, such as kill oneself, harm another, or join someone in the afterlife

Question 77

In a mental status exam what would you observe for with perceptions and what are its clinical implications?

Answer 77

Observations: hallucinations may occur in any of the five major sensory modalities:

• Auditory – sound
• Visual – sight
• Tactile – touch
• Gustatory – taste
• Olfactory – smell
• Cenesthetic: feeling body functions such as blood pulsing through veins, food digesting, or urine forming
• Kinesthetic: sensation of movement while actually motionless

Clinical implications:

• Auditory hallucinations suggest schizophrenia
• Visual hallucinations suggest organic mental disorders
• Tactile hallucinations suggest organic mental disorders, cocaine abuse, and delirium tremens

Question 78

In a mental status exam what is “thought content”, what would you observe for, and what are its clinical implications?

Answer 78

Thought content:

• refers to “what” the patient is thinking

**Observations: **

• Delusions: false belief that is firmly maintained even though it is not shared by others and is contradicted by social reality (may be religious, somatic, grandiose, or paranoid)
• Thought broadcasting: belief that one’s thoughts are being aired to the outside world
• Thought insertion: belief that thoughts are being placed into one’s mind by outside people or influences
• Depersonalization: the feeling of having lost self-identity and that things around the person are different, strange, or unreal
• Hypochondriasis: somatic over concern with and morbid attention to details of body functioning
• Ideas of reference: incorrect interpretation of casual incidents and external events as having direct personal references
• Magical thinking: belief that thinking equates with doing, characterized by lack of realistic relationship between cause and effect
• Nihilistic ideas: thoughts of nonexistence and hopelessness
• Obsession: an idea, emotion, or impulse that repetitively and insistently forces itself into consciousness, although t is unwelcome
• Phobia: a morbid fear associated with extreme anxiety

Clinical implications:

• Obsessions and phobias are associated with anxiety disorders
• Delusions, depersonalization, and ideas of reference suggest schizophrenia and other psychotic disorders
• it is important that the nurse only obtain information about the patient’s thinking and not challenge or try to correct the patient’s beliefs

Question 79

In a mental status exam what is “thought process”, what would you observe for, and what are its clinical implications?

Answer 79

Thought process:

• “how” of the patient’s self-expression

Observations:

• Circumstantial: thought and speech associated with excessive and unnecessary detail that is usually relevant to a question, and an answer is eventually provided
• Flight of ideas: over-productive speech characterized by rapid shifting from one topic to another and fragmenting ideas
• Loose associations: lack of a logical relationship between thoughts and ideas that renders speech and thought inexact, vague, diffuse, and unfocused
• Neologisms: new word or words created by the patient; often a blend of other words
• Perseveration: involuntary, excessive continuation or repetition of a single response, idea, or activity; may apply to speech or movement, but most often verbal
• Tangential: similar to circumstantial but the person never returns to the central point and never answers the original question
• Thought blocking: sudden halt in the train of thought or in the middle of a sentence
• Word salad: series of words that seem totally unrelated

Clinical implications:

• Circumstantial thinking may be a sign of defensiveness or paranoid thinking
• Loose associations and neologisms suggest schizophrenia or other psychotic disorders
• Flight of ideas indicates mania
• Perseveration is often associated with brain damage and psychotic disorders
• Word salad represents at the highest level of thought disorganization

Question 80

In a mental status exam what would you observe for with level of consciousness and what are its clinical implications?

Answer 80

Observations:

• Can be described as confused, sedated, or stuporous
• In addition, the patient should be questioned regarding orientation to time, place, and person

Clinical implications:

• Patients with organic mental disorders may give grossly inaccurate answers, with orientation to person remaining intact longer than orientation to time or place
• Patients with schizophrenic disorders may say that they are someone else or somewhere else or reveal a personalized orientation to the world

Question 81

In a mental status exam what would you observe for with memory and what are its clinical implications?

Answer 81

Observations:

• Remote memory: recall of events, info, and people from the distant past
  
  • Confabulation is a possibility, because the nurse can’t tell what is true and isn’t from the past; the patient may make up stores about situations or events that cannot be remembered
• Recent memory: recall of events, info, and people from the past week or so
• Immediate memory: recall of info or data to which a person was just exposed

Clinical implications:

• Loss of memory occurs with organic mental disorders, dissociative disorder, and conversion disorder
• Patients with Alzheimer disease retain remote memory longer than recent memory
• Anxiety and depression can impair immediate retention and recent memory

Question 82

In a mental status exam what is “Level of concentration and calculation”, what would you observe for, and what are its clinical implications?

Answer 82

Concentration:

• is the patient’s ability to pay attention during the course of the interview

Calculation:

• is the person’s ability to do simple math

Observations:

• Calculation can be assessed by:
  
  • Counting from 1 to 20 rapidly
  • Do simple calculations
  • Serially subtract 7 from 100

Clinical implications:

• Many psychiatric illnesses impair the ability to concentrate and complete simple calculations
• It is particularly important to differentiate among organic mental disorder, anxiety, and depression

Question 83

In a mental status exam what would you observe for with Information and intelligence and what are its clinical implications?

Answer 83

Observations:

• The nurse should assess the patient’s last grade of schooling completed, general knowledge, and use of vocabulary

Clinical implications:

• The patient’s educational level and any learning disabilities should be carefully evaluated
• Mental retardation should be ruled out whenever possible
• The patient’s level of literacy may be part of a general assessment, but it also is an important factor in any health teaching or didactic information presented to the patient
• the nurse should be cautious about judging intelligence after a brief and limited contact typical of the time it takes to conduct a mental status exam

Question 84

In a mental status exam what is “judgement”, what would you observe for, and what are its clinical implications?

Answer 84

Judgment:

• involves making decisions that are constructive and adaptive

Observations:

• can be evaluated by exploring the patient’s involvement in activities, relationships, and vocational choices

Clinical implications:

• Judgment is impaired in organic mental disorders, schizophrenia, psychotic disorders, intoxication, and borderline or low IQ

Question 85

In a mental status exam what is “insight”, what would you observe for, and what are its clinical implications?

Answer 85

Insight:

• the patient’s understanding of the nature of one’s problem or illness

Observations:

• important for the nurse to determine whether the patient accepts or denies the presence of a problem or illness; in addition, the nurse should ask if the patient blames the problem on someone else or some external factors

Clinical implications:

• Insight is impaired in those with many psychotic illnesses, including organic mental disorders, psychosis, substance abuse, eating disorders, personality disorders, and borderline or low IQ
• Whether a patient sees the need for treatment is important to the formation of the therapeutic alliance, establishment of mutual goals, and implementation of and adherence to the treatment plan
• Motivational interviewing can assess the patient’s readiness to change

Question 86

What is The mini-mental state examination (MMSE)?

Answer 86

a simplified, scored form of the cognitive mental status exam with 11 questions; requires 5-10 minutes

Question 87

What are some Intelligence tests?

Answer 87

1. Wechsler Adult Intelligence Scale (WAIS)
2. Wechsler Intelligence Scale for Children (WISC)

• Projective tests: reflect aspects of a person’s personality, including reality testing ability, impulse control, ego defense, interpersonal conflicts, and self-concept

Question 88

What is the purpose of Behavioral rating scales
?

Answer 88

• Measure the extent of the patient’s problems
• Make an accurate diagnosis
• Track patient progress over time
• Document the efficacy of treatment

Question 89

What is Primary prevention?

Answer 89

lowering the incidence of a mental disorder by reducing the rate at which new cases of a disorder develop

Question 90

What is Secondary prevention?

Answer 90

involves decreasing the prevalence of a mental disorder by reducing the number of existing cases through early case finding, screening, and prompt, effective treatment

Question 91

What is Tertiary prevention?

Answer 91

attempts to reduce the severity of a mental disorder and its associated disability through rehabilitative activities

Question 92

What are Maturational crises?

Answer 92

• developmental events requiring role changes
• Transitional periods during adolescence, parenthood, marriage, midlife, and retirement are key times for the onset of maturational crises

Question 93

What are Situational crises?

Answer 93

• occur when a life event upsets an individual’s or group’s psychological equilibrium
• Examples: loss of a job, loss of a loved one, unwanted pregnancy, onset or worsening of a medical illness, divorce, school problems, witnessing a crime

Question 94

What is Neurosis:?

Answer 94

describes a mental disorder characterized by anxiety that involves no distortion of reality; neurotic disorders are maladaptive anxiety responses associated with moderate and severe levels of anxiety

Question 95

What is Psychosis?

Answer 95

• disintegrative and involves a significant distortion of reality; can emerge with the panic level of anxiety
• The medical diagnoses related to anxiety include panic disorder with or without agoraphobia, agoraphobia, specific phobia, social phobia, OCD, PTSD, acute stress disorder, and GAD

Question 96

What is Stigma reduction?

Answer 96

An important aspect of mental health promotion involves activities related to dispelling myths and stereotypes associated with vulnerable groups, providing knowledge of normal parameters, increasing sensitivity to psychosocial factors affecting health and illness, and enhancing the ability to give sensitive, supportive, and humanistic health care

Question 97

What is a stigma and what are the 3 types?

Answer 97

• Stigma: a mark of disgrace or discredit that is used to identify and separate out people whom society sees as deviant, sinful, or dangerous;
• Three types:
  
  • Public – what the public does to those with mental illness
  • Self – when individuals internalize public stigma and harm themselves
  • Label avoidance - when individuals who are not mentally ill avoid mental health care so as not to be marked with the label

Question 98

Health consequences of stigmas?

Answer 98

• Makes people conceal or deny their symptoms
• Results in delays in treatment
• Discourages adherence to effective treatments
• Isolates the individual and family
• Lowers self-esteem and potential for self-care
• Limits access to quality health care
• Negatively affects the attitudes of health care providers
• Contributes to more severe forms of illness
• Limits the community’s response to illness
• Stigma reduction initiatives must take place on both individual and community levels
• Everyone needs to understand that no one is immune to mental illness or emotional problems and that the fear, anxiety, and even anger felt about some people who experience these problems may reflect some of our own deepest fears and anxieties

Question 99

What does the DSMV 5 axes 1 classify?

Answer 99

clinical syndromes

Question 100

What does the DSMV 5 axes 2 classify?

Answer 100

• personality disorders
• Axis I and II include the entire classification of mental disorders plus conditions that are not attributable to a mental disorder but that are a focus of attention or treatment

Question 101

What does the DSMV 5 axes 3 classify?

Answer 101

• general medical conditions
• Axis III allows the clinician to identify any physical disorder relevant to the understanding or treatment of the individual

Question 102

What does the DSMV 5 axes 4 classify?

Answer 102

• psychosocial and environmental problems
• Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders

Question 103

What does the DSMV 5 axes 5 classify?

Answer 103

• global assessment of functioning
• Axis V is for reportingthe clinician’s judgment of the individual’s overall level of functioning

Question 104

What is voluntary admission and what are some of its characteristics?

Answer 104

Voluntary admission:

• any citizen of lawful age may apply in writing for admission to a public or private psychiatric hospital

Characteristics:

• The person agrees to receive treatment and abide by hospital rules
• If someone is too ill to apply but voluntarily seeks help, a parent or legal guardian may request admission (people under the age of 16)
• Voluntary admission is preferred because it is similar to a medical hospitalization and indicates that the patient acknowledges problems in living, seeks help in coping with them, and will participate in finding solutions
• When voluntarily admitted, the patient retains all civil rights, including the right to vote, have a driver’s license, buy and sell property, manage personal affairs, hold office, practice a profession, and engage in a business

Question 105

What is involuntary admission?

Answer 105

Involuntary admission (commitment):

• Means that the patient did not request hospitalization and may have opposed it or was indecisive and did not resist it; most laws permit commitment of the mentally ill on one or more of the following three grounds:
  
  1. Dangerous to self or others
  2. Mentally ill and in need of treatment
  3. Unable to provide for own basic needs
• Emergency hospitalization: most state laws limit the length of emergency commitment to 48-72 hours

*

Question 106

Describe the commitment process

Answer 106

Commitment process:

• Begins with a sworn petition by a relative, friend, public official, physician, or any interested citizen stating that the person is mentally ill and needs treatment
• Then, one or two physicians must assess the person’s mental status (some states require psychiatrist)
• The decision of whether to hospitalize the patient is made next; the person who makes the decision determines the nature of the commitment:
  
  • Medical certification means that physicians make the decision
  • Court or judicial commitment is made by a judge or jury in a formal hearing
  • Administrative commitment is determined by a special tribunal of hearing officers

Question 107

What is Short term or observational hospitalization?

Answer 107

: used for diagnosis and short term therapy and does not require an emergency situation

Question 108

What is Long term hospitalization?

Answer 108

provides for hospitalization for an indefinite time or until the patient is ready for discharge

Question 109

What are the patients rights while in the hospital?

Answer 109

1. Right to communicate
2. Right to keep personal effects
3. Right to enter into contractual relationships
4. Right to education
5. Right to habeas corpus:
6. Right to privacy:

Question 110

Describe a patient’s right to communicate

Answer 110

Right to communicate with people outside the hospital with telephone privileges, sending letters, etc

Question 111

Describe a patient’s right to keep personal effects

Answer 111

patient may bring clothing and personal items to the hospital, taking into consideration the amount of storage space available

Question 112

Describe a patient’s right to enter into contractural relationships

Answer 112

• court considers contracts valid if the person understands the circumstances of the contract and its consequences

Question 113

What is Incompetence?

Answer 113

Incompetence: a legal term without a precise medical meaning; the following must be shown in court:

• The person has a mental disorder
• This disorder causes a defect in judgment
• This defect makes the person incapable of handling personal affairs
• If ruled incompetent, a person cannot vote, marry, drive, or make contracts

Question 114

Describe a patient’s right to habeas corpus

Answer 114

provides for the speedy release of any person who claims to be detained illegally

Question 115

Describe a patient’s right to privacy

Answer 115

confidentiality means not disclosing information about a person to someone else unless authorized by that person

Question 116

Describe a healthcare worker’s responsibility to a patient’s privacy

Answer 116

• Every psychiatric professional is responsible for protecting a patient’s right to confidentiality, including even the knowledge that a person is in treatment or a hospital
• Clinicians are free from legal responsibility if they release information after they obtain the patient’s written and signed consent
• HIPAA guarantees patients four rights related to the release of information:
  
  • To be educated about HIPAA privacy protection
  • To have access to their own medical records
  • To request correction or amendment of their health information to which they object
  • To require their permission for disclosure of their own personal information

Question 117

Who doe the original medical record belong to?

Answer 117

The physical record is property of the treatment facility or therapist, but the information inside of it belongs to the patient; thus the original record should never be given to the patient; only a copy of it should be provided

Question 118

What is Testimonial privilege?

Answer 118

• applies only in court related proceedings; includes communication between husband and wife, attorney and client, and clergy and church member
  
  • The right to reveal information belongs to the person who spoke, and the listener cannot disclose the information unless the speaker gives permission
  • Testimonial privilege between health professionals and patients exists only if established by law

Question 119

What is the Circle of confidentiality?

Answer 119

• A model that shows with whom patient information may be shared with
• Within the circle are treatment team members, staff supervisors, health care students and their faculty, and consultants who actually see the patient
  
  • All these people must be informed about the patient’s clinical condition to be able to help
  • The patient is also inside the circle because they can reveal any aspect of their lives, problems, treatments, and expierences to anyone

Question 120

What is major depressive disorder?

Answer 120

A mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or longer. It can occur once or repeatedly over the course of a lifetime.

Question 121

What are the Diagnostic Criteria for
Major Depression?

Answer 121

Five or more of the following symptoms occurring in the same two week period:

1. Weight gain or loss
2. Insomnia or hypersomnia
3. Psychomotor agitation or retardation
4. Fatigue
5. Feelings of worthlessness
6. Impaired concentration
7. Thoughts of suicide or death

​**AND **At least one major symptoms:

1. Depressed mood
2. Anhedonia (inability to experience pleasure from activities usually found enjoyable)

Question 122

What role does genetics play in mood disorders?

Answer 122

• Both heredity and environment play an important role in severe mood disturbances; MDD and bipolar are familial disorders
• The lifetime risk is 20% for relatives of people with depression and 24% for relatives of people with bipolar disorder
• Identical twins has a 2-4 times greater risk than fraternal twins

Question 123

What are some Essential features of major depressive disorder?

Answer 123

• May involve a single episode or a recurrent depressive illness but does not include a manic episode
• Behaviors associated with depression: key element of a behavioral assessment is change of the patient’s usual patterns
• Anxiety often accompanies depression
• Somatic complaints
• Postpartum onset

Question 124

What are some characteristics of depression?

Answer 124

• Culture affects the symptomatic expression, clinical presentation, and effective treatment of depression
• A high incidence of depression is found among all patients hospitalized for medical illnesses & Depressive conditions are highly prevalent in primary care setting
• More than 50% of those who have one episode will eventually have another, and 25% of patients will have chronic, recurrent depression
• Only one third of all people with depression seek help, are accurately diagnosed, and obtain appropriate treatment

Question 125

What are the different types of depression screening tools?

Answer 125

• Beck Depression Inventory
• Zung self-Rating Depression Scale
• Hamilton Depression Rating Scale
• Center for Epidemiological Studies – Depression Scale

Question 126

What are some nursing interventions for depression?

Answer 126

• Physical care, psychopharmacology, somatic therapies
• Cognitive Behavioral Therapy: help patients explore their feelings and their view of the problem; focus on modifying the patient’s thinking; the patient can be helped to examine the accuracy of perceptions, logic, and conclusions
• Be quiet, warm, and accepting
• Rapport is best established with the depressed patient through shared time, even if the patient talks little, and through supportive companionship
• Sleep deprivation therapy
• Express feelings of hope for patient and that the future will be better; tell patient that expressing feelings is normal and necessary

Question 127

What are some goals in the plan of care for patients with mood disorders?

Answer 127

The patient will be emotionally responsive and return to a preillness level of functioning

Goals:

• To allow recognition and continuous expression of feelings, including denial, hopelessness, anger, guilt, blame, helplessness, regret, hope, and relief, within a supportive therapeutic atmosphere
• To allow for gradual analysis of stressors while strengthening the patient’s self-esteem
• To increase the patient’s sense of identity, control, awareness of choices, and responsibility for behavior
• To encourage healthy interpersonal ties with others
• The promote understanding of maladaptive emotions and to acquire adaptive coping responses to stressors
• Specific short-term goals should be developed based on the behaviors of the patient, present areas of difficulty, and relevant stressors
• The patient’s participation in setting these goals can be significant first steps in regaining mastery over life

Question 128

What are some medications used to treat depression?

Answer 128

• Tricyclic antidepressants (TCA)
• Monoamine oxidase inhibitors (MAOIs)
• Selective serotonin reuptake inhibitors (SSRI)
• Other antidepressants

Question 129

What are Kubler-Ross’s Stages of Grief?

Answer 129

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Question 130

What is a Delayed grief reaction?

Answer 130

persistent absence of emotion with undue delay in work of mourning or grieving

Question 131

What is a Distorted grief reaction?

Answer 131

Emotions triggered by deliberate recall of circumstances surrounding loss or occurrence

Question 132

What are some nursing interventions for grief?

Answer 132

• Assess stage in the grief process.
• Help actualize the loss by talking about it.
• Encourage expression of feelings.

Question 133

What is uncomplicated grief?

Answer 133

It is an adaptive response, it is a self-limited process of realization that makes the fact of the loss real

Question 134

What is Dysthymia (Persistent Depressive Disorder)?

Answer 134

• It is a milder form of depression lasting 2 or more years.
• It is a chronic condition, and many patients with dysthymia eventually develop major depressive episodes, but there are fewer related depressive symptoms

Question 135

What are some Nonpharmacological treatments for mood disorders?

Answer 135

• Cognitive and behavioral therapy
• Phototherapy
• Sleep deprivation therapy
• Transcranial magnetic therapy
• Vagal nerve stimulation
• Electroconvusive therapy

Question 136

What is cognitive and behavioral therapy and what are the 3 goals for this therapy?

Answer 136

• It is a method of changing patient’s thought processes, behaviors, and emotions.
• Has proven efficacy for both depressive and bipolar disorders
• Nurses have three major aims:
  
  • To increase the patient’s sense of control over goals and behavior
  • To increase the patient’s self-esteem
  • To help the patient modify dysfunctional thinking patterns

Question 137

What is phototherapy?

Answer 137

• Light therapy; a physiological treatment in which patients are exposed to bright artificial light for a specified amount of time each day
• Appears to be effective in the short-term treatment of mild to moderate SAD

Question 138

What is sleep deprivation therapy?

Answer 138

Research indicates that depriving some depressed patients of a night’s sleep improves their clinical condition; MOA is unknown

Question 139

What is Transcranial magnetic therapy?

Answer 139

• Noninvasive procedure in which a changing magnetic field is introduced into the brain to influence the brain’s activity with the goal of treating mood disorders
• Adverse effect: potential for inducing seizures
• With TMS the brain is directly stimulated to produce neurochemical changes

Question 140

Why is vagal nerve stimulation used and what are some side effects of this therapy?

Answer 140

• It is used in the treatment of affective disorders, particularly treatment resistant depression
• The left vagus is used because it is composed of mostly afferent sensory fibers that connect to the brainstem and deep brain structures
• Side effects: hoarseness, throat pain, neck pain, headache, SOB

Question 141

What is electroconvulsive therapy and for what type of patients is this therapy used for?

Answer 141

• ECT is a specific therapy for patients with severe depressions who have somatic delusions and delusional guilt accompanied by a lack of interest in the world, suicidal ideation, and weight loss
• Used with depressed patients, particularly those with recurrent depressions and resistance to drug therapy

Question 142

What are some side effects of electroconvulsive therapy?

Answer 142

• Cardiovascular effects
• Systemic effects include: headaches, nausea, muscle soreness, and drowsiness may occur
• Cognitive effects: confusion immediately after the seizure and memory disturbance during the treatment course
  
  • Short term memory loss
• AFTER ECT check vital signs and precautions from general anesthesia

Question 143

What are some nursing interventions for patients having electroconvulsive therapy?

Answer 143

• Emotional support and education
• Pretreatment nursing care: reviewing recommended consultations, noting that any abnormalities in lab tests have been addressed, and checking that equipment and supplies are adequate and functional
• Nurse should remain with the patient throughout the treatment to provide support
• Posttreatment care: the area should contain oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment
• The nurse should clarify that most memory problems will pass within several weeks

Question 144

What is bipolar disorder?

Answer 144

• A condition in which people go back and forth between periods of a very good or irritable mood and depression.
• The “mood swings” between mania and depression can be very quick

Question 145

What are some essential features of bipolar disorder?

Answer 145

• Includes one or more manic episodes, with our without a major depressive episode
• Manic behavior, the essential feature of bipolar disorder, is a distinct period of intense psychophysiological activation; the predominant mood is elevated or irritable
• Patients may have misperceptions about their power and importance and may involve themselves in senseless, irresponsible, or risky activities
• Grandiose symptoms are evident
• Physical changes they experience, such as abundant energy and heightened sexual appetite, are caused by inadequate nutrition, partly because manic patients have no time to eat; serious weight loss is also related to their insomnia and overactivity
• As mania intensifies, formal and logical speech is replaced by loud, rapid, and confusing language, referred to as pressured speech -> can lead to loose associations and flight of ideas
• May experience lability of mood with rapid shifts to periods of depression

Question 146

What is Bipolar disorder with rapid cycling?

Answer 146

Defined as having four or more episodes per year; four or more major depressive, manic, hypomanic, or mixed episodes within a 12 month period

Question 147

What is Bipolar 1 disorder?

Answer 147

Occurs when a patient has one or more manic episodes and often one or more major depressive episodes. They are not better explained by other psychiatric disorders and are not the direct result of a substance or other medical condition.

Question 148

What are the Criteria for a Manic Episode?

Answer 148

• Period of abnormally persistent, elevated, and expansive, or irritable mood, lasting at least one week.

Three or more of seven symptoms must be present:

• Inflated self esteem or grandiosity
• Decreased need for sleeping
• More talkative than usual or pressure to keep talking
• Flight of ideas or subjective experience that thoughts are racing
• Distractibility
• Increase in goal-directed activity
• Excessive involvement in pleasurable activities that have a high potential for painful consequences

Question 149

What are some characteristics of bipolar disorder?

Answer 149

• Risk factors are being female and having a family history of bipolar
• Most people start showing symptoms in their late teens
• On average, a person is free of symptoms for about 5 years between the first and second episodes
• Associated with increased premature mortality secondary to general medical illnesses

Question 150

What are some Behaviors Associated with Mania?

Answer 150

• Elevated, euphoric, or expansive moods
• Irritability
• Sleep disturbances
• Excessive spending
• Sexual overactivity
• Flamboyant dress
• Hyperactive, intrusive
• Grandiosity
• Verbosity
• Flight of ideas
• Rapid, pressured speech

Question 151

What is bipolar 2 disorder?

Answer 151

• Bipolar II is similar to bipolar I disorder, with moods cycling between high and low over time.
• However, in bipolar II disorder, the “up” moods never reach full-on mania. The less-intense elevated moods in bipolar II disorder are called hypomanic episodes, or hypomania.

Question 152

What is the criteria to be diagnosed with Bipolar 2 disorder?

Answer 152

• Presence or history of one or more major depressive episodes
• Presence or history of at least one hypomanic episode
• Has never had a manic episode
• Symptoms are not from a substance or general medical condition
  
  • Symptoms can cause significant distress or impair social, occupational, or other functioning
• Other psychiatric disorders are ruled out

Question 153

What is hypomania?

Answer 153

• Persistently elevated, expansive, or irritable mood that is clearly different from usual for at least 4 days
• Has many of the symptoms of mania except no psychotic features
• Function has changed, which others have observed
• No marked impairment in social, occupational, or other functioning
• Hospitalization not required

Question 154

What is cyclothymic disorder?

Answer 154

It iss a disorder resembling bipolar disorder but with less severe symptoms, characterized by repeated periods of nonpsychotic depression and hypomania for at least two years

Question 155

What is the criteria to be diagnosed with cyclothymic disorder?

Answer 155

• Has for at least 2 years, had numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for major depressive episode
• Has not been without symptoms for more than 2 months at a time
• Has had no manic, hypomanic, or major depressive episodes during the 2 year period

Question 156

What are some nursing interventions for bipolar disorder?

Answer 156

• Patients with bipolar illness may be very talkative and need simple explanations and concise, truthful answers to questions
• Constrictive limit setting on manic patients’ behavior is an essential part of the plan
• One goal of nursing care is to increase the patient’s self-control, and this should be kept in mind when setting limits
• Physiological treatments
• Manic patients primarily need protection from themselves
• Non-adherence is a major problem
• Somatic therapy
• Expressing feelings: these patients are often hyperverbal and need help from the nurse in pacing and moderating their expression
• Helping the patients to speak more slowly and to follow one line of thought is an important area for nursing intervention
• Cognetive behavioral therapy: behavior change; social skill building
• Family group involvement
• Education

Question 157

What are some characteristics of suicide?

Answer 157

• 10th leading cause of death in the US
• 3rd leading killer of young people
• Are most likely under-reported
• Women attempt suicide three times as often as men: men are more likely to complete a suicide
• Highest rate of suicide is among Caucasian men over 80 years of age.
• Guns account for half of all completed suicides

Question 158

What are some risk factors for suicide?

Answer 158

• Hospitalized depressed patients
• Elderly patients
• Patients with alcoholism
• Depressed adolescents
• Patients with severe mood disturbances

Question 159

What are some nursing diagnoses for patients at risk for suicide and what are some goals for these patients?

Answer 159

Nursing diagnoses:

• Maladaptive self-protective responses are risk for suicide
• self-mutilation
• noncompliance
• risk for self-directed violence

Goals of care:

• Patient will not physically harm himself or herself; highest priority should be given to the preservation of life

Question 160

What are some nursing interventions for patients with suicide?

Answer 160

• Motivational interviewing
• Assess patient’s judgment, availability of a responsible family member or close friend who is willing to stay with the patient
• Protect the patient from harm!

Question 161

What are some issues related to protection and safety for suicide patients?

Answer 161

• The highest priority nursing activity with self-destructive patients is to protect them from inflicting further harm on themselves and, if suicidal, from killing themselves
• Suicidal patients may appear to be feeling much better immediately before making an attempt
• Although no suicide contracts have been used in clinical practice for many years, they have found to be NOT effective
• The patient should be supervised at all times
• The nurse should monitor any medications the patient receives

Question 162

What are some strategies to prevent suicide?

Answer 162

• Gun control and decreased availability of lethal weapons
• Limitations on the sale and availability of alcohol and drugs
• Increased public and professional awareness about depression and suicide
• Less attention to and reinforcement of suicidal behavior in the media
• Establishment of community-based crisis intervention clinics
• Campaigns to decrease the stigma associated with psychiatric care
• Increased insurance benefits for psychiatric and substance abuse disorders
• Develop broad-based support for suicide prevention
• Develop and implement strategies to reduce the stigma associated with being a consumer of mental health, substance abuse, or suicide prevention services
• Develop and implement suicide prevention programs
• Promote efforts to reduce access to lethal means and methods of self-harm
• Implement training for recognition of at-risk behavior and delivery of effective treatment
• Improve access to and community linkages with mental health and substance abuse services
• Improve reporting and portrayals of suicidal behavior, mental illness, and substance abuse in the entertainment and news media
• Promote and support research on suicide and suicide prevention
• Improve and expand surveillance systems

Question 163

What is the MOA for SSRI’S?

Answer 163

Block reuptake of serotonin at the presynaptic membrane. This results in an increase of available serotonin in the synapse and therefore at postsynaptic receptors, promoting serotonin neurotransmission

Question 164

What are the side effects for SSRI’S?

Answer 164

Weight gain, lower seizure threshold, serotonin syndrome, agitation, anxiety, nausea, diarrhea, insomnia, sexual dysfunction

Cytochrome p-450 inhibition

Question 165

What are the effects of inhibiting Cytochrome P-450?

Answer 165

• Inhibits metabolism of TCAs, trazodone, barbiturates, most benzodiazepines, carbamazepine, narcotics, neuroleptics, phenytoin, valproate, verapamil
• This effect can be potentially life threatening because it increases serum concentrations as well as therapeutic and toxic effects of these drugs

Question 166

What is serotonin syndrome and what are some characteristics?

Answer 166

• a life-threatening emergency resulting from excess CNS 5-HTcaused by combining 5-HT enhancing drugs or administering SSRIs too close to the discontinuation of MAOIs (SSRIs)
• confusion, disorientation, shivering, Dilated pupils, Headache, diarrhea, rapid heart rate, heavy sweating

Question 167

What is the MOA for Tricyclic Antidepressants?

Answer 167

serotonin and NE reuptake inhibition, as well as blockade of three receptors not implicated in depression: muscarinic cholinergic, histamine, and alpha-noradrenergic receptors

Question 168

What are the side effects of Tricyclic Antidepressants?

Answer 168

TCAs can have dangerous cardiac side effects and are lethal in overdose, sedation, weight gain, orthostatic hypotension, dizziness

Question 169

What is the MOA for MAOI’s?

Answer 169

inhibit both types of the enzyme( MAO A and MAO B) that metabolizes serotonin and norepinephrine; this inhibition is irreversible; lasting until the body is able to manufacture new MAO after the drug is discontinued

Question 170

What are the side effects of MAOI’s?

Answer 170

Dangerous elevation in blood pressure can result from high levels of NE not metabolized by MAO; avoid foods and drugs that are NE agonists, they can cause hypertensive crisis

Question 171

What is Tegretol used to treat and what are the side effects?

Answer 171

• Used to treat bipolar disorder
• Side effects: drowsiness, dizziness, ataxia, double vision, blurred vision, nausea, fatigue, GI upset, skin reactions, P450 drug, agranulocytosis (rare decrease in WBC that is permanent); lethal in overdose

Question 172

What is depakote used for and what are the side effects?

Answer 172

• Used for bipolar disorder, it is a derivative of valproic acid, it has a superior therapeutic index, a better toxicity profile, and a wider range of effectiveness in subtypes of bipolar disorder
• Side effects: GI complaints, tremor, sedation, headache, dizziness, ataxia, increased appetite/weight gain, thrombocytopenia, pancreatitis, hepatic dysfunction

Question 173

What is a hypertensive crisis and what are the signs and symptoms?

Answer 173

• A severe and potentially life-threatening increase in blood pressure and can be caused by MOI’s.
  
  • Don’t take foods with tiramine (no wine, cherries, cheeses, blue cheese, cheddar cheese, sour cream, alvacado, chocolates) and MAOI’s at the same time
• Symptoms include:
  
  • flushed face, dialated pupils, headaches

Question 174

What is the lithium and what is it used for?

Answer 174

A naturally occurring salt that is first line for patients with acute mania and for the long term prevention of recurrent episodes; exact MOA is unknown, but many neurotransmitter functions are altered by the drug

Question 175

What are some side effects of taking lithium?

Answer 175

Because it is excreted by the kidneys, it can adversely affect the thyroid, has a narrow therapeutic index and can quickly become fatal, initial and ongoing health assessment and laboratory monitoring is required; lithium toxicity is a medical emergency requiring rapid treatment

Question 176

What is the therapeutic range of lithium?

Answer 176

0.6 – 1.4 mEq/L Lithium in the blood

Question 177

What are some common causes of an increase in lithium levels?

Answer 177

• Decreased sodium intake
• Diuretic therapy
• Decreased renal functioning
• Fluid and electrolyte loss, sweating, diarrhea, dehydration, fever, vomiting
• Medical illness
• Overdose
• Nonsteroidal antiinflammatory drug therapy

Question 178

How would you manage a patient with lithium toxicity?

Answer 178

• Assess quickly; obtain rapid history of incident, especially dosing; offer support and explanations to the patient.
• Hold all lithium doses
• Obtain lithium blood level immediately; obtain electrolytes, BUN, creatinine, urinalysis, CBC when possible
• Vigorously hydrate: 5 to 6 L/day; balance electrolytes; IV line; indwelling urinary catheter
• Implement osmotic diuresis with urea or mannitol
• Ensure adequate intake of sodium chloride to promote excretion of lithium

Question 179

What is Schizophrenia?

Answer 179

A mental disorder that makes it hard to yell the difference between what is real and not real

Question 180

What causes schizophrenia?

Answer 180

Nobody is completely sure, there are:¨

• Neurophysiological theories
• Genetic theories
• Environmental and developmental factors
• Probably due to Abnormalities in brain structure

Question 181

What areas of the brain are affected in Schizophrenia?

Answer 181

• Pre-frontal cortex
• Anterior cingulate cortex
• Limbic regions-hippocampus
• Striatum

Question 182

What are some neurological soft signs associated with prefrontal cortical dysfunction in schizophrenia?

Answer 182

• Astereognosis: Inability to recognize objects by the sense of touch (e.g., differentiating a nickel from a dime)
• Agraphesthesia: Inability to recognize numbers or letters traced on the skin
• Dysdiadochokinesia: Impairment of the ability to perform smooth, alternating movements (e.g., turning the hand face up and face down rapidly)
• Mild muscle twitches, choreiform and ticlike movements, grimacing
• Impaired fine motor skills and abnormal motor tone Increased rate of eye blinking
• Abnormal smooth pursuit eye movements (SPEMs): Diff iculty following movement of objects

Question 183

What are some neurological hard signs associated with prefrontal cortical dysfunction in schizophrenia?

Answer 183

Loss of function, weakness, diminished reflexes, paralysis caused by a cerebrovascular accident, tumor, traumatic injury, etc

Question 184

What is the diagnostic criteria for schizophrenia?

Answer 184

A disturbance that lasts for at least 6 months and includes at least a month of active-phase symptoms” meaning 2 or more of the following:

• delusions
• hallucinations
• disorganized speech
• grossly disorganized or catatonic behavior
• negative symptoms

Question 185

What is the Onset, Course, and Prognosis for schizophrenia?

Answer 185

¨Peak incidence:

• Males: 15-25 years of age
• Females: 25-35 years of age

Course of illness:

• Extremely variable
• Often chronic
• Sometimes episodic only

Prognosis:

• Intensity of psychosis diminishes with age

Question 186

What are some factors related to poor prognosis’s with schizophrenai?

Answer 186

¨Factors related to poor prognosis:

• Early age of onset
• Insidious onset
• Poor premorbid adjustment
• Sustained emotional withdrawal
• Inappropriate affective response
• Enlarged cerebral ventricles
• Perinatal brain injury
• Poor response to medications

Question 187

What are some positive symptoms associated with schizophrenia?

Answer 187

• Delusions
• Hallucinations
• Though disorder
• Disorganized speech
• Bizarre behavior
• Inappropriate affect

Question 188

What are negative symptoms in relation to schizophrenia?

Answer 188

Diminished normal behaviors; diminution or loss of normal brain function; usually unresponsive to traditional antipsychotics and more responsive of atypical antipsychotics

Question 189

What are positive symptoms in relation to schizophrenia?

Answer 189

They are exaggerated normal behaviors; an exaggeration or distortion of normal brain function; usually responsive to all categories of antipsychotic drugs

Question 190

What are some negative symptoms associated with schizophrenia?

Answer 190

• Affective flattening
• Alogia
• Avolition/apathy
• Anhedonia/asociality
• Attentional deficit

Question 191

What are the gender differences associated with schizophrenia?

Answer 191

Tendencies of women compared with men:

• Late onset schizophrenia
• Less severe course of illness
• Exhibit more positive and less negative symptoms
• More affective symptoms
• Respond to lower doses of antipsychotic medication
• Higher level of social functioning
• Fewer structural brain abnormalities

Question 192

What are some Nursing Diagnoses related to schizophrenia?

Answer 192

• Impaired verbal communication
• Disturbed sensory perception
• Impaired social isolation
• Disturbed personal identity

Question 193

What are some expected outcoes with a patient with schizophrenia?

Answer 193

the patient will live, learn, and work at a maximum possible level of success, as defined by the individual

Question 194

What are the phrases of illness with schizophrenia?

Answer 194

• Acute phase
• Stabilization phase
• Stable phase
• Relapse

Question 195

What are some nursing interventions during the Acute Phase of schizophrenia?

Answer 195

• Provide for patient safety
• Reduction of over stimulation
• Stress reduction
• Establishment of therapeutic relationship
• Provide psychosocial education to patient and family

Question 196

What are some nursing interventions during the stabilization phase of schizophrenia?

Answer 196

• Psychoeducation
• Psychosocial Rehabilitation

Question 197

What are some nursing interventions during the stable phase of schizophrenia?

Answer 197

• Independent living skills training
• Social skills training
• Cognitive rehabilitation
• Vocational rehabilitation

Question 198

How would you treat relapses during schizophrenia?

Answer 198

Teach patient and family:

• Recognize warning signs
• Get to a safe place where someone can monitor symptoms
• Reduce stress demands
• Take medications
• Talk to a trusted person
• Avoid negative people

Question 199

What are hallucinations?

Answer 199

False perceptual distortions that occur in maladaptive neurobiological responses, and there is no identifiable external orinternal stimuluses.

Question 200

What are the different types of hallucinations?

Answer 200

• Auditory
• Visual
• Olfactory
• Gustatory
• Tactile
• Cenesthetic
• Kinesthetic

Question 201

What are auditory hallucinations?

Answer 201

Audible thoughts in which the patient hears voices that are speaking what the patient is thinking and commands that tell the patient to do something, sometimes harmful or dangerous

Question 202

What are some characteristics of visualhallucinations?

Answer 202

Visual stimuli in the form of flashes of light, geometric figures, cartoon figures, or elaborate and complex scenes or visions. Visions can be pleasant or terrifying, as in seeing monsters

Question 203

What are olfactory hallucinations?

Answer 203

Putrid, foul, and rancid smells such as blood, urine, or feces; occasionally the odors can be pleasant. Olfactory hallucinations are typically associated with stroke, tumor, seizures, and the dementias

Question 204

What are gustatory hallucinations?

Answer 204

Putrid, foul, and rancid smells such as blood, urine, or feces; occasionally the odors can be pleasant.

Question 205

What are tactile hallucinations?

Answer 205

Experiencing pain or discomfort with no apparent stimuli. Feeling electrical sensations coming from the ground, inanimate objects, or other people

Question 206

What are cenesthetic hallucinations?

Answer 206

Feeling body functions such as blood pulsing through veins and arteries, food digesting, or urine forming

Question 207

What are kinesthetic hallucinations?

Answer 207

Sensation of movement while standing motionless

Question 208

How would you manage hallucinations?

Answer 208

• Understanding characteristics of the hallucination and identifying the related anxiety level is important
• Remember Hallucinations are very real to the person having them
• Honesty, genuineness, and openness are the foundation for effective communication during hallucinations
• Maintain eye contact, speak simply and in a slightly louder voice than usual, call the patient by name, use touch as appropriate (patient needs sensory validation to override the abnormal sensory processes that are occurring in the brain)

Question 209

What is the goal of interventions for patients who are hallucinating?

Answer 209

To help them increase awareness of these symptoms so that they can distinguish between the world of psychosis and the world of reality experienced by others without schizophrenia

Question 210

How would you manage a patient with delusions?

Answer 210

• Patients cope with delusions in several ways. Some adapt by learning to live with them, others seek to understand the symptom and become empowered to manage delusions when they occur
• Development of trust is important; easier through nonverbal communication
• It is essential for the nurse to approach the patient with calmness and empathy
• Patients are sensitive to rejection; nurse should not underestimate the power of delusions
• Place the delusion in a time frame and identify triggers
• Assess the intensity, frequency, and duration of the delusion
• Identify emotional components of the delusion
• Observe for evidence of concrete thinking
• Observe speech for symptoms of a thought disorder
• Observe for the ability to accurately use cause and effect reasoning
• Distinguish between the description of the experience and the facts of the situation
• Carefully question the facts as they are presented and their meaning
• Discuss consequences of the delusion when the person is ready
• Promote distraction as a way to stop focusing on the delusion

Question 211

How would you prevent and management of Aggressive Behavior with schizophrenic patients?

Answer 211

• Self awareness
• Communication
• Maintain safe environment
• Administer psychopharmacology
• Crisis management
• Seclusion

When patient is aggressive try least restrictive measures first

Question 212

What is Neuroleptic Malignant Syndrome
?

Answer 212

A rare but potentially fatal (14% to 30% mortality) side effect of antipsychotic drugs, side effects include:

• fever
• tachycardia
• sweating
• muscle rigidity
• tremor
• incontinence
• stupor

Question 213

How would you treat neuroleptic malignant syndrome?

Answer 213

Treatment for NMS includes stopping the triggering drug and initiating supportive care

Question 214

What is cognition and how are people with schizophrenia affected?

Answer 214

• Cognition is the act or process of knowing
• People with schizophrenia are often unable to produce complex logical thoughts or express coherent sentences, because neurotransmission in the brain’s information processing system is malfunctioning

Question 215

What are some memory problems associated with schizophrenia?

Answer 215

• forgetfulness
• disinterest
• difficulty learning
• lack of compliance w/ meds

Question 216

What are some attention disturbances in schizophrenia?

Answer 216

• difficulty completing tasks
• difficulty concentrating on work
• distractibility

Question 217

Describe the form and organization of speech of patients with schizophrenia

Answer 217

• may include loose associations
• word salad
• tangentiality - with only slight relevance to the current subject
• illogicality
• circumstantiality
• pressured speech
• poverty of speech
• distractible speech
• clanging

Question 218

How do decision making problems affect patients with schizophrenia?

Answer 218

These problems affect one’s:

• insight
• judgment
• logic
• decisiveness
• planning
• ability to carry out decisions
• abstract thought

Question 219

What are some problems with thought content in schitzophrenic patients?

Answer 219

• Paranoia
• grandiosity
• religious
• nihilistic
• somatic delusions
  
  • Delusions can be further complicated by thought withdrawal, thought insertion, thought control, or thought broadcasting

Question 220

What is a delusion?

Answer 220

a personal belief based on an incorrect inference of external reality; false belief that is firmly maintained even though it is not shared by others and is contradicted by social reality

Question 221

What is a perception?

Answer 221

the identification and interpretation of a stimulus based on information received through sight, sound, taste, touch, and smell.

Question 222

What are some characteristics associated with emotion in schizophrenic patients?

Answer 222

• Mood and affect: broad, restricted, blunted, flat, and inappropriate
• Schizophrenics usually have symptoms of hypoexpression
• Alexithymia
• Anhedonia
• Apathy

Question 223

What is Alexithymia?

Answer 223

difficulty naming and describing emotions

Question 224

What is Anhedonia?

Answer 224

inability or decreased ability to experience pleasure, joy, intimacy, and closeness

Question 225

What is Apathy?

Answer 225

lack of feelings, emotions, interests, or concern

Question 226

What are some behaviors and movements associated with schizophrenic patients?

Answer 226

• Maladaptive behaviors in schizophrenia include deteriorated appearance, lack of persistence and work/school, avolition (lack of energy or drive), repetitive/stereotyped behavior, aggression, agitation, and negativism
• Maladaptive movements include catataonia, abnormal eye movements, grimacing, apraxia/echopraxia, abnormal gait, mannerisms, and extrapyramidal side effects of psychotropic medications

Question 227

What are some socializing problems experienced by schizophrenic patients?

Answer 227

• inability to communicate coherently
• Loss of drive and interest
• deterioration of social skills
• poor personal hygiene
• paranoia

Question 228

What are some specific problems seen in schizophrenic patients when developing relationships?

Answer 228

• Social inappropriateness
• disinterest in recreational activities
• inappropriate sexual behavior
• stigma-related withdrawal by friends, families and peers

Question 229

What are some atypical antipsychotics?

Answer 229

• Aripiprazole (abilify)
• Clozapine (Clozaril)
• Risperidone (Risperdal) = EPS, tardive dyskinesia
• Quetiapine (Seroquel) = draw cbc before drug is given, no new prescriptions given until the cbc is drawn
• Olanzapine (Zyprexa) = metabolic syndrome
• Ziprasidone (Geodon) = prolonged qt interval

Question 230

What is the MOA for Atypical antipsychotics?

Answer 230

block effects at the dopamine₂ and serotonin₂ postsynaptic receptors; thus, they are DA and 5-HT antagonists

Question 231

What are some characteristics of atypical antipsychotics?

Answer 231

• Apriprazole is unique in that it is the first of a new generation of atypical antipsychotics, a dopamine-serotonin stabilizer; it is a partial agonist at D₂ and 5-HT_1A receptors and has antagonistic activity at 5-HT_2A receptors
• Atypical antipsychotics improve the positive symptoms of schizophrenia, but unlike the typical drugs, they also improve the negative symptoms
• Reported to treat mood symptoms, hostility, violence, suicidal behavior, difficulty with socialization, and the cognitive impairment seen in schizophrenia

Question 232

What are the 2 great disadvantages of atypical antipsychotics?

Answer 232

• They can result in metabolic syndrome with problems related to weight gain, diabetes, and dyslipidemia, often resulting in cardiovascular disease
• They cost considerably more than the typical antipsychotics

Question 233

What are some side effects of atypical antipsychotics?

Answer 233

• Resperidone tends to elevate serum prolactin levels and may cause extrapyramidal effects at higher doses
• Sedation is commonly observed in patients taking quetiapine, olanzapine, or clozapine
• Zirpasidone has been associated with mild to moderate QT interval prolongation in up to 5% of patients
• Clozapine is often reserved for patients with treatment resistant illness because of its side effects of agranulocytosis, seizures, and myocarditis
• Severe allergic reaction can occur with Saphris

Question 234

What are some typical antipsychotic medications?

Answer 234

• Haloperidol (Haldol)
• Loxapine (Loxitane)
• Thioridazine (Mellaril)
• Molindone (Moban)

Question 235

What is the MOA for typical antipsychotics?

Answer 235

predominantly dopamine antagonists; they block postsynaptic D₂ receptors in several DA tracts in the brain, accounting for a decrease in positive symptoms of schizophrenia

Question 236

What are the side effects for typical antipsychotics?

Answer 236

• Extrapyramidal symptoms and tardive dyskinesia; result mainly from nonadherence with drug regimens
• A rare but potentially fatal side effect is neuroleptic malignant syndrome; S/S include fever, tachycardia, sweating, muscle rigidity, tremor, incontinence, and stupor
  
  • Treatment includes stopping the triggering drug and initiating supportive care

Question 237

How do extrapyramidal symptoms occur?

Answer 237

They often result in patient nonadherence with drug regimens

Question 238

What are the 2 categories of extrapyramidal symptoms?

Answer 238

• Dyskinesias are movement disorders.
• Dystonias are muscle tension disorders.

Question 239

What are dyskinesias?

Answer 239

Dyskinesias are movement disorders and can include any

of a number of repetitive, involuntary, and purposeless

body or facial movements:

• Tongue movements, such as “tongue thrusts” or “flycatching” movements
• Lip smacking
• Finger movements
• Eye blinking
• Movements of the arms or legs.
• An individual may or may not be aware of these movements.

These movements are recognizable, and many people

fear that others will know they are taking an antipsychotic medication due to these unusual movements

Question 240

What are some nursing considerations for extrampyramidal symptoms?

Answer 240

• General treatment principles:
• Tolerance usually develops by the third month.
• Decrease dose of drug.
• Add a drug to treat EPS; then taper after 3 months on the antipsychotic.
• Use a drug with a lower EPS profile.
• Give patient education and support.

Question 241

What are some drugs used to treat extrapyramidal side effects?

Answer 241

• Anticholinergics:
  
  • Benztropine
  • Trihexyphenidyl
  • Biperiden
• Antihistamine
  
  • Benadryl
• Dopamine agonist:
  
  • Amantadine
• Benzodiazepines
  
  • Diazepam
  • Lorazepam
  • Clonazepam

Question 242

When do tardive dyskinesia symptoms occur?

Answer 242

symptoms appear during long-term treatment (often after several years) with an antipsychotic. They are more likely to be permanent even after the medication

is stopped.

Question 243

What are some nursing considerations for tardive dyskinesia symptoms?

Answer 243

• Can occur after use (usually long use) of conventional antipsychotics
• stereotyped involuntary movements (tongue protrusion, lip smacking, chewing, blinking, grimacing, choreiform movements of limbs and trunk, foot tapping)
• if using typical antipsychotics, use preventive measures and assess often
• consider changing to an atypical antipsychotic drug
• there is no treatment at present for TD

Question 244

What is metabolic syndrome?

Answer 244

A group of problems related to weight gain, diabetes, dyslipidemia, often resulting in cardiovascular disease

Question 245

What are some nursing considerations for metabolic syndrome?

Answer 245

Patient education on healthy lifestyle—eating, exercise, smoking cessation.

Question 246

What is a religious delusion?

Answer 246

belief that one is favored by a higher being or is an instrument of that being

Question 247

What is a somatic delusion?

Answer 247

belief that one’s body or parts of one’s body are diseased or distorted

Question 248

What is a grandiose delusion?

Answer 248

belief that one possesses greatness or special powers

Question 249

What is a paranoid delusion?

Answer 249

excessive or irrational suspicion and distrust of others, characterized by systematized delusions that others are “out to get them” or spying on
them

Question 250

What is thought broadcasting?

Answer 250

belief that one’s thoughts are being aired to the outside world

Question 251

What is thought insertion?

Answer 251

belief that thoughts are being placed into one’s mind by outside people or influences

Question 252

What is depersonalization?

Answer 252

the feeling of having lost self-identity and that things around the person are different, strange, or unreal

Question 253

What is Hypochondriasis?

Answer 253

somatic overconcern with and morbid attention to details of body functioning

Question 254

What are ideas of reference?

Answer 254

incorrect interpretation of casual incidents and external events as having direct personal references

Question 255

What is magical thinking?

Answer 255

belief that thinking equates with doing, characterized by lack of realistic relationship between cause and effect

Question 256

What are nihilistic ideas?

Answer 256

thoughts of nonexistence and hopelessness

Question 257

What is an obsession?

Answer 257

an idea, emotion, or impulse that repetitively and insistently forces itself into consciousness, although it is unwelcome

Question 258

What is a phobia?

Answer 258

a morbid fear associated with extreme anxiety

Question 259

What is a circumstantial thought process?

Answer 259

thought and speech associated with excessive and unnecessary detail that is usually relevant to a question, and an answer is eventually provided

Question 260

What is the “flight of ideas” thought process?

Answer 260

overproductive speech characterized by rapid shifting from one topic to another and fragmenting ideas

Question 261

What is the loose associations thought processes?

Answer 261

lack of a logical relationship between thoughts and ideas that renders speech and thought inexact, vague, diffuse, and unfocused

Question 262

What are neologisms?

Answer 262

new word or words created by the patient, often a blend of other words

Question 263

What is the “perseveration” thought process?

Answer 263

involuntary, excessive continuation or repetition of a single response, idea, or activity; may apply to speech or movement, but most often verbal

Question 264

What is a “tangential” thought process?

Answer 264

similar to circumstantial but the person never returns to the central point and never answers the original question

Question 265

What is “thought blocking”?

Answer 265

sudden halt in the train of thought or in the middle of a sentence

Question 266

What is a “word salad”

Answer 266

series of words that seem totally unrelated

Question 267

What is gaiting and how does it pertain to schizophrenia?

Answer 267

• Gating is an electrical process involving electrolytes. It refers to inhibitory and excitatory nerve action potentials and the feedback occurring within the nervous system related to completed nerve transmissions.
• Decreased gating is demonstrated by a person’s inability to selectively attend to stimuli.
• For example, at a baseball game the person with schizophrenia would be unable to differentiate the noise from the crowd from the music ,the team,or the public address system

Question 268

What is the kindling effect?

Answer 268

An increased responsiveness to low doses of stimulation overtime, resulting in seizures due to intermittent and repeated stimulating by low-level electrical impulses or low-dose chemicals such as cocaine.