exam 2 study grid

Question 1

trazodone

Answer 1

• tetracyclic antidepressant agent
• action: alters the effects of serotonin in the CNS
• pharmacokinetics: metabolism and exretion. extensively metabolized by the liver and minimal excretion of unchanged drug by the kidneys
• half life: 5 to 9 hours
• uses: major depression. off label use: insomnia, chronic pain syndromes
• contraindications: hypersensitivity; recover. after MI; concurrent electroconvulsive therapy; concurrent use of MAOI inhibitors or MAOI like durgs; angle closure glaucoma
• use cautiously in: cardiovascular disease. suicidal behavior; may increase risk of suicide attempt/ideation, especially during early treatment or dose adjustment; severe hepatic or renal disease; lactation
• side effects: potential for increased suicidal tendencies, sedation, dry mouth, agitation, postural hypertension, headache, arthralgia, dizziness, insomnia, confusion, and tremors. most common: HTN, dry mouth, drowsiness, suicidal thoughts
• nursing implications: monitor BP and pulse rate before and during initial therapy. Monitor ECG’s in pts with pre existing cardiac disease before and periodically during therapy to detect arrhythmias. assess for possible sexual dysfunction, assess for serotonin syndrome

Question 2

serotonin syndrome

Answer 2

• mental changes (agitation, hallucinations, coma)
• autonomic instability (tachycardia, labile BP, hyperthermi)
• neuromuscular aberrations (hyperreflexia, incoordination)
• GI symptoms

Question 3

Haloperidol

Answer 3

• indications: acute and chronic psychotic disorders, including schizophrenia, manic states and drug induced psychoses
• action: alters the effects of dopamine in the CNS. also has antichoinergic and alpha adrenergic blcking activity.
• therapeutic effects: diminished signs and symptoms of psychosis. improved behavior in children w/ tourette yndrome or other behavioral problems
• pharmacokinetics: concentrates in liver, crosses placenta; enters breast milk
• mostly metabolized by the liver
• half life: 21-24 hours
• contraindications: hypersensitivity; angle closure glaucoma; bone marrow depression; CNS depression; Parkinsonism; severe liver or cardiovascular disease; women lactating
• use catiously in: cardiac disease; diabetes; respiratory insufficiency; prosthetic hyperplasia; cns tumors; intestinal obstruction; seizures; patients at risk for falls
• side effects: torsades de pointes, hpotension, QT interval prolongation, tachycardia, ventricular arrhythmias, blurred vision, dry eyes, dry mouth, constipation, sizures, extrapyramidal reactions, tardive dysinesia, respiratory depression, neuroleptic malignant syndrome
• nursing implications: assess mental status (orientation, mood, behavior) prior to and periodically during therapy; assess positive and negative symptoms of schizophrenia; monitor BP and pulse prior to and frequently during the period of dose adjustments. may cause qt interval changes on ecg; monitor pt for onset of akathesia, which may appear within six hours of first dose and may be difficult to distinguish from psychotic agitation

Question 4

antipsychotics are used for…

Answer 4

• treat psychotic behavior and schizophrenia and other disdorders that may include violent or potentially violent behavior
• typical antipsychotics treat thepositive symptoms of schizophrenia, such as hallucinations, delusions, and suspiciousness
• atypical antipsychotic agents reduce the negative symptoms of schizophrenia, such as flat affect, social withdrawal, and difficulty w/ abstract thinking

Question 5

side effects of antipsychotics

Answer 5

• atypical antipsychotic medications have fewer side effects than typical
• a few of these side ffects of typical psychotropics arephotosensitivity, darkening of the skin from increased pimentation, anticholinergic effects such as dry mouth, and extrapyramidal symptoms

Question 6

extrapyramidal symptoms include

Answer 6

• drug induced parkinsonism (pseudoparkinsonism). symptoms appear 1-8 weeks after the pt begins the medication. akinesia, shuffling gait, drooling, fatigue, mask like facial expressions, tremors, and muscle rigidity
• akathisia: symptoms appear 2-10 weeks after the pt starts taking the medication. agitation and motor restlessness; appears more frequently in women
• dystonia: symptoms appear 1-8 weeks after the pt starts taking the medication. manifest as bizarre distortions or involuntary movements of any muscle group. tongue, eyes, face, neck, or any larger muscle group can become tightened into an unnatural position or have irregular pastic movements
  requires immediate medical attention
• tardive dyskinesia: symptoms appear within 1-8 weeks after the pt starts taking the medication. manifestations inclde rhthmic involuntary movements that look like chewing, sucking, or licking motions. frowning and blinking constantly are also common. previously thought to be irreversible, but can be treated with Ingrezza and Austedo. monitor for development of neuroleptic malignant syndrome. may also cause leukocytosis, elevated liver function tests, elevated ck
• fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control

Question 7

nursing considerations with antipsychotics

Answer 7

• monitor pts body movements using the abnormal involuntary movement (aim) FORM\
• monitor pts BP. may fluctuate from high to low
• observe for signs of Parkinsonism
• observe for signs of EPS or NMS and carefully monitor blood work for abnmormal results
• some antipsychotics interact with calcium containing medications. the pt should avoid taking antacids or calcium supplements 1-2 hours after oral administration
• antipsychotics medication should be discontinued slowly, never stopped abruptly

Question 8

4 assessments for mental status exam

Answer 8

• appearance
• behavior
• level of consciousness
• orientation
• content of thought
• memory
• speech and ability to communicate
• mood and affect
• abstract thinking/judgment
• perception

Question 9

mental status examination: appearance

Answer 9

• observation of ptstress, hygiene, posture, actions, and reactions to health care personnel. observe for wounds and scars
• normal parameters: clean, hair combed; clothing intact and appropriate to weather or situation; teeth in good repair; posture erect; cooperates w/ healthcare personnel
• alterations to normal assessment: displays either unusual apathy or concern abotu appearance

Question 10

mental status exam: behavior

Answer 10

• objective: normal parameters cooperates w/ health care personnel, makes diret eye contact
• alterations to normal assessment: displays uncooperative, hostile, or suspicious type behaviors toward healthcare personnel. restless

Question 11

mental status exam: level of consciousness

Answer 11

• subjective and objective assessment of the pts degree of alertness (wakefulness)
• normal parameters: awareness is measured on a continuum that ranges from unconsciousness to mania. “normal alertness” is the desired ehavior
• alterations to normal assessment: if the pt is difficult to arouse and keep awake or finds it difficult to feel calm that is not with normal limits

Question 12

mental status exam: orientation

Answer 12

• the degree of pts knowledge of self
• normal parameters: orientatio measures the person’s ability to know who they are, where they are, and the day and time usually with 1-2 days of the actual day and time
• alterations to normal assessment: abnormal results of orientation are the pts inability to correctly answer questions pertaining to themselves or to commonly known social information

Question 13

mental status exam: content of thought

Answer 13

• subjective assessment of what the pt is thinking and the process the pt uses in thinking
• normal parameters: usually undertaken by the psychologist or psychiatrist to determine the pts general though content and pattern. although nurses may contribute to the assessment of thought by documenting statements the pt makes regarding daily care and routines
• alterations to normal assessment: behaviors including flight of ideas, loose associations, phobias, delusions, and obsessions may become apparent

Question 14

mental status exam: memory

Answer 14

• subjective assessment of the pts ability to recall recent and remote information and/or events
• recent memory: recall of events that are immediately passed or up to within 2 wks before the assessment. one measurement technique is to verbally list 5 items and after 1 minute the pt should be able to recall 4-5 of those items
• remote memory: recall events of the past beyond 2 weeks before assessment. questions pertaining to where they were born, where they went to grade school, and so on

Question 15

mental status exam: speech and ability to communicate

Answer 15

• objective and subjective assessment of aspects of pts use of verbal and nonverbal communication
• normal parameters: pt can coherently produce words appropriate to age and education. rate of speech reflects other psychomotor activity. volume s not too soft or too loud
• alterations to normal assessment: limited speech production: rate of speech is inconsistent w? other psychomotor activity. volume is not appropriate to situation. suttering, word repetition, or neologisms may indicate physical or psychological illness; hyper talkative; mumbled or slurred speech

Question 16

mental status exam: mood and affect

Answer 16

• subjective (mood) and objective assessment of the pt stated feelings and emotions. Affect measures the outward expression of those feelings
• normal parameters: facial expressions and body language (affect) should match stated mood. Affect should change to fluctuate w/ the changes in mood
• alterations to normal assessment: mood and affect do not match

Question 17

mental status exam: abstract thinking/judgment

Answer 17

• subejctive assessment of a pts ability to make appropriate decisions about their situation or to understand concepts
• give pts a proverb to interpret, such as “you can’t teach an old dog new tricks.” pt should be able to give some sort of acceptable interpretation such as “old habits are hard to break”
• or give pt a situation to solve (judgment)
• alterations to normal assessment: pt cannot interpret the proverb in an acceptable manner. pt cannot complete problem solving questions appropriately

Question 18

mental status exam: perception

Answer 18

• assess the way a person experiences reality. assessment is based on the pts statements about their environment and the behaviors associated with those statements
• normal parameters: all 5 senses are monitored for interaction w/ the pts reality. pts insight into their condition is also assessed.
• alterations to normal assessment: presence of hallucinations and illusions

Question 19

helping interview

Answer 19

• the helping interview is used to determine or isolate a particular concern of the pt and to help the pt learn to help themselves
• be honest: tell the pt the purpose of the interview
• be assertive: if the interview is mandatory, let the pt know that it is needed to provide the pt with the proper care. if possible, agree upon a mutually acceptable time to conduct the interview
• be sensitive: sometimes the questions are very difficult or embarassing for the pt to answer. assure the pt that you understand their concerns and that the information they share is part of their medical record
• use empathy: let the pt know that you are interested in what is being said and that you are there to be helpful. acknowledge the pts feelings but do not judge the pt
• use open ended questions: personalize the questions as much as possible. use this time to discuss and clarify as much information as you can to avoid having to repeat parts of the interview later.

Question 20

emotional response to stress

Answer 20

• the four stages of crisis: intial exposure, crisis, adaptive, post crisis

Question 21

four phases of crisis: intial exposure to stressor

Answer 21

• person feels “fine”
• will often deny stress level and in fact state a feeling of well being

Question 22

four phages of crisis: crisis

Answer 22

• person denies problem is out of control
• withdrawals or rationalize his behaviors and stress
• uses defense mechanism of projection frequently

Question 23

the four phases of crisis: adaptive

Answer 23

• crisis is perceived in a positive way
• anxiety decreases
• person attempts to regain self esteem and is able to start socializing again
• person is able to do some positive problem solivng

Question 24

four phases of crisis: post crisi

Answer 24

• both positive and negative functioning may be seen
• person may have developed a more positive, effective way of coping w/ stress or may show ineffective adaptation, such as being critical, hostile, depressed, or using food or chemicals such as alcohol to deal w/ what has happened

Question 25

nursing responsibilities during four stages of crisis

Answer 25

• ensure safety
• diffuse the situation
• determine the problem
• decrease the anxiety level
• retun the pt to pre crisis level of functioning

Question 26

safety for suicide risk: nursing interventions fr pts at risk of suicide

Answer 26

• frequent monitoring: check on the suiicdal pt frequently but avoid a predictable routine and ensure that the pt is checked during extra busy imes like shift change. if the pt is actively suicidal, a psychiatric consultation will be required and the pt may be placed on a 1-1 precation until the pt can be moved to an appropriate treatment setting. 1:1 precautions: a statff member will be required to accompany the pt too and remain w the pt in the bathroom
• safety: keep any potentially harmful items away from the pt such as knives, scissors, glass, razor blades, belts, nail files, electrical cords and even linens. informed visiors of anyr estrictions so that they do not bring items with pt may request. ensure the windows cannot be opened. the room may need to be searched periodically and the pt may need a body search and close monitoring int he bathroom. pts who are very high risk for suicide will need to wear paper gons and to have paper bedding. plastic trash bags with the pt could use to suffocate themselves should not be used on the pts room
• communication: ask outright if the pt is considering suicide and if so how and when. a pt is at higher risk if they have a specific plan with a highly lethal method that is available to them. asking a pt to talk about suicidal thoughts does not increase the chance of their completing a suicide. rather it demonstrates caring and acknowledges their value as a person. when talking to someone who is suicidal, avoid platitutdes like “think what this would do to your children.” often the suicidal person is so immersed in feelings of hopelessness and isolation that they are unable to identify ith how others are feeling. when working on problem solving, break down one problem into manageable steps rather than looking at the whole picture, which can be overhelming. most people ewho are suicidal have ambivalent or mixed feelings about taking action. Supporting the reasons the preson does not want to end their life can help the person to reevaluate the situation

Question 27

therapeutic communication

Question 28

antidepressant medication options:

Answer 28

• TCAs
• MAOIs
• SNRIs
• SSRIS
• atypical antidepressants

Question 29

side effects of TCAs

Answer 29

• example: amitriptyline
• indication: depression, anxiety, neuropathic pain from diabetes and fibromyalgia.
• side effects: dry body can’t see, pee, spit or shit
• may cause orthostatic hypotension so teach pt slow position changes
• urinary retention
• never take with MAOIs, need a 2 week washout period

Question 30

side effects of MAOIs

Answer 30

• examples: phenelzine, elegiline, isocarboxazid, tranylcypromine
• indication: very powerful antidepressants for depression, panic disorder and social phobia. used for depression that is resistant to other meds
  0 increases availability of norepinephrine, serotonin and dopamine
• assess for further expressions from the pt of hopelessness, despair, suicidal thoughts, and thoughts of self harm
• side effects: massive htn crisis risk, headache, increased agitation, avoid tyramine (wine, cheese, processed meats, chocolate/caffeine), otc

Question 31

side effects of SNRIs

Answer 31

• example: duloxetine. indication: depression, neuropathic pain from diabetes and fibromyalgia. patient education: if someone with fibromyalgia is prescribed this and doesn’t have depression they need education on the purpose that it is to help with their pain.
• side effects: insomnia, headaches, diarrhea or constipation, fatigue, dry mouth, avoid alcoholic beverages due to sedation, if you have diabetes duloxetine may affect blood sugar, marijuana use may increase the levels of SNRIs in the body and make you more likely to feel these side effects

Question 32

side effects of SSRIs

Answer 32

• ex: sertraline, citalopram, escitalopram, paroxetine, fluoxetine
• indication: depression, anxiety, ptsd
• side effects: sexual dysfunction, weight gain, insomnia, suicide risk increased, slow onset and slow taper off
• signs of serotonin syndrome: sweaty and hot with fever, rigid muscles with restlessness and agitation, increased heart rate

Question 33

side effects of atypical antidepressants

Answer 33

• avoid ETOH and other sedatives
• indication: depression and sleep aid (trazodone). take at night, teach slow position changes due to risk of orthostatic hypotension. rare: priapism. erection lasting 4+ hours = go to hospital
• indication: depression and smoking cessation aid (wellbutrin). side effects include insomnia, HA, weight loss. patient teaching: never crush, chew, cut especially XR or SR. never double up on a missed dose.

Question 34

panic attack

Answer 34

• panic disorder: a recurrent condition , an abrupt surge of extreme fear or discomfort that cannot be controlled nd that reaches a peak in a short period of time. this disorder can lead to intense fear and worry about it happening again
• the DSM 5 idenifies 13 symptoms, of which FOUR or more need to be present for a diagnosis of panic didsorder

Question 35

13 symptoms of panic disorder

Answer 35

• fear f being out of control or going crazy
• fear of dying
• disassociation
• nausea or GI upset
• a feeling of choking
• diaphoresis
• chest pain
• palpitations, increase in heart rate
• chills or being folushed
• numbness or tinglig
• shaking or tremors
• unsteadiness or feeling faint
• a feeling of being suffocated or unable to catch one’s breath

Question 36

panic disorder treated with

Answer 36

alprazolam
buspirone
chloridazepoxide
oxazepam
clonazepam
diazepam
lorazepam
propranolol
hydroxyzine

Question 37

antianxiety drugs: uses

Answer 37

decreases the effects of stress or mild depression without causing sedation

Question 38

antianxiety drugs: side effects

Answer 38

can cause physical and psychological dependence, drowsiness, lethargy, fainting, postural hypotension, nausea, and vomiting

Question 39

antianxiety drugs: nursing considrations

Answer 39

administer IM dosages deeply, slowly, and into large muscle masses
- discontinue slowly

Question 40

antianxiety drugs: pt teaching

Answer 40

teach the pt and family that it is not safe to drive or use alcohol while using this classification of medication
- instruct to change positions slowly

Question 41

neuroleptic malignant syndrome

Answer 41

• rare but potentially fatal reaction to treatment with some antipsychotic medications
• symptoms include muscle rigidity, hyperpyrexia, fluctuations in bp, and altered LOC
• early recognition and immediate medical care are important. signs of ANS instability that frequently accompany NMS include labile bp, taypnea, tachycardia, sialorrhea, diaphoresis, flushing, skin pallor, and incontinence. when symptoms appear, progression can be rapid and can reach peak intensity in as little as 3 days. FEVER = fever, encephalopathy, vital signs unstable, elevated enzymes (CPK), rigidity of muscles
• some antipsychotics such as clozapine are known to cause serious blood dyscrasias and require regular monitoring of blood counts
  0 the high potency first generation antipsychotics such as fluphenazine, trifluoperazine, haloperidol, loxapine, pimozide, perphenazine, and thyroxine are most likely to cause NMS

Question 42

who is most likely to be at risk of development neuroleptic malignant syndrome

Answer 42

• any individual starting an antipsychotic has the potential risk for developing NMS. almost all dopamine antagonists can cause NMS and higher potency antipsychotics pose a greater risk compared with low potency agents and atypical antipsychotics

Question 43

nursing process: goals/evaluation

Answer 43

• accuracy of verbal and written reporting of the pts progress will help determine whether the interventions have been helpful or that they need to be reevaluated and changed
• in some instances, some of the interventions can be terminated depending on the pts progress

Question 44

nursing outcomes classification (NOC)

Answer 44

• standardized language that provides outcome statements, a set of indicators describing specific pt, caregiver, family, or community states related to the outcome, and to five point measurement scale to facilitate racking pts across the care settings
• NOC can help demonstrte pt progress even when outcomes are not fully met
• it is applicable in all care settings and specialties

Question 45

some questions to reflect for the teaching plan

Answer 45

• how do you know the pt has grasped the teaching
• what do you look for
• do you need to ask for feedback or return demonstration
• does the feedback or return demonstration need to be perfect
• how did you do as a teacher
• did you achieve the plan
• did you have enough time
• what will you do differently next time
• does the pt show evidence that their behavior may change as a result of the teaching plan
• evaluation criteria may change from time to time as well

Question 46

MAOIs: contrandications

Answer 46

• should be given carefully to pts who have asthma, CHF, cerebral vascular disease, glaucoma, hypertension, schizophrenia, alcoholism, liver or kidney disorders, or severe headaches, as well as those who are over 60 years old who are pregnant

Question 47

cognitive group therapy

Answer 47

• the goal is to decrease the pts emotional discomfort, increase the pts social functioning, increase the pts ability to behave or to perform in a manner appropriate for the situation
• group therapy: can include formal psychotherapy groups where patients meet w/ a therapist regularly as part of their treatment; self help programs are also a form of group therapy; as a rule AA meetings are “closed”; therapists and counselors are facilitators. they do not heal the pts the patient heals themselves. ideally pts take the suggestions give try them and see if it works. nurses can reinforce the good work pts do in learning to keep themselves healthy. nurses can also emind pts gently that they are doing their own healing
• an offshoot of REBT is known as CBT. CBT is behavioral therapy that focuses on examining the relationships between thoughts, feelings, and behaviors. CBT is differnt from traditional psychodynamic psychotherapy and that the therapist and the pt actively worked together to help the pt recover from mental illness.

Question 48

ECT

Answer 48

• ect has an extensive history. not as traumatizing to the pt as it was in the 50s and can be done as an outpatient procedure
• alternatve where nothing else works. can be used for depression or schizoprenia where medication hasn’t been effective.
• nurses carefully monitor bp and pulse before and after treatment as ect delivers a small electrical charge to the brain for about 30 seconds, causing a “seizure”. pt is sedated/unconscious.
• desired outcome; pt will state and exhibit appropriate mood and affect or measurable improvement in mood and affect
• nursing considerations: monitor vitals before and after treatmnt, maintain safety after the treatment, premedicate if ordered
• pt teaching: may be disoriented after treatment, may lose short term memory, side effects may last up to 24 hours