Exam II Flashcards
Mood: (Mood can be described as (depression, anxiety, guilt), euthymic (normal), or euphoric (implying a pathologically elevated sense of well-being)
Pervasive and sustained emotion that influences one’s perception of the world and how one functions.
Mood
What emotions are involved in a dysphoric mood?
Depression, anxiety, guilt
Depression, anxiety and guilt define what type of mood?
Dysphoric
How is depression defined?
Feelings of severe despondency and dejection.
Common mental state characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, poor concentration.
Depression
What is a normal mood called?
Euthymic (normal)
Mood that implies a pathologically elevated sense of well-being.
Euphoric
Three moods
Dysphoric
Euthymic
Euphoric
What is an outward emotional expression that provides insight into a person’s mood.
Affect
The following are types of what:
Blunted
Bright
Flat
Inappropriate
Labile
Restricted or constricted
Affects
Decreased ability to express emotion through your facial expressions, tone of voice, and physical movements is what type of affect?
Blunted. Someone with a blunted affect displays little feeling in emotional contexts. A person recalling their father’s death might simply recount the factual details of the death. The person might not share much information about how they felt. They may show little facial expression or speak in a monotone voice.
Pleasant expression, often accompanied by smiles, even laughter is what type of affect?
Bright affect
A severely restricted or nonexistent expression of emotion is what type of affect?
Flat. A person with flat affect does not express emotion the way other people do.
An individual’s display of emotions that do not properly fit a circumstance.
Inappropriate affect
Rapid, often exaggerated changes in mood, where strong emotions or feelings (uncontrollable laughing or crying, or heightened irritability or temper) occur.
Labile
A reduction in an individual’s expressive range and the intensity of emotional responses.
Restricted or constricted. Constricted affect is that an individual cannot feel the full range of human emotions or feel these emotions’ diminished intensities. Both flat and blunted affects are types of constricted affect as they refer to different levels of individuals being able to express their emotions.
The following are characteristics of what condition?
- Primary mood of depressive disorders
- Can be overwhelming
- If untreated, has significant negative effect on quality of life
- Increases risk of suicide
Depression
The depressive disorder we focus on.
Major depressive disorder
Symptoms of what condition:
- Often undetected and under treated
- Commonly associated with chronic illness
- Symptoms possibly confused with those of dementia or stroke
- Highest suicide rates in those older than 75 years (giving up after a medical dilemma)
Depressive disorders
- Commonly a progressively recurrent illness
- Episodes tend to occur more frequently, become more severe, for longer duration
- Onset may occur in puberty, highest onset in persons in 20s – see it most often
- Family history is important, history repeats itself
Major depressive disorder
Diagnostic criteria for what condition?
- One or more episodes for at least 2 weeks
- 4 of 7 additional symptoms must be present (FYI):
— Disruption in sleep, appetite (or weight), concentration, or energy
— Psychomotor agitation or retardation
— Excessive guilt or feelings of worthlessness
— Suicidal ideation
Major Depressive Disorder
What is an important criteria for major depressive disorder?
One or more episodes for at least 2 weeks.
Risk factors for what condition:
- Prior episode
- Family history
- Lack of social support
- Lack of coping abilities
- Current substance use or abuse
- Medical and/or mental illness comorbidity
Major depressive disorder
T/F: Culture can influence experience and communication of symptoms of depression.
True
What can influence the experience of and communication of symptoms of depression?
Culture
The goal of what condition is to reduce the likelihood of relapse and recurrence?
Depression
What is an essential part of treatment for major depressive disorder?
Collaborative care between PCP and mental health specialist
These are the goals of what condition?
- Reduce or control symptoms and, if possible, eliminate signs and symptoms
- Improve occupational and psychosocial function as much as possible
- Reduce the likelihood of relapse and recurrence
Major depressive disorder
Possible medical issues related to depression?
Hypothyroidism, pain
Safety issue associated with major depressive disorder?
Self-destructive thoughts and suicidal ideation – risk should be routinely conducted and assessed.
T/F: A complete physical exam is not necessary for a patient who presents with a mental disorder?
False. A review of systems, thorough history of medical problems, past surgeries, medical hospitalizations, head injuries, episodes of LOC, OB/GYN history, and physical examination with baseline vital signs is necesary to rule ot a physical disorder. This includes baseline laboratory tests and an ECG.
What three factors should be investigated in a physical assessment for a person with major depressive disorder?
Appetite
Sleep patterns
Fatigue
T/F: Substance abuse is infrequently a problem in those with major depressive disorder.
False. Many with depression also have substance abuse disorder.
What is the difference between congruent and incongruent mood and affect?
Congruent – mood and affect match
Incongruent – mood and affect do not match
Scale for depressive disorder?
Hamilton Rating Scale for Depression (HAM-D). Walter likes the Hamilton, gives you more differentiation between what they’re saying and what the scale is presenting.
What is the difference between anhedonia, motivation, and rumination?
Anhedonia (no desire for the things you used to like), amotivation (no motivation), rumination (repetitive thinking or dwelling on negative feelings and distress and their causes and consequences)
No desire for the things you used to like is called what?
Anhedonia
What is it called when you have no motivation to do anything?
Amotivation
What is repetitive thinking or dwelling on negative feelings and distress and their causes and consequences called?
Rumination
What is a lack of energy called?
Lack of energy = anergia
Suicidal thoughts and behaviors are priority only if what?
They’re presently/actively trying to harm themselves.
A one-to-one is necessary when what?
If have SI and tell you how they’ll do it, is one-to-one.
Should interview time intervals be long or short when talking with patients with major depressive disorder?
Time intervals with patient – short time with them so you don’t overwhelm them.
T/F: Personal care should be an option left up to the patient with major depressive disorder.
False: A nurse should assist and direct in personal care, not being demanding but assist and give guidance.
What is the timeframe with which antidepressants should improve symptoms?
- 7 days - Initial improvement with some antidepressants
- 2-4 weeks is the usual time frame
- Several weeks - complete relief of symptoms
Types of antidepressants:
SSRIs
SRNIs
Tricyclic (TCAs)
MAOIs
Citalopram, escitalopram oxalate (Lexapro), and sertraline (Zoloft) are what types of antidepressants?
SSRIs (Cit, Esc, Ser)
Side effects of SSRIs
- Increased risk of SI (more energy to carry through)
- Headache, tremors, trouble sleeping
- GI issues: Nausea, dry mouth, constipation, urinary retention
- Sexual dysfunction
How to start/stop SSRIs.
Slow onset and slow taper
T/F: MAOIs work better when taken with an antidepressant.
False: Don’t mix MAOI and antidepressant. Can lead to serotonin syndrome. Take 2 weeks to taper off MAOI before starting antidepressant.
What herbal supplement should you avoid when taking an SSRI?
St. John’s Wort
Most antidepressants cause what change in blood pressure and what patient education should accompany this change?
Decreased BP. Teach slow position changes.
What changes in weight do antidepressants normally cause?
Weight gain
SSRIs given mainly for what conditions?
Depression, anxiety, PTSD
What is the mode of action of SSRIs?
Inhibits reuptake of serotonin so more serotonin is available by the body.
What are the side effects of antidepressants?
Weight gain
Sexual dysfunction
Insomnia
Side effects of SSRIs
Headache
Anxiety
Insomnia,
Transient N/V/D
Sedation
Sexual dysfunction
Diastolic hypertension, Increased perspiration
What occurs when patient uses drugs/vitamins that increase serotonin levels when on an SSRI.
Serotonin Syndrome
T/F: Never mix St. John’s Wort, SSRIs and Tramadol (opioid).
True. Could lead to serotonin syndrome.
Symptoms of Serotonin Syndrome
S - sweaty, fever
R - Rigid muscles, restlessness, agitation (hyperreflexia, tremors), are neuromuscular problems
I - Increased heart rate (tachycardia) from autonomic instability
(N/V/D)
The following are side effects of what drug class?
Headache
Anxiety
Insomnia,
Transient N/V/D
Sedation
Sexual dysfunction
Diastolic hypertension, Increased perspiration
SSRIs
What drugs are SNRIs?
Duloxetine
Nefazodone (May cause liver problems)
How do SNRIs work?
Prevention of reuptake of norepinephrine and serotonin at presynaptic site
Drugs that are tricyclic antidepressants
amitriptyline
Action of TCAs
Blocks reuptake of serotonin and norepinephrine in the brain.
Side effects of TCAs
Sedation
Orthostatic hypotension
Anticholinergic side effects (ex. dry mouth. blurry vision, constipation, hallucinations, memory problems, trouble urinating)
Cardiotoxic
What is the most adverse side effect of TCAs?
Potential for cardiotoxicity, where retention comes in – a lot of weight on the heart, some heart failure going on.
Contraindicated with second-degree AV block
May precipitate heart failure, MI, arrhythmias, stroke
TCAs are contraindicated in what condition?
Contraindicated with second-degree AV block
TCAs are used in the treatment of what conditions?
Depression
Bipolar
What drug is an MAOI
Phenelzine (Nardil)
Action of MAOIs
Blocks monoamine oxidase which causes increase in epinephrine, norepinephrine, dopamine, and serotonin which stimulates the CNS.
What condition is treated with MAOIs?
Depression
Side effects of MAOIs
Orthostatic hypotension
Dizziness
Blurred vision
Constipation
Dry mouth
N/V
What foods to avoid with MAOIs
Tyramine foods:
Aged cheeses
Wine
Fermented/aged meats
Chocolate
Caffeinated beverages
Sour cream/yogurt
What is the adverse affect of MAOIs
Hypertensive crisis
- headache
- stiff necks
- N/V
- Fever
- Dilated pupils
What is the nursing priority for patients undergoing ECT?
Post-op care like any surgical patient
Mood lability is a sign of what disorder?
Bipolar
The following of symptoms of what condition?
- Elevated, expansive, or irritable mood
- Elevated self-esteem, grandiose delusions;
- Speech is pressured, more talkative than usual, may be difficult to interrupt
- Flight of ideas or racing thoughts
- Distractibility
- Need less sleep
- Energy increased
Mania of bipolar disorder
What is the difference between bipolar 1 and bipolar 2?
Bipolar 1 is mania
Bipolar 2 is depressive
The following is a symptom of what disorder?
Excessive involvement in pleasurable activities with little regard for painful consequences.
Mania (bipolar 1)
When a person is in a state of mania, how can they be protected from their impulsive, erratic in behavior?
Hospitalization
Can mania have a cause other than mental disorder?
Yes, certain meds or physical disorders
T/F: Bipolar is a chronic cyclic disorder.
True
What is the cause of suicidal ideations in manic patients?
Impulsivity, not depression.
When are the symptoms of bipolar ! normally seen?
Before the age of 25
What is a common comorbidity in bipolar 1 patients?
Substance use: alcohol, marijuana
What is the goal of treatment in bipolar 1?
Minimize and prevent episodes
Bipolar disorder is often misdiagnosed as what?
Misdiagnosed as depression leading to delay in proper treatment.
Antidepressants can precipitate manic episode – not getting better, try mood stabilizer and get better, means were misdiagnosed.
Lab tests important in mania?
Thyroid/electrolytes
While in the acute phase of bipolar 1, what type of medication is usually administered because it works fast?
Antipsychotic or atypical antipsychotic
What is the gold standard in mood stabilizing drugs?
Lithium
What is the normal onset of lithium?
5-7 days, as long as 2 weeks
What is therapeutic level of lithium?
Acute phase: 0.8 to 1.4 mEq/L
Maintenance: 0.4 to 1 Higher will put in lithium toxicity. Do blood tests every few weeks in acute phase, q3-6 months for maintenance, or monthly.
How often should blood tests for lithium be performed?
Acute phase: every few weeks
Maintenance: q3-6 months for maintenance, or monthly.
What are the side effects of lithium?
Thirst, metallic taste, increased urinary frequency, fine head tremor, drowsiness, and mild diarrhea
Symptoms of lithium toxicity
Severe diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination (think hyponatremia)
Lab tests for lithium use
CBC, thyroid, creatinine, watch kidney function, caution with diruetics.
How to anticonvulsant drugs work with bipolar?
Reduce repetitive firing of action potentials in the nerves
Anticonvulsant to use with bipolar
Carbamazepine
Bipolar II is what symptom and not as easily recognized because it mimics…
Mostly depressed: mimics Major Depressive Disorder
This is the definition of what?
“A strong, uncomfortable emotional response to a provocation that is unwanted and incongruent with one’s values, beliefs, or rights”
Anger
What is currently the only anger-related disorder listed on DSM-5?
Intermittent explosive disorder
What is the treatment for intermittent explosive disorder?
SSRIs, behavioral therapy.
T/F: Anger management for violent behavior is very effective.
False. Anger management for violent behavior is often ineffective.
What are the following:
- Effectively modulate the physiologic arousal
- Alter any irrational thoughts that fuel the behavior
- Modify maladaptive behaviors to prevent problem solving
Goals of anger management
T/F: Cognitive Behavioral Therapy is often recommended for uncontrolled anger.
True. CBT is everything with anger management.
Nursing interventions when dealing with an angry client
- Maintain calm demeanor and control of self.
- Discuss consequences of behavior
- Set limits on behavior
- Don’t use stern or authoritative tone
- Therapeutic touch MAY NOT be appropriate especially if dealing with paranoia or signs of aggression.
Extreme aggression = ?
Violence
What has a greater intensity and destruction than aggression?
Violence
All violence = ?
Not all aggression = ?
Aggression
Violence
T/F: When dealing with a violent patient always consider the most restrictive measures first.
False, still always consider the least restrictive intervention first.
If violence is eminent, what do you do first?
Call for help.
What is the least restrictive intervention?
Offering PRN meds
What is the most restrictive intervention?
Restraints
What are the following steps for?
- Use nonthreatening body language
- Respecting personal space and boundaries
- Immediate access to door of room
- Know where colleagues are; they know where you are
- Appropriate clothing and accessories
De-escalation
The psychiatric inpatient nurse hears yelling in the dayroom. The nurse enters the dayroom to find a client yelling and knocking over chairs. Which response(s) by the nurse would demonstrate an appropriate de-escalation technique? Select all that apply.
a. In a calm, firm voice tell the client that aggression is not allowed.
b. Ask the client to go to their room or the quiet room to regain control.
c. Offer the client as-needed antianxiety medication.
d. Signal for additional staff to circle the client.
e. Ask for assistance to restrain the client.
a, b, c
A client who has been yelling and progresses to physical aggression is considered to be in the escalation phase of anger. The nurse must take control of the situation by providing directions to the client in a calm, firm voice. The client should be directed to take a time-out for cooling off in a quiet area or their room. The nurse should tell the client that aggressive behavior is not acceptable and that the nurse is there to help the client regain control. The client should be offered medications to help manage their emotions. Only if these interventions are unsuccessful should the nurse advance to obtaining assistance from other staff members. Having staff circle the client or restrain the client is inappropriate at this phase and likely to worsen rather than de-escalate the situation.
The nurse is working with a client that demonstrates anger and aggression. Which is the most effective action by the nurse to prevent the angry client’s behavior from escalating to physical aggression?
a. Getting as far away from the client as possible
b. Engaging the client in dialogue
c. Telling the client to calm down now
d. Allowing the client to get their way initially
b
In a psychiatric setting, engaging the hostile person is most effective to prevent the behavior from escalating to physical aggression. In the psychiatric setting, it is not possible to get as far away from the client as possible. Yelling at the client will likely escalate the hostility. Ensuring that the client gets their way may eliminate frustration that may lead to acting out, but it is unrealistic and not ultimately helpful to the client.
The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on what?
a. Client’s mood
b. Client’s safety
c. Court order
d. Physician’s order
b
The use of restraints is warranted only when the client’s safety is in jeopardy and other, less restrictive measures have not been effective. The nurse does not base the decision on the client’s mood or court order. Just because there is a physician’s order for use of restraints, this does not mean that they are appropriate in every situation; this is based on nursing judgment.
When interacting with a client in the day room, the nurse determines that a violent physical outburst is imminent. Which would be most important for the nurse to do?
a. Offer the client choices
b. Obtain assistance from other staff members
c. Confront the client
d. Tell the client to calm down
b
Although is it important to work with clients to find solutions, to approach them calmly, and to empathize and avoid power struggles, safety is the priority because the outburst is imminent. The nurse needs to enlist the aid of a colleagues for protection and assistance. The nurse should use nonthreatening body language and not confront the client, which could exacerbate the client’s current state. Telling the client to calm down would be inappropriate and, like confrontation, exacerbate the situation.
A nurse is assessing a client. Which behaviors would alert the nurse to a possible impending aggressive episode? Select all that apply.
a. quiet tone of voice
b. mumbling
c. pacing
d. staring eye contact
e. sarcastic comments
b, c, d, e
Usually there are some observable precursors to aggression and violence. In a study of aggressive episodes in an emergency department, the following behaviors indicated an impending aggressive episode: (1) staring or glaring as a way of intimidation; (2) tone and volume of voice, such as a raised voice, sarcastic comments, and urgent or demeaning speech; (3) anxiety among clients, family, or friends; (4) mumbling that shows increasing frustration; and (5) pacing that indicates increased agitation.
What is the main feature of schizophrenia?
Psychosis
State in which a person experiences hallucinations, delusions, or disorganized thoughts, speech, or behavior.
Psychosis
What symptoms of psychosis are helpful in making a diagnosis?
Positive symptoms: delusions and hallucinations
When do symptoms of psychosis normally appear?
Late adolescence or early adulthood (18-24 years)
Main focus of schizophrenia treatment?
Stabilization
What is the major concern of schizophrenic patients?
Relapse
What is the main reason schizophrenic patients relapse?
Lack of medication compliance.
Three phases of care for clients with aggression.
Immediate - decrease imminent danger of violence toward self and others
Stabilization - Educate the client and increase coping ability
Community - Long-term goals of maintaining treatment regimen.
The nurse is performing a mental health assessment for a client with schizophrenia. Which statement made by the client demonstrates that the client is having auditory hallucinations?
“Can you hear those children singing in the room with us?”
“Those voices keep telling me that I need to get a knife and cut myself.”
“I keep smelling feces in the room, and I can’t get the odor out of my nose.”
“I keep tasting things that are foul like onions and garlic but I don’t eat those.”
“Can you hear those children singing in the room with us?”
Auditory hallucinations, the most common type, involve hearing sounds, most often voices, talking to or about the client. Command hallucinations are voices demanding that the client take action, often to harm self or others, and are considered dangerous. Olfactory hallucinations involve smells or odors. Gustatory hallucinations involve a taste lingering in the mouth or the sense that food tastes like something else.
A nursing student is preparing to care for a client diagnosed with schizophrenia. When interacting with the client, the student notices that the client is highly suspicious and guarded, stating, “They’re out to get me.” The student identifies this as what?
Autistic thinking
Paranoia
Stilted language
Pressured speech
Paranoia
The client is demonstrating paranoia, defined as suspiciousness and guardedness that are unrealistic and often accompanied by grandiosity. Autistic thinking is the restrictive thinking to the literal and immediate so that the individual has private rules of logic and reasoning that make no sense to anyone else. Stilted language is the use of overly and inappropriately artificial formal language. Pressured speech is reflected by the client speaking as if the words were being forced out.
A client who is suspicious has been placed in a room with a roommate. The night nurse assesses the situation and reports that this client has been awake for the past 3 nights. For which behaviors will the nurse assess for the client’s wakefulness?
The client is fearful of what the roommate might do to the client while sleeping.
The client is a light sleeper and unaccustomed to a roommate.
The client is watching for an opportunity to escape.
The client is worrying about family problems.
The client is fearful of what the roommate might do to the client while sleeping.
Clients who have suspicion trust no one and believe others are going to harm them. It is plausible that this client has a fear of being harmed. Pondering an escape, being a light sleeper and unaccustomed to a roommate, and worrying about family problems are less likely manifestations of suspicion, which is the defining characteristic of this client.
A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medications. After teaching the client and family about managing the disorder, a nurse determines that the education was effective when a family member states which symptom(s) should be reported immediately? Select all that apply.
- elevated temperature
- tremor
- decreased blood pressure
- weight gain
- muscle rigidity
Elevated temp
MM rigidity
Clients receiving antipsychotic therapy need to be alerted to the potential for complications, including neuroleptic malignant syndrome, a life-threatening condition that can occur with antipsychotic agents. This syndrome is manifested by severe muscle rigidity and elevated temperature that can rapidly accelerate. The nurse should instruct the client to seek immediate care if an elevated temperature or muscle rigidity develops. Tremor also should be reported, but this is not a life-threatening manifestation. Decreased blood pressure and weight gain can occur with antipsychotic agents, but these are not life threatening.
A client states, “I am dead. I have come back from the dead.” Which is the most appropriate response by the nurse?
“What is it like to feel dead?”
“No you didn’t. People don’t come back from the dead.”
“Show me what you did in art therapy this morning.”
“I’ll get your medicine and you’ll feel better.“
“Show me what you did in art therapy this morning.”
The client experiencing delusions believes them and cannot be convinced they are false or untrue. It is the nurse’s responsibility to present and maintain reality by making simple statements. Asking the client what they did in art therapy will have the client present the reality. The nurse must avoid openly confronting the delusion or arguing with the client about it. The nurse must also avoid reinforcing the delusional belief by “playing along” with what the client says. Inferring that the client is not feeling well supports the delusion of death.
The nurse is performing a mental health assessment for a client with schizophrenia. Which statement made by the client demonstrates that the client is having auditory hallucinations?
“Can you hear those children singing in the room with us?”
“Those voices keep telling me that I need to get a knife and cut myself.”
“I keep smelling feces in the room, and I can’t get the odor out of my nose.”
“I keep tasting things that are foul like onions and garlic but I don’t eat those.”
“Can you hear those children singing in the room with us?”
Auditory hallucinations, the most common type, involve hearing sounds, most often voices, talking to or about the client. Command hallucinations are voices demanding that the client take action, often to harm self or others, and are considered dangerous. Olfactory hallucinations involve smells or odors. Gustatory hallucinations involve a taste lingering in the mouth or the sense that food tastes like something else.
A nurse is preparing to administer prescribed antipsychotic medication to a client with psychosis. The nurse identifies the prescribed medication as a first-generation antipsychotic drug. Which drug would the nurse most likely be administering?
Fluphenazine
Aripiprazole
Clozapine
Olanzapine
Fluphenazine is a first-generation antipsychotic medication. The other listed drugs are second-generation antipsychotics.
The client is diagnosed with schizophrenia and the nurse is observing for effects of medication during the teaching session. Which medication rarely causes extrapyramidal side effects (EPS)?
Ziprasidone - Geodon
Chlorpromazine
Haloperidol
Fluphenazine
Ziprasidone - Geodon
First-generation antipsychotic drugs cause a greater incidence of EPS than do atypical antipsychotic drugs, with ziprasidone rarely causing EPS. Chlorpromazine, haloperidol, and fluphenazine are all first-generation antipsychotic drugs.
Which are negative symptoms associated with schizophrenia? Select all that apply.
ambivalence
avolition
anhedonia
delusions
Hallucinations
ambivalence
avolition
anhedonia
Negative symptoms of schizophrenia include ambivalence, avolition, and anhedonia. Positive symptoms of schizophrenia include delusions and hallucinations.
What is avolition (- symptom of schizophrenia)?
Avolition is a total lack of motivation that makes it hard to get anything done.
The client with schizophrenia taking antipsychotic medication is conversing with the nurse when the eye’s roll back in a locked position (oculogyric crisis). Which is the priority action by the nurse? (dystonic rx)
Place the client on seizure precautions.
Refer the client to the ophthalmologist.
Advocate for an increase in the antipsychotic medication.
Administer diphenhydramine IM immediately.
Administer diphenhydramine IM immediately.
Oculogyric crisis is the occurrence of the eye rolling back in a locked position, which occurs with acute dystonia. Acute treatment consists of diphenhydramine given either intramuscularly or intravenously, or benztropine given intramuscularly. The client is not experiencing a seizure at this time, and the issue is not a dysfunction of the eye itself. The cause of the issue is the antipsychotic medication, and the increased dose would create more dystonia.
Which type of antipsychotic medication is most likely to produce extrapyramidal effects?
Atypical antipsychotic drugs
First-generation antipsychotic drugs
The conventional, or first-generation antipsychotic drugs are effective in treating target positive symptoms but also produces many extrapyramidal side effects because of the blocking of the D2 receptors. Newer, atypical or second-generation antipsychotic drugs are relatively weak blockers of D2, which may account for the lower incidence of extrapyramidal side effects.
