Mental Health

Question 1

Clozapine

Answer 1

✓ Clozapine is an atypical antipsychotic reserved for those who have not responded to other agents.

✓ This medication is used to treat schizophrenia as well as mood disorders that may cause significant aggression or violence.

✓ This medication carries serious effects, including agranulocytosis, myocarditis, sialorrhea, and weight gain.

✓ The client will require frequent laboratory work to monitor their neutrophil count.

Question 2

Side Effects of Atypical Antipsychotics (Clozapine, Ziprasidone, olanzapine, risperadone)

Answer 2

more withdrawal symptoms than typical antipsychotics; headache, anxiety, muscle aches, agitation, abnormal skin sensations; may cause metabolic syndrome.

Question 3

Side Effects of typical Antipsychotics (haloperidol, fluphenazine, thiothixene, chlorpromazine)

Answer 3

tardive dyskinesia, restlessness, sexual problems, sedation, weight gain, dry mouth, constipation.

Question 4

Uses of Atypical Antipsychotics

Answer 4

schizophrenia, mood dx, childhood disorders such as autism.

Question 5

Medications commonly used for opioid-misuse disorder

Answer 5

Naltrexone, Methadone, and Buprenorphine are three agents approved for the management of opioid use disorder. These medications have various mechanisms of action.

Naltrexone is an opioid receptor antagonist and may be administered as a single dose injection.
Buprenorphine is a partial agonist and is available in preparations such as sublingual tablets or film.
Methadone is a full agonist that may be used daily. It is dispensed in a supervised setting.
Medications used in opioid use disorder are efficacious when combined with appropriate counseling. The nurse should advocate for appropriate treatment choices such as buprenorphine, methadone, or naltrexone. Caution must be taken with methadone and buprenorphine as these two medications may cause respiratory depression when combined with other CNS depressants.

Question 6

Altruism

Answer 6

Altruism is generally a positive defense mechanism that, when utilized appropriately, causes an individual to feel caring and concern for others and act for the well-being of others. Although this defense mechanism is generally regarded as a positive one, it may be maladaptive if a client threatens the health or safety of themselves or others (for example, a client adopts several stray animals, but it threatens the health of others in the household).

Question 7

Antisocial Personality disorder

Answer 7

Antisocial personality disorder has clinical features such as superficial charm, deceit, failure to follow societal norms, and the inability to demonstrate empathy. Client management involves setting limits and maintaining a structured environment. The nurse should ensure that the environment is safe because an individual with an antisocial personality disorder may be impulsive and act out with anger. No medication is approved/indicated for this disorder; however, early intervention with psychotherapy is helpful.

Question 8

Lithium Indications

Answer 8

BPD

Question 9

Therapeutic levels of lithium

Answer 9

0.6 - 1.2 mEq/L

Question 10

Side effects of lithium use

Answer 10

fine hand tremor, weight gain, acne, and hair loss

Question 11

symptoms of lithium toxicity

Answer 11

vomiting, ataxia, confusion, blurred vision

Question 12

which labs do you monitor for a patient on lithium?

Answer 12

thyroid panel, creatinine, sodium, and lithium

Question 13

Which drugs should a patient on lithium avoid?

Answer 13

ACE inhibitors, NSAIDs, diuretics

Question 14

recommended diet and PO intake for patient on lithium

Answer 14

1-2 litres water per day
high salt diet

Question 15

The Cycle of Violence

Answer 15

The cycle of violence is a model developed in 1979 by Lenore Walker to explain the co-existence of disorder with love. It may be tough for those who have never experienced domestic abuse to understand why it is difficult for an abused individual to “just quickly leave” the relationship. Understanding the cycle of violence may help plan appropriate interventions to break the cycle and stop domestic violence. Violence often occurs in a repetitive cycle and usually consists of three phases: (1) the Tension phase, (2) the Acute explosion phase (Crisis phase), and (3) the Honeymoon Phase (calm phase).

In the first phase (tension-building), the abuser gets angry, argumentative, and starts threatening. Minor fights may occur. In this phase, victims often report a feeling of walking on eggshells. As the period progresses, tension continues to build.
In the second phase (explosion/crisis), significant verbal or physical abuse will occur. Major violent acts such as physical or sexual attacks will follow and may result in injury.
In the third phase (Calm phase or Honeymoon period), the abuser expresses sorrow and feelings of guilt. The abuser shows love and promises to change and get himself/herself help. The victim feels like things are getting much better, but the phase does not last. The cycle starts all over again and the three steps repeat over time. It is, therefore, hard to end an abusive relationship since the three phases of love, hope, and fear, keep the cycle moving. The cycle is progressive as well. With every period, the abuse may get worse during the explosion phase.

Question 16

Gold standard treatment for bipolar mania

Answer 16

Mood stabilizers
Vaproic acid is a mood stabilizer and is efficacious in treating mania because it has a fast onset.
* Monitor therapeutic level (50-125
mcg/mL This medication is very hepatotoxic,
monitor liver function tests Watch hemoglobin and platelets; this medication may cause blood
dyscrasias Reinforce adherence to the dosing
schedule A multivitamin may be prescribed to offset the vitamin deficiencies
caused by this medication Women should not conceive and use birth control while taking this
medication

Question 17

Key Interventions for a patient in a delusion

Answer 17

Key interventions for a client experiencing a delusion include -

Build trust by being open, honest, genuine, and reliable.
Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner.
Ask the client to describe their beliefs.
Do not use avoidance. Inquire about the delusion and its content.
Never debate the delusional content.
Validate if part of the delusion is real. Example - “Yes, there was a package at the nurses’ station, but it did not contain a recording device.”

Question 18

Kubler-Ross Model for Grieving

Answer 18

The correct ordered sequence is Denial, Anger, Bargaining, Depression, and Acceptance (“DABDA”).

Denial: Refuses to believe that loss is happening. The client is unready to deal with practical problems, i.e. prosthesis after the loss of a leg. May assume artificial cheerfulness to prolong denial. This client is currently in denial.
Anger: The client or family may direct anger at nurses or staff about matters that generally would not bother them.
Bargaining: Seeks to bargain to avoid loss (e.g. “let me just live until ___ and then I will be ready to die”).
Depression: Grieves over what has happened and what cannot be. May talk freely (e.g. reviewing past losses such as money or a job), or may withdraw.
Acceptance: Comes to terms with the loss. May have decreased interest in surroundings and support people. May wish to begin making plans (e.g. will, prosthesis, altered living arrangements).

Question 19

PTSD

Answer 19

Post-traumatic stress disorder (PTSD) is characterized by ongoing and unyielding nightmares, flashbacks to a previous event, and intrusive, threatening thoughts. Post-traumatic stress disorder occurs primarily among those who have witnessed and/or been exposed to a severe traumatic event (i.e., warfare, rape, witnessing a murder, etc.) likely to invoke feelings of fear, helplessness, or horror in the individual who witnesses the event.
Symptoms of post-traumatic stress disorder can be subdivided into categories: intrusions, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity.
Diagnosis is based on history.
Treatment often consists of exposure therapy and/or drug therapy (most commonly, selective serotonin reuptake inhibitors (SSRIs)).
Many post-traumatic stress disorder clients also experience survivor’s guilt.

Question 20

panic disorder

Answer 20

A panic disorder occurs when the client experiences repeated panic attacks, typically accompanied by fears about future attacks or changes in behavior to avoid situations that might predispose the client to additional attacks.

Question 21

phobia

Answer 21

A phobia is a fear of and/or anxiety regarding a particular situation or object to a degree that is out of proportion to the actual danger or risk. Contact with the situation or object is usually avoided when possible, but if exposure occurs, anxiety quickly develops.

Question 22

Anxiety Disorder

Answer 22

The term “anxiety disorders” is a broad umbrella term encompassing numerous anxiety-related psychiatric disorders, including, but not limited to, agoraphobia, generalized anxiety disorder, acute stress disorder, social phobia, post-traumatic stress disorder, etc. Anxiety disorders are characterized by varying degrees of generalized anxiety ranging from mild to severe. Treatments vary based on the client’s specific anxiety disorder(s), but typically involve a combination of psychotherapy specific for the disorder and medication therapy treatment (most commonly benzodiazepines and/or selective serotonin reuptake inhibitors (SSRIs)). Clients with an anxiety disorder are more likely than other individuals to experience depression. Although post-traumatic stress disorder is included under the umbrella term of anxiety disorders, this is not the best answer to this question.

Question 23

Deescalation Techniques

Answer 23

• Maintain the client’s self-esteem and dignity
• Maintain calmness (your own and the clients)
• Assess the client and the situation
• Identify stressors and stress indicators
• Respond as early as possible
• Use a calm, clear tone of voice
• Invest time
• Remain honest
• Determine what the patient considers to be needed
• Identify goals
• Avoid invading personal space; in times of high anxiety, personal space increases
• Avoid arguing
• Give several clear options
• Use genuineness and empathy
• Be assertive (not aggressive)
• Do not take chances; maintain personal safety

Question 24

Which stage of development would an eight year old be in?

Answer 24

Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds. In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, and it results in inferiority.

Question 25

which stage of development would a 2-3 year old be in?

Answer 25

Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, and it leads to a sense of autonomy. When they are not successful, they think they are a failure, and it results in shame and self-doubt.

Question 26

which stage of development lasts from birth to 18 months

Answer 26

Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop a sense of confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will build mistrust.

Question 27

which stage of development lasts from 3-5 years of age

Answer 27

Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds. In Initiative vs. Guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty.

Question 28

Methadone

Answer 28

Methadone is an efficacious medication used in the treatment of opioid use disorder, chronic pain, and in the treatment of neonatal abstinence syndrome. This medication requires close monitoring and counseling for opioid use disorder. Periodic blood tests are required as this medication may be hepatotoxic. This medication has been shown to decrease the transmission of blood-borne pathogens such as HIV and Hepatitis C. This is because the reduction of intravenous drug use decreases the risk of the transmission of these pathogens. Drowsiness is a common side effect of this medication as it is an opioid agonist.
Treatment for opioid use disorder includes naltrexone, methadone, or buprenorphine. These medications have proven efficacy in this disorder, and when combined with counseling and appropriate monitoring, they may assist a patient in attaining opioid abstinence.

Question 29

Positive symptoms of Schizophrenia

Answer 29

✓ Positive symptoms include things that add something to the client. They include:

Hallucinations: Experiences involving the apparent perception of something not present.
They can include any five senses: touch, taste, smell, sight, or hearing.
Auditory hallucinations, when the client hears something that is not present, are common in schizophrenia.
Delusions: Fixed, false beliefs that conflict with reality.
Types of delusions include persecution, grandeur, and jealousy
Thought and speech disorganization

Question 30

Negative symptoms of schizophrenia

Answer 30

✓ Negative symptoms are things that take something away from the client. They include:

Apathy: A lack of interest, enthusiasm, or concern.
Alogia: Also known as ‘poverty of speech,’ alogia is difficulty with speaking or the tendency to speak little due to brain impairment.
Anhedonia: The inability to feel pleasure.
Avolition: A total lack of motivation that makes it hard to get anything done
Flattened affect

Question 31

Which foods should be avoided by a patient taking MAOIs for depression?

Answer 31

Foods high in tryptophan, tyramine, and caffeine, such as chocolate and cheese, may precipitate a hypertensive crisis. Monoamine oxidase inhibitors (MAOIs) were the first type of antidepressant developed. They ease depression by affecting neurotransmitters in the brain. Although they are active, they’ve generally been replaced by antidepressants that are safer and cause fewer side effects. MAOIs can cause dangerously high blood pressure when taken with certain foods or medications. Because of this, diet restrictions and avoiding certain other drugs are required while on an MAOI therapy. Despite side effects, these medications are still a good option for some people. In some instances, they relieve depression when other treatments have failed.

Question 32

Intimate Partner Violence Considerations

Answer 32

✓ Intimate partner violence (IPV) could be a current or previous partner or spouse
✓ IPV occurs in heterosexual and same-sex relationships where intimacy may not be present
✓ Nurses should assess all clients for IPV
✓ IPV may be physical, psychological (emotional), sexual, financial, stalking, neglect, or abandonment
✓ Nurses should inform clients that information regarding IPV will be kept confidential and shared with the treating physician
✓ The nurse should also inform the client that most jurisdictions require reporting of IPV; the nurse should inform the client that any IPV will be reported
✓ Interactions between the victim and the perpetrator may demonstrate the victim seeking approval from the perpetrator, the perpetrator reluctant to leave the victim alone, or frequent interruptions during the assessment
✓ Cases of IPV reported by the nurse are kept anonymous, and that should not dissuade the nurse from reporting
✓ It is not enough for the nurse to report suspicions of abuse to the supervisor; that does not absolve the nurses’ legal and ethical responsibility to report the IPV

Question 33

Treatment For Spiritual Distress

Answer 33

Spiritual distress should be treated with a referral to the clergy and psychosocial support of the client after assessing the client for the sources of their mental pain rather than diazepam. For example, if the cause of the mental illness is unresolved guilt, the nurse and other members of the healthcare team should educate the client about the purpose of sin, they should facilitate the person’s making amends to others, and also advise the client that all humans have faults; nobody is perfect and without errors.

Question 34

Terminal Delirium Treatment

Answer 34

Antipsychotic agents such as dopamine antagonists (haloperidol) are often used as an initial pharmacological treatment in terminal delirium. Benzodiazepines (lorazepam) are not recommended in treating delirium because they may cause paradoxical excitation that worsens delirium. Benzodiazepines (BZDs) are indicated if the dopamine antagonist fails to relieve agitation or if more sedation is desired. BZDs are also used in treating agitation without delirium.

Question 35

Delirium

Answer 35

Delirium is an altered sensorium. It is characterized by acute changes in the patient’s level of consciousness.
Hyperactive delirium is characterized by agitation, restlessness, and emotional lability. Hypoactive delirium is characterized by flat affect, apathy, lethargy, or decreased responsiveness.
Causes: Many causes of delirium include medications (dexamethasone, opioid toxicity), nicotine withdrawal, dehydration, uncontrolled pain, constipation, urinary retention, infection, hypoxia, renal failure, hyponatremia, hypercalcemia, hypoglycemia, and emotional distress.
Management: Initially, non-pharmacological interventions should be attempted to identify and address reversible etiology and relieve terminal agitation/delirium. For example, address the reversible causes such as treating constipation or discontinuing medications such as dexamethasone, modifying precipitating factors such as sensory deprivation or uncontrolled pain, etc. If no rapidly reversible factors are identified or if the patient is terminal, dopamine antagonists must be used.

Question 36

Severe Anxiety Symptoms

Answer 36

Severe anxiety causes an individual to experience a narrow perceptual field, an inability to problem-solve, and somatic symptoms such as dizziness, palpitations, diaphoresis, and a feeling of impending doom. Staying with the client provides an assurance and enables the nurse to give the client simple and short directions, if necessary.
Severe anxiety is marked by -
Greatly reduced and distorted perceptual field
Focuses on details or one specific detail
Attention is scattered
Inability to problem solve
A feeling of impending doom
Interventions include staying with the client because their behavior may become unpredictable, coaching breathing if the client develops hyperventilation, giving the client short and simple cues, and obtaining prescriptive medication (if necessary). The nurse should ensure that the environment is tranquil and does not have excessive stimuli.

Question 37

Borderline Personality Disorder

Answer 37

✓ A borderline personality disorder is about five times more common in first-degree biological relatives with the same disorder compared with the general population

✓ This disorder is characterized by the individual having an unstable self-image, fear of rejection, impulsivity, and emotional dysregulation

✓ A key intervention for a client with BPD is to assess for suicidality

✓ Parasuicide is common with this personality disorder; however, it is essential to keep this client safe

✓ Defense mechanisms commonly seen in this personality disorder include splitting, projective identification, and denial

✓ Treatment is therapy, specifically dialectal behavioral therapy, which focuses on emotional regulation and strategies to respond to stressors in a mature way

✓ No medication is approved to treat any personality disorder

Question 38

Tricyclic antidepressants

Answer 38

Tricyclic antidepressants include nortriptyline, amitriptyline, and imipramine. These medications are utilized in the treatment of depressive and obsessive-compulsive disorders. This class of medications possesses significant anticholinergic effects and, therefore, would not be recommended for older adults. Overdose of a TCA is extremely serious because these medications are cardiotoxic.

Question 39

The nurse is preparing to discharge clients from the nursing unit. Which client has the greatest need to be referred for outpatient community services?
A. A client newly diagnosed with skin cancer that lives with family.
B. A client recovering from a stroke and is discharged to inpatient rehab.
C. A client who is homeless and has a substance use disorder.
D. A client leaving against medical advice for the treatment of cellulitis.

Answer 39

Individuals with difficulty obtaining and sustaining housing have high rates of treatment non-adherence. Lack of adequate housing poses a serious threat to treatment adherence because of the lack of privacy, storage of medications, and a sense of detachment from the community. This client should be referred for outpatient services because they are homeless and have a substance use disorder. Both are issues that may be mitigated with community services.
An RN may initiate referrals. The nurse should identify clients with the most significant need for community services. Examples of clients needing community services include:

Homelessness
Complex conditions (HIV, cancer)
Insufficient support systems
Financial instability

Question 40

Restraints Considerations

Answer 40

Restraints should be used as a last resort if alternative methods are not effective.
A nurse should never threaten a client with restraints. This is considered assault.
The nurse may place a client who is violent in restraints without an order from the primary healthcare provider (PHCP). If this was to occur, the nurse has one hour to inform the provider and obtain an order.
Restraints are never as needed (PRN). They should be discontinued at the earliest possible time.
When restraining a client, the reason for the restraint must be explained to the client and the behavior the client needs to demonstrate for the restraints to be discontinued.
The nurse should observe the client at frequent intervals to offer nutrition & toileting, assess their behavioral status, obtain vital signs, and provide range of motion. These intervals are determined by the facility and the type of restraint—the more restrictive the restraint and the younger the client, the more frequent assessment.
Restraints must be able to quickly be removed via a quick release buckle (knots are no longer recommended).
The nurses’ documentation must be comprehensive, describing the reasoning for the restraints, alternatives utilized, the education provided to the client, the type of restraint utilized, how it was secured, and the ongoing behavior necessary to continue the restraint. The nurse should also document the intervals at which the restraints were released.

Question 41

Sertraline

Answer 41

Sertraline is a potent, selective serotonin reuptake inhibitor. Sertraline is indicated in treating anxiety, obsessive-compulsive, and depressive disorders. In this client, it is likely the sertraline is being used for the client’s anxiety. This medication has a favorable cardiac side-effect profile and is aptly prescribed for this client. SSRIs take four to six weeks to gain efficacy. A new medication may be attempted if no efficacy is observed in twelve weeks. Most SSRIs cause a decrease in libido and sexual performance. This may be a temporary effect. SSRIs typically cause gastrointestinal distress once they are started and may be lessened by taking the medication with food. This effect generally resolves on its own. An example of an atypical antipsychotic would be aripiprazole or ziprasidone. An example of a tricyclic antidepressant would be doxepin or nortriptyline.

Question 42

Zoplidem

Answer 42

Zolpidem is a non-benzodiazepine sedative-hypnotic indicated in the treatment of insomnia. Zolpidem has a rapid onset and should be taken immediately before the planned bedtime. Falls are a significant concern with this medication, especially for older adults. Another consideration is suicidality, as zolpidem has precipitated clients to experience suicidality. This medication should not be taken with alcohol or other CNS depressants because of the risk of respiratory depression. An example of a benzodiazepine would be alprazolam or diazepam. An example of an anticonvulsant would be topiramate or phenytoin. A persistent, painful erection (priapism) should be reported for trazodone - not zolpidem.

Question 43

Clinical Findings of Schizophrenia

Answer 43

Clinical features of schizophrenia include positive and negative symptoms. Anhedonia, avolition, and delusions are all associated with this psychiatric disorder.
Schizophrenia symptoms are divided into positive or negative symptoms.

Positive symptoms include things that add something to the client. They include:

Hallucinations: Experiences involving the apparent perception of something not present.
They can include any of the five senses: touch, taste, smell, sight, or hearing.
Auditory hallucinations, when the client hears something that is not present, are common in schizophrenia.
Delusions: Fixed, false beliefs that conflict with reality.
Types of delusions include persecution, grandeur, and jealousy
Thought and speech disorganization
Negative symptoms are things that take something away from the client. They include:

Apathy: A lack of interest, enthusiasm, or concern.
Alogia: Also known as ‘poverty of speech,’ alogia is difficulty with speaking or the tendency to speak little due to brain impairment.
Anhedonia: The inability to feel pleasure.
Avolition: A total lack of motivation that makes it hard to get anything done
Flattened affect