Rasmussen Mental Health Exam 2 LATEST 2025 UPDATE WITH

COMPLETE QUESTIONS AND CORRECTLY WELL DEFINED

ANSWERS 100%GUARANTEED PASS!!!

Stress - CORRECT ANSWER-"Fight or flight response"

In times of stress the sympathetic nervous system assumes control and sends
signals to the adrenal glands, releasing epinephrine (adrenaline). The circulating
adrenaline causes these expected effects:

Increases heart rate

Increases respiration rate

Increases blood pressure

Increases blood flow to skeletal muscles

Increases muscle tension

Apprehension

Unhappiness or sorrow

Decreased appetite

Increased metabolism and glucose use

Depressed immune system

Prolonged stress - CORRECT ANSWER-Maladaptive response

When stress is prolonged or people are not able to relax, they remain in chronic
low levels of stress. The body stays alert for a prolonged period of time. A
sustained increase in the chemicals produced by the stress response (cortisol,
adrenaline, and other catecholamines) can have damaging effects on the body,
causing physical diseases including a substantial negative effect on the immune
system, leaving individuals vulnerable to autoimmune diseases.

Prolonged stress causes:

-Chronic anxiety or panic attacks

-Depression, chronic pain, sleep disturbances

-Weight gain or loss

-Increased risk for MI and stroke

-Poor diabetes control, hypertension, fatigue, irritability, decreased ability to

concentrate

-Increased risk for infection

Nursing interventions for stress - CORRECT ANSWER-**Cognitave behavioral therapy

and SSRI's are first line of treatment

Do not abruptly discontinue medication; can cause suicidal ideations

Assess risk for suicide and implement safety precautions

Monitor pt's ability to perform ADL's and encourage independence

Therapeutic communication develop nurse-client relationship

Counseling

Posttraumatic Stress Disorder (PTSD) - CORRECT ANSWER-People who

experience/witness any traumatic event. Will feel extraordinary helplessness or
powerlessness in the face of stressors; lack of energy; sad with blunted affect;
poor grooming/lack of hygiene; slow speech, decreased verbalization, delayed
responses.

Four cardinal symptoms of PTSD - CORRECT ANSWER-• Intrusive reexperiencing of

the initial trauma (flashbacks, nightmares, unwanted distressing memories of the
event, feelings of unreality)

• Avoidance (avoid all memories and feelings as well as people or places that
might recall the event)

• Persistent negative alterations in cognitions and mood (distorted cognitions

about themselves and others [fear, guilt] and feelings of detachment)

• Alteration and arousal and activity (irritability, angry outbursts, self-destructive

behavior, exaggerated startle response, hypervigilance, sleep difficulties)
Optimal outcomes for PTSD patients - CORRECT ANSWER-• Patient and others will
remain safe.

• Patient will receive treatment for co-occurring conditions.

• Patient will attend support group meetings.

• Patient will expand social support network.

• Patient will exhibit an increase in restful sleep periods.

• Patient will have fewer nightmares and flashbacks.

• Patient will express decreased irritability.

• Patient will be able to demonstrate effective anxiety reduction techniques

Pharmacotherapy for PTSD - CORRECT ANSWER-Depression -> Antidepressants

Flashbacks -> SSRI antidepressants (fluoxetine), buspirone augmentation of SSRI,

second-generation antipsychotics
Panic attacks -> Antidepressants, MAOI's, high-potency benzodiazepines

Hyperarousal -> Antidepressants, benzodiazepines, α2-adrenergic agonists,

anticonvulsants

Nightmares -> prazosin (Minipress)

Nursing diagnosis for PTSD - CORRECT ANSWER-Disturbed thought process

Sleep deprivation r/t nightmares associated with traumatic event

Post-trauma syndrome r/t exposure to traumatic event

***Prioritize nursing diagnoses for PTSD related to safety/violence and self-harm

Cognitive behavioral therapy - CORRECT ANSWER-Uses cognitive reframing to help

the patient identify negative thoughts that produce anxiety, examine the cause,
and develop supportive ideas that replace negative self-talk.

Stress management techniques - CORRECT ANSWER-Relaxation techniques

-Meditation

-Guided imagery
-Breathing exercises

-Journal writing

-Priority restructuring

Reframing

-Changes the way we look at and feel about things

-There are many ways to interpret the same reality such as seeing the glass as half
full rather than half empty

Sleep

-Getting healthy amounts of sleep (8 hrs)

Aerobic exercise

-It is recommended for at least 30 minutes, three times a week

Lower/eliminate caffeine intake

-Such a simple measure can lead to more energy, fewer muscle aches, and greater
relaxation

Anxiety - CORRECT ANSWER-Feeling of apprehension, uneasiness, uncertainty, or

dread resulting from a real or perceived threat whose actual source is unknown or
unrecognized.
Generalized anxiety disorder (GAD) - CORRECT ANSWER-Basically, GAD is
characterized by excessive, persistent, and uncontrollable anxiety, and by
excessive and constant worrying. It is sometimes referred to as the "worry
disease."

**Symptoms lasted for 6 months

(e.g., What if I'm late? ...What if I fail? ...What if I am fired?)

Manifestations of GAD - CORRECT ANSWER-Restlessness

Muscle tension

Avoidance of stressful activities or events

Procrastination in decision making

Increased effort preparing for stressful activities

Seeks repeated reassurance

Pacing

Mild anxiety - CORRECT ANSWER-May have heightened perceptual field.

Is alert and can see, hear, and grasp what is happening in the environment. Can
identify issues that are disturbing and are producing anxiety.

Able to work effectively toward a goal and examine alternatives.

Manifestations of mild anxiety - CORRECT ANSWER--Slight discomfort

-Attention-seeking behaviors

-Restlessness

-Irritability or impatience

-Mild tension-relieving behavior: foot or finger tapping, lip chewing, fidgeting

Moderate anxiety - CORRECT ANSWER-Has narrow perceptual field; grasps less of

what is occurring. Can attend to more if pointed out by another (selective
inattention).

Able to solve problems but not at optimal ability

Benefits from guidance of others.

Manifestations of moderate anxiety - CORRECT ANSWER--Voice tremors

-Change in voice pitch

-Difficulty concentrating; SELECTIVE ATTENTION

-Shakiness

-Repetitive questioning

-Somatic complaints (e.g., urinary frequency and urgency, headache, backache,

insomnia)

-Increased respiration rate

-Increased pulse rate

-Increased muscle tension

-More extreme tension-relieving behavior; pacing, banging hands on table

Interventions for mild to moderate anxiety - CORRECT ANSWER-Help patient focus

and problem solve using specific communication techniques:

-let them express feelings to make them feel better

-open ended questions

-giving broad openings

-explore and seek clarification

-remain calm and be willing to listen

Severe anxiety - CORRECT ANSWER-Has greatly reduced perceptual field.

Focuses on details or one specific detail.

Attention scattered.

Completely absorbed with self.

May not be able to attend to events in environment even when pointed out by
others.

In severe to panic levels of anxiety, the environment is blocked out; it is as if these

events are not occurring.

Unable to see connections between events or details. Has distorted perceptions.

Manifestations of severe anxiety - CORRECT ANSWER--Feelings of dread

-Ineffective functioning

-Confusion
-Purposeless activity

-Sense of impending doom

-More intense somatic complaints (e.g., dizziness, nausea, headache,

sleeplessness)

-Hyperventilation

-TACHYCARDIA

-DIAPHORESIS

-Withdrawal

-Loud and rapid speech

-Threats and demands

Panic level of anxiety - CORRECT ANSWER-Unable to focus on the environment.

Experiences the utmost state of terror and emotional paralysis; feels he or she
"ceases to exist."
May have hallucinations or delusions that take the place of reality.

May be mute or have extreme psychomotor agitation leading to exhaustion.

Shows disorganized or irrational reasoning.

Manifestations of panic levels of anxiety - CORRECT ANSWER--Experience of terror

-Immobility or severe hyperactivity or flight

-Dilated pupils

-Unintelligible communication or inability to speak

-Severe shakiness

-Sleeplessness

-Severe withdrawal

-Hallucinations or delusions; likely out of touch with reality

Interventions for severe to panic levels of anxiety - CORRECT ANSWER-Patients are
unable to problem solve - the nurse needs to be concerned with patient safety
and that of others.

Physical needs (fluid and rest) must be met to prevent exhaustion.

Need a quiet environment with minimal stimulation.

NOT a good time to have them express how they are feeling

Make the patient feel understood to decrease feelings of anxiety and isolation.

Provide gross motor skill activities to drain some of the tension.

Medications and restraints should only be used after more personal and less
restrictive interventions have failed.

Panic attack - CORRECT ANSWER-Sudden onset of extreme apprehension or fear,

usually associated with feelings of impending doom: "I am going to die." Typically,
panic attacks occur suddenly, are extremely intense, and can last for 15 to 30
minutes before they subside.

The feelings of terror present during a panic attack are so severe that normal
function is suspended, the perceptual field is severely limited, and
misinterpretation of reality may occur. Severe personality disorganization is
evident.

Manifestations of a panic attack - CORRECT ANSWER-**Often mistaken by the

patient for a heart attack, patient go to ER

Palpitations

SOB

Choking or smothering sensation

Chest pain

Nausea

Chills or hot flashes

Fear of dying or insanity

Obsessive compulsive disorder (OCD) - CORRECT ANSWER-Patient has intrusive

thoughts of unrealistic obsessions and tries to control these thoughts with
compulsive behaviors (ex: repetitive cleaning of a particular object or washing of
hands a certain amount of time before they are satisfied).

Obsessions or compulsions are time-consuming and result in impaired social and

occupational functioning.
Agoraphobia - CORRECT ANSWER-An intense, excessive anxiety about or fear of being
in places where they feel vulnerable or unsafe. The feared places or situations are
avoided by the individual in an effort to control anxiety.

Examples:

-Being alone outside the home

-Using public transportation (traveling in a car, bus, or airplane)

-Being in open spaces (bridges, marketplaces, or parking lots)

-Being in an enclosed place (elevators, churches, or theaters)

-Being in a crowd

Healthy defense mechanism -

Altruism - CORRECT ANSWER-Dealing with anxiety by reaching out to others

Ex: A nurse who lost a family member in a fire is a volunteer firefighter

Healthy defense mechanism -

Sublimation - CORRECT ANSWER-Dealing with unacceptable feelings or impulses by

unconsciously substituting acceptable forms of expression

Ex: A person who is still angry and hostile toward his boss sublimates those
feelings by working out vigorously at the gym during his lunch period.
Healthy defense mechanism -

Suppression - CORRECT ANSWER-Conscious denial of unpleasant thoughts and

feelings.

ADAPTIVE - Student puts off thinking about a fight she had with her friend so she
can focus on a test.

MALADAPTIVE - A person who has lost his job states he will worry about paying
his bills next week.

Intermediate defense mechanism - Repression - CORRECT ANSWER-**CORNERSTONE

defense mechanism. First line of psychological defense against anxiety.

Exclusion of unpleasant or unwanted experiences, emotions, or ideas from

conscious awareness.

ADAPTIVE - A person preparing to give a speech unconsciously forgets about the

time when he was young and kids laughed at him while on stage.

MALADAPTIVE - A person who has a fear of the dentist continually forgets to go to

his dental appointments.

Intermediate defense mechanism - Regression - CORRECT ANSWER-Sudden use of

childlike or primitive behaviors that don't correlate with the person's current
developmental level.
ADAPTIVE - A child temporarily wets the bed when she learns that her pet died.

MALADAPTIVE - A person who has a disagreement with a co-worker begins

throwing things at her office.

Intermediate defense mechanism - Displacement - CORRECT ANSWER-Transfer of

emotions associated with a particular person, object, or situation to another
person, object, or situation that is nonthreatening.

ADAPTIVE - An adolescent angrily punches a punching bag after losing a game.

MALADAPTIVE - A person who is angry about losing his job destroys his child's
favorite toy.

Intermediate defense mechanism - Reaction formation - CORRECT ANSWER-

Overcompensating or demonstrating the opposite behavior of what is felt.

ADAPTIVE - A man who is trying to quit smoking repeatedly talks to adolescents

about the dangers of nicotine.

MALADAPTIVE - You don't like your nurse manager but you bring her chocolates.
Intermediate defense mechanism - Undoing - CORRECT ANSWER-Performing an act
to make up for prior behavior

ADAPTIVE - An adolescent completes his chores without being prompted after

having an argument with his parent.

MALADAPTIVE - A man buys his wife flowers and gifts following an incident of
domestic abuse.

Intermediate defense mechanism - Rationalization - CORRECT ANSWER-Creating

reasonable and acceptable explanations for unacceptable behavior.

ADAPTIVE USE: An adolescent boy says, "she must already have a boyfriend"
when rejected by a girl.

MALADAPTIVE USE: A young adult explains he had to drive home from a party
after drinking alcohol because he had to feed his dog.

Immature defense mechanism - Dissociation - CORRECT ANSWER-Creating a

temporary compartmentalization or lack of connection between the person's
identity, memory, or how they perceive the environment.

ADAPTIVE USE: A parent blocks out the distracting noise of her children in order
to focus while driving in traffic.
MALADAPTIVE USE: A woman forgets who she is following a sexual assault.

Immature defense mechanism -Denial - CORRECT ANSWER-Pretending the truth is

not reality to manage the anxiety of acknowledging what is real.

ADAPTIVE USE: A person initially says, "No, that can't be true" when told they
have cancer.

MALADAPTIVE USE: A parent who is informed that his son was killed in combat
tells everyone one month later that he is coming home for the holidays.

Intermediate defense mechanism - Compensation - CORRECT ANSWER-Emphasizing

strengths to make up for weaknesses.

ADAPTIVE USE: An adolescent who is physically unable to play contact sports

excels in academic competitions.

MALADAPTIVE USE: A person who is shy works at computer skills to avoid

socialization.

Intermediate defense mechanism - Identification - CORRECT ANSWER-Conscious or

unconscious assumption of the

characteristics of another individual or group.

ADAPTIVE USE: A girl who has a chronic illness pretends to be a nurse for her
dolls.

MALADAPTIVE USE: A child who observes his father be abusive toward his mother
becomes a bully at school.

Intermediate defense mechanism - Intellectualization - CORRECT ANSWER-Separation

of emotions and logical facts when analyzing or coping with a situation or event.

ADAPTIVE USE: A law enforcement officer blocks out the emotional aspect of a
crime so he can objectively focus on the investigation.

MALADAPTIVE USE: A person who learns he has a terminal illness focuses on

creating a will and financial matters rather than acknowledging his grief.

Immature defense mechanism - Conversion - CORRECT ANSWER-Responding to stress

through the unconscious

development of physical manifestations not caused by a physical illness.

ADAPTIVE USE: n/a

MALADAPTIVE USE: A person experiences deafness after his partner tells him she
wants a divorce.
Immature defense mechanism - Splitting - CORRECT ANSWER-Demonstrating an
inability to reconcile negative and positive attributes of self or others.

ADAPTIVE USE: n/a

MALADAPTIVE USE: A client tells a nurse that she is the only one who cares about
her, yet the following day, the same client refuses to talk to the nurse.

Immature defense mechanism - Projection - CORRECT ANSWER-Attributing one's

unacceptable thoughts and feelings onto another who does not have them.

ADAPTIVE USE: n/a

MALADAPTIVE USE: A married woman who is attracted to another man accuses

her husband of having an extramarital affair.

Nursing diagnoses related to anxiety - CORRECT ANSWER-Anxiety (moderate, severe,

panic)

Fear

Ineffective coping

Social isolation

Self-care deficit

Ineffective role performance

Risk for injury

Disturbed thought process

Patient outcomes for phobia - CORRECT ANSWER-Patients will:

• Develop skills at reframing anxiety-provoking situation (by date).

• Work with nurse/clinician to desensitize self to feared object or situation (by

date).

• Demonstrate one new relaxation skill that works well for them (by date).

Patient outcomes for GAD - CORRECT ANSWER-Patients will:

• State increased ability to make decisions and problem solve.

• Demonstrate ability to perform usual tasks even though still moderately anxious
(by date).

• Demonstrate one cognitive or behavioral coping skill that helps reduce anxious
feelings (by date).

Patient outcomes for OCD - CORRECT ANSWER-Patients will:

• Demonstrate techniques that can distract and distance self from thoughts that
are anxiety producing (by date).

• Decrease time spent in ritualistic behaviors.

• Demonstrate increased amount of time spent with family and friends and on
pleasurable activities.

• State they have more control over intrusive thoughts and rituals (by date).

Medications for panic disorder - CORRECT ANSWER-• SSRIs are treatment of choice:
paroxetine (Paxil), sertraline (Zoloft), fluoxetine (Prozac), citalopram (Celexa),
fluvoxamine (Luvox)

• If patients do not respond to SSRIs, short-term treatment with a benzodiazepine

may be used:

diazepam (Valium), lorazepam (Ativan), oxazepam (Serax), chlordiazepoxide

(Librium), clorazepate (Tranxene)

• Or patients may switch to another type of antidepressant such as a SNRI:

venlafaxine (Effexor)

• Or TCA's: clomipramine (Anafranil), amytriptyline (Elavil), imipramine (Tofranil)

Medications for GAD - CORRECT ANSWER-When medications are indicated:

• **Buspirone (BuSpar) reduces rumination and worry, NOT ADDICTIVE

• SSRI *escitalopram (Lexapro), paroxetine (Paxil), sertraline (Zoloft), fluoxetine

(Prozac), citalopram (Celexa), fluvoxamine (Luvox)]

• TCA 's *clomipramine (Anafranil), amytriptyline (Elavil), imipramine (Tofranil)+

• Investigational drugs include pregabalin and other anticonvulsants

Medications for OCD - CORRECT ANSWER-• SSRIs reduce OCD symptoms directly
(fluvoxamine [Luvox] and fluoxetine [Prozac])

• TCAs (clomipramine *Anafranil+)

Benzodiazepines - CORRECT ANSWER-QUICK ONSET

Prescribed for SHORT-TERM treatment only; not recommended for use by

patients with substance use problems (because of potential for dependence).
Benzodiazepines can be highly addictive and are prescribed for short periods of
time, especially when used to self-medicate for anxiety/depression.

Should not be given to women who are pregnant or breast-feeding.

Patient teaching for benzodiazepines - CORRECT ANSWER--Take as prescribed, don't

abruptly stop or change dose without instruction from doctor

-When discontinuing, drug must be tapered over several weeks

-Avoid alcohol and other CNS depressants

-Advise the client and family to watch for manifestations of overdose. Notify the
provider if these occur

-Medications should be taken with, or shortly after, meals or snacks to reduce

gastrointestinal discomfort

Nursing considerations for benzodiazepines - CORRECT ANSWER-● For oral toxicity,

gastric lavage is used, followed by the administration of activated charcoal or
saline cathartics.

● Flumazenil is administered to counteract sedation and reverse the adverse

effects.
● Monitor vital signs, maintain patent airway, and provide fluids to maintain
blood pressure.

● Ensure availability of resuscitation equipment

Buspirone (BuSpar) - CORRECT ANSWER-An alternative anxiolytic medication that

does NOT CAUSE DEPENDENCE.

**However, 2 to 4 weeks are required for it to become fully effective.

This medication does not interfere with activities because it does not cause
sedation (therefore you CAN DRINK ALCOHOL)

Buspirone is contraindicated for concurrent use with MAOI antidepressants, or for

14 days after MAOIs are discontinued. Hypertensive crisis can result.

Erythromycin, ketoconazole, St. John's wort, and grapefruit juice can increase the
effects of buspirone.

Patient teaching for buspirone - CORRECT ANSWER-● Advise the client to take the
medication with meals to prevent gastric irritation.

● Medication should be administered at the same time every day.

● Advise the client that effects do not occur immediately. It can take 1 week to
notice first therapeutic effects, and 2 to 6 weeks to reach full therapeutic benefit.
Medication should be taken on a regular basis, rather than an as‑needed basis.

● Instruct clients that tolerance, dependence, or withdrawal manifestations are

not an issue with this medication.

SSRI's - CORRECT ANSWER-SSRIs are the first-line treatment for anxiety disorders,
OCD, and BDD.

They are preferable to the tricyclic antidepressants (TCAs) because they have a
more rapid onset of action, have fewer problematic side effects, and are more
effective.

First few days/weeks: nausea, diaphoresis, tremor, fatigue, drowsiness may occur.

After 5 to 6 weeks of therapy: sexual dysfunction, weight gain, or headaches may

occur.

For depression: May worsen symptoms of depression in the beginning, before the
medication is effective (up to 4 weeks to achieve therapeutic effects)

Patient education for SSRI's - CORRECT ANSWER-***REPORT INCREASED SUICIDAL

THOUGHTS
***OBSERVE FOR S&S OF SEROTONIN SYNDROME AND STOP MED!! NOTIFY THE
DOCTOR!

Avoid alcohol

Advise the client that adverse effects can include nausea, headache, and central
nervous system stimulation (agitation, insomnia, anxiety).

Advise the client that SSRIs may be taken with food. Sleep disturbances are
minimized by taking the medication in the morning.

Instruct the client to avoid the concurrent use

of St. John's wort, which can increase the risk of

serotonin syndrome.

Instruct the client that sexual dysfunction can occur and to notify provider if
effects are intolerable.

Instruct the client to take the medication on a daily

basis to establish therapeutic plasma levels.

Assist the client with medication regimen adherence by informing the client that
it can take up to 4 weeks to achieve therapeutic effects.

Serotonin syndrome s&s - CORRECT ANSWER-Agitation, confusion, disorientation,

difficulty

concentrating, anxiety, hallucinations, hyperreflexia, fever, diaphoresis,

incoordination, tremors

Usually begins 2 to 72 hr after initiation of treatment

Resolves when the medication is discontinued

Common symptoms of depression - CORRECT ANSWER-• Mood of sadness, despair,

emptiness

• Negative, pessimistic thinking

• Loss of ability to experience pleasure in life (anhedonia)

• Low self-esteem

• Apathy, low motivation, and social withdrawal

• Excessive emotional sensitivity

• Irritability and low frustration tolerance

• Insomnia or hypersomnia

• Disruption (mild to severe) in concentration or ability to make decisions

• Suicidal ideation

• Excessive guilt

• Indecisiveness

Anhedonia - CORRECT ANSWER-Lack of pleasure in things that used to be

pleasurable. Such as a painter that doesn't want to paint anymore.

Beck's cognitive triad - CORRECT ANSWER-Three automatic negative thoughts that

are responsible for the development of depression:

1. A negative, self-deprecating view of self: "I really never do anything well;

everyone else seems smarter."
2. A pessimistic view of the world: "Once you're down, you can't get up. Look
around, poverty, homelessness, sickness, war, and despair are every place you
look."

3. The belief that negative reinforcement (or no validation for the self) will
continue: "It doesn't matter what you do; nothing ever gets better. I'll be in this
stupid job the rest of my life."

The phrase automatic negative thoughts refers to thoughts that are repetitive,
unintended, and not readily controllable. This cognitive triad seems to be
consistent in all types of depression, regardless of clinical subtype.

Questions to ask for risk for suicide - CORRECT ANSWER-• "You have said you are
depressed. Tell me what that is like for you."

• "When you feel depressed, what thoughts go through your mind?"

• "Have you ever thought about taking your own life in the past? Now? Do you
have a plan? Do you have the means to carry out your plan? Is there anything that
would prevent you from carrying out your plan?"

Individuals at higher risk for committing suicide - CORRECT ANSWER-A patient that
HAS a plan AND a weapon
Older, single, lonely individuals with multiple health problems are more likely to
commit suicide than individuals with a great family support system and always in
the midst of people.

Males are more commonly committing suicide than females.

Suicide precautions within the facility - CORRECT ANSWER-● Initiate one‑on‑one

constant supervision around

the clock, always having the client AT ARM'S LENGTH AWAY

● Document the client's location, mood, quoted

statements, and behavior every 15 min or per

facility protocol (suicide observation)

● Search the client's belongings with the client present. Remove all potentially
harmful items from the client's room and vicinity.

● Allow the client to use only plastic eating utensils. Count utensils when brought
into and out of the client's room.

● Check the environment for possible hazards (such as windows that open,
overhead pipes that are easily accessible, non‑breakaway shower rods,
non‑recessed shower nozzles).
● Ensure that the client's hands are always visible, even when sleeping.

● Do not assign to a private room and keep door open at all times.

● Ensure that the client swallows all medications. Clients can try to hoard
medication until there is enough for a suicide attempt.

● Identify whether the client's current medications can be lethal with overdose. If
so, collaborate with the provider to have less dangerous medications substituted
if possible.

● Restrict visitors from bringing possibly harmful items to the client.

Nursing diagnoses related to depression - CORRECT ANSWER-Risk for suicide

Risk for self-mutilation

Ineffective coping

Interrupted family processes

Risk for impaired parent/infant/child attachment

Ineffective role performance

Hopelessness

Chronic low self-esteem

Situational low self-esteem

Impaired social interaction

Social isolation

Risk for loneliness

Communication interventions for depression - CORRECT ANSWER-1. Help the patient

question underlying assumptions and beliefs and consider alternate explanations
to problems.

2. Work with the patient to identify cognitive distortions that encourage negative
self-appraisal. For example:

a. Overgeneralizations

b. Self-blame

c. Mind reading

d. Discounting of positive attributes

3. Encourage activities that can raise self-esteem. Identify need for

a. problem-solving skills

b. coping skills

c. assertiveness skills.

4. Discuss physical activities the patient enjoys (e.g., running, weightlifting).

Explain that initially 10 to 15 minutes a day 3 or 4 times a week has short-term
benefits.
5. Encourage formation of supportive relationships, such as through support
groups, therapy, and peer support.

6. Provide information referrals, when needed, for spiritual/religious information

(e.g., readings, programs, tapes, community resources).

Physical interventions for depression - Nutrition & Anorexia - CORRECT ANSWER-1.

Offer small, high-calorie, and high-protein snacks frequently throughout the day
and evening.

2. Offer high-protein and high-calorie fluids frequently throughout the day and
evening.

3. When possible, encourage family or friends to remain with the patient during
meals.

4. Ask the patient which foods or drinks he or she likes. Offer choices. Involve the
dietitian.

5. Weigh the patient weekly and observe the patient's eating patterns.

Physical interventions for depression - Sleep & Insomnia - CORRECT ANSWER-1.

Provide periods of rest after activities.
2. Encourage the patient to get up and dress and to stay out of bed during the
day.

3. Encourage the use of relaxation measures in the evening (e.g., tepid bath,
warm milk).

4. Reduce environmental and physical stimulants in the evening—provide

decaffeinated coffee, soft lights, soft music, quiet activities.

Physical interventions for depression - Self care deficits - CORRECT ANSWER-1.

Encourage the use of toothbrush, washcloth, soap, makeup, shaving equipment,
and so forth.

2. When appropriate, give step-by-step reminders such as, "Wash the right side of
your face, now the left."

Physical interventions for depression - Elimination - CORRECT ANSWER-1. Monitor

intake and output, especially bowel movements.

2. Offer foods high in fiber and provide periods of exercise.

3. Encourage the intake of fluids.

4. Evaluate the need for laxatives and enemas.

SSRI's - CORRECT ANSWER-Citalopram (Celexa)

Escitalopram (Lexapro)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

Potential side effects of SSRI's - CORRECT ANSWER-• Headache, which usually

dissipates in a few days

• Nausea, which usually dissipates in a few days

• Sleeplessness and/or drowsiness during day, which usually dissipates in a few

weeks

• Tremors and/or dizziness

• Sexual problems: reduces sexual drive, problems having and enjoying sex

• Agitation, feeling jittery and nervous; rare serotonin syndrome; rare activation
of suicidal ideation
TCA's - CORRECT ANSWER-**Imipramine (Tofranil)

Amitriptyline (Elavil)

Clomipramine (Anafranil)

Desipramine (Norpramin)

Doxepin (Sinequan)

Maprotiline (Ludiomil)

Nortriptyline (Pamelor)

Protriptyline (Vivactil)

Trimipramine (Surmontil)

Amoxapine (Asendin)

Potential side effects of TCA's - CORRECT ANSWER-***Anticholinergic effects (be

careful in older adults, start LOW and go SLOW)

• Dry mouth

• Constipation

• Bladder problems (hard to empty bladder, weak urine stream, men with
enlarged prostate may be more affected)

• Sexual problems include reduced sex drive, problems having and enjoying sex
• Blurred vision, which usually dissipates quickly

• Drowsiness

MAOI's - CORRECT ANSWER-**Phenelzine (Nardil)

Isocarboxazid (Marplan)

Tranylcypromine (Parnate)

Potential side effects of MAOI's - CORRECT ANSWER-• Hypotension

• Sedation, weakness, fatigue

• Insomnia

• Changes in cardiac rhythm

• Muscle cramps

• Anorgasmia or sexual impotence

• Urinary hesitancy or constipation

• Weight gain

MAOI's & tyramine - CORRECT ANSWER-MAOI's inhibit the breakdown of tyramine in

the liver.

Increased levels of tyramine can lead to high blood pressure, HYPERTENSIVE

CRISIS, and eventually cerebrovascular accident and death.

Therefore people taking MAOIs must restrict their intake of tyramine so that their
blood pressure does not rise to dangerous levels.

Tyramine foods include: - CORRECT ANSWER-Avocados

Figs

Fermented or smoked meats (sausage, pepperoni, salami, bologna)

Liver

Dried or cured fish (salmon, herring)

Practically all cheeses, especially hard cheeses

Some imported beers, tap (draft) beers, some wines, Chianti

Protein dietary supplements

Soups (may contain protein extract)

Shrimp paste

Soy sauce

Chocolate

Ginsing

Hypertensive crisis - CORRECT ANSWER-• Severe headache

• Stiff, sore neck

• Flushing; cold, clammy skin

• Tachycardia

• Severe nosebleeds, dilated pupils

• Chest pain, stroke, coma, death

• Nausea and vomiting

1. Patient should go to local emergency department immediately—blood pressure
should be checked.

2. One of the following may be given to lower blood pressure:

• 5 mg of intravenous phentolamine (Regitine) or

• Oral chlorpromazine or

• Nifedipine (Procardia) (calcium channel blocker), 10 mg sublingually

Patient teaching for MAOI's - CORRECT ANSWER-• Tell the patient and the patient's
family to avoid tyramine foods and all medications (ESPECIALLY OTC COLD MEDS)
unless prescribed by and discussed with the patient's physician.

• Give the patient a wallet card describing the MAOI regimen.

• Instruct the patient to avoid Chinese restaurants (where soy sauce, sherry,
brewer's yeast, and other contraindicated products may be used).

• Tell the patient to go to the emergency department immediately if he or she has

a severe headache.

• Ideally, monitor the patient's blood pressure during the first 6 weeks of
treatment (for both hypotensive and hypertensive effects).
• Instruct the patient that after the MAOI is stopped, dietary and drug restrictions
should be maintained for 14 days.

Patient teaching for ALL antidepressants - CORRECT ANSWER-● Do not discontinue

medication suddenly.

● Therapeutic effects are not immediate, and it can take several weeks or more to
reach full therapeutic benefits.

● Avoid hazardous activities, such as driving or operating heavy

equipment/machinery, due to the potential adverse effect of sedation.

● Notify the provider of any thoughts of suicide.

● Avoid alcohol while taking an antidepressant.

Electroconvulsive therapy (ECT) - CORRECT ANSWER-One of the most effective

treatments for major depression with psychotic symptoms and for treatment of
patients with life-threatening psychiatric conditions

ECT is useful in treating patients with major depressive and bipolar depressive
disorders, especially when psychotic symptoms are present (e.g., delusions of
guilt, somatic delusions, or delusions of infidelity).
Patients who have depression with marked psychomotor retardation and stupor
also respond well.

However, ECT is not necessarily effective in patients with chronic depression,

atypical depression, personality disorders, drug dependence, or depression
secondary to situational or social difficulties.

Potential adverse reactions to ECT - CORRECT ANSWER-On awakening from ECT, the
patient may be confused and disoriented.

The nurse and significant others may need to orient the patient frequently during
the course of treatment.

Many patients state that they have memory deficits for the first few weeks after
treatment.

Vagus nerve stimulation - CORRECT ANSWER-Long-term treatment for patients with

treatment-resistant depression (TRD)

Involves surgically implanting a device called a pulse generator into the upper left
chest.

The pulse generator is connected by a wire to the left vagus nerve; when the
generator is stimulated electrical impulses are transmitted to areas of the brain
that affect mood centers.
When successful, there is an improvement of depressive symptoms.

Because the vagus nerve affects many functions of the brain, VNS is being studied
for other conditions as well (e.g., anxiety disorder, Alzheimer's disease, migraines,
and chronic pain/fibromyalgia).

Light therapy - CORRECT ANSWER-First-line treatment for seasonal affective disorder

(SAD) with or without medication.

Full-spectrum wavelength light is the specific type of light used.

People with SAD often live in climates in which there are marked seasonal
differences in the amount of daylight.

Seasonal variations in mood disorders in the Southern Hemisphere are the

reverse of those in the Northern Hemisphere.

Inhibits nocturnal secretion of melatonin

Exposure of the face to 10,000‑lux light box 30 min/day, once or in two divided
doses

Verbal cues for suicidal ideations - CORRECT ANSWER-Overt statements

• "I can't take it anymore."

• "Life isn't worth living anymore."

• "I wish I were dead."

• "Everyone would be better off if I died."

Covert statements

• "It's okay now. Everything will be fine."

• "Things will never work out."

• "I won't be a problem much longer."

• "Nothing feels good to me anymore, and probably never will."

• "How can I give my body to medical science?"

Behavioral cues for suicidal ideations - CORRECT ANSWER-• Giving away prized
possessions

• Writing farewell notes

• Making out a will

• Putting personal affairs in order

• Having global insomnia

• Exhibiting a sudden and unexpected improvement in mood after being

depressed or withdrawn

• Neglecting personal hygiene

Bipolar I disorder - CORRECT ANSWER-The patient has at least one episode of mania
alternating with major depression

Bipolar II disorder - CORRECT ANSWER-The patient has one or more hypomanic

episodes alternating with major depressive episodes

Mania - CORRECT ANSWER-An exaggerated elevated, expansive, or irritable mood,

accompanied by a persistent increase in activity and/or energy.

Usually requires hospitalization, last at least 1 week.

Hypomania - CORRECT ANSWER-Essentially a less severe and less intense form of

mania and may only last 2 to 4 days in most cases, and accompanied by 3 or more
manifestations of mania.

Hospitalization is not required, and the patient who has hypomania is less
impaired.

Manic behavior - CORRECT ANSWER-● Labile mood with euphoria

● Agitation and irritability

● Restlessness
● Dislike of interference and intolerance of criticism

● Increase in talking and activity

● Flight of ideas: rapid, continuous speech with sudden and frequent topic change

● Grandiose view of self and abilities (grandiosity)

● Impulsivity: spending money, giving away money

or possessions

● Demanding and manipulative behavior

● Distractibility and decreased attention span

● Poor judgment

● Attention‑seeking behavior: flashy dress and makeup, inappropriate behavior

● Impairment in social and occupational functioning

● Decreased sleep
● Neglect of ADLs, including nutrition and hydration

● Possible presence of delusions and hallucinations

● Denial of illness

Nursing diagnoses related to bipolar disorder - CORRECT ANSWER-Risk for injury

Impaired mood regulation

Labile emotional control

Imbalanced Nutrition: Less than body requirements

Deficient fluid volume

Disturbed thought processes

Interrupted family processes

Caregiver role strain

Disturbed sleep pattern

Interventions for acute mania - Communication - CORRECT ANSWER-1. Use firm and
calm approach: "John, come with me. Eat this sandwich."

2. Use short and concise explanations or statements.

3. Remain neutral; avoid power struggles and value judgments.

4. Be consistent in approach and expectations.

5. Have frequent staff meetings to plan consistent approaches and to set agreed-
on limits.

6. With other staff, decide on limits, tell patient in simple, concrete terms with
consequences; for example, "John, do not yell at or hit Peter. If you cannot
control yourself, we will help you" or "The seclusion room will help you feel less
out of control and prevent harm to yourself and others."

7. Hear and act on legitimate complaints.

8. Firmly redirect energy into more appropriate and constructive channels.

Interventions for acute mania - Within mental health facility - CORRECT ANSWER-1.
Maintain low level of stimuli in patient's environment (away from bright lights,
loud noises, and people).

2. Provide structured solitary activities with nurse or aide.

3. Provide frequent high-calorie fluids.

4. Provide frequent rest periods.

5. Redirect violent behavior through physical exercise (walking)

6. When warranted in acute mania, use antipsychotics and seclusion to minimize

physical harm via physician's order.

7. Observe for signs of lithium toxicity.

8. Protect patient from giving away money and possessions. Hold valuables in
hospital safe until rational judgment returns.

Interventions for acute mania - Nutrition - CORRECT ANSWER-1. Monitor intake,

output, and vital signs.
2. Offer frequent high-calorie protein drinks and FINGER FOODS (sandwiches,
fruit, milkshakes).

3. Frequently remind patient to eat. "Tom, finish your milkshake." "Sally, eat this
banana."

Interventions for acute mania - Sleep - CORRECT ANSWER-1. Encourage frequent rest
periods during the day.

2. Keep patient in areas of low stimulation.

3. At night, provide warm baths, soothing music, and medication when indicated.
Avoid giving patient caffeine.

Interventions for acute mania - Hygiene - CORRECT ANSWER-1. Supervise choice of

clothes; minimize flamboyant and bizarre dress (garish stripes or plaids and loud,
unmatching colors).

2. Give simple step-by-step reminders for hygiene and dress. "Here is your razor.
Shave the left side ... now the right side. Here is your toothbrush. Put the
toothpaste on the brush."
Interventions for acute mania - Elimination - CORRECT ANSWER-1. Monitor bowel
habits; offer fluids and foods that are high in fiber. Evaluate need for laxative.
Encourage patient to go to the bathroom.

Pharmacotherapy for bipolar disorders - CORRECT ANSWER-Mood stabilizer: Lithium

carbonate

Anticonvulsants: Divalproex (Depakote), carbamazepine (Tegretol), lamotrigine

(Lamictal)

Anxiolytics: Clonazepam (Klonopin) and lorazepam (Ativan)

Antipsychotics: olanzapine (Zyprexa), risperidone (Risperdal), aripiprazole

(Abilify), and ziprasidone (Geodon), quetiapine (Seroquel)

Lithium - CORRECT ANSWER-The major disadvantage of lithium is that improvement

is gradual. Antimanic effects begin slowly after the onset of treatment, but it can
take up to 3 weeks to show improvement and up to months for stabilization.

***VERY NARROW THERAPEUTIC WINDOW

(0.5-1.5 mEq/L)

Serum levels need to be checked frequently, 12 hours after last dose

For acute mania, a blood level of 0.6 to 1.2 mEq/L would be within the initial
range.

For maintenance therapy, lithium levels should range from 0.4 to 1.0 mEq/L,
however, levels of 0.6 to 0.8 mEq/L are effective for most.

***Levels higher than 1.5 mEq/L can result in significant toxicity

Cases of severe lithium toxicity with levels of 2 mEq/L or greater constitute a life-
threatening emergency. In such cases, gastric lavage and treatment with urea,
mannitol, and aminophylline can hasten lithium excretion. Hemodialysis also may
be used in extreme cases.

Expected side effects for lithium at a therapeutic level - CORRECT ANSWER-0.4 to 1

mEq/L

-Fine hand tremor, polyuria, and mild thirst

-Mild nausea and general discomfort

-Weight gain

Interventions:

Symptoms may persist throughout therapy. These symptoms often subside during
treatment. Give with food to decrease nausea. Weight gain may be helped with
diet, exercise, and nutritional management.
Early signs of lithium toxicity - CORRECT ANSWER-1.5 mEq/L

-Diaphoresis

-Nausea

-Vomiting

-Diarrhea

-Thirst

-Polyuria

-Slurred speech

-Muscle weakness

Interventions:

Medication should be withheld, blood lithium levels measured, and dosage re-
evaluated. Administer new dosage based on serum lithium and sodium levels.

Advanced signs of lithium toxicity - CORRECT ANSWER-1.5 to 2.0 mEq/L

-Coarse hand tremor

-Persistent GI upset

-Mental confusion

-Muscle hyperirritability
-EEG changes

-Incoordination

Interventions:

Instruct the client to withhold the medication, and

notify the provider. Administer new dosage based on serum lithium and sodium
levels. Excretion needs to be promoted.

Severe lithium toxicity - CORRECT ANSWER-2 to 2.5 mEq/L

-Ataxia

-Serious EEG changes

-Blurred vision

-Clonic movements

-Large output of dilute urine

-Tinnitus

-Seizures

-Stupor

-Severe hypotension

-Coma

-Death is usually secondary to pulmonary complications

Interventions:

There is no known antidote for lithium poisoning. The drug is stopped, and
excretion is hastened. If patient is alert, an emetic is administered. Otherwise,
gastric lavage and treatment with urea, mannitol, and aminophylline hasten
lithium excretion.

Deadly lithium toxicity - CORRECT ANSWER->2.5 mEq/L Symptoms may progress

rapidly

-Coma

-Cardiac dysrhythmia

-Peripheral circulatory collapse

-Proteinuria

-Oliguria

-Death

Intervention:

Hemodialysis

Dehydration with patients on lithium - CORRECT ANSWER-Any activity or issue

(diarrhea, vomiting, excessive exercise) that can lead to dehydration will cause
the concentration of lithium in the blood to be elevated. This causes lithium
toxicity.
Salt intake with patients on lithium - CORRECT ANSWER-When salt intake is increased
you retain water. This leads to an over diluted intravascular compartment (over
diluted blood stream). This causes the lithium levels to be too low, which is sub-
therapeutic.

Carbemazepine (Tegretol) - CORRECT ANSWER-• Agranulocytosis and aplastic anemia

are most serious adverse reactions

• Blood levels should be monitored throughout first 8 weeks because drug

induces liver enzymes that speed its own metabolism. Dosage may need to be
adjusted to maintain serum level of 6-8 mg/L.

• Immediate action when severe adverse reactions appear (confusion, difficulty

breathing, irregular heartbeat, skin rash or hives, jaundice)

• Best use is for treatment and prevention of manic episodes. It is less effective
for treatment and prevention of depression

• Teratogenic. Do not use in pregnancy

Lamotrigine (Lamictal) - CORRECT ANSWER-• Life-threatening rash reported in 3 out

of every 1000 individuals (Stevens-Johnson syndrome)

• Rare but potential aseptic meningitis risk with lamotrigine

• Use caution when renal, hepatic, or cardiac function is impaired

• Often used in combination with other mood-stabilizing drugs, it is a good drug

for long-term maintenance therapy

• First-line treatment for bipolar depression and is approved for acute and
maintenance therapy

Divalproex (Depakote) - CORRECT ANSWER-• Baseline liver function tests should be

performed and results monitored at regular intervals due to the risk of blood
dyscrasias, hepatotoxicity, and pancreatitis.

• Useful in treating lithium nonresponders who are in acute mania, who

experience rapid cycles, who are in dysphoric mania, or who have not responded
to carbamazepine. It is also helpful in preventing manic episodes.

• Best use for men and older women. Can cause PCOS in non-childbearing age
women and birth defects in pregnant women.

Schizophrenia s&s - Positive symptoms - CORRECT ANSWER-Manifestation of things

that are not normally present. These are the most easily identified
manifestations.

● Hallucinations

● Delusions
● Alterations in speech

● Bizarre behavior, such as walking backward constantly

Schizophrenia s&s - Negative symptoms - CORRECT ANSWER-Absence of things that

are normally present. These manifestations are more difficult to treat successfully
than positive symptoms.

● Affect: Usually blunted (narrow range of expression) or flat (facial expression

never changes)

● Alogia: Poverty of thought or speech. The client might sit with a visitor but only
mumble or respond vaguely to questions.

● Anergia: Lack of energy

● Anhedonia: Lack of pleasure or joy. The client is

indifferent to things that often make others happy, such as looking at beautiful
scenery or doing things that used to bring them pleasure such as painting.

● Avolition: Lack of motivation in activities and hygiene.

Schizophrenia s&s - Cognitive symptoms - CORRECT ANSWER-The most debilitating

symptoms. Problems with thinking make it very difficult for the client to live
independently.
● Disordered thinking

● Inability to make decisions

● Poor problem‑solving ability

● Difficulty concentrating to perform tasks

● Memory deficits

● Long‑term memory

● Working memory, such as inability to follow directions to find an address

Schizophrenia s&s - Mood symptoms - CORRECT ANSWER-● Depression

● Anxiety

● Dysphoria

● Suicidal ideations

● Demoralization

Extreme motor agitation - CORRECT ANSWER-Excited physical behavior, such as

running about, in response to inner and outer stimuli, which can be harmful to
self as well as to others.

Stereotyped behaviors - CORRECT ANSWER-Motor patterns that originally had

meaning to the person (sweeping the floor, washing windows) but are now
mechanical and lack purpose.
Automatic obedience - CORRECT ANSWER-The performance by a catatonic patient of
all simple commands in a robot-like fashion.

Way flexibility - CORRECT ANSWER-Seen in catatonia, is evidenced by excessive

maintenance of posture. Patients can hold unusual postures for long periods of
time.

Stupor - CORRECT ANSWER-State in which the catatonic patient is motionless for long
periods and may even appear to be in a coma.

Negativism - CORRECT ANSWER-Doing the opposite of what is requested.

Echopraxia - CORRECT ANSWER-Purposeful imitation of movements made by others.

Depersonalization - CORRECT ANSWER-Nonspecific feeling that a person has lost

their identity; the self is different or unreal.

People may be concerned that body parts do not belong to them, or they may
have an acute sensation that the body has drastically changed.

For example, a woman may see her fingers as snakes or her arms as rotting wood.
A man may look in a mirror and state that his face is that of an animal. **USUALLY
THIS MEANS YOU'RE INVADING THEIR SPACE.
Derealization - CORRECT ANSWER-The false perception by a person that the
environment has changed.

For example, everything seems bigger or smaller, or familiar surroundings have

become strange and unfamiliar.

Associative looseness - CORRECT ANSWER-Joining statements; thinking becomes

haphazard, illogical, and confused.

For example, talking about Christmas, then flying, then jumping.

DO NOT tell them that they are saying things wrong! Instead, say "I'm sorry, I
don't understand what you're saying."

Neologisms - CORRECT ANSWER-Made‑up words that have meaning only to

the patient, such as, "I tranged and flittled."

Echolalia - CORRECT ANSWER-Pathological repeating of another's words by imitation

and is often seen in people with catatonia.

Clang association - CORRECT ANSWER-The meaningless rhyming of words, often in a

forceful manner ("On the track ... have a Big Mac ... or get the sack"), in which the
rhyming is often more important than the context of the word.
This form of speech pattern may be seen in individuals with schizophrenia;
however, it may also be seen in people in the manic phase of a bipolar disorder or
in individuals with a cognitive disorder, such as Alzheimer's disease or HIV-related
dementia.

Word salad - CORRECT ANSWER-Words jumbled together with little meaning

or significance to the listener, such as, "Hip hooray, the flip is cast and
wide‑sprinting in the forest."

Nursing diagnoses related to schizophrenia - CORRECT ANSWER-Disturbed sensory

perception: auditory or visual

Impaired environmental interpretation syndrome

Risk for self-directed/other-directed violence

Ineffective impulse control

Disturbed thought processes

Disturbed personal identity

Social isolation
Impaired social interaction

Risk for loneliness

Ineffective relationship

Risk for compromised human dignity

Chronic low self-esteem

Risk for suicide

Treatment focus for phase I - CORRECT ANSWER-Acute: Onset, Exacerbation, or

Relapse

During phase I the clinical focus is on crisis intervention, acute symptom

stabilization (medication), and safety.

Interventions:

Acute psychopharmacological treatment

Limit setting
Supportive and directive care

Psychiatric, medical, neurological evaluation

Meeting with family

During the acute phase of the illness, the nurse should maintain eye contact, call
the patient by name, and speak simply.

Treatment focus for phase II - CORRECT ANSWER-Stabilization Phase; Adaptive

Plateau

During phase II the clinical focus is the understanding and acceptance of illness

Interventions:

-Support and teaching

-Medication teaching and side effect management

-Direct assistance with situational problems

-Identification of prodromal and acute symptoms and signs of relapse

-Continued psychoeducational work with families as needed

Treatment focus for phase III - CORRECT ANSWER-Maintenance Phase; Health

Promotion

During phase III the clinical focuses are:

-Social, vocational, and self-care skills

-Learning or relearning

-Identification of realistic expectations

-Adaptation to deficits

Interventions:

-Attention to details of self-care, social, and work functioning

-Direct intervention with family and/or employers

-Cognitive and social skills enhancement

-Medication maintenance

-Continued psychoeducational intervention with families as needed

-Involvement with recovery groups and strategies

Interventions for hallucinations - CORRECT ANSWER-1. Watch patients for cues that
they may be hallucinating (eyes darting to one side, muttering, or staring
sideways; changes in facial expressions).

2. Ask patients directly if they are hallucinating. "Are you hearing voices?" "What
are they saying to you?"

3. If voices are telling patients to harm self or others (command hallucinations):

-Notify appropriate authority

-If in the community, evaluate need for hospitalization.

4. Document what patients say, if they are a threat to self or others, who was
contacted and notified and when.

5. Accept the fact that the voices are real to patients, but explain that you do not
hear the voices. Refer to the voices as "your voices" or "the voices that you hear."

6. Present a calm demeanor and stay with patients while they are hallucinating.
At times you can tell patients to tell the "voices they hear" to go away.

7. Keep patients focused on simple, basic, reality-based topics. Help patients focus
on one idea at a time.

8. Help patients identify times and situations when hallucinations are the most
prevalent and intense.

9. Assess for signs of increase in anxiety, fear, or agitation and intervene as soon
as possible.

Interventions for delusions - CORRECT ANSWER-1. Assess if external controls are

needed: if patient is agitated and believes someone is going to harm him or her or
if patient must harm someone else to survive; use safety measures.

2. Be aware that the patient's delusions represent the way that he or she is
experiencing reality.
3. Identify feelings:

-If belief is an attempt to "get" the patient, then the patient is experiencing fear.

-If belief is someone is controlling the patient's thoughts, then the patient is
experiencing helplessness.

4. Engage the individual in yoga, exercise, walking, etc.

5. Do not argue with the patient's beliefs or try to correct false beliefs with logic
or facts.

6. Do not touch the patient; use gestures very carefully, particularly if the patient
is paranoid.

Interventions for delusions in the paranoid patient - CORRECT ANSWER-1. Place

yourself beside patient not face-to-face

2. Avoid direct eye contact

3. A paranoid patient might not eat or drink, thinking the food is poisoned. Offer
food and fluids in closed containers such as a can of soda, a carton of yogurt,
unpeeled fruit, or a hardboiled egg
4. After understanding the patient's underlying feelings (fear, helplessness),
engage the patient in reality-based activities such as cards or crafts.

5. If the patient is paranoid, often intellectual functions are higher and may
respond better to more intellectually taxing noncompetitive activities.

6. Observe for events that trigger delusions.

7. If anxiety escalates and the patient loses control, use least restrictive
interventions (one-to-one therapy, prn medications, last resort seclusion).

Extrapyramidal symptoms (EPS) - CORRECT ANSWER-Akathisia

Acute dystonia

Pseudoparkinsonism

Tardive dyskinesia

Akathisia - CORRECT ANSWER-MANIFESTATIONS

● Inability to sit or stand still

● Continual pacing and agitation

NURSING CONSIDERATIONS

● Observe for akathisia for the first 2 months after the initiation of treatment. Can
occur in as little as 2 hours following the first dose.
● Manage with antiparkinsonian agents, beta blockers, or lorazepam/diazepam.

● Monitor for increased risk for suicide in clients who have severe akathisia.

Acute dystonia - CORRECT ANSWER-MANIFESTATIONS

● Severe spasm of the tongue, neck, face, and back

● Crisis situation that requires rapid treatment

NURSING CONSIDERATIONS

● Begin to monitor for acute dystonia anywhere between 1 to 5 days after

administration of first dose.

● Treat with an antiparkinsonian agents such

as benztropine.

● IM or IV administration diphenhydramine can also be beneficial.

● Stay with the client and monitor the airway until

spasms subside (usually 5 to 15 min).

Pseudoparkinsonism - CORRECT ANSWER-MANIFESTATIONS

● Bradykinesia

● Rigidity

● Shuffling gait

● Drooling

● Tremors
NURSING CONSIDERATIONS

● Observe for pseudoparkinsonism for the first month after the initiation of
therapy. Can occur in as little as 5 hours following the first dose.

● Treat with an antiparkinsonian agent, such as

benztropine or trihexyphenidyl.

● Implement interventions to reduce the risk for falling.

Tardive dyskinesia (TD) - CORRECT ANSWER-MANIFESTATIONS

● Late EPS's, which can require months to years of

medication therapy for TD to develop

● Involuntary movements of the tongue and face, such as LIP SMACKING and
protruding or ROLLING TONGUE

● Involuntary movements of the arms, legs, and trunk

NURSING CONSIDERATIONS

● Evaluate the client every 3 months. If TD appears,

dosage should be lowered, or the client should be

switched to another type of antipsychotic agent.

● Once TD develops, it usually does not decrease, even with discontinuation of

the medication.

● There is not a treatment for TD.

● Teach client that purposeful muscle movement helps to control the involuntary
TD.

Neuroleptic malignant syndrome (NMS) - CORRECT ANSWER-MANIFESTATIONS

● Sudden high fever

● Blood pressure fluctuations

● Diaphoresis

● Tachycardia

● Muscle rigidity

● Drooling

● Decreased level of consciousness

● Coma

● Tachypnea

NURSING CONSIDERATIONS

● This life‑threatening medical emergency can occur within the first week of
treatment or any time thereafter.

● Stop antipsychotic medication.

● Monitor vital signs.

● Apply cooling blankets.

● Administer antipyretics

● Increase the client's fluid intake.

● Administer dantrolene or bromocriptine to induce muscle relaxation.

● Administer medication as prescribed to treat arrhythmias.

● Assist with immediate transfer to an ICU.

First-generation antipsychotics/TYPICAL (conventional) - CORRECT ANSWER-● Used

mainly to control positive symptoms of psychotic disorders.

● Due to adverse effects, first‑generation antipsychotic medications are reserved

for clients who are

-Using them successfully and can tolerate the

adverse effects.

-Concerned about the cost associated with

second‑generation antipsychotic medications.

● First‑generation agents are classified as either

low‑, medium‑, or high‑potency depending on their association with

extrapyramidal symptoms (EPSs), level of sedation, and anticholinergic adverse
effects.

Low potency - CORRECT ANSWER-Low EPSs, high sedation, and high anticholinergic
adverse effects

Medium potency - CORRECT ANSWER-Moderate EPSs, moderate sedation, and low

anticholinergic adverse effects
High potency - CORRECT ANSWER-High EPSs, low sedation, and low anticholinergic
adverse effects

First-generation (typical) antipsychotics are: - CORRECT ANSWER-**haloperidol

(Haldol) - high potency

chlorpromazine (Thorazine) - low potency

fluphenazine (Prolixin) - high potency

loxapine (Loxitane) - medium potency

thioridazine (Mellaril) - low potency

perphenazine (Trilafon) - medium potency

trifluoperazine (Stelazine) - high potency

Second-generation antipsychotics/ATYPICAL - CORRECT ANSWER-**Often chosen as

FIRST-LINE TREATMENT FOR SCHIZOPHRENIA because they are more effective
with fewer adverse effects.

ADVANTAGES

● Relief of both positive and negative symptoms

● Decrease in affective findings (depression, anxiety) and suicidal behaviors

● Improvement of neurocognitive defects, such as

poor memory

● Fewer or no EPSs, including tardive dyskinesia, due to less dopamine blockade

● Fewer anticholinergic effects, with the exception

of clozapine, which has a high incidence of

anticholinergic effects. This is because most of the

atypical antipsychotics cause little or no blockade of cholinergic receptors.

● Less relapse

Second-generation ansypsychotics (atypical) are: - CORRECT ANSWER-**risperidone

(Risperdal)

asenapine (Saphris)

clozapine (Clozaril)

iloperidone (Fanapt)

lurasidone (Latuda)

olanzapine (Zyprexa)

paliperidone (Invega)

quetiapine (Seroquel)

ziprasidone (Geodon)

Haloperidol (Haldol) - CORRECT ANSWER-Routes: Oral tablet, oral concentrate, short-

acting IM injection, long-acting IM injection (lasts 3-4 weeks)

Special considerations:

• Low sedative properties; used in large doses with assaultive patients to avoid
severe side effect of hypotension
• Lessens chance of falls from dizziness or hypotension

• High EPS symptoms

• Can prolong the QT interval, leading to dysrhythmias

• Tardive dyskinesia

Loxapine (Loxitane) - CORRECT ANSWER-Routes: Oral capsule, oral concentrate,

short-acting IM injection

Special considerations:

• EPS symptoms

• Seizures

• Confusion

• NMS

• Anticholinergic effects

• Orthostatic hypotension, EEG changes, tachycardia, cardiac arrest

Chlorpromazine (Thorazine) - CORRECT ANSWER-Routes: Oral tablet, oral solution,

suppository capsule, short-acting IM injection

Special considerations:

• Increased sensitivity to sun

• Highest sedative and hypotensive effects

• High Antocholinergic effects

• Sedation

• Lowers seizure threshold

• Rare: agranulocytosis and NMS

Clozapine (Clozaril) - CORRECT ANSWER-Routes: Oral tablet, ODT

Special considerations:

• Not first line; refractory cases only

• ***Agranulocytosis; scheduled WBC count required

• High seizure rate

• Increased risk for diabetes

• Significant weight gain

• High lipid abnormalities

• Excessive salivation

• Tachycardia

• High anticholinergic effects

Nursing diagnoses related to adult ADHD - CORRECT ANSWER-Impaired social

interaction

Ineffective impulse control

Ineffective relationship

Defensive coping

Compromised family coping

Impaired adjustment

Anxiety

Personal identity disturbance

Pharmacotherapy for adult ADHD - CORRECT ANSWER-Stimulants are the most

widely used medication for ADHD:

methylphenidate (Ritalin)

dextroamphetamine (Dexedrine)

dextroamphetamine-amphetamine (Adderall XR)

lisdexamfetamine (Vyvanse)

Other medications used to treat ADHD include antidepressants such as:

bupropion (Wellbutrin)

atomoxetine (Strattera)

Risperidone (Risperdal) - CORRECT ANSWER-Routes: Oral tablet, ODT

Special considerations:

• Orthostatic hypotension/dizziness

• Insomnia

• Sedation

• Rarely NMS or TD

• Sexual dysfunction

• Weight gain

• Moderate lipid abnormalities

• Increased risk for diabetes

Asenapine (Saphris) - CORRECT ANSWER-Routes: ODT

Special considerations:

• Low risk of diabetes, weight gain, dyslipidemia, and anticholinergic effects

• Drowsiness

• Prolonged QT interval

• EPS (higher doses)

• Causes temporary numbing of the mouth

Patient education in regards to medication compliance - CORRECT ANSWER-Although
most individuals prefer oral medications, those who are non-adherent to
medication therapy and are prone to frequent relapse, and/or would find it more
convenient for their situation, are candidates for long-lasting injectable
formulations (usually lasting 2 to 4 weeks).

Adult Attention-Deficit/Hyperactivity Disorder (ADHD) - CORRECT ANSWER-Involves a

persistent pattern of inattention, impaired ability to focus and concentrate, and
hyperactivity and impulsivity that are more noticeable and more severe than
would otherwise be seen at a given developmental level.

Common presentations include impaired focusing and concentration,

disorganization, impulsiveness, impaired task completion, irritability and impaired
frustration tolerance, labile mood, and impaired
social/relational/educational/vocational functioning.