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RNSG2213/RNSG 2213 Mental Health Nursing Review
for Exam 2 Level 3 (Answered) Latest Version. Graded
A+.
How are anticonvulsants used in the treatment of anxiety? – ANS Usually used in adjunct to other medications, help relieve the symptoms of anxiety Valporic acid, gabapentin (neurontin How are antidepressants used to treat anxiety? - ANSFirst line treatment for anxiety disorders, secondary benefit of treating co-occurring depressive disorders. SSRIs and SNRIs preferred over TCAs as they have less side effects •SSRIs: celexa (citalopram) Lexapro (escitalopram) Prozac (fluoxetine) paxil (paroxetine) zoloft (sertraline) •SNRIs: cymbalta (duloxetine) and Effexor (venlafaxine) •tricyclics: anafranil (clomipramine): for OCD How are beta blockers used in the treatment of anxiety? – ANS Used for panic disorders and social anxiety. Decreases heart rate, contractility and blood pressure to relieve physical symptoms of anxiety Propranolol (Inderal) How are beta-blockers used in the treatment of anxiety? – ANS Blocks the hormones epinephrine/adrenaline. Decrease heart rate, contractility and blood pressure to decrease somatic feelings of anxiety. Propranolol (Inderal) and atenolol (Tenormin) How do biochemical factors effect depression? – ANS Biochemical factors: changes in the neurotransmitters and the limbic system, hypothalamus, prefrontal cortex, hippocampus and amygdala. Low serotonin and norepinephrine, and dysfunction in glutamate, dopamine, GABA and acetylcholine. *PET scan reveals a less active brain How do genetics effect depression? – ANS interact with environmental factors, first degree family members are 2-4 times more likely to develop. Increased risk for comorbidity (substance abuse) increased risk for occurrence and earlier onset How do hormone effect depression? – ANS Many depressed patients have increased levels of cortisol caused by chronic stress
*depressed individuals display hyperactivity in HPA axis How do stressful life events effect depression? - ANSEarly life experiences such as harsh/abusive parenting can make a person more psychologically sensitive to rejection and stress. Implications: social separations, job loss, loss of self esteem, death of someone important, extreme poverty How is generalized anxiety disorder diagnosed? - ANSAn individuals symptoms must persist for most days during a 6 month period and have at least three of the following symptoms: •restlessness •fatigue •poor concentration •irritability •muscle tension •sleep disturbances How should you communicate someone who is experiencing mild to moderate anxiety?
- ANS•be simple, direct and calm •identify the persons anxiety and assess it "you look upset" •encourage the patient to talk about feelings and concerns, use nonverbal language to demonstrate interest •focus on the patients concerns, do not introduce irrelevant topics and do ask clarifying questions "I'm not sure what you mean, can you give me an example?" •help identify thoughts or feelings before the onset of anxiety and encourage problem solving. The person may need assistance with this. •explore behaviors that have worked to relieve anxiety in the past and provide outlets for dissipating excess energy (walking, exercising) How you should you communicate with someone with severe to panic levels of anxiety?
- ANS•maintain a calm manner and ALWAYS remain with the person (prevent feelings of abandonment) •use clear and simply statements in a low-pitched, slow voice. You may need to repeat yourself •move to a quieter environment, decrease stimuli •reinforce reality if distortions occur, focus on the now and what's happening in the environment •safety is an overall goal, attend to physical needs when necessary (warmth, elimination, pain relief, family contact) •provide opportunities for movement and exercise (walk/pace with them) but set physical limits for safety "you may not hit anyone here. If you can't control yourself, we will help you." Be firm and authoritative. •assess need for medications (benzodiazepines)
What are compulsions? - ANSRitualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. Relief is only temporary though this compulsive acts must be repeated many times. •hand washing •checking a door multiple times •counting •praying What are concerns when taking benzodiazepines? - ANSHigh risk for development of tolerance, dependency and withdrawal Contraindications: •adults with narrow angle glaucoma •older adults due to decreased renal functioning and decreased metabolism *Do not stop abruptly. Can cause withdrawal syndrome. Withdrawal can result in seizures Cannot be taken with alcohol, can cause respiratory depression and death What are considerations in the nurse/patient relationship in patients with depression? - ANS•accept patient as they are and for where they are. Try to anticipate their needs •acknowledge their emotional pain in a gentle manner and offer work through it with them, provide hope •point out small visible accomplishments •never compare patients to others who may have it worse •do not reinforce hallucinations, delusions or irrational beliefs •do not take anger personally •manage time to try and spend 5-10 extra minutes with them, even if it is in silence. Actively listen, be accessible and consistent •reinforce decision making once they feel ready •encourage patients expressions of thoughts and feelings, do not judge or minimize them *empathy What are contraindications for electroconvulsive therapy? - ANS•recent myocardial infarction/heart conditions •brain tumors and patients with increased intracranial pressure. Not indicated for dysphoric disorder, personality disorders, drug dependency or depression secondary to situational/social difficulties What are defense mechanisms? - ANSUnconscious defense mechanisms used by an individuals for anxiety reduction. They protect people from painful awareness of feelings or memories that can provoke overwhelming anxiety
•adaptive: helps one decrease anxiety without creating problems for an individual •maladaptive: may be destructive or unhealthy for an individual What are foods that contain tyramine? - ANS•avocados, figs, bananas, soy beans •fermented foods, saurkraut •dried or cured meat and fish, liver, nearly all cheeses •foods with yeast, soy sauce •beer and wine •protein supplements/extracts What are high and low risks forms of lethality in suicidal patients? - ANSHigh: guns, jumping, hanging, carbon monoxide poisoning, staging a car crash Low: taking pills, cutting wrists What are immature defense mechanisms? - ANSPassive aggression Acting-out behaviors Dissociation Devaluation Idealization Splitting Projection Denial What are intermediate defense mechanisms? - ANS*Repression: cornerstone of defense mechanisms. Displacement Reaction formation Somatization Undoing Rationalization What are MAOIs? - ANSBlocks monoamine oxidase which destroys monoamines. (Subgroup: catecholamines: epinephrine, norepinephrine, dopamine)
•speak to them in a calm, non authoritarian manner •help them verbalize stressors and their feelings •help guide them through other anxiety reducing behaviors as opposed to their obsessions and rituals •provide simply tasks and activities to refocus What are nursing considerations when working with a patient with a phobic disorder? - ANS•accept the patients fears with a noncritical attitude •encourage the patient to verbalize their fears •discuss the reality of the situation •do NOT force the patient to be in contact with the object or put themselves into the situation •teach and practice relaxation techniques What are obsessions? - ANSThoughts, impulses or images that persist and recur so they cannot be dismissed from the mind. They are often senseless but still cause anxiety. •hurting a loved one •fear of contamination •needing things to be symmetrical What are OCD related disorders? - ANSBody dysmorphic disorder: preoccupation with an imagined defective body part. Can include obsessive thinking (being ugly) and compulsive behaviors (mirror checking, skin picking, excessive grooming) Hoarding disorder: excessive collecting of items that may or may not have value and the persistent difficulty to discard or part with possessions. Can include mood or anxiety disorder, impairment in daily living, reduced insight and indecisiveness. Trichitillomania: recurrent twisting or pulling of one's hair resulting in hair damage or loss. Excoriation disorder: recurrent skin picking resulting in skin lesions, infections and scaring. What are personality disorders? - ANSAn enduring pattern of inner experience and behavior that deviates from the individuals culture. People tend to be inflexible and unpredictable, coping strategies tend to be primitive and immature. People frequently lack insight into how this behavior contributes to causing distress. Have a tendency to blame others. *HIGHLY comorbid. Usually seek treatment for depression, anxiety, suicidal ideation, self mutilation, substance abuse, somatic symptom disorder, eating disorders, PTSD What are phobic disorders? What are specific phobia? - ANSA persistent, intense irrational fear of an object, activity or situation that leads to a desire for/actual avoidance
High levels of anxiety or fear in response to specific objects such dogs, spiders, heights, enclosed spaces, blood or getting injections Treatment: exposure therapy tend to run in families, no evidence for biological dysfunction What are protective factors against suicide? - ANS•family or community support •religious beliefs •restricted access to lethal weapons l •access to health care for disorders •development of effected coping skills/problem solving •intact reality testing Meds: lithium for mood and clozapine for psychotic disorders What are psychotherapies for depression? - ANSFirst line treatments Cognitive behavior therapy: for mild and moderate depression. Focuses on evaluating, challenging and modifying dysfunctional/negative thought patterns. largest weight of evidence for efficacy. Interpersonal psychotherapy: a structured and brief intervention that addresses the social issues that maintain depression Problem solving therapy: teaches how to define personal problems, develop multiple solutions and identify the best one, implementing it and assessing its effectiveness What are risk factors for developing depression? - ANS•family history of mood disorders •having a serious medical condition •having a chronic disability •lacking a good support system •having a history of abuse/trauma •early loss of a significant other •poverty •loss of employment •having a substance abuse disorder •post partum period What are secondary gains? - ANSBenefits derived from the conversion disorder symptoms (patient cannot walk/has paralyzed arms/is too sick to exert themselves so someone else does their chores for them/waits upon them) What are side effects and nursing considerations for MAOIs? - ANSSE: •sweating
•cardiotoxicity (use in caution with older adults) cause lead to myocardial infarction, heart block, tachycardia and dysthymia Nursing considerations: •avoid in older adults and patients with cardiac disease •contraindicated in patients with: cardiac problems, pregnancy, history of seizures, glaucoma •patients must get ECG and cardiac work up before beginning •usually given at night •urinary retention and constipation require immediate medical attention •do NOT take with alcohol (CNS depression) MAOIs, barbiturates, Antabuse or benzodiazepines What are side effects and nursing considerations for Valproate? - ANSGI pain, tremors, sedation, hair loss and weight gain. Toxicity: ataxia, confusion, coma Monitor platelet count, serum amylase and lipase for liver and pancreas function. What are side effects and potential long term effects or electroconvulsive therapy? - ANSConfusion and disorientation, headache, body soreness, nausea and short term memory loss *patient not to drive for 24 hours post ECT •anterograde: difficulty remembering new things •retrograde: difficulty remembering memories before/leading up to the event (up to 6 months) •amnesia *ECT does NOT cause brain damage What are SNRIs? - ANSInhibit the reuptake if serotonin-norepinephrine go treat, depression, anxiety and neuropathic pain. •venlafaxine (Effexor) •duloxetine (Cymbalta) *Use with caution in patients with hypertension What are somatic symptom disorders? - ANSThe involuntary presence of one or more physical symptoms that impairs occupational and social functions. However, medical tests are "normal" or do not explain the symptoms. Usually caused to offer a means to indicate distress when patients cannot express their emotions with words. What are some mental status assessment findings in patients with bipolar disorder? - ANS•appearance: inappropriate dress, bizarre garb, disheveled •speech: rapid, pressured, loud, disorganized, flight of ideas, clang, incoherent
•mood: irritable, angry, elevated mood, euphoria, depression •hallucinations/delusions: altered sensory perceptions, paranoia, grandiosity •disruptive behavior: sarcastic, guarded, demanding, threatening behavior, assaultive •insight/judgement, impaired: hypersexual, intrusive, in depression: unrealistically negative Assess physiological safety: dehydration, cardiac status, not eating, not sleeping, wether patient is a danger to self or others: poor impulse control, inappropriate sexual activity, anger Assess for coexisting conditions: substance abuse, cardiac problems, financial crisis, family crisis What are some nursing assessment findings in patients with depression? - ANSAffect: lack of eye contact, monotone voice, flat affect, sighing, few responses Thoughts: poor memory/concentration, intrusive negative thoughts, delusions, recurrent thoughts of death Mood: guilt, anger, anxiety, worthlessness, helplessness, hopelessness, irritability Physical behavior: psychomotor retardation, insomnia/hypersomnia, constipation, anorexia, overeating, changes in libido Cognitive/communication: slowed thinking, slow speech, decreased comprehension, indecisive *depression is not a normal part of aging. As health deteriorates, risk for depression increases. Adults are more likely to report physical problems (decreased self care, irritability) than emotional *memory difficulties and psychomotor retardation can be mistaken for early signs of dementia What are some nursing interventions and considerations in patients with bipolar disorder? - ANSSafety is the number one priority •rest, hydrate/nutrition, reestablish physical well being •assess for suicide, guilt, hopelessness •develop rapport, help patient feel understood and accepted •consistently set limits, all staff on board with communication •be are of clients efforts to split off staff •be calm, firm and neutral. Resist becoming defensive •state unit policy, do not argue, debate or defend rules •reinforce reality for disturbances in perception. Watch for poor judgement and intrusiveness
Carbamazepine: used with treatment resistant bipolar disorder with lithium. Works better in patients with rapid cycling, mixed states and acute mania. Therapeutic range: 4-12ug/mL Lamotrigine: first line treatment for bipolar depression and acute and maintenance therapy. What are the atypical antipsychotics used in bipolar disorder? And their nursing considerations? - ANSHelp to control agitation, anxiety and insomnia during severe acute manic episodes. Used to stabilize mood. Also used for bipolar depression and prevention of relapse Quetiapine, lurasidone, olanzapine, aripiprazole Monitor for EPS, weight gain and other reactions What are the benzodiazepines used in bipolar disorder? Their nursing considerations? - ANSUseful in the treatment of acute mania, psychomotor agitation, anxiety and insomnia. Slow the activity in the brain by enhancing GABA. Klonopin (clonazepan) and Ativan (lorazepam) Deadly when combined with alcohol. Avoid in patients with history of substance abuse What are the causes of depression? - ANSGenetics Biochemical factors Stressful life situations Diathesis-stress model Cognitive theory Learned helplessness What are the four healthy defense mechanisms? - ANSAltruism Sublimation Humor Suppression What are the four levels of anxiety? - ANSMild: normal experiences of everyday life. Ability to perceive reality is brought into sharp focus and logical reasoning remains intact. Restlessness and mild irritability may be present. Moderate: a persons perceptual field narrows. Concentration and logical thinking becomes hampered but learning and problem solving can still take place. Increased pulse and respirations and other mild somatic symptoms may be present.
Severe: field of focus is greatly reduced, person may be overly focused on a single detail or may have distorted and scattered ideas. Learning and problem solving can no longer occur. Hyperventilation and feelings of dread or doom may be present. Panic: most extreme and markedly disturbed behavior. Person is no longer able to process event in the environment and may lose touch with reality. Confusion, shouting, severe withdrawal and hallucinations may be present. What are the four main antidepressant medication groups? - ANS1. Selective serotonin reuptake inhibitors (SSRIs)
- Atypical antidepressants (non-SSRIs)
- Tricyclic antidepressants (TCAs)
- Monoamine oxidase inhibitors (MAOIs) What are the four major classes of medications for bipolar disorder? - ANS1. Lithium
- Anticonvulsants
- Antipsychotics
- Benzodiazepines *Antidepressants are not recommended because of risk for inducing mania. If used, used with a mood stabilizer and risks/benefits must be weighed What are the side effects/adverse effects of lithium? - ANSExpected: fine tremors, nausea, weight gain, mild thirst, polyuria, sedation Early toxicity (1.5mEq/L): fine tremors, nausea, weight gain, mild thirst, polyuria, sedation, vomiting, diarrhea, slurred speech, muscle weakness Advanced toxicity (1.5-2.0mEq/L): coarse hand tremors, mental confusion, incoordination Severe toxicity (2.0-2.5mEq/L) ataxia, blurred vision, tinnitus, clonic movements, large output of dilute urine, seizures, stupor, severe hypotension, coma
2.5mEq/L: delirium, seizures, cardiac dysthymia, death Treatment for toxicity: gastric lavage and urea, mannitol and aminophylline to hasten excretion What are the three clusters of personality disorders? - ANSCluster A: the weird •schizoid •schizotypal •paranoid Cluster B: the wild
What are tricyclic antidepressants? - ANSThe oldest antidepressants, block the reuptake of norepinephrine and serotonin •activating: norpramin (Desipramine) and vivactil (Protripyline) •sedating: amitriptyline (Elavil) and sinequan (doxepin) *can cause myocardial infarction, heart block, tachycardia and dysthymia What can trigger a bipolar episode? - ANS•lack of sleep or an irregular schedule •relationship conflicts •abusing drugs (cocaine/anohetamines) and alcohol •antidepressants •seasonal changes •childbirth •grief •job loss What does neuro-imaging reveal in a person with bipolar disorder? - ANS•reduced hippocampal volume •reduced bilateral cerebral gray matter •dysfunction in the prefrontal cortex •dysfunction in the límbic system What is agoraphobia? - ANSIntense and excessive anxiety about being in public or open places/situations where escape or help might not be possible. Feared places are avoided by the individual (avoidant behavior is important in the diagnosis) Treatment: •SSRIs •Cognitive behavioral therapy •social training skills and calming techniques •avoid caffeine What is altruism? - ANSemotional conflicts and stressors are addressed by meeting the needs of others, the person recurves gratification either vicariously or from the responses of others (after a personal tragedy, one becomes a volunteer to help others going through the same experience) What is antisocial personality disorder? - ANSCharacterized by a persistent disregard and violation of the rights of others, with a lack of remorse for actions and hurting others. Can be charming or charismatic and have a sense of entitlement. They are selfish, manipulative and disinhibited and there is frequently a history of lying, deception, conning of others for profit or pleasure and disregard for the law and rights of others. May engage in risky and dangerous behaviors. *cannot be diagnosed until age 18 Treatment:
•peer counseling •psychoeducational and self help groups *essential for all staff to agree on rules and stick with them. Set firm, clear, realistic limits and be consistent. Ignore flattery and discuss behavioral problems objectively. Help them gain insight, do not shame or punish them What is anxiety? - ANSA feeling of apprehension, uneasiness, uncertainty or dread resulting from a real or perceived threat whose actual source is unknown or unrecognized. Anxiety is ubiquitous, anxiety disorders are not. Anxiety disorders cause significant distress and social/occupational dysfunction What is aversion therapy? - ANSan undesirable behavior is associated with an unpleasant stimuli (taking a drug that causes vomiting when mixed with alcohol, thus the person will not want to drink when they smell alcohol as this produces memories of vomiting) What is avoidant personality disorder? - ANSCharacterized by high levels of anxiety and outward fear with feeling sit low self-worth. They are hyper sensitive to criticism, rejection and tent to avoid situations that require socializaron. They have very poor self esteem, often viewing themselves are socially inept, personally unappealing or inferior to others and are reluctant to take risks for fear of embarrassment or inadequacy. Treatment: •individual/group therapy •SSRIs What is borderline personality disorder? - ANSCharacterized by unstable mood and self image, marked impulsivity and splitting. There is difficulty with self regulations and an inability to soothe oneself during times of stress. Individuals have unstable relationships characterized by alternation between idealizations and devaluation. They fear abandonment. *self injurious behavior and suicidality are common. Do NOT minimize or ignore self harm threats. Ask direct questions assessing their plan, intent and lethality Treatment: •dialectical behavior therapy •coping skills, anger management •expressive arts •psychotherapy *team approach and communication is necessary. Show empathy while maintaining boundaries. Be honest, consistent and matter of fact but do not show anger or irritation. Encourage self-responsibility and appropriate behaviors
What is denial? - ANSinvolves escaping unpleasant realities by ignoring their existence (someone with a substance use disorder denying they have a problem because they can "stop at any moment if they wanted") What is dependent personality disorder? - ANSCharacterized by an excessive need to be taken care of, they may solicit caretaking by clinging and being excessively submissive. They are inhibited and fearful/reluctant to express disagreement for fear of rejection or loss of support. They are unrealistically preoccupied with fears of caring for themselves, being left alone and their high levels of anxiety intensifies their inability to complete anything on their own. Treatment: •CBT with goal to become more independent •SSRIs for depression and anxiety What is devaluation? - ANSwhen emotional conflicts or stressors are handled by attributing negative qualities to another to make the one's self good by contrast (the loser of an award saying the award "doesn't mean anything anyways") What is dialectical behavior therapy? - ANSA treatment developed for borderline personality disorder. Clinician attempts to motivate the client towards changes in behavior while simultaneously validating existing thoughts and feelings. Goal is to minimize maladaptive behaviors related to poor impulse control and emotional regulation What is displacement? - ANStransferring of emotions associated with a specific person, object or situation into another that is nonthreatening (a mans boss yells at him so he yells at his wife who yells at her son who hurts the pet cat) What is dissociation? - ANSa disruption in the usual integrated functions of consciousness, memory, identity and perception of the environment. Only seen in severe stressors (a mothers son is struck by a car and she forgets everything that happened after she went to check on him) What is Electroconvulsive Therapy? It's indications? - ANSCan be used for episodes of acute mania and depression when the client does not tolerate/fails to respond to lithium or other drugs. Indications: •catatonic symptoms •treatment resistant mania and depression •need for rapid control of symptoms (severe suicidal behavior, agitation, violent) •can be used during pregnancy What is electroconvulsive therapy? What is it used to treat? What are its potential adverse reactions? - ANSDone under general anesthesia, small electrical currents are
passed through the brain to trigger brief seizures. Seems to cause changes in the brains chemistry to quickly alter its chemistry. One of the most effective treatments for treatment-resistant depression, major depression with psychotic symptoms and patients with life-threatening psychiatric conditions such as self harm and acute mania. What is exposure and response prevention? - ANSAn individuals obsession is provoked and they must not engage in their ritual or obsession (plunging hands into a basket of discarded tissues and sit there without washing one's hands) What is factitious disorder? - ANSIntentionally faking symptoms in order to assume the sick rol. However, there are NO obvious external benefits such as financial gain or avoiding work. May be for emotional gain (attention, sympathy, emotional feedback) person may exaggerate, fabricate or induce real symptoms (injection of substance into self to form an abscess, abuse medications to falsify labs le, injure self) What is generalized anxiety disorder? - ANSExcessive worry or anxiety about a number of events or activities (health, job/test performance, financial well-being, social acceptance) difficult to shake feelings of worry and may be unable to relax. *highly comorbid: substance abuse, depression, suicide Causes: •genetics (runs in families) •behavioral and developmental Treatment: •cognitive behavioral therapy, relaxation techniques, stress management, exercise, controlled breathing •buspirone (Buspar) SSRIs, SNRIs antihistamine (hydroxyzine) What is histrionic personality disorder? - ANSCharacterized by excessive emotionality and attention seeking. Manipulate others through self-dramatization and exaggerated emotions. They demand to be the center of attention and may act with inappropriate and sexually seductive/provocative behavior. Their relationships appear more intimate than they actually are and there can be sudden emotional shifts and emotional lability. What is humor? (As a defense mechanism) - ANSdealing with emotional conflicts or stressors by emphasizing the amusing or ironing aspect of the conflict or stressor What is hypomania and it's characteristics? - ANSLess severe and less intense form of mania that must last at least four days. Psychotic symptoms are not present. What is idealization? - ANSexaggerated positive qualities are attributed to another to avoid emotional conflict or stress. Disappointment can occur when the object of idealization does not meet idealizations. The individual mag then devalue and reject the
