NCLEX Case Study Review: Mental Health Nursing

NCLEX_RN: Mental Health Nursing

Angelique, age 18 years, has recently demonstrated a change in behavior and has difficulty concentrating. She is HIV positive. Angelique came to the outpatient clinic because she was not feeling well. She states that she does not know what’s wrong and is reluctant to “open up” during her visit. The nurse understands that in order to help Angelique, the nurse must obtain her trust.

Matching:

What strategies either facilitate or impede trust in a therapeutic communication process in the nurse–
patient relationship?

Match the elements of a therapeutic relationship in Column A with the nursing interventions in Column B:

Therapeutic relationship / Nursing Interventions
Therapeutic relationship / Nursing Interventions

Matching:

Match the therapeutic or nontherapeutic communication techniques in Column A with the nurse statements in Column B:

Match: Therapeutic or nontherapeutic communication techniques
Match: Therapeutic or nontherapeutic communication techniques

Fill in the blanks:

Fill in the blanks using the following list:
Sympathy
Asking why
False reassurance
Giving advice
Seeking clarification
Exploring
Broad opening
Countertransference

Therapeutic communication includes:_____________________________________________________
Nontherapeutic communication includes:__________________________________________________

Select all that apply:

Setting boundaries for patients is done in order to accomplish which of the following?
A. Setting rules of behavior that guide interaction with others
B. Allowingapatientandnursetoconnectsafelyinatherapeuticrelationshipbasedonthepatient’sneeds
C. Making sure the patient does not influence other patients
D. Helping us control the impact others have on us as well as our impact on others
E. Helping families of patients better understand the diagnosis

After the assessment, the nurse identifies that Angelique complains of having a lack of energy, which has persisted for several weeks. Neither Angelique’s self-report nor her laboratory results reflect current or recent substance use.

Select all that apply:

Angelique expresses a loss of interest and pleasure in activities and believes her life is going nowhere and looks bleak. She also says that she does not feel like getting out of bed in the morning and has no interest in sleeping or eating. What symptoms will the nurse report?

A. Echolalia,apathy,delusions
B. Obsessions,compulsions,hypersomnia
C. Perseveration,somatization,dissociation
D. Anergia,anhedonia,insomnia
E. Hopelessness,helplessness,negativism

Exhibit-format:

Angelique sees an advanced practice registered nurse (APRN) who records the following findings: Patient states that she is tired all the time and sleeps a lot.
Patient has lost 5 lb in 2 months and lacks concentration. She has difficulty finishing a thought process. The APRN understands that these manifestations may indicate a diagnosis of:
A. Obsessive-compulsive behavior
B. Depression
C. Personality disorder
D. Addiction

TIP: Risk factors versus protective factors

From a health perspective, risk factors are things that increase a person’s chance of getting a disorder. Protective factors are things that decrease the chance of getting a disorder.

Matching:

Identify risk factors and protective factors for depression. Use the letter in Column A to indicate whether
the attribute is a risk or protective factor in Column B:

Match: Risk factors and protective factors for depression
Match: Risk factors and protective factors for depression

Select all that apply:

What are accepted “truths” about suicide?
A. Asking about it gives the patient the idea
B. Only some depressed patients are at risk
C. Asking gives the patient permission to talk about it
D. History of attempts increases risk
E. A plan increases risk
F. It is a rational decision

Psychiatric History

Angelique had her first depressive episode when she was 15 years old, after the death of her mother. She received family support but did not take any medication and was not involved in traditional counseling services. Recently, Angelique, now 18 years old, discovered that she is HIV positive; this occurred roughly on the anniversary of her mother’s passing. Nurses must understand that suicidal tendencies are increased around the anniversary dates of the death of a significant other or family member and also when individuals are diagnosed with a chronic or disabling medical illness, such as HIV. This is of particular importance if the individual experiences significant hopelessness and social stigma.

True/False:

Facts about suicide:

A. Suicide is one of the top 10 causes of death among all age groups.
True____
False____

B. Suicide is the third leading cause of death among 15- to 24-year-olds.
True____
False____

C. White people are twice as likely to die by suicide as non-White people.
True____
False____

D. White men commit more than 70% of all U.S. suicides.
True____
False____

E. The number of elderly suicides is decreasing.
True____
False____

F. The ethnic groups with the highest suicide rates are Asians and Blacks.
True____
False____

G. Decreased serotonin levels play a role in suicidal behavior.
True____
False____

H. The person who is suicidal often has the desire to be free of pain and to be saved.
True____
False____

Fill in the blanks:

Word list:

Directly
Suicide plan
Family history
Secrecy
Confidentiality
Lethality
Coping

Suicide assessment:

Ask ________ about suicidal thoughts/behavior.
Identify whether the person has a __________
Explore whether the person has a ___________ of suicide.
Do not swear to _________
Discuss the limits of __________
Suicidal intent and ___________
Assess the person’s __________ potential.

Most suicide attempts are expressions of extreme distress, not bids for attention. Suicidal behavior develops along a continuum.

Matching:

Match the definitions in Column A with the terms in Column B:

Match Definitions
Match Definitions
Match Definitions
Match Definitions

Angelique requires inpatient psychiatric care because of her worsening condition and concerns related to her safety. She is admitted for treatment and safety measures.

Fill in the blank:

Angelique has the right to before health care interventions are undertaken.

Select all that apply:

Informed consent includes which of the following:
A. Adequate and accurate knowledge and information
B. An individual with legal capacity to consent
C. The understanding that it is changeable
D. Consent is given voluntarily
E. Family input

True/False:

Voluntary patients are considered competent unless otherwise adjudicated and therefore have the absolute right to refuse treatment, including psychotropic medications, unless they are dangerous to themselves or others.

____ True
____ False

Select all that apply:

Voluntary patients have the right to:
A. Refuse treatments
B. Sign a 72-hour notice to leave
C. Receivevisitors
D. Use cell phone on unit
E. Refuse antianxiety medication if violent
F. Smoke cigarettes on a smoke-free unit

Select all that apply:

Involuntary patients have the right to:
A. Receive visitors
B. Sign a 72-hour notice to leave
C. Vote
D. Refuse antianxiety medication if calm
E. Make phone calls
F. Smoke cigarettes if the unit has accommodations for it

Select all that apply:

Angelique will start on a selective serotonin reuptake inhibitor (SSRI). Which would the nurse anticipate
giving from this group?
A. Lithium carbonate (Lithobid)
B. Fluoxetine(Prozac)
C. Risperidone(Risperdal)
D. Paroxetine(Paxil)
E. Sertraline(Zoloft)

Multiple-choice:

Antidepressant drugs, such as fluoxetine and sertraline, selectively act on:
A. Acetylcholine receptors
B. Norepinephrine receptors
C. Serotoninreceptors
D. Melatoninreceptors

Multiple-choice:

Angelique is prescribed medication for a psychiatric disorder. After 3 days, the patient tells the nurse that
she has been constipated. The nurse should instruct the patient to:
A. Eat more high-protein foods
B. Increase fiber and fluid intake
C. Take a stool softener
D. Have patience as this will subside

Multiple-choice:

Before administering a medication for the first time, an important assessment to make on a patient with
a psychiatric disorder, like Angelique, is to determine his or her:
A. Culturalbackground
B. Height and weight
C. Preexistingsymptoms
D. Physical stamina

Multiple-choice:

A major side effect of bupropion (Wellbutrin) is:
A. Seizures
B. Urinary frequency
C. Palpitations
D. Hallucinations

Multiple-choice:

Angelique has been prescribed the drug paroxetine (Paxil) for depression. The nurse should explain to her
that selective serotonin reuptake inhibitors (SSRIs) may have a side effect of:
A. Hypertension
B. Gastrointestinaldistress
C. Rigidity
D. Increased sexual desire

Select all that apply:

Angelique has been prescribed the drug sertraline (Zoloft), a selective serotonin reuptake inhibitor
(SSRI), for depression. The nurse should teach her to report possible side effects of:

A. Sleep disturbance
B. Increased sexual desire
C. Drymouth
D. Agranulocytosis
E. Agitation
F. Hypertension

Select all that apply:

According to best practices for patient teaching, the nurse must also do which of the following:
A. Give Angelique a pamphlet to read later
B. Have Angelique read the pamphlet to the nurse
C. Have Angelique do a teach-back of the possible side effects
D. Have Angelique tell the nurse what she will do (inform provider) if she has side effects
E. Document in the chart what was taught and the patient’s response
F. Send the patient to pharmacy to get a medication printout

Select all that apply:

The nurse recognizes that more teaching is needed if Angelique says which of the following?
A. “I can stop the medication if I feel better.”
B. “The depression will be gone after 1 week.”
C. “If I have a side effect, I just stop the medication.”
D. “I must report suicidal thoughts with or without a plan to my provider.”
F. “I can take over-the-counter St. John’s wort with my prescribed antidepressant.”
G. “I can drink alcohol.”


The nurse is also caring for Luke. He is 65 years old and recently lost his wife of 42 years to breast cancer. He is depressed and was referred by his son because he has lost interest in all his normal activities and his hygiene has declined.

Multiple-choice:

In a hospitalized patient who has been prescribed desvenlafaxine (Pristiq), the nurse should monitor for:
A. Nausea
B. Hypertension
C. Somnolence
D. Constipation

Matching:

To examine differences in antidepressant therapy, match the effects in Column A to the medications in Column B:

Differences in antidepressant therapy
Differences in antidepressant therapy

Matching:

Match medications in Column A to the common side effects in Column B:

Match medications to common side effects
Match medications to common side effects

Select all that apply:

Luke has been placed on phenelzine (Nardil). The teaching was successful if Luke says he will avoid foods such as:
A. Redwine
B. Bananas and raisins
C. Agedcheese
D. Liver
E. Apples
F. Pepperoni

True/False:

Plant and herbal remedies are natural, so they are good to take with all medications.
_____ True
_____ False

Fill in the blanks:

The nurse caring for Luke knows that serotonin is a that regulates many functions, including mood, appetite, and sensory perception. With too much serotonin in the brain, a condition called serotonin syndrome (SS) can occur. Name four symptoms of SS: ____________, ____________, ___________, and ___________.

Multiple-choice:

Luke must also be told to check the fine print of over-the-counter (OTC) cold medication (and others) and check
with his provider. Taking an monoamine oxidase inhibitor (MAOI) with such medications (if prohibited) can cause:
A. Anaphylactic shock
B. Neuroleptic malignant syndrome
C. Hypertensive crisis
D. Seizures

On admission assessment, the nurse notes that Luke has a lack of energy, a lack of appetite with a 10-lb weight loss, constipation, and difficulty sleeping with early-morning awakening. Luke admits to having suicidal thoughts at times, but has no current plan.

Ordering:
Place the nursing interventions in priority order from 1 to 5:
_____ Provide assistance with activities of daily living (ADL)
_____ Encourage a high-fiber nutritious diet
_____ Monitor for suicidal ideation and contract for safety
_____ Teach about medications
_____ Promote sleep hygiene

Luke’s son tells the nurse that he does not understand why his father does not “snap out of this” and “what is depression anyway?”

Select all that apply:

What is the best response by the nurse to the son?
A. “Depression is an illness that can be treated.”
B. “Depression is his choice.”
C. “It is just the usual grieving response.”
D. “Depression may be a chronic illness with remissions and exacerbations.”
E. “Depression may have a genetic and an environmental component.”

Luke tells the nurse that his roommate told him he may strangle Luke if he does not do what the roommate wants.

Select all that apply:

The nurse should provide for Luke’s safety by:
A. Placing the roommate into four-point restraints
B. Reviewing the unit procedure on violence precautions
C. Identifying the evidence-based practice for preventing violence
D. Notifying the health team (doctor and supervisor)
E. Placing the roommate in a private room
F. Assessing the roommate for violence threat and placing on one-to-one observation

The nurse is introducing interventions to help Luke effectively grieve for the loss of his wife, increase his self-esteem, and meet his needs for love and belonging (both needs on Maslow’s hierarchy).

Select all that apply:

The nursing interventions to meet these underlying needs might include:
A. Providing Luke an activity to create something
B. Giving Luke medications
C. Providing television in lounges
D. Developing a grief support group
E. Acknowledging Luke’s achievements by displaying his works on unit
F. Encouraging family participation in Luke’s activities and recovery (family teaching)

Luke is about to be discharged to home and outpatient therapy.The nurse discusses these plans with Luke.

Select all that apply:

Which statements by Luke would indicate movement to positive achievement of the discharge plan?
A. “I plan to attend therapy.”
B. “I don’t like going home to an empty house.”
C. “I am going to visit my son and grandchildren.”
D. “I am joining a volunteer group.”
E. “I will stop my medication if too expensive.”
F. “I am going to exercise at the gym.”


During Angelique’s hospitalization,she presents with auditory hallucinations,hearing her mother’s voice saying “join me,” and visual hallucinations of mice running on the floor. These hallucinations have increased in intensity during the past week. She also exhibits fluctuations in mood and has been more irritable for about 4 days. This mood state was clearly different from her usual nondepressed mood (euthymia). After assessment by the health care team and obtaining Angelique’s approval, she is started on a low-dose antipsychotic and a mood stabilizer.

Matching:

Match the nursing interventions in Column A with the side effects of the antipsychotic medications in Column B:

Antipsychotic medications - Nursing interventions
Antipsychotic medications – Nursing interventions

Exhibit-format:

The nurse reviews the patient data:

Vital signs (VS): Temperature: 98.2oF, respiratory rate (RR): 24 breaths per minute, heart rate (HR), 90 beats per minute (bpm), blood pressure (BP): 132/86 mmHg

Physical examination: Head symmetrical, dull affective responses, pupils equal and reactive to light and accommodation (PERLA), difficulty in fully extending arms and ataxic gait

The nurse suspects that these assessment findings are consistent with:
A. Parkinson’s disease
B. Extrapyramidal side effects (EPSE)
C. Transient ischemic attack (TIA)
D. Signs of overdose

Select all that apply:

Which of the following is true about the atypical antipsychotics?
A. Cause fewer or no extrapyramidal side effects (EPSE)
B. Used to treat both positive and negative symptoms of schizophrenia
C. Exert both dopamine and serotonin receptor blocking action
D. Cause more EPSE
E. Treat only positive symptoms of schizophrenia

Select all that apply:

In teaching about the antipsychotics, the nurse would tell her to do the following:
A. Stop taking meds when you feel better
B. Report adverse effects promptly
C. Do not drink alcohol
D. Do not take over-the-counter (OTC) meds causing drowsiness
E. Do not drive or use hazardous equipment or do activities needing alertness
F. Give medication 1 week to relieve symptoms

Fill in the blanks:

What two neurotransmitters in the body are targeted with atypical and typical antipsychotics?
1. __________________________________________________________________
2. __________________________________________________________________

Matching:

Indicate whether the medication in Column A is a typical or atypical antipsychotic in Column B:

Typical or atypical antipsychotic medication
Typical or atypical antipsychotic medication

Matching:

Please match the effects in Column A with the medications in Column B:

Medication Effects
Medication Effects

Multiple-choice:

Angelique complains of itching and dermatitis after taking a medication for a psychiatric disorder; after 3
days, the nurse should:
A. Reassure the patient
B. Offer the patient soothing lotions
C. Contact the physician
D. Offer the patient a warm tub bath


Marina, age 31 years, is being admitted as an inpatient because of a psychosis; she was first admitted at the age of 18 years. At the time of referral, it had been 2 years since Marina’s last admission. Diagnosis at discharge was schizophrenia. The most prominent symptom Marina reported experiencing was auditory hallucinations with derogatory comment “you’re a freak of nature” and “you’ll never move on,” which increased with stress. She had been prescribed ziprasidone (Geodon) for a number of years, but she was not getting the same relief recently. Marina lives in a structured facility and is in contact with the community mental health nurse.

Multiple-choice:

When Marina requires larger doses of a given medication to maintain its therapeutic effect, the nurse determines that she has developed:
A. Abuse
B. Tolerance
C. Addiction
D. Allergies

Multiple-choice:

Which of the following atypical antipsychotic agents is associated with the most weight gain?
A. Ziprasidone(Geodon)
B. Aripiprazole(Abilify)
C. Olanzapine(Zyprexa)
D. Quetiapine(Seroquel)
E. Risperidone(Risperdal)

Select all that apply:

Schizophrenia spectrum includes:
A. Borderline personality
B. Schizotypal personality
C. Schizophreniform disorder
D. Schizoaffective disorder
E. Psychosis not otherwise specified

Select all that apply:

Which of the following is true about schizophrenia?
A. Initial symptoms most often occur in early adulthood
B. The patients usually do not need medication
C. It requires long-term treatment
D. Families require support and education
E. Cause is clearly known

Marina reveals to the nurse that she does not understand English very well because it is her second language. Russian is her first. She also reveals that she is Russian Orthodox and requires certain dietary provisions.

Select all that apply:

What should the nurse do to provide culturally competent care for Marina?
A. Get a family member to translate
B. Insist Marina eat what other patients eat
C. Contact a hospital-approved translator
D. Meet Marina’s request for dietary consult
E. Ask Marina whether she would like to have clergy visit

Marina shares with the nurse that the voices have started telling her to kill herself, but Marina tells the nurse to keep it a secret.

Select all that apply:

What should the nurse do?
A. Reassure Marina she will not tell
B. Tell Marina she cannot keep it a secret
C. Notify the health team
D. Place Marina on one-to-one observation
E. Ask Marina’s roommate to watch her
F. Put Marina in a seclusion room

Even though extrapyramidal side effects (EPSE) are rare with atypical antipsychotics, the doctor writes a prescription for as-needed medication.

Fill in the blanks:
_____________________________________________________________, _____________________________________________________ and _____________________________________________
_____ are examples of anticholinergic, antihistamine, and dopamine agonists to treat extrapyramidal side
effects (EPSE).

Select all that apply:

What teaching should the nurse include for both Marina and her family caregiver?
A. Return for white blood cell (WBC) testing as prescribed
B. Notify provider of any infection or fever
C. Take over-the-counter (OTC) medications as she wishes
D. Call 911 if Marina has command hallucinations to hurt herself or others
E. Do teach-back to evaluate what they understood
F. Have an interpreter present

Select all that apply:

Please select the top-10 signs of schizophrenia:
A. Delusions (believing things that are not true)
B. Hallucinations (seeing or hearing things that are not there)
C. Depression
D. Disorganized thinking
E. Agitation
F. Mania
G. Violence
H. Using drugs and alcohol
I. Low intellect
J. Disorganized speech (e.g., frequent derailment or incoherence)
K. Grossly disorganized or catatonic behavior
L. Lack of drive or initiative
M. Social withdrawal
N. Apathy
O. Emotional unresponsiveness

Multiple-choice:

Most drug metabolism occurs in the
A. Liver
B. Stomach
C. Brain
D. Gallbladder

Multiple-choice:

If Marina is prescribed a neuroleptic drug to treat a psychiatric disorder, the nurse should explain to her and her family that neuroleptic drugs are the same as:
A. Antipsychoticmedications
B. Central nervous system depressants
C. Anticholinesteraseinhibitors
D. Tranquilizers

Multiple-choice:

A patient diagnosed with schizophrenia is being treated with traditional antipsychotic medications. The nurse should explain to the patient and the patient’s family that one negative symptom that may worsen during drug therapy is:
A. Insomnia
B. Social withdrawal
C. Hallucinations
D. Delusions

Multiple-choice:

Marina has been taking clozapine (Clozaril) for 6 weeks and visits the clinic complaining of fever, sore
throat, and mouth sores. The nurse contacts the patient’s physician as these symptoms are indicative of:
A. Severeanemia
B. Bacterial infection
C. Viralinfection
D. Agranulocytosis

Matching:

Match the symptoms in Column A to the disorder in Column B:

Match symptom and disorder
Match symptom and disorder

José, age 17 years, began to isolate himself and exhibit progressively more extravagant behavior (eating in his room alone, spending more and more time staring at himself in the mirror), suspiciousness, and agitation in the year before being referred to a psychiatric department. Four months before entering the department, he consulted a psychiatric nurse practitioner, who prescribed oral haloperidol (Haldol) 2 mg/d.After several weeks of treatment, José showed increasingly unusual behavior and was sub- sequently brought to a psychiatric hospital.There, he was given a single dose of oral haloperidol (5 mg) and within hours began to experience fever (38.5°C/101.3°F), muscular rigidity, and increased creatine phosphokinase (CPK) levels to 1,920 IU/L, and leukocytosis (cells numbering 20,600/mL). After ruling out organic pathology (normal brain CT and cerebral spinal fluid [CSF] examination with glucose 64 mg/d, proteins 34 mg/d and no cells), this was deemed to be a case of neuroleptic malignant syndrome (NMS).

Multiple-choice:

The nurse is caring for José, who has been taking haloperidol (Haldol) for 3 days.
To assess José for neuroleptic malignant syndrome (NMS), the nurse should assess the patient’s:
A. Bloodpressure
B. Serum sodium level
C. Temperature
D. Weight

Multiple-choice:

Two medications that the nurse may give that are key in treating neuroleptic malignant syndrome (NMS) include:
A. Aspirin and lorazepam
B. Calcium and lithium
C. Bromocriptine (Parlodel) and dantrolene (Dantrium)
D. Lamictal (Lamotrigine) and olanzopine (Zyprexa)

Select all that apply:

Because neuroleptic malignant syndrome (NMS) is a life-threatening illness that may lead to rhabdomyolysis and renal failure, the nurse anticipates the following interventions:
A. Place the patient on isolation precautions
B. Hold Haldol (or other antipsychotic) and call provider
C. Call 911 and prepare for transfer
D. Admission to the intensive care unit (ICU)
E. Use cooling blanket, antipyretic, fluids, and hemodialysis at the medical hospital

Because the nurse does not see this problem often (NMS is rare), she delegates the search for hospital policy and evidence-based practice in the literature to the other RN.

Select all that apply:

In evaluating the intervention that was taken for meeting the Quality and Safety Education for Nurses (QSEN) standards, the nurse reviews:
A. Whether hospital procedure agrees with the literature best practices
B. Whether staff like the interventions
C. Whether staff collaborate as a team
D. Whether staff could find the procedure
E. Whether staff consider the patient response

Select all that apply:

What are the risk factors that place José at risk for neuroleptic malignant syndrome (NMS)?
A. Young age
B. Hispanic ethnicity
C. Male gender
D. Presence of affective illness and agitation

Select all that apply:

Which of the following statements are true of electroconvulsive therapy (ECT)?
A. Changes personality
B. Changesneurotransmitters
C. Causes a seizure
D. Uses muscle relaxant and general anesthesia
E. Always used before trying medication
F. Is given in a series of treatments

True/False:

A. Nurse can delegate pre- and post-electroconvulsive therapy(ECT) assessment to a mental health technician.
_____True
_____False
B. Patient may return to unit and sleep, then wake up confused.
_____True
_____False
C. Patient may complain of headache post-ECT.
_____True
_____False
D. Patient disorientation and short-term memory problem usually resolves within 24 hours.
_____True
_____False
E. Patient cannot refuse ECT.
_____True
_____False
F. Patient or guardian must sign an informed consent for ECT.
_____True
_____False
G. ECT cannot be done as an outpatient.
_____True
_____False
H. Nurse administers the voltage.
_____True
_____False

José must be taught about his medication before he is discharged.

Select all that apply:

The nurse would teach that Depakote:
A. Must be taken as directed
B. Is a neuroleptic
C. Is an anticonvulsant used as a mood stabilizer
D. Can be stopped abruptly
E. Abrupt withdrawal can cause a seizure

José tells the nurse that he sometimes drinks alcohol to relax.

Select all that apply:

What should the nurse tell him about his plan to drink alcohol?
A. Alcohol use is fine.
B. Alcohol use is not an effective way of coping.
C. Take his medication instead.
D. Do not drink alcohol with medication.
E. Practice relaxation techniques or listen to music as good coping skills.

José is Hispanic.The nurse knows that in order to give culturally competent care, it is important to consider certain aspects of his culture.

Select all that apply:

The nurse addresses the following:
A. Family is highly valued
B. Religion, primarily Catholic, is important
C. Health is thought to be God’s will
D. Religion is not important
E. Hispanics tend to be verbally expressive

José also states that he plans to spend several months of the year in Puerto Rico with his relatives there. He explains that when he is there, he goes to a folk healer who gives him “treatments” that do not include his medication.

Select all that apply:

What interventions should the nurse make?
A. Forbid him from using the healer
B. Tell him to listen to the healer
C. Explain the importance of taking medication
D. Encourage family to support taking medication
E. Discuss folk customs that complement Western medicine

Multiple-choice:

The drug that is most successful in treating the side effect of akathisia is:
A. Carbamazepine(Tegretol)
B. Diazepam(Valium)
C. Lorazepam(Ativan)
D. Propranolol(Inderal)

Multiple-choice:

If José has been diagnosed with a manic disorder, the nurse anticipates that the physician will most likely prescribe:
A. Clonazepam (Klonopin)
B. Lorazepam (Ativan)
C. Imipramine (Tofranil)
D. Lithium (Lithobid)

Multiple-choice:

When a patient is prescribed 300 mg of oral lithium three times a day, the nurse should instruct the
patient to contact the physician if he or she experiences:
A. Metallictaste
B. Urinaryfrequency C. Loosestools
D. Thirst

Multiple-choice:

Lithium is:
A. Ananticonvulsant
B. Asalt
C. A nickel by-product
D. A thyroid-stimulating hormone

Multiple-choice:

The nurse is caring for a hospitalized patient who has been diagnosed with mixed mania and is not
responding to lithium therapy. The nurse anticipates that the physician will most likely prescribe:
A. Tricyclic antidepressants
B. Anticonvulsants
C. Sedatives
D. Stimulants

True/False:

A. Lithium is contraindicated in pregnancy because of possible congenital defects.
_____True
_____False
B. Continuous gastrointestinal (GI) upset may be a sign of toxic reaction.
_____True
_____False
C. Lithium levels are not needed if the patient follows orders.
_____True
_____False
D. If sodium decreases, the lithium level decreases.
_____True
_____False
E. Full effect takes 2 to 3 weeks.
_____True
_____False
F. Long-term use may lead to hypothyroidism.
_____True
_____False


Tamara, age 34 years, is admitted through the emergency department (ED) by her significant other. She paces constantly, has not slept well in a week, and is worried all the time. Tamara is admitted with the diagnosis of mixed mania.

Multiple-choice:

The nurse is caring for Tamara who has been hospitalized with mixed mania and is to receive lamotrigine
(Lamictol) as a medication. The nurse should explain to her that the target symptom of this medication is:
A. Anxiety
B. Lethargy
C. Mood stability
D. Sedation

True/False:

A. Normal serum levels of divalproex sodium (Depakote) are 150 to 200 mcg/mL.
_____True
_____False
B. The therapeutic range for serum divalproex sodium (Depakote) is 50 to 120 mcg/mL.
_____True
_____False

Multiple-choice:

A patient with mixed mania is prescribed carbamazepine (Tegretol). The nurse should instruct the patient
that toxic side effects can occur if he or she concurrently takes a medication such as:
A. Lithium
B. Amoxicillin
C. Cimetidine
D. Buspirone

Multiple-choice:

A patient who has been taking the medication carbamazepine (Tegretol) tells the nurse that he has been continually nauseated. The nurse should explain to the patient that the nausea may be decreased if the medication is:
A. Decreased in dosage
B. Taken at bedtime
C. Supplemented with zinc
D. Taken with food

True/False:

Electroconvulsive therapy (ECT) is a type of somatic treatment in which an electric current is applied to the
chest area through electrodes placed on the chest. The current is sufficient to induce a grand mal seizure.
_____True
_____False

Multiple-choice:

Electroconvulsive therapy (ECT) is thought to work by:
A. Decreasing dopamine levels
B. Increasing acetylcholine levels
C. Stabilizing histamine and epinephrine levels
D. Increasing norepinephrine and serotonin levels


While in the hospital, Angelique attends group therapy. There are several therapeutic factors of group therapy.

Matching:

Match the communication interventions between Columns A and B:


Social History

Angelique lives with her boyfriend and she will be discharged from the hospital in a few days, given the status of her psychological improvement. She is interested in developing an psychiatric advance directive and she wants assistance to develop one.

Select all that apply:

Advantages of a psychiatric advance directive include:
A. An advance directive empowers the patient to make his or her treatment preferences known.
B. An advance directive will improve communication between the patient and the physician.
C. It can prevent clashes with professionals over treatment and may prevent forced treatment.
D. Having an advance directive may shorten a patient’s hospital stay.

True/False:

A psychiatric advance directive can cover medical and surgical treatment.
_____True
_____False

Dietary History

Angelique is slightly overweight. She feels much better and intends to change her diet and exercise activity. Given her family history of hypertension, she plans to drastically decrease the sodium in her diet and start taking a natural herbal supplement (St. John’s wort) to improve her health. The psychopharmacologic medications Angelique is taking include lithium (Litobid), sertraline (Zoloft), and buspirone (Buspar).

Fill in the blanks:

Name two concerns noted in the changes Angelique intends to make after discharge from the hospital.
1._______________________________________________________________
2._______________________________________________________________

While Angelique is preparing for discharge, she asks to have a family meeting that includes not only her boyfriend but her father as well. She informs the nurse that her father speaks English but prefers using her native language, Spanish.

Multiple-choice:

Having a Spanish-speaking interpreter for the father during the family meeting demonstrates:
A. Marginalizing
B. Culturalinsensitivity
C. Support for the patient’s recovery process
D. Assuming inferior cognition

True/False:

Good psychiatric nursing care involves treating all patients equally.
_____True
_____False

Select all that apply:

Patients’ rights under the law include:
A. Right to treatment
B. Right to assent
C. Right to refuse treatment
D. Right to informed consent
E. Rights surrounding involuntary commitment
F. Psychiatric advance directives
G. Rights regarding seclusion and restraint

TIP: American Psychiatric Association classifications of psychiatric disorders

Axis I: Major Psychiatric Disorders
Axis II: Personality Disorders and Intellectual Disability Axis III: Medical Conditions
Axis IV: Psychosocial/Environmental Problems
Axis V: Global Assessment of Functioning (GAF)

Angelique’s case of new-onset depression, co-occurring medical illness (HIV), and the implications for proactive nursing interventions and family support are clearly indicated. Building effective rapport can promote therapeutic engagement and sharing of information, particularly as it relates to understanding what Angelique is experiencing. It also offers an opportunity for nurses to clarify any concerns or misinterpreted information. Ongoing education is relevant for both patient and family.

Self-advocacy in developing a psychiatric advance directive helps give voice to Angelique’s wishes. She also had the opportunity to share this with her boyfriend and other family members. It is important to note that Angelique’s case illustrated the importance of cultural sensitivity as it relates to “comfort language” among family members.This means that professional nurses must be aware of patients’ and their family members’ language preference when receiving information, particularly when patients are bilingual and indicate that English is their second language.


Matthew is a 36-year-old male. He comes to the ED psychiatric crisis unit with his wife. The nurse, Dave, documents the following assessment:
Progress Note
10/2/14
1600
36-year-old male admitted to the ED psychiatric crisis unit
Vital signs: Temperature: 99.6oF, pulse: 88 bpm, respiratory rate (RR): 24 breaths per minute, blood pressure (BP): 120/80 mmHg
Patient states “I am having thoughts of killing self with my Army gun”
History of drinking every day
Last drink was 1 day ago
Blood alcohol level (BAL) equals 0

Multiple-choice:

What is the nurse’s priority nursing diagnosis for Matthew?
A. Ineffective individual coping
B. Alteration in thought process
C. Alteration in self-concept
D. Potential for violence (against self)

Multiple-choice:

The nurse initiates a verbal contract with Matthew for which of the following?
A. Safety
B. Admission
C. Monitoring
D. Drinking

Matthew refuses to contract, which the nurse documents and then informs the physician of this. Dave then records Matthew’s history. Matthew is a computer technician who was deployed twice to Afghanistan by his Army Reserve unit.While in combat, he saw several of his fellow soldiers get wounded or die. He states:“I only joined the reserves for some extra money to support my family.”When he returned from the second deployment a couple of months ago, he started feeling very anxious around loud noises such as cars backfiring. He also has flashbacks and nightmares. He is suspicious and startled if anyone suddenly “walks up to me,” even his wife and children. He has not gone to the Veterans Affairs (VA) for screening or help because “I don’t trust them and it could hurt my record.”

Multiple-choice:

The nurse recognizes that Matthew’s symptoms may be consistent with which disorder?
A. Social anxiety disorder
B. Posttraumatic stress disorder
C. Dissociative identity disorder
D. Paranoiddisorder

Dave decides to speak with Matthew’s wife, who accompanied Matthew to the ED, to get collateral information.The wife reports that Matthew has been drinking heavily (one six-pack per day), fighting with her, arguing with his boss, and being short tem- pered with his children. The wife found him yesterday holding his gun while drinking. Matthew told her,“I should have died with my buddies.” The family physician was called and she directed Matthew’s wife to take Matthew to the ED psychiatric unit.

Select all that apply:

What other nursing diagnoses can the nurse record at this point?
A. Ineffective individual coping
B. Ineffective family coping
C. Alteration in sleep pattern
D. Anxiety
E. Alteration in self-concept
F. Alteration in thought process (suicidal ideation)

The physician writes the diagnoses of depression not otherwise specified (NOS, Code 311) with suicidal ideation, posttraumatic stress disorder (PTSD), and alcohol use. The physician arranges for admission to the inpatient psychiatric unit.

Select all that apply:

The nurse prepares a situation, background, assessment, recommendation (SBAR) report for the
psychiatric inpatient unit nurse. What information is critical to convey in terms of safety and continuity?
A. Patient admission for depression not otherwise specified (NOS) with suicidal ideation
B. Patient has plan and weapon at home (gun)
C. Patient drinks heavily, last drink 1 day ago
D. Patient refuses to contract for safety
E. Patient is a computer technician
F. Maintain on one-to-one observation until further assessment

On admission to the psychiatric unit, Matthew acknowledges that he has thoughts and a plan of using his gun to kill himself. He did admit that he hid the loaded gun in the house.

True/False:
Which of the following statements are true or false in reference to suicidal/homicidal patients?
A. Ask patient directly about suicidal/homicidal thoughts
_____True
_____False
B. Ask the family whether the patient has suicidal/homicidal thoughts
_____True
_____False
C. Depressed patients are not high risk
_____True
_____False
D. Establish a safety contract with the patient
_____True
_____False
E. Assume that the patient is just seeking attention
_____True
_____False
F. Patient is thinking rationally
_____True
_____False
G. Remove access to weapons
_____True
_____False
H. Patient’s right to bear arms is primary
_____True
_____False
I. Duty to inform potential victim of declared threat
_____True
_____False

The evening nurse, Karen, finds Matthew pacing and begging to be discharged. Matthew says, “Why didn’t I die instead of my buddies?” He is afraid to go to sleep because of the nightmares he has of being back in the war. Karen notifies the physician that Matthew still refuses to contract for safety. Karen decides to give Matthew as-needed medication for anxiety.

Select all that apply:

When the nurse goes to the medication-dispensing machine (Pyxis) for antianxiety medication, the drawer is empty. The nurse goes to another unit and takes lorazepam (Ativan) from the unit’s supply. This system workaround works for the short term, but may cause a problem in the long term. Why?
A. Manager not informed
B. Supply not replaced
C. Staff continues “time-saving” short cut
D. Identification of patient may be bypassed
E. Medication amount may be incorrect
F. Hospital does not want to know as long as patient is satisfied

Matthew attends therapies and takes medication for depression and anxiety and is treated for alcohol use. He attends Dual-Diagnosis Unit groups, Alcoholics Anonymous (AA) meetings, and a PTSD support group.

Select all that apply:

What issues about alcohol use would indicate that the nurse and Matthew are in the working phase of
the nurse–patient relationship?
A. Patient denies he has a problem with alcohol.
B. Patient identifies problems in marriage related to alcohol use.
C. Patient discusses how alcohol impairs his work.
D. Patient claims arguments with boss are definitely harassment by the boss.
E. Patient feels remorse for being impatient with his children.
F. Patient says goodbye and states he will continue Alcoholics Anonymous (AA) meetings after discharge.

Matthew speaks with the health care team about discharge plans and services the VA has to offer veterans with PTSD and other disorders that often accompany it, such as anxiety, depression substance use, aggressive behavior, and homicidal and/or suicidal behavior. Matthew decides he is willing to go to outpatient VA counseling and support groups. He contracts for safety and agrees to submit his gun to his reserve unit. Because his wife has been affected, she agrees to go to Al Anon and a VA support group for mil- itary spouses.The children will attendVA and AA support groups for children.

Multiple-choice:

One of the groups his wife will attend is Al Anon. Which statement by the wife demonstrates recovery
and improvement in their relationship?
A. “When my husband comes home I will hide the bottles of alcohol.”
B. “If he doesn’t go into work, I will call and say he is sick.”
C. “I will continue to be both mother and father to the children.”
D. “I will take care of myself and let him manage his own responsibilities.”

Multiple-choice:

What is the best response by the nurse when Matthew tells the same story over and over again of how his buddies died?
A. Listen and be nonjudgmental
B. Give suggestions for what he could do
C. Set limits and terminate discussion
D. Clarify and probe further

Multiple-choice:

Which statement by Matthew best demonstrates that he is coping better with his survivor guilt?
A. “I wish I had died instead of my buddies.”
B. “I don’t know why they died, they were better than me.”
C. “If I had fought harder my buddies would be here.”
D. “I am still here; I can help others with their memories.”

Matthew continues outpatient treatment at the VA. He finds their services are especially helpful because they understand his needs. He finds that his wife and children are better able to cope with him and the times he still occasionally retreats to his “man cave” to regroup. He also received a therapy dog for veterans and joined a martial arts class to channel his aggression appropriately. He goes to the VA support groups for PTSD and AA and wants to help newer veterans learn what he learned about coping.


Sarah is a 40-year-old woman admitted to the ED of her local community hospital.The nurse documents the following assessment:
Progress Notes
11/15/14
0100
African American female admitted with multiple facial lacerations and other blunt head trauma. Patient is confused; disoriented to person, place, and time; and is lethargic. Assessment
Vital signs:Temperature: 98.6oF, pulse: 68 beats per minute (bpm), respiratory rate (RR): 14 breaths per minute, blood pressure (BP): 100/70 mmHg, blood alcohol level (BAL): 0.28. MRI of head is negative.
Complete physical examination is completed by the ED physician, Dr. James.

Multiple-choice:

Which of the following conditions is the patient most likely experiencing?
A. Amphetamine intoxication
B. Alcohol withdrawal
C. Alcohol intoxication
D. Alcoholic dementia

Sarah informs the nurse that she was drinking at a bar where a man asked her to go with him. He followed her to her car and he physically and sexually assaulted her. Sarah says her head hurts. Because of the assault, Sarah is seen by a sexual assault nurse examiner (SANE), Kathy, and by the ED crisis team.

Select all that apply:

After Sarah is medically cleared, what disorder(s) is the crisis team focused on preventing?
A. Dissociativefugue
B. Borderline personality disorder
C. Acute stress disorder
D. Depression
E. Delusionaldisorder
F. Somatization disorder

Select all that apply:

Which of the following is true about rape?
A. It is never the victim’s fault.
B. The victim probably provoked it.
C. Only women who lose control get raped.
D. “No” sometimes means “yes.”
E. If a person is drunk, he or she cannot consent.
F. It is an act of aggression and control.

Sarah’s history includes her acknowledgment that she has been drinking heavily since her divorce at the age of 28. She states that she attended an alcohol rehabilitation program but relapsed. She also states that she smokes one pack of cigarettes per day.

Multiple-choice:

Considering Sarah’s chronic use of alcohol, what is the most important information that the nurse should obtain and report?
A. Type of alcoholic drink
B. Time of last drink
C. Source of alcohol
D. Drinking at home alone or in a bar

TIP: Alcohol withdrawal

At 6 to 8 hours after the last drink, the patient is at risk of signs of alcohol withdrawal. The nurse must know the signs and report them immediately to the primary care provider (PCP) for withdrawal management. If not, the patient is in danger of seizures and progression to delirium tremens (DTs) within 48–72 hours.

Multiple-choice:

Which of the following would be signs of alcohol withdrawal?
A. Slurred speech, ataxia, hypothermia
B. Decreased reflexes, hypotension, drowsiness
C. Bradycardia, sedation, decreased respiration
D. Mild tremors, tachycardia, hypertension

Select all that apply:

The nurse has the responsibility to foster and document the following interventions for Sarah in order to adhere to The Joint Commission (TJC) and Centers for Medicare & Medicaid Core Measures for quality and safety, which is required for accreditation and reimbursement of hospitals.
A. Median time from emergency department (ED) arrival to ED departure
B. Admit decision time to ED transfer
C. Encourage and offer a smoking-cessation program; document acceptance or refusal
D. Screen and document alcohol intoxication; document treatment acceptance or refusal
E. Refuse admission to those who refuse screening and treatment for alcohol, drugs, and tobacco use
F. Report alcohol and drug use to police

Select all that apply:

In the following list, which are the measures on which patients and families rate hospitals for quality?
A. Communication with doctors
B. Communication on social media
C. Communication with nurses
D. Responsiveness of hospital staff
E. Painmanagement
F. Medication communication
G. Pettherapy
H. Dischargeinformation
I. Clean and quiet environment
J. Hotel accommodations

Sarah is now exclaiming:“I need a drink!” She is also complaining of hand tremors. Progress Notes
11/15/14
0700
Her nursing assessment is: Vital signs: Temperature: 98.6oF, pulse: 98 bpm, RR: 28 breaths per minute, BP: 140/90 mmHg. Patient anxious with hand tremors. Patient requesting “a drink.” Patient states “I usually have a drink in the morning for my nerves.” Patient exhibiting signs of alcohol withdrawal. Notified Dr. James of urgent need for withdrawal treatment.—K.Walsh, RN

Matching:

Sarah is in the process of being transferred to the inpatient psychiatric unit. The nurse, Kathy, is giving
a situation, background, assessment, recommendation (SBAR) report to the psychiatric inpatient nurse, Marie. Based on the aforementioned progress note, Kathy gives a report to Marie. Match the information in Column A with the parts of SBAR in column B:

Parts of SBAR
Parts of SBAR

Select all that apply:

The nurse anticipates that the primary care provider (PCP) may order which of the following medications
for withdrawal?
A. Sertraline(Zoloft)
B. Clonidine(Catapres)
C. Lithium carbonate (Lithobid)
D. Oxazepam(Serax)
E. Propanolol(Inderal)
F. Lorazepam (Ativan)

TIP: Patient Safety

Patient safety is a major goal of TJC and a nursing standard. Measures include reporting deteriorating patient status as well as using SBAR to improve communication.

On the psychiatric inpatient unit, Sarah tells Marie she has been feeling depressed since her divorce and that her husband wants to take the children (ages 12, 9, and 6 years). Her ex-husband claims that Sarah is an unfit mother. Sarah tearfully tells Marie that the children are currently home alone and that she fears losing them since she has no family to help her. She also says she is afraid the man who assaulted her will do so again. Sarah admits to thoughts of suicide and that “everyone would be better off without me.” Marie gives the lorazepam (Ativan) for withdrawal that the physician ordered.

Ordering:

What is the nurse’s priority at this time in terms of Sarah’s interdisciplinary care plan? Place the following nursing diagnoses in priority order from 1 to 6:
_____Ineffective individual coping
_____Ineffective parenting
_____Potential for violence (against self)
_____Ineffective grieving
_____Alteration in nutrition (less than requirements)
_____Risk for injury (seizure from withdrawal)

Select all that apply:

The nurse implements nursing interventions for a suicidal patient. What does this include?
A. Establish a patient contract for safety
B. Place the patient in seclusion and restraints
C. Place the patient on one-to-one observation
D. Allow the patient to go off unit
E. Give the patient knitting needles in group
F. Notify physician of suicide ideation

Select all that apply:

Sarah has been dually diagnosed with major depression and substance use (alcohol). The medication
group of first choice for depression is the selective serotonin reuptake inhibitors (SSRIs). Why?
A. They have no adverse effects
B. They have side effects such as headache, nausea, drowsiness, insomnia, and sexual dysfunction
C. They are less expensive
D. They may take up to 5 weeks for full effect
E. Suicide risk increases in the first couple of weeks
F. They may be taken with alcohol

Select all that apply:

Sarah is being discharged to a drug and alcohol rehabilitation program. What are the nurse’s
responsibilities?
A. Provide teaching about discharge plan
B. Report patient dissatisfaction with discharge plan
C. Give a situation, background, assessment, recommendation (SBAR) report to rehabilitation program
D. Consult with social services for safety of children
E. Tell the patient she may resume alcohol in future if she handles it better
F. Encourage continued participation in Alcoholics Anonymous (AA) and sexual trauma support group

Sarah tells Marie that she thinks she can control her drinking if she does not have so much stress. She believes that her ex-husband and children drove her to drink and her drinking was not that bad. It was her only way to deal with her problems and that going to that bar made her drink too much.

Select all that apply:

What defense mechanism(s) is Sarah using?
A. Rationalization
B. Projection
C. Minimization
D. Repression
E. Denial
F. Reaction formation

After her rehabilitation program, Sarah continues her outpatient therapy and attends AA meetings and the sexual trauma survivors’ group. Through social service support she receives job training and finds employment. She is able to obtain joint custody of her children because of her sobriety and is now supporting her family. She is much more hopeful about her future.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Back to top