2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Chapter 10 Stress Responses and Stress Management:
Walter Cannon research in the sympathetic nervous system, which
is a part of the autonomic nervous system. He described acute
stress response, now commonly described as fight (aggression) and
flight (withdrawal). We all react to stressors differently depending
on developmental stage, previous experiences, and sociocultural
background.
Psychological stressors include events like financial challenges, loss
of a job, divorce, death of a loved one, and can also be related to
changes that are considered positive like marriage and the birth of
a new baby.
Physiological stressors include environmental conditions such as trauma, infection, hemorrhage, hunger,
and pain, excessive heat/cold.
HPA axis – The Hypothalamic-Pituitary-Adrenal axis – propels us to be alert. The hypothalamus secrets
the hormone ACTH (adrenocorticotropic hormone) – the result is more cortisol is produced to increase
glucose in blood and increase muscle endurance. Keeps us alert!
GAS-General Adaptation Syndrome (Hans Selye)
The alarm stage is the initial, brief, and adaptive response (fight or flight) to the stressor. It begins with
the eyes or ears sending information such as a car running a light or the sound of a fire alarm to the
brain’s amygdala. If the amygdala, which processes emotional data, interprets the event as dangerous, it
sounds the alarm to the hypothalamus. The alarm stage is intense, and no organism can sustain this
level for long. If the threat subsides, the other part of the autonomic nervous system, the
parasympathetic nervous system, slowly puts on the brakes. It allows the body to rest and digest (versus
fight or flight) and dampens the stress response. If the threat continues, the resistance stage follows.
Usually stressors are successfully overcome! The third stage is exhaustion, where stress can become
chronic and contribute to anxiety disorders, major depressive disorder, sleep disorders, digestive
problems, heart disease, and weight gain.
Stress can be acute or chronic – and lead to significant health problems:
Acute stress can lead to sad mood, loss of appetite, increased B/P, risk for clots/stoke, decreased
memory and learning, impotence
Chronic stress can lead to anxiety/panic, Major Depressive Disorder, lowered resistance, anorexia or
overeating, insulin-resistant diabetes, greater risk for cardiac events/respiratory issues
Stress may result in malfunctions in the immune system that are implicated in autoimmune disorders,
immunodeficiency, and hypersensitivities.
Note the brain-immune system connection!
Stress is INDIVIDUAL and impacted by perception, temperament, support systems, age, gender,
culture/religion/spirituality
Interventions:
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Relaxation exercises, biofeedback, mindfulness, meditation
Cognitive reframing, journaling, humor
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Chapter 15 Anxiety and Obsessive-Compulsive Related Disorders:
Know the 4 levels of anxiety (pg. 272, Table 15.1)
Assessment of signs and symptoms: Trembling and a pounding heart are noted with severe anxiety.
Voice tremors and tension are reflective of moderate anxiety. Restlessness and irritability are associated
with mild anxiety. Withdrawal and hallucinations occur in relation to panic.
Interventions The nurse should encourage the client to continue using relaxation techniques. Basic-level
psychiatric-mental health registered nurses use counseling to reduce anxiety, enhance coping and
communication skills, and intervene in crises. When patients request or prefer to use integrative
therapies, the nurse performs assessment and teaching as appropriate.
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Cognitive restructuring helps the patient (1) identify automatic negative beliefs that
cause anxiety, (2) explore the basis for these thoughts, (3) reevaluate the situation
realistically, and (4) replace negative self-talk with supportive ideas.
Behavioral therapy involves teaching and physical practice of activities to decrease
anxious or avoidant behavior
Guided imagery focuses on pleasant images and replaces negative or stressful feelings.
Guided imagery may be self-directed or led by a practitioner or a recording.
Progressive relaxation can be used anywhere and involves eliminating muscle
contraction, which helps reduce anxiety.
Biofeedback involves using a recording device and cannot be used anywhere.
Meditation helps a client relax but not by eliminating muscle contraction.
**Know adaptive and maladaptive use of defense mechanisms, the nurse should consider the intensity,
duration, and frequency of use. Refer to Table 15.2 (pg. 274) for examples of adaptive and maladaptive
defense mechanisms.
Examples of Defense Mechanisms
Sublimination (Always
Undoing
Identification
Denial
Healthy)
Altruism
Splitting
Dissociation
Projection (Always
Unhealthy)
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
**What are defense mechanisms in the 1st place?? (Automatic coping styles that “protect” individuals
from anxiety by blocking feelings, conflicts, and memories)
Common Defense Mechanisms:
Restructuring involves changing an activity in a way that will decrease
a stimulation that sets the client off.
Rationalization refers to a client providing a logical explanation for
inappropriate behavior.
Displacement refers to when a client transfers an emotional reaction
from an object or person to another object or person.
Projection refers to when a client attributes their thoughts onto
another person.
Repression is an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from
conscious awareness.
Denial – ignoring the existence of a thought/feeling.
General Anxiety Disorder (GAD) – Excessive worry for 6 months (more days of worry than not) that
include 3 or more of these symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle
tension, sleep disturbance.
Interventions: immediate- stay with patient, decrease stimulation, simple directions, reassure patient
you are there to help; then, education, CBT, reframing
Social Anxiety Disorder – fear brought on by social situations; most common = Fear of Public Speaking
Panic Disorder – panic attack, feeling of impending doom, often unexpected and seemingly out of
nowhere, common comorbidities = substance use disorder, depression
Phobias: persistent irrational fear resulting in high anxiety – see table 15.4; common agoraphobia (open
spaces) and acrophobia (heights)
Many of us have fears about something or other; it is a problem when a person’s daily functioning is
impaired due to a phobia.
Obsessions, Compulsions & OCD:
Obsessions: Are thoughts and there are many types. Perfectionism
typically includes choosing a behavior that the client thinks will
impress others, like getting to work early, leaving late, finishing work
earlier than requested. Harm obsession is when the client has
thought and then compulsively performs a repetitive action because
they believe not performing the action will cause them harm.
Violent obsessions involve a compulsive behavior that the client
performs to avoid having to carry out a violent thought.
Compulsions: Are actions and a compulsive act is a ritualistic behavior performed by a client with OCD.
Persistent thoughts with an attempt to suppress the thoughts can cause severe anxiety for a client,
which can manifest with symptoms such as pacing, increased breathing, and facial flushing.
Contamination compulsion is observed when the client avoids touching all objects and scrubs their
hands or obsessively washes their hands whenever the client must touch something.
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Trichotillomania (hair pulling disorder) is often accompanied by trichophagia (secretly swallowing the
pulled hair), which can lead to trichobezoar (mass of hair or hair ball trapped in the GI system (fatal=
obstruction or perforation of the GI system). The skin and immune systems can also be affected by this
disorder because skin picking is often accompanied by trichotillomania, and the client picks scabs, which
can lead to scars and infection. Assessment of the GI system is a priority with this disorder.
Body Dysmorphic Disorder:
Although these patients tend to have a normal appearance, their
preoccupation with an imagined defective body part results in
obsessional thinking and compulsive behavior such as mirror
checking and camouflaging. Clients may be well aware that their
thoughts are distorted, or they may be completely unsure about
existence of the defect. False assumptions about the importance of
appearance, fear of rejection by others, perfectionism, and
conviction of being disfigured lead to overwhelming emotions of disgust, shame, and depression.
Patients are frequently concerned with their skin, hair, nose, stomach, teeth, weight, and breasts/chest.
Men tend to be concerned with body build and the appearance of their genitals and body build. Women
focus on the appearance of their skin, stomach, weight, breasts, buttocks, thighs, legs, hips, and toes.
Chapter 16 Trauma, Stressor- Related, and Dissociative Disorders
Traumatic life events are associated with a wide range of psychiatric and other medical disorders.
Traumatic events may be interpersonal trauma, sexual abuse, physical abuse, severe neglect, emotional
abuse, repeated abandonment, or sudden and traumatic loss in childhood, adolescence, or adulthood
Trauma-informed care is a treatment framework that involves recognizing and responding to the effects
of all types of trauma. Integrating trauma-informed care into all healthcare settings can reduce the
pervasive and damaging effects of trauma.
PTSD and Acute Stress Disorder:
Assessment: PTSD in preschool children may manifest
as a reduction in play, repetitive play that includes
aspects of the traumatic event, social withdrawal,
and negative emotions such as fear, guilt, anger,
horror, sadness, shame, or confusion. Children may
blame themselves for the traumatic event and
manifest persistent negative thoughts. There may be
a feeling of detachment or estrangement from others
and diminished interest or participation in significant
activities. Often there is irritability, aggressive or selfdestructive behavior, sleep disturbances, problems
concentrating, and hypervigilance.
The traumatized child has suffered significant fragmentation of relationships with others. An essential
healing ingredient is improving relationships and connection to others. The nurse-patient relationship
provides a foundation of connection and caring. Box 16.1 identifies interventions appropriate for a child
who has suffered a specific trauma.
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Dissociative Disorders: occur after significant adverse experiences of trauma (think ACES); genetic and
neurobiological etiology.
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Dissociative Amnesia -inability to recall personal information
Depersonalization/derealization Disorder – Depersonalization: recurring feelings of
unreality or detachment from oneself; Derealization – focus on outside world
Usually clears in short order; may refer for CBT. Meds to tx symptoms; co-morbidities are depression
and anxiety.
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Dissociative Identity Disorder – two or more distinct personalities with different
behaviors, relationships, usually a result of significant trauma.
RN Role – assess, screen for suicide, support simple routine, refer for therapy, provide support, health
teaching, assist with reducing anxiety
No specific meds however may treat symptoms (if depression or anxiety)
Attachment Disorders – psychiatric conditions that are related to emotional attachment to others
Chapter 26 Crisis and Disaster
Crisis:
The client is in a crisis, the primary goal for crisis intervention is to make the client feel safe, ensure
safety and help them feel less anxious. The nurse should stay with the client, and explaining there is
someone who can help would be the first step.
Homeostasis – a stable state or equilibrium.
Coping Strategies in Crisis/Anxiety/Stress: The nurse determines resources by assessing the patient’s
support systems. When available, family and friends can be involved by offering emotional or material
support. The more clearly the person can define the problem, the more likely the person will identify
effective solutions. Nurses should inquire what coping mechanisms have worked for the client in the
past.
Types of Crises:
Maturational – occurs as we develop – marriage, birth of child, retirement
Situational – events that are often unexpected and distressing – divorce, death of spouse
Adventitious – comes from outside; a chance happening – hurricane, pandemic
Prevention of Crisis:
Primary – teaching, help reduce life changes, recognizing potential problems
Secondary – intervening during a crisis
Tertiary – long-term support post crisis
Interventions:
Crisis Intervention teams
Crisis stabilization facilities
Crisis hot-lines
Disaster response teams
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Chapter 18 Eating and Elimination Disorders
In bulimia nervosa and anorexia nervosa electrolyte imbalances (low K+) and low albumin can
be issues.
Bulimia Nervosa Health teaching focuses on not only the eating disorder but also meal
planning, use of relaxation techniques, maintenance of a healthy diet and exercise, coping skills,
the physical and emotional effects of binging and purging, and the impact of cognitive
distortions.
The nurse should explain to the client diagnosed with bulimia nervosa that their teeth will
eventually deteriorate because the emesis produced during purging is acidic from the gastric acid
and erodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte
imbalance.
The milieu of an eating-disorder unit is purposefully organized to help a client establish more
adaptive behavioral patterns, including normalizing eating. The highly structured environment
includes precise meal times, adherence to the selected menu, observation during and after meals,
and regularly scheduled weighing.
Anorexia Nervosa The most important outcome is the attainment of a safe weight. Under or
malnourished clients are at risk for electrolyte imbalances and death. A client with anorexia
nervosa is underweight and may have growth of fine, downy hair called lanugo on their face and
back. Cool mottled skin, low blood pressure, pulse, and temperature are findings consistent with
a malnourished, dehydrated state noted in clients with anorexia nervosa.
The milieu of an eating-disorder unit is purposefully organized to help a client establish more
adaptive behavioral patterns, including normalizing eating. The highly structured environment
includes precise meal times, adherence to the selected menu, observation during and after meals,
and regularly scheduled weighing.
Clients diagnosed with anorexia nervosa need a highly structured environment that includes
precise meal times, adherence to the selected menu, observation during and after meals, and
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
regularly scheduled weighing. Close monitoring of the client involves supervising the client in
the bathroom after eating to prevent self-induced vomiting.
Allowing the client to make limited food choices as weight gain progresses allows them to make
limited choices based on positive outcomes. More control can be relinquished to the client as
they progress toward meeting their goals. Allowing the client to freedom to decide on a personal
exercise routine allows full freedom that the client may not be ready to assume. Assist the client
in resolving personal issues contributing to the eating disorder and providing positive
reinforcement for weight gain and behaviors that promote weight gain are supportive measures.
Thoughts and behaviors associated with anorexia nervosa include terror of gaining weight,
preoccupation with thoughts of food, view of the self as fat even when emaciated, peculiar
handling of food: cutting food into small bits, pushing pieces of food around the plate, possible
development of rigorous exercise regimen, possible self-induced vomiting, use of laxatives and
diuretics, and cognition so disturbed that the individual judges their self-worth by his or her
weight.
Rumination Disorder: Rumination disorder is characterized by undigested food being returned
to the mouth. It is then re-chewed, re-swallowed, or spit out. Rumination disorder may be
diagnosed after 1 month of symptoms. Rumination symptoms can occur at any age, and the onset
in infants is between 3 and 12 months. Intellectual development disorder is associated with
rumination. Neglect is a predisposing factor for the development of this disorder. The symptoms
frequently remit spontaneously but may become habitual and result in severe malnutrition and
even death.
Pica is the persistent eating of substances such as dirt or paint. Eating non-food items interferes
with nutrition and may be dangerous.
Chapter 19 Sleep-Wake Disorders
Hypersomnolence disorder is associated with excessive daytime sleepiness and has a prevalence
of about 5% to 10% in individuals who seek help in sleep disorder clinics. Hypersomnolence
disorder is chronic (3 months or more) and begins in young adulthood. It affects males and
females equally.
Narcolepsy is defined as individuals who have an uncontrollable urge to sleep.
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Circadian Rhythm Disorder occurs when there is a misalignment between the timing of the
individual’s normal circadian rhythm and external factors that affect the timing or the duration of
sleep.
Sleep Diagnostics & Studies Sleep testing is often indicated for clients complaining of sleep
disturbance or excessive sleepiness that impairs social and vocational functioning. There are four
common diagnostic procedures used in the evaluation of sleep disorders. Polysomnography is the
most common sleep test and is used to diagnose and evaluate clients with sleep-related breathing
disorders and nocturnal seizure disorders. It usually involves one or two nights of sleep in a lab
with electrodes and monitors placed on the head, chest, and legs. Technicians record brain wave
activity, eye movement, muscle tone, heart rhythm, and breathing. The multiple sleep latency test
(MSLT) is a daytime nap test used to objectively measure sleepiness in a sleep-conducive
setting. Polysomnography and MSLT performed the day after a polysomnography evaluation and
are routinely indicated in clients suspected of having narcolepsy. The maintenance of
wakefulness test (MWT) evaluates a client's ability to remain awake in a situation conducive to
sleep. It is used to document adequate alertness in individuals with careers such as airline pilots
for which sleepiness would pose a risk to public safety. Actigraphy involves using a wrist watchtype tracker that records body movement over a period of time and is helpful in evaluating sleep
patterns and sleep duration. It is used for clients with circadian rhythm disorders and insomnia.
Insomnia Predisposing factors to insomnia include a prior history of poor-quality sleep, a history
of depression and anxiety, or a hyperarousal state. Clients at risk of developing insomnia may
describe themselves as light sleepers and night owls. Precipitating factors are external events that
trigger insomnia. Personal and vocational difficulties, medical and psychiatric disorders, grief,
and changes in role or identity (as seen with retirement) are examples of precipitating factors.
Perpetuating factors are sleep practices and attributes that maintain the sleep complaint, such as
excessive caffeine or alcohol use, spending excessive amounts of time in bed or napping, and
worrying about the consequences of insomnia.
Interventions:
It is best to avoid trying to complete office work before bedtime because such activity may create
excessive mental stimulation and thereby inhibit sleep initiation. Intake of caffeinated beverages
should be avoided in the afternoon and evening; a small (8-oz) cup of regular coffee in the
morning is acceptable and would not be expected to interfere with sleep at night. Maintaining a
consistent bedtime is part of a healthy sleep regimen; routines are helpful for inducing sleep.
Chapter 20 Sexual Dysfunction, Gender Dysphoria, and Paraphilias
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Female orgasmic disorder is sometimes referred to as inhibited female orgasm or anorgasmia
and is defined as the recurrent or persistent inhibition of female orgasm. It is manifested by the
recurrent delay in or absence of orgasm after a normal sexual excitement phase achieved by
masturbation or coitus. For it to be considered a clinically significant problem, it must have
occurred for at least 6 months during most sexual encounters. Orgasmic difficulties cause
clinically significant distress in the woman.
Asexuality is reported in individuals that do not have a desire for sexual relations. Asexuality is
different from celibacy, which is a conscious choice to abstain from sex even though the desire is
there.
Exhibitionistic Disorder is characterized by urges to expose oneself to unsuspecting strangers.
Exhibitionistic disorder involves illegal activity with the intentional display of the genitals in a
public place. Clients with a history of exposing themselves to others often feel deep remorse,
guilt, and shame over inappropriate behaviors. They seek to control their fantasies and urges. A
priority outcome for this client is to identify feelings that lead to impulsive actions and
consequences and ultimately learn to practice self-restraint of impulsive behaviors.
Pedophilic disorder involves intense sexual urges, behaviors, or fantasies involving sexual
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activity with a prepubescent child. Pedophilic disorder is, unfortunately, the most common
paraphilic disorder. It involves a predominant or exclusive sexual interest toward prepubescent
children (generally 13 years or younger). Sexual fantasies can lead some individuals to seek
physical contact with these sexually immature children. One strategy is to avoid environments
that evoke such sexual desires. A subtype of this disorder refers to pubescents between ages 11
and 14. Termed hebephilia, this attraction is unacceptable in most cultures and represents a
profound violation of the boundaries of childhood. Critics of pathologizing this attraction to
pubescent young people by calling it a mental disorder say that adults have always had a sexual
interest in this age group and that it is a legal issue and not a disorder. Because pedophilia is
illegal, its exact incidence is unknown. For the definition of pedophilia to be met, the perpetrator
must be at least 16 years of age and at least 5 years older than the victim. The nature of child
molestation ranges from undressing and looking at the child to genital fondling or oral sex,
penetration, and even torture It is important the client be able to identify triggers of such urges
and behaviors. It is not a priority to identify relapse prevention strategies when triggers have not
been identified. Daily therapy can help the client identify triggers, and verbalizing follow-up care
is not a priority during the first week of hospitalization.
Voyeurism is an illegal activity that begins in adolescence or early adulthood. It is characterized
by seeking sexual arousal through viewing, usually secretly, other people in intimate situations
(e.g., naked, in the process of disrobing, or engaging in sexual activity).
Transvestic disorder is when sexual satisfaction is achieved by dressing in the clothing of the
opposite gender. This behavior is related to fetishism but often goes beyond the use of one
particular object. Generally, this behavior develops early in life and is associated with someone
with whom the person is closely associated, whether in a loving relationship or through abuse.
Unlike gender dysphoria, there are no sexual orientation issues, and clients with transvestic
disorder do not desire a sex change. Transvestites are usually heterosexual. Many cross-dress
only in specific sexual situations, and they often receive the cooperation and support of their
partners. This is more common in men than in women.
Frotteuristic disorder is rubbing up against or touching a nonconsenting person.
Sexual masochism involves the achievement of sexual satisfaction by being humiliated, beaten,
bound, or otherwise made to suffer. Sexual masochistic practices are more common among men
than among women. In either case, participants tend to know this is a “game,” and actual
humiliation or pain is avoided.
The standard treatment for paraphilic disorders is cognitive-behavioral therapy.
Gender dysphoria Individuals dealing with gender dysphoria may feel profound social and
internal guilt and shame related to their sexual proclivities. Biological assignment does not
necessarily determine whether individuals think of themselves as male or female. When
biological sex differs from gender identity, the individual may suffer from gender dysphoria, or
feelings of unease about their incongruent maleness or femaleness. A man might describe
himself as “a woman trapped in a man’s body.”
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
A nursing diagnosis appropriate for gender dysphoria includes disturbed personal identity related
to incongruence between expressed (beliefs) and assigned (inborn) gender. Outcomes include
seeking social support, using healthy coping behaviors to resolve sexual identity issues, and
acknowledging and accepting sexual identity.
Cross gender activities are not necessarily related to gender identity and not likely to be carried
into adulthood is supported by current research.
Dyspareunia (pelvic pain during intercourse): A thorough physical and gynecological
examination will be performed to assess for physiological causes of the client's symptoms. If no
pathology exists, the client may be experiencing genito-pelvic pain/penetration disorder.
Symptoms of this disorder include pain with vaginal intercourse and difficulty with penetration.
Chapter 12 Schizophrenia Spectrum Disorders
A chemical imbalance of the brain leads to altered perceptions, such as auditory (voices) or
visual (images) hallucinations. Hallucinations, or false sensory perceptions, may occur in all five
senses. The most common perceptual errors are hallucinations. Hallucinations occur when a
person perceives a sensory experience for which no external stimulus exists (e.g., hearing a voice
when no one is speaking). A command hallucination is a particularly disturbing symptom that
directs a person to take action. This type of hallucination must be monitored carefully because
they may be dangerous, for example, telling a client to "jump out the window" or "hit that
nurse." Command hallucinations are often frightening and may be a warning sign of an
impending psychiatric emergency. Tactile hallucinations are felt as bodily sensations. Olfactory
hallucinations are described as smelling odors.
See table 12.1 page 198.
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A client that believes he or she is receiving messages through the radio is experiencing
referential delusions. These delusions involve the client interpreting events within the
environment as being directed toward him or herself.
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Grandiose delusions are a false or unusual belief about one's greatness.
A client experiencing erotomaniac delusions believe a person desires you romantically.
A client experiencing persecutory delusions believes they are singled out for harm.
The nurse should prioritize the nursing diagnosis based on the risk of violence directed toward
self or others. A client who hears voices commanding him to kill someone is at risk for otherdirected violence. Other risk factors for violence include aggressive body language, verbal
aggression, catatonic excitement, and rage reactions.
Table 12. 2 identifies signs/symptoms and nursing diagnoses for schizophrenia. Pg. 201
Planning/Treatment-Schizophrenia
For agitated clients, the most appropriate nursing intervention is to reduce excess stimulation,
which can further agitate the client. Providing increased supervision or isolating the client may
increase agitation and the client’s risk for violence. Pg. 205 Table 12.3
The nurse will anticipate the client's treatment to include medication, group therapy, social skills
training, and supportive family therapy. Deterrent therapy is not a therapy used for clients with
schizophrenia. It is a medication therapy to prevent a client from using a certain substance such
as alcohol.
Nursing considerations and goals: Establish a trusting relationship with a client with
schizophrenia. Reliable, honesty, and consistency when interacting with a client with
schizophrenia are important to establishing a trusting relationship with the client. The nurse
should also convey acceptance of the client's needs and maintain a calm attitude when dealing
with agitated behavior.
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Medications:
First-generation antipsychotics (FGAs) are dopamine (D2) antagonists in both limbic and
motor centers. Blockage of D2 receptors in motor areas causes extrapyramidal side effects (EPS).
FGAs target the positive symptoms of schizophrenia.
Haloperidol (Haldol): A sudden high fever is a sign of neuroleptic syndrome, a rare but serious
complication of first-generation antipsychotics. Dry mouth, drowsiness, and hypotension are all
potential side effects of the haloperidol.
Second-generation antipsychotics (SGAs) also known as atypical antipsychotics, generally
have lower risk of extrapyramidal side effects and tardive dyskinesia compared with FGAs.
SGAs target both the negative and positive symptoms of schizophrenia. Most SGAs differ from
older medications pharmacologically in that serotonin 5HT2 receptor binding exceeds their
affinity for dopamine D2 receptors.
Clozapine: Atypical antipsychotic drug that can cause agranulocytosis; therefore, it is necessary
to monitor the WBC count. The hemoglobin is within a normal range. Clozapine may cause
elevated blood glucose; however, the level reported is within a normal range. Clozapine has no
adverse effect on the liver, and the client's bilirubin is within an acceptable range.
Risperidone (Risperdal): A. Risperdal can cause orthostatic hypotension; therefore, the client
should be instructed to change positions slowly to avoid dizziness. Risperidone should be taken
with food to avoid gastric upset. Risperidone should not be stopped abruptly; rather, it is reduced
gradually to prevent sudden recurrence of psychotic symptoms. Risperidone may cause fatigue.
Risperidone is an atypical antipsychotic that has been effective in the treatment of positive
symptoms of schizophrenia and providing maintenance therapy to prevent the exacerbation of
schizophrenic symptoms. Positive symptoms of schizophrenia include somatic delusions,
hallucinations, and disorganized speech. Social isolation and flat affect are negative symptoms of
schizophrenia.
Third-generation antipsychotics (TGAs) are basically a subset of SGAs. Aripiprazole is a
relatively new approved TGA which has high affinity and low intrinsic activity partial D2 agonist.
Although the compound has effects on several other receptors, many of the leading figures in
schizophrenia biology have labeled aripiprazole as the first “dopamine stabilizer”. Aripiprazole is
currently the only approved TGA.
Aripiprazole: Antipsychotics, such as aripiprazole place the client at risk for neuroleptic
malignant syndrome, which is a life-threatening condition. The nurse will report a temperature of
101.9 to the provider.
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Lisdexamfetamine dimesylate (Vyvanse), a central nervous stimulant used to treat attentiondeficit/hyperactivity disorder and is approved to treat binge-eating disorder in adults. This drug is
the only FDA-approved medication to treat moderate to severe binge-eating disorder. Vyvanse is
a stimulant and can be misused. Common side effects include dry mouth and insomnia, but more
serious side effects can occur. However, while FDA approved, it still may not be the first-line
therapy.
Definitions:
Tardive Dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue,
trunk, and extremities that is a side effect of typical antipsychotic medications. persistent
extrapyramidal symptoms characterized by involving involuntary rhythmic movements.
Akathisia is characterized by motor restlessness that causes pacing, repetitive movements, or an
inability to stay still or remain in one place. It can be severe and distressing to clients and can be
mistaken for anxiety or agitation.
Pseudo parkinsonism is a temporary group of symptoms that looks like Parkinson's disease:
tremor, reduced accessory movements (e.g., arms swinging when walking), gait impairment,
reduced facial expressiveness (mask faces), and slowing of motor behavior (bradykinesia).
Acute dystonia is characterized by a sudden, sustained contraction of one or several muscle
groups, usually of the head and neck.
Paranoia The most appropriate nursing intervention is to provide personal space to respect the
client’s boundaries. Providing the client personal space may serve to reduce anxiety, thus
reducing the risk of violence. Avoid whispering around these clients as they may believe the staff
is talking about them. Treatment of choice is psychotherapy.
Neuroleptic malignant syndrome (NMS) is a rare but dangerous complication of firstgeneration antipsychotics. A client with NMS experiences severe muscle rigidity, dysphasia,
flexor-extensor posturing, reduced or absent speech and movement, and decreased
responsiveness. Hyperpyrexia is the main feature with a temperature over 103°F. Autonomic
dysfunction symptoms include hypertension, tachycardia, diaphoresis, incontinence, delirium,
stupor, and coma can also occur. Pg. 217
Agranulocytosis: Marked decrease is granulated WBC making the client susceptible to
infection. Signs and symptoms are fever, flu-like symptoms, sore throat and chills.
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Psychotic Polydipsia compulsive drinking of excess fluids. It occurs in up to 20% of individuals
with schizophrenia and causes hyponatremia (also known as water intoxication). Symptoms
include confusion, delirium, hallucinations, worsening of existing psychotic symptoms, and
ultimately coma. Contributing factors include antipsychotic medication (causes dry mouth),
compulsive behavior (present in some with schizophrenia), and neuroendocrine abnormality. The
nurse should consider the possibility of hyponatremia when there is a sudden increase in
psychotic symptoms, particularly if delirium (e.g., disorientation, restlessness, fluctuating vital
signs) is also present. Pg. 194
Chapters 24 Personality Disorders
Personality Disorders:
Cluster A: Odd/Eccentric (know types in this class)
Cluster B: Intrusive/Erratic/Inconsiderate (know types in this class)
Cluster C: Anxiety/Fear (know types in this class)
Personality Disorders are often difficult and, in some cases, seem impossible to treat. There are
no psychotropic medications explicitly approved for the treatment of personality disorders.
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Cluster A: Odd/Eccentric
Schizoid Personality disorder Clients diagnosed with schizoid personality disorder appear cold,
aloof, indifferent to others, and prefer to work in isolation avoiding social situations.
Schizotypal personality disorder Individuals with schizotypal personality disorder are aloof
and isolated and behave in a bland and apathetic manner. The person experiences magical
thinking, ideas of reference, illusions, and depersonalization as part of daily life.
Paranoid personality disorder is characterized by a longstanding distrust and suspiciousness of
others based on a belief, which is unsupported by evidence, that others want to exploit, harm, or
deceive the person. Individuals with paranoid personality disorder and delusional accusations
should be dealt with in a realistic manner that does not humiliate the patient. Informing the
client, they are safe in the unit is a realistic, clear and straightforward response. Individuals with
paranoid personality disorder tend to reject treatment. Individual therapy focuses on the
development of a professional and trusting relationship. Clients with paranoia are difficult to
interview because they are reluctant to share information about themselves for fear that the
information will be used against them. Psychotherapy is the first line of treatment for paranoid
personality disorder.
Cluster B: Intrusive/Erratic/Inconsiderate
Histrionic Personality Disorder is characterized by an individual tending to be selfdramatizing, attention-seeking, over gregarious, and seductive.
Borderline Personality Disorder One of the primary features of borderline personality disorder
is emotional lability, that is, rapidly moving from one emotional extreme to another. Typically,
these emotional shifts include responding to situations with emotions out of proportion to the
circumstances, pathological fear of separation, and intense sensitivity to perceived personal
rejection. Another disruptive trait common in people with a borderline personality disorder is
impulsivity. Impulsivity is manifested in acting quickly in response to emotions without
considering the consequences. This impulsivity results in damaged relationships and even suicide
attempts. Self-destructive behaviors are prominent in this disorder. Ineffective and often harmful
self-soothing habits such as cutting, promiscuous sexual behavior, and psychological numbing
with substances are common and may result in unintentional death. Chronic suicidal ideation is
also a common feature of this disorder and influences the likelihood of accidental deaths. A
client with a diagnosis of borderline personality disorder may be involved with staff splitting
behaviors, for example spreading rumors about a particular nurse. Nurses should provide clear
and consistent boundaries and limits to this staff splitting behavior.
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Antisocial personality disorder the goal of treatment for clients diagnosed with an antisocial
personality disorder is to reduce their inflexible personality traits that interfere with functioning
and relationships. Antisocial personality disorder is characterized by a pattern of disregard for
and violation of others' rights. People with this disorder may be more commonly referred to as
sociopaths. This diagnosis is reserved for adults, but symptoms are evident by the mid-teens.
Symptoms tend to peak during the late teenage years and into the mid-20s. By around 40 years of
age, the symptoms may abate and improve even without treatment. The main pathological traits
characteristic of antisocial personality disorder is antagonistic behaviors such as being deceitful
and manipulative for personal gain or hostile if needs are blocked. The disorder is also
characterized by disinhibited behaviors such as high risk-taking, disregard for responsibility, and
impulsivity. Criminal misconduct and substance misuse are common in this population. People
with this disorder are mostly concerned with gaining personal power or pleasure, and in
relationships, they focus on their own gratification to an extreme. They have little to no capacity
for intimacy and will exploit others if it benefits them in relationships. One of the most
disturbing qualities associated with an antisocial personality disorder is a profound lack of
empathy, also known as callousness.
Narcissistic personality disorder is characterized by feelings of entitlement, an exaggerated
belief in one’s own importance, and a lack of empathy. In reality, people with this disorder suffer
from weak self-esteem and hypersensitivity to criticism. People with narcissistic personality
disorder come across as arrogant and as having an inflated view of their self-importance. The
individual with this disorder has a need for constant admiration and a lack of empathy for others,
which strains most relationships over time. They are very sensitive to rejection and criticism and
can be disparaging to others. A sense of personal entitlement, paired with a lack of social
empathy, may result in the exploitation of other people
Cluster C: Anxiety/Fear
Avoidant personality disorder Clients with an avoidant personality disorder are extremely
sensitive to rejection, feel inadequate, and are socially inhibited. They avoid interpersonal
contact due to fears of rejection or criticism. Nurses should use a friendly, accepting, and
reassuring approach. Being pushed into social situations can cause severe anxiety for these
patients. Convey an attitude of acceptance toward patient fears. Provide the patient exercises to
enhance new social skills but use caution because any failure can increase feelings of poor selfworth. Assertiveness training can assist the person in learning to express needs.
Dependent personality disorder is characterized by a pattern of submissive and clinging
behavior related to an overwhelming need to be cared for. This need results in intense fears of
separation. People with dependent personality disorder have a high need to be taken care of. This
need can lead to patterns of submissiveness with fears of separation and abandonment by others.
Because they lack confidence in their own ability or judgment, they may manipulate others to
assume responsibility for such activities as finances or child rearing.
2023 Q2 NUR208 EXAM 2 STUDY GUIDE
Obsessive-compulsive Personality Disorder. Individuals with Obsessive-compulsive
Personality Disorder are very serious, formal, and have difficulty expressing emotions. They are
perfectionistic and preoccupied with rules and need to do a task over and over again. They have
limited emotional expression and exhibit stubbornness, perseverance, and indecisiveness.
Preoccupation with orderliness, perfectionism, and control are the hallmarks of this disorder.