Mental Health Archer Review Crash Course Welcome! ● ● ● Please stay muted so that there is no background noise. If you have a question please enter it in the chat and I will respond as quickly as possible! We will be taking a 10 minute break halfway through the course Introduction ● ● ● Morgan Taylor, BSN, RN, CCRN Pediatric nurse at heart Units I’ve worked on: ○ ○ ○ ○ ○ ○ ● ● PICU PCICU NICU Mother-Baby ED Bone Marrow Transplant Current position: Children’s Resource Unit… a little bit of everything pediatrics! Fun fact: I got married in my backyard this year because….COVID. My niece and nephew totally stole the show! Anxiety Bipolar Disorder Mental Health High Yield NCLEX topics Depression Schizophrenia Eating disorders Alcohol Withdrawal Suicidal ideations Anxiety What is anxiety? ● ● ● ● The body’s natural response to stress A feeling of fear, worry, and nervousness about what’s to come. Can be normal!! Concerning if it is chronic and in response to normal life activities. Therapeutic Management ● ● ● ● ● Determine what triggers the anxiety Reorient the patient Rationalize their thoughts - be logical. Help restructure their thoughts Address any physical symptoms Levels of anxiety ● Mild ○ ○ ● Moderate ○ ○ ○ ○ ● Normal & healthy. No intervention needed. Still able to function Ensure safe environment Establish trust/rapport Encourage expression of thoughts and help problem solve Severe ○ ○ ● Panic ○ ○ ○ ○ ○ ○ Patient education ● Know what triggers the anxiety! ○ ○ ● Needs help to function Anti-anxiety PRN medication Avoid triggers Have a plan for what to do when triggers occur Have a designated person to call for help Unable to function Decream stimuli Calm environment Monitor for self-harm Daily anti-anxiety medication Anti-anxiety PRN medication Medications - Antianxiety Agents ● Short acting ○ ○ ● Midazolam (Versed) Diazepam (Valium) Intermediate - Long acting ○ ○ ○ Action: general CNS depression Nursing Considerations: ● ● ● Avoid alcohol Monitor for respiratory depression Antidote - flumazenil Clonazepam (Klonopin) Alprazolam (Xanax) Lorazepam (Ativan) NCLEX Question A widower has been complaining that he could not sleep, he is short of breath, extremely anxious, and has been having a sense of impending doom. Which response by the nurse is most appropriate? A. B. C. D. “Just relax. You’re in a safe place now. You have nothing to worry about.” “Has anything happened recently, or is there anything in the past that could have triggered these feelings?” “The medication I have given you will help decrease these feelings of anxiety.” “Why don’t you take some deep breaths to help you calm down?” Answer: B Rationale: Option B reassures the client and provides an opportunity to gain insight into the root of the client’s anxiety. Telling the client she has nothing to worry about dismisses the client’s feelings and only gives her false reassurance. Simply giving her medications and instructing her to calm down doesn’t allow the client to verbalize her feelings, which is necessary for her to understand and resolve the cause of anxiety. Options A, C, and D are therefore incorrect. Depression What is Depression? ● ● ● ● “The feeling of severe despondency and dejection” A state of low mood Aversion to activity Affects their thoughts, behaviors, and feelings. Columbia-Suicide Severity Rating Scale Therapeutic management ● Safe environment - assess risk for self harm ○ ○ ● Therapy ○ ○ ● ● ● ● One to one observation Remove potentially harmful items Express feelings Validate their frustration and sadness Get moving! ADLs Nutrition/hydration Good sleep hygiene Antidepressants ● ● MAOIs ○ Tranylcypromine ○ Isocarboxazid ○ Phenelzine ○ selegiline SSRIs ○ ○ ○ ○ ● Fluoxetine Sertraline Escitalopram Citalopram TCAs ○ Amitriptyline ○ Nortriptyline ○ Protriptyline Monoamine Oxidase Inhibitors Examples: tranylcypromine, isocarboxazid, phenelzine, selegiline Indication: Depression Action: blocks monoamine oxidase enzymes to increase the levels of ALL neurotransmitters ( dopamine, norepinephrine, epinephrine, serotonin) Nursing Considerations: ● Avoid foods that are high in tyramine. ○ ○ ○ ● Aged cheeses Wine Pickled meats Side effect - hypertensive crisis SSRIs Examples: Fluoxetine, Sertraline, Escitalopram, Citalopram Indication: Depression Action: Prevent reuptake of serotonin increasing the availability of serotonin in the body. Nursing Considerations: ● Monitor for serotonin syndrome ○ ● Hypertension, confusion, anxiety, tremors, ataxia, sweating. Suicide precautions important for 2-3 weeks ○ ○ When the patient’s mood starts to improve, they are are an inreased risk for suicide Why? They now have the energy to follow through with a plan. TCA’s Examples: Amitriptyline, Nortriptyline, Protriptyline Indication: Depression Action: Prevents the reuptake of norepinephrine and serotonin increasing these neurotransmitters in the body.. Nursing Considerations: ● Monitor for anticholinergic side effects ○ Dry mouth, constipation, urinary retention NCLEX Question You are putting together a community health presentation about the signs and symptoms of depression to promote awareness of the disease and educate the public. Which of the following signs and symptoms would be essential to include? Select all that apply. A. B. C. D. Anhedonia Flight of ideas Looseness of associations Sleep disturbances Answer: A and D A is correct. Anhedonia is a common symptom of depression. It is defined as the loss of pleasure in usually pleasurable things. For example, a mother who usually loves going to see her children in their dance recitals says she no longer wants to go. The things that once brought someone joy do not do that anymore due to depression. This can be difficult for families to understand and can cause a lot of frustration. You should educate your community that this is not the patient’s fault, but a part of the disease process of depression. B is incorrect. Flight of ideas is not a typical symptom of depression, but rather mania. Flight of ideas is defined as a rapid shifting of ideas with only superficial associative connections between them that is expressed as a disconnected rambling from subject to subject.” It is tough to have a coherent conversation with someone who is experiencing a flight of ideas because they jump from topic to topic so quickly. It is common that this symptom of mania presents in the manic phases of bipolar disorder, but not in depression alone. C is incorrect. Looseness of associations is a common symptom of schizophrenia, but not of depression. Looseness of associations is defined as speech that is disconnected and fragmented, with the individual jumping from one idea to another unrelated or indirectly related idea.” People who have schizophrenia often have disorganized thoughts and are unable to communicate those thoughts to others in a coherent manner. This is not usually the case with a patient experiencing depression. D is correct. Sleep disturbances are an incredibly common symptom in depression and should undoubtedly be a point of education. In patients suffering from depression, their sleep disturbances usually occur when they wake up in the middle of the night and are unable to go back to sleep. In patients suffering from anxiety, there are also significant sleep disturbances, but the trouble is usually falling asleep rather than staying asleep. Bipolar Disorder What is Bipolar Disorder? ● ● A mood disorder where there is difficulty regulating extreme emotions. There a periods of mania, periods of depression, and the inability to self-regulate these emotions. ○ ○ Mania: “A mood disorder marked by hyperactive wildly optimistic state” Depression: “The feeling of severe despondency and dejection” Therapeutic Management ● ● ● ● ● ● ● Manage acute episodes Identify triggers to prevent future episodes of mania Safe environment Calm, controlled, focused interactions Don’t argue while in a manic state Provide high-calorie, finger food they can eat on the go Protect their privacy ○ ● ● Appropriate clothing Set boundaries Ensure medication compliance ○ ○ ○ During Mania: anti-anxiety Antipsychotics - haloperidol, zyprexa, abilify, risperdal Mood stabilizers - lithium Lithium Indication: Mania Action: Inhibits excitatory neurotransmitters such as dopamine and glutamate, and promotes GABA-mediated neurotransmission. Nursing Considerations: ● ● Do not administer with NSAIDS Monitor drug levels: ○ ● ● Therapeutic level - 0.5-1.5mEq/L Encourage adequate fluid intake Side effects: ○ Seizures, arrhythmias, fatigue, confusion, nausea, anorexia, hypothyroidism, tremors Haloperidol Therapeutic class: Antipsychotic Indication: Schizophrenia, mania, aggressive behavior, agitation Action: Inhibits the effects of dopamine Nursing Considerations: ● ● ● ● Monitor for extrapyramidal side effects Tardive dyskinesia Neuroleptic malignant syndrome Can prolong the QT interval ○ Weekly EKG NCLEX Question The psychiatric nurse is providing care for a patient who has just calmed down after exhibiting inappropriate behaviors related to Bipolar disorder. The nurse knows that which of the following is the best way to help prevent another unseemly episode? A. B. C. D. Identify the consequences of the behavior Assist the client in understanding triggering events or feelings that may have lead to the outburst. Ensure that the patient’s safety is upheld Offer the patient clear options to deal with their current behavior Answer: B The correct answer is B. The psychiatric nurse would be most effective in preventing further inappropriate episodes by assisting the client in understanding what may have triggered the event. Choice A is incorrect. Identifying the consequences of inappropriate behavior would be a more appropriate intervention before the patient’s response began escalating. Since this patient is calm, identifying values is not the most effective option to prevent recurring episodes. Choice C is incorrect. Ensuring the patient’s safety is intact is always a priority but is a more appropriate action during the patient’s episode of inappropriate behavior rather than while the patient is calm. Choice D is incorrect. A patient experiencing an episode of inappropriate behavior related to bipolar disorder is unlikely to absorb patient teaching. Teaching is best understood when the patient is calm and states readiness to learn. Break! Back at... Schizophrenia What is Schizophrenia? ● ● A long-term mental disorder involving a breakdown in the relation between thought, emotion, and behavior. There is faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation Assessment Findings ● Delusions ○ ● “False belief firmly held to be true despite rational argument” ■ Persecution ■ Jealousy ■ Grandeur Hallucinations ○ “a sensory experience of something that does not exist outside the mind” ■ Auditory ■ Olfactory ■ Tactile ■ Visual ■ Gustatory Therapeutic Management ● Delusions ○ ○ ○ ○ ○ ○ ○ ○ ● Provide a safe environment Ask about the delusion to understand what they are experiencing Validate real aspects of the delusion Do not argue about the delusion Reflect on how it makes them feel Focus on FEELINGS, not the actual delusion Be honest Set limits Hallucinations ○ Provide a safe environment ○ ○ ○ ○ ○ ○ ○ Stay focused on reality Be direct Set limits Decreation stimulation Don’t touch them when experiencing a hallucination Auditory hallucinations Are they telling them to do something? Therapeutic Management Cont. ● Safety, safety, safety!!! ○ ● ● ● ● ● Address their physical needs Don’t make promises you can’t keep Be present Silence is okay Start small and gradually progress ○ ○ ○ ● Monitor for self-harm and/or SI 1:1 activities Small groups Basic tasks → more complex Antipsychotics: haloperidol, zyprexa, risperdol Haloperidol Therapeutic class: Antipsychotic Indication: Schizophrenia, mania, aggressive behavior, agitation Action: Inhibits the effects of dopamine Nursing Considerations: ● ● ● ● Monitor for extrapyramidal side effects Tardive dyskinesia Neuroleptic malignant syndrome Can prolong the QT interval ○ Weekly EKG NCLEX Question The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric patients around him are getting angry. What is the most appropriate action of the nurse? a. b. c. d. Restrain the client Escort the other clients from the day room Give Haloperidol IM Approach the client calmly accompanied by two other staff Answer: D A is incorrect. Restraining the client should be the last approach for the nurse. The first intervention should be to talk to the client to remove him from the day room. B is incorrect. The nurse should not try to remove the other clients from the room. The nurse should first remove the client from the place. C is incorrect. An IM injection of Haldol will take 30 minutes to become active. The nurse needs to remove the client from the day before the situation escalates. D is correct. The first intervention is to approach the client calmly and attempt to remove him from the day room. Staff members should not contact the agitated client alone but should be accompanied by other personnel. Anorexia Nervosa What is anorexia nervosa? “An emotional disorder characterized by an obsessive desire to lose weight by refusing to eat.” ● ● ● ● ● Preoccupation with food Distorted body image Low self-esteem Afraid of becoming overweight Typical patient is a perfectionist/overachiever Assessment Findings ● ● ● ● ● ● ● ● ● ● ● Low body temperature Bradycardia Hypotension Cyanosis Electrolyte abnormalities Hormonal imbalances Sleep disturbances Bone degeneration→ Osteoporosis Amenorrhea Lanugo GI upset Therapeutic Management ● Address physiological issues first ○ ● Ensure safety ○ ○ ● ● ● ● Maslow’s hierarchy of needs SI Self harm Establish rapport Validate their feelings No judgement Explore triggers ○ ○ Help make a plan to avoid What to do when triggered NCLEX Question Which of the following statements indicates body image distortion in a patient with anorexia nervosa? A. B. C. D. I wish I looked like my mom I hate how my body looks I wish I could wear tank tops I’m so overweight Answer: D Patients with anorexia perceive themselves to look differently than they do. Many see someone in the mirror, which weighs more than their desired weight. Despite being too thin, this client will not eat in hopes of getting the perfect body. The correct answer is D. A, B, and C are incorrect. Although these are signs of low self-esteem, these statements do not reflect body image distortion. Bulimia Nervosa Assessment Findings ● ● ● ● ● Labile mood Low libido Esophageal varices Tooth enamel break down Helplessness Therapeutic Management ● Address medical issues ○ ● ● ● ● Electrolyte imbalances Provide a safe environment Monitor for self-harm and suicidal ideations Validate their feelings Help identify triggers and avoid NCLEX Question A nurse is assigned to care for a client with bulimia nervosa. Which intervention should the nurse apply following the patient’s meals? a. Instruct the client to get some exercise or go for a walk after meals b. Restrict client from going to the bathroom for 90 minutes c. Ask the client to lie down for 2 hours after eating d. Encourage patient to start an intense exercise program Answer: B The nurse should observe the client while eating and prevent the client from using the bathroom for 90 minutes after meals to break the purging cycle. Exercise is not encouraged until the client has shown adequate weight gain. Until then, training should be done in moderation. There is no need for the patient to lie down after meals. The correct answer is option B, while options A, C, and D are incorrect. Therapeutic Communication Open-ended questions ● Provides the patient with an opportunity to express their thoughts ● Encourages communication ● Focuses on patient centered responses ● Allows the patient to be in charge of the direction of the conversation. Never dismiss a patient’s feelings ● ● Important to make sure the patient knows they are heard. Their feelings should be validated. ● ● ● ● “You have nothing to worry about” “It will all be okay” “Others have it worse off than you do” “I’ll just give you some medication so you can relax” Never give false reassurance ● ● These are promises you can’t always keep Don’t give you any chance to explore the patient’s feelings. ● ● ● “Nothing bad can happen to you here” “It will all be alright” “You don’t need to worry you’re safe here” Therapeutic Silence ● ● ● Effective for patients in the acute phase of severe depression Makes no demands of them Simply be with them Connection ● ● Build rapport with the patient Try to remove any biases you have Active listening ● ● ● ● Really listen to what the patient is telling you Rephrase what they have said to you so they know you are listening Clarify what was meant so they have the chance to correct you if you misunderstood them Show empathy Never ask WHY ● ● ● ● Why statements are not therapeutic. This points the finger at the client and makes them feel as if it is their fault they are having these feelings. Asking why someone feels the way they do invalidates them It will not promote the open and honest communication that is necessary for a therapeutic environment. NCLEX Question A client is scheduled for hip replacement surgery. She expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most therapeutic? A. B. C. D. “Everyone is nervous before any surgery. What you feel is completely normal.” “Here’s what’s going to happen to you during the procedure. I will explain to you in detail.” “Can you tell me what you have been told about the surgery?” “Let me tell you about the care you will receive and the pain you should anticipate after the surgery.” Answer: C Rationale: Open-ended questions that facilitate further discussion is most therapeutic in this situation. Option C provides the patient with an opportunity to express her thoughts further and would give the nurse a baseline of the patient’s knowledge and readiness for the surgery; thus, the correct answer. This way, the nurse can come up with appropriate explanations around what the client already knows and by filling in facts. Options A, B, and D will only increase the patient’s level of anxiety and are, therefore, incorrect. NCLEX Question A woman comes into the emergency room complaining of insomnia, anxiety, the difficulty of breathing, and a sense of impending doom. After being assessed by the physician, no physiological abnormalities were found. However, the client is still anxious and apprehensive. What is the most appropriate statement by the nurse to the patient? A. B. C. D. “Don’t worry, you’re safe here. Just try to relax.” “Can you think of anything that happened recently or in the past that might have triggered these feelings?” “We gave you something that should calm you down.” “Take slow, deep breaths and try to relax. Nothing bad will happen to you here.” Answer: B A is incorrect. This statement disregards the client’s feelings and offers false reassurance. This is an inappropriate response by the nurse. B is correct. This question offers reassurance and provides an opportunity for the nurse to gain insight into the client’s anxiety. This is an appropriate statement by the nurse. C is incorrect. Telling the client that you gave him some medication disregards his feelings and does not allow him to discuss those feelings. This statement also offers some form of false reassurance to the client. D is incorrect. This statement disregards the client’s feelings and offers false reassurance. This is an inappropriate response by the nurse. NCLEX Question Which of the following statements would be effective therapeutic communication with a client who is struggling with severe depression? Select all that apply. A. B. C. D. “Great work today in group therapy Steve. you were really talkative today!” “I’d like to just sit with you for a while Steve.” “Tell me how you’re feeling Steve. I’d like to understand.” “Why are you feeling depressed today Steve?” Answer: B and C A is incorrect. Although this sounds like an encouraging thing to say, compliments are not always therapeutic in patients suffering from depression. They have very little to no self-esteem, and often take compliments the wrong way. Even though you meant to encourage Steve by telling him he was talkative, he will likely make this as saying he was talking too much and should be quieter next time. B is correct. The therapeutic communication technique of silence is very active with patients in the severe phase of depression. These patients have very little, if any, energy. Making absolutely no demands or requests of them, but being present and supportive, is often the best way to begin a therapeutic relationship. C is correct. This is an appropriate therapeutic statement for a client experiencing depression. They often feel helpless, and as if no one understands the pain that they are going through. Asking them open-ended questions and letting them know you want to understand what is going on will encourage them to express their feelings and begin to work towards recovery. D is incorrect. Why statements are not therapeutic. This points the finger at the client and makes them feel as if it is their fault they are having these feelings. Asking why someone feels the way they do invalidates them, and will not promote the open and honest communication that is necessary for a therapeutic environment. Wrap up questions NCLEX Question You are caring for a Jehovah's Witness patient who is experiencing high anxiety because he needs a blood transfusion to survive, but his religion forbids him from having it. Which of the following would be the most appropriate nursing diagnosis for this client? A. B. C. D. Spiritual Distress related to anxiety over whether to accept a blood transfusion Mental Pain associated with imminent and inevitable death Anxiety-related to deciding whether to take a blood transfusion and violate one's religious beliefs or to die Social Isolation related to being of another religion than the hospital staff Answer: C The correct answer is C. The client’s spirituality or religious beliefs are part of the etiology of the problem, which is anxiety, and not the problem itself. A, B, and D are incorrect. The client's problem is anxiety related to a decision, not spiritual distress, spiritual pain, or social isolation. NCLEX Question Which of the following is an appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide? A. B. C. D. Privacy and a client room without stimulation or the presence of others. An empathetic and non-judgment exploration of the client’s feelings. Probing the client for details of their suicide plan. The use of restraints and seclusion. Answer: B Correct Answer is B. An empathetic and nonjudgment exploration of the client’s feelings and facilitating the client’s open verbalization of their beliefs is the only appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide, as based on the client information provided in this question. Choice A is incorrect. Privacy and a client room without stimulation or the presence of others are contraindicated with severe depression and thoughts of suicide because one to one monitoring is necessary. Choice C is incorrect. Probing the client for details of their suicide plan is not an appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide because probing is not therapeutic, and it is invasive. Choice D is incorrect. The use of restraints and seclusion is not an appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide because control and privacy are not indicated until all other preventive alternative interventions have failed. The client is in immediate danger, which is not found in this question. Upcoming Archer Review Courses: Thank you for joining our Crash Course! ● Fundamentals ○ Jan 15th 2-5 CST ● FULL RAPID PREP REVIEW ○ JAN. 21st & 22nd ○ 8am-6pm CST
