NR 326 Mental Health - exam 2
suicide risk factors - answer single (2x), divorced, gender (women attempt more, men
succeed more often), having someone close to person who committed suicide, increase
with age, religion, socioeconomic status, mental illness, stressful life events, alcohol/
drug use, family hx of suicide, bullying
priority intervention for pt. w/ suicidal ideation - answer-Placing the client on suicide
precautions with one-to-one observation provides a safe environment for an actively
suicidal client. •Maintaining client safety should always be a priority nursing intervention.
positive symptoms of schizophrenia - answer(presence of things not normally present)
hallucinations, delusions (false, fixed beliefs), strange motor movements, speech
alterations, agitation.
negative symptoms of schizophrenia - answer(absence of things that are normally
present) 5 A's: Affect (flat affect) Alogia (decrease thought/speech), Anergia (lack of
energy), Anhedonia (lack of pleasure), Avolition (lack of motivation for activities)
Lithium toxicity - answertoxic >1.5: coarse tremors, confusion, hypotension, seizures,
tinnitus, coma/death
patient teaching for lithium - answer-if going outside for activity, need to rehydrate
-Take the medication regularly.•Do not drive or operate dangerous machinery.•Do not
skimp on dietary sodium and maintain appropriate diet.•Know pregnancy risks.•Carry
identification noting taking lithium.•Be aware of side effects and symptoms of
toxicity.•Notify physician if vomiting or diarrhea occur.•Have serum lithium level checked
every 1 to 2 months.
nursing intervention for pt. in manic episode of bipolar disorder - answer· Provide safe
environment. Protect pt from poor judgement (giving away money, sexual indiscretions)
· Decrease stimulation
· 1:1 observation, seclusion, or restraints may be necessary if pt is risk for self or others
· Provide frequent rest periods
· Monitor sleep, fluid and food intake.
· Provide high-calorie portable snacks (finger food)
· Set limits, give concise explanations, use calm approach
· Medications: lithium, anticonvulsants, antipsychotic meds, anti-anxiety meds,
antidepressants.
bipolar mania - answerexcessively elevated mood, lasting more than a week.
MAOI's (what not to eat) - answerNo tyramine foods
, core of OCD - answeranxiety
s/s of PTSD - answerFlashbacks, distressing dreams, difficulty concentrating, insomnia,
anxiety, irritability, detachment from others, hypervigilance, exaggerated startle
response, feeling of guilt and negative self image.
pt. attempts suicide (even if only once) - answerpt. put at high suicide risk immediately
initiated
extrapyramidal EPS - answer· dystonia, Parkinson's symptoms, tardive dyskinesia (lip
smacking, tongue rolling) akathisia (muscle quivering, restlessness)
Neuroleptic malignant syndrome - answerAdverse reaction to antipsychotics
Neuroleptic malignant syndrome (s/s) - answerfever, dysrhythmias, BP fluctuations,
muscle rigidity
word salad - answerwords are jumbled together in meaningless way
Neologisms - answermade-up words that only the pt understands
Flights of ideas - answereach sentence relates to a different topic. Listener unable to
follow pt thoughts
Echolalia - answerpt repeats exactly what is said to him
Clang association - answermeaningless rhyming of words
interventions for pt w/ depression - answergive pt. time to gather thoughts and decide
what they want to say
nursing assessment of suicidal pt. - answer-Ask questions ( how serious is the intent?
Do you have a plan?)
-Verbal cues: I want to die!, This is the last time you will see me, I wont be around much
longer for the doctor to have to worry about, or I don't have anything worth living for
anymore.
-Coping strategies: how did you handle previous crisis? How is this different from other
crisis?
interventions for pt. not wanting to take meds - answerdecanoate (long term injection of
haldol)
priority for pt. w/ manic behavior - answersafety
what to do for depressed pt. exhibiting uplifted mood - answerprioritize safety
suicide risk factors - answer single (2x), divorced, gender (women attempt more, men
succeed more often), having someone close to person who committed suicide, increase
with age, religion, socioeconomic status, mental illness, stressful life events, alcohol/
drug use, family hx of suicide, bullying
priority intervention for pt. w/ suicidal ideation - answer-Placing the client on suicide
precautions with one-to-one observation provides a safe environment for an actively
suicidal client. •Maintaining client safety should always be a priority nursing intervention.
positive symptoms of schizophrenia - answer(presence of things not normally present)
hallucinations, delusions (false, fixed beliefs), strange motor movements, speech
alterations, agitation.
negative symptoms of schizophrenia - answer(absence of things that are normally
present) 5 A's: Affect (flat affect) Alogia (decrease thought/speech), Anergia (lack of
energy), Anhedonia (lack of pleasure), Avolition (lack of motivation for activities)
Lithium toxicity - answertoxic >1.5: coarse tremors, confusion, hypotension, seizures,
tinnitus, coma/death
patient teaching for lithium - answer-if going outside for activity, need to rehydrate
-Take the medication regularly.•Do not drive or operate dangerous machinery.•Do not
skimp on dietary sodium and maintain appropriate diet.•Know pregnancy risks.•Carry
identification noting taking lithium.•Be aware of side effects and symptoms of
toxicity.•Notify physician if vomiting or diarrhea occur.•Have serum lithium level checked
every 1 to 2 months.
nursing intervention for pt. in manic episode of bipolar disorder - answer· Provide safe
environment. Protect pt from poor judgement (giving away money, sexual indiscretions)
· Decrease stimulation
· 1:1 observation, seclusion, or restraints may be necessary if pt is risk for self or others
· Provide frequent rest periods
· Monitor sleep, fluid and food intake.
· Provide high-calorie portable snacks (finger food)
· Set limits, give concise explanations, use calm approach
· Medications: lithium, anticonvulsants, antipsychotic meds, anti-anxiety meds,
antidepressants.
bipolar mania - answerexcessively elevated mood, lasting more than a week.
MAOI's (what not to eat) - answerNo tyramine foods
, core of OCD - answeranxiety
s/s of PTSD - answerFlashbacks, distressing dreams, difficulty concentrating, insomnia,
anxiety, irritability, detachment from others, hypervigilance, exaggerated startle
response, feeling of guilt and negative self image.
pt. attempts suicide (even if only once) - answerpt. put at high suicide risk immediately
initiated
extrapyramidal EPS - answer· dystonia, Parkinson's symptoms, tardive dyskinesia (lip
smacking, tongue rolling) akathisia (muscle quivering, restlessness)
Neuroleptic malignant syndrome - answerAdverse reaction to antipsychotics
Neuroleptic malignant syndrome (s/s) - answerfever, dysrhythmias, BP fluctuations,
muscle rigidity
word salad - answerwords are jumbled together in meaningless way
Neologisms - answermade-up words that only the pt understands
Flights of ideas - answereach sentence relates to a different topic. Listener unable to
follow pt thoughts
Echolalia - answerpt repeats exactly what is said to him
Clang association - answermeaningless rhyming of words
interventions for pt w/ depression - answergive pt. time to gather thoughts and decide
what they want to say
nursing assessment of suicidal pt. - answer-Ask questions ( how serious is the intent?
Do you have a plan?)
-Verbal cues: I want to die!, This is the last time you will see me, I wont be around much
longer for the doctor to have to worry about, or I don't have anything worth living for
anymore.
-Coping strategies: how did you handle previous crisis? How is this different from other
crisis?
interventions for pt. not wanting to take meds - answerdecanoate (long term injection of
haldol)
priority for pt. w/ manic behavior - answersafety
what to do for depressed pt. exhibiting uplifted mood - answerprioritize safety
