Mental Health Final Exam Study Guide PDF

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1 Mental Health Final Exam

Diagnostic Classes of Substance Abuse     

Intoxication: use of a substance that results in maladaptive behavior Withdrawal syndrome: refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases Detoxification: the process of safely withdrawing from a substance Substance abuse: drug is used outside the medical or social norm despite negative consequences Substance dependence: problem associated with addiction

Alcoholism 

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First episode of intoxication → continuing problems with alcohol → first blackout → continued drinking → development of tolerance → tolerance break → continued drinking → functioning becoming affected → periods of abstinence/temporary controlled drinking → escalation of alcohol intake → more problems → subsequent crisis → continuation of cycle Related disorders: gambling, caffeine and tobacco additions CNS depressant: relaxation/loss of inhibitions 1. Slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judgment 2. Aggressive behavior or display inappropriate sexual behavior; the person who is intoxicated may experience a blackout Treatment of an alcohol overdose: gastric lavage or dialysis to remove the drug and support of respiratory and cardiovascular functioning in an intensive care unit Symptoms of withdrawal 1. Onset within 4 to 12 hours after cessation or marked reduction of alcohol intake; peaking on second day; complete in about 5 days 2. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium (DTs) 3. Benzodiazepines for safe withdrawal

Substance Abuse Treatment      

Concept: medical illnesses, chronic, progressive, characterized by remissions and relapses Treatment models: Hazelden Clinic model and 12-step program of Alcoholics Anonymous Individual, group counseling Treatment settings Pharmacologic treatment: safe withdrawal; prevent relapse Medications help manage withdrawal or cravings, but is not a specific treatment for substance abuse

2 Alcohol Intoxication and Overdose    

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An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression This combination can cause aspiration pneumonia or pulmonary obstruction Alcohol-induced hypotension: can lead to cardiovascular shock and death Treatment: similar to that for any central nervous system depressant—gastric lavage or dialysis to remove the drug, and support of respiratory and cardiovascular functioning in an intensive care unit The administration of central nervous system stimulants is contraindicated

Physiological Effects of Alcoholism/Long Term (Box 19.1)          

Cardiac myopathy Wernicke encephalopathy: an acute neurological condition characterized by a clinical triad of ophthalmoparesis with nystagmus, ataxia, and confusion Korsakoff psychosis: a late complication of persistent Wernicke encephalopathy and results in memory deficits, confusion, and behavioral changes Pancreatitis Esophagitis Hepatitis Cirrhosis Leukopenia Thrombocytopenia Ascites

Alcohol Withdrawal and Detoxification     

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Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms: coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremens Alcohol withdrawal usually peaks on the second day and is over in about 5 days; withdrawal may take 1 to 2 weeks Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms Total scores less than 8 indicate mild withdrawal, scores from 8 to 15 indicate moderate withdrawal (marked arousal), and scores greater than 15 indicate severe withdrawal (Clinical Institute Withdrawal Assessment of Alcohol Scale)

Disulfiram (Antabuse)

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Use: aversion therapy for alcoholism Never give to a patient that is intoxicated or without their consent Mechanism of action: inhibition of enzyme involved with alcohol metabolism Adverse reaction with alcohol ingestion Side effects: fatigue, drowsiness, halitosis, tremor, impotence Drug interactions: with phenytoin, isoniazid, warfarin, barbiturates, long-acting benzodiazepines Client teaching: avoidance of alcohol, including common products that may contain it (will cause same symptoms if the client has taken it with alcohol) 1) Shaving cream, deodorant, OTC cough preparations, vanilla extract

Elder Considerations  

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Approximately 30% to 60% of elders in treatment began drinking abusively after age 60 Risk factors for late-onset substance include chronic illness that causes pain, long-term use of prescription medication (sedative-hypnotics, anxiolytics), life stress, loss, social isolation, grief, depression, and an abundance of discretionary time and money Physical problems associated with substance abuse develop more quickly in elders

Types of Therapy Groups 

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Psychotherapy Group: the goal of a psychotherapy group is for members to learn about their behavior and to make positive changes in their behavior by interacting and communicating with others as a member of a group 1) Open groups are ongoing and run indefinitely, allowing members to join or leave the group as they need to 2) Closed groups are structured to keep the same members in the group for a specified number of sessions Family Therapy: the goals include understanding how family dynamics contribute to the client’s psychopathology, mobilizing the family’s inherent strengths and functional resources, restructuring maladaptive family behavioral styles, and strengthening family problem-solving behavior Family Education: the curriculum focuses on schizophrenia, bipolar disorder, clinical depression, panic disorder, and obsessive–compulsive disorder Education Groups: the goal is to provide information to members on a specific issue—for instance, stress management, medication management, or assertiveness training Support Groups: are organized to help members who share a common problem cope with it Self-Help Groups: members share a common experience, but the group is not a formal or structured therapy group (no identifiable leader)

Therapeutic Techniques (Table 6.1)

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Accepting—indicating reception Broad openings—allowing the client to take the initiative in introducing the topic Consensual validation—searching for mutual understanding, for accord in the meaning of the words Encouraging comparison—asking that similarities and differences be noted Reflecting—directing client actions, thoughts, and feelings back to client Restating—repeating the main idea expressed Exploring—delving further into a subject or an idea Silence—absence of verbal communication, which provides time for the client to put thoughts or feelings into words, to regain composure, or to continue talking Voicing doubt—expressing uncertainty about the reality of the client’s perceptions

Nontherapeutic Techniques (Table 6.2)       

Advising—telling the client what to do Challenging—demanding proof from the client Agreeing—indicating accord with the client Introducing an unrelated topic—changing the subject Disagreeing—opposing the client’s ideas Giving approval—sanctioning the client’s behavior or ideas Reassuring—indicating there is no reason for anxiety or other feelings of discomfort

Avoiding Nontherapeutic Communication     

These responses cut off communication and make it more difficult for the interaction to continue Responses such as “everything will work out” or “maybe tomorrow will be a better day” may be intended to comfort the client, but instead may impede the communication process Asking “why” questions (in an effort to gain information) may be perceived as criticism by the client, conveying a negative judgment from the nurse Overt cues are clear, direct statements of intent, such as “I want to die.” The message is clear that the client is thinking of suicide or self-harm Covert cues are vague or indirect messages that need interpretation and exploration—for example, if a client says, “Nothing can help me.”

Components of Therapeutic Relationship 

Trust

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1) Will build when the client is confident in the nurse and when the nurse establishes integrity and reliability 2) Behaviors such as caring, interest, understanding, consistency, honesty, promise keeping, listening 3) Congruence: occurs when words and actions match Genuine Interest 1) When the nurse is comfortable with him or herself, aware of his or her strengths and limitations, and clearly focused, the client perceives a genuine person showing genuine interest 2) Self-comfort, self-awareness of strengths and limitations, clear focus Empathy 1) Empathy is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client 2) Client and nurse giving “gift of self” (client feeling safe enough to share feeling and the nurse listening to understand) 3) Different from sympathy (feelings of concern or compassion; focus shifting to nurse’s feelings 4) Acceptance (no judgments; set boundaries) 5) Positive regard (unconditional nonjudgmental attitude)

Nonverbal Communication Skills (more accurate, 2/3 of communication)

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Facial movements connect with words to illustrate meaning; this connection demonstrates the speaker’s internal dialogue 1) An expressive face portrays the person’s moment-by-moment thoughts, feelings, and needs. These expressions may be evident even when the person does not want to reveal his or her emotions 2) An impassive face is frozen into an emotionless deadpan expression similar to a mask 3) A confusing facial expression is one that is the opposite of what the person wants to convey. A person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing facial expression Body language (e.g., gestures, postures, movements, and body positions) is a nonverbal form of communication Closed body positions, such as crossed legs or arms folded across the chest, indicate that the interaction might threaten the listener who is defensive or not accepting A better, more accepting body position is to sit facing the client with both feet on the floor, knees parallel, hands at the side of the body, and legs uncrossed or crossed only at the ankle This open posture demonstrates unconditional positive regard, trust, care, and acceptance Vocal cues are nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the sender’s message The use of extraneous words with long, tedious descriptions is called circumstantiality; it can indicate the client is confused about what is important or is a poor historian Eye contact, looking into the other person’s eyes during communication, is used to assess the other person and the environment and to indicate whose turn it is to speak; it increases during listening but decreases while speaking Silence or long pauses in communication may indicate many different things. The client may be depressed and struggling to find the energy to talk. Sometimes, pauses indicate the client is thoughtfully considering the question before responding

Categories of Mood Disorders (pg. 285)

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The primary mood disorders are major depressive disorder and bipolar disorder (formerly called manic-depressive illness) A major depressive episode lasts at least 2 weeks, during which the person experiences a depressed mood or loss of pleasure in nearly all activities About 20% have delusions and hallucinations; this combination is referred to as psychotic depression Bipolar disorder is diagnosed when a person’s mood fluctuates to extremes of mania and/or depression, as described previously Mania: a distinct period during which mood is abnormally and persistently elevated, expansive, or irritable (typically last 1 week or more) 1. Mania episode = inflated self-esteem, “pleasure driven” = high rate of consequences Pressured speech: unrelenting, rapid, often loud talking without pauses Hypomania: a period of abnormally and persistently elevated, expansive, or irritable mood and some other milder symptoms of mania Difference between Mania and Hypomania 1. Hypomanic episodes do not impair the person’s ability to function (in fact, he or she may be quite productive), and there are no psychotic features (delusions and hallucinations) Rapid Cycling: a mixed episode is diagnosed when the person experiences both mania and depression nearly every day for at least 1 week Major depressive disorder: lasts at least 2 weeks Bipolar I disorder: one or more manic or mixed episodes usually accompanied by major depressive episodes Bipolar II disorder: one or more major depressive episodes accompanied by at least one hypomanic episode

Anticonvulsants Used as Mood Stabilizers (Table 17.6)

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Generic (Trade) Name

Carbamazepine (Tegretol)

Divalproex (Depakote)

Lamotrigine (Lamictal)

Side Effects

Dizziness, hypotension, ataxia, sedation, blurred vision, leukopenia, and rashes

Ataxia, drowsiness, weakness, fatigue, menstrual changes, dyspepsia, nausea, vomiting, weight gain, and hair loss

Nursing Implications Assist client in rising slowly from sitting position Report rashes to physician

Provide rest periods Administer with food Establish balanced nutrition

Assist client in rising slowly from sitting Dizziness, hypotension, ataxia, coordination, sedation, position headache, weakness, fatigue, menstrual changes, sore throat, flu-like symptoms, blurred or double vision, nausea, Provide rest periods vomiting, and rashes Administer with food Report rashes to physician

Bipolar Disorder (pg. 305)   

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Bipolar disorder: involves extreme mood swings from episodes of mania to episodes of depression They have poor judgment and rapid thoughts, actions, and speech If a person’s first episode of bipolar illness is a depressed phase, he or she might be diagnosed with major depression; a diagnosis of bipolar disorder may not be made until the person experiences a manic episode Manic episodes begin suddenly, last from a few weeks to several months Manic episodes typically begin suddenly with rapid escalation of symptoms over a few days, and they last from a few weeks to several months The diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem, sleeplessness, pressured speech, flight of ideas, reduced ability to filter extraneous stimuli, distractibility, increased activities with increased energy, and multiple, grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments

Treatment for Bipolar (Lifelong Tx) (pg. 306)

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Antimanic agent = Lithium: a salt contained in the human body; it is similar to gold, copper, magnesium, manganese, and other trace elements Lithium’s action peaks in 30 minutes to 4 hours for regular forms and in 4 to 6 hours for the slow-release form It crosses the blood–brain barrier and placenta and is distributed in sweat and breast milk Lithium use during pregnancy is not recommended because it can lead to first-trimester developmental abnormalities Onset of action is 5 to 14 days; with this lag period, antipsychotic or antidepressant agents are used carefully in combination with lithium to reduce symptoms in acutely manic or acutely depressed clients The half-life of lithium is 20 to 27 hours Anticonvulsant drugs: several anticonvulsants traditionally used to treat seizure disorders have proved helpful in stabilizing the moods of people with bipolar illness Psychotherapy useful in mildly depressive or normal portion of bipolar cycle (not manic stages)

Mood-Stabilizing Drugs   

Lithium, some anticonvulsants (carbamazepine, valproic acid; gabapentin, topiramate, oxcarbazepine, and lamotrigine) Use: treatment of bipolar disorders Mechanism of Action 1) Normalize reuptake of certain neurotransmitters (lithium) 2) Increase levels of GABA (valproic acid, topiramate) 3) Kindling process (valproic acid, carbamazepine) = manages small episodes

Side Effects of Mood-Stabilizing Drugs 

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Lithium: nausea, diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, metallic taste, fatigue, lethargy; weight gain, acne (later in therapy) 1) Toxicity: severe diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination Carbamazepine and valproic acid: drowsiness, sedation, dry mouth, blurred vision Carbamazepine: rash, orthostatic hypotension (aplastic anemia and agranulocytosis) Valproic acid: weight gain, alopecia, hand tremor (monitored for hepatic failure) Topiramate: dizziness, sedation, weight loss

Client Teaching (Mood-Stabilizing Drugs)   

Periodic monitoring of blood levels = 12 hours after last dose Drug with meals Safety measures (waiting to drive until dizziness, lethargy, fatigue or blurred vision goes away)

10 Warning 

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Lamotrigine: can cause serious rashes requiring hospitalization, including Stevens-Johnson syndrome and, rarely, life-threatening toxic epidermal necrolysis. The risk for serious rashes is greater in children younger than 16 year Lithium: toxicity is closely related to serum lithium levels and can occur at therapeutic doses. The serum lithium level should be about 1 mEq/L. Serum lithium levels of less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic Valproic Acid/Derivatives: can cause hepatic failure, resulting in fatality. Liver function tests should be performed before therapy and at frequent intervals thereafter, especially for the first 6 months. Can produce teratogenic effects such as neural tube defects (e.g., spina bifida). Can cause life-threatening pancreatitis in both children and adults. Can occur shortly after initiation or after years of therapy Carbamazepine: can cause aplastic anemia and agranulocytosis at a rate five to eight times greater than the general population. Pretreatment hematologic baseline data should be obtained and monitored periodically throughout therapy to discover lowered WBC or platelet count

Mood Disorders (pg. 285)    

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Everyone occasionally feels sad, low, and tired, with the desire to stay in bed and shut out the world These episodes are often accompanied by anergia (lack of energy), exhaustion, agitation, noise intolerance, and slow thinking processes, all of which make decisions difficult At the other end of the mood spectrum are episodes of exaggeratedly energetic behavior In an elated mood, stamina for work, family, and social events is untiring. This feeling of being “on top of the world” also recedes in a few days to a euthymic mood (average affect and activity) Mood disorders, also called affective disorders, are pervasive alterations in emotions that are manifested by depression, mania or both Most common psychiatric di...