exam and Rationale - exam and Rationale (Set 2) 1. After administeri...

NCLEX RN Comprehensive Mental Health exam and Rationale (Set 2)

• After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the

female client carefully for which of the following?

• Respiratory depression
• Epilepsy
• Kidney failure
• Cerebral edema

Correct Answer: A. Respiratory depression

After administering naloxone (Narcan) the nurse should monitor the client’s respiratory status carefully because the drug is short-acting & respiratory depression may recur after its effects wear off. Once the pharmacological effects of naloxone have worn off, there is a possibility that respiratory depression may recur, and without monitoring, this could spell real trouble for the patient.Option B: Naloxone has few side effects. The most common are those of acute withdrawal from opioids, such as anxiety, aggression, nausea, vomiting, diarrhea, abdominal pain, and rhinorrhea. In rare cases, the use of naloxone can precipitate noncardiogenic pulmonary edema. The incidence of naloxone-induced noncardiogenic pulmonary edema is estimated to be between 0.2% and 3.6% of patients who have received naloxone and are transported to the emergency department.Option C: In chronic opioid users, naloxone requires slow administration to individuals who are dependent on opioids. All patients who have responded to naloxone should be continuously monitored for at least six to 12 hours since some opioids (methadone, fentanyl, buprenorphine) have a much longer half-life than naloxone. The half-life of naloxone in adults varies from 30 to 80 minutes. The patient should have vital signs, including pulse oximetry, monitored until obtaining a full recovery.Option D: Symptoms include persistent hypoxia, despite the resolution of respiratory depression secondary to acute overdose. Patients may also have a cough productive of the classic “pink, frothy sputum” indicative of pulmonary edema. Chest radiography will be consistent with the findings of pulmonary edema. It bears mention that the onset of noncardiogenic pulmonary edema occurs within 4 hours in most patients. However, there have been case reports of delayed onset of up to 8 hours after naloxone administration.

• When teaching Mario with a typical depression about foods to avoid while taking

phenelzine(Nardil), which of the following would the nurse in charge include?

• Roasted chicken 1 / 4

• Fresh fish

• Salami
• Hamburger

Correct Answer: C. Salami

Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis will occur. MAOIs prevent the breakdown of tyramine found in the body as well as certain foods, drinks, and other medications.Patients that take MAOIs and consume tyramine-containing foods or drinks will exhibit high serum tyramine level. A high level of tyramine can cause a sudden increase in blood pressure, called the tyramine pressor response. Even though it is rare, a high tyramine level can trigger a cerebral hemorrhage, which can even result in death.Option A: Eating foods with high tyramine can trigger a reaction that can have serious consequences.Patients should know that tyramine can increase with the aging of food; they should be encouraged to have foods that are fresh instead of leftovers or food prepared hours earlier.Option B: Examples of high levels of tyramine in food are types of fish, as well as types of meat, including sausage, turkey, liver, and salami. Also, certain fruits can contain tyramine like overripe fruits, avocados, bananas, raisins, or figs. Further examples are cheeses, alcohol, and fava beans; all of these should be avoided even after two weeks of stopping MAOIs. Anyone taking MAOIs is at risk for an adverse hypertensive reaction, with accompanying morbidity.Option D: Depending on the MAOI prescribed, some can cause patients to go into a coma, and others (e.g., overdosing on tranylcypromine) can result in death. The severity not only depends on the amount consumed but also on which type of MAOIs the patient took. For example, phenelzine and tranylcypromine being nonselective and nonreversible, increase the risk of a patient experiencing a hypertensive crisis when ingested with tyramine.

• A client with chronic schizophrenia who takes neuroleptic medication is admitted to the

psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These

findings suggest which life-threatening reaction:

• Tardive dyskinesia
• Dystonia

• Neuroleptic malignant syndrome
• Akathisia

Correct Answer: C. Neuroleptic malignant syndrome

The client’s signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Neuroleptic malignant syndrome (NMS) is a life-threatening syndrome associated with the use of dopamine-receptor antagonist medications or with rapid withdrawal of dopaminergic medications. NMS has been associated with virtually every neuroleptic agent but is more commonly reported with the typical antipsychotics like haloperidol and 2 / 4

fluphenazine. Classic clinical characteristics include mental status changes, fever, muscle rigidity, and autonomic instability. While uncommon, NMS remains an important part of the differential diagnosis of fever and mental status changes because it requires early diagnosis and treatment to prevent significant mortality and death.Option A: Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Tardive dyskinesia (TD) is a syndrome which includes a group of iatrogenic movement disorders caused due to a blockade of dopamine receptors. The movement disorders include akathisia, dystonia, buccolingual stereotypy, myoclonus, chorea, tics and other abnormal involuntary movements which are commonly caused by the long-term use of typical antipsychotics.Option B: Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Dystonia is defined by involuntary maintained contraction of agonist and antagonist muscles yielding abnormal posturing, twisting and repetitive movements, or tremulous and can be initiated or worsened by attempted movement. Dystonia is a dynamic disorder that changes in severity based on the activity and posture. Dystonia may assume a pattern of overextension or over- flexion of the hand, inversion of the foot, lateral flexion or retroflection of the head, torsion of the spine with arching and twisting of the back, forceful closure of the eyes, or a fixed grimace. It may come to an end when the body is in action and during sleep.Option D: Akathisia causes restlessness, anxiety, and jitteriness. Akathisia is defined as an inability to remain still. It is a neuropsychiatric syndrome that is associated with psychomotor restlessness. The individual with akathisia will generally experience an intense sensation of unease or an inner restlessness that usually involves the lower extremities. This results in a compulsion to move. In most cases the movement is repetitive. The individual may cross, uncross, swing, or shift from one foot to the other. To the observer, this may appear as a persistent fidget

• A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis.

Which findings should alert the nurse that the client is experiencing pseudoparkinsonism?

• Restlessness, difficulty sitting still, and pacing
• Involuntary rolling of the eyes

• Tremors, shuffling gait, and masklike face
• Extremity and neck spasms, facial grimacing, and jerky movements

Correct Answer: C. Tremors, shuffling gait, and mask-like face

Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and “pill-rolling.” Despite being a low-potency drug, chlorpromazine can still cause extrapyramidal side effects (EPS) such as acute dystonia, akathisia, parkinsonism, and tardive dyskinesia (TD). The evolution of EPS side effects can occur through hours to days. Acute dystonia refers to muscle stiffness or spasm of the head, neck, and eye muscles that can start hours after starting the medication.Akathisia includes restlessness and fast pacing. Parkinsonism includes bradykinesia, “cogwheel” rigidity, and shuffling gait. 3 / 4

Option A: Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. Patients are at risk of developing neuroleptic malignant syndrome (NMS), which is a life-threatening manifestation, where the patient presents with “lead-pipe” muscle rigidity, autonomous instability, hyperpyrexia more than 40 degrees Celsius, altered mental status, leukocytosis, and elevated serum creatinine kinase.Option B: An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered an emergency. Chlorpromazine use also requires caution in patients with cerebrovascular and cardiovascular diseases. Patients should start on a low dose of chlorpromazine as an initial dosage, and the increase in subsequent dosing should be gradual.However, treatment should be discontinued if the patient develops agranulocytosis.Option D: Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing. Chlorpromazine belongs to the category of typical antipsychotics or neuroleptics, also known as first-generation antipsychotics (FGAs). It produces its antipsychotic effect by the post-synaptic blockade at the D2 receptors in the mesolimbic pathway. However, the blockade of D2 receptors in the nigrostriatal pathway is responsible for its extrapyramidal side effects.

• Which of the following assessments would provide the best information about the client’s

physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal?

• Sleeping pattern
• Mental alertness
• Nutritional status

• Vital signs

Correct Answer: D. Vital signs

Monitoring of vital signs provides the best information about the client’s overall physiologic status during alcohol withdrawal & the physiologic response to the medication used. Alcohol withdrawal symptoms occur when patients stop drinking or significantly decrease their alcohol intake after long- term dependence. Withdrawal has a broad range of symptoms from mild tremors to a condition called delirium tremens, which results in seizures and could progress to death if not recognized and treated promptly. The reported mortality rates for patients who experience delirium tremens is anywhere from 1-5%.Option A: Alcohol withdrawal can range from very mild symptoms to the severe form, which is named delirium tremens. The hallmark is autonomic dysfunction resulting from the excitation of the central nervous system. Mild signs/symptoms can arise within six hours of alcohol cessation. If symptoms do not progress to more severe symptoms within 24 to 48 hours, the patient will likely recover.Option B: Nurses monitoring alcoholic patients should be familiar with signs and symptoms of alcohol withdrawal and communicate to the interprofessional team if there are any deviations from

• / 4