NCLEX RN Mental Health and Psychiatric

NCLEX RN Mental Health and Psychiatric Nursing

• Anxiety Disorders and Stress )

(Set 3)

• Tristan is on Lithium and has suffered from diarrhea and vomiting. What should the nurse in-

charge do first:

• Recognize this as a drug interaction.
• Give the client Cogentin.
• Reassure the client that these are common side effects of lithium therapy.

• Hold the next dose and obtain an order for a stat serum lithium level.

Correct Answer: D. Hold the next dose and obtain an order for a stat serum lithium level Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and a test is done to validate the observation. Monitoring of therapeutic levels includes trough plasma levels drawn 8 to 12 hours after the last dose. The therapeutic range is 1.0 to 1.5 mEq/L for acute treatment and 0.6 to 1.2 mEq/L for chronic therapy. Monitoring should be done every 1 to 2 weeks until reaching the desired therapeutic levels. Then, check lithium levels every 2 to 3 months for six months. It is also important to monitor patients for dehydration and lower the dose when there are signs of infection, excessive sweating, or diarrhea. Toxic levels are when the drug level is more than 2 mEq/L.Option A: The manifestations are not due to drug interaction. Lithium has a very narrow therapeutic index, and toxic levels are when the drug is above 2 mEq/L, which is very close to its therapeutic range. Lithium toxicity can cause interstitial nephritis, arrhythmia, sick sinus syndrome, hypotension, T wave abnormalities, and bradycardia. Rarely, toxicity can cause pseudotumor cerebri and seizures.Lithium toxicity has no antidote.Option B: Cogentin is used to manage the extrapyramidal symptom side effects of antipsychotics.Benztropine is used to treat symptoms of Parkinson’s disease or involuntary movements due to the side effects of certain psychiatric drugs (antipsychotics such as chlorpromazine/haloperidol).Benztropine belongs to a class of medication called anticholinergics that work by blocking a certain natural substance (acetylcholine). This helps decrease muscle stiffness, sweating, and the production of saliva, and helps improve walking ability in people with Parkinson’s disease.Option C: The common side effects of Lithium are fine hand tremors, nausea, polyuria, and polydipsia. Lithium can cause several adverse effects. Typically the side effects are dose-related.Treatment for lithium toxicity is primarily hydration and to stop the drug. Give hydration with normal saline, which will also enhance lithium excretion. Avoid all diuretics. If the patient has severe renal dysfunction or failure, or severely altered mental status, then start with hemodialysis. 20 to 30 mg of propranolol given 2 to 3 times per day may help reduce tremors. 1 / 4

• What herbal medication for depression, widely used in Europe, is now being prescribed in the

United States?

• Ginkgo biloba
• Echinacea

• St. John's wort
• Ephedra

Correct Answer: C. St. John’s wort

St. John’s wort has been found to have serotonin-elevating properties, similar to prescription antidepressants. St. John’s Wort (Hypericum perforatum) is commonly used to treat mild-to-moderate depression. Several bioactive compounds have been identified in St. John’s Wort that work synergistically to provide its antidepressant and anti-inflammatory attributes. St. John’s Wort was more efficacious than standard antidepressant therapy in patients with mild-to-moderate depression.Option A: Ginkgo biloba is prescribed to enhance mental acuity. Ginkgo biloba is commonly used to improve memory and cognition in the elderly suffering from impaired cerebral circulation.Mitochondrial dysfunction is one theory proposed as the leading cause of cognitive decline. The two main components in Gingko biloba leaves are flavonoids and terpenes tri lactones. Together, these compounds enhance and protect mitochondrial function and scavenge reactive molecules like hydroxyl and peroxyl radicals, nitric oxide, and superoxide ions.

Option B: Echinacea has immune-stimulating properties. Echinacea is known as an

immunostimulant, boosting both innate and specific immunity. It has also demonstrated anti-viral, anti-inflammatory, and antimicrobial effects. Intracellular bactericidal activity and enhanced phagocytosis were also observed. A randomized, double-blind study of 473 patients virologically confirmed with influenza infection, showed Echinacea was as effective as oseltamivir with fewer adverse events and reduced risk.Option D: Ephedra is a naturally occurring stimulant that is similar to ephedrine. Ephedra is a medicinal preparation from the plant Ephedra sinica. Several additional species belonging to the genus Ephedra have traditionally been used for a variety of medicinal purposes, and are a possible candidate for the Soma plant of Indo-Iranian religion.

• A male client recently admitted to the hospital with sharp, substernal chest pain suddenly

complains of palpitations. Nurse Ryan notes a rise in the client’s arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use?

• Coronary artery spasm 2 / 4

• Bradyarrhythmias
• Neurobehavioral deficits
• Panic disorder

Correct Answer: A. Coronary artery spasm

Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Cocaine and its metabolites may cause arterial vasoconstriction hours after use. Epicardial coronary arteries are especially vulnerable to these effects, leading to a decreased myocardial oxygen supply.Option B: Consequently, the drug is more likely to cause tachyarrhythmias than bradyarrhythmias.Cocaine-induced central sympathetic stimulation and direct cardiac effects may lead to tachycardia, hypertension, and coronary or cerebral artery vasoconstriction leading to myocardial infarction and stroke.Option C: Although neurobehavioral deficits are common in neonates born to cocaine users, they are rare in adults. CNS reactions may be more excitatory than depressant. In its mild form, the patient may display anxiety, restlessness, and excitement. Full-body tonic-clonic seizures may result from moderate to severe CNS stimulation. These seizures are often followed by CNS depression, with death resulting from respiratory failure and/or asphyxiation if concomitant emesis is present.Option D: As craving for the drug increases, a person who’s addicted to cocaine typically experiences euphoria followed by depression, not panic disorder. Cardiovascular toxicity and agitation are best-treated first-line with benzodiazepines to decrease CNS sympathetic outflow.However, there is a risk of over-sedation and respiratory depression with escalating and numerous doses of benzodiazepines, which is often necessary. Non-dihydropyridine calcium channel blockers such as diltiazem and verapamil have shown the ability to reduce hypertension reliably, but not tachycardia.

• A male client is hospitalized with fractures of the right femur and right humerus sustained in a

motorcycle accident. Police suspect the client was intoxicated at the time of the accident.Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. Nurse Gian realizes that these symptoms probably result from:

• Acetate accumulation

• Thiamine deficiency
• Triglyceride buildup.
• A below-normal serum potassium level

Correct Answer: B. Thiamine deficiency 3 / 4

Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake.Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop.Option A: When thiamine stores are depleted (which takes about 4 weeks after stopping intake), symptoms start to appear. When evaluating for thiamine deficiency, the typical history may include poor nutritional intake, excessive alcohol intake, or the patient belonging to the special populations of individuals previously mentioned (pregnant women, recipients of bariatric surgery, patients with prolonged diuretic use, anyone with poor overall nutritional status, etc.).Option C: Initial symptoms of B1 deficiency include anorexia, irritability, and difficulties with short- term memory. With prolonged thiamine deficiency, patients may endorse loss of sensation in the extremities, symptoms of heart failure including swelling of the hands or feet and chest pain related to demand ischemia, or feelings of vertigo, double vision, and memory loss. Additionally, close friends and family of the patient may describe confusion or symptoms of confabulation.Option D: Detection of thiamine deficiency relies on relevant history and physical exam findings and follow up with laboratory testing for confirmation. Functional enzymatic assay of transketolase activity is the activity of transketolase measured before and after the addition of thiamine pyrophosphate; >25% stimulation response is abnormal. Measurement of thiamine or the phosphorylated esters of thiamine in serum or blood using high-performance liquid chromatography is used. Urine studies exist but are not a reliable test for the evaluation of total body thiamine.

5. Nurse Myrna develops a counter-transference reaction. This is evidenced by:

• Revealing personal information to the client.
• Focusing on the feelings of the client.
• Confronting the client about discrepancies in verbal or nonverbal behavior.
• The client feels angry towards the nurse who resembles his mother.

Correct Answer: A. Revealing personal information to the client

Counter-transference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. Countertransference is defined as redirection of a psychotherapist’s feelings toward a client – or, more generally, as a therapist’s emotional entanglement with a client. Just as transference is the concept of a client redirecting feelings meant for others onto the therapist, countertransference is the reaction to a client’s transference, in which the counselor projects his or her feelings unconsciously onto the client. How countertransference is used in therapy can make it either helpful or problematic.Option B: It is important for the therapist to understand the role that of transference and countertransference, and deal with those emotions in such a way that the core of the counseling relationship is not shattered by these feelings. Once countertransference is recognized, it is important that the therapist acknowledge and work through those feelings.

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