NSG 221 Mental Health Exam Three (Modules 7, 8, 9, & 10)
T/F Depressed individuals who are newly taking antidepressant medication are at an increased risk for suicide - correct answer True
T/F Antidepressant medications can be discontinued quickly by a client - correct answer False
T/F Electroconvulsive therapy can be safely administered to pregnant women - correct answer Tru
T/F Depressed individuals can experience a lack of energy known as anhedonia - correct answer False
T/F A lithium level of 1.6 mEq/L is within the therapeutic range - correct answer False (0.6 to 1.2)
Kindling Definition - correct answer A process by which seizure activity in the brain is initially stimulated by the cumulative effects of stress, low amounts of electrical impulses, or chemicals that sensitize the neuronal pathways
Clients taking MAOIs and who eat foods containing tyramine risk experiencing a BLANK, which is potentially fatal - correct answer BLANK: hypertensive crisis
An individual experiencing mania can exhibit rapidly changing emotions, also known as: - correct answer Liable
What is the term that refers to having thoughts of killing oneself? - correct answer Suicidal Ideation
Mild Anxiety Definition - correct answer Mild anxiety is a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect him or herself. Mild anxiety often motivates people to make changes or engage in goal-directed activity. Mild Anxiety Physiological Responses: - correct answer Restlessness, Fidgeting, GI "butterflies", Difficulty Sleeping, Hypersensitivity to Noise.
Moderate Anxiety Definition - correct answer Moderate anxiety is the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated. In moderate anxiety, the person can still process information, solve problems, and learn new things with assistance from others. He or she has difficulty concentrating independently but can be redirected to the topic.
Moderate Anxiety Physiological Responses: - correct answer Muscle Tension, Diaphoresis, Pounding Pulse, Headache, Dry Mouth, Fast Speech, GI Upset, Frequent Urination
Severe Anxiety/Panic Definition - correct answer As the person progresses to severe anxiety and panic, more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantly. A person with severe anxiety has trouble thinking and reasoning. Muscles tighten, and vital signs increase. The person paces; is restless, irritable, and angry; or uses other similar emotional-
psychomotor means to release tension. In panic, the emotional-psychomotor realm predominates with accompanying fight, flight, or freeze responses. Adrenaline surge greatly increases vital signs. Pupils enlarge to let in more light, and the only cognitive process focuses on the person's defense.
Severe Anxiety Physiological Response: - correct answer Severe headache, Nausea, vomiting, and diarrhea, Trembling, Rigid stance, Vertigo, Pale, Tachycardia, Chest pain
Panic Physiological Responses: - correct answer May bolt and run or totally immobile and mute, Dilated pupils, Increased blood pressure and pulse, Flight, fight, or freeze
Nursing Interventions Mild Anxiety: - correct answer Mild anxiety is an asset to the client and requires no
direct intervention. People with mild anxiety can learn and solve problems and are even eager for information. Teaching can be effective when the client is mildly anxious.
Nursing Interventions Moderate Anxiety: - correct answer With moderate anxiety, the nurse must be certain that the client is following what the nurse is saying. The client's attention can wander, and he or she may have some difficulty concentrating over time. Speaking in short, simple, and easy-to-understand
sentences is effective; the nurse must stop to ensure that the client is still taking in information correctly.
The nurse may need to redirect the client back to the topic if the client goes off on a tangent. Nursing Interventions: Panic - correct answer During panic anxiety, the person's safety is the primary concern. The nurse must keep talking to the person in a comforting manner, even though the client cannot process what the nurse is saying. Going to a small, quiet, and nonstimulating environment may help reduce anxiety. The nurse can reassure the person that this is anxiety, it will pass, and he or she is in
a safe place. The nurse should remain with the client until the panic recedes. Panic-level anxiety is not indefinite, but it can last from 5 to 30 minutes.
Nursing interventions Severe Anxiety: - correct answer When anxiety becomes severe, the client can no longer pay attention or take in information. The nurse's goal must be to lower the person's anxiety level to moderate or mild before proceeding with anything else. It is also essential to remain with the person because anxiety is likely to worsen if he or she is left alone. Talking to the client in a low, calm, and soothing voice can help. If the person cannot sit still, walking with him or her while talking can be effective. What the nurse talks about matters less than how he or she says the words. Helping the person
take deep even breaths can help lower anxiety.
Malingering - correct answer Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms; it is motivated by external incentives such as avoiding work, evading
criminal prosecution, obtaining financial compensation, or obtaining drugs. People who malinger have no real physical symptoms or grossly exaggerate relatively minor symptoms. Their purpose is some external incentive or outcome that they view as important and results directly from the illness. People who malinger can stop the physical symptoms as soon as they have gained what they wanted
Factitious Disorder - correct answer Factitious disorder, imposed on self, occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. People with factitious disorder may even inflict injury on themselves to receive attention
Munchausen & Munchausen by Proxy - correct answer The common term for factitious disorder imposed on self is Munchausen syndrome. A variation of factitious disorder, imposed on others, is commonly called Munchausen syndrome by proxy, and occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a "hero" for saving the victim
Primary Gain - correct answer Primary gains are the direct internal benefits that being sick provides, such
as relief of anxiety, conflict, or distress
