Alcohol withdrawal syndrome 

Onset since last

Manifestations Symptoms/signs
drink (hrs) 
Anxiety, insomnia, tremors, diaphoresis, palpitations,
Mild withdrawal 6-24
gastrointestinal upset, intact orientation
Seizures Single or multiple generalized tonic-clonic 12-48
Alcoholic Visual, auditory, or tactile; intact orientation; stable vital
12-48
hallucinosis signs
Confusion, agitation, fever, tachycardia, hypertension,
Delirium tremens 48-96
diaphoresis, hallucinations
alcohol withdrawal 
Delirium tremens and other withdrawal symptoms can be prevented with benzodiazepine administration
during hospitalization.  The stages of alcohol withdrawal do not always occur as a progressive sequence.
Signs and symptoms of delirium tremens include agitation, fever, tachycardia, hypertension, and
diaphoresis.

Delirium
The signs are acute mental status changes that fluctuate and inattention with disorganized thinking
and/or altered level of consciousness.  The disorganized thinking includes hallucinations.  Risk factors for
delirium include older age, prior cognitive impairment, presence of infection, severe illness or multiple
comorbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and pain.
Delirium has an abrupt onset and is a symptom of other problems.  Up to 60% of hospitalized elderly
clients have delirium prior to or during hospitalization, but it is often missed by nursing.

Lithium carbonate
Is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a
mood disorder) and bipolar disorders.  Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L);
levels >1.5 mEq/L are considered toxic.
Lithium toxicity can be acute (eg, ingesting a bottle of lithium tablets in a suicide attempt) or chronic (eg,
slow accumulation due to decreased renal function or drug-drug interactions).  Acute or acute-on-chronic
toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea);
neurologic manifestations occur later.  However, neurologic manifestations occur early
in chronic toxicity.  Common neurologic manifestations include ataxia, confusion, or agitation, and
neuromuscular excitability (eg, tremor, myoclonic jerks).  Chronic toxicity also manifests as diabetes
insipidus (eg, polyuria, polydipsia).
Clients with conditions that increase serum lithium levels (eg, dehydration, hyponatremia, severe renal
dysfunction and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide diuretics) are
at increased risk for toxicity (>1.5 mEq/L).
Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients
receiving lithium therapy.
  Lithium and sodium are closely related in the body.

Clozapine (Clozaril)
is an atypical antipsychotic medication used to manage schizophrenia in clients who have not improved
with other antipsychotic medications.  Clozapine is highly effective at controlling schizophrenia;
however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease
(myocarditis), and seizures.
Pretreatment assessment and ongoing monitoring of WBC and ANC are necessary. A client must have a
white blood cell (WBC) count of ≥3500/mm3 and an ANC of ≥2000/mm3 before starting
Agranulocytosis (decreased neutrophils) increases the risk for infection.  Clients require serial monitoring
of white blood cell counts and frequent assessment for signs of infection (eg, sore throat, fever, flulike
symptoms), which should be reported immediately to the health care provider
Weight gain is a common side effect
Hypersalivation and drooling are common side effects.

Zolpidem (Ambien)
is a hypnotic medication that induces sleep for clients with sleep disturbances (eg, acute mania).

monoamine oxidase inhibitors (MAOIs)

 isocarboxazid, phenelzine, and tranylcypromine.  selegiline [Emsam]
These first-generation antidepressants are used only for resistant depression due to serious adverse
affects.  These medications inhibit the enzyme that breaks up norepinephrine, serotonin, and dopamine,
thereby increasing their availability in the body.
Clients taking MAOIs or other antidepressants are at increased risk for suicidal ideation,
particularly children, adolescents, and young adults.  The risk of suicidal thoughts can be more prevalent
when starting the medication or with dose increases.
avoid tyramine-containing foods (eg, cheese, overripe fruit, liquor, beef/chicken liver, fermented
products) due to risk of hypertensive crisis. 

Ziprasidone hydrochloride (Geodon)
clients should be monitored for cardiac effects (including prolonged QT interval), hypotension, and/or
seizure activity.  Alcohol interacts with ziprasidone and increases the potential for an adverse effect from
the drug.
A baseline electrocardiogram and potassium are usually checked.  At a minimum, the client should be
placed on a cardiac monitor. 

selective serotonin reuptake inhibitor (SSRI)

Paroxetine (Paxil)
citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft)

often prescribed for major depression and anxiety disorders.

The major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual
dysfunction, weight gain, and serotonin syndrome (excess doses).  It may take several weeks for the
therapeutic effects of SSRIs to begin; they should never be discontinued abruptly.
Dosages should be gradually tapered before discontinuation to avoid withdrawal symptoms.
Most clients will start to see symptom improvement in 1-2 weeks.  However, some may take several
weeks and require dose adjustments. 
teach the client to eat a healthy diet and engage in regular exercise to combat the weight gain.
The sexual dysfunction side effect may decrease or cease after a 2- to 4-week waiting period for the
therapeutic effect, or the client may be able to switch to a different antidepressant medication (eg,
bupropion).

Trazodone (Oleptro),
a serotonin modulator, is used to treat major depressive disorders.
 In addition, it blocks alpha and H1 receptors, leading to orthostatic hypotension and sedation,
respectively.  Priapism (prolonged erection) is another serious side effect, though rare.
However, concurrent intake of other medications or substances that cause sedation can be detrimental;
these include benzodiazepines (eg, alprazolam, lorazepam, diazepam), sedating antihistamines (eg,
chlorpheniramine, hydroxyzine), and alcohol

Benzodiazepines 
(eg, alprazolam [Xanax], lorazepam [Ativan], clonazepam, diazepam)
Commonly used antianxiety drugs.  They work by potentiating endogenous GABA, a neurotransmitter
that decreases excitability of nerve cells, particularly in the limbic system of the brain, which controls
emotions.  Benzodiazepines may cause sedation, which can interfere with daytime activities.  Giving the
dose at bedtime will help the client sleep.
should never be stopped abruptly

Neuroleptic malignant syndrome (NMS)

rare but potentially life-threatening reaction.  NMS is most often seen with the "typical" antipsychotics
(eg, haloperidol, fluphenazine).  However, even the newer "atypical" antipsychotic drugs (eg, clozapine,
risperidone, olanzapine) can cause the syndrome.
NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg,
sweating, hypertension, tachycardia, dysrhythmia, tachypnea). Treatment is supportive and is directed at
reducing fever and muscle rigidity and preventing complications.  Treatment in an intensive care unit
(ICU) may be required.  The most important intervention is to immediately discontinue the antipsychotic
medication and notify the HCP for further assessment.

Benztropine (Cogentin) 
is an anticholinergic medication used to treat some extrapyramidal symptoms, which are side effects of
some antipsychotic medications.  These side effects include:
 Pseudoparkinsonism: Symptoms that resemble parkinsonism (eg, masklike face, shuffling gait,
rigidity, resting tremor, psychomotor retardation [bradykinesia])
 Dystonia: Abnormal muscle movements of the face, neck, and trunk caused by sustained
muscular contractions (eg, torticollis, oculogyric crisis, opisthotonos)

Serotonin syndrome
 a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are
administered simultaneously or in overdose.  Drugs, which may trigger this reaction, include (SSRIs),
(MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol.
Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic
dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular
hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia).

Bupropion hydrochloride (Wellbutrin) 
an atypical antidepressant used to treat depressive disorders, including major depressive disorder,
seasonal affective disorder, and persistent depressive disorder (dysthymia).  Preparations of bupropion
hydrochloride include immediate-release, sustained release (SR), and extended-release (XL) tablets.
Any medication marked SR or XL should not be chewed, cut, or crushed due to the risk of adverse effects
from too rapid absorption of the drug.  No form of bupropion hydrochloride should be altered; tablets
should be swallowed whole, with or without food.  Seizures are of particular concern if a client takes a
high or toxic dose of bupropion hydrochloride.
Clients on any kind of antidepressant need to be monitored closely for worsening depression, sudden or
unusual behavior or mood changes, and the emergence of suicidal thoughts and behaviors.  Clients with a
diagnosis of depression and/or their family members need education and information on the increased risk
of suicide 
Additional instructions to a client about the use of bupropion hydrochloride include the following:
 Limit alcohol; inform the health care provider if you are used to consuming large amounts of
alcohol
 Do not double up on the medication if a scheduled dose is missed 
 Take the medication at the same time each day
 It may take several weeks to feel the effects of bupropion hydrochloride 
 Weight loss may occur when taking this medication

Opioid intoxication
Characteristic clinical features include the following:
 Depressed mental status
 Decreased respiratory rate (<12/min) (most notable)
 Constricted (miotic) pupils (may not be present in every client)
 Decreased/absent bowel sounds
Mild hypotension from histamine release and bradycardia from central nervous system (CNS) depression
may also be present.  Concurrent intake of other CNS depressants (eg, alcohol) can worsen the respiratory
depression.
Naloxone (Narcan) is a potent narcotic antagonist that can reverse symptoms (respiratory depression,
sedation, hypotension) associated with suspected opioid overdose without producing any opioid-like
effects.  The usual dose is 0.4 mg IV (in non-opioid dependent clients), typically given via IV push.  The
therapeutic effect is rapid, within 1-2 minutes, and dosing may be repeated in 2-3 minutes.  It is the
priority action to reverse CNS and respiratory depression .

Electroconvulsive therapy (ECT) 

Induces a generalized seizure by passing an electrical current through electrodes applied to the scalp. 
Although the exact mechanism is unknown, 15-20–second seizures are proven effective in treating mood
disorders (eg, major depression, bipolar disorder) and schizophrenia.  Client teaching includes:
 NPO status is required for 6-8 hours prior to treatment except for sips of water with medications 
 Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be
administered; clients are unconscious and feel no pain during the procedure.
 Driving is not permitted during the course of ECT treatment 
 Temporary memory loss and confusion in the immediate recovery period are common side effects
of ECT 
Post-treatment nursing care includes monitoring vital signs, ensuring a patent airway, assessing mental
status, and providing frequent reorientation during periods of postictal confusion.
Valproic acid (Depakote) is an anticonvulsant that is also prescribed for bipolar disorder; therefore, it
would prevent the therapeutic effect of ECT.  Any prescribed anticonvulsants should be discontinued
prior to ECT.

Dementia 
Individuals with dementia may wander and become lost during any stage of the disease.  The most
effective strategy to prevent wandering is to make modifications to secure the environment.  These
include:
 Placing locks above or below eye level on doors that lead to the outside.  Clients with Alzheimer
disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front
of them or they purposely move their heads
 Adding a motion sensor or alarm that goes off when someone tries to exit
 Placing a large stop sign on door exits
  Disguising a door with a curtain or wall hanging
 Using childproof doorknob covers
 Placing a black mat or black strip by an exit.  The client may perceive this as an impassable black
hole due to changes in depth perception.
Sundowning
Refers to the increased confusion experienced by an individual with dementia; it occurs at night, when
lighting is inadequate, or when the client is excessively fatigued.  Wandering is a common associated
behavior.  A client with mild-to-moderate dementia may need frequent reality reorientation to promote
appropriate behaviors.  However, with advanced dementia, reality orientation may not be effective and
might cause the client to feel anxious, leading to inappropriate behaviors and aggression.  In this
situation, validation therapy is more appropriate and involves recognizing and exploring the client’s
feelings and concerns but not reinforcing or arguing with any incorrect perceptions.

Borderline personality disorder

Individuals with  (BPD) live in fear of rejection and abandonment.  To avoid abandonment, they use
manipulation and control, often unconsciously, to prevent a person from leaving.
The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature,
such as distancing from the other person.  An individual with BPD may also engage in self harm or
suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving.

Alcohol 
is a toxin that causes central nervous system depression.  Acute alcohol intoxication can cause confusion,
coordination impairment, drowsiness, slurred speech, mood swings, and uninhibited actions.  Alcohol can
also cause hypoglycemia, especially in clients with diabetes mellitus.  Although the client is intoxicated,
it is difficult to determine if the confusion is caused by alcohol or hypoglycemia or both.  The priority is
to monitor blood glucose during the night to watch for hypoglycemia, which would require immediate
intervention.
Alcohol withdrawal generally starts within 8 hours after the last drink and peaks at 24-72 hours.
Individuals with obsessive-compulsive personality disorder are typically self-willed and
obstinate, punctual, pay attention to rules and regulations, and need to control both internal and external
experiences.  These traits are very extreme and result in rigidity and inflexibility.  
Alcoholism 
Clients can have hypoglycemia.  They can also have thiamine (vitamin B1) deficiency related to poor
nutrient intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine
absorption.  Thiamine deficiency can result in Wernicke encephalopathy (WE).  Untreated WE can lead
to death or neurologic morbidity (Korsakoff psychosis).
In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the
body; this can worsen thiamine deficiency, which in turn can precipitate the development of WE in a
previously unaffected individual.  Because the signs of alcohol intoxication and WE are similar, all
intoxicated clients should be given IV thiamine before or with IV glucose
usually have additional nutritional deficiencies (eg, folic acid, magnesium).  Magnesium and multiple
vitamins should also be given to these clients.  However, thiamine is the essential vitamin to administer
before or with IV glucose in a client with suspected alcoholism.

Narcissistic personality disorder

Who may behave in grandiose, demanding, and entitled ways and needs to have his/her own way. The
clinical characteristics of narcissistic personality disorder can best be explained as an attempt to maintain
a fragile self-esteem that was damaged during childhood due to an environment that was highly critical,
demanding, and fostered a sense of inferiority.

Histrionic personality disorder

Is characterized by persistent attention-seeking behavior and exaggerated emotionality.  The client with
this disorder demands immediate gratification and has little tolerance for frustration.

Dependent personality disorder

Who tends to be passive and submissive and wants to please others.

Paranoid personality disorder

Who may feel slighted or is overly sensitive.

Agoraphobia
Is characterized by intense anxiety about being in a situation from which there may be difficulty escaping
in the event of a panic attack.  A person with agoraphobia may avoid open spaces, closed spaces, riding in
public or private transportation, going outside the home, bridges/tunnels, and crowds.

Generalized anxiety disorder

The anxiety is evident in various situations and can impact all areas of an individual's life (eg, workplace,
family/relationships, general well-being).

Social anxiety disorder

Individuals fear being scrutinized, observed, or embarrassed in social or performance settings (eg, public
speaking, eating in public).

Postmortem care 
of a child is a highly stressful and emotional time for family and staff members.  After death, the
psychosocial care of the family and the bond between parent and child should be facilitated through
specific interventions intended to assist parents through the grieving process.  Parents should be allowed
as much time as they need with the child's body and should not be rushed while they say goodbye.
The nurse should be present to provide emotional support and identify if parents wish to help participate
in some or all care activities, such as bathing and dressing the child.  Parents should be allowed time to
cuddle with and speak, read, or sing to the child, as well as perform special activities associated with
cultural beliefs

Known risk factors and the concept of their accumulation to help predict who is at a higher risk of
committing suicide.
S Sex (men kill themselves more often than women; women make more attempts)
A Age (teenagers/young adults, age >45)
D Depression (and hopelessness)
P Prior history of suicide attempt
E Ethanol and/or drug abuse
R Rational thinking loss (hearing voices to harm self)
S Support system loss (living alone)
O Organized plan; having a method in mind (with lethality and availability)
N No significant other
S Sickness (terminal illness)
Catatonic schizophrenia
A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a
diagnosis of schizophrenia and include at least 2 of the following additional features:
 Immobility—the client remains in a fixed stupor or position for long periods
o Refuses to move about or engage in activities of daily living
o May have brief spurts of excitement or hyperactivity
 Remaining mute
 Bizarre postures—the client holds the body rigidly in one position
 Extreme negativism—the client resists instructions or attempts to be moved
 Waxy flexibility—the client's limbs stay in the same position in which they are placed by another
person
 Staring
 Stereotyped movements, prominent mannerisms, or grimacing
Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food
intake and are at high risk for dehydration and malnutrition.  The priority nursing action is to anticipate
the client's needs, and to ensure that the client is well hydrated and has adequate nourishment.  Some
clients will need total care.

Cognitive behavioral therapy (CBT)

can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical
conditions such as insomnia and smoking.  These types of disorders are characterized by maladaptive
reactions to stress, anxiety, and conflict.  CBT requires that the client learn the skill of self-observation
and to apply more adaptive coping interventions.
CBT involves 5 basic components:
 Education about the client's specific disorder
 Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and
assess the severity
 Physical control strategies – deep breathing and muscle relaxation exercises
 Cognitive restructuring – learning new ways to reframe thinking patterns, challenging negative
thoughts
 Behavioral strategies – focusing on situations that cause anxiety and practicing new coping
behaviors, desensitization to anxiety-provoking situations or events

Attention-deficit hyperactivity disorder (ADHD) 

A key feature is hyperactivity; however, some children with ADHD behave aggressively and
have difficulty controlling anger, especially when frustrated or if unable to meet demands and challenges.
An immediate intervention to help settle an out-of-control child is deep breathing.  Taking slow, deep
breaths relaxes the body, slows the heart rate, and distracts the child from inappropriate behaviors. 
Asking the child to blow up a balloon provides an easy mode of distraction and engages the child in a
deep breathing exercise.  After the child is calm, the nurse and the child can further discuss the disruptive
behavior.
Nursing interventions include the following:
 Stay calm and remove the child from the source of frustration/anger
 Assist the child in calming down with deep breathing exercises
 Discuss what precipitated the behavior and why the behavior is wrong
 Discuss acceptable ways of expressing anger and frustration
 Acknowledge that controlling anger is difficult
 Provide rewards for appropriate behavior
 Discuss the consequences of inappropriate behavior
The key nursing intervention to help the child with ADHD adjust to hospitalization is providing a calm,
structured, organized, and consistent environment .  A written chart or list of daily activities will help
remind the child of what to expect and what will happen at any given time.  A structured environment
helps these children organize their thoughts and activities.
Two common misunderstandings about ADHD are that children outgrow it as they become adults, and
that dietary modifications (eg, restricting additives and/or sugar) will improve or "cure" the symptoms. 
Neither statement is true.  These individuals learn to cope with and manage their symptoms as they grow
older, but they do not outgrow ADHD.
The diagnosis of ADHD includes the presence of hyperactivity, impulsiveness, and inattention.  The
negative consequences of the core manifestations include impaired social skills, poor self-esteem,
academic or work failure, increased risk for depression and anxiety, and increased risk for substance
abuse.

Manipulative behaviors
Such as attempts at staff splitting, are common in clients with borderline and antisocial personality
disorders, substance abuse problems, somatic symptom disorder, and bipolar disorder (during the manic
phase).  The manipulative behavior is aimed at gaining control/power over a person/situation or for
material gratification.
Clients manipulate by flattery or by pitting staff members against each other.  They may "tell" on a staff
member or act in a way to give the impression of sincerity and caring.
Nursing interventions for manipulative behaviors include:
 Setting limits that are realistic, nonpunitive, and enforceable
 Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of
unacceptable behaviors
 Enforcing all unit, hospital, or center rules
 Ensuring consistency from all staff members in enforcing set limits
Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible
behavior, and blame others for their behavior.  Nursing interventions include setting firm limits and
making clients aware of the rules and acceptable behaviors.

Bulimia nervosa
Characterized by episodes of uncontrollable binge eating (consuming very large amounts of food)
followed by inappropriate behaviors to prevent weight gain.  Self-induced vomiting within 1-2 hours of
binge eating is the more typical behavior; use of enemas and laxatives, and frequent, intense exercise are
also characteristic behaviors of the client with bulimia nervosa.
Signs that a parent or friend of someone with this disorder might notice include the following:
 Trips to the bathroom after meals
 Disappearance of large amounts of food
 Finding hidden wrappers and empty containers of food, especially foods that are sweet and easily
consumed
 Smells of vomit; finding packages of laxatives or enemas
 Getting up in the middle of the night followed by a trip to the bathroom some time later
 Engaging in intense physical exercise despite fatigue or pain
 Swelling of the cheeks due to parotid gland damage and enlargement; staining of the teeth
 Periods of starvation
 Preoccupation with weight, food, and dieting

Hallucinations
The priority nursing action is to explore the content of the hallucinations.  This client may be
experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and
harm.  After the content of the hallucinations has been explored, implementing an intervention may be
necessary to reduce the potential for violence.
Hallucinations are false sensory perceptions that have no external stimuli.  They can occur in any of the 5
senses.  Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory
(smell), and gustatory (taste).
Additional ways to deal with hallucinations include the following:
 Telling the client that you know they are real to the client but that you do not hear the voices (or
see the vision, feel the sensation)
 Not arguing with or challenging the client about the hallucinations
 Directing the client to a reality-oriented topic of conversation or activity
Antipsychotic medication therapy is the first-line treatment of hallucinations and other psychotic
symptoms.  However, most psychotropic drugs may take some time to be completely effective and may
not eliminate hallucinatory episodes entirely.  Clients should be encouraged to develop alternate methods
for coping with the hallucinations.
One approach is increasing the amount of external auditory stimulation in the environment.  Individuals
with auditory hallucinations have reported that increasing the amount of external sound (eg, watching TV
or listening to music through headphones) makes it easier to ignore internal sounds from the
hallucinations.
Other methods of managing auditory hallucinations include voice dismissal (telling the voices to go
away) and cognitive behavioral therapy (assists clients in learning new ways to think about and deal with
their symptoms).

Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they

believe that people's motives are malicious and assume that others are out to exploit, harm, or deceive
them.
These thoughts permeate every aspect of their lives and interfere with their relationships.  Individuals
with paranoid personality disorder are usually difficult to get along with as they may express their
suspicion and hostility by arguing, complaining, making sarcastic comments, or being stubborn.  Because
these clients do not trust others, they have a strong need to be self-sufficient and maintain a high degree
of control over their environment.

acute manic episode is characterized by the following:

 Excessive psychomotor activity
 Euphoric mood
 Poor impulse control
 Flight of ideas, non-stop talking
 Poor attention span, distractibility
 Hallucinations and delusions
 Insomnia
 Wearing bizarre or inappropriate clothing, jewelry, and makeup
 Neglected hygiene and inadequate nutritional intake
The care plan for a client experiencing an acute manic episode includes the following:
 Reduction of environmental stimuli
o Providing a quiet, calm environment
o Limiting the number of people who come in contact with the client
o One-on-one interactions rather than group activities
o Low lighting
 A structured schedule of activities to help the client stay focused
 Physical activities to help relieve excess energy
  Providing high-protein, high-calorie meals and snacks that are easy to eat
 Setting limits on behavior

Psychomotor retardation
A clinical symptom of major depressive disorder.  Manifestations of psychomotor retardation include
slowed speech, decreased movement, and impaired cognitive function.  The individual may not have the
energy or ability to perform activities of daily living or to interact with others.  Psychomotor retardation
may range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and
behavior).

Psychomotor agitation
Characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic eye
movement.

Psychogenic dystonia
Is a psychogenic movement disorder characterized by involuntary muscle contractions that cause slow,
repetitive movements such as twisting and abnormal postures.

Psychogenic gait
Is a psychogenic movement disorder characterized by unusual standing postures and walking.  The client
may experience knee buckling and falling or may veer from side to side as if staggering.

Somatization
A term to describe physical symptoms that cannot be explained by a medical condition or disease

Major Depression S&S- SIG E CAPS

Sleep (Increased or decreased)
Interest deficit (anhedonia)
Guilt (Worthless, hopeless)
Energy deficit
Concentration deficit
Appetite (increased or decreased)
Psychomotor retardation or agitation
Suicidality

Long-term treatment with medication alone is not necessarily the best approach to treat insomnia. 
Nonpharmacological strategies for improving sleep hygiene include:
 Avoiding naps throughout the day
 Engaging in physical activity or exercise, preferably at least 5 hours before bedtime
 Receiving at least 20 minutes of natural sunlight each day, ideally in the morning, to improve
sleep patterns
 Avoiding caffeinated beverages after noon
 Avoiding alcohol and/or smoking at bedtime
 Participating in a relaxing activity before bedtime (eg, warm bath, reading, listening to soft
music)
 Decreasing environmental stimuli; making sure the bedroom is dark, cool, and quiet
 Avoiding heavy meals or large amounts of fluids at bedtime
 Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime, which
promotes comfort and relaxation to aid sleepiness
The legal criteria for involuntary admission include:
 The individual appears to be an imminent danger to self or others.
 The individual has a grave disability (ie, is unable to adequately care for basic needs [food,
clothing, shelter, medical care, personal safety]) as a result of a mental illness 
Clients also have the right to the least restrictive environment in which treatment can be provided in a
safe manner.  Involuntary commitment is generally used as a last resort in dealing with a client whose
illness is so severe that judgment and insight in deciding to refuse treatment are markedly impaired.

Intimate partner violence (IPV)

is abusive behavior inflicted by one partner against the other in an intimate relationship.  IPV occurs in all
religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex
partnerships.  IPV often begins or intensifies during pregnancy.  Victims often stay in the relationship due
to fear, financial or child custody concerns, or religious beliefs, among other reasons.

Dissociative identity disorder

A condition in which 2 or more identities alternately control the client's behavior.  The alternate identities
likely develop as a response to abuse or traumatic events and serve to protect the client from stressful
memories.  The client may not be aware of the alternate identities and may be confused by "lost time"
and gaps in memory.  Switching between identities occurs as a reaction to stress and individual triggers. 
The goal of treatment is to integrate the identities into one personality while maintaining safety.
The client should journal about feelings and dissociation triggers and use a grounding technique (eg, deep
breathing, rubbing a stone, counting coins) to counter dissociative episodes.  Identities may be volatile
and should be monitored for indications of harm to self or others. The nurse should attempt to form
trusting, therapeutic relationships with each identity to explore feelings and facilitate identity integration.

Adolescent clients are at increased risk for developing depressive and anxiety-related mood disorders
as they begin to identify their role in adult life and develop new personal relationships.  However, they
frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or
cranky mood rather than a sad or dejected mood.  Signs of depression in adolescent clients include:
 Hypersomnolence or insomnia; napping during daily activities 
 Low self-esteem; withdrawal from previously enjoyable activities
 Outbursts of angry, aggressive, or delinquent behavior (eg, vandalism, absenteeism);
inappropriate sexual behavior 
 Weight gain or loss; increased food intake or lack of interest in eating 
Depression is also a significant cause of suicide in adolescents.

Clients with persecutory delusions (paranoid delusions)

believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned).  Focusing on
the client's feelings secondary to the delusion is an example of empathy, one of the most important parts
of the therapeutic nurse-client relationship.  When nurses attempt to understand clients' feelings and their
meaning, clients realize that someone is trying to understand them and the nurse-client relationship grows
Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about
the delusions 
For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to
know that someone is trying to poison you."  Reality orientation may also be helpful by telling the client,
"What you are thinking is part of your disease and not real."
**When a client switches from a tricyclic antidepressant (TCA) (eg, imipramine, amitriptyline,
nortriptyline) to a monoamine oxidase inhibitor(MAOI) (eg, phenelzine, isocarboxazid, tranylcypromine),
a drug-free period of at least 2 weeks should elapse between the tapered discontinuation of the TCA and
the initiation of the MAOI.  This timing is based on the half-life value and allows for the first medication
to leave the system.
Without a washout period, the client could experience hypertensive crisis (eg, blurred vision, dizziness,
severe headache, shortness of breath).  If the TCA is withdrawn abruptly, the client may experience a
discontinuation syndrome.
There must be a minimum of 14 days between the administration of MAOIs and SSRIs to avoid serotonin
syndrome; these medications cannot be administered concurrently.

Types of impaired thought processes seen in individuals with schizophrenia include the following:
 Neologisms – made-up words or phrases usually of a bizarre nature; the words have meaning to
the client only.  Example:  "I would like to have a phjinox."
 Concrete thinking – literal interpretation of an idea; the client has difficulty with abstract
thinking.  Example:  The phrase, "The grass is always greener on the other side," would be
interpreted to mean that the grass somewhere else is literally greener
 Loose associations – rapid shifting from one idea to another, with little or no connection to logic
or rationality 
 Echolalia – repetition of words, usually uttered by someone else
 Tangentiality – going from one topic to the next without getting to the point of the original idea
or topic 
 Word salad – a mix of words and/or phrases having no meaning except to the client.  Example: 
"Here what comes table, sky, apple." 
 Clang associations – rhyming words in a meaningless, illogical manner.  Example:  "The pike
likes to hike and Mike fed the bike near the tyke."
 Perseveration – repeating the same words or phrases in response to different questions

Anorexia Nervosa
The clinical manifestations of anorexia nervosa include extreme weight loss, amenorrhea, bradycardia,
cold intolerance, dry skin, and lanugo.  Life-threatening complications, such as cardiac arrhythmias
associated with hypokalemia, may develop.
Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery
process can take several months.
Anorexia nervosa manifests as cold intolerance.
Anorexia nervosa manifests as lengthy and vigorous exercise.
Treatment for a client requiring hospitalization for anorexia nervosa should focus on the short-term
outcomes of increasing caloric intake, promoting gradual weight gain, and addressing medical conditions
caused by starvation.

Defense mechanisms
Displacement- occurs when a person shifts uncomfortable feelings or impulses about one situation or
person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings or
impulses.
Compensation- involves experiencing a perceived deficit in one area and making up for it by
overachieving in another.  An example is someone not doing well academically who focuses on doing
well in sports.
Projection- involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning
it to another person.  An example is a husband with thoughts of infidelity who then accuses his wife of
being unfaithful.
Reaction formation -involves transforming an unacceptable feeling or impulse into its opposite.  An
example is a client with cancer who fears dying but behaves in an overly optimistic and fearless manner
about his treatment and prognosis.

Panic Attack
The priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay
with the client in a calm environment and offer support and reassurance that the client is safe and secure.
Additional nursing actions while the client is experiencing panic symptoms include:
 Maintaining a calm, matter-of-fact approach
 Speaking calmly and using simple, clear words and phrases when providing information on
emergency department procedures
 Placing the client in a room with as little stimuli as possible
 Administering an anti-anxiety medication such as a benzodiazepine (per health care provider
prescription)
 Having the client breathe into a paper bag if hyperventilation is a problem

Memantine
Is a medication used in the treatment of moderate to severe Alzheimer disease (AD).  It slows the
progression of AD symptoms, and improvement may be seen in the client's behavior, cognitive
functioning, and ability to perform activities of daily living.

Delusions
fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or
persuasion.  Categories of delusions include the following:
 Persecutory – client thinks others are "out to get me"
 Ideas of reference – common events refer specifically to the client
 Grandiose – client has the perception of special importance or powers that are not realistic
 Somatic – false ideas about bodily functioning
 Control – "Don't drink the tap water.  That's how the government controls us."
 Nihilistic – "It doesn't matter if I take my medicine.  I'm already dead."
Nursing interventions include the following:
 Not arguing or challenging the belief
 Reinforcing reality by talking about and encouraging the client to participate in real events.  The
nurse should not delve into or have long conversations about the delusional belief system.
Codependent behaviors
are those that allow the codependent person to maintain control by fulfilling the needs of the addict first. 
Behaviors such as keeping the addiction secret, suffering physical or psychological abuse from the addict,
not allowing the addict to suffer the consequences of actions, and making excuses for the addict's habit
are hallmarks of codependency.  If the addict isn't happy, the codependent person will try to make the
addict happy.  Codependent persons will focus all their attention on others at the expense of their
own sense of self.  Codependent spouses, friends, and family members keep the client from focusing on
treatment; this behavior is counterproductive to both themselves and the client.

Typical characteristics of perpetrators of child abuse include:

1. Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly
critical of the child
2. Confusion between punishment and discipline; having a stern, authoritative approach to
discipline
 3. Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social
support, and isolation 
4. Low self-esteem – a sense of incompetence or unworthiness as a parent
5. A history of substance abuse, use of alcohol or drugs at the time the abuse occurs 
6. Punitive treatment and/or abuse as a child
7. Lack of parenting skills, inexperience, minimal knowledge about child care and child
development, and young parental age 
8. Resentment or rejection of the child
9. Low tolerance for frustration and poor impulse control
10. Attempts to conceal the child's injury or being evasive about an injury; shows little concern about
the child's injury
(Child abusers are not easily identified by appearance; they often appear calm and well in control.
Both men and women abuse children at approximately the same rate.  Men may be more likely to
physically harm a child; women are more likely to neglect a child.
Only about 10% of child abusers have a diagnosis of a mental illness.

**  isosorbide has actions identical to nitroglycerin and can cause hypotension from vasodilation.  It
should be held when the systolic blood pressure is <90 mm Hg.  Perfusion to the kidneys is inadequate if
the systolic blood pressure is <80 mm Hg.  Because the pressure is so low, the nurse does not want to
lower it further by giving the drug.

** A "normal" fasting glucose level (70-99 mg/dL [3.9-5.5 mmol/L]) indicates that the dosing is correct
and should be given to continue control of blood glucose.

** Among the components necessary for recovery are self-direction and responsibility, holistic care, and
hope.  When all the components are reasonably represented, recovery is demonstrated by the client's
ability to function in all aspects of living to the highest level of capacity.

** The 3 categories of PTSD symptoms include re-experiencing the traumatic event, avoiding reminders
of the trauma, and increased anxiety and emotional arousal.
The nurse should encourage clients with posttraumatic stress disorder to talk about the experience at their
own pace, listen actively to build trust, and allow clients to vent.  This will assist in decreasing their
feelings of isolation.
The first step toward resolution of posttraumatic stress disorder (PTSD) is the client's readiness (ability
and willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety.

** Functional disorders are currently undiagnosable medical issues and should not be confused with
psychosomatic illness, attention-seeking behavior, or malingering.