Mental Health Nursing Concepts Flashcards

A client with bipolar disorder type I is admitted in a manic episode and prescribed lithium carbonate 300 mg TID. On day 4, the client reports blurred vision, coarse hand tremors, and confusion. Serum lithium level returns at 1.8 mEq/L. Which nursing action is the priority?

Answer: Hold lithium, notify the physician, and prepare for IV fluid administration

A lithium level of 1.8 mEq/L exceeds the therapeutic range (0.6–1.2 mEq/L for maintenance; up to 1.5 mEq/L for acute mania) and the client is displaying signs of toxicity (blurred vision, coarse tremors, confusion). The priority action is to hold the medication, notify the physician immediately, and prepare for IV hydration to promote lithium excretion. Administering another dose risks severe toxicity. Dose reduction without physician order is outside nursing scope. Oral fluids alone are insufficient at this toxicity level.

A practical nurse is caring for a client prescribed clozapine for treatment-resistant schizophrenia. The client's absolute neutrophil count (ANC) today is 900 cells/mm³, down from 1,400 cells/mm³ last week. Which intervention is most appropriate?

Answer: Withhold clozapine, notify the prescriber, and increase monitoring frequency

An ANC of 900 cells/mm³ indicates moderate neutropenia and a significant decline from baseline, placing the client at risk for clozapine-induced agranulocytosis, a life-threatening adverse effect. The nurse must withhold the dose and immediately notify the prescriber. Monitoring frequency must increase (not extend to monthly). Permanent discontinuation and reverse isolation are decisions made by the physician after further evaluation — the nurse should not independently make that determination. Administering the dose in this situation is unsafe.

During a mental status examination, a client with a suspected psychotic disorder responds to questions by shifting rapidly from one loosely related idea to another without reaching a logical conclusion. The nurse documents this thought pattern as:

Answer: Loosening of associations

Loosening of associations (also called derailment) describes a thought pattern where ideas shift from one topic to another with only a tenuous or absent logical connection, and the client never arrives at a point. Flight of ideas involves rapid, pressured speech where connections between topics are still somewhat discernible (often by rhyming or tangential association) and is more characteristic of mania. Circumstantiality involves excessive detail but eventually reaches the point. Thought blocking is an abrupt, unexplained pause mid-thought.

A nurse working on an inpatient psychiatric unit notices that a colleague routinely tells clients in distress, 'I understand exactly how you feel — I've been through the same thing myself.' Which therapeutic communication principle does this behaviour most directly violate?

Answer: Maintaining professional boundaries through appropriate self-disclosure

While empathy and validation are therapeutic, routine and unsolicited personal disclosure by the nurse shifts the focus from the client to the nurse, blurs the professional therapeutic relationship, and can burden the client with the nurse's experiences. Appropriate self-disclosure in psychiatric nursing is limited, purposeful, and always client-centred. This does not primarily violate active listening (which concerns attending behaviours), empathic validation (acknowledging feelings), or non-judgmental acceptance (avoiding moral judgement).

A client with borderline personality disorder is being discharged after a brief hospitalization for self-harm. She tells the nurse, 'My therapist is the only one who truly gets me, but you nurses are completely useless.' Which concept best explains this client's statement, and what is the most therapeutic nursing response?

Answer: Splitting; acknowledge the client's feelings without reinforcing the idealization or devaluation, and maintain consistent team communication

Splitting is a hallmark defence mechanism in borderline personality disorder where the client divides people into entirely 'good' or 'bad' categories, unable to integrate ambivalent feelings. The therapeutic response is to calmly acknowledge the client's feelings without validating the split (neither agreeing she is useless nor dismissing the idealization of the therapist) and ensure the entire team communicates consistently so the split cannot be reinforced through team division. Transference involves projecting past relationship feelings onto one person. Projection involves attributing one's own unacceptable feelings to others. Countertransference describes the nurse's own emotional reactions.

A nurse is conducting a risk assessment for a client with major depressive disorder who has just been prescribed an SSRI. The client states, 'I finally feel like I have more energy and things might get better.' The nurse is most concerned because:

Answer: The client's improved energy in the early phase of treatment may provide enough motivation to act on previously formed suicidal ideation

This is a critical safety concept: SSRIs often improve psychomotor energy and motivation before mood fully lifts (typically in the first 1–2 weeks of treatment). During this window, a client who had suicidal ideation but was too psychomotorically retarded to act may now have the energy to follow through on a plan while the depressive cognitions remain. This is a well-established period of heightened suicide risk. SSRIs do not reach therapeutic antidepressant effect within 48 hours, so the interpretation in option A is incorrect. The optimism alone does not indicate remission. Serotonin syndrome presents with hyperthermia, clonus, and agitation — not energy alone.