Psychiatric and Mental Health Nursing Flashcards

A patient on lithium carbonate for bipolar I disorder presents to a Saudi psychiatric unit with coarse tremors, ataxia, slurred speech, and worsening confusion. His serum lithium level is 2.3 mEq/L. Which intervention is the PRIORITY?

Answer: Discontinue lithium immediately and initiate IV isotonic saline hydration

A serum lithium level of 2.3 mEq/L represents moderate toxicity (2.0–2.5 mEq/L), manifesting as CNS symptoms (ataxia, confusion) and neuromuscular signs. The priority is stopping lithium and restoring sodium balance with IV normal saline, as sodium competes with lithium for renal reabsorption, promoting lithium excretion. Hemodialysis is reserved for severe toxicity (levels >3.5 mEq/L, or severe/refractory symptoms). Reducing the dose is inadequate for moderate toxicity. Sodium bicarbonate is not a standard intervention for lithium toxicity.

Under the Saudi Mental Health Law (Royal Decree No. M/63, 1435H), which combination of criteria is REQUIRED to justify involuntary psychiatric hospitalization?

Answer: The patient poses a danger to self or others AND voluntary treatment is not achievable

Under Saudi Mental Health Law (Royal Decree M/63, 1435H), involuntary (compulsory) admission requires both conditions: (1) the patient presents a clear danger to themselves or others due to a mental disorder, AND (2) voluntary treatment cannot be achieved. Family consent or request alone does not satisfy the legal threshold; the law protects patient autonomy and requires the dual criteria to be met. This aligns with international human rights frameworks adopted by the Kingdom.

A patient with treatment-resistant schizophrenia on clozapine has a routine absolute neutrophil count (ANC) of 420 cells/mm³. He is currently asymptomatic for infection. What is the MOST appropriate nursing action?

Answer: Permanently discontinue clozapine, initiate protective isolation, and place the patient on the do-not-rechallenge registry

An ANC below 500 cells/mm³ constitutes severe agranulocytosis. Per clozapine monitoring protocols (including REMS guidelines followed in Saudi practice), severe agranulocytosis mandates immediate and permanent discontinuation of clozapine. The patient must be placed on a do-not-rechallenge registry to prevent re-exposure. Protective isolation is initiated due to the profound infection risk. Dose reduction or temporary withholding is only appropriate for mild neutropenia (ANC 1000–1499); it is dangerously insufficient at this level.

A psychiatric nurse is evaluating two deteriorating patients. Patient A (on haloperidol) developed hyperthermia (40.2°C), 'lead-pipe' generalized rigidity, diaphoresis, and a markedly elevated CK over 48–72 hours. Patient B (on sertraline + tramadol started 6 hours ago) developed fever, agitation, diaphoresis, inducible clonus, and hyperreflexia within 2 hours of a dose change. Which feature BEST differentiates these two conditions?

Answer: The type of neuromuscular abnormality and onset timeline

The most reliable differentiator between Neuroleptic Malignant Syndrome (NMS) and Serotonin Syndrome (SS) is the combination of neuromuscular findings and onset speed. NMS presents with 'lead-pipe' rigidity and hyporeflexia/bradyreflexia, developing over days. SS presents with clonus (especially inducible), hyperreflexia, and tremor, developing within hours of serotonergic agent initiation or dose change. Both can cause hyperthermia, diaphoresis, and autonomic instability. CK is markedly elevated in NMS due to rhabdomyolysis; it is usually normal or mildly elevated in SS.

A psychiatrist at a Saudi tertiary hospital recommends electroconvulsive therapy (ECT) for a patient with severe, psychotic, treatment-resistant major depressive disorder. During the pre-ECT nursing assessment, the nurse discovers the patient has a brain CT showing a 3 cm meningioma with significant surrounding edema and early midline shift. How should the nurse proceed?

Answer: Postpone ECT and immediately report the finding to the treatment team, as this represents the closest condition to an absolute contraindication

While ECT has no universally accepted absolute contraindications, a space-occupying intracranial lesion with raised intracranial pressure (ICP) and mass effect (evidenced by surrounding edema and midline shift) is the condition most consistently cited as the closest to an absolute contraindication. ECT causes a transient surge in ICP during the seizure, which could precipitate brain herniation in this patient. The nurse must halt the process and escalate immediately to the treatment team for neurosurgical consultation before any ECT proceeds. Steroid pre-treatment alone is insufficient without neurosurgical clearance.

A psychiatric nurse has been assigned to a male patient admitted for major depressive disorder. Over several weeks, she notices she becomes distressed when he misses sessions, brings him personal items 'to cheer him up,' stays late on her shifts specifically to be available to him, and realizes he resembles her younger brother who died by suicide. This clinical phenomenon is BEST described as:

Answer: Countertransference — the nurse is experiencing an unconscious emotional response rooted in her own personal history

Countertransference refers to the nurse's (or clinician's) unconscious emotional reactions toward a patient, driven by the nurse's own unresolved conflicts, experiences, or needs — in this case, her unresolved grief over her brother's suicide. It differs from transference (which is the patient projecting feelings onto the clinician). While the behaviors described also constitute boundary violations, the root mechanism is countertransference. Recognizing it is essential; the nurse must bring this to clinical supervision immediately. Unexamined countertransference can severely compromise therapeutic integrity and patient safety, particularly with suicidal patients.