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Mental Health Nursing II & Pharmacology III - UNMEB 2023
SECTION A: Objective Questions (20 marks)
💡 Exam Strategy: Mental health questions often test prioritization and therapeutic techniques. Pharmacology requires knowing drug classes, mechanisms, and specific uses. For "NOT" questions, eliminate the obviously correct options first!
1
In the management of chronic alcoholism, which of the following pharmacological agents acts by providing acute sensitivity to alcohol?
(b) Disulfiram
Disulfiram (Antabuse) causes acute alcohol sensitivity by irreversibly inhibiting aldehyde dehydrogenase. When alcohol is consumed, acetaldehyde accumulates causing disulfiram-alcohol reaction: flushing, nausea, vomiting, tachycardia, hypotension. This aversive conditioning deters drinking. Patient must understand risks and avoid all alcohol sources (mouthwash, cough syrup) for 14 days after last dose.
ALCOHOL TREATMENT: "DDD" - Detox (benzodiazepines), Disulfiram (aversion), Drugs (acamprosate, naltrexone)
2
Loosening of association is commonly seen in patients with
(c) Schizophrenia
Loosening of associations (derailment) is a cardinal thought disorder in schizophrenia, where the patient loses the logical connection between ideas. Speech jumps from one unrelated topic to another, making conversation incoherent. This reflects underlying cognitive disorganization and is one of Andreasen's "positive" symptoms of schizophrenia, indicating formal thought disorder.
🧩 Thought Disorder Patterns: Schizophrenia = Loose associations, Mania = Flight of ideas, Dementia = Tangentiality, Depression = Poverty of speech
3
Which of the following individuals is at highest risk for suicide?
(d) Low socio-economic status with recent diagnosis of cancer
This combination represents the highest suicide risk profile: low SES (poverty, reduced access to care, hopelessness) PLUS recent cancer diagnosis (perceived as death sentence, severe pain, treatment burden, loss of meaning). Cancer patients have suicide risk 2-4 times higher than general population, especially in first year after diagnosis. Low SES compounds this with lack of social support and mental health services.
SUICIDE RISK HIERARCHY: "CHAOS" - Cancer, Hopelessness, Alcohol, Old age, Social isolation
4
Which of the following is NOT an appropriate nursing diagnosis for a child with mental retardation?
(a) Aggressive behavior related to self care deficit
This is an inaccurate nursing diagnosis formulation. It incorrectly links aggressive behavior directly to self-care deficit, which is a "related to" clause that doesn't logically follow. Aggression in MR is typically related to communication frustration, sensory overload, or environmental demands, not directly to inability to perform self-care. A proper diagnosis would be "Aggressive behavior related to inability to communicate needs effectively" or "Self-care deficit related to cognitive impairment."
📝 Nursing Diagnosis Format: "Problem related to cause as evidenced by manifestations." Must show logical link between etiology and problem!
5
The priority nursing action for a patient with status epilepticus is to
(a) Loosen tight clothing
Priority is airway, breathing, circulation (ABC). Loosening tight clothing around the neck/chest facilitates breathing and prevents respiratory compromise during prolonged seizures. While medication administration is crucial, the FIRST action is to ensure physical safety and airway patency. Status epilepticus is a medical emergency requiring immediate intervention to prevent brain damage and death.
🚨 Status Epilepticus Protocol: ABC → Time seizure → IV access → Lorazepam 0.1 mg/kg → Glucose check → Second-line AEDs → ICU. NEVER force jaws open!
6
While developing a plan of care for an adolescent with an eating disorder, the nurse includes
(c) Family therapy to modify dysfunctional patterns
Family therapy is the most evidence-based approach for adolescent eating disorders. The Maudsley Model (Family-Based Treatment) has the strongest evidence, empowering parents to take control of refeeding while addressing family dynamics, communication patterns, and enmeshment that maintain the disorder. Eating disorders in adolescents are fundamentally family systems problems requiring family-level intervention.
EATING DISORDER PRIORITIES: "F-E-E-D" - Family therapy, Eating restoration, Electrolyte monitoring, Decision-making capacity assessment
7
Which of the following treatment options is most relevant for sexually traumatized children?
(b) Analytical play therapy
Analytical play therapy is specifically designed for traumatized children who cannot verbalize experiences. Through symbolic play with dolls, sandbox, drawing, children reenact and process trauma safely. The therapist interprets symbolic content to understand trauma narrative without direct questioning that could retraumatize. This approach respects child's developmental stage and need for indirect expression of overwhelming experiences.
🎭 Play is Children's Language: Traumatized children lack verbal capacity for traumatic memories. Play provides symbolic distance to process safely. Never force verbal disclosure!
8
Flamboyant dressing and extravagance are typical signs seen in patients suffering from
(b) Mania
Flamboyant dressing and extravagance are classic signs of mania reflecting disinhibition, grandiosity, and heightened self-esteem. Patients wear bright colors, excessive jewelry, provocative clothing, and make impulsive luxury purchases they cannot afford. This behavioral manifestation indicates impaired judgment and frontal lobe dysfunction characteristic of manic episodes in bipolar disorder.
MANIC APPEARANCE: "FLASH" - Flamboyant, Loud, Attention-seeking, Sexually provocative, Hyperactive
9
Patient's suffering from anxiety due to phobia are best managed through
(a) Desensitization
Systematic desensitization is the gold standard for phobia treatment. This behavioral therapy involves graduated exposure to feared stimulus while using relaxation techniques. Hierarchy goes from least to most anxiety-provoking situations. Pairing relaxation with exposure extinguishes conditioned fear response. Evidence-based for specific phobias, social phobia, and agoraphobia with 80-90% efficacy.
🪜 Desensitization Steps: 1) Learn relaxation, 2) Create fear hierarchy, 3) Exposure + Relaxation, 4) Gradual progression. Works by counter-conditioning!
10
Which of the following is a cardinal feature of catatonic stupor?
(c) Negativism
Negativism is a cardinal feature of catatonic stupor - patient actively resists movement or does opposite of what is asked (mitgehen, gegenhalten). May refuse to eat, drink, or cooperate with any requests. This oppositional behavior is involuntary and reflects extreme psychomotor disturbance. DSM-5 includes negativism as one of 12 catatonic signs (along with stupor, catalepsy, waxy flexibility).
CATATONIC SIGNS: "St. WNC" - Stupor, Waxy flexibility, Negativism, Catalepsy
11
Which of the following narcotic drugs is prescribed concomitantly with bisacodyl to counteract its side effects?
❌ Morphine
Morphine (a narcotic) causes severe constipation, requiring a concomitant stimulant laxative like bisacodyl.
💊 Opioid-Induced Constipation: Manage with osmotics (PEG), stimulants (senna), or peripherally acting mu-opioid antagonists (methylnaltrexone, naloxegol).
12
The nurse informs a woman interested in depo-provera that its side effects exclude
(d) Infertility
Depo-Provera (medroxyprogesterone acetate) does NOT cause permanent infertility. Fertility returns after discontinuation, though there may be a delay of 6-12 months before ovulation resumes. This is a reversible contraceptive method. All other options are known side effects: headaches (common), blood clots (rare but serious risk with progestins), and numbness can occur with injection site reactions or nerve irritation.
DEPO SIDE EFFECTS: "BONE-HEAD" - Bleeding irregularities, Osteoporosis, Nausea, Weight gain, Headache, Emotional lability, Amenorrhea, Depression
13
Which of the following drugs is administered to a patient suffering from atropine toxicity?
(b) Physostigmine
Physostigmine is the antidote for anticholinergic (atropine) toxicity. It's a tertiary amine that crosses blood-brain barrier and inhibits acetylcholinesterase, increasing acetylcholine to counteract atropine's anticholinergic effects. Reverses CNS symptoms (delirium, seizures) and peripheral symptoms (dry mouth, tachycardia, hyperthermia). Given IV slowly (1-2 mg over 5 min) with cardiac monitoring due to risk of bradycardia and seizures.
🧪 Anticholinergic Toxidrome: "Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter." Physostigmine is diagnostic AND therapeutic!
14
Which of the following newly introduced vaccines is administered together with measles at 9 months of age?
(b) Yellow fever
In Uganda and other endemic regions, yellow fever vaccine is administered at 9 months alongside measles vaccine per the Expanded Programme on Immunization (EPI) schedule. This is co-administration at same visit (different sites/injection equipment). Yellow fever vaccine is a live attenuated vaccine providing lifetime immunity. Hepatitis B is at birth, 6 weeks, 10 weeks; rotavirus at 6, 10 weeks; MMR at 12-15 months.
Uganda EPI Schedule: "BY6-9-12" - Birth (BCG, Polio0, HepB0), Yellow fever at 9 months, Measles at 9 months, MMR at 12 months
15
Which of the following drugs is administered to inhibit uterine contractions in a pregnant woman experiencing premature labour?
(a) Salbutamol
Salbutamol (albuterol) is a beta-2 adrenergic agonist tocolytic that inhibits uterine contractions by increasing cAMP and decreasing intracellular calcium in myometrial cells. Given IV infusion (10-20 mcg/min) for acute preterm labor. Relaxes smooth muscle including bronchi and uterus. Side effects: maternal tachycardia, tremor, hyperglycemia, pulmonary edema. Second-line to nifedipine due to side effect profile.
TOCOLYTICS: "N-A-S" - Nifedipine (Ca channel blocker), Atosiban (oxytocin antagonist), Salbutamol (beta-agonist)
16
Which of the following doses of magnesium sulphate is administered as a maintenance dose in a patient with eclampsia?
(a) 5g of 50%
Magnesium sulfate maintenance dose for eclampsia is 5g of 50% solution IM every 4 hours alternating buttocks (or 1g/hour IV infusion). Loading dose is 4-6g IV over 15-20 minutes. Total duration is 24 hours postpartum or last seizure. This regimen prevents recurrent seizures by CNS depression and vasodilation. Monitor for toxicity: loss of deep tendon reflexes, respiratory depression, decreased urine output.
MAG SULFATE REGIMEN: "4-5-24" - 4g load, 5g maintenance q4h, continue for 24 hours
⚠️ Toxicity Signs: Loss of deep tendon reflexes (first sign), respiratory depression (<12 breaths/min), oliguria (<30 mL/hr). Antidote: 10% Calcium gluconate 10 mL IV slow push!
17
Bromocriptine antagonises the action of
(c) Prolactine
Bromocriptine is a dopamine D2 receptor agonist that suppresses prolactin secretion from anterior pituitary. Dopamine normally inhibits prolactin release (prolactin-inhibiting factor). Bromocriptine mimics this action, lowering prolactin levels. Used for hyperprolactinemia, prolactinomas, and lactation suppression. Must be taken with food to reduce nausea. Contraindicated in uncontrolled hypertension.
BROMOCRIPTINE MECHANISM: "D2-LOW-PRL" - D2 agonist, LOWers ProLactin
18
Which of the following is NOT an indication of misoprostol?
(b) Management of antepartum haemorrhage
Antepartum hemorrhage (APH) is a CONTRAINDICATION for misoprostol. APH (from placenta previa, abruptio placentae) requires emergency delivery (C-section) and hemodynamic stabilization, NOT uterine stimulation. Misoprostol would worsen bleeding by stimulating uterine contractions. Its use in APH could cause catastrophic maternal-fetal outcomes.
⚠️ Critical Contraindication: Misoprostol should NEVER be used with suspected uterine scar (previous C-section) for induction due to risk of uterine rupture!
19
Which of the following drugs is administered to block opioid receptors associated with reward effects of alcohol use?
(b) Naltrexone
Naltrexone is a mu-opioid receptor antagonist that blocks the rewarding effects of alcohol. Alcohol releases endogenous opioids (endorphins) which activate dopamine reward pathways. By blocking opioid receptors, naltrexone reduces craving and prevents the "high" from drinking. Used in alcohol dependence maintenance therapy. Available as oral daily or monthly IM injection (Vivitrol). Must be opioid-free for 7 days before starting.
ALCOHOL PHARMACOTHERAPY: "N-A-D" - Naltrexone (blocks reward), Acamprosate (reduces craving), Disulfiram (aversive)
20
Which of the following is a commonly used synthetic form of opium?
(d) Methadone
Methadone is a fully synthetic opioid agonist used in opioid dependence treatment. It has long half-life (24-36 hours), preventing withdrawal symptoms for 24+ hours. Binds to mu-opioid receptors, reducing craving and euphoria from illicit opioids. Allows normalization of body functions and engagement in rehabilitation. Must be dispensed through licensed opioid treatment programs. Risk of overdose in first 2 weeks due to QT prolongation and respiratory depression.
OPIOID TYPES: "Natural - Semi - Synthetic" - Opium (natural), Heroin (semi), Methadone (synthetic)
⚕️ Methadone Maintenance: Daily supervised dosing prevents diversion. Must combine with counseling and psychosocial support. Buprenorphine (Suboxone) is safer alternative with lower overdose risk.
SECTION B: Fill in the Blank Spaces (10 marks)
21
A life threatening eating disorder characterized by marked fear of obesity is called ________________
Anorexia nervosa
Anorexia nervosa has the highest mortality rate of any psychiatric disorder (10-20%). Core features: restriction of energy intake leading to significantly low weight, intense fear of gaining weight or becoming fat, and disturbance in self-perceived weight/shape. Subtypes: restricting type and binge-purge type. Complications include cardiac arrhythmias, refeeding syndrome, osteoporosis, and suicide. Requires multidisciplinary treatment: medical, nutritional, psychiatric.
22
Intentional falsification of symptoms to assume a sick role is called ________________
Factitious disorder (or Munchausen syndrome)
Factitious disorder involves deliberate production of physical or psychological symptoms to obtain the sick role and medical attention without external rewards (no financial gain). Patients may self-inject, contaminate wounds, or falsify labs. They subject themselves to painful procedures. Differs from malingering where external secondary gain is present. Requires careful non-confrontational management to avoid "doctor shopping."
23
Repetitive wetting of one's clothes or bed by children older than 5 years of age is referred to as ________________
Enuresis
Enuresis is involuntary voiding of urine in children >5 years (or developmental equivalent). Subtypes: nocturnal (night), diurnal (day), or mixed. Primary enuresis: never achieved continence. Secondary enuresis: relapse after 6 months of dryness. Etiology: genetic, developmental delay, small bladder capacity, nocturnal polyuria, overactive bladder, psychological stress. Treatment: behavioral (bedwetting alarm), pharmacological (desmopressin, imipramine), and addressing underlying issues.
24
Presence of anxiety coupled with severe motor restlessness is known as ________________
Akathisia (or severe psychomotor agitation)
Akathisia is a neuropsychiatric syndrome characterized by subjective inner restlessness and objective motor restlessness. Patients report inability to sit still, compelling need to move, and anxiety. Manifests as pacing, shifting weight, rocking. Common side effect of antipsychotics (dopamine blockade) and SSRIs. Can be mistaken for worsening psychosis but is actually an extrapyramidal symptom. Treat by reducing offending drug or adding beta-blocker (propranolol), benzodiazepine, or anticholinergic.
25
The type of electro-convulsive therapy that involves administering drugs to relax muscles is called ________________
Modified ECT (or Modified electroconvulsive therapy)
Modified ECT involves muscle relaxation with succinylcholine and general anesthesia with short-acting barbiturate (thiopental or propofol). This prevents the violent tonic-clonic convulsions and associated fractures/dislocations seen in unmodified ECT. Pre-treatment with atropine reduces bradycardia and secretions. Modified ECT is the standard of care worldwide, making it a safe and humane procedure. Still induces therapeutic seizure in brain while muscles remain paralyzed.
26
Immunological agents administered to prevent disease progression in most autoimmune joint disorders are collectively called ________________
Disease-modifying antirheumatic drugs (DMARDs)
DMARDs are immunosuppressive/immunomodulatory drugs that slow or halt progression of rheumatoid arthritis and other autoimmune joint diseases. Conventional synthetic DMARDs: methotrexate, sulfasalazine, leflunomide. Biological DMARDs: TNF inhibitors (etanercept, infliximab), IL-6 inhibitors (tocilizumab), JAK inhibitors (tofacitinib). They suppress immune system to prevent joint destruction. Require monitoring for infection, hepatotoxicity, and bone marrow suppression. Unlike NSAIDs, they modify disease course, not just symptoms.
27
The generic name for Viagra is called ________________
Sildenafil citrate
Sildenafil is a phosphodiesterase type 5 (PDE5) inhibitor. Originally developed for hypertension, it was found to cause penile erections. Works by inhibiting PDE5 enzyme that degrades cyclic GMP in corpus cavernosum. Increased cGMP causes smooth muscle relaxation and vasodilation, enhancing blood flow for erection. Also used for pulmonary arterial hypertension (Revatio brand). Contraindicated with nitrates due to severe hypotension. Side effects: headache, flushing, visual disturbances, priapism.
28
The active ingredient in contraceptives recommended for lactating women with infants below six months of age is called ________________
Progestin-only (levonorgestrel or norethindrone) - the "mini-pill" or Depo-Provera
Progestin-only contraceptives are first-line for breastfeeding women because estrogen suppresses milk production. Progestin-only methods (mini-pill, Depo-Provera, implant) do not significantly affect milk supply or infant growth. Safe for postpartum use immediately after delivery. However, WHO recommends waiting 6 weeks postpartum for Depo-Provera to avoid infant exposure, while mini-pill can be started immediately. Copper IUD is also excellent non-hormonal option.
29
The route of administration of measles vaccine is ________________
Subcutaneous (SC) injection
Measles vaccine is administered via subcutaneous injection into the fatty tissue of the upper outer arm. This route is used for live attenuated vaccines that require slower absorption than IM. Angle of insertion is 45 degrees. Needle size: 25-27 gauge, 5/8" length. Reconstituted vaccine must be used within 6 hours. Cannot be given IM or IV as this can cause reduced immunogenicity or adverse reactions. If given >6 hours after reconstitution, vaccine loses potency and must be discarded.
30
The substance administered to reactivate acetylcholinesterase after organophosphate poisoning is ________________
Pralidoxime (2-PAM)
Pralidoxime is an oxime that reactivates acetylcholinesterase inhibited by organophosphates. Organophosphates (pesticides, nerve agents) phosphorylate acetylcholinesterase, causing irreversible inhibition. Pralidoxime attaches to the enzyme and removes the phosphate group, restoring enzyme function. Must be given within 24-48 hours before "aging" occurs (irreversible binding). Administered IV slowly (over 15-30 minutes) to prevent hypertension. Given with atropine to control muscarinic symptoms. Repeat doses may be needed.
ORGANOPHOSPHATE ANTIDOTES: "A-P-R" - Atropine (muscarinic), Pralidoxime (reactivates enzyme), Respiratory support
☠️ Organophosphate Poisoning Signs: "DUMBBELSS" - Diarrhea, Urination, Miosis, Bronchorrhea, Bradycardia, Lacrimation, Sweating, Salivation. Give atropine until secretions dry up!
SECTION B: Short Essay Questions (10 marks)
31
Outline five (5) predictors of poor prognosis in schizophrenia. (5 marks)
Poor prognosis factors indicate treatment resistance and chronic disability:
1. Young age of onset (<18 years): Earlier onset associated with more severe neurodevelopmental abnormalities, worse cognitive impairment, and poorer functional recovery.
2. Insidious onset and long duration of untreated psychosis (DUP >2 years): Gradual onset and delay in treatment leads to neurodegeneration and entrenched symptoms that become treatment-resistant.
3. Prominent negative symptoms: Flat affect, avolition, anhedonia, alogia predict poor response to antipsychotics and greater functional disability compared to positive symptoms.
4. Family history of schizophrenia with poor outcome: Genetic loading for severe illness and treatment resistance increases likelihood of similar poor response in patient.
5. Poor premorbid social and occupational functioning: History of social isolation, academic failure, and occupational instability before illness onset predicts inability to achieve functional recovery.
📉 Prognosis Rule: Positive symptoms = better outcome, Negative symptoms = worse outcome, Cognitive deficits = worst outcome. Early intervention is critical!
32
Outline five (5) non-contraceptive benefits of combined oral contraceptives. (5 marks)
COCs have significant therapeutic benefits beyond pregnancy prevention:
1. Regulates menstrual cycles and reduces heavy menstrual bleeding: Stabilizes endometrium reducing menorrhagia and dysmenorrhea by 60-70%, prevents ovulatory dysfunction bleeding.
2. Reduces risk of ovarian and endometrial cancer: 50% reduction in ovarian cancer risk with 5 years use; 30-50% reduction in endometrial cancer. Protection persists 15+ years after stopping.
3. Manages acne and hirsutism: Reduces androgen production and increases sex hormone binding globulin; improves acne by 50-70% and reduces excess hair growth in PCOS.
4. Prevents ovarian cysts: Suppresses ovulation preventing formation of functional ovarian cysts and reduces recurrence of benign cysts.
5. Reduces premenstrual syndrome (PMS) and endometriosis symptoms: Stabilizes hormonal fluctuations reducing mood, breast tenderness, bloating. Suppresses endometrial implants reducing pain and progression.
SECTION C: Long Essay Questions (60 marks)
33
(a) Outline five (5) predisposing factors to generalized anxiety disorder in children. (5 marks)
(b) Outline ten (10) assessment findings for a child with anxiety disorder. (10 marks)
(c) Outline five (5) management measures shared with caregivers of a child suffering from generalized anxiety disorder. (5 marks)
(b) Outline ten (10) assessment findings for a child with anxiety disorder. (10 marks)
(c) Outline five (5) management measures shared with caregivers of a child suffering from generalized anxiety disorder. (5 marks)
(a) Predisposing Factors to GAD in Children:
1. Genetic vulnerability and family history: Children of parents with anxiety disorders have 3-5x increased risk due to genetic predisposition and modeled anxious behaviors.
2. Overprotective/controlling parenting style: Parents who are excessively cautious, prevent independence, and reinforce avoidance behaviors prevent child from developing coping skills.
3. Traumatic or stressful life events: Abuse, bullying, parental divorce, school pressure, medical illness can trigger excessive worry and anxiety.
4. Temperamental traits: Inhibited, shy temperament (behavioral inhibition) and difficulty with uncertainty predisposes to anxiety disorders.
5. Neurobiological factors: Overactive amygdala (fear center) and dysregulated HPA axis lead to heightened stress response and threat perception.
(b) Assessment Findings for Child with Anxiety Disorder:
1. Excessive worry about multiple domains: Academic performance, social competence, health, safety, future events - worries are disproportionate to actual risk.
2. Somatic complaints: Frequent stomachaches, headaches, muscle tension, fatigue, sleep disturbances without medical cause, especially before school or stressful events.
3. Behavioral avoidance: School refusal, avoiding social situations, new activities, or speaking in public due to fear of negative evaluation.
4. Restlessness and hypervigilance: Constant fidgeting, difficulty sitting still, easily startled, scanning environment for threats, poor concentration.
5. Sleep disturbances: Difficulty falling asleep, frequent nightmares, restless sleep, insisting on sleeping with parents due to nighttime fears.
6. Perfectionism and need for reassurance: Excessive checking of work, seeking constant approval, inability to tolerate uncertainty or mistakes.
7. Irritability and emotional lability: Frequent tearfulness, tantrums when faced with anxiety-provoking situations, low frustration tolerance.
8. Physical signs of autonomic arousal: Rapid breathing, sweating, trembling, racing heart, dilated pupils during anxiety episodes.
9. Social withdrawal and peer relationship difficulties: Isolating from peers, difficulty making friends, appearing scared or shy in social situations.
10. Impaired academic functioning: Declining grades, test anxiety, difficulty completing assignments due to perfectionism and concentration problems.
(c) Management Measures for Caregivers:
1. Psychoeducation about anxiety: Explain that anxiety is treatable, brain-based condition; reduce guilt and stigma; teach that avoidance worsens anxiety.
2. Gradual exposure and response prevention: Guide caregivers to create fear hierarchy and encourage child to face fears gradually while preventing avoidance behaviors.
3. Modeling and reinforcement of brave behaviors: Teach parents to demonstrate calm coping, praise effort not just success, use reward systems for anxiety-facing behaviors.
4. Establish consistent routines and structure: Predictable schedules reduce uncertainty; teach relaxation techniques (deep breathing, progressive muscle relaxation) for child to use during anxiety.
5. Limit reassurance-seeking: Teach caregivers to set boundaries on repeated reassurance questions; respond with "You've already asked that, what do you think?" to promote self-reliance.
34
(a) Outline five (5) key points considered in suicide risk assessment. (5 marks)
(b) Outline three (3) appropriate nursing diagnoses for a patient admitted with features suggestive of suicide behaviour. (3 marks)
(c) Outline twelve (12) nursing actions implemented for a patient admitted with suicidal ideations. (12 marks)
(b) Outline three (3) appropriate nursing diagnoses for a patient admitted with features suggestive of suicide behaviour. (3 marks)
(c) Outline twelve (12) nursing actions implemented for a patient admitted with suicidal ideations. (12 marks)
(a) Key Points in Suicide Risk Assessment:
1. Presence and specificity of suicidal ideation: Assess if thoughts are fleeting vs. persistent, and whether there is a specific plan (method, time, place). Specific plans indicate higher risk than vague thoughts.
2. Access to lethal means: Evaluate availability of firearms, medications, sharp objects, or other methods. Access to highly lethal means (guns) dramatically increases completed suicide risk.
3. Previous suicide attempts: History of attempts is the strongest predictor of future attempts and completions. Assess method, lethality, and timing of previous attempts.
4. Protective factors and reasons for living: Assess family support, religious beliefs, future goals, responsibility to children. Strong protective factors can mitigate risk temporarily.
5. Underlying mental state and substance use: Evaluate severity of depression, psychosis (especially command hallucinations), impulsivity, and current alcohol/drug intoxication which can disinhibit suicidal behavior.
(b) Nursing Diagnoses for Suicidal Behavior:
1. Risk for suicide related to severe depression and feelings of hopelessness: Evidence: verbalized suicidal ideation, previous attempts, social isolation, giving away possessions.
2. Hopelessness related to perception of insurmountable life stressors: Evidence: statements of "no way out," flat affect, inability to identify reasons for living, poor eye contact.
3. Social isolation related to withdrawal from support systems: Evidence: living alone, alienated from family, no visitors, states "nobody cares if I die," avoids group activities.
(c) Nursing Actions for Suicidal Ideations:
1. Implement 1:1 continuous observation: Assign dedicated staff member within arm's reach at all times; document every 15 minutes; prevents opportunity for self-harm.
2. Conduct environmental safety check: Remove all potential ligature points, sharp objects, medications, cords, glass, and plastic bags from patient's environment.
3. Search patient belongings for contraband: Thoroughly check personal items for hidden medications, sharps, or ligatures upon admission and after visits.
4. Develop therapeutic rapport and trust: Spend time listening without judgment; convey genuine concern; encourage expression of feelings to reduce isolation.
5. Administer and monitor psychotropic medications: Ensure patient swallows medication, observe for therapeutic effects and side effects; collaborate with psychiatrist for urgent medication review.
6. Conduct frequent risk reassessment: Reassess suicide risk every shift and with any behavioral change; document findings meticulously in objective language.
7. Involve family in care and safety planning: Educate family about warning signs, need for removal of means at home, and how to provide support without being overly intrusive.
8. Encourage and supervise participation in therapeutic activities: Facilitate attendance in groups, occupational therapy, and recreational activities to promote engagement and distraction from suicidal thoughts.
9. Provide basic needs and personal care assistance: Help with hygiene, meals, and comfort measures as patient may lack motivation for self-care; maintains dignity and human connection.
10. Create no-suicide contract during lucid moments: Obtain verbal/written agreement to seek help before acting on suicidal thoughts; discuss coping strategies for when urges intensify.
11. Monitor for warning signs of imminent attempt: Watch for sudden mood improvement (may indicate decision to die), giving away belongings, or preoccupation with death.
12. Ensure adequate sleep and nutrition: Provide calm environment, bedtime routine, and monitor food intake; sleep deprivation and malnutrition worsen depression and impulse control.
SUICIDE PREVENTION ACTIONS: "SAFE-T-NURSE" - Search, Assess, Follow, Observe, Remove means, Therapy, Nutrition, Urge monitoring, Rest, Support, Educate
🚨 NEVER leave suicidal patient alone! Even for bathroom breaks. Use suicide-resistant rooms, remove all personal belongings, provide hospital gown. Safety is non-negotiable!
35
(a) Outline five (5) nursing diagnoses for a patient with narcotic abuse. (5 marks)
(b) Outline ten (10) priority nursing interventions for managing a 30 year old man with narcotic abuse disorder for the 1st week of admission. (10 marks)
(c) Outline five (5) measures implemented to minimize abuse of narcotics in Uganda. (5 marks)
(b) Outline ten (10) priority nursing interventions for managing a 30 year old man with narcotic abuse disorder for the 1st week of admission. (10 marks)
(c) Outline five (5) measures implemented to minimize abuse of narcotics in Uganda. (5 marks)
(a) Nursing Diagnoses for Narcotic Abuse:
1. Risk for injury related to central nervous system depression and overdose: Evidence: drowsiness, respiratory rate <12/min, constricted pupils, history of using unknown quantities.
2. Imbalanced nutrition: less than body requirements related to inadequate dietary intake: Evidence: weight loss, poor appetite, neglecting meals while seeking drugs, malabsorption due to chronic constipation.
3. Ineffective coping related to dependence on substances as stress management: Evidence: inability to deal with stress without opioids, verbalized inability to stop using, continued use despite negative consequences.
4. Risk for infection related to intravenous drug use and immunosuppression: Evidence: track marks, sharing needles, abscesses, HIV/Hepatitis C positive status, cellulitis.
5. Disturbed sleep pattern related to withdrawal symptoms and drug-seeking behavior: Evidence: insomnia during withdrawal, daytime sleeping, irregular sleep-wake cycles, nightmares.
(b) 1st Week Nursing Interventions for Narcotic Abuse:
1. Monitor for signs of withdrawal and provide symptom management: Assess using CIWA-Ar scale, administer prescribed methadone or buprenorphine to alleviate withdrawal symptoms (nausea, vomiting, diarrhea, muscle cramps, anxiety).
2. Maintain airway and respiratory monitoring: Check respiratory rate every 2-4 hours, especially if tapering; have naloxone readily available; watch for signs of respiratory depression if patient obtains illicit substances.
3. Provide supportive care for withdrawal symptoms: Administer antiemetics, antidiarrheals, analgesics (non-opioid), encourage fluid intake; provide quiet environment, dim lighting for photophobia.
4. Initiate nutritional support: Provide small frequent meals, high-calorie supplements to address malnutrition; monitor weight and electrolytes; treat constipation with fluids and fiber.
5. Establish therapeutic relationship and build trust: Approach non-judgmentally, maintain consistent boundaries, show empathy to reduce shame and increase engagement in treatment.
6. Monitor for infection and provide wound care: Inspect IV sites for abscesses, cellulitis; culture and treat infections; educate about safer injection practices; test for HIV/Hepatitis.
7. Implement suicide and self-harm precautions: High risk during withdrawal and early abstinence; assess depression and suicidal ideation; remove means; provide close observation if needed.
8. Provide education about addiction as a disease: Explain neurobiology of dependence, withdrawal, and recovery; reduce self-blame; set realistic expectations for recovery process.
9. Facilitate transition to maintenance therapy: Coordinate with addiction specialist for methadone/buprenorphine maintenance; ensure continuity of care plan for discharge.
10. Engage family and social support: With patient consent, involve family in treatment planning; educate about enabling behaviors; facilitate family therapy to address dysfunctional dynamics.
(c) Measures to Minimize Narcotic Abuse in Uganda:
1. Strict regulation and control of narcotic prescribing: Narcotic prescribing limits, special prescription forms, monitoring of physician prescribing patterns, mandatory training for prescribers.
2. Establishment of national drug tracking system: Electronic database to monitor narcotic distribution from manufacturer to pharmacy to patient; prevents diversion and "doctor shopping."
3. Public education campaigns: Community awareness about dangers of opioid misuse, proper disposal of unused medications, and available treatment resources; reduces stigma and increases help-seeking.
4. Expansion of addiction treatment services: Increase availability of methadone maintenance clinics, counseling services, and rehabilitation centers; integrate into primary healthcare.
5. Law enforcement interdiction of illicit narcotics: Strengthen border control, crack down on heroin trafficking, prosecute illegal pharmaceutical distribution networks while ensuring access for legitimate medical use.
ABUSE PREVENTION: "R-C-P-E-L" - Regulation, Control, Public education, Enforcement, Legal treatment access
💉 Harm Reduction Approach: Provide clean needles, naloxone distribution, safe consumption sites. Stigma and punishment drive addiction underground. Treatment works better than incarceration!