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The psychiatrist on call comes in to evaluate J.B. after meeting with J.B., the psychiatrist writes an order for escitalopram (Lexapro) 10 mg daily at bedtime.
  J.B. is scheduled to see the psychiatrist the day after he
  is discharged from the hospital.
  What special instructions will you give him regarding the Lexapro? Select all that apply.
  a. The full effects of the medication might not be seen for 4 to 6 weeks.
  b. The medication may cause nausea, dry mouth, sedation, and insomnia.
  c. There are no known food interactions.
  d. The herbal product St. John's wort will enhance the action of the Lexapro.
  e. Taking a glass of wine at bedtime will help him go to sleep.
  Why do you think that a drug in the SSRI class was chosen over a tricyclic antidepressant or a
  monoamine oxidase inhibitor (MAOI)?

Question 2

You decide to notify J.B.'s physician about your findings. the attending physician calls in a psychiatrist to evaluate J.B.
  Identify two treatments that are available for depression.
  Would J.B. be a candidate for electroconvulsive therapy (ECT)? Why or why not?

Question 3

You use the sadPeRsONsscale to assess J.B.'s potential for suicide and find that he is at a 4 on the 10-point scale. J.B. tells you that he has just had general thoughts of suicide
  but has not really thought about how he would do it. you recall that there are two types of suicide methods based on lethality:
  higher-risk or hard methods, and lower-risk or soft methods.
  Which of these would be considered soft methods of suicide? Select all that apply.
  a. Using a gun
  b. Slashing one's wrist
  c. Hanging
  d. Poisoning with carbon monoxide
  e. Ingesting pills
  f. Inhaling natural gas
  What immediate interventions would you carry out for J.B.?

Question 4

You are working the day shift on a medical inpatient unit. you are discussing discharge instructions with J.B., an 86-year-old man who was admitted for mitral valve repair
  His serum blood glucose had been
  averaging 250 mg/dL or higher for the past several months. during this admission, his dosage of insulin
  was adjusted and he was given additional education in managing his diet. While you are giving these
  instructions, J.B. tells you his wife died 9 months ago. He becomes tearful when telling you about that loss
  and the loneliness he has been feeling. He tells you he just doesn't feel good lately, feels sad much of the
  time, and hasn't been involved in his normal activities. He has few friends left in the community because
  most of them have passed away. He has a daughter in town, but she is busy with her work and grandchil-dren. He tells you that he has been feeling so down the past few months that he has had thoughts about
  What other information should you ask J.B. regarding his thoughts of suicide?
  What characteristics of J.B. put him at high risk for suicide?
  Which psychiatric disorders can result in suicidal ideations or gestures? Name at least three
  What questions would you ask J.B. to determine whether he is clinically depressed? Name at
  least six.
  Ill people often have trouble sleeping, experience a change in appetite, reduce their level of
  activity, and have thoughts of death. How can you tell the difference between old age with
  illness and depression?
  List five of the most common signs of depression in the older adult.

Question 5

K.B. is discharged and sees his primary care physician 2days later. K.B. receives a prescription for donepe-zil (aricept) 5 mg PO per night
  as you review the prescription with K.B.'s daughter, she tells you that she is
  excited because she did not know there were medications that could cure alzheimer's disease.
  How do you respond?
  What is the best answer for her question?
  K.B.'s daughter mentions that she has found him out in the front yard and once in the
  neighbor's yard. What are some interventions that you can suggest to promote safety
  for K.B.?

Question 6

After review of K.B.'s history and diagnostic test results, K.B. is diagnosed with alzheimer's dementia. the physician calls a family conference to discuss the implications with K.B. and his daughter.
  What neuroanatomic changes are seen in individuals with Alzheimer's disease?
  List at least three interventions you would plan for K.B.

Question 7

You are the nurse working triage in the emergency department. this afternoon, a woman brings in her father, K.B., who is 74 years old
  the daughter reports that over the past year she has noticed her father has
  progressively had problems with his mental capacity. these changes have developed gradually but seem
  to be getting worse. at times he is alert and at other times he seems disoriented, depressed, and tearful.
  He is forgetting things and doing things out of the ordinary, such as placing the milk in the cupboard and
  sugar in the refrigerator. K.B. reports that he has been having memory problems for the past year and
  at times has difficulty remembering the names of family members and friends. His neighbor found him
  down the street 2 days ago, and K.B. did not know where he was. this morning he thought it was night-time and wondered what his daughter was doing at his house. He could not pour his own coffee, and he
  seems to be getting more agitated. a review of his past medical history is significant for hypercholester-olemia and coronary artery disease. He had a myocardial infarction 5 years ago. K.B.'s vital signs today are
  all within normal limits.
  What are some cognitive changes seen in a number of elderly patients?
  You know that physiologic age-related changes in the elderly can influence cognitive
  functioning. Name and discuss one.
  For each behavior listed, specify whether it is associated with delirium (DL) or dementia (DM).
  ______ a. Gradual and insidious onset
  ______ b. Hallucinations or delusions
  ______ c. A sudden, acute onset of symptoms
  ______ d. Progressive functional impairment
  ______ e. Inability to perform activities of daily living (ADLs)
  ______ f. Incoherent interactions with others
  ______ g. Possible wandering behavior
  ______ h. Behavioral disorders that often worsen at night
  Based on the information provided by the daughter, do you think K.B. is showing signs of
  delirium or dementia? Explain.
  You know that there are several types of dementia that result in cognitive changes. List two of
  these types of dementia.
  How can the level or degree of the dementia impairment be determined?
  A number of diagnostic tests have been ordered for K.B. From the tests listed, which would
  be used to diagnose dementia?
  ______ Mental status examinations
  ______ Toxicology screen
  ______ Mini-Mental State Examination
  ______ Electrocardiogram
  ______ Electroencephalogram
  ______ Complete metabolic panel
  ______ Complete blood count with differential
  ______ Thyroid function tests
  ______ Colonoscopy
  ______ Rapid plasma reagin (RPR) test
  ______ Serum B12 level
  ______ Bleeding time
  ______ Human immunodeficiency virus screening
  ______ Liver function tests
  ______ Vision and hearing evaluation
  ______ Magnetic resonance imaging (MRI)

Question 8

One month ago, J.P., a 50-year-old man, came to the outpatient clinic with complaints of mild shortness of breath and some mild intermittent chest pain
  He described himself as a high-stress, type apersonal-ity who owns his own business and works long hours. He has smoked one pack of cigarettes per day for
  the past 30 years. He has tried to quit several times and was successful for as long as 6 months at a time,
  but when business became stressful, he started smoking again. J.P. said he has been trying to lose the
  extra 30 pounds he is carrying but stated it is difficult to exercise because of the long hours of work. The
  cardiac workup is negative for coronary artery disease, and he has returned for a follow-up visit. during
  the discussion about lifestyle changes, J.P. expresses interest in medical hypnosis for stress management
  and smoking cessation. He would like more information. you are the case manager for the clinic and meet
  with J.P. to discuss medical hypnosis.
  J.P. asks, What is hypnosis? What will you tell him?
  J.P. asks what you mean by trance state. Explain the term.
  J.P. wants to know what you mean by subconscious mind.Explain the term
  J.P. asks, How does hypnosis work to help someone change a subconscious belief? How will
  you respond?
  J.P. states he has seen TV shows where people did silly things on stage during hypnosis. He
  wants to know how medical hypnosis is different. Explain.
  J.P. asks, Is there a way to know if hypnosis will work? Please respond.
  J.P. wants to know what happens during a hypnosis session. You inform him that medical
  hypnosis has several components: patient preparation and education, establishing a rapport
  and a trusting relationship, induction and deepening, hypnotic suggestions, and reawakening
  from the trance state. Briefly explain each step.
  J.P. asks, How effective is hypnosis in helping someone stop smoking? How will you
  J.P. asks whether hypnosis is contraindicated for anyone. What will you tell him?
  J.P. apologizes for being full of questions but wants to know whether hypnosis has to be
  done with a hypnotist or if he can do it himself with a downloadable mp3 file. How will you
  J.P. asks you how he would go about finding a hypnotist. What will you tell him?
  J.P. states he would like to read more about hypnosis on the Internet. List three credible
  websites you could give him.
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The answer to question 1  Answers: a, b, c
Taking St. John's wort with an SSRI such as Lexapro might increase the risk of serotonin syndrome.
Drinking alcohol with SSRIs might increase sedative effects. Both of these interactions are potentially

Tricyclic antidepressants would be risky, considering J.B.'s history of heart problems. MAOIs are
effective antidepressants. However, these drugs require food restrictions and have the potential
to cause hypertensive crisis; if these food restrictions will not be followed, MAOIs are not the first

The answer to question 2   Antidepressant medications: selective serotonin reuptake inhibitors (SSRIs), tricyclics, and
monoamine oxidase inhibitors (MAOIs)
 Electroconvulsive therapy

Although ECT is successful in many patients with depression and those with suicidal thoughts, ECT
would be very risky for J.B., considering his heart problems and recent heart valve replacement. The
seizure induced by ECT will stress the heart at the onset and for up to 10 minutes afterward.

The answer to question 3  Answer: b, e, f
These lower-risk methods, also called soft methods, are less lethal than the higher-risk methods
such as using a gun, hanging, or inhaling carbon monoxide.

 Conduct an immediate assessment of his safety. This will need to be done by a mental health
 Contact the physician and alert him or her to your findings.
 Facilitate the referral to community mental health services.
 Ensure that J.B. is not left alone. Monitor him closely.

The answer to question 4   Does he have a specific plan for suicide?
 Has he ever attempted suicide in the past?
 Does he have any weapons at home?
 Does he drink alcohol, and, if so, how much and how often? Does he use any drugs?
 Will he be alone once he goes home?

 The highest suicide rate among males is in those aged 75 years or older.
 Depression often occurs with chronic illnesses, such as diabetes mellitus, cardiovascular disease,
stroke, and cancer.
 Loneliness or social isolation are risk factors, and he has had a recent loss.

 Major depressive disorder
 Bipolar disorder, which is characterized by episodes of major depression accompanied by episodes
of mania
 Dysthymic disorder, which is a less severe but more chronic type of depression
 History of alcohol or substance abuse

 Tell me about your sleep. Do you have difficulty falling asleep, staying asleep, or waking up early?
 How would you describe your appetite?
 Have you had any recent unintentional change in your weight?
 Tell me about your concentration. Are you able to read the newspaper or watch a TV show from
beginning to end?
 How is your energy level?
 How would you describe your mood or your spirits?
 Have you had any thoughts of death recently?
 Are there activities that you enjoy or give you pleasure?
 Have you lost interest in activities that you used to enjoy?

Depression includes feelings of worthlessness, hopelessness, indecisiveness, and guilt. Ill people
might still express a sense of satisfaction as they think back over their lives, their connection with
family members, and their participation in a spiritual life. Ill people may still have the ability to
concentrate on positive things.

 Persistent sad mood
 Loss of interest in activities that were once pleasurable
 Insomnia or hypersomnia
 A significant change in appetite with weight loss or weight gain
 Loss of energy
 Difficulty with concentration
 Feelings of worthlessness or guilt
 Thoughts of death or suicide
 Isolating oneself from others

The answer to question 5  two weeks later, K.B.'s daughter calls the physician's office and states, I realize that the aricept will not
cure my dad, but there has been no improvement at all. are we wasting our money?

This medication might take 4 to 6 weeks for an improvement to be noted. If after that time no
improvement is seen, the dose may be increased to 10 mg/day. For now, she needs to give the
medication more time to have an effect.

 Obtain a wearable tracking device for K.B. Such devices can assist with locating him if he wanders
out of sight.
 Place locks on the doors that are more complex and difficult to open.
 Obtain a medical alert bracelet for K.B. that contains his name, address, and telephone number.
 Alert neighbors and the local law enforcement authorities about K.B.'s wandering tendencies.
 Consider installing a door alarm device that would provide warning if he opens the door.

The answer to question 6  Changes seen in the brain include destruction of the proteins of nerve cells of the cerebral cortex by
diffuse infiltration with neurofibrillary tangles and plaques (nonfunctional tissue). These tangles and
plaques are a result of the death of nerve cells within the brain.

 Educate his daughter and other caregivers about providing a safe environment at home for him.
This includes such things as not allowing K.B. to cook alone (e.g., unplug the stove), conducting a
risk assessment for falls, and not allowing him to go out alone if he is prone to disorientation.
 Provide orientation aids, such as a calendar and clock.
 Educate the family about support groups and online resources for caregivers.
 Instruct the daughter to not allow K.B. to drive alone. Educate her that he might not be able to
drive at all as the dementia progresses.
 Instruct the family to keep environmental stimuli to a minimum.
 Maintain a daily routine; do not vary activities from day to day.
 Refer the patient to his primary care physician for possible medications that can slow the
progression and improve daily functioning when started in the early stages of dementia

The answer to question 7   Loss of short-term memory and accompanying benign forgetfulness
 Poorer performance on complex learning tasks
 Slowing of the thought processes

 Decreased visual acuity and accommodation can result in decreased ability to process visual cues.
Yellowing and flattening of the cornea can lead to difficulty distinguishing colors.
 Fewer functional cochlear cells can lead to a decreased ability to process auditory input.

Delirium:b, c, e, f, h
Dementia:a, d, g

Dementia. The onset has been gradual, he has had progressive cognitive impairment (forgetting
things, placing milk in the cupboard, wondering about his daughter, unable to pour coffee, difficulty
remembering names), and he has shown wandering behavior. This behavior does not show the
sudden onset, hallucinations, or incoherent interactions that are more likely to occur with delirium. A
distinguishing feature between dementia and delirium is the onset, with dementia demonstrating a
slow onset, whereas delirium has a sudden onset.

 Alzheimer's disease
 Diffuse Lewy body dementia
 Frontotemporal dementia
 Vascular dementia
 Parkinson's disease dementia

A psychologist administers neuropsychological testing in the major domains of thinking and
memory, verbal and expressive abilities, constructional skills, and executive functions. This
information helps determine whether the patient can continue to handle his or her own finances, to
drive, or to perform instrumental activities of daily living.

Only the colonoscopy and bleeding time would have no relevance in diagnosing a dementia

The answer to question 8  Medical hypnosis is a state of highly focused attention (trance state) in which external stimuli are
diminished and suggestions become far more effective than usual. Changes in a person's behavior,
conduct, or actions are the results of the acceptance by the subconscious mind of suggestions made
during the hypnosis sessions.

Trance state is a perfectly normal and common state that just about everyone has experienced,
such as driving safely to your destination without remembering how you got there or seeing
familiar landmarks. Whenever someone concentrates deeply, he or she automatically slips into the
natural hypnotic state. In hypnosis, the trance state is deepened, enabling the therapist to make
suggestions that might be accepted by the subconscious mind more readily than when a person is in
an unrelaxed state. During hypnosis, people maintain control of their experience; they can come out
of the trance at any time and can voluntarily reject any suggestion that is contrary to their wishes or

The mind is divided into the conscious and subconscious mind. The conscious mind gathers and
analyzes information for storage in the brain's memory. The subconscious mind uses the stored
information to operate the body and govern emotions. The conscious mind is dominant most of
the time. When conscious awareness is lowered, subconscious awareness automatically becomes
dominant. During hypnosis, outside stimuli are reduced and the person enters a trance state. The
subconscious mind accepts the therapist's suggestions as true, as long as they do not conflict with
the person's belief system. The subconscious stores the thoughts and influences the future.

The study of psychoneuroimmunology, or the study of the mind-body connection, is beginning to
shed some light on how thinking and the body's function are intertwined. Researchers have found
that when a person is asked a question, the subconscious brain continues to search for another or
better answer to the question. For example, people often remember a piece of information after
the conscious mind has stopped thinking about the forgotten information. This is because the
subconscious mind continues to search through memory for the answer. The intent of hypnosis is to
relax learned limitations and permit the subconscious mind to relearn something; it changes one's
thinking to incorporate what one wants to believe in. For example, hypnosis will not help a person
stop smoking if that person really does not want to stop smoking.

Medical hypnosis is very different from stage hypnosis. In stage hypnosis, the hypnotist quickly
selects from the audience those people who can easily and quickly be hypnotized and are highly
suggestible. Direct suggestions can be dramatic but have limited usefulness. Medical hypnosis is
used to remove difficulties, symptoms, and suffering. It uses the beneficial powers of the mind to
search and recall all experiences causing the person's problems. The person's brain recalls the facts in
the development of the problems and then creates suggestions of his or her own that often lead to
the complete and successful removal of difficulties.

People vary in their degree of responsiveness to hypnotic suggestions; this is called their
hypnotizabilityor hypnotic susceptibility.Most people can be hypnotized to some degree. There are
tools that are used to determine a person's hypnotizability: the Penn State Scale of Hypnotizability,
the Stanford Hypnotic Susceptibility Scale, and the Barber Suggestibility Scale. People are rated as
having high, moderate, or low hypnotizability, depending on how they score on the test. The tests
help guide the therapist toward the most effective hypnotic technique.

Preparation and education:The patient is informed of the myths, misconceptions, and benefits of
hypnosis. The key points include (1) the motivation to change must come from within and (2)
hypnotic suggestion must be reinforced by repetition. The patient must practice daily with self-hypnosis techniques; listening to an audiotape of each session will reinforce the desired change.
Establish a rapport and a trusting relationship:Establishing a respectful rapport with the patient
is vital because hypnosis is a cooperative venture. The person has to feel free to be himself or
Induction and deepening:The therapist assists the patient in achieving a relaxed state of body and
mind so that his or her subconscious awareness can become dominant. This state of hypnosis
is marked by increased muscle relaxation, increased mental focus on the hypnotist's voice, and
increased susceptibility to suggestion.
Hypnotic suggestions:There are many techniques and strategies for hypnotic suggestions, as well as
methods of subconscious exploration and problem solving. The individual is instructed in
self-hypnosis, which allows the hypnotic suggestions to become incorporated into the patient's
own thought system. When the suggestions become the patient's own, they are followed more
readily because desire is enhanced and resistance is reduced.

Hypnosis cannot make you do something you really do not want to do. The literature suggests that
hypnosis is unlikely to be effective when used alone but is effective when part of a multicomponent
program involving hypnosis and counseling, health education, and nicotine replacement therapy.

Hypnosis is contraindicated for those trying to recover repressed memories; those who are afraid of
being hypnotized; those who receive secondary gains from being ill; and those who have dementia,
mental retardation, paranoid characteristics, borderline personality disorder, schizophrenia,
epilepsy, and some types of strokes.

Hypnosis can be done either way, but hypnosis done to gain insight into a particular issue, such as
smoking cessation, is best accomplished in sessions with a certified hypnotist who will tailor the
sessions to the needs, personality, and motivation of those involved. In general, self-hypnosis CDs
will not be as effective. However, using the self-hypnosis audio combined with seeing a hypnotist
can yield better results. A great method for doing this is to see a hypnotist on a regular basis, then
listen to self-hypnosis CDs daily in between sessions.

Most states do not have licensure for hypnotists or hypnotherapists. Certification is available; the
two main certifying bodies are the American Society of Clinical Hypnosis (ASCH) and the National
Board for Certified Clinical Hypnotherapists (NBCCH). Both recommend that when a selecting
someone to help with a particular goal, such as smoking cessation, you choose a provider who is
properly trained and credentialed. Persons credentialed by the ASCH and NBCCH hold graduate
degrees and valid licenses in fields such as medicine, psychology, social work, or nursing. An
additional benefit of choosing a licensed health care provider is that health care insurance may
reimburse for services provided, although you should determine this in advance by contacting the
insurer or asking the provider. It is important to check references from both professional colleagues
and former patients to determine therapist skill and patient satisfaction. Does he or she have
experience with the type of hypnosis you need?

American Psychological Association: www.apa.org/divisions/div30
American Psychotherapy and Medical Hypnosis Association: http://apmha.com
American Society of Clinical Hypnosis: www.asch.net
National Center for Complementary and Alternative medicine: http://nccam.nih.gov
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