It is 1000 hours in the emergency department (ED) when the ambulance brings in G.G., a 35 -year-old man who is having difficulty breathing. He complains of chest pain, tightness in the chest, dizziness, palpitations, nausea, paresthesia, and feelings of impending doom. He states, "I don't think I'm going to make it. I must be having a heart attack." He is diaphoretic and trembling. His vital signs are 184 / 92,104,28,98.4$^{\circ} \mathrm{F}$ $\left(36.9^{\circ} \mathrm{C}\right.$ ). These symptoms began at work during a meeting at approximately 0920 and became progressively worse. A co-worker called 911 and stayed with him until the first responder arrived. The patient has no apparent history of cardiac problems.

Following the full medical workup, including testing to rule out MI, pulmonary embolism, and thyroid disorders, it is determined that G.G.'s condition is stable. His shortness of breath and anxiety resolve after he is given lorazepam (Ativan) $1 \mathrm{mg}$ IV push (IVP). The lab work and ECG results are all within normal parameters, and there is no evidence of any physical disorder. A diagnosis of a panic attack is made. G.G. admits to having had 3 similar episodes in the past 2 weeks; however, they were not nearly as severe or long-lasting.

G.G. shares with the ED staff that he has been under severe stress at work and home. He tells them he is going through a divorce, he lost a child last summer in a motor vehicle accident, and his company is downsizing. He will probably be out of a job soon. He hasn't been sleeping well for the past couple of months and has lost about 20 pounds (9 kg).

G.G.'s condition is stable and the ED physician discusses what has happened with G.G. The physician provides G.G. a prescription for alprazolam (Xanax) 0.5 mg tid for 1 week and a referral to see his primary care physician for further treatment and evaluation. For each class of medications used to treat panic attacks, what will your patient teaching include?

You are working on an inpatient psychiatric unit and need to do an initial assessment of R.B., who has just been admitted. He has a diagnosis of schizophrenia, paranoid type. He is 22 years old and has been attending the local university and living at home with his parents. R.B. has always been a good student and has been socially active. Last semester his grades began declining. He became very withdrawn and spends most of his time alone in his room. His personal self-care has deteriorated as he can go days without bathing. Prior to admission, R.B. spent several weeks in seclusion. He refused to join family gatherings, isolated himself, and closed the blinds. Within the past 2 days, he refused to eat, stating, "They have contaminated the food." As you approach R.B., you note that he appears to be talking to himself. When you talk to him, he looks around and answers in a whisper but gives you little information. He states, "They are watching me and told me not to cooperate."

The psychiatrist evaluates R.B. by conducting a mental status assessment and ordering antipsychotic medications with close monitoring in the inpatient setting. Identify the class of antipsychotic medications considered as first-line therapy for schizophrenia?

You are the registered nurse case manager in an outpatient mental health clinic. S.T. is here today for her outpatient mental health appointment. She was diagnosed with bipolar disorder type $\| 2$ years ago and has been stable for the past year. Her last episode was one of mania that required hospitalization. S.T. is 29 years old, married, with two children aged 2 and 4. She reports that her mood is better than it has been in a long time and she has lots of energy. When asked whether she thinks this is a recurrence of mania, she says no, she thinks that things are just finally getting better.

Lithium (Eskalith) is a mood stabilizer commonly used to treat bipolar disorders. S.T. has been taking lithium for a year. List additional lab examinations that should be routinely performed while S.T. is taking lithium.

You are on duty in the emergency department (ED) when a "code blue" is called. As the code nurse, you grab the crash cart and rush to the code, which is in the employee lounge of the operating room. On the couch, you find a nurse, Z.H., unconscious, dusky, and barely breathing; she has a palpable pulse.

Z.H. is given an ampule of $50 \mathrm{~mL}_{50} \mathrm{~W}$ and $0.4 \mathrm{mg}$ naloxone IV push. Her respirations improve slightly, and her pulse increases to 56. She is transported to the ED. State the onset and duration times for IV naloxone.

You are working the afternoon shift in an inpatient psychiatric unit. The patients are in the day room watching a movie when suddenly someone starts yelling. You and other staff members rush to the day room to find J.J., a 48-year-old male patient, crouched in the corner behind a chair, yelling at the other patients, "Get down. Get down quick." You and the other staff are able to calm J.J. and the other patients and take J.J. to his room. He apologizes for his outburst and explains to you that the movie brought back memories of his experiences in the Gulf War. He had forgotten where he was and thought he was in combat again. He describes to you in detail the memory he had of being ambushed by the enemy and watching several of his comrades be killed. You review J.J.'s chart and note that he was a Gulf War veteran admitted with posttraumatic stress disorder (PTSD).

While you are in J.J.'s room, he states that he would like to rest for a while, and he requests something to "calm his nerves." You check his Medication Administration Record (MAR) and review the PRN (as needed) medications listed.

PRN Medications:

Acetaminophen (Tylenol) $650 \mathrm{mg}$ P0 every 6 hours prn for pain or fever Alprazolam (Niravam) orally dissolving tablet, $0.5 \mathrm{mg}$ by mouth every 4 hours prn for anxiety Zolpidem (Ambien CR) extended release, $12.5 \mathrm{mg}$ PO at bedtime prn for sleep

You decide to notify J.J.'s physician about his reaction to the movie. The physician writes an order to start paroxetine (Paxil). How does this medication differ from alprazolam?

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 is $250 \mathrm{mg} / \mathrm{dL}$ (13.9 $\mathrm{mmol} / \mathrm{L}$ ) and increasing 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 his loss and the loneliness he has been feeling. J.B. states he just doesn't feel good lately and feels sad most of the time. J.B. also expresses his lack of involvement 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 grandchildren. He tells you he has been feeling "depressed" the last few months with thoughts of suicide.

You use the SAD PERSONS scale 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 he has general thoughts of suicide but has not really thought about how he would do it. You recall that there are 2 types of suicide methods based on lethality: higher risk or hard methods and lower risk or soft methods.

You decide to notify J.B.'s physician about your findings. The attending physician calls in a psychiatrist to evaluate J.B. In addition, Suicide Precautions are ordered. Which interventions are part of Suicide Precautions? Select all that apply.

a. Document his behavior every shift. b. He is not permitted to leave his room. c. No glass or metal dishes or utensils with meals. d. Observe him swallow each dose of oral medication. e. One-to-one observation and interaction 24 hours per day.

J.G., a 49-year-old man, was assessed in the emergency department (ED) 4 days ago. He was diagnosed with alcohol intoxication and released after 8 hours to his brother's care. He was readmitted to the ED 12 hours ago with a gastrointestinal (GI) bleed and is being transferred to the intensive care unit (ICU). His diagnosis is upper Gl bleeding and alcohol intoxication.

You are assigned to J.G. for the remainder of your shift. According to the ED notes, his admission vital signs (VS) were 84/56,110,26, and he was vomiting bright red blood. He was given IV fluids and transfused 6 units of packed red blood cells (PRBCs) in the ED. On initial assessment, you note that J.G.'s VS are $102.2^{\circ} \mathrm{F}\left(39^{\circ} \mathrm{C}\right)$, 174/98,110,24. He has a slight tremor in his hands, is diaphoretic, and he appears anxious. He reports a headache and appears flushed. No report of vomiting, frank red blood, or melena in the stools, according to the chart, for the past 5 hours. In response to your questions, J.G. denies he has an alcohol problem but later on admits to drinking approximately a fifth of vodka daily for the past 2 months. He admits to having seizures while withdrawing from alcohol in the past. He tells you that he "just can't help it" and has strong urges to drink, but that he never means"to drink very much." He has had trouble keeping a job over the past several months.

Admission Laboratory Work:

$$\begin{array}{ll}\text { Hgb } & 10.9 \mathrm{~g} / \mathrm{dL}(109 \mathrm{~g} / \mathrm{L}) \\ \text { Hct } & 23 \% \\ \text { ALT (formerly SGPT) } & 69 \text { units } / \mathrm{L} \\ \text { AST (formerly SGOT) } & 111 \text { units/L } \\ \text { GGT } & 75 \text { units } / \mathrm{L} \\ \text { ETOH } & 291 \mathrm{mg} / \mathrm{dL}(63 \mathrm{mmol} / \mathrm{L}) \\ \text { aPTT } & 35 \text { secons } \\ \text { PT/INR } & 12 \text { seconds/1.0 } \\ \text { Hepatitis C Screening } & \text { Negative }\end{array}$$

You discuss with J.G. and his brother about the history of his alcohol use. You conclude J.G. may be demonstrating behaviors of alcohol use disorder. What would be helpful for J.G.'s physician to know regarding J.G.'s substance use history?

J.G., a 49-year-old man, was assessed in the emergency department (ED) 4 days ago. He was diagnosed with alcohol intoxication and released after 8 hours to his brother's care. He was readmitted to the ED 12 hours ago with a gastrointestinal (GI) bleed and is being transferred to the intensive care unit (ICU). His diagnosis is upper Gl bleeding and alcohol intoxication.

You are assigned to J.G. for the remainder of your shift. According to the ED notes, his admission vital signs (VS) were 84/56,110,26, and he was vomiting bright red blood. He was given IV fluids and transfused 6 units of packed red blood cells (PRBCs) in the ED. On initial assessment, you note that J.G.'s VS are $102.2^{\circ} \mathrm{F}\left(39^{\circ} \mathrm{C}\right)$, 174/98,110,24. He has a slight tremor in his hands, is diaphoretic, and he appears anxious. He reports a headache and appears flushed. No report of vomiting, frank red blood, or melena in the stools, according to the chart, for the past 5 hours. In response to your questions, J.G. denies he has an alcohol problem but later on admits to drinking approximately a fifth of vodka daily for the past 2 months. He admits to having seizures while withdrawing from alcohol in the past. He tells you that he "just can't help it" and has strong urges to drink, but that he never means"to drink very much." He has had trouble keeping a job over the past several months.

Admission Laboratory Work:

$$\begin{array}{ll}\text { Hgb } & 10.9 \mathrm{~g} / \mathrm{dL}(109 \mathrm{~g} / \mathrm{L}) \\ \text { Hct } & 23 \% \\ \text { ALT (formerly SGPT) } & 69 \text { units } / \mathrm{L} \\ \text { AST (formerly SGOT) } & 111 \text { units/L } \\ \text { GGT } & 75 \text { units } / \mathrm{L} \\ \text { ETOH } & 291 \mathrm{mg} / \mathrm{dL}(63 \mathrm{mmol} / \mathrm{L}) \\ \text { aPTT } & 35 \text { secons } \\ \text { PT/INR } & 12 \text { seconds/1.0 } \\ \text { Hepatitis C Screening } & \text { Negative }\end{array}$$

You discuss with J.G. and his brother about the history of his alcohol use. You conclude J.G. may be demonstrating behaviors of alcohol use disorder. Based on the DSM-V criteria, how would you rate the severity of J.G.'s alcohol use? Explain your decision.

a. No problem b. Mild c. Moderate d. Severe

It is 1000 hours in the emergency department (ED) when the ambulance brings in G.G., a 35 -year-old man who is having difficulty breathing. He complains of chest pain, tightness in the chest, dizziness, palpitations, nausea, paresthesia, and feelings of impending doom. He states, "I don't think I'm going to make it. I must be having a heart attack." He is diaphoretic and trembling. His vital signs are 184 / 92,104,28,98.4$^{\circ} \mathrm{F}$ $\left(36.9^{\circ} \mathrm{C}\right.$ ). These symptoms began at work during a meeting at approximately 0920 and became progressively worse. A co-worker called 911 and stayed with him until the first responder arrived. The patient has no apparent history of cardiac problems.

Following the full medical workup, including testing to rule out MI, pulmonary embolism, and thyroid disorders, it is determined that G.G.'s condition is stable. His shortness of breath and anxiety resolve after he is given lorazepam (Ativan) $1 \mathrm{mg}$ IV push (IVP). The lab work and ECG results are all within normal parameters, and there is no evidence of any physical disorder. A diagnosis of a panic attack is made. G.G. admits to having had 3 similar episodes in the past 2 weeks; however, they were not nearly as severe or long-lasting.

G.G. shares with the ED staff that he has been under severe stress at work and home. He tells them he is going through a divorce, he lost a child last summer in a motor vehicle accident, and his company is downsizing. He will probably be out of a job soon. He hasn't been sleeping well for the past couple of months and has lost about 20 pounds (9 kg). What are the possible symptoms of a panic attack? Select all that apply.

a. Sweating b. Drowsiness c. Palpitations d. Hallucinations e. Feelings of choking f. Feelings of unreality

You are working the afternoon shift in an inpatient psychiatric unit. The patients are in the day room watching a movie when suddenly someone starts yelling. You and other staff members rush to the day room to find J.J., a 48-year-old male patient, crouched in the corner behind a chair, yelling at the other patients, "Get down. Get down quick." You and the other staff are able to calm J.J. and the other patients and take J.J. to his room. He apologizes for his outburst and explains to you that the movie brought back memories of his experiences in the Gulf War. He had forgotten where he was and thought he was in combat again. He describes to you in detail the memory he had of being ambushed by the enemy and watching several of his comrades be killed. You review J.J.'s chart and note that he was a Gulf War veteran admitted with posttraumatic stress disorder (PTSD).

While you are in J.J.'s room, he states that he would like to rest for a while, and he requests something to "calm his nerves." You check his Medication Administration Record (MAR) and review the PRN (as needed) medications listed.

PRN Medications:

Acetaminophen (Tylenol) $650 \mathrm{mg}$ P0 every 6 hours prn for pain or fever Alprazolam (Niravam) orally dissolving tablet, $0.5 \mathrm{mg}$ by mouth every 4 hours prn for anxiety Zolpidem (Ambien CR) extended release, $12.5 \mathrm{mg}$ PO at bedtime prn for sleep

What are the adverse effects of long-term use of benzodiazepine anxiolytics?

You are the registered nurse case manager in an outpatient mental health clinic. S.T. is here today for her outpatient mental health appointment. She was diagnosed with bipolar disorder type $\| 2$ years ago and has been stable for the past year. Her last episode was one of mania that required hospitalization. S.T. is 29 years old, married, with two children aged 2 and 4. She reports that her mood is better than it has been in a long time and she has lots of energy. When asked whether she thinks this is a recurrence of mania, she says no, she thinks that things are just finally getting better.

Lithium (Eskalith) is a mood stabilizer commonly used to treat bipolar disorders. S.T. has been taking lithium for a year. S.T.'s maintenance lithium level results are reported as $1.0 \mathrm{mEq} / \mathrm{L}(1.0 \mathrm{mmol} / \mathrm{L})$. Interpret these results.

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 is $250 \mathrm{mg} / \mathrm{dL}$ (13.9 $\mathrm{mmol} / \mathrm{L}$ ) and increasing 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 his loss and the loneliness he has been feeling. J.B. states he just doesn't feel good lately and feels sad most of the time. J.B. also expresses his lack of involvement 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 grandchildren. He tells you he has been feeling "depressed" the last few months with thoughts of suicide.

You use the SAD PERSONS scale 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 he has general thoughts of suicide but has not really thought about how he would do it. You recall that there are 2 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. Hanging b. Using a gun c. Ingesting pills d. Inhaling natural gas e. Slashing one's wrist f. Poisoning with carbon monoxide

You are on duty in the emergency department (ED) when a "code blue" is called. As the code nurse, you grab the crash cart and rush to the code, which is in the employee lounge of the operating room. On the couch, you find a nurse, Z.H., unconscious, dusky, and barely breathing; she has a palpable pulse.

Z.H. is given an ampule of $50 \mathrm{~mL}_{50} \mathrm{~W}$ and $0.4 \mathrm{mg}$ naloxone IV push. Her respirations improve slightly, and her pulse increases to 56. She is transported to the ED. Within 5 minutes of receiving the naloxone, Z.H. is starting to respond. Why do you need to continue to observe her closely? Select all that apply.

a. Opioid dosage may exceed that of the naloxone. b. Z.H. may develop pulmonary edema after receiving naloxone. c. A common adverse effect of naloxone is the onset of atrial fibrillation. d. The risk for developing diabetic ketoacidosis is high after receiving naloxone and $\mathrm{D}_{50} \mathrm{~W}$. e. Rapidly reversing the effects of the drug overdose will cause a rebound decline in level of consciousness.

You are working on an inpatient psychiatric unit and need to do an initial assessment of R.B., who has just been admitted. He has a diagnosis of schizophrenia, paranoid type. He is 22 years old and has been attending the local university and living at home with his parents. R.B. has always been a good student and has been socially active. Last semester his grades began declining. He became very withdrawn and spends most of his time alone in his room. His personal self-care has deteriorated as he can go days without bathing. Prior to admission, R.B. spent several weeks in seclusion. He refused to join family gatherings, isolated himself, and closed the blinds. Within the past 2 days, he refused to eat, stating, "They have contaminated the food." As you approach R.B., you note that he appears to be talking to himself. When you talk to him, he looks around and answers in a whisper but gives you little information. He states, "They are watching me and told me not to cooperate." What are the most important initial interventions for treating R.B.?