Mental Health Nursing
Domain 6 - Mental Health Nursing
This domain tests mental state assessment, therapeutic communication, risk assessment, de-escalation, legal frameworks for involuntary care, and the safe monitoring of psychotropic medication. It also expects awareness of Fiji's context, where stigma, family involvement and traditional healing strongly influence care.
Core rules
- Mental state examination covers appearance and behaviour, speech, mood and affect, thought form and content, perception, cognition, insight and judgement. Record what you observe, not conclusions.
- Therapeutic communication: open questions, reflection, paraphrasing, silence, clarifying. Avoid false reassurance, arguing with delusions, colluding with hallucinations, and promising secrecy.
- Risk assessment must be explicit: suicidal ideation, plan, means, previous attempts, protective factors; and risk to others. Ask directly - asking does not plant the idea.
- Restraint and seclusion are last resorts, used only under legal authority, for the shortest time, with continuous observation, documentation and medical review.
- De-escalation: reduce stimulation, use a calm voice, offer space and choices, address the unmet need (pain, fear, withdrawal), and offer oral medication before considering parenteral treatment.
- Medication monitoring: clozapine requires regular full blood counts for neutropenia; lithium requires serum levels (therapeutic range roughly 0.6–1.0 mmol/L) plus renal and thyroid checks; watch for extrapyramidal effects and neuroleptic malignant syndrome (rigidity, fever, altered consciousness, raised creatine kinase).
- Know the grounds and safeguards for involuntary admission under the national mental health legislation, including review and the right to appeal.
Worked example
A man with schizophrenia is shouting that staff are poisoning his food and is pacing with clenched fists. Reasoning: this is escalating risk driven by a delusion, not 'naughtiness'. First: ensure safety of others, clear the area, keep a exit route, reduce noise, use one calm speaker at a distance, acknowledge his fear without agreeing ('you feel unsafe about the food'), offer a choice such as eating a sealed packet he opens himself, offer oral medication. Restraint only if there is imminent danger, then under legal authority with continuous monitoring and documentation.
Traps
- Arguing that the delusion is untrue.
- Promising to keep suicidal thoughts secret.
- Using restraint as a first response or without documentation.
- Missing lithium toxicity (coarse tremor, vomiting, ataxia) or neuroleptic malignant syndrome.
- Labelling physical symptoms as 'psychiatric' without excluding delirium, hypoglycaemia or infection.