Mental Health Nursing
Mental health items test assessment, risk management and the safe use of psychotropic drugs. The exam favours the least restrictive intervention that maintains safety, and it expects you to take physical symptoms in a person with mental illness seriously rather than dismissing them as psychosomatic.
Assessment
- Mental state examination covers appearance and behaviour, speech, mood and affect, thought form and content, perception, cognition, insight and judgement.
- Ask directly about suicidal ideation and plans. Asking does not increase risk and is required for adequate assessment.
- Highest acute risk factors: previous attempt, hopelessness, access to means, recent loss, command hallucinations and substance use. Document protective factors too.
Therapeutic communication
- Use open questions, reflection, clarification and silence. Explore the meaning behind a delusion rather than arguing with it, and never collude with it.
- Avoid false reassurance, asking why questions, and giving premature advice.
Law and restraint
- Under the Mental Health Ordinance (Cap. 136), detention for assessment or treatment must follow the statutory process; the patient retains rights to information, to appeal and to a second opinion.
- Use the least restrictive option. Restraint requires a documented risk assessment, prescription or policy authority, frequent observation, and review.
Psychotropic emergencies
- Neuroleptic malignant syndrome: fever, lead-pipe rigidity, autonomic instability and raised creatine kinase after antipsychotics. Stop the drug, hydrate, and treat with dantrolene or bromocriptine as prescribed.
- Serotonin syndrome: agitation, clonus, hyperreflexia and fever after serotonergic drugs.
- Lithium has a narrow therapeutic range of about 0.6 to 1.0 mmol/L. Toxicity causes coarse tremor, vomiting, diarrhoea, ataxia and confusion, and is precipitated by dehydration, NSAIDs, thiazides and ACE inhibitors.
Worked example
A man on lithium is admitted with gastroenteritis and vomiting. He now has a coarse tremor and is unsteady walking. What is the priority? Reasoning: dehydration has reduced lithium clearance and produced toxicity. Priority is to stop the lithium, obtain a serum lithium level and electrolytes including renal function, give prescribed intravenous fluids, withhold NSAIDs and thiazides, and monitor neurology and renal function. Giving the next scheduled lithium dose and an antiemetic is wrong. In severe toxicity with seizures or reduced consciousness, haemodialysis is the definitive treatment.
Traps that cost marks
- Arguing with a delusion or playing along with it.
- Assuming physical complaints in a person with mental illness are psychosomatic.
- Using restraint as a first-line response to agitation rather than de-escalation.