Mental health Exam 1

What is mental health?

state of well-being that forms the foundation for emotions, thinking, learning, communication, resilience, and self-esteem. It enables individuals to cope with stress, build relationships, achieve developmental milestones, and function effectively in daily life, occupations, and society.

What is mental illness?

refers to health conditions involving disturbances in emotion, thinking, or behavior—alone or in combination—that cause distress and impair functioning in social, work, or family life.”

What factors influence someone’s mental health over time?

• Genetics,

• SDOH- social and community context, neighborhood and built environment, health and healthcare, economic stability, food and nutrition, and education, trauma or

• history of abuse,

• medical illness (often chronic, such as thyroid problems, cancer, or diabetes),

• social factors, biological or genetic factors, or use of substances (alcohol or recreational drugs)​​​​​​​.

What are some common communication mistakes that might harm the therapeutic relationship?

a) Giving False Reassurance: Phrases like “Everything will be fine” can undermine the patient’s feelings.

b) Judgmental Statements: Avoid imposing personal opinions or making the patient feel judged.

c) Interrupting: Let the patient express their thoughts fully before responding.

d) Giving Advice Too Soon: Avoid offering solutions immediately without fully understanding the patient’s perspective

What are the key components of a therapeutic relationship?

1. Patient-Centered Focus: Always prioritize the needs, feelings, and concerns of the patient.

2. Active Listening: Fully concentrating, understanding, responding, and remembering what the patient is saying and provide feedback.

3. Empathy: The ability to understand and share the feelings of the patient while maintaining professional boundaries.

4. Respect and Dignity: Treating patients with honor, regardless of their background or condition.

5. Confidentiality: Ensuring that all patient information is private and shared only with authorized individuals.

6. Silence: Silence allows time for meaningful reflection.

7. Questions: Questions allow the nurse to obtain specific or additional information from the client.

-Open-ended questions: Facilitates spontaneous responses and interactive discussion

-Closed-ended questions: Helpful if used sparingly during the initial interaction to obtain specific data. Avoid using repeated closed-ended questions which can block further communication.

-Projective questions: Uses “what if” or similar questions to assist clients in exploring feelings and to gain greater understanding of problems and possible solutions

-Presupposition questions: Explores the client’s life goals or motivations by presenting a hypothetical situation in which the client no longer has the mental health disorder

8. Clarifying techniques: This technique is used to determine if the message received

was accurate:

9. Restating: Uses the client’s exact words.

10. Reflecting: Directs the focus back to the client in order for the client to examine feelings.

11. Paraphrasing: Restates the client’s feelings and thoughts for the client to confirm what has been communicated.

12. Exploring: Allows the nurse to gather more information regarding important topics mentioned by the client.

13. Offering general leads, broad opening statements: This encourages the client to determine where the communication can start and to continue talking.

14. Showing acceptance and recognition: This technique acknowledges the nurse’s interest and nonjudgmental attitude.

15. Focusing: This technique helps the client to concentrate on what is important.

16. Giving information: This technique provides details that the client might need for decision making.

17. Presenting reality: This technique is used to help the client focus on what is actually happening and to dispel delusions, hallucinations, or faulty beliefs.

18. Summarizing: Summarizing emphasizes important points and reviews what has been discussed.

19. Offering self: Use of this technique demonstrates a willingness to spend time with the client. Indicates to the client that the nurse has genuine concern.

20. Touch: If appropriate, therapeutic touch communicates caring and can provide comfort to the client.

21. Seating: A client experiencing manifestations of hyperactivity, or increased anxiety, may have difficulties in communicating while sitting. Consider walking around the room or unit to improve communication adherence.

22. Motivational Interviewing: A style of communication that assists clients in developing motivation to resolve insecurities and ambivalent feelings towards behavior change.

What are barriers that may interfere with building rapport in a mental health setting?

a) Asking irrelevant personal questions

b) Offering personal opinions

c) Giving advice

d) Giving false reassurance

e) Minimizing feelings

f) Changing the topic

g) Asking “why” questions

h) Offering value judgments

i) Excessive questioning

j) Rapid questioning

k) Giving approval or disapproval

More non therapeutic methods?

o Interrupting the Patient

o Using Medical Jargon

o Offering Personal Opinions

o Showing Disapproval

o Failing to Make Eye Contact

o Using Patronizing Language

o Overgeneralizing

o Being Defensive

o Changing the Subject Hastily

o False Reassurance

o Ignoring the Patient's Concerns

o Using Stereotypes

o Showing Impatience

o Excessive Questioning

o Making Assumptions

o Displaying Closed Body Language

o Using Sarcasm

o Avoiding Difficult Topics

o Focusing on the Clinician's Agenda

o Minimizing the Patient's Feelings

What is milieu therapy?

trauma-informed, therapeutic environment that prioritizes safety and client engagement in recovery. Nurses coordinate, plan, and implement care within this setting, incorporating client and family education, rights, and expectations.

Maintaining the milieu is a continuous nursing intervention.

What are aspects of milieu therapy?

supportive setting designed to promote safety, healing, and personal growth. Its goal is to help clients develop adaptive coping strategies, improve communication and relationship skills, and practice appropriate behaviors that can be carried into daily life outside the treatment setting

What is the DSM -5?

a book used by mental health professionals to diagnose mental health disorders in clients following standard criteria. It includes expected assessment findings for disorders and helps with planning, implementing, and evaluating care.

Why is it important for nurses to understand how disorders are classified?

Nurses often use the DSM-5-TR diagnosis description as a reference to assist with planning, implementing, and evaluating client care.

Maslow’s Hierarchy of Needs

• Self actualization-morality, creativity, spontaneity, acceptance, experience purpose, meaning and inner potential

• SELF-ESTEEM- confidence, achievement, respect of others, the need to be a unique

• individual

• LOVE AND BELONGING- friendship, family, intimacy, sense of connection

• SAFETY AND SECURITY- health, employment, property, family and social ability

• PHYSIOLOGICAL NEEDS- breathing, food, water, shelter, clothing, sleep (comes first it’s essential for survival)

What level comes after phycological in Maslow hierarchy of needs and why?

Safety needs (especially suicide risk, self-harm, or harm to others). Safety is critical in psychiatric care.

If a patient shares that they are experiencing housing insecurity, who should be involved in their care?

Social worker or case manager

Who else might be on a mental health treatment team?

• family,

• social worker,

• therapist,

• psychiatrist,

• case manager,

• counselors,

• pharmacists,

• occupational therapist, and

• mental health technicians.

What is capacity? And who decides it? 

• client’s ability to understand information, use reasonable thought processes, communicate their wishes, and understand the consequences of their decisions. 

• Providers (nurses, physicians) evaluate capacity at the bedside (it can change day-to-day).

What is competency and who decides it?

• legal status determined reflects whether a person has the mental and cognitive skills needed to make any type of decision.

• determined by a judge only during a hearing or presentation of evidence.

• Courts often decide competence (it’s more permanent and global).

Why do psychiatric medications work well for some patients but not for others?

Some people have different genetics that make medications not work as well, also if the patient has comorbidities/chronic illnesses can decrease the absorption rates of medicine.

What biological, psychological, or environmental factors might contribute to relapse despite treatment?

Comorbidities, homelessness, SDOH, substance use disorder.

Why is cultural awareness essential in mental health nursing?

Cultural awareness in mental health nursing = understanding how culture shapes illness, coping, and care → essential for safe, effective, client-centered recovery.

How can a patient’s background influence how they express symptoms or accept treatment?

a) may affect mental illness by influencing causes and symptoms and create more risk for specific groups​​​​​​​.

b) And to come up with a plan that is client centered. It provides direction in assessing a client’s cultural background.

c) The CFI consists of questions that help to assess how culture influences problems, how a client sees the problems and causes and accesses available support systems, and/or how a client seeks help in problem-solving. The CFI also helps clinicians to identify the needs of the client with regard to mental health. The CFI-I assesses the same areas and may be used to add information from someone who knows the client well​​​​​​​.

What does “least restrictive” mean in a psychiatric setting?

nurses should focus on prevention and minimize restraint use, reserving it only for behavioral emergencies involving risk of harm to self or others.

Can you give an example of escalating interventions from least to most restrictive?

• LEAST- Verbal de-escalation

• Diversion/redirection- Timeout

• PRN medications (with consent when possible)

• Seclusion

• MOST- Restraints (last resort)-chemical and physical

What are the legal and ethical requirements for using restraints?

a) Clients have the legal right to dignified treatment, while being kept safe.

b) Restraints are used only if a client poses an immediate danger to themselves or another person.

c) Care should always be taken to give the client as much power as possible to regain composure, change behavior, and de-escalate emotions.

d) inform clients on admission about the seclusion and restraint policy, to avoid any misunderstandings. In this way, the client takes ownership of behavior in the facility, understands boundaries and consequences, and is empowered to avoid seclusion or restraint

e) Clients should never be secluded or left alone in a locked room, unsupervised, or left in a prone or supine position. Clients who are agitated may assume awkward positions or try to extricate themselves from restraints.

f) They may have adverse reactions or side effects from chemical restraints. A registered nurse must monitor the client who is physically restrained.

g) They must be reassessed to see if restraints can be taken off

What must be documented, and how often must a patient be reassessed?

a) Order from the provider in emergent situations.

b) Behavior leading up to application of restraints or chemical restraints.

c) Indication that the least restrictive or de-escalation techniques were attempted before use of restraints.

d) Type of restraint. If physical restraint was used, the location and proper application of restraint and client’s response must be indicated.

e) Interventions and client’s response while restrained, including comfort care, food or hydrations, range of motion, elimination, and attempts for less restrictive interventions.

f) Ongoing or continuous monitoring documented every 15 min for violent restraints and every 2 hours for non violent restraints must include client’s behavior, observations of circulation of limbs restrained, and skin checks.

g) Plan for discontinuation of restraints and criteria for discontinuation.

Why is cultural competency important in nursing?

it provides autonomy for the client, promotes equity in the delivery of care, and guides clinical treatment and nursing interventions based upon the client’s, rather than the nurse’s, needs and preferences.

Write down the 5 DSM-5 criteria for Substance Use Disorder (SUD) (this can also be applied to any non-substance addiction):

1. impaired control (difficulty reducing substance use)

2. social problems (disruptions in relationships or responsibilities)

3. risky use (using substances in hazardous situations)

4. tolerance (needing more of the substance for the same effect)

5. withdrawal (experiencing physical or psychological symptoms when not using the substance)

What are at least 3 common predisposing factors for addiction?

1. Genetic vulnerability

2. Mental health condition

3. Environmental influences (childhood trauma/low socioeconomic status)

(chronic stress and exposure to substance use at an early age can increase the risk.)

What is Wernicke’s Encephalopathy?

Confusion, ataxia, and eye movement abnormalities due to thiamine deficiency

What is Korsakoff’s Psychosis?

Irreversible memory disorder caused by long-term thiamine deficiency

What is Naloxone (Narcan)?

Reversal agent for opioid overdose

What is Delirium Tremens (DTs)?

Severe alcohol withdrawal with hallucinations and autonomic instability

What is CIWA-Ar?

Assessment tool for alcohol withdrawal severity

The first-line class of medications used to treat acute alcohol withdrawal is 

benzodiazepines

The reversal agent for opioid overdose is

Naloxone (Narcan).

The vitamin that should be given before glucose in clients with chronic alcohol use is

vitamin B1 (thiamine).

Wernicke’s-Korsakoff’s syndrome is caused by a deficiency in

vitamin B1 (thiamine).

Symptoms of opioid toxicity include

diminished lung sounds, pinpoint pupils, and low respiratory rate. These are critical signs that require immediate intervention, often with naloxone to reverse the effects.

Delirium treatments typically occur within

4 to 6 hours after last alcohol intake?

A non-pharmacologic treatment option for SUD is

private and group counseling, education, and harm reduction strategies such as community resources to reduce risks like needle sharing or disease transmission.

A systemic effect of chronic alcohol use on the liver is

cirrhosis, which involves scarring and loss of liver function. This can progress to liver failure if untreated.

True or False? Naloxone can be administered intranasally or intramuscularly.

True

True or false? CIWA-Ar is used to assess opioid withdrawal.

FALSE- alcohol withdrawals

True or False? Pupillary constriction is a key symptom of opioid overdose.

TRUE

True or false?  Benzodiazepines are contraindicated for alcohol withdrawal in clients with cirrhosis.

FALSE

True or false? Gambling disorder is a type of non-substance addiction recognized in DSM-5.

True

Why is it important to recognize early warning signs of substance use?

Recognizing early warning signs of substance use is important for timely intervention, preventing potential harm, and providing the necessary support to address the issue effectively.

 How might misconceptions or stigma impact patient care for clients with SUD?

Misconceptions or stigma can lead to judgment or lack of empathy, discouraging and hindering clients with SUD from seeking help and less likely to be honest, impacting the quality of care they receive. Bias in treatment can result in healthcare providers unconsciously providing lower quality care, underestimate pain or dismiss symptoms. All these outcomes can result in poor engagement, higher relapse rates and missed opportunities for early intervention.

List two behaviors associated with non-substance addictions like gambling:

• financial losses

• damaged relationships

What are the DSM-5 criteria for diagnosing Schizophrenia?

·   Two or more of these symptoms for at least 1 month: (and at least one must be either 1, 2, or 3)

o   1. Hallucinations

o   2. Delusions (can be bizarre or nonbizarre)

o   3. Disorganized speech (ex: incoherence, frequent derailment, etc.)

o   4. Grossly disorganize or catatonic behavior

o   5. Negative symptoms

·       Continuous disturbance for 6 months

·       Impact on function

o   Social or occupational dysfunction

·       Note: catatonia can be used as a specifier for any other diagnosis

What are potential causes (etiology) of Schizophrenia?

·       Genetic inheritance

·       Family relationships

·       Chemical imbalance in the brain

o   Increased dopamine

o   NE, serotonin, GABA

o   Autoimmune

·       Environmental factors

What are the positive symptoms of schizophrenia?

·       Hallucinations

·       Delusions

·       Disorganized speech & thoughts

Note: more likely to affect language & reasoning

What are the negative symptoms of schizophrenia?

·       Social withdrawal

·       Blunted affect

·       Anhedonia – inability to feel pleasure (from normally rewarding stimuli)

·       Alogia – poverty of speech, decrease in outward speech, thought seem disjointed & communication is not clear

·       Avolition – lack of motivation

·       Anergia – lack of energy, fatigue

Which symptoms are positive (schizophrenia?)

• Disorganized speech

• Delusions

• Hallucinations

Which symptoms are negative (schizophrenia?)

• Social withdrawal

• Flat affect

• Lack of motivation

What are Extrapyramidal Side Effects (EPS)? How might they present in a patient?

• Dystonia

• Pseudoparkinsonism

• Akathisia

• Tardive Dyskinesia

What are symptoms of Tardive Dyskinesia?

·       Pouting lips, puckering lips, lip smacking, tongue roll and protrusion

·       Squinting eyes

·       Grimacing

·       Twisting, tapping of lower extremities

·       Irreversible!

What are symptoms of Akathisia?

• Unable to stand or sit still – pacing & agitated

• Restlessness

• Fidgetiness

What are symptoms of Pseudoparkinsonism?

• Muscle rigidity

• Masked facies

• Shuffling gait

• Resting tremor

What are symptoms of Dystonia?

• Cramping, muscle spasms

• Spasms of tongue, neck, face, back

• SAFETY: oculogyric crisis- a neurological episode characterized by a sustained, involuntary, and often upward deviation of the eyes that can last from seconds to hours

What are some non-pharmacologic interventions used to support individuals with psychotic disorders?

·       Psychosocial treatment

o   Cognitive behavioral therapy

o   Behavioral skills training

o   Supported employment

o   Cognitive remediation & interventions

·       Coordinated specialty care (CSC) programs

o   Recovery-focused – ppl w/ first episode psychosis (an early stage of schizophrenia)

·       Assertive community treatment

o   Especially for people who experience multiple hospitalizations or homelessness

·       Treatment of co-occurring conditions

o   Ex: substance use

What are the key differences between first-generation and second-generation antipsychotics?

1^st generation controls positive manifestations of psychotic disorders and blocks D2 receptors. 2^nd generation – controls positive AND negative manifestations, blocks D2, 5HT2A, and other receptors

Why are second-generation antipsychotics typically used as first-line treatment?

• Treats both positive AND negative symptoms

• Fewer side effects

• Blocks dopamine & 5HT2a & other receptors

What are the unique considerations and serious risks associated with clozapine?

• Clozapine – antipsychotic

• Consider risk for:

• Agranulocytosis – life threatening low WBC count

• Metabolic syndrome

• Abdominal obesity (waist circumference >40 in men, >35 in women)

• Elevated triglycerides (≥150 mg/dL)

• Low HDL cholesterol (<40 mg/dL in men, <50 mg/dL in women)

• Elevated blood pressure (≥130/85 mmHg)

• Elevated fasting glucose (≥100 mg/dL)

• Myocarditis and cardiomyopathy

• Seizure risk (dose dependent)

• Severe constipation

• Orthostatic hypotension, bradycardia

Which antipsychotic drugs are 1st generation?

• Haloperidol 1^st

• Chlorpromazine 1^st

• Loxapine 1^st

Which antipsychotic drugs are 2nd generation?

• Risperidone 2^nd

• Olanzapine 2^nd

• Quetiapine 2^nd

What symptoms are antipsychotic medications intended to improve?

Decrease positive, negative, and cognitive symptoms of psychosis

What is Neuroleptic Malignant Syndrome (NMS)? What are its key symptoms?

Life threatening reaction to antipsychotic medication

·       Sudden dopamine blockage

Key symptoms

·       Muscle rigidity

·       Altered mental status

·       High fever

·       Altered mental state

·       Elevated creatine kinase (CK)

·       Autonomic instability – fluctuating BP, tachycardia, diaphoresis, incontinence

How can you differentiate between Neuroleptic Malignant Syndrome and Serotonin Syndrome?

NMS:

o   Gradual onset

o   Rigid

o   Decreased reflexes

o   Normal pupils

o   Notes: dopamine blockade

·Serotonin syndrome

o   Abrupt onset

o   Tremors

o   Increased reflexes

o   Mydriasis (pupil dilation)

o   Note: excess serotonin

What is metabolic syndrome and why is it a concern in psychiatric care?

• Multiple conditions – abdominal obesity, HTN, hyperglycemia, dyslipidemia

• Increases risk for: T2DM, cardiovascular disease, stroke

• Concern in psychiatric care:

• Antipsychotics can increase the risk for metabolic syndrome:  Increases appetite & weight gain

• Increases blood glucose & lipid levels

• Contributes to insulin resistance

What are the diagnostic criteria for metabolic syndrome?

must have 3 of the following:

• Abdominal obesity (waist circumference >40 in men, >35 in women)

• Elevated triglycerides (≥150 mg/dL)

• Low HDL cholesterol (<40 mg/dL in men, <50 mg/dL in women)

• Elevated blood pressure (≥130/85 mmHg)

• Elevated fasting glucose (≥100 mg/dL)

Which mental health medications are associated with a higher risk of metabolic syndrome?

• 2^nd generation medications

• Higher risk – clozapine, olanzapine

What lab values and physical health indicators should be monitored for clients taking second-generation antipsychotics?

·       Weight

·       Blood glucose

·       Cardiac – BP, ECG

·       CBC, lipid panel

·LFTs, prolactin

How should a nurse ask about hallucinations in a nonjudgmental, therapeutic way?

• Acknowledge their experience

• Assess for safety

• Ask open ended questions

Develop two open-ended questions that assess for hallucinations without reinforcing them.

• Can you share with me what the voices are saying? How does that make you feel?

• Can you tell me what you are experiencing right now?

What are the different types of delusions a client with schizophrenia may experience?

• Grandiose

• Persecutory

• Delusion of control

• Thought insertion

How does identifying the type of delusion inform your nursing approach?

• Built trust – knowing type of delusion will adjust how you will build rapport

• Can adjust care plan based on type of delusions

• Helps us know how to respond safely – some delusions may have a risk of self harm or harm to others

What are the symptoms of MDD?

• Major Depressive Disorder involves persistent depression without mania, with symptoms like loss of interest, sleep issues, and suicidal thoughts.

What are the symptoms of Bipolar I?

requires at least one manic episode, often with severe functional impairment or psychosis

What are the symptoms of Bipolar II?

 includes hypomania and depression but no full manic episodes. Causes for these disorders involve genetic, neurological, and environmental factors, and proper diagnosis often includes ruling out substance-related causes

How does knowing the signs and symptoms of Major Depressive Disorder, Bipolar I, and Bipolar II (from the DSM-5) help you as a nurse care for and advocate for your patients?

• Knowing the signs and symptoms of these mood disorders helps you as a nurse assess your patients effectively for risks like suicidality and impaired functionality. It allows you to provide empathetic care, educate them about their condition and treatment, and ensure their safety by implementing therapeutic interventions and connecting them with appropriate resources. By understanding their specific challenges, you can advocate for proper care and support systems tailored to their needs

What symptoms commonly present with depression?

• persistent feelings of sadness,

• hopelessness,

• worthlessness,

• loss of interest in activities,

• fatigue or low energy,

• sleep disturbances,

• changes in appetite or weight,

• difficulty concentrating

• thoughts of death or suicide

How can depression include psychosis, and how should nurses respond?

• Depression can include psychosis, particularly in severe cases, where individuals may experience delusions or hallucinations that align with their depressive themes, such as feelings of guilt or worthlessness. Nurses should provide a calm and supportive environment, conduct thorough assessments, and ensure the client is referred for immediate professional help, including therapy and medication if needed

What is the difference between mania and hypomania?

• Mania: diminished need for sleep, must last 7 days and impair function

• Hypomania: need to last 3-4 days or less

• Mania is a more severe form of elevated mood than hypomania. Mania can include psychotic features, require hospitalization, and significantly impair functioning

• hypomania is less severe and doesn't lead to major disruptions

• Both share similar symptoms like high energy and decreased need for sleep but differ in intensity and impact.

How does mania typically present in a patient?

• An elevated, expansive, or irritable mood. 

• Inflated self-esteem (grandiosity), racing thoughts, hyperactivity, poor judgment (like overspending or hypersexuality), lack of sleep, and rapid or verbose speech

What is the focus of nursing care when a patient is acutely manic?

• Ensuring safety, reducing stimulation, and addressing basic needs like rest and hydration

• Setting clear boundaries, using calm communication, and managing agitation with medication (like atypical antipsychotics) are also key priorities

What non-pharmacologic treatments are helpful for depression (e.g., CBT, group therapy, peer support)?

• Exercise,

• therapy,

• support system,

• hygiene,

• nutrition,

• light therapy,

• cognitive behavioral psychotherapy

What is ECT (Electroconvulsive Therapy)? What should the nurse teach the patient about what to expect before and after the procedure?

• A treatment that is most effective. Used in severe cases of depression. Used general anesthesia, monitoring. Safe and tolerant procedure. Psychotic depression use or bipolar depression, severe schizophrenia, severely SI. Block activity, apply small stimulus > small 30 sec seizure. 1-3 treatments will notice improvement. Family will notice before patient. Mild cases of depression will not respond to ECT or alcohol induce depression will not respond. Headache, sore muscles, memory loss (most common) are possible side effects. Invasive procedure.

• Uses pain meds, benzo

• Electroconvulsive

Which antidepressant drug class is most lethal in overdose and why?

• (TCAs) Tricyclics- Cause deadly cardiac arrythmias and seizure

What are signs and symptoms of serotonin syndrome?

• Agitation,

• confusion,

• rapid heart rate,

• high blood pressure,

• shivering,

• fever,

• diarrhea,

• muscle rigidity,

• tremors, and

• seizures

What are complications of serotonin syndrome if left untreated?

• If left untreated, complications like severe hyperthermia, seizures, and organ failure can occur, which can be life-threatening.

How is serotonin syndrome treated?

• It’s treated by discontinuing serotonergic medications, providing IV fluids, benzodiazepines for sedation, and administering cyproheptadine as an antidote

Which antidepressant drug class requires food restrictions?

• MAOIs like Phenelzine require food restrictions because they inhibit the breakdown of tyramine, which can lead to a hypertensive crisis

What foods should be avoided in MAOIs and why?

• Foods high in tyramine includes aged cheeses, smoked meats, red wine, beer, chocolate, avocados, and soy products. Avoiding these foods is essential to prevent dangerous blood pressure spikes

Which antidepressant class is contraindicated for patients with a seizure history?

• Bupropion and tricyclic

• Which class of antidepressants requires close blood pressure monitoring?

• Monoamine oxidase inhibitors (MAOIs)

What is the therapeutic range for lithium?

• 0.6 to 1.2 mEq/L

Who is at risk for lithium toxicity?

• Known chronic Kidney disease

What labs should be monitored? (Lithium)

• serum lithium levels,

• renal function tests,

• electrolytes,

• glucose, and

• thyroid-stimulating hormone

what are signs/symptoms of lithium toxicity?

• Nausea,

• Vomiting,

• Lethargy,

• tremor,

• fatigue,

• confusion,

• agitation,

• delirium,

• tachycardia,

• hyper tone,

• coma,

• seizures