BSN Mental Health and Psychiatric Nursing 1 — Questions and Answers
Question 1: A patient with schizophrenia tells the nurse that the television is sending them personal messages. The nurse correctly identifies this as:
- An idea of reference (Correct answer)
- A command hallucination
- Thought broadcasting
- Nihilistic delusion
Correct answer: An idea of reference
An idea of reference is a delusion in which a patient believes that external events, objects, or people have a special personal meaning directed at them.
Question 2: A patient is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which nursing intervention takes priority during the first 24 hours?
- Assess for suicidal ideation and means (Correct answer)
- Encourage participation in group therapy
- Establish a regular sleep schedule
- Provide written educational material about depression
Correct answer: Assess for suicidal ideation and means
Safety assessment for suicidal ideation is always the first priority when caring for a patient with major depressive disorder.
Question 3: A nurse is using therapeutic communication with a patient who says, 'I don't know what to do about my marriage.' Which response best demonstrates the technique of reflection?
- 'It sounds like you're feeling confused about your marriage.' (Correct answer)
- 'Have you thought about seeing a marriage counselor?'
- 'Tell me what the specific problems in your marriage are.'
- 'Many couples go through difficult times; you're not alone.'
Correct answer: 'It sounds like you're feeling confused about your marriage.'
Reflection restates the emotional content of the patient's message back to them, encouraging further exploration of feelings.
Question 4: A patient with bipolar disorder is in a manic episode and is pacing the hallway, talking rapidly, and refusing to eat. What is the nurse's priority intervention?
- Provide high-calorie finger foods the patient can eat while moving (Correct answer)
- Insist the patient sit down in the dining room for a full meal
- Administer PRN antipsychotic medication to reduce activity
- Place the patient in a quiet room and allow them to rest undisturbed
Correct answer: Provide high-calorie finger foods the patient can eat while moving
During mania, patients cannot focus long enough to sit and eat; portable, high-calorie foods maintain nutrition without increasing agitation.
Question 5: A patient is taking haloperidol (Haldol) and develops sustained muscle spasms in the neck, facial grimacing, and tongue protrusion. The nurse recognizes this as:
- Acute dystonia (Correct answer)
- Tardive dyskinesia
- Akathisia
- Neuroleptic malignant syndrome
Correct answer: Acute dystonia
Acute dystonia is an early extrapyramidal side effect of antipsychotics characterized by involuntary muscle contractions typically affecting the head and neck.
Question 6: When a nurse uses the technique of 'setting limits' with a manipulative patient, the primary purpose is to:
- Establish consistent, predictable boundaries to promote safe behavior (Correct answer)
- Punish the patient for manipulative actions
- Isolate the patient from the therapeutic milieu
- Demonstrate authority and control over the unit
Correct answer: Establish consistent, predictable boundaries to promote safe behavior
Limit setting provides a structured, consistent environment that promotes patient safety and reduces manipulative behaviors without being punitive.
BSN Mental Health and Psychiatric Nursing 1
A patient with schizophrenia tells the nurse that the television is sending them personal messages.
The nurse correctly identifies this as: