NCLEX Mental Health and Psychiatric Nursing 1 — Questions and Answers

Question 1: A patient with schizophrenia tells the nurse, 'The CIA has implanted a chip in my brain to monitor my thoughts.' How should the nurse respond therapeutically?

Tell the patient the CIA does not implant chips in people's brains
Acknowledge the patient's distress without reinforcing or arguing against the delusion (Correct answer)
Ask detailed questions about the CIA to explore the delusion further
Change the subject immediately and discuss discharge planning

Correct answer: Acknowledge the patient's distress without reinforcing or arguing against the delusion

Therapeutic communication with delusional patients involves acknowledging the distress the delusion causes without reinforcing the false belief or arguing against it, as arguing typically escalates agitation.

Delusions are fixed, false beliefs that are resistant to logic or evidence. Arguing with the patient ('That's not true') typically reinforces the delusion and damages trust. Reinforcing it by agreeing or asking for elaboration is also inappropriate. The therapeutic approach: acknowledge feelings ('I can see this is very frightening for you'), express concern for the patient's well-being, gently redirect to here-and-now coping, and build therapeutic alliance. Antipsychotic medications (first-line: atypical antipsychotics like risperidone, olanzapine) address positive symptoms including delusions. Validate feelings without validating false content.

Question 2: A patient is admitted with a diagnosis of major depressive disorder. Which nursing intervention has the highest priority?

Encourage group therapy attendance
Assess for suicidal ideation and means (Correct answer)
Establish a structured activity schedule
Teach the patient about antidepressant medications

Correct answer: Assess for suicidal ideation and means

Safety is the priority in psychiatric nursing. Major depression carries significant suicide risk, making assessment for suicidal ideation, plan, and means the first and highest-priority intervention.

Major depressive disorder (MDD) carries a significant risk of suicide (approximately 15% lifetime mortality in severe untreated cases). On admission, the nurse must conduct a thorough suicide risk assessment: (1) Ideation — passive ('I wish I were dead') vs. active ('I want to kill myself'); (2) Plan — does the patient have a specific plan?; (3) Means — does the patient have access to lethal means (firearms, medications)?; (4) Intent — does the patient intend to act?; (5) Prior attempts — strongest predictor of future attempt. Based on risk level, implement the appropriate level of observation (1:1 for imminent risk). All other interventions follow once safety is established.

Question 3: A patient taking lithium carbonate for bipolar disorder develops coarse tremors, vomiting, and confusion. The serum lithium level is 2.4 mEq/L. The nurse should:

Reassure the patient that tremors are a normal side effect of lithium
Hold lithium, notify the provider, and prepare for supportive care as lithium toxicity is present (Correct answer)
Administer the next scheduled lithium dose as the level is within therapeutic range
Decrease sodium intake to correct the lithium level

Correct answer: Hold lithium, notify the provider, and prepare for supportive care as lithium toxicity is present

Therapeutic lithium range is 0.6–1.2 mEq/L (maintenance) or 0.8–1.2 mEq/L (acute mania). A level of 2.4 mEq/L is toxic. Coarse tremor, vomiting, and confusion indicate moderate-to-severe toxicity requiring immediate intervention.

Lithium has a narrow therapeutic index: maintenance 0.6–1.2 mEq/L; acute mania 0.8–1.2 mEq/L. Toxicity levels and manifestations: 1.5–2.0 mEq/L (mild): nausea, vomiting, fine tremor, fatigue; 2.0–2.5 mEq/L (moderate): coarse tremor, confusion, drowsiness, ataxia, slurred speech; >2.5 mEq/L (severe): seizures, cardiac dysrhythmias, coma, death. Management: hold lithium, notify provider, monitor ECG, IV hydration (normal saline promotes lithium excretion), dialysis for severe cases. Lithium is excreted by the kidneys — dehydration, low sodium diet, NSAIDs, and ACE inhibitors all increase lithium levels. Lithium has no specific antidote.

Question 4: A patient on a psychiatric unit with bipolar disorder states, 'I am the president of the United States and I need a phone right now to call the Pentagon.' The nurse recognizes this as:

A hallucination
Grandiose delusion consistent with mania (Correct answer)
Confabulation
Dissociation

Correct answer: Grandiose delusion consistent with mania

A grandiose delusion is a fixed, false belief about having special powers, identity, or importance. Believing one is the president when not is a classic grandiose delusion seen in manic episodes.

Grandiose delusions are false beliefs of inflated worth, power, knowledge, identity, or special relationships with a famous person. They are characteristic of bipolar I mania, as well as schizophrenia. In contrast: hallucinations are sensory perceptions without external stimuli; confabulation is filling memory gaps with fabricated information (seen in Korsakoff syndrome); dissociation is a disruption in identity, consciousness, or memory. Other manifestations of mania include decreased need for sleep, pressured speech, flight of ideas, hyperactivity, impulsivity, distractibility, and excessive goal-directed activity. Antipsychotics and mood stabilizers are used to treat acute mania.

Question 5: A nurse is conducting a suicide risk assessment using the SAD PERSONS mnemonic. Which factor should the nurse assess?

Social engagement levels and activity
Sex, age, depression, previous attempts, ethanol use, rational thinking loss, social support lacking, organized plan, no spouse, and sickness (Correct answer)
Self-esteem and daily living functioning
Sleep patterns and appetite disturbance

Correct answer: Sex, age, depression, previous attempts, ethanol use, rational thinking loss, social support lacking, organized plan, no spouse, and sickness

SAD PERSONS is a validated suicide risk assessment tool. Each letter represents a risk factor: Sex, Age, Depression, Previous attempt, Ethanol, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness.

The SAD PERSONS scale assigns points for risk factors: S=male sex; A=age <19 or >45; D=depression or hopelessness; P=previous attempt (strongest predictor); E=excessive alcohol or substance use; R=rational thinking loss (psychosis); S=social support lacking; O=organized/specific plan; N=no spouse (widowed/divorced/single); S=sickness (chronic illness). Total score guides level of care: 0–2 may not need intervention; 5–6 close follow-up; 7–10 hospital admission. While various tools exist (Columbia Protocol, PHQ-9), understanding these key risk factors helps nurses triage suicide risk appropriately. Always document all suicide risk assessments.

Question 6: A patient with anorexia nervosa has a BMI of 15 and is medically unstable. Which nursing intervention is the priority?

Encourage the patient to discuss feelings about body image
Monitor vital signs, electrolytes, and cardiac rhythm for complications of malnutrition (Correct answer)
Begin group therapy about healthy eating habits
Provide dietary education about daily caloric requirements

Correct answer: Monitor vital signs, electrolytes, and cardiac rhythm for complications of malnutrition

At a BMI of 15 with medical instability, physiologic complications of severe malnutrition (electrolyte imbalances, cardiac dysrhythmias, refeeding syndrome) are life-threatening and require priority monitoring.

Anorexia nervosa has the highest mortality rate of any psychiatric disorder (5–10%), primarily from medical complications. BMI <17.5 is a diagnostic criterion. Medical complications of severe malnutrition include: (1) Electrolyte imbalances — hypokalemia, hypophosphatemia, hypomagnesemia causing cardiac dysrhythmias; (2) Bradycardia, hypotension, orthostatic hypotension; (3) Refeeding syndrome — when nutrition is reintroduced too rapidly, causing dangerous shifts of phosphate, potassium, and magnesium into cells; (4) Bone loss, amenorrhea; (5) Leukopenia, anemia. Priority nursing: continuous cardiac monitoring, electrolyte replacement, careful titration of nutritional support, daily weights, monitoring intake/output. Medical stability precedes psychological treatment.

Question 7: A nurse is working with a patient who has borderline personality disorder (BPD). Which behavior is most characteristic of this diagnosis?

Flat affect and social withdrawal lasting months
Intense, unstable interpersonal relationships with alternating idealization and devaluation (Correct answer)
Persistent inflexible rituals to control anxiety
Grandiosity and decreased need for sleep

Correct answer: Intense, unstable interpersonal relationships with alternating idealization and devaluation

BPD is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect. Splitting (idealizing/devaluing others) is a hallmark defense mechanism seen in BPD.

Borderline Personality Disorder (BPD) DSM-5 criteria include a pervasive pattern of: (1) Frantic efforts to avoid abandonment; (2) Unstable, intense interpersonal relationships (splitting — 'all good' or 'all bad'); (3) Identity disturbance; (4) Impulsivity in self-damaging areas; (5) Recurrent self-mutilation or suicidal behavior; (6) Emotional dysregulation; (7) Chronic emptiness; (8) Inappropriate intense anger; (9) Stress-related paranoia or dissociation. 'Splitting' is the defense mechanism of viewing people as all good or all bad, shifting rapidly. Staff may feel manipulated. Dialectical Behavior Therapy (DBT) is the evidence-based treatment. Set consistent limits and communicate calmly. Countertransference is a risk for nurses.

Question 8: A nurse notices a patient who has been agitated and pacing is suddenly very calm and states 'I've made my decision.' What should the nurse interpret this behavioral change as?

Positive response to therapy and medication
A possible sign of resolution of suicidal crisis after deciding to act (Correct answer)
Breakthrough of underlying depression requiring dosage adjustment
Normal behavioral fluctuation in psychiatric patients

Correct answer: A possible sign of resolution of suicidal crisis after deciding to act

A sudden, calm behavioral change in a previously agitated suicidal patient may indicate the patient has made a decision to act on suicidal ideation and feels relief. This requires immediate safety assessment.

The 'calm before the storm' phenomenon is a well-recognized warning sign in suicidal patients. When a patient who has been distressed, agitated, or expressing suicidal thoughts suddenly becomes calm or states 'I've made my decision,' this may reflect resolution of ambivalence after deciding to act on suicidal ideation. The relief from having made the decision produces observable calm. This is a psychiatric emergency. Nurses should: (1) Immediately assess suicidal ideation and plan; (2) Implement 1:1 constant observation; (3) Remove all potential means from the environment; (4) Notify the provider and treatment team; (5) Do not leave the patient alone. This pattern can occur before serious suicide attempts.

Question 9: Which intervention is most therapeutic when caring for a patient experiencing alcohol withdrawal on day 2 of admission?

Encourage rapid oral hydration and mobilization
Administer prescribed benzodiazepines per CIWA protocol and monitor closely for seizures (Correct answer)
Restrict fluids and maintain a quiet environment only
Provide thiamine after completing the CIWA assessment

Correct answer: Administer prescribed benzodiazepines per CIWA protocol and monitor closely for seizures

Benzodiazepines (lorazepam, diazepam, chlordiazepoxide) are first-line for alcohol withdrawal to prevent delirium tremens and seizures. CIWA (Clinical Institute Withdrawal Assessment) guides dosing. Thiamine should be given before or with glucose.

Alcohol withdrawal can be life-threatening. Timeline: 6–24 hours: anxiety, tremors, diaphoresis, tachycardia, hypertension; 24–48 hours: withdrawal seizures (generalized tonic-clonic); 48–72 hours: delirium tremens (DTs) — hallucinations, extreme agitation, severe autonomic instability with mortality 5–15% if untreated. CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) scale scores 10 parameters (tremor, sweats, anxiety, agitation, nausea/vomiting, tactile/auditory/visual disturbances, headache, orientation). Benzodiazepines are first-line: diazepam or lorazepam. Thiamine 100 mg IV/IM BEFORE glucose to prevent Wernicke's encephalopathy (confusion, ataxia, ophthalmoplegia). Monitor closely on day 2–3 when seizure/DT risk peaks.

Question 10: A patient prescribed haloperidol (Haldol) develops muscle rigidity, hyperthermia (103°F), diaphoresis, and altered consciousness. What condition does this represent?

Tardive dyskinesia
Neuroleptic malignant syndrome (NMS) (Correct answer)
Extrapyramidal side effect (EPS)
Serotonin syndrome

Correct answer: Neuroleptic malignant syndrome (NMS)

Neuroleptic Malignant Syndrome (NMS) is a rare but potentially fatal reaction to antipsychotics, characterized by the tetrad: hyperthermia, muscle rigidity, altered consciousness, and autonomic instability.

Neuroleptic Malignant Syndrome (NMS) is a rare, life-threatening adverse reaction to antipsychotic (neuroleptic) medications, caused by dopamine D2 receptor blockade in the hypothalamus and basal ganglia. Classic tetrad: (1) Hyperthermia (>38°C); (2) Severe muscle rigidity ('lead pipe' rigidity); (3) Altered mental status (confusion, agitation, stupor, coma); (4) Autonomic instability (tachycardia, labile BP, diaphoresis, incontinence). Labs: elevated CK (muscle breakdown), leukocytosis, metabolic acidosis. Treatment: (1) Immediately stop antipsychotic; (2) ICU admission; (3) Aggressive cooling; (4) IV hydration; (5) Dantrolene (muscle relaxant) or bromocriptine (dopamine agonist). Mortality 10–20% if untreated. Compare serotonin syndrome: hyperreflexia, clonus, serotonergic drug-related.

Question 11: A patient with post-traumatic stress disorder (PTSD) is being assessed. Which symptom is NOT a diagnostic criterion for PTSD?

Intrusive re-experiencing of the trauma (flashbacks)
Hypervigilance and exaggerated startle response
Persistent elevated mood and euphoria (Correct answer)
Avoidance of stimuli associated with the trauma

Correct answer: Persistent elevated mood and euphoria

PTSD is characterized by intrusion symptoms, avoidance, negative cognitions/mood changes (not elevated mood), and hyperarousal/reactivity. Persistent elevated mood and euphoria are not PTSD criteria.

DSM-5 PTSD diagnostic criteria (exposure to actual or threatened death, serious injury, or sexual violence, followed by): (1) Intrusion symptoms: flashbacks, nightmares, intrusive memories, intense psychological/physiological reactions to cues; (2) Avoidance: of thoughts/feelings or external reminders; (3) Negative alterations in cognition and mood: amnesia, negative beliefs, distorted blame, persistent negative emotions (fear, horror, guilt, shame), diminished interest, detachment, inability to experience positive emotions (emotional numbing); (4) Hyperarousal: hypervigilance, exaggerated startle, sleep disturbance, irritability/aggression, reckless behavior. Elevated/euphoric mood is not a feature — that would suggest bipolar disorder or another condition.

Question 12: A patient reports hearing voices telling them to hurt a specific person. What is the nurse's priority ethical and legal obligation?

Keep this information confidential per HIPAA
Warn the identified potential victim and notify the provider per duty to warn laws (Correct answer)
Discuss this in the next scheduled group therapy session
Document the finding and observe the patient without action

Correct answer: Warn the identified potential victim and notify the provider per duty to warn laws

The duty to warn (Tarasoff duty) requires mental health professionals to take reasonable steps to protect identified third parties from credible threats. This supersedes patient confidentiality.

The Tarasoff decision (1976, Tarasoff v. Regents of University of California) established the 'duty to warn' and 'duty to protect': when a patient makes a credible, specific threat against an identifiable third party, mental health providers have a legal obligation to notify the intended victim and appropriate authorities. This is an exception to patient confidentiality (HIPAA). The nurse should: (1) Immediately notify the treating provider; (2) Document the threat in detail; (3) Implement safety measures for the patient; (4) Follow facility protocol for warning the potential victim; (5) Law enforcement notification may be indicated. The duty to warn varies by state law — nurses must know their state's statutes. This takes priority over routine confidentiality.

Question 13: A nurse is using de-escalation techniques with an agitated patient. Which approach is most therapeutic?

Stand close to the patient to show empathy and connection
Speak in a calm, slow voice, offer choices, maintain non-threatening body posture and personal space (Correct answer)
Tell the patient they will be restrained if they don't calm down
Gather multiple staff to surround the patient and show force

Correct answer: Speak in a calm, slow voice, offer choices, maintain non-threatening body posture and personal space

Therapeutic de-escalation involves calm verbal communication, offering choices to restore sense of control, maintaining appropriate personal space (3–6 feet), and non-threatening body language.

Psychiatric de-escalation is a set of techniques used to defuse agitation and prevent violence without restraint. Key principles: (1) Self-awareness — remain calm, monitor your own voice/tone/body language; (2) Personal space — maintain 3–6 feet (violating space escalates agitation); (3) Non-threatening posture — sideways stance, hands visible, at eye level; (4) Communication — calm, slow, quiet voice; simple, clear sentences; empathic listening; acknowledge feelings; (5) Offer choices to restore sense of control; (6) Avoid power struggles; (7) Set limits clearly and respectfully. Threats of restraint, multiple staff surrounding the patient, or invading personal space increase agitation. Restraint and seclusion are last-resort interventions with strict legal and regulatory requirements.

Question 14: A patient newly prescribed sertraline (Zoloft) for depression asks when they will start feeling better. The nurse's best response is:

Most patients feel complete relief within 3 days
Full therapeutic effect typically requires 4–6 weeks; some improvement in sleep and energy may be noticed in the first 1–2 weeks (Correct answer)
If it doesn't work within 1 week, the medication needs to be changed
The medication should be stopped immediately if you feel no better after 2 weeks

Correct answer: Full therapeutic effect typically requires 4–6 weeks; some improvement in sleep and energy may be noticed in the first 1–2 weeks

SSRIs typically require 4–6 weeks for full antidepressant effect. Early improvements in sleep and energy may be noticed in weeks 1–2. Patients should not stop abruptly or change medications after just 1–2 weeks.

Selective serotonin reuptake inhibitors (SSRIs) like sertraline (Zoloft) are first-line for MDD. Key patient education points: (1) Full antidepressant effect takes 4–6 weeks; do not stop prematurely; (2) Early improvements (sleep, appetite, energy) may occur in weeks 1–2, before mood fully lifts; (3) Some side effects (nausea, insomnia, anxiety) may be worse at the start and improve; (4) NEVER abruptly stop SSRIs — SSRI discontinuation syndrome (dizziness, nausea, flu-like symptoms, 'brain zaps'); taper under provider guidance; (5) Monitor for activation syndrome in young patients (<25) — increased agitation and suicidality in early treatment; (6) Report any worsening of suicidal thoughts immediately.

Question 15: Which therapeutic communication technique does the nurse use when responding to a patient's statement 'Nobody cares about me' with 'It sounds like you feel very alone and uncared for'?

Offering general leads
Reflecting (Correct answer)
Restating
Clarifying

Correct answer: Reflecting

Reflecting involves paraphrasing and directing the patient's feelings back to them to encourage exploration and show understanding. It validates the emotional content of the patient's message.

Therapeutic communication techniques: (1) Reflecting: paraphrasing the emotional content/feelings to encourage exploration ('It sounds like you feel very alone') — validates feelings, encourages deeper exploration; (2) Restating: repeating the exact words back ('Nobody cares about you?') — encourages the patient to continue; (3) Clarifying: asking for more information ('What do you mean by nobody cares?'); (4) Offering general leads: 'Go on,' 'Tell me more'; (5) Summarizing: condensing what was said; (6) Focusing: directing attention to a specific point; (7) Silence: allowing time for reflection. Non-therapeutic techniques include giving advice, offering false reassurance, defending, agreeing/disagreeing, changing the subject, and probing.

Question 16: A patient with obsessive-compulsive disorder (OCD) spends 3 hours daily checking door locks. The nurse understands that the compulsive checking behavior functions to:

Fulfill an intrinsic desire for control and power
Temporarily reduce the anxiety caused by obsessive thoughts (Correct answer)
Provide sensory stimulation to a depleted nervous system
Fulfill unconscious aggressive impulses

Correct answer: Temporarily reduce the anxiety caused by obsessive thoughts

Compulsions are repetitive behaviors performed to reduce the anxiety or distress caused by obsessions. Checking locks temporarily relieves the anxiety from obsessive thoughts about being burglarized or harmed.

OCD involves a cycle: (1) Obsessions — intrusive, unwanted, anxiety-provoking thoughts, images, or urges (e.g., 'I left the door unlocked and something terrible will happen'); (2) Anxiety/distress escalates; (3) Compulsions — repetitive mental or behavioral rituals performed to reduce the anxiety (checking, washing, counting, arranging); (4) Temporary relief; (5) Cycle repeats. The compulsion provides momentary anxiety relief but reinforces the obsession-compulsion cycle, making it worse over time. Insight is often preserved. Evidence-based treatment: (1) Exposure and Response Prevention (ERP) therapy — gold standard; (2) SSRIs at higher doses (fluoxetine, sertraline, clomipramine); (3) Combined ERP + medication. Abrupt interruption of rituals increases anxiety and is not therapeutic.

Question 17: A patient in the psychiatric unit has been placed in seclusion. What is the most important nursing responsibility while the patient is in seclusion?

Ensure the seclusion room is completely silent and dark
Monitor the patient at least every 15 minutes, document behaviors, and assess physical needs (Correct answer)
Continue seclusion without time limits until the patient is fully calm
Leave the patient alone entirely to allow self-regulation

Correct answer: Monitor the patient at least every 15 minutes, document behaviors, and assess physical needs

The Joint Commission and CMS regulations require continuous monitoring of secluded patients, with in-person visual checks at least every 15 minutes, documentation, and assessment of physical needs (hydration, elimination, injury).

Seclusion (involuntary confinement in a room) is a restrictive intervention used only when patients pose imminent danger and less restrictive measures have failed. Regulatory requirements (Joint Commission, CMS): (1) Provider order required (or immediate clinical justification with rapid follow-up order); (2) Time limits on orders (adults: 4 hours; adolescents: 2 hours; children: 1 hour); (3) Direct visual check at least every 15 minutes (many facilities require continuous monitoring); (4) In-person face-to-face evaluation by LIP within 1 hour; (5) Document rationale, behavior, patient condition, less restrictive alternatives tried; (6) Assess physical needs: hydration, nutrition, toilet access, skin integrity; (7) Debriefing after the episode. Seclusion must never be used as punishment.

Question 18: A nurse is teaching a patient about clonazepam prescribed for panic disorder. Which statement by the patient requires clarification?

I understand this medication can cause drowsiness and to avoid driving
I can take extra doses if I feel a panic attack coming on (Correct answer)
I should not abruptly stop this medication without talking to my doctor
I should avoid alcohol while taking this medication

Correct answer: I can take extra doses if I feel a panic attack coming on

Taking extra benzodiazepine doses without direction from the provider risks physical dependence, tolerance, and overdose. The patient must take only the prescribed dose — this statement indicates a dangerous misunderstanding.

Clonazepam is a long-acting benzodiazepine used for panic disorder. Critical patient education: (1) Take ONLY as prescribed — do not self-increase doses; (2) Do NOT abruptly discontinue — benzodiazepine withdrawal can cause life-threatening seizures, delirium, and severe anxiety; taper required; (3) Avoid alcohol and CNS depressants — additive CNS/respiratory depression; (4) Causes sedation, impaired coordination — avoid driving, operating machinery; (5) Physical dependence develops with regular use even at therapeutic doses; (6) Cross-tolerance with alcohol; (7) Risk of respiratory depression with opioid combination; (8) Report paradoxical reactions (increased agitation, aggression). The prescription should include specific instructions about panic attacks.

Question 19: A patient with schizophrenia has been stable on olanzapine for 2 years. Which long-term adverse effects should the nurse monitor for?

Pulmonary fibrosis and thyroid dysfunction
Weight gain, metabolic syndrome, hyperglycemia, and tardive dyskinesia (Correct answer)
Renal failure and hepatotoxicity only
Bone marrow suppression requiring weekly WBC monitoring

Correct answer: Weight gain, metabolic syndrome, hyperglycemia, and tardive dyskinesia

Atypical antipsychotics like olanzapine cause metabolic syndrome (weight gain, dyslipidemia, insulin resistance, hyperglycemia) and tardive dyskinesia with long-term use. Metabolic monitoring is essential.

Olanzapine (Zyprexa) is a second-generation (atypical) antipsychotic. Long-term monitoring is essential for: (1) Metabolic syndrome: weight gain (significant — olanzapine has the highest metabolic risk among atypicals), dyslipidemia, insulin resistance, type 2 diabetes — monitor fasting glucose, lipids, weight, waist circumference regularly; (2) Tardive dyskinesia (TD): involuntary repetitive movements (tongue thrusting, lip smacking, choreoathetoid movements) — assess with AIMS (Abnormal Involuntary Movement Scale) every 6–12 months; (3) Orthostatic hypotension; (4) Anticholinergic effects. Weekly WBC is required for clozapine (not olanzapine) due to agranulocytosis risk. Pulmonary fibrosis is associated with amiodarone.

Question 20: A patient is experiencing a dissociative episode. Which nursing intervention is most appropriate?

Leave the patient alone until the episode resolves spontaneously
Use grounding techniques: encourage the patient to focus on sensory cues in the present environment (Correct answer)
Firmly remind the patient that what they are experiencing is not real
Administer an antipsychotic medication immediately

Correct answer: Use grounding techniques: encourage the patient to focus on sensory cues in the present environment

Grounding techniques (5-4-3-2-1 sensory method, physical sensation focus) bring the patient back to present reality during dissociation. They are evidence-based, non-pharmacological interventions for dissociative episodes.

Dissociation involves disruption in consciousness, memory, identity, or perception. Dissociative episodes may occur in PTSD, dissociative disorders, or as responses to trauma triggers. Grounding techniques help reconnect the patient to the present: (1) 5-4-3-2-1 technique: name 5 things you can see, 4 you can touch, 3 you can hear, 2 you can smell, 1 you can taste; (2) Physical grounding: feel feet on floor, hold a cold ice cube, take slow deep breaths; (3) Verbal re-orientation: calm, clear reminders of safety and location. Telling the patient 'it's not real' is dismissive and unhelpful. Antipsychotics are not indicated for dissociation (not a psychotic disorder). Leaving alone may allow escalation and unsafe behavior.

Question 21: A nurse is working with a patient who uses splitting as a defense mechanism on the psychiatric unit. Which approach is most effective?

Allow the patient to choose favorite staff members for all care
Maintain consistent limits and communicate regularly with all team members to present a unified approach (Correct answer)
Encourage the patient to express why certain staff are 'bad' to ventilate feelings
Avoid discussing the splitting behavior to prevent reinforcing it

Correct answer: Maintain consistent limits and communicate regularly with all team members to present a unified approach

Splitting is best managed with consistent limit-setting and staff communication. When the team presents a unified, consistent approach, patients with BPD cannot manipulate staff through idealization/devaluation cycles.

Splitting (seen primarily in BPD) is the unconscious defense mechanism of categorizing people as all good or all bad. In a psychiatric unit, this manifests as a patient praising some staff ('you're the only one who understands me') and disparaging others. This can create staff conflict and counter-therapeutic splitting within the team itself. Effective management: (1) Regular team meetings to ensure consistent limit-setting across all staff; (2) Clear, written behavioral contracts that all staff enforce identically; (3) Avoid special treatment for 'idealized' staff; (4) Maintain professional therapeutic boundaries; (5) Supervision and peer support to manage counter-transference. Allowing the patient to choose staff or to ventilate about 'bad' staff reinforces splitting.

Question 22: A patient recovering from opioid use disorder is prescribed buprenorphine/naloxone (Suboxone). The nurse should teach the patient that naloxone is included in this formulation to:

Enhance the pain-relieving effects of buprenorphine
Deter misuse by injection — naloxone blocks opioid effects if injected but is inactive when taken sublingually (Correct answer)
Replace methadone as a more potent opioid agonist
Prevent nausea caused by buprenorphine

Correct answer: Deter misuse by injection — naloxone blocks opioid effects if injected but is inactive when taken sublingually

Naloxone is added to buprenorphine to deter intravenous misuse. When taken sublingually as directed, naloxone has minimal bioavailability. If injected, naloxone precipitates acute opioid withdrawal, discouraging misuse.

Suboxone (buprenorphine/naloxone) is used for medication-assisted treatment (MAT) of opioid use disorder. Buprenorphine is a partial opioid agonist (provides sufficient opioid effect to prevent withdrawal without euphoria at therapeutic doses). Naloxone is an opioid antagonist added as an abuse-deterrent. When taken sublingually (as prescribed), naloxone is poorly absorbed and produces minimal systemic effect. If the tablet is dissolved and injected, naloxone is absorbed, blocks opioid receptors, and precipitates immediate, severe opioid withdrawal — discouraging IV misuse. The 4:1 ratio of buprenorphine to naloxone is standard. Suboxone is superior to methadone in outpatient settings due to lower diversion potential and ability to prescribe in office settings.

Question 23: A patient is placed on a psychiatric hold under an involuntary commitment order. Which right does the patient retain?

The right to leave the facility at any time
The right to be treated with dignity, to refuse non-emergency treatment, and to communicate with an attorney (Correct answer)
The right to determine their own treatment plan without provider input
The right to access all portions of their medical record immediately

Correct answer: The right to be treated with dignity, to refuse non-emergency treatment, and to communicate with an attorney

Involuntary commitment restricts freedom of movement but does not eliminate all rights. Patients retain rights to dignity, communication with an attorney, and can refuse non-emergency treatments (though this may be overridden by court order).

Patients' rights under involuntary psychiatric commitment (varies by state but general principles): Retained rights include: (1) Humane treatment and freedom from abuse; (2) Communication with attorney and access to courts; (3) Right to refuse non-emergency treatment (may be overridden by court order if patient lacks decision-making capacity); (4) Confidentiality within certain limits; (5) Right to least restrictive treatment environment; (6) Informed consent for procedures when capacity is present. Lost/restricted rights: (1) Physical freedom/right to leave; (2) Some autonomy if found incompetent. Nurses must document and protect patient rights. Violations can result in legal liability. Forced treatment without due process violates constitutional rights.

Question 24: A nurse observes a colleague who appears intoxicated on the unit. What is the appropriate action?

Ignore it as this is a personal matter unrelated to patient care
Report the observation to the nurse manager and ensure patient safety immediately (Correct answer)
Confront the colleague privately and suggest they go home
Wait until the end of the shift to report the behavior

Correct answer: Report the observation to the nurse manager and ensure patient safety immediately

An impaired nurse represents an immediate patient safety threat. The nurse has both an ethical and legal obligation to report to the nurse manager immediately to protect patients and ensure safe care.

Healthcare provider impairment (substance use, mental health, fatigue) is a patient safety issue and an ethical obligation for nurses. ANA Code of Ethics requires nurses to address impaired practice. Steps: (1) Remove the suspected impaired nurse from direct patient care immediately — patient safety is priority; (2) Report to the nurse manager or supervisor; (3) Follow facility protocol for impairment — objective documentation of observed behaviors; (4) In many states, reporting to the Board of Nursing is required; (5) Peer assistance programs help impaired nurses obtain treatment. Covering up impairment, confronting alone without reporting, or delaying reporting could result in patient harm, nurse liability, and professional consequences. Most states have mandatory reporting laws for impaired practitioners.

Question 25: A patient with generalized anxiety disorder (GAD) is hyperventilating. Which intervention should the nurse implement first?

Administer lorazepam as ordered
Guide the patient in slow, controlled breathing and remain calm and present (Correct answer)
Leave the patient alone in a quiet room
Ask the patient to explain what is causing the anxiety

Correct answer: Guide the patient in slow, controlled breathing and remain calm and present

Hyperventilation causes respiratory alkalosis, which worsens anxiety. Guided slow breathing restores normal CO2 levels and activates the parasympathetic nervous system, reducing the acute anxiety response.

Hyperventilation during anxiety causes respiratory alkalosis (decreased pCO2), leading to peripheral and perioral tingling, lightheadedness, chest tightness — symptoms that further increase anxiety in a positive feedback loop. First intervention: calm, reassuring presence and guided controlled breathing. Techniques: (1) Diaphragmatic breathing — slow, deep inhalation over 4 seconds, hold 1–2 seconds, exhale over 6 seconds; (2) 4-7-8 breathing; (3) Pursed lip breathing. The nurse's calm, regulated presence is itself therapeutic. After stabilizing, cognitive interventions can be used. Benzodiazepines (lorazepam) are appropriate if non-pharmacological measures fail. Asking the patient to explain the cause during acute hyperventilation is not the first priority and may worsen the episode.

NCLEX Mental Health and Psychiatric Nursing 1

A patient with schizophrenia tells the nurse, 'The CIA has implanted a chip in my brain to monitor my thoughts.' How should the nurse respond therapeutically?

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