Mental Health and Psychiatric Nursing Flashcards
25 cards from real NCLEX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 20 Mental Health and Psychiatric Nursing flashcards as text
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?
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.
A patient is admitted with a diagnosis of major depressive disorder. Which nursing intervention has the highest priority?
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.
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:
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.
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:
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.
A nurse is conducting a suicide risk assessment using the SAD PERSONS mnemonic. Which factor should the nurse assess?
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.
A patient with anorexia nervosa has a BMI of 15 and is medically unstable. Which nursing intervention is the priority?
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.
A nurse is working with a patient who has borderline personality disorder (BPD). Which behavior is most characteristic of this diagnosis?
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.
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?
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.
Which intervention is most therapeutic when caring for a patient experiencing alcohol withdrawal on day 2 of admission?
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.
A patient prescribed haloperidol (Haldol) develops muscle rigidity, hyperthermia (103°F), diaphoresis, and altered consciousness. What condition does this represent?
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.
A patient with post-traumatic stress disorder (PTSD) is being assessed. Which symptom is NOT a diagnostic criterion for PTSD?
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.
A patient reports hearing voices telling them to hurt a specific person. What is the nurse's priority ethical and legal obligation?
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.
A nurse is using de-escalation techniques with an agitated patient. Which approach is most therapeutic?
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.
A patient newly prescribed sertraline (Zoloft) for depression asks when they will start feeling better. The nurse's best response is:
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.
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'?
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.
A patient with obsessive-compulsive disorder (OCD) spends 3 hours daily checking door locks. The nurse understands that the compulsive checking behavior functions to:
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.
A patient in the psychiatric unit has been placed in seclusion. What is the most important nursing responsibility while the patient is in seclusion?
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).
A nurse is teaching a patient about clonazepam prescribed for panic disorder. Which statement by the patient requires clarification?
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.
A patient with schizophrenia has been stable on olanzapine for 2 years. Which long-term adverse effects should the nurse monitor for?
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.
A patient is experiencing a dissociative episode. Which nursing intervention is most appropriate?
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.