NCLEX Mental Health & Psychiatric Nursing Practice Exam

NCLEX Mental Health & Psychiatric Nursing Practice Exam

 

A nurse is caring for a patient diagnosed with schizophrenia. Which of the following symptoms should the nurse expect to observe?

A) Auditory hallucinations
B) Increased energy levels
C) Fear of being in public places
D) Apathy toward loved ones

 

The nurse is caring for a patient with generalized anxiety disorder (GAD). Which of the following interventions is most appropriate?

A) Encourage the patient to avoid stressful situations
B) Teach relaxation techniques and deep breathing exercises
C) Limit opportunities for social interaction to reduce anxiety
D) Provide the patient with a sedative for immediate relief

 

A patient with major depressive disorder (MDD) is receiving therapy. Which of the following should the nurse assess for as a potential side effect of the antidepressant?

A) Weight loss
B) Excessive sleepiness
C) Suicidal thoughts
D) High blood pressure

 

A nurse is caring for a patient with a diagnosis of bipolar disorder. Which of the following behaviors is characteristic of the manic phase of the illness?

A) Withdrawal from social activities
B) Decreased energy and increased sleep
C) Grandiosity and excessive talkativeness
D) Difficulty concentrating on tasks

 

A nurse is teaching a patient with post-traumatic stress disorder (PTSD) how to manage symptoms. Which statement by the patient indicates a need for further teaching?

A) “I will avoid situations that trigger memories of the trauma.”
B) “I will practice mindfulness and relaxation techniques.”
C) “I will talk about the trauma with my family and friends.”
D) “I will seek professional counseling to help process my experiences.”

 

A patient diagnosed with obsessive-compulsive disorder (OCD) is engaging in compulsive hand washing. The nurse should:

A) Ignore the behavior and encourage normal activities
B) Set limits on the behavior to reduce anxiety
C) Allow the patient to wash their hands as needed
D) Remind the patient to stop the hand washing

 

The nurse is caring for a patient with anorexia nervosa. Which of the following should be a priority in the nursing care plan?

A) Encourage the patient to eat high-calorie foods
B) Establish a structured eating schedule
C) Provide information about nutrition and exercise
D) Develop a reward system for weight gain

 

A nurse is assessing a patient with schizophrenia. The nurse observes that the patient is speaking in a way that is disconnected and fragmented. This behavior is known as:

A) Tangential speech
B) Flight of ideas
C) Word salad
D) Clang association

 

A nurse is providing care to a patient with borderline personality disorder. Which of the following is the most effective way to manage this patient’s behavior?

A) Set clear and consistent boundaries
B) Allow the patient to make independent decisions
C) Ignore the patient’s manipulative behaviors
D) Be flexible with the rules to reduce anxiety

 

A patient diagnosed with depression is prescribed fluoxetine. The nurse should monitor for which of the following side effects?

A) Decreased appetite
B) Insomnia and agitation
C) Hypotension
D) Weight gain

 

The nurse is caring for a patient diagnosed with a panic disorder. The nurse understands that the main feature of a panic attack is:

A) Muscle weakness
B) Increased desire for sleep
C) Sudden onset of intense fear or discomfort
D) Prolonged sadness and hopelessness

 

A nurse is caring for a patient experiencing an alcohol withdrawal. Which of the following is a priority intervention?

A) Monitor vital signs closely
B) Encourage fluid intake to prevent dehydration
C) Encourage the patient to eat solid foods
D) Provide a quiet environment with minimal stimuli

 

A patient with depression is prescribed a tricyclic antidepressant (TCA). Which side effect should the nurse educate the patient about?

A) Drowsiness
B) Nausea
C) Weight loss
D) Decreased libido

 

The nurse is caring for a patient with an eating disorder who has been hospitalized for weight restoration. The nurse should be aware that which of the following could indicate a medical emergency?

A) The patient refuses to eat breakfast
B) The patient exhibits obsessive thoughts about food
C) The patient experiences an electrolyte imbalance
D) The patient is constantly weighing themselves

 

A patient diagnosed with depression expresses feelings of guilt and worthlessness. The nurse should respond with:

A) “Try not to think about the past; look toward the future.”
B) “I can see you’re feeling very bad about yourself. Let’s talk about it.”
C) “You’re being too hard on yourself; everyone makes mistakes.”
D) “You should be grateful for what you have, not feel sorry for yourself.”

 

A nurse is caring for a patient with schizophrenia who exhibits delusional thinking. The nurse should:

A) Confront the delusion directly
B) Ignore the delusion and continue with care
C) Acknowledge the delusion and focus on reality
D) Reinforce the delusion to provide comfort

 

A nurse is assessing a patient with a history of substance use disorder. Which of the following is a priority assessment?

A) Blood pressure and heart rate
B) Level of consciousness
C) History of withdrawal symptoms
D) Nutritional status

 

A nurse is caring for a patient with a diagnosis of schizophrenia. The patient is refusing to take medication. The nurse should:

A) Force the patient to take the medication
B) Explain the benefits of the medication and encourage adherence
C) Administer the medication covertly
D) Allow the patient to decide whether to take the medication or not

 

A nurse is caring for a patient with a manic episode. Which of the following interventions is most appropriate?

A) Provide a structured routine and minimize distractions
B) Allow the patient to make decisions based on their impulses
C) Offer the patient a high-calorie, high-protein diet
D) Encourage excessive exercise to release energy

 

A nurse is caring for a patient with an anxiety disorder. Which of the following strategies should the nurse prioritize in the care plan?

A) Reducing exposure to anxiety-provoking situations
B) Encouraging the patient to face anxiety triggers gradually
C) Prescribing antianxiety medications as needed
D) Avoiding any discussions about the patient’s anxiety

 

A patient with post-traumatic stress disorder (PTSD) is exhibiting hypervigilance. The nurse should:

A) Encourage the patient to avoid talking about the trauma
B) Ensure the environment is calm and predictable
C) Allow the patient to make decisions about their care independently
D) Encourage the patient to confront their fear directly

 

A nurse is caring for a patient with dissociative identity disorder (DID). Which of the following is the most appropriate nursing action?

A) Challenge the patient’s alternate identities
B) Acknowledge and accept the patient’s identities
C) Ignore the presence of the alternate personalities
D) Encourage the patient to discuss their trauma in detail

 

A patient with bipolar disorder is being discharged after a manic episode. The nurse should provide which of the following instructions to the patient?

A) “Engage in high-energy activities to burn off extra energy.”
B) “Monitor your mood and seek help if you feel you’re becoming manic.”
C) “Limit your social interactions to avoid overwhelming stimulation.”
D) “Sleep as much as possible to recover from your manic episode.”

 

A patient is receiving treatment for obsessive-compulsive disorder (OCD). Which of the following is an appropriate goal for this patient?

A) The patient will cease all compulsive behaviors within one week.
B) The patient will recognize the need to control compulsive behaviors.
C) The patient will engage in compulsive behaviors to decrease anxiety.
D) The patient will avoid situations that trigger obsessive thoughts.

 

A nurse is caring for a patient with a history of self-harm. Which of the following actions should the nurse prioritize?

A) Encourage the patient to stop self-harming immediately
B) Monitor the patient for signs of suicidal ideation
C) Provide a quiet, isolated environment for the patient
D) Discuss the patient’s feelings of anger and frustration

 

A nurse is caring for a patient diagnosed with a psychotic disorder who exhibits catatonia. The nurse should:

A) Provide medications to reduce the patient’s symptoms
B) Encourage the patient to engage in physical activity
C) Provide sensory stimulation to break the stupor
D) Monitor the patient closely for any changes in behavior

 

A nurse is caring for a patient who has just been diagnosed with depression. The nurse should prioritize which of the following?

A) Establishing a therapeutic relationship
B) Providing family therapy
C) Teaching the patient about the risks of antidepressants
D) Encouraging the patient to increase their physical activity

 

A nurse is providing care to a patient experiencing acute alcohol withdrawal. Which of the following is a priority?

A) Monitor for signs of delirium tremens
B) Encourage oral fluid intake to prevent dehydration
C) Provide a low-sugar diet to prevent hypoglycemia
D) Establish a routine for medication administration

 

A nurse is providing care for a patient with antisocial personality disorder. Which of the following behaviors should the nurse expect to observe?

A) Excessive guilt and remorse
B) Difficulty maintaining relationships
C) Exhibiting impulsive and reckless behavior
D) A strong desire to please others

 

A nurse is caring for a patient with schizophrenia who is exhibiting auditory hallucinations. The nurse should:

A) Tell the patient that the voices are not real
B) Provide a quiet environment and limit stimulation
C) Encourage the patient to confront the voices directly
D) Ignore the hallucinations and focus on reality

 

31. A nurse is caring for a patient with major depressive disorder. The nurse notices the patient is talking about death. What is the most appropriate action?

A) Ignore the statement because it is common for people to talk about death
B) Encourage the patient to express feelings of hopelessness
C) Ask the patient directly about thoughts of suicide or self-harm
D) Suggest the patient try to focus on positive things in their life

 

32. A nurse is providing care for a patient who is experiencing a panic attack. Which of the following actions should the nurse take?

A) Encourage the patient to take deep breaths and focus on their breathing
B) Reassure the patient that there is nothing to worry about
C) Leave the patient alone to calm down without interference
D) Administer an anti-anxiety medication immediately

 

33. A nurse is assessing a patient with bipolar disorder who is currently experiencing a manic episode. Which of the following would be most characteristic of this phase?

A) Lack of energy and motivation
B) Excessive spending and impulsive behavior
C) Increased need for sleep
D) Withdrawn behavior and isolation

 

34. The nurse is teaching a patient with generalized anxiety disorder (GAD) relaxation techniques. Which of the following should the nurse encourage the patient to do?

A) Focus on positive affirmations
B) Engage in deep breathing exercises to slow the heart rate
C) Avoid all social interactions to prevent anxiety
D) Limit any physical activity to avoid triggering anxiety

 

35. A nurse is caring for a patient with post-traumatic stress disorder (PTSD) who is experiencing flashbacks. Which of the following interventions is most appropriate?

A) Encourage the patient to relive the traumatic event in detail
B) Provide a calm and safe environment to help ground the patient
C) Help the patient confront the traumatic memories immediately
D) Ignore the flashbacks and continue with the patient’s regular routine

 

36. The nurse is caring for a patient with a history of alcohol dependence. The patient is admitted for detoxification. Which of the following is the most important action during the first 24 hours of admission?

A) Encourage the patient to begin attending Alcoholics Anonymous (AA) meetings
B) Provide a quiet, dimly lit environment to reduce stimulation
C) Administer medications to prevent alcohol withdrawal symptoms
D) Encourage fluid intake to prevent dehydration

 

37. A nurse is working with a patient diagnosed with a personality disorder. Which of the following is the most effective way to address manipulative behavior?

A) Set clear, consistent boundaries and enforce them
B) Allow the patient to make all decisions regarding treatment
C) Ignore the manipulative behavior to avoid conflict
D) Praise the patient for engaging in therapy even when manipulative

 

38. A nurse is caring for a patient with anorexia nervosa. Which of the following is a priority intervention?

A) Administer appetite stimulants to increase food intake
B) Encourage the patient to eat in a group setting
C) Monitor the patient’s vital signs and weight closely
D) Teach the patient about the importance of exercise and diet

 

39. The nurse is teaching a patient with obsessive-compulsive disorder (OCD) about the treatment plan. The nurse explains that the patient will be gradually exposed to anxiety-provoking situations. This technique is known as:

A) Cognitive-behavioral therapy
B) Flooding
C) Systematic desensitization
D) Behavioral reinforcement

 

40. A nurse is caring for a patient diagnosed with schizophrenia who is exhibiting disorganized speech. Which of the following is an example of disorganized speech?

A) “I’m the king of the world, and everyone should bow down to me.”
B) “I went to the store, and then the sky turned blue.”
C) “I will stop talking if I need to, but don’t tell me what to do.”
D) “The clouds are talking to me.”

 

41. A nurse is caring for a patient who is recovering from a manic episode. The nurse recognizes that the patient is at risk for:

A) Self-mutilation
B) Impulsive behavior
C) Severe withdrawal symptoms
D) Excessive sleep

 

42. A nurse is teaching a patient about selective serotonin reuptake inhibitors (SSRIs) used to treat depression. Which of the following should the nurse include in the teaching plan?

A) “This medication may cause drowsiness, so avoid activities like driving.”
B) “It may take several weeks for the full therapeutic effect to be felt.”
C) “If you experience increased energy, stop the medication immediately.”
D) “SSRIs should be taken with food to avoid gastrointestinal upset.”

 

43. A nurse is caring for a patient diagnosed with a personality disorder who exhibits excessive jealousy and possessiveness. The nurse recognizes that these behaviors are often seen in which disorder?

A) Borderline personality disorder
B) Narcissistic personality disorder
C) Antisocial personality disorder
D) Paranoid personality disorder

 

44. A nurse is working with a patient diagnosed with dissociative identity disorder (DID). Which of the following interventions is most important?

A) Establish a structured environment and schedule for the patient
B) Encourage the patient to confront and discuss traumatic memories
C) Teach the patient coping mechanisms to deal with alternate identities
D) Support the patient in integrating the different identities into one

 

45. A nurse is caring for a patient who is taking lithium for bipolar disorder. Which of the following is the most important laboratory value to monitor?

A) Sodium levels
B) Liver function tests
C) Creatinine levels
D) Thyroid function tests

 

46. A nurse is providing care to a patient diagnosed with obsessive-compulsive disorder (OCD). The nurse encourages the patient to gradually reduce compulsive behavior. Which of the following is an important part of this plan?

A) Establish a set time for performing compulsive rituals
B) Allow the patient to engage in compulsive behaviors to reduce anxiety
C) Provide positive reinforcement for reducing compulsive behaviors
D) Use medications to prevent the occurrence of compulsions

 

47. The nurse is teaching a patient diagnosed with depression about their medication regimen. Which statement by the patient indicates the need for further teaching?

A) “I should report any thoughts of suicide to my healthcare provider immediately.”
B) “I can stop the medication as soon as I start feeling better.”
C) “I should not suddenly stop taking this medication without consulting my provider.”
D) “It may take a few weeks for the full effect of the medication to work.”

 

48. A nurse is caring for a patient with a history of bipolar disorder who is in the manic phase. Which of the following behaviors would the nurse most likely observe?

A) The patient spends excessive time alone, avoiding social interaction.
B) The patient exhibits feelings of worthlessness and guilt.
C) The patient displays impulsivity, including reckless spending.
D) The patient experiences feelings of intense sadness and despair.

 

49. A nurse is working with a patient diagnosed with schizophrenia. The patient expresses paranoid thoughts. Which of the following is the best approach for the nurse?

A) Reassure the patient that their thoughts are not real
B) Acknowledge the patient’s feelings but focus on reality
C) Avoid engaging in any conversation about the delusion
D) Challenge the delusion by providing contradictory evidence

 

50. The nurse is caring for a patient diagnosed with a substance use disorder. The nurse should be most concerned about which of the following signs of withdrawal?

A) Increased appetite
B) Vomiting and tremors
C) Excessive sleep
D) Improved mood and energy levels

 

51. A nurse is caring for a patient diagnosed with borderline personality disorder. The nurse should:

A) Set firm and consistent boundaries with the patient
B) Encourage the patient to engage in self-harming behavior
C) Allow the patient to make their own decisions about treatment
D) Offer emotional support without setting limits on behavior

 

52. The nurse is working with a patient diagnosed with generalized anxiety disorder (GAD). Which of the following is the most effective intervention?

A) Limit the patient’s exposure to anxiety-provoking situations
B) Encourage the patient to express feelings of worry freely
C) Teach relaxation techniques and stress management strategies
D) Provide medications to control anxiety symptoms

 

53. A nurse is caring for a patient receiving an antipsychotic medication. The nurse notices the patient has developed a shuffling gait and muscle rigidity. Which of the following is the most likely side effect of the medication?

A) Parkinsonism
B) Tardive dyskinesia
C) Neuroleptic malignant syndrome
D) Akathisia

 

54. A nurse is teaching a patient with depression about cognitive-behavioral therapy (CBT). Which of the following should the nurse emphasize as a key concept of CBT?

A) Changing negative thought patterns to improve emotional responses
B) Focusing on past experiences to resolve current issues
C) Developing strong coping mechanisms to avoid emotional distress
D) Using medication to regulate mood and behavior

 

55. A nurse is caring for a patient with a history of manic episodes. Which of the following statements should be included in the teaching plan?

A) “Avoid activities that could lead to impulsive or risky behavior.”
B) “Increase your caffeine intake to help manage energy levels.”
C) “Engage in physical exercise to release extra energy.”
D) “Focus on staying isolated to avoid overstimulation.”

 

56. A nurse is caring for a patient diagnosed with schizophrenia who is experiencing auditory hallucinations. Which of the following is the best intervention?

A) Tell the patient that the voices are not real
B) Encourage the patient to ignore the voices and focus on their surroundings
C) Distract the patient with a soothing activity to help focus on reality
D) Tell the patient to follow the voices’ instructions as a way to reduce anxiety

 

57. A nurse is teaching a patient with bipolar disorder about their treatment plan. Which statement by the patient indicates the need for further teaching?

A) “I will take my medications every day as prescribed.”
B) “I will avoid alcohol and drugs to prevent mood swings.”
C) “I will stop my medication when I feel better.”
D) “I will attend counseling sessions to help manage my symptoms.”

 

58. A nurse is assessing a patient who is experiencing a panic attack. Which of the following is the priority intervention?

A) Administer an anxiolytic medication immediately
B) Remain with the patient and provide reassurance
C) Encourage the patient to focus on their breathing and relax
D) Redirect the patient’s attention to another subject

 

59. A nurse is working with a patient diagnosed with anorexia nervosa. Which of the following behaviors is most indicative of this eating disorder?

A) Refusal to eat meals with family members
B) Excessive exercise and distorted body image
C) Frequent use of laxatives and purging
D) Recurrent episodes of binge eating

 

60. A nurse is caring for a patient with major depressive disorder who is experiencing feelings of hopelessness and worthlessness. What is the nurse’s priority action?

A) Encourage the patient to engage in physical activity to elevate mood
B) Establish a safety plan to prevent self-harm or suicide
C) Encourage the patient to share their feelings with family members
D) Focus on identifying the underlying causes of the depression

 

61. The nurse is teaching a patient who is newly prescribed an antidepressant. Which of the following should the nurse emphasize as a potential side effect of selective serotonin reuptake inhibitors (SSRIs)?

A) Drowsiness and dizziness
B) Increased energy and alertness
C) Sexual dysfunction and weight gain
D) Constipation and dry mouth

 

62. A nurse is working with a patient diagnosed with obsessive-compulsive disorder (OCD). Which of the following is an example of a compulsion?

A) Constantly checking locks and appliances
B) Repeating phrases or actions to relieve anxiety
C) Engaging in avoidance behaviors
D) Focusing on negative thoughts

 

63. The nurse is caring for a patient with borderline personality disorder. Which of the following behaviors would be most characteristic of this disorder?

A) Lack of empathy for others
B) Extreme mood swings and impulsivity
C) Chronic disregard for social norms
D) Grandiose sense of self-importance

 

64. A nurse is caring for a patient who is experiencing a delusion of grandeur. Which of the following is the most appropriate intervention?

A) Tell the patient that their belief is false
B) Encourage the patient to express their feelings and thoughts
C) Agree with the delusion to make the patient feel supported
D) Avoid engaging in conversation about the delusion

 

65. A nurse is working with a patient diagnosed with post-traumatic stress disorder (PTSD). The patient has frequent flashbacks and nightmares. Which of the following interventions is most appropriate?

A) Encourage the patient to relive the traumatic event
B) Provide a calm, quiet environment to reduce stress
C) Discourage the patient from talking about the trauma
D) Increase stimulation to help the patient cope with the flashbacks

 

66. The nurse is caring for a patient who is being treated for alcohol withdrawal. Which of the following symptoms would be most concerning and require immediate intervention?

A) Tremors and sweating
B) Nausea and vomiting
C) Seizures and confusion
D) Increased heart rate and hypertension

 

67. A nurse is working with a patient diagnosed with a personality disorder. Which of the following strategies is most effective when working with manipulative behavior?

A) Set firm, clear boundaries and be consistent in enforcing them
B) Give in to the patient’s demands to avoid confrontation
C) Discuss the manipulative behavior openly with the patient every time it occurs
D) Allow the patient to control the therapeutic relationship

 

68. A nurse is caring for a patient diagnosed with anxiety disorder who is prescribed a benzodiazepine. Which of the following is most important to assess before administration?

A) The patient’s level of anxiety
B) The patient’s heart rate and blood pressure
C) The patient’s risk for substance abuse
D) The patient’s ability to sleep at night

 

69. A nurse is teaching a patient with bipolar disorder about the signs of a manic episode. Which of the following statements by the patient indicates the need for further teaching?

A) “I might have increased energy and activity.”
B) “I may have trouble focusing and feel very distracted.”
C) “I will need more sleep during a manic episode.”
D) “I might have grandiose thoughts and engage in impulsive behavior.”

 

70. A nurse is caring for a patient diagnosed with schizophrenia who is exhibiting negative symptoms. Which of the following is an example of a negative symptom?

A) Delusions of persecution
B) Auditory hallucinations
C) Lack of motivation and flat affect
D) Disorganized speech

 

71. A nurse is teaching a patient with depression about self-care strategies. Which of the following should the nurse emphasize?

A) Engaging in regular exercise to improve mood
B) Isolating from others to avoid negative feelings
C) Avoiding any stressful situations
D) Relying on medication alone to manage symptoms

 

72. A nurse is assessing a patient who has been taking an antipsychotic medication for several weeks. Which of the following signs and symptoms should the nurse monitor for signs of neuroleptic malignant syndrome (NMS)?

A) Increased appetite and weight gain
B) Muscle rigidity, fever, and altered mental status
C) Tremors and dry mouth
D) Severe constipation and blurred vision

 

73. A nurse is working with a patient who is receiving electroconvulsive therapy (ECT) for depression. Which of the following is an expected side effect immediately after the procedure?

A) Memory loss and confusion
B) Excessive sedation and fatigue
C) Increased appetite and weight gain
D) Decreased blood pressure and dizziness

 

74. A nurse is caring for a patient with a history of severe anxiety. The patient expresses fear of an upcoming medical procedure. Which of the following is the best approach to address the patient’s anxiety?

A) Encourage the patient to avoid thinking about the procedure
B) Provide clear, detailed information about the procedure to reduce uncertainty
C) Disregard the patient’s concerns to focus on the procedure itself
D) Reassure the patient that everything will be fine, and they should not worry

 

75. A nurse is assessing a patient with major depressive disorder who is experiencing anhedonia. Which of the following symptoms would the nurse expect to find?

A) Loss of interest or pleasure in activities
B) Increased energy and activity levels
C) Excessive sleep and lethargy
D) Rapid speech and impulsive behavior

 

76. The nurse is providing care for a patient who is prescribed lithium. The nurse should monitor for which of the following signs of lithium toxicity?

A) Shaking hands and slight tremors
B) Increased thirst, polyuria, and nausea
C) Blurred vision and constipation
D) Weight loss and excessive urination

 

77. A nurse is caring for a patient who is experiencing a depressive episode. Which of the following should the nurse include in the patient’s care plan?

A) Encourage social withdrawal and isolation
B) Promote physical activity and structured daily routines
C) Limit communication with family members to prevent overwhelming the patient
D) Focus solely on medication management and avoid therapy

 

78. A nurse is working with a patient diagnosed with schizophrenia who exhibits cognitive symptoms. Which of the following interventions is most appropriate?

A) Focus on reducing the patient’s anxiety
B) Provide memory aids and promote structured activities
C) Encourage the patient to engage in social interactions
D) Reinforce delusions to improve the patient’s sense of reality

 

79. The nurse is caring for a patient with a history of substance abuse. The patient is concerned about withdrawal symptoms. Which of the following is the priority intervention?

A) Encourage the patient to self-medicate with over-the-counter medications
B) Assess for withdrawal symptoms and provide appropriate medications
C) Reassure the patient that withdrawal symptoms are not serious
D) Monitor for physical symptoms but avoid giving medications

 

80. A nurse is working with a patient diagnosed with a personality disorder who frequently manipulates others. Which of the following is the best strategy for the nurse?

A) Set clear, consistent boundaries and reinforce them
B) Allow the patient to make decisions to foster autonomy
C) Ignore the manipulative behavior to avoid confrontation
D) Reward the patient’s manipulative behavior when it leads to desired outcomes

 

81. A nurse is assessing a patient who is experiencing symptoms of acute stress disorder after a traumatic event. Which of the following is a common symptom of this disorder?

A) Flashbacks of the traumatic event
B) Intense fear of social situations
C) Increased energy and activity levels
D) Paranoia and distrust of others

 

82. A nurse is working with a patient diagnosed with anorexia nervosa. Which of the following is the priority intervention for the nurse?

A) Monitor the patient’s food intake and weight regularly
B) Encourage the patient to participate in group therapy
C) Focus on improving the patient’s self-esteem and body image
D) Allow the patient to make their own meal choices

 

83. The nurse is caring for a patient with a history of alcohol use disorder. The patient is exhibiting signs of alcohol withdrawal. Which of the following should the nurse expect to assess?

A) Bradycardia and hypotension
B) Tremors, nausea, and increased blood pressure
C) Drowsiness and decreased respirations
D) Decreased temperature and low blood sugar

 

84. A nurse is caring for a patient diagnosed with obsessive-compulsive disorder (OCD). Which of the following is an appropriate nursing intervention to assist the patient with compulsions?

A) Encourage the patient to suppress compulsions
B) Allow the patient to perform rituals as needed to reduce anxiety
C) Redirect the patient’s attention to more positive activities
D) Prevent the patient from engaging in rituals to promote coping

 

85. A nurse is assessing a patient diagnosed with bipolar disorder who is currently in a manic episode. Which of the following behaviors would be most concerning?

A) Rapid speech and high energy levels
B) Increased activity levels and decreased need for sleep
C) Impulsive spending and reckless behavior
D) Excessive talking and grandiose thinking

 

86. A nurse is caring for a patient with a diagnosis of schizophrenia. The patient exhibits catatonia. Which of the following actions should the nurse take?

A) Force the patient to move if they are unable to do so on their own
B) Provide a calm, structured environment to minimize overstimulation
C) Encourage the patient to engage in social activities to reduce isolation
D) Restrain the patient to prevent harm to themselves

 

87. A nurse is caring for a patient diagnosed with major depressive disorder. Which of the following is the priority nursing intervention?

A) Establishing a trusting relationship and offering emotional support
B) Encouraging the patient to express their feelings openly
C) Monitoring the patient’s food and fluid intake
D) Assessing the patient’s risk for self-harm and suicide

 

88. A nurse is caring for a patient who is receiving lithium therapy for bipolar disorder. Which of the following findings should be reported to the healthcare provider immediately?

A) Mild hand tremors and nausea
B) Weight gain and increased thirst
C) Muscle weakness and confusion
D) Dry mouth and drowsiness

 

89. A nurse is working with a patient diagnosed with generalized anxiety disorder. Which of the following interventions is most effective in helping the patient manage anxiety?

A) Administering an anxiolytic medication only as needed
B) Encouraging the patient to engage in relaxation techniques, such as deep breathing
C) Reassuring the patient that there is no reason to be anxious
D) Engaging the patient in physical activity to distract from anxious thoughts

 

90. The nurse is caring for a patient with post-traumatic stress disorder (PTSD). The patient reports frequent nightmares. Which of the following is the most appropriate intervention?

A) Encourage the patient to confront the trauma through detailed recall
B) Teach the patient relaxation techniques before bedtime
C) Encourage the patient to avoid discussing the trauma
D) Reassure the patient that nightmares are a normal response to stress

 

91. A nurse is caring for a patient diagnosed with borderline personality disorder. Which of the following is an effective strategy to manage manipulative behavior?

A) Avoid setting limits on the patient’s behavior to reduce conflict
B) Consistently reinforce boundaries and expectations
C) Allow the patient to have control over all decisions
D) Ignore the patient’s manipulative behaviors to prevent confrontation

 

92. A nurse is assessing a patient diagnosed with schizophrenia. Which of the following is an example of a positive symptom?

A) Affective flattening
B) A lack of motivation
C) Auditory hallucinations
D) Impaired thought processes

 

93. The nurse is caring for a patient who has been prescribed an antidepressant. Which of the following should the nurse educate the patient about?

A) The medication will cause immediate relief of depressive symptoms
B) The medication may take several weeks to show full effectiveness
C) The medication will cause significant weight loss within the first few days
D) The medication should be stopped if the patient begins feeling better

 

94. A nurse is caring for a patient with a history of substance abuse who is receiving treatment for withdrawal. Which of the following should the nurse monitor for as a complication of withdrawal?

A) Hypothermia and bradycardia
B) Hyperthermia and delirium
C) Severe lethargy and hypotension
D) Hypoglycemia and fatigue

 

95. A nurse is working with a patient diagnosed with bipolar disorder. The patient is in a manic episode and is demonstrating poor judgment and risky behavior. What is the priority nursing intervention?

A) Encourage the patient to participate in group therapy
B) Provide a structured environment and ensure safety
C) Focus on increasing the patient’s self-esteem
D) Redirect the patient’s energy into physical exercise

 

96. A nurse is caring for a patient diagnosed with depression. Which of the following symptoms is most likely to indicate that the patient is at high risk for suicide?

A) Increased appetite and excessive sleeping
B) Disinterest in activities and giving away personal belongings
C) Difficulty concentrating and feelings of guilt
D) Excessive energy and talking about future plans

 

97. A nurse is caring for a patient with a history of chronic anxiety. The patient has been prescribed selective serotonin reuptake inhibitors (SSRIs). Which of the following is an important teaching point for the nurse to include?

A) “You should expect to feel immediate relief of symptoms.”
B) “It is important to take this medication as prescribed, even if you feel better.”
C) “This medication can cause weight loss and increase energy.”
D) “You may stop taking this medication if you feel any side effects.”

 

98. A nurse is caring for a patient who is being discharged after an inpatient stay for major depressive disorder. Which of the following is the most important consideration before discharge?

A) Ensuring the patient has access to appropriate community resources and support
B) Encouraging the patient to continue socializing with friends and family
C) Focusing on the patient’s dietary needs and restrictions
D) Increasing the patient’s physical activity and exercise levels

 

99. A nurse is working with a patient diagnosed with schizophrenia. Which of the following interventions is most appropriate when the patient exhibits signs of delusions?

A) Tell the patient that their delusions are not real
B) Gently redirect the patient’s attention to a different topic
C) Agree with the patient’s delusions to help them feel understood
D) Ignore the patient’s delusions to avoid reinforcing them

 

100. The nurse is caring for a patient diagnosed with social anxiety disorder. Which of the following is the most effective intervention?

A) Encourage the patient to engage in social interactions to overcome fear
B) Help the patient avoid social situations to reduce anxiety
C) Provide reassurance that social situations will always cause anxiety
D) Teach the patient relaxation techniques to manage anxiety in social situations

 

101. A nurse is caring for a patient with post-traumatic stress disorder (PTSD) who has flashbacks to a traumatic event. Which of the following is the best intervention?

A) Encourage the patient to relive the traumatic event to promote emotional release
B) Provide a quiet, safe space and offer reassurance during flashbacks
C) Discourage the patient from talking about the trauma to avoid distress
D) Tell the patient to stop focusing on the past and move forward

 

102. A nurse is caring for a patient diagnosed with a panic disorder. The patient begins experiencing a panic attack. Which of the following is the most appropriate nursing intervention?

A) Reassure the patient that there is no physical harm occurring
B) Encourage the patient to take deep, slow breaths
C) Offer the patient medication to alleviate symptoms immediately
D) Let the patient know their behavior is unacceptable

 

103. A nurse is caring for a patient with an eating disorder who is excessively exercising and refusing to eat. Which of the following is the priority nursing intervention?

A) Encourage the patient to increase physical activity to relieve stress
B) Implement a structured meal plan and monitor the patient’s weight closely
C) Discuss the importance of exercise in maintaining good health
D) Focus on teaching the patient relaxation techniques to reduce anxiety

 

104. A nurse is teaching a patient about selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression. Which statement by the patient indicates an understanding of the teaching?

A) “The medication will start working right away, and I will feel better soon.”
B) “I should stop taking this medication if I start feeling better.”
C) “It may take several weeks for the medication to help improve my mood.”
D) “I will likely need to take this medication for only a short time.”

 

105. A nurse is caring for a patient who is diagnosed with major depressive disorder and has a history of suicide attempts. Which of the following actions is the priority?

A) Encourage the patient to express their feelings in writing
B) Assess the patient for suicidal thoughts and implement safety precautions
C) Provide reassurance that the patient will feel better soon
D) Teach the patient coping mechanisms for managing stress

 

106. A nurse is caring for a patient diagnosed with schizophrenia who has difficulty distinguishing between reality and their delusions. Which of the following is the most effective approach?

A) Attempt to convince the patient that their delusions are not real
B) Engage the patient in a conversation about their delusions
C) Redirect the patient’s focus away from the delusions and encourage reality-based thinking
D) Ignore the patient’s delusions to avoid reinforcing them

 

107. A nurse is teaching a patient with bipolar disorder about the importance of medication adherence. Which of the following is the most appropriate statement for the nurse to make?

A) “You may feel better without the medication, but it’s important to keep taking it to prevent relapses.”
B) “You can stop taking your medication once you feel stable.”
C) “If you miss a dose, you can take two doses the next day.”
D) “This medication should be taken only during manic episodes.”

 

108. A nurse is caring for a patient who is experiencing a manic episode. Which of the following interventions should the nurse implement to ensure patient safety?

A) Allow the patient to make decisions regarding their treatment plan
B) Provide a low-stimulation environment with structured activities
C) Encourage the patient to participate in group therapy immediately
D) Provide excessive choices to allow the patient to feel in control

 

109. A nurse is caring for a patient diagnosed with obsessive-compulsive disorder (OCD). Which of the following is an appropriate nursing intervention?

A) Encourage the patient to suppress compulsions in order to decrease anxiety
B) Provide time for the patient to perform rituals without interruption
C) Discourage the patient from performing compulsive behaviors
D) Help the patient understand that their compulsive behaviors are irrational

 

110. A nurse is caring for a patient who is experiencing alcohol withdrawal. The patient is experiencing agitation, tremors, and sweating. Which of the following should the nurse monitor closely for?

A) Hypertension and delirium tremens (DTs)
B) Dehydration and hyperglycemia
C) Hypotension and bradycardia
D) Hypothermia and slow reflexes

 

111. A nurse is providing discharge instructions to a patient who is prescribed an antidepressant. Which of the following should be included in the teaching?

A) “You may experience a significant increase in energy right away.”
B) “It may take several weeks to feel the full effects of the medication.”
C) “The medication is only needed when you feel depressed.”
D) “You can stop taking the medication if you experience any side effects.”

 

112. A nurse is assessing a patient diagnosed with a borderline personality disorder. Which of the following characteristics is most associated with this disorder?

A) A tendency to avoid social interactions and withdraw from relationships
B) A history of extreme and unstable relationships and emotions
C) An inability to express emotions or affect
D) A preoccupation with perfectionism and orderliness

 

113. A nurse is caring for a patient diagnosed with antisocial personality disorder. Which of the following behaviors would the nurse most likely observe in the patient?

A) Excessive guilt and remorse
B) Manipulative behavior and a lack of remorse
C) Intense fear of social situations
D) Need for approval and attention from others

 

114. A nurse is assessing a patient who has been diagnosed with a personality disorder. Which of the following is the most important priority for nursing care?

A) Establishing a structured, predictable environment
B) Encouraging the patient to engage in social activities
C) Focusing on long-term goals of therapy
D) Encouraging the patient to focus on the past and discuss unresolved issues

 

115. A nurse is providing care to a patient with substance use disorder who is in recovery. Which of the following is an appropriate intervention to prevent relapse?

A) Encourage the patient to avoid discussing their substance use history
B) Help the patient identify triggers and develop coping strategies
C) Tell the patient to avoid all social situations to prevent temptation
D) Allow the patient to make decisions about their treatment plan without guidance

 

116. A nurse is caring for a patient diagnosed with schizophrenia. The patient is exhibiting poor hygiene and social withdrawal. Which of the following should the nurse address first?

A) Encouraging the patient to engage in group therapy
B) Providing assistance with grooming and hygiene
C) Educating the patient about their diagnosis and treatment plan
D) Encouraging the patient to interact with family members

 

117. A nurse is teaching a patient who is being started on lithium therapy for bipolar disorder. Which of the following instructions should the nurse provide?

A) “You should avoid taking this medication with food to improve absorption.”
B) “You should maintain a consistent intake of salt and fluid while on this medication.”
C) “You may stop taking the medication if you start feeling better.”
D) “You should avoid drinking fluids to prevent excessive hydration.”

 

118. A nurse is caring for a patient diagnosed with a major depressive episode. The nurse recognizes that which of the following symptoms is the most concerning regarding the patient’s safety?

A) Poor appetite and fatigue
B) Increased irritability and difficulty sleeping
C) Lack of interest in activities and giving away personal belongings
D) Increased energy levels and talking more rapidly than usual

 

119. A nurse is caring for a patient diagnosed with social anxiety disorder. Which of the following interventions is most likely to help the patient manage anxiety in social situations?

A) Encourage the patient to avoid all social interactions
B) Encourage the patient to gradually increase social interaction in a controlled setting
C) Suggest that the patient limit talking to only close friends and family
D) Provide relaxation techniques only during acute anxiety episodes

 

120. A nurse is caring for a patient diagnosed with generalized anxiety disorder. Which of the following is the most appropriate intervention?

A) Encourage the patient to avoid thinking about worries or stressors
B) Help the patient develop healthy coping strategies to manage anxiety
C) Reassure the patient that there is nothing to worry about
D) Encourage the patient to focus on their anxiety to gain control over it

 

121. A nurse is teaching a patient about cognitive-behavioral therapy (CBT) as a treatment option for anxiety. Which of the following statements by the patient indicates understanding of the teaching?

A) “CBT helps me express my feelings openly without judgment.”
B) “CBT focuses on changing negative thought patterns and behaviors.”
C) “CBT involves medication to alleviate symptoms of anxiety.”
D) “CBT helps me forget about past traumatic events.”

 

122. A nurse is assessing a patient with a history of panic disorder. The nurse observes the patient taking very shallow breaths and appears agitated. Which nursing intervention is best to implement?

A) Encourage the patient to lie down and rest
B) Perform deep breathing exercises with the patient
C) Allow the patient to express their feelings without interruption
D) Offer medication to calm the patient immediately

 

123. A nurse is providing care for a patient who is exhibiting signs of obsessive-compulsive disorder (OCD). The nurse understands that the primary goal of therapy for this patient is:

A) To eliminate all obsessive thoughts
B) To decrease the anxiety associated with compulsions
C) To improve self-esteem and personal hygiene
D) To change the patient’s environment

 

124. A nurse is caring for a patient who is recovering from substance abuse. The patient states, “I can quit whenever I want to.” Which response by the nurse would be most appropriate?

A) “You should avoid making excuses for your behavior.”
B) “It’s important to recognize that addiction is a complex issue.”
C) “You are in control of your choices; just try harder.”
D) “It’s okay to have difficulty quitting; many people feel this way.”

 

125. A nurse is educating a patient about a new medication prescribed for schizophrenia. The nurse should tell the patient to report which of the following immediately?

A) Mild headache and increased appetite
B) Feeling of being “too calm” and relaxed
C) Muscle stiffness and a high fever
D) Fatigue and drowsiness

 

126. A nurse is conducting a mental health assessment of a patient. The nurse knows that lack of response to the environment and inability to interact socially are symptoms often associated with which mental health condition?

A) Bipolar disorder
B) Schizophrenia
C) Major depressive disorder
D) Post-traumatic stress disorder

 

127. A nurse is caring for a patient who has been diagnosed with borderline personality disorder. The nurse should prioritize which of the following interventions?

A) Encouraging the patient to make decisions independently
B) Providing structure and consistent boundaries
C) Allowing the patient to express all feelings without restraint
D) Engaging in deep psychological discussions

 

128. A nurse is caring for a patient experiencing withdrawal symptoms related to alcohol use. The nurse should be alert for which most common early signs of withdrawal?

A) Hyperactivity and paranoia
B) Tremors, sweating, and anxiety
C) Hallucinations and disorientation
D) Slurred speech and memory impairment

 

129. A nurse is educating a patient on bipolar disorder. The nurse should emphasize that which of the following is most important in the treatment of this condition?

A) Taking medication on an as-needed basis
B) Regular monitoring and maintenance therapy
C) Adhering to strict dietary guidelines
D) Engaging in individual therapy once a week

 

130. A nurse is counseling a patient with major depressive disorder who is also having difficulty with sleep. The nurse should recommend which of the following interventions?

A) Engage in vigorous exercise during the evening hours
B) Use caffeine late in the day to stay awake
C) Avoid watching television for an hour before bedtime
D) Take frequent long naps during the day

 

131. A nurse is assessing a patient who is showing signs of a manic episode. Which of the following behaviors would the nurse most likely observe?

A) Excessive social withdrawal and sadness
B) Increased talkativeness and impulsivity
C) Heightened need for sleep and rest
D) Extreme preoccupation with personal hygiene

 

132. A nurse is discussing assertiveness training with a patient diagnosed with social anxiety disorder. The nurse should emphasize that assertiveness involves which of the following?

A) Being aggressive to achieve one’s own goals
B) Being honest and direct while respecting others
C) Focusing on self without regard for others’ feelings
D) Avoiding conflict to maintain relationships

 

133. A nurse is caring for a patient with schizophrenia who experiences delusions. The best approach by the nurse would be:

A) Confront the patient and explain that the delusions are not real
B) Encourage the patient to discuss the content of the delusions
C) Reinforce reality-based activities and reassure the patient
D) Ignore the delusions and encourage interaction with others

 

134. A nurse is working with a patient who has a history of panic attacks. The nurse should educate the patient about which of the following signs of an upcoming panic attack?

A) Feeling relaxed and calm
B) Increased need for sleep and withdrawal
C) Heart palpitations and shortness of breath
D) Reduced appetite and lack of concentration

 

135. A nurse is assessing a patient for suicidal ideation. The nurse should ask which of the following questions first?

A) “Have you ever felt this way before?”
B) “Have you been feeling depressed lately?”
C) “Do you have a plan to harm yourself?”
D) “Are you feeling worthless or hopeless?”

 

136. A nurse is caring for a patient who is in an acute crisis related to substance abuse. The nurse should prioritize which of the following interventions?

A) Educate the patient on long-term treatment options
B) Engage the patient in individual therapy
C) Provide immediate safety and stabilization
D) Involve family members in the treatment plan

 

137. A nurse is working with a patient diagnosed with obsessive-compulsive disorder (OCD). Which of the following is the most appropriate intervention?

A) Confront the patient about the irrationality of their compulsions
B) Ignore the compulsive behaviors and avoid reinforcing them
C) Encourage the patient to engage in rituals to reduce anxiety
D) Provide time and structured activities to redirect focus

 

138. A nurse is educating a patient with bipolar disorder about medication adherence. The nurse should emphasize which of the following points?

A) Medications should be discontinued if side effects occur
B) It is important to take medication only during manic episodes
C) Medication compliance is necessary to prevent mood swings
D) Medication should be stopped once the patient feels better

 

139. A nurse is counseling a patient who has recently been diagnosed with major depressive disorder. The nurse should include which of the following in the plan of care?

A) Encourage the patient to engage in a high level of physical activity
B) Suggest that the patient make major life changes immediately
C) Promote social interactions and support from family members
D) Advise the patient to sleep as much as possible

 

140. A nurse is working with a patient who is experiencing severe anxiety. Which of the following is the most appropriate intervention for the nurse to implement?

A) Ignore the patient’s feelings and focus on tasks
B) Encourage rapid-paced activities to distract the patient
C) Provide a quiet, calm environment and reassure the patient
D) Encourage frequent, intense physical exercise

 

141. A nurse is caring for a patient with schizophrenia who is refusing to take their medication. Which is the most appropriate response by the nurse?

A) “You need to take the medication to get better.”
B) “I understand that you may not feel like taking the medication, but it will help control your symptoms.”
C) “You can refuse medication, but your condition may worsen.”
D) “If you don’t take the medication, I will report you to the doctor.”

 

142. A nurse is caring for a patient with post-traumatic stress disorder (PTSD). The nurse knows that which of the following is the most common trigger for PTSD symptoms?

A) Loud noises
B) Emotional stressors or reminders of trauma
C) Social isolation
D) Medication side effects

 

143. A nurse is caring for a patient with depression. The nurse should be alert for which of the following symptoms indicating possible suicidal ideation?

A) Withdrawal from social interactions
B) Increase in appetite and energy
C) Excessive laughter and cheerful mood
D) Sudden improvement in mood with a plan to die

 

144. A nurse is caring for a patient who is exhibiting severe agitation and restlessness. Which of the following actions should the nurse take first?

A) Administer a PRN sedative medication
B) Allow the patient to engage in physical activities
C) Provide a quiet, non-stimulating environment
D) Encourage the patient to talk about their feelings

 

145. A nurse is caring for a patient diagnosed with anorexia nervosa. The nurse understands that the primary goal of treatment for this disorder is:

A) Weight restoration to normal levels
B) Establishment of a healthy body image
C) Prevention of further weight loss
D) Nutritional counseling and education

 

146. A nurse is conducting a mental health assessment on a patient diagnosed with depression. Which of the following would be a priority for the nurse to assess?

A) Recent stressors and social support
B) History of chronic illness
C) Sleep patterns and eating habits
D) Suicidal ideation and plans

 

147. A nurse is caring for a patient who is experiencing a manic episode. The nurse should focus on which of the following interventions?

A) Provide a structured environment and limit stimulation
B) Encourage the patient to engage in group therapy
C) Allow the patient to make decisions independently
D) Encourage the patient to rest and sleep

 

148. A nurse is preparing to administer an antipsychotic medication to a patient with schizophrenia. The nurse should assess for which of the following before administration?

A) Weight and blood pressure
B) Pulse and respiratory rate
C) Blood glucose and kidney function
D) History of allergic reactions

 

149. A nurse is working with a patient diagnosed with bipolar disorder. Which of the following should the nurse assess regularly?

A) The patient’s sleep patterns
B) The patient’s social interactions
C) The patient’s level of appetite
D) The patient’s family dynamics

 

150. A nurse is caring for a patient diagnosed with generalized anxiety disorder (GAD). The nurse should teach the patient which of the following coping strategies?

A) Use deep breathing techniques to reduce anxiety
B) Avoid engaging in any social activities
C) Limit physical activity to prevent exhaustion
D) Focus on negative thoughts to face anxiety head-on

 

151. A nurse is discussing coping strategies with a patient who is experiencing major depressive disorder. Which strategy should the nurse recommend?

A) Isolating oneself from others to focus on personal thoughts
B) Engaging in physical activity, such as walking or swimming
C) Avoiding any social contact to prevent feelings of inadequacy
D) Overloading oneself with work to distract from symptoms

 

152. A nurse is caring for a patient with a history of alcohol use disorder. Which of the following would indicate that the patient is experiencing alcohol withdrawal?

A) Decreased heart rate and blood pressure
B) Delirium, tremors, and sweating
C) Increased appetite and weight gain
D) Hypothermia and shallow breathing

 

153. A nurse is educating a patient about the side effects of selective serotonin reuptake inhibitors (SSRIs). The nurse should emphasize which of the following potential side effects?

A) Weight loss and dry mouth
B) Drowsiness and increased appetite
C) Insomnia and sexual dysfunction
D) Increased energy and decreased anxiety

 

154. A nurse is caring for a patient with obsessive-compulsive disorder (OCD). The nurse understands that the most effective treatment for OCD includes which of the following?

A) Medication only
B) Exposure therapy and response prevention
C) Psychoanalysis and free association
D) Stress management and relaxation techniques

 

155. A nurse is caring for a patient with schizophrenia who has been prescribed a first-generation antipsychotic medication. The nurse should monitor for which of the following side effects?

A) Tardive dyskinesia
B) Weight loss
C) Low blood sugar
D) Excessive drowsiness

 

156. A nurse is preparing to discharge a patient with a history of depression. The nurse should ensure that which of the following is in place before discharge?

A) A follow-up appointment with a mental health provider
B) A prescription for a sedative medication
C) Arrangements for a long-term care facility
D) A list of recreational activities

 

157. A nurse is assessing a patient with a history of alcohol use disorder. The nurse should be alert for which of the following signs of alcohol intoxication?

A) Hyperactive reflexes
B) Slurred speech and uncoordinated movements
C) Excessive sweating and fever
D) Decreased appetite and weight loss

 

158. A nurse is providing care for a patient diagnosed with bipolar disorder. The nurse should recognize that the patient’s mood may alternate between:

A) Irritable and euphoric
B) Depressed and euthymic
C) Manic and depressive episodes
D) Anxious and obsessive behavior

 

159. A nurse is conducting a mental health assessment on a patient diagnosed with a personality disorder. Which of the following behaviors would the nurse most likely observe in a patient with antisocial personality disorder?

A) Fear of social rejection and criticism
B) Inability to trust others and constant suspicion
C) A pattern of deceitfulness and violation of others’ rights
D) Extreme need for approval and admiration from others

 

160. A nurse is caring for a patient who is experiencing a panic attack. Which of the following interventions should the nurse implement?

A) Encourage the patient to talk about past trauma
B) Guide the patient through controlled breathing techniques
C) Tell the patient to ignore the symptoms and focus on a distraction
D) Administer a sedative immediately

 

161. A nurse is educating a patient on the proper use of lithium for bipolar disorder. The nurse should emphasize the importance of monitoring for which of the following signs of lithium toxicity?

A) Excessive thirst and urination
B) Rapid heart rate and low blood pressure
C) Nausea, vomiting, and tremors
D) Increased appetite and weight gain

 

162. A nurse is caring for a patient with depression who is experiencing feelings of hopelessness. The nurse should implement which of the following interventions first?

A) Suggest that the patient engage in daily exercise
B) Ask the patient directly about suicidal thoughts or plans
C) Encourage the patient to participate in group activities
D) Remind the patient of the importance of self-care

 

163. A nurse is assessing a patient with anxiety. The nurse should recognize that which of the following is a common physical symptom of anxiety?

A) Muscle tension and restlessness
B) Decreased heart rate and drowsiness
C) Decreased respiratory rate and fatigue
D) Excessive hunger and weight gain

 

164. A nurse is caring for a patient with a history of self-harm. The nurse should prioritize which of the following interventions?

A) Encourage the patient to discuss past traumas
B) Provide a safe environment and limit access to sharp objects
C) Focus on improving the patient’s self-esteem
D) Implement strict punishment for self-harming behaviors

 

165. A nurse is caring for a patient with generalized anxiety disorder (GAD). Which of the following interventions is most appropriate for managing anxiety?

A) Limit social interactions and activities
B) Teach relaxation techniques and stress management
C) Encourage the patient to focus on negative thoughts
D) Discourage seeking professional help or therapy

 

Questions and Answers for Study Guide

 

A 25-year-old patient is admitted to the psychiatric unit with a diagnosis of major depressive disorder. As the nurse, you are tasked with developing a plan of care for this patient. Discuss the priority nursing interventions, including pharmacological and non-pharmacological approaches, to manage the patient’s depression.

 

Answer:

The priority nursing interventions for a patient with major depressive disorder (MDD) should focus on ensuring safety, addressing the patient’s immediate needs, and providing a comprehensive approach to manage both symptoms and underlying factors.

1. Safety Assessment:
   The first priority is to assess the patient for any risk of self-harm or suicide. This includes asking direct questions about suicidal thoughts, plans, and intentions. If the patient is at high risk for suicide, close observation, a safe environment, and possibly a suicide watch may be necessary.
2. Pharmacological Interventions:
   Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), are commonly prescribed to help balance neurotransmitters in the brain. A nurse should educate the patient about the expected benefits and potential side effects of medications, including possible delayed onset of effects. Monitoring for side effects like nausea, insomnia, or sexual dysfunction is critical.
3. Non-pharmacological Interventions:
   • Cognitive Behavioral Therapy (CBT): CBT is an evidence-based therapy that helps patients identify and challenge negative thought patterns and behaviors. As part of a holistic treatment approach, a nurse may refer the patient to a therapist for ongoing sessions.
   • Exercise and Physical Activity: Encouraging regular physical activity is beneficial, as exercise helps release endorphins, which can improve mood and overall well-being.
   • Sleep Hygiene: The nurse should educate the patient on the importance of maintaining a consistent sleep schedule and creating a calming environment to improve sleep quality.
   • Social Support and Group Therapy: Encouraging the patient to engage in support groups or family therapy can reduce isolation and provide emotional support.
4. Patient Education:
   The nurse should provide education about the nature of depression, available treatment options, and the importance of adhering to prescribed medications and therapies. It is crucial to address any misconceptions about depression being a sign of personal weakness or failure.

By combining pharmacological treatments with non-pharmacological approaches, nurses can effectively contribute to the patient’s recovery from major depressive disorder.

 

(2) A patient with schizophrenia is experiencing auditory hallucinations, stating that they hear voices telling them to harm others. As a psychiatric nurse, describe the steps you would take to ensure the safety of both the patient and others. Include communication strategies and interventions.

Answer:

Schizophrenia is a chronic and severe mental health disorder that often includes symptoms like auditory hallucinations. In this scenario, the patient is experiencing auditory hallucinations where voices are instructing harmful actions. The nurse’s role is to ensure the safety of the patient and others while providing compassionate care.

1. Safety First:
   The first priority is ensuring the immediate safety of the patient, staff, and others. The nurse should assess the patient’s risk of harming themselves or others by directly addressing the hallucinations. If the patient verbalizes intentions to harm others, the nurse must intervene immediately by informing the healthcare team and potentially initiating a higher level of observation (e.g., a 1:1 sitter) to prevent harm.
2. Calm, Therapeutic Communication:
   The nurse should approach the patient calmly and non-judgmentally. Acknowledge the patient’s experience without reinforcing the content of the hallucinations. For example, the nurse can say, “I understand that you are hearing voices, but I am here with you and we will work through this together.”
   Reassuring the patient that they are safe and in a controlled environment helps reduce anxiety. Avoid arguing with the patient about the reality of the hallucinations, as this may escalate the situation.
3. Medication Administration:
   Antipsychotic medications, particularly second-generation (atypical) antipsychotics, are often prescribed to manage auditory hallucinations in patients with schizophrenia. The nurse should ensure that the patient receives prescribed medications on time and observe for any side effects. Monitoring for adverse reactions, such as extrapyramidal symptoms (EPS), is essential.
4. Creating a Low-Stimulation Environment:
   Reducing environmental stimuli can help the patient focus and decrease anxiety. Providing a quiet, safe, and calm environment may reduce the intensity of hallucinations. The nurse may consider dimming the lights and limiting unnecessary conversations or loud noises in the environment.
5. Engaging in Reality-Oriented Activities:
   Helping the patient engage in reality-oriented activities (such as listening to music, drawing, or completing simple tasks) may distract from the hallucinations and promote a sense of accomplishment. A nurse should encourage participation in structured activities or therapy sessions to foster a sense of control.
6. Collaborating with the Healthcare Team:
   Continuous communication with the multidisciplinary team—including the psychiatrist, social worker, and therapist—is crucial for developing a comprehensive treatment plan. The team may reassess the treatment regimen and make adjustments based on the patient’s response to therapy and medication.

By taking a holistic and proactive approach to managing auditory hallucinations, the nurse ensures that the patient’s needs are met, the environment remains safe, and appropriate interventions are implemented promptly.

 

(3) A 40-year-old patient with generalized anxiety disorder (GAD) reports feelings of excessive worry, restlessness, and difficulty concentrating for the past several months. As a psychiatric nurse, discuss the assessment, treatment options, and supportive interventions that you would recommend for this patient.

Answer:

Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable worry and anxiety that significantly interferes with daily functioning. As a psychiatric nurse, it is important to assess the patient’s symptoms thoroughly and offer both pharmacological and non-pharmacological treatments to help manage the condition.

1. Comprehensive Assessment:
   The nurse’s initial step is to conduct a thorough assessment to understand the severity of the anxiety symptoms. The nurse should assess:
   • Duration, intensity, and triggers of the anxiety
   • Physical symptoms (e.g., muscle tension, sleep disturbances, irritability)
   • Impact of anxiety on daily activities and work or social functioning
   • History of past psychiatric diagnoses or treatments
   • Family history of anxiety or mood disorders

   Tools such as the Generalized Anxiety Disorder 7 (GAD-7) scale can be used to quantify the severity of anxiety symptoms.

2. Pharmacological Treatment:
   The first-line pharmacological treatment for GAD typically involves selective serotonin reuptake inhibitors (SSRIs), such as sertraline or escitalopram. Other options may include serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine or duloxetine. These medications help regulate serotonin and norepinephrine levels in the brain, which are often imbalanced in individuals with anxiety disorders.
   Benzodiazepines may be used as short-term solutions for acute anxiety but are not recommended for long-term management due to the risk of dependence. The nurse should educate the patient about the side effects and risks of medications, especially the potential sedative effects of benzodiazepines.
3. Non-Pharmacological Interventions:
   • Cognitive Behavioral Therapy (CBT): CBT is the most effective form of therapy for managing GAD. It helps patients identify and challenge irrational thoughts and develop healthier coping mechanisms. The nurse should refer the patient to a licensed therapist for CBT sessions.
   • Relaxation Techniques: Techniques such as deep breathing, progressive muscle relaxation, and guided imagery can help the patient reduce physical symptoms of anxiety. The nurse should demonstrate and encourage these techniques during the assessment and follow-up visits.
   • Lifestyle Modifications: Encouraging regular exercise, a balanced diet, and adequate sleep can improve overall mental well-being and reduce anxiety levels.
   • Mindfulness and Meditation: Encouraging mindfulness practices and meditation can help the patient focus on the present moment, which may reduce worry about future events.
4. Supportive Interventions:
   The nurse should provide education about anxiety and the importance of treatment adherence. Building a strong nurse-patient relationship based on trust and support can encourage the patient to follow through with treatment. Additionally, involving family members or close friends in the treatment process may provide the patient with a strong support system.

Through a combination of pharmacological treatments, therapy, and supportive interventions, nurses can help patients with GAD manage their symptoms effectively and improve their quality of life.

 

(4) A 30-year-old female patient with a diagnosis of borderline personality disorder (BPD) has been admitted to the psychiatric unit following a self-harm episode. Discuss the nursing interventions, therapeutic communication strategies, and treatment modalities that should be considered for this patient.

Answer:

Borderline personality disorder (BPD) is characterized by intense emotional instability, impulsive behavior, fear of abandonment, and difficulty maintaining stable relationships. When a patient with BPD is admitted after a self-harm episode, the nurse’s approach should be focused on ensuring safety, establishing therapeutic rapport, and providing appropriate therapeutic interventions.

1. Safety and Immediate Interventions:
   The first priority is to assess the patient’s risk of self-harm or suicide. Since patients with BPD often engage in self-destructive behaviors, the nurse should conduct a thorough risk assessment and ensure that the environment is safe. If necessary, a 1:1 observation or suicide watch should be implemented. Any self-inflicted injuries should be treated, and the patient’s immediate physical needs should be addressed.
2. Therapeutic Communication Strategies:
   Establishing a trusting nurse-patient relationship is essential in the care of patients with BPD. The nurse should use clear, nonjudgmental communication and avoid engaging in power struggles or emotional confrontation.
   • Validation and Empathy: The nurse should validate the patient’s feelings while acknowledging the intensity of their emotions without reinforcing maladaptive behavior. For example, “I understand that you’re feeling overwhelmed right now, and I’m here to help you through this.”
   • Setting Boundaries: Nurses must establish clear, consistent boundaries with patients who have BPD to avoid manipulation or emotional escalation. It is important to remain firm yet compassionate in maintaining boundaries.
3. Pharmacological Interventions:
   While no medications are approved specifically for BPD, medications may be prescribed to treat symptoms such as mood instability or depression. Antidepressants (SSRIs or SNRIs), mood stabilizers (such as lamotrigine), and antipsychotic medications (like aripiprazole) may be used to manage emotional dysregulation and impulsivity. The nurse should educate the patient on the purpose of medication and monitor for side effects, including weight gain or sedation.
4. Psychotherapy and Treatment Modalities:
   • Dialectical Behavior Therapy (DBT): DBT is the most effective form of psychotherapy for individuals with BPD. It emphasizes skills such as mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. The nurse may refer the patient to a therapist who specializes in DBT and encourage the patient to participate in both individual and group therapy.
   • Cognitive Behavioral Therapy (CBT): CBT may also be effective for addressing dysfunctional thought patterns.
   • Group Therapy: Involving the patient in group therapy provides an opportunity to practice interpersonal skills and helps reduce feelings of isolation. Group therapy can also offer emotional support from others facing similar challenges.
5. Patient Education and Long-Term Care:
   The nurse should educate the patient about BPD, its symptoms, and the importance of long-term treatment. It is essential to emphasize the need for ongoing psychotherapy and medication adherence. Encouraging the patient to develop healthy coping strategies, such as journaling or engaging in creative outlets, can improve emotional regulation and reduce impulsive behaviors.

By utilizing a combination of safety measures, therapeutic communication, pharmacological interventions, and evidence-based therapies, the nurse can provide comprehensive care to patients with BPD, improving their chances for long-term recovery.

 

(5) A 50-year-old male patient with a history of alcohol use disorder (AUD) is being discharged from a rehabilitation center after completing a detoxification program. As the psychiatric nurse, discuss the key components of discharge planning, relapse prevention, and community resources that should be considered for this patient.

 

Answer:

Alcohol use disorder (AUD) is a chronic condition that often requires long-term treatment and support. Discharge planning for a patient recovering from alcohol detoxification should focus on relapse prevention, ongoing therapy, and connecting the patient with resources to maintain sobriety and support recovery.

1. Comprehensive Discharge Planning:
   Discharge planning should begin early during the patient’s rehabilitation process and be individualized to meet the patient’s unique needs.
   • Assessment of Readiness: The nurse should assess the patient’s readiness for discharge, ensuring that they have gained insight into their addiction and are motivated to continue treatment post-discharge.
   • Medical Follow-Up: The patient should be scheduled for follow-up appointments with the psychiatrist, addiction counselor, or primary care provider to monitor their progress and manage any co-occurring mental health disorders, such as anxiety or depression.
   • Medication Management: If appropriate, medications such as disulfiram (Antabuse), acamprosate (Campral), or naltrexone (Vivitrol) may be prescribed to help prevent relapse by reducing cravings or causing unpleasant reactions to alcohol. The nurse should provide instructions on proper medication use and potential side effects.
2. Relapse Prevention Strategies:
   Relapse prevention is a crucial aspect of discharge planning for individuals recovering from AUD. The nurse should work with the patient to develop a personalized relapse prevention plan, which may include the following strategies:
   • Trigger Identification: Helping the patient identify triggers for alcohol use (such as stress, social situations, or negative emotions) is important in preventing relapse.
   • Coping Mechanisms: The nurse should encourage the patient to develop healthier coping mechanisms for managing stress, such as exercise, mindfulness, or relaxation techniques.
   • Avoiding High-Risk Situations: The patient should be advised to avoid environments or individuals that may encourage alcohol use.
   • Support Systems: Strengthening the patient’s support system is crucial for long-term recovery. This can include family involvement in therapy, joining a support group like Alcoholics Anonymous (AA), and maintaining a sober network.
3. Community Resources and Support Groups:
   Connecting the patient with community resources is essential for their ongoing recovery. The nurse should provide information on local support groups, counseling services, and outpatient programs.
   • Alcoholics Anonymous (AA): AA meetings are an important resource for individuals with AUD, providing peer support, accountability, and encouragement in maintaining sobriety. The nurse should encourage the patient to attend regular meetings and introduce the concept of the 12-step program.
   • Outpatient Counseling: Continuing therapy with a licensed addiction counselor or attending group therapy can help the patient address underlying issues related to their alcohol use.
   • Community Resources: Referring the patient to community-based organizations that offer recovery services, housing support, or job placement assistance can help reduce barriers to long-term sobriety.
4. Ongoing Education and Family Support:
   The nurse should provide ongoing education to the patient about AUD, the importance of long-term recovery, and available resources. Family involvement in treatment and recovery is also important, as family members can provide support and help maintain accountability. The nurse should offer education to the patient’s family on how they can support the patient’s recovery process and recognize warning signs of relapse.

By ensuring comprehensive discharge planning, emphasizing relapse prevention, and connecting the patient with appropriate community resources, the nurse can play a key role in supporting the patient’s long-term recovery from alcohol use disorder.

 

(6) A 65-year-old patient is diagnosed with Alzheimer’s disease (AD) and has been showing increasing signs of confusion, memory loss, and difficulty performing activities of daily living (ADLs). As a psychiatric nurse, discuss the nursing care interventions that should be implemented to enhance the patient’s quality of life and provide support to the family.

 

Answer:

Alzheimer’s disease (AD) is a progressive neurodegenerative disorder characterized by cognitive decline, memory loss, and difficulty with daily functioning. Nursing care for a patient with AD should focus on improving their quality of life, promoting independence to the extent possible, and providing emotional and practical support to both the patient and their family.

1. Assessment and Individualized Care Planning:
   The nurse should conduct a thorough assessment to understand the patient’s cognitive, physical, and emotional state. This includes evaluating the patient’s level of memory impairment, ability to perform activities of daily living (ADLs), and any behavioral symptoms such as agitation or aggression. A personalized care plan should be developed to address these needs and promote functional independence.
2. Promoting Cognitive Functioning and Independence:
   While cognitive decline cannot be reversed, the nurse can implement strategies to slow the progression of symptoms and enhance the patient’s quality of life:
   • Structured Routine: Creating a consistent daily routine helps reduce confusion and anxiety. The nurse should encourage caregivers to keep the patient’s environment predictable and organized.
   • Cognitive Stimulation: Engaging the patient in activities that stimulate cognitive functioning, such as puzzles, memory games, or reminiscence therapy, can help maintain cognitive abilities for a longer period.
   • Assistance with ADLs: As the disease progresses, the nurse should provide assistance with basic activities such as bathing, dressing, and eating, while encouraging the patient to perform these tasks independently as much as possible.
3. Managing Behavioral Symptoms:
   Many patients with AD experience behavioral symptoms such as aggression, wandering, or resistance to care. The nurse should use the following interventions:
   • Redirection and Calm Communication: When the patient becomes agitated, using calm and soothing tones while redirecting their attention to a familiar activity can help reduce agitation.
   • Safe Environment: Ensuring that the patient’s environment is free from hazards is important to prevent falls or injury, especially in patients who may wander.
   • Medication Management: In some cases, medications such as cholinesterase inhibitors (donepezil) or memantine may be prescribed to help manage cognitive symptoms. The nurse should monitor for side effects, such as gastrointestinal distress.
4. Support for the Family:
   Alzheimer’s disease is challenging not only for the patient but also for their family members. The nurse should provide the family with information on how to care for the patient and manage the progression of the disease.
   • Education on Disease Progression: Educating the family about the stages of AD can help them understand what to expect and plan for future care needs.
   • Respite Care: The nurse should encourage family caregivers to seek respite care to prevent caregiver burnout. Providing information on local support groups and community resources can help families connect with others facing similar challenges.
   • Emotional Support: Offering emotional support to the family and providing a safe space for them to express concerns can help alleviate the stress of caregiving.

By focusing on enhancing the patient’s independence, managing behavioral symptoms, and supporting the family, the nurse can play a pivotal role in improving the quality of life for both the patient and their caregivers.

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