Health and Psychiatric Nursing NCLEX Quiz

Psychiatric Assessment and Fundamentals of Mental Health and Psychiatric Nursing NCLEX Quiz A 48-year-old Hispanic woman is seen by a psychiatric clinical nurse specialist after receiving a call by her son. According to the son, since his father's death 7 months ago, his mother has lost 30 pounds and can't sleep. During her initial visit, the patient states, 'My husband talks to me in his visits, but his words make no sense to me. I don't understand what he wants me to do.' What is an appropriate nursing diagnosis?

• Ineffective denial.
• Bipolar mood disorder.
• Hyper-religiosity.
• Grieving. - correct answerD. Grieving.

Reason: Grieving may be characterized by weight loss, sleep disturbances, and

messages from beyond.

Your neighbor's husband comes to talk to you. He says his wife has not left the house in

• weeks, has a flat mood, and has lost interest in her usual activities. You recognize

these as the primary symptoms of

• Depression.
• Schizophrenia.
• Suicidal ideation.
• Bipolar manic episodes. - correct answerA. Depression.

Reason: Depressed mood and anhedonia (loss of interest or pleasure in activities) are the primary symptoms of major depression.

Your patient is ready for discharge after a 30-day hospitalization for manic depression.About 30 minutes before his discharge, his roommate comes to you and says, 'He is talking crazy.' When you ask your patient how he is feeling, he states, 'I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.' Which type of mania-related symptoms is this patient exhibiting?

• Social.
• Cognitive.
• Behavioral.
• Perceptual. - correct answerB. Cognitive.

Reason: Cognitive symptoms include inflated self-esteem and grandiosity.

You need to assess whether a patient who has a mood disorder is ready for discharge.Which statement would indicate readiness for discharge?

• Right now, I can't bathe myself or dress myself, but I feel good about that.
• Going home will be fun, but if it isn't fun, I can always make my mother help me or tell

her to do so. She better help me.

• I will take my medicines as I should and know to call the number you gave me if I

have bad thoughts.

• Taking care of myself is important, but it's okay if I don't want to do anything. - correct

answerC. I will take my medicines as I should and know to call the number you gave me if I have bad thoughts.

Reason: Verbalization of a plan for help and demonstration of care are realistic discharge criteria.

An angry patient is in the community room. She picks up a chair and uses it to hit another patient on the head. When you come into the community room, what should your first response to the patient holding the chair be?

• Are you crazy? Hitting people can hurt them!
• Hitting others is unacceptable. Please put the chair completely down on the floor.
• How would you like it if I hit you over the head with a chair?
• You're in big trouble now. It's probably prison you are looking at! - correct answerB.

Hitting others is unacceptable. Please put the chair completely down on the floor.

Reason: Use words to indicate your lack of acceptance of the patient's behavior in a nonthreatening voice or tone.

A 22-year-old female is admitted to the unit following a suicide attempt. She has a 2- week history of depression as well as a history of abusing multiple substances and anorexia nervosa. What is your first nursing priority?

• Socialization.
• Contracting for eating behavior.
• Safety.
• Administering the Beck depression scale. - correct answerC. Safety.

Reason: Safety is the major principle underlying psychiatric nursing.

Gerald was admitted to the psychiatric acute care unit because he stood in the center of a main two-way street in his underwear and a T-shirt, shouting, 'I am being held against my will. I have personal rights.' Gerald was diagnosed with bipolar disorder, manic type.Which of the following interventions will add to everyone's safety in the acute care environment?

• Have hectic surroundings.
• Have consistent unit routines.
• Minimize staff interventions.
• Medicate the patient only if he has private health insurance. - correct answerB. Have

consistent unit routines.

Reason: Quiet environments with consistent routines will help calm patients and add to safety.

Your patient has just been physically cleaned up after slicing his left arm 8 times. To show an appropriate evaluative response, which of the following would be your best statement?

• I could care less if you cut yourself. It doesn't hurt me.
• If you wouldn't cut yourself, you would have a much happier life.
• You are lucky someone found you in time. Now you can help us make you better.
• The behavior of cutting is not acceptable. - correct answerD. The behavior of cutting

is not acceptable.

Reason: Focus on the behavior, not the person. Be neutral, but not indifferent.

A 22-year-old female was admitted to the mental health unit with major depression and suicidal ideation. She has a history of cutting her wrists intermittently throughout the last

• years. On days 1 and 2, the patient stays in her room and eats only 20% of her meals.

On day 3, she eats 80% of her meals and is talking to others in group. The nurse should consider that the patient is

• Showing improvement.
• Highly suicidal.
• Exhibiting mood swings.
• In need of electroshock therapy. - correct answerA. Showing improvement.

Reason: The patient improvement is based on increased socialization and increased appetite.

A 21-year-old patient has a diagnosis of schizophrenia and is stuporous, yet exhibits sudden, excessive motor activity with repetitive sit-ups. What is this behavior called?

• Delusional.
• Hallucinogenic.
• Paranoid.
• Catatonic. - correct answerD. Catatonic.

Reason: Catatonic schizophrenia occurs suddenly and includes motor immobility or excessive motor activity.

A 16-year-old girl is admitted for her first psychotic break. Her parents feel very guilty.What is your best nursing response?

• No one really knows the cause of schizophrenia. It is not your fault and is not due to

anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves.

• Does anyone in your family have schizophrenia, as this disease is known to be

genetic?

• You may feel bad now, but there are so many other bad things out there, such as

cancer and paralysis.

• Let me share with you some websites to help you deal with your guilt. - correct

answerA. No one really knows the cause of schizophrenia. It is not your fault and is not due to anything you did in the past. It is important to understand this, to support your daughter, and to find support for yourselves.

Reason: Schizophrenia has a multifocal origin and its cause may include a genetic component. Support is needed for both patients and caregivers.

A physical indicator of possible abuse in a battered woman would be a fracture of the distal bones, such as the skull, face, or extremities.

A. TRUE

• FALSE - correct answerA. TRUE

Reason: Musculoskeletal fractures and sprains, especially of distal versus proximal bones, are indications of battering. Also assess for dislocated shoulders and old fractures.

Which of the following statements indicates that your patient, who has schizophrenia, is ready to manage a relapse?

• I will think of a plan of action before I get these racing thoughts again.
• I will not drink alcohol and will exercise daily. This will help me stay well.
• If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and

talk to her. She or I will call my therapist.

• When I feel stressed, I will sit near my bed and wait to feel better. - correct answerC.

If I start feeling badly and don't sleep very much, then I will tell my friend Sandy and talk to her. She or I will call my therapist.

Reason: Managing a relapse includes a plan of action, involvement of a friend or family member, and, after identification of signs, notification of a therapist.

Your patient has a diagnosis of schizophrenia and believes that his thoughts are broadcast from his head. What is the most appropriate nursing diagnosis?

• Risk for self-directed violence.
• Disturbed sensory perception.
• Impaired verbal communication.
• Disturbed thought processes. - correct answerD. Disturbed thought processes.

Reason: Thought broadcasting and thought withdrawal are disturbed thought

processes.

As a nurse, you wish to reinforce functional behavior in your schizophrenic patient.Which intervention will accomplish reinforcement?

• Praise the patient for reality-based perceptions and cessation of acting-out

behaviors.

• Educate the patient about the symptoms of schizophrenia.
• Facilitate learning about the importance of medication compliance using written

materials for reinforcing medication use.

• Focus on the feelings of delusion to reinforce reality and decrease false beliefs by

talking to the patient. - correct answerA. Praise the patient for reality-based perceptions and cessation of acting-out behaviors.