BSN Mental Health and Psychiatric Nursing 2 — Questions and Answers
Question 1: A patient with alcohol use disorder is admitted for detoxification. Which finding indicates the patient may be developing delirium tremens (DTs)?
- Severe agitation, diaphoresis, and visual hallucinations 48–72 hours after last drink (Correct answer)
- Mild tremors and anxiety 6 hours after last drink
- Nausea and vomiting within 2 hours of last drink
- Insomnia and irritability on the day of admission
Correct answer: Severe agitation, diaphoresis, and visual hallucinations 48–72 hours after last drink
Delirium tremens typically begins 48–72 hours after alcohol cessation and presents with autonomic instability, agitation, and hallucinations.
Question 2: A patient with anorexia nervosa is admitted for medical stabilization. Which laboratory finding is the most life-threatening concern during refeeding?
- Severe hypophosphatemia (refeeding syndrome) (Correct answer)
- Mild hyponatremia (sodium 133 mEq/L)
- Elevated liver enzymes
- Low hemoglobin of 10.5 g/dL
Correct answer: Severe hypophosphatemia (refeeding syndrome)
Refeeding syndrome causes a dangerous shift of phosphate into cells as metabolism resumes, leading to cardiac arrhythmias and respiratory failure.
Question 3: A patient is admitted after a serious suicide attempt. After stabilization, the patient tells the nurse, 'I feel better now. I don't need to be here.' How should the nurse interpret this statement?
- The statement may indicate the patient has made a decision to complete the act and feels relief (Correct answer)
- The patient has experienced genuine remission and may be ready for discharge
- The patient is using manipulation to get an early discharge
- This is a normal response after a failed suicide attempt
Correct answer: The statement may indicate the patient has made a decision to complete the act and feels relief
Sudden calm or resolution of distress after a serious attempt can indicate the patient has accepted a plan and feels relieved of their burden—not improvement.
Question 4: A patient with borderline personality disorder engages in 'splitting' on the inpatient unit, telling one nurse that they are the 'best nurse' while stating another nurse is 'terrible.' The appropriate nursing response is to:
- Communicate consistently with the entire nursing team and maintain uniform boundaries (Correct answer)
- Validate the patient's positive feedback and address the complaint about the other nurse
- Reassure the patient and try to improve the therapeutic relationship with the 'terrible' nurse
- Document the behavior and avoid further interaction to prevent escalation
Correct answer: Communicate consistently with the entire nursing team and maintain uniform boundaries
Splitting is managed by maintaining consistency across all staff through regular team communication and uniform limit-setting.
Question 5: A patient with post-traumatic stress disorder (PTSD) is experiencing a flashback. Which nursing response is most therapeutic?
- Speak in a calm, steady voice and orient the patient to the present environment (Correct answer)
- Stay silent and give the patient space until the flashback resolves
- Encourage the patient to talk about the traumatic event in detail
- Administer a PRN benzodiazepine immediately
Correct answer: Speak in a calm, steady voice and orient the patient to the present environment
Grounding techniques and calm reorientation bring the patient back to the present reality, reducing the intensity of the flashback.
Question 6: Which statement by a patient taking selective serotonin reuptake inhibitors (SSRIs) indicates correct understanding of the medication?
- 'I may not notice a full improvement in my mood for 4–6 weeks.' (Correct answer)
- 'I should feel better within 2–3 days of starting the medication.'
- 'I can stop taking the medication as soon as I feel normal again.'
- 'I should take an extra dose if I feel especially depressed one day.'
Correct answer: 'I may not notice a full improvement in my mood for 4–6 weeks.'
SSRIs have a delayed therapeutic onset of 4–6 weeks due to the time required for neuroadaptive changes in serotonin receptor sensitivity.
BSN Mental Health and Psychiatric Nursing 2
A patient with alcohol use disorder is admitted for detoxification.
Which finding indicates the patient may be developing delirium tremens (DTs)?