Clinical Nurse Specialist Psychiatric & Mental Health Nursing 2 — Questions and Answers
Question 1: A patient with borderline personality disorder engages in splitting by telling the night nurse that the day nurse is 'incompetent and cruel.' The most therapeutic CNS response to the team is to:
- Investigate whether the day nurse was actually harmful
- Implement consistent limit-setting and unified team communication strategies (Correct answer)
- Allow the patient to vent feelings without team involvement
- Reassign the patient to a nurse they prefer
Correct answer: Implement consistent limit-setting and unified team communication strategies
Splitting is managed by maintaining a unified, consistent treatment team approach with clear limit-setting, preventing staff from being divided into 'all good' or 'all bad' roles.
Question 2: Which of the following is the FIRST priority intervention when de-escalating a verbally aggressive patient in an inpatient psychiatric unit?
- Administer an oral PRN benzodiazepine
- Ensure personal safety and position yourself near the exit (Correct answer)
- Establish a therapeutic alliance through verbal intervention
- Call for additional staff to stand nearby as a show of force
Correct answer: Ensure personal safety and position yourself near the exit
Before any therapeutic intervention, the CNS must ensure personal safety by positioning themselves near an exit and maintaining a safe distance, as safety is always the first clinical priority.
Question 3: A patient with post-traumatic stress disorder (PTSD) is experiencing hypervigilance, nightmares, and avoidance of trauma reminders. Which first-line evidence-based psychotherapy is recommended by VA/DoD clinical practice guidelines?
- Psychodynamic therapy
- Prolonged Exposure (PE) therapy (Correct answer)
- Dialectical Behavior Therapy (DBT)
- Interpersonal therapy (IPT)
Correct answer: Prolonged Exposure (PE) therapy
Prolonged Exposure (PE) therapy is a first-line, evidence-based psychotherapy for PTSD that involves systematic, repeated engagement with trauma memories and reminders to reduce avoidance and distress.
Question 4: A CNS assessing a patient for alcohol use disorder uses the CIWA-Ar scale. A score of 15 on this scale indicates:
- Mild withdrawal requiring observation only
- Moderate withdrawal requiring pharmacological intervention (Correct answer)
- Severe withdrawal with imminent seizure risk requiring ICU transfer
- No withdrawal symptoms; patient is stable for discharge
Correct answer: Moderate withdrawal requiring pharmacological intervention
CIWA-Ar scores of 8–15 indicate moderate alcohol withdrawal, typically requiring pharmacological treatment (usually benzodiazepines) to prevent progression to severe withdrawal or delirium tremens.
Question 5: The use of physical restraints in an inpatient psychiatric setting requires which of the following per The Joint Commission standards?
- Standing order from the attending physician
- Face-to-face evaluation within one hour of restraint initiation (Correct answer)
- Nursing supervisor approval before application
- Patient consent documented in the chart
Correct answer: Face-to-face evaluation within one hour of restraint initiation
The Joint Commission requires that a physician or licensed independent practitioner conduct a face-to-face evaluation within one hour of initiating restraints to ensure patient safety and appropriateness.
Question 6: A patient taking lithium for bipolar disorder presents with coarse tremor, confusion, and ataxia. The serum lithium level is 2.1 mEq/L. The CNS should anticipate:
- Increasing the lithium dose to achieve therapeutic effect
- Holding the next lithium dose and monitoring symptoms closely
- Immediate discontinuation and supportive treatment for toxicity (Correct answer)
- Administering flumazenil as an antidote
Correct answer: Immediate discontinuation and supportive treatment for toxicity
A lithium level above 2.0 mEq/L with neurological symptoms (tremor, confusion, ataxia) indicates severe lithium toxicity requiring immediate discontinuation, hydration, and supportive care — potentially dialysis.
Question 7: Cognitive Behavioral Therapy (CBT) for depression primarily targets which mechanism to reduce depressive symptoms?
- Unconscious conflicts from early childhood experiences
- Maladaptive thought patterns and their influence on behavior and emotions (Correct answer)
- Interpersonal role disputes and transitions affecting mood
- Neurochemical imbalances corrected through behavioral activation alone
Correct answer: Maladaptive thought patterns and their influence on behavior and emotions
CBT is based on the cognitive model, targeting the identification and restructuring of maladaptive (negative, distorted) thought patterns (cognitive distortions) that perpetuate depressive symptoms.
Clinical Nurse Specialist Psychiatric & Mental Health Nursing 2
A patient with borderline personality disorder engages in splitting by telling the night nurse that the day nurse is 'incompetent and cruel.' The most therapeutic CNS response to the team is to: