Psychiatric Nursing Flashcards

Which type of hallucination is most commonly reported in schizophrenia?

Answer: Auditory hallucinations (hearing voices)

Auditory hallucinations (hearing voices) occur in approximately 70% of patients with schizophrenia and are the most diagnostically significant. The voices may comment on behavior, converse with each other, or give commands. Visual hallucinations are more common in delirium or organic causes.

A patient expresses intent to harm a specific identified person. What is the nurse's legal and ethical obligation?

Answer: Warn the identified victim, notify law enforcement, and document per the Tarasoff duty-to-warn principle

The Tarasoff ruling (duty to protect/warn) obligates mental health professionals to take reasonable steps to protect identifiable third parties from a patient's stated intent to harm. This includes warning the potential victim, notifying law enforcement, and taking clinical action (e.g., hospitalization).

Which statement by a patient with major depressive disorder (MDD) indicates the most immediate safety risk?

Answer: 'I have a plan to kill myself tonight with the pills I saved'

A specific plan with identified method and timeline (tonight, saved pills) constitutes high-risk suicidal ideation requiring immediate intervention (psychiatric hold, removing means, constant observation). Passive death wish and ideation without plan carry lower immediate risk.

A patient with schizophrenia insists their thoughts are being broadcast on television. What type of symptom is this?

Answer: Thought broadcasting (a delusion of reference)

Thought broadcasting is a Schneiderian first-rank symptom of schizophrenia in which the patient believes their thoughts are being transmitted to others or broadcast publicly (e.g., on TV or radio). It is a delusion — a fixed false belief — not a hallucination.

What is the nurse's appropriate response when a depressed patient says 'I'll never get better. Things will always be bad'?

Answer: Gently challenge cognitive distortion: 'You're describing things as permanent — what evidence do you have that this is always true?'

The statement reflects cognitive distortions (permanence and pervasiveness) consistent with Beck's cognitive triad. A therapeutic response gently challenges the distortion using Socratic questioning while acknowledging the patient's pain. Agreeing reinforces hopelessness; false reassurance dismisses feelings.

Which assessment scale is commonly used to evaluate the severity of alcohol withdrawal?

Answer: CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol)

The CIWA-Ar is the standard validated tool for quantifying alcohol withdrawal severity and guiding benzodiazepine dosing using a symptom-triggered protocol. The AUDIT and CAGE screen for alcohol use disorder. MMSE assesses cognitive function, not withdrawal severity.