DOH Nursing Psychiatric Nursing 3

Question 1

What is the correct nursing response to a patient in the psychiatric unit who is about to hit another patient?

Accepted Answer

Step between them, use a calm firm voice, direct the agitated patient to a quiet area, and call for assistance

Answer

De-escalation is the first-line response: use a calm, firm voice, maintain safe distance, redirect to a quiet space, and call for backup. Physical intervention (restraint) is a last resort when de-escalation fails and safety is at risk. Follow facility policy on team response.

Question 2

A patient with alcohol use disorder who stopped drinking 48 hours ago develops tremors, tachycardia, and visual hallucinations. What condition is occurring?

Accepted Answer

Alcohol withdrawal delirium (delirium tremens)

Answer

Delirium tremens (DT) typically peaks at 48–72 hours after last drink. Features: severe autonomic hyperactivity, confusion, hallucinations (visual/tactile), tremors, and seizure risk. Without treatment (benzodiazepines, thiamine), DTs carry up to 5% mortality. It is a medical emergency.

Question 3

Which side effect of antipsychotic medications is characterized by an inner feeling of restlessness and inability to sit still?

Accepted Answer

Akathisia

Answer

Akathisia is a distressing subjective sense of inner restlessness with an irresistible urge to move, often manifesting as pacing. It is a common cause of non-adherence. It differs from dystonia (acute muscle spasm), tardive dyskinesia (late involuntary movements), and drug-induced Parkinsonism.

Question 4

A nurse implements a 'no-suicide contract' with a patient. What is the most important limitation of this approach?

Accepted Answer

Research shows no-suicide contracts do not reliably prevent suicide and should not replace a comprehensive safety plan

Answer

No-suicide contracts lack evidence of effectiveness. Patients in crisis may sign contracts to avoid hospitalization or closer monitoring. Evidence-based practice favors collaborative safety planning (Stanley-Brown Safety Planning Intervention), which identifies warning signs, coping strategies, and resources.

Question 5

What is the primary goal of motivational interviewing (MI) in addiction nursing?

Accepted Answer

Elicit the patient's own motivation for change by exploring ambivalence without confrontation

Answer

MI is a collaborative, patient-centered approach that explores and resolves ambivalence. The nurse uses open-ended questions, affirmations, reflective listening, and summaries (OARS) to help patients identify their own reasons for change. Confrontation is explicitly avoided.

DOH Nursing Practice Test

DOH Nursing Practice Test

DOH Nursing Psychiatric Nursing 3