ISPN & CGFNS Mental Health Assessment in Psychiatric Nursing 2 — Questions and Answers
Question 1: Which acronym is used to systematically assess the features of a patient's hallucinations in psychiatric nursing?
- STAMP: Severity, Triggers, Affect, Meaning, Pattern (Correct answer)
- CIWA: Clinical Institute Withdrawal Assessment
- NEWS: National Early Warning Score
- SOAP: Subjective, Objective, Assessment, Plan
Correct answer: STAMP: Severity, Triggers, Affect, Meaning, Pattern
Structured acronyms like STAMP help psychiatric nurses assess the features of hallucinations systematically, including triggers, meaning, and frequency.
Question 2: A patient with bipolar disorder is admitted in a manic state. Which MSE finding is most expected?
- Pressured speech and grandiosity (Correct answer)
- Mutism and poverty of speech
- Flat affect and social withdrawal
- Disorientation to time and place
Correct answer: Pressured speech and grandiosity
Pressured speech (fast, difficult to interrupt) and grandiosity (inflated self-esteem) are hallmark MSE findings during a manic episode of bipolar disorder.
Question 3: Which tool is used in psychiatric nursing to assess the risk of violence toward others?
- Brøset Violence Checklist (BVC) (Correct answer)
- CAGE questionnaire
- CIWA-Ar
- Hamilton Anxiety Rating Scale
Correct answer: Brøset Violence Checklist (BVC)
The Brøset Violence Checklist (BVC) is a validated tool used in inpatient psychiatric settings to assess short-term risk of patient violence.
Question 4: In a psychiatric assessment, 'loosening of associations' refers to which thought process abnormality?
- Disorganized thinking where connections between ideas are unclear or absent (Correct answer)
- Inability to start new topics of conversation
- Repeating the same word or phrase involuntarily
- Abrupt stopping of speech mid-sentence
Correct answer: Disorganized thinking where connections between ideas are unclear or absent
Loosening of associations describes disorganized thinking where the logical connection between sequential ideas is unclear, a common feature of psychotic disorders.
Question 5: When conducting a psychiatric nursing assessment, asking 'What would you do if you found a stamped, addressed envelope on the sidewalk?' tests which cognitive function?
- Abstract thinking and judgment (Correct answer)
- Long-term memory
- Spatial orientation
- Language fluency
Correct answer: Abstract thinking and judgment
This classic question assesses abstract thinking and judgment by evaluating whether the patient can reason beyond a literal level and make a socially appropriate decision.
Question 6: Which psychiatric nursing assessment strategy is most effective when a patient is acutely psychotic and paranoid?
- Using a calm, non-threatening tone and avoiding sudden movements (Correct answer)
- Confronting the patient's delusions directly with factual evidence
- Restraining the patient immediately as a precaution
- Leaving the patient alone in the room to self-calm
Correct answer: Using a calm, non-threatening tone and avoiding sudden movements
A calm, non-threatening approach de-escalates paranoid patients by reducing perceived threat, which is safer and more therapeutic than confrontation or physical intervention.
ISPN & CGFNS Mental Health Assessment in Psychiatric Nursing 2
Which acronym is used to systematically assess the features of a patient's hallucinations in psychiatric nursing?