Mental Health Assessment in Psychiatric Nursing Flashcards

Which assessment tool is specifically used to identify symptoms of post-traumatic stress disorder (PTSD) in a psychiatric nursing evaluation?

Answer: PTSD Checklist for DSM-5 (PCL-5)

The PCL-5 is a validated 20-item self-report measure that assesses the presence and severity of DSM-5 PTSD symptoms.

In a psychiatric nursing assessment, which finding suggests a patient may have a thought insertion delusion?

Answer: The patient believes external forces are placing thoughts into their mind

Thought insertion is a delusion in which the patient believes that external entities or forces are implanting thoughts into their mind, a symptom of psychosis.

Which scale is used in psychiatric nursing to monitor alcohol withdrawal severity?

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

The CIWA-Ar is the standard clinical tool for monitoring alcohol withdrawal symptoms and guiding pharmacological management in detoxification settings.

A psychiatric nurse notes a patient has 'poor insight' into their illness. What does this mean clinically?

Answer: The patient does not recognize that they have a mental illness or need treatment

Poor insight means the patient lacks awareness that they have a mental illness or that their symptoms require treatment, which is common in schizophrenia and mania.

What is the purpose of the Columbia Suicide Severity Rating Scale (C-SSRS) in psychiatric nursing?

Answer: To systematically assess and document the severity of suicidal ideation and behavior

The C-SSRS provides a structured, validated framework to assess the intensity and nature of suicidal ideation and behavior, supporting clinical decision-making and safety planning.

When a patient states 'I feel like two different people living in the same body,' which assessment domain should the psychiatric nurse explore further?

Answer: Dissociation and identity disturbance

Feeling like two different people describes a possible dissociative experience or identity disturbance, which requires further assessment for dissociative disorders or trauma history.