NCLEX Mental Health and Psychiatric Nursing

Question 1

A patient with schizophrenia tells the nurse, 'The CIA has implanted a chip in my brain to monitor my thoughts.' How should the nurse respond therapeutically?

Accepted Answer

Acknowledge the patient's distress without reinforcing or arguing against the delusion

Answer

Tell the patient the CIA does not implant chips in people's brains

Answer

Ask detailed questions about the CIA to explore the delusion further

Answer

Change the subject immediately and discuss discharge planning

Question 2

A patient is admitted with a diagnosis of major depressive disorder. Which nursing intervention has the highest priority?

Accepted Answer

Assess for suicidal ideation and means

Answer

Encourage group therapy attendance

Answer

Establish a structured activity schedule

Answer

Teach the patient about antidepressant medications

Question 3

A patient taking lithium carbonate for bipolar disorder develops coarse tremors, vomiting, and confusion. The serum lithium level is 2.4 mEq/L. The nurse should:

Accepted Answer

Hold lithium, notify the provider, and prepare for supportive care as lithium toxicity is present

Answer

Reassure the patient that tremors are a normal side effect of lithium

Answer

Administer the next scheduled lithium dose as the level is within therapeutic range

Answer

Decrease sodium intake to correct the lithium level

Question 4

A patient on a psychiatric unit with bipolar disorder states, 'I am the president of the United States and I need a phone right now to call the Pentagon.' The nurse recognizes this as:

Accepted Answer

Grandiose delusion consistent with mania

Answer

A hallucination

Answer

Confabulation

Answer

Dissociation

Question 5

A nurse is conducting a suicide risk assessment using the SAD PERSONS mnemonic. Which factor should the nurse assess?

Accepted Answer

Sex, age, depression, previous attempts, ethanol use, rational thinking loss, social support lacking, organized plan, no spouse, and sickness

Answer

Social engagement levels and activity

Answer

Self-esteem and daily living functioning

Answer

Sleep patterns and appetite disturbance

Question 6

A patient with anorexia nervosa has a BMI of 15 and is medically unstable. Which nursing intervention is the priority?

Accepted Answer

Monitor vital signs, electrolytes, and cardiac rhythm for complications of malnutrition

Answer

Encourage the patient to discuss feelings about body image

Answer

Begin group therapy about healthy eating habits

Answer

Provide dietary education about daily caloric requirements

Question 7

A nurse is working with a patient who has borderline personality disorder (BPD). Which behavior is most characteristic of this diagnosis?

Accepted Answer

Intense, unstable interpersonal relationships with alternating idealization and devaluation

Answer

Flat affect and social withdrawal lasting months

Answer

Persistent inflexible rituals to control anxiety

Answer

Grandiosity and decreased need for sleep

Question 8

A nurse notices a patient who has been agitated and pacing is suddenly very calm and states 'I've made my decision.' What should the nurse interpret this behavioral change as?

Accepted Answer

A possible sign of resolution of suicidal crisis after deciding to act

Answer

Positive response to therapy and medication

Answer

Breakthrough of underlying depression requiring dosage adjustment

Answer

Normal behavioral fluctuation in psychiatric patients

Question 9

Which intervention is most therapeutic when caring for a patient experiencing alcohol withdrawal on day 2 of admission?

Accepted Answer

Administer prescribed benzodiazepines per CIWA protocol and monitor closely for seizures

Answer

Encourage rapid oral hydration and mobilization

Answer

Restrict fluids and maintain a quiet environment only

Answer

Provide thiamine after completing the CIWA assessment

Question 10

A patient prescribed haloperidol (Haldol) develops muscle rigidity, hyperthermia (103°F), diaphoresis, and altered consciousness. What condition does this represent?

Accepted Answer

Neuroleptic malignant syndrome (NMS)

Answer

Tardive dyskinesia

Answer

Extrapyramidal side effect (EPS)

Answer

Serotonin syndrome